Updated on: November 19, 2014

Inoculate Your Emergency Department Staff Against ICD-10 Stress Syndrome

By Herman M. Fountain, MD, MBA, CPE
Original story posted on: November 10, 2014

According to the most recent statistics from the Centers for Disease Control and Prevention (CDC), there were 129.8 million visits to emergency departments across America last year. Almost 38 million were injury-related and 13.3 percent of those seeking treatment were admitted. To put that into perspective, during that same reporting period, the total population of the U.S. was roughly 308 million, meaning that the equivalent of 41 percent of the population visited the emergency room. 

The drama inside emergency rooms as depicted on popular television shows doesn’t correlate to what really happens. While there are many life-threatening cases involving heart attacks and traumatic injuries or poisonings, there are also a lot of colds, flus, and insect bites. It’s no surprise that emergency departments have become a default source of care for populations without access to primary care, and that high rates of repeat patient visits to emergency departments and readmissions are straining the resources in our healthcare delivery system. Many of these patients are over 65 and suffer from multiple chronic conditions.

Emergency department physicians and their allied clinical staff must balance the competing demands of treatment and documentation. Documentation has long been a challenge for all physicians, and a recent study I discussed during a Sept. 30 ICD-10monitor webinar is a cautionary tale. This retrospective study of four million patients conducted by Humedica concluded that as many of 40 percent had significant comorbidities that were uncoded. These uncoded patients were chronic users of emergency department resources. Once these patients were appropriately identified and documented, their consumption of emergency department resources began to shift as they gravitated toward the more appropriate ambulatory setting, where, with proper focus and treatment, their chronic conditions such as hypertension and diabetes showed steady and sustained improvement. And this is in an ICD-9 world! 

But instead of analyzing the patient population of the emergency room, perhaps we need to more closely examine the health of providers themselves, whether they are practicing in the emergency department or in an ambulatory setting.

Recent research published in the Archives of Internal Medicine sought to explore the rates of job burnout among a large national sample of U.S. physicians in 20 different specialties compared with U.S. workers in other professions. Questionnaires were sent to more than 27,000 practicing physicians, netting a 26.7 percent response rate. Those conducting the survey found that physicians tend to experience burnout at far greater rates than many other professions, and front-line providers suffer the highest levels of burnout. In fact, two-thirds of all emergency department physicians studied claimed to suffer this. A probability-based sample of 3,442 working U.S. adults showed they experienced levels of burnout at a 28.7-percent level.

One root cause of physician burnout is dealing with healthcare regulations such as meaningful use, IPPS, value-based Purchasing, and others. And now there’s ICD-10, which many are calling the “Y2K of healthcare.” ICD-10 introduces so many new concepts that physicians and their allied clinical support teams, especially inside the emergency room, likely will begin to experience symptoms of anxiety and frustration that my colleagues at ICDLogic call “ICD-10 Stress Syndrome.” That frustration will increase as they are taken away from patients and subjected to endless hours of webinars and ICD-10 training videos. Anxiety will mount in levels proportionate to the number of additional coding queries they must answer.

Most administrators wrongly assume that these webinars and videos are sufficient education. But they are not considering the degradation of information that occurs after the physician is exposed to the learning stimulus. While all individuals vary in their ability to learn and retain information, a leading German researcher once proved that “forgetting curves” are nearly identical. On average, within 24 hours, students forget nearly 70 percent of what they are taught. So why do we think physicians will remember what they are taught about the complexities of ICD-10?

Many administrators and practice managers wrongly assume that electronic health record (EHR) and practice management system vendors will supply ICD-10 solutions that will be easy for clinicians to navigate. After looking at some of the larger vendor approaches to ICD-10, I think that faith is misplaced. Of the dozen or so EHR and PM systems that we at ICDLogic have studied, all provide the physician with a long, scrolling pick list of options. Many had varying degrees of filters that helped with longer option lists, but none provided the kind of guidance needed to understand new coding definitions and terms that are introduced in ICD-10. EHR and PM companies do not have core competencies in documentation, so we should not assume that their ICD-10 solutions provide sound documentation guidance. Generating the right code, however, is only half the battle. A physician also must have dictated or written notes that support the code assignments.

In the last few months a number of computer-assisted clinical documentation improvement (CACDI) learning and workflow tools have been introduced to help with ICD-10. Many, like ICDLogic’s Cypher, help physicians learn ICD-10 while generating and supporting code assignments in ICD-9.

It’s time to ditch the codebooks and laminated cards. And it’s also time to reassess the return on investment that hospitals and private practices get from boot camps, seminars and video training. Give clinicians tools they can use currently with care in the emergency room or in any other care setting. 

It’s time to accept a 21st-century code set and teach clinicians how to harness its power with 21stcentury automated workflow and teaching tools.

About the Author

Herman M. Fountain, MD, MBA, CPE has more than 35 years of clinical and management experience in Emergency Medicine at large urban hospitals in Miami and California. Most recently he was Medical Director of a Federally Qualified Health Clinic in Florida. His interests are diversified and include Medical Management, QA/UR and the use of Health Care IT to provide physicians with efficient coding and billing solutions that enhance productivity and competitive value.

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