Taiwan Medical and Health Information Management Association
Saturday, July 28, 2012
Nelly Leon-Chisen, RHIA, Director Coding and Classification
American Hospital Association
Lee H. Hilborne, MD, MPH,
The Impact of ICD-10-CM and
ICD-10-PCS on Medical
Documentation, Patient Safety
And Quality Initiatives
Medical Director, Care
Coordination
UCLA Health System
Health Services Researcher
RAND Corporation
Medical Director
Quest Diagnostics
http://www.uclahealth.org/
2
Public Reporting Of Data Is A Driving
Force
• Transparency is a property of a high reliability organization
• Many initiatives are emerging to evaluate and report quality
of care and patient safety
• Reported data serve four common interconnected purposes
– Quality Improvement
– Public Reporting
– Pay-For-Performance
– Research
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
3
Where Does The Pressure Originate?
• Employers
– Reducing costs
– Improving clinical quality
– Comparative performance data available in the public
domain (e.g. Leapfrog Group, National Business Coalition on
Health)
• Health plans
– Data to describe providers’ and enrollee’s actions, costs, and
health outcomes
– Analysis of comparative performance data and pricing
• Consumer concerns
– Medical errors
– Increased cost
– Lack of coverage
– Access to comparative performance
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
4
Copyright (c) 2012 by American Hospital Association. All rights reserved.
Pay For Performance Is On Everybody’s Mind
• Also called value based purchasing
• Differential payment to hospitals
and physicians based on
performance on a set of specified
measures
– Quality
– Efficiency
– Patient experiences
– Structural reforms (e.g.,
information technology)
• Aligns financial incentives with
delivery of high quality care
• Rapidly expanding programs
0
50
100
150
200
P4P Programs
2003 2004 2005
2006 2008
5
Private Sector Initiates Most Pay for
Performance Programs
• Most link relatively small bonus payments to better
performance on specific process measures with outcome
correlation
• Focus on costly and relatively common conditions
• Hospital “pay for performance” (P4P) experiments are run
either by commercial plans or by employer-payer coalitions
• Most include process and structure measures
– Some include condition specific clinical outcome
measures
– But process measures are easiest to identify because
what was actually done gets coded
• Wide range of incremental revenue from successful
performance—from less than 1% to 15%
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
6
Pay For Performance Is A Centers for
Medicare & Medicaid Priority
• Shift in payment considerations
– Payment traditionally based on the process of care (what was
done)
– P4P: Outcome influences payment (treatment impact); better
outcomes paid more
– Value-based purchasing
• Goal
– Right care for every patient every time
– Conforms to Institute of Medicine (IOM) quality domains
• Safe
• Effective
• Centered on the patient’s needs
• Timely
• Efficient
• Equitable
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
7
Medicare Programs Target Multiple Settings
• Various initiatives to encourage improved quality
of care in all health care settings:
– Hospitals
– Physicians’ offices
– Ambulatory care facilities
– Nursing homes
– Home health care agencies
– Dialysis facilities
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
8
Quality Reporting Programs Working With CMS Are
Dramatically Impacting Hospital Care
• The Hospital Quality Alliance (HQA)
– Created in 2002 as the USA’s first multi-stakeholder
private/public organization dedicated to developing, reporting
and updating information about hospital quality performance,
and encouraging efforts to improve hospital quality.
– Transferred the quality measure review processes to the
Measures Application Partnership (MAP) in 2012.
– Catalyzed adoption of the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS), the nation’s first
standardized survey for measuring patients’ perceptions of their
hospital care.
– Introduced the nation’s first measures of surgical site infections.
– Virtually all of the 10 core measures that the HQA first put
forward now are above 95 percent compliance.
– Advised CMS on the creation of Hospital Compare
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
9
Quality Reporting Programs Working With CMS Are
Dramatically Impacting Hospital Care (cont.)
• Hospital Compare www.hospitalcompare.hhs.gov
– The nation’s broadest compendium of publicly available,
internet accessible and comparable national hospital
quality measures.
– Currently reports on more than 50 performance
measures for inpatient and outpatient care and allows
the public and health care providers to compare the
performance of more than 4,500 hospitals across the
nation.
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
http://www.hospitalcompare.hhs.gov/
10
Addressing Quality Creates Data Challenges
• Retrospective chart abstraction
– Burdensome
– Time-consuming
– Mostly manual process
– Able to collect more specific clinical measures
• Administrative claims data
– More efficient
– Quality reporting as a by-product of the administrative
process
– Codes do not provide level of detail necessary
– Concerns over accuracy of coded data
Copyright (c) 2012 by American Hospital Association. All rights reserved.
http://www.uclahealth.org/
11
We Focused On Patient Safety In Taiwan - 2003
http://www.uclahealth.org/
12
We Agreed Safety Is Not New And Surely Not
Unique to the USA
“Grant me the courage to realize my daily mistakes so
that tomorrow I shall be able to see and understand in a
better light what I could not comprehend in the dim light
of yesterday” Maimonides (1135-1204)
“I would give great praise to the physician whose
mistakes are small for perfect accuracy is seldom to be
seen” Hippocrates
“…even admitting to the full extent the great value of the
hospital improvements in recent years, a vast deal of
the suffering, and some at least of the mortality, in these
establishments is avoidable.” Florence Nightingale, 1863
http://www.uclahealth.org/
13
Safety Has Reached Our Patients’ Journals
http://www.uclahealth.org/
14
Errors Made News In Taiwan Too
United Daily News
2 December 2002
http://www.uclahealth.org/
15
We Discussed Changing The Culture In Which
We Practice
• Vague/slippery concept
– “How we get things done around here”
– Unofficial organizing principles; the way problems are
solved; organizational glue
– We know it when we see it
– It eats strategy for lunch
• But there are some themes
– Corporate self-esteem
– Organizational structures that are important
– How the organization views itself/outside world
– Degrees of autonomy/collaboration, expectations,
hierarchies of decision making
http://www.uclahealth.org/
16
The Heart Of Culture Change In Medical Care
• The idea that medical errors are caused by bad
systems is a transforming concept
• Complex systems have latent errors
– Design of work
– Conditions of work
– Training
– Design and maintenance of equipment
• Must have clear responsibility to make the changes
needed
• Safety must trump personal preferences
• Safety is everyone
