Lessons Learned from Experiences in Thailand on: ICD Morbidity Use Cases Chamaree Chuapetcharasopon, MD chamareec@gmail.com
HOW GOOD THE DOCTORS ARE AT ICD 10??
Myths? We should not let doctors code ICD 10 because They will not do it. They will not do it right. They are too busy to do it.. How good the doctors are at ICD 10 if we let them use it?
Bumrungrad International: Lesson Learned
Bumrungrad International: Lesson Learned Founded in 1980; now public company. 500 Beds Tertiary Care Private Hospital 300 Full Time Physicians 900 Part Time Physicians 900 registered nurses, 4700 employees 3000+ OPD cases /Day 1 millions OPD visits 400,000 were international patients. Stage 3 EMR adoption model (HIMSS USA) EMR using scanned document and electronic clinical note, flow sheet, CDSS (Error prescription checking)
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Bumrungrad International: Lesson Learned Situations: Coders responsible for IPD cases. Not enough coders for OPD documents. Doctors key in diagnosis before charging fee. Doctors do not give reasonable diagnosis on the electronic form(using F/U, ). Difficult to get statistics of diseases from Outpatient clinic (scanned documents) which is important for business planning.
Bumrungrad International: Lesson Learned Decision: Doctors must select ICD 10 before doctor s fee can be charged. Current EMR can support ICD and No license for SNOMED CT to use with the current EMR Doctors still need to give clinical diagnosis on the OPD clinical record. How to get there?
Bumrungrad International: Lesson Learned Buy in the executives, physician s champions. Start from small area to enterprise. Prepare ICD 10 list for each specialty and subspecialty (with the help from physician s champions) Provide list of commonly used ICD 10 for each specialty both hard copy for each OPD room/ specialty and online. 24 hours support by medical informatics physician and coders using mobile device.
Example of the list
Internal communication Doctor s request form
Bumrungrad International: Lesson Learned After implementation (2008-2009) Audit OPD clinical record and EMR each month by medical record department. Medical record department regularly report problems found to medical record committee (Physician committee) as part of monthly meeting. Medical record committee selects major problems found to report to medical staff organization meeting. Re-educated the physicians for the errors found.
Bumrungrad International: Lesson Learned Report problems as Incompleteness cases Divided into 6 categories Wrong principal diagnosis coding/no principal diagnosis coding Wrong Comorbidity coding Incomplete coding Use ICD 10 for diagnosis(in OPD clinical record) No external cause coding Not clear diagnosis/no diagnosis
Coding Audit Summary Monthly Average 2009 2010 Total Doctors that have OPD visits Total Doctors including in coding audit 643 643 529 509 Total Sampling (cases) 3,619 2,151 % of Sampling 4% 3% Complete cases 2,957 1,818 % of Completeness 81.7% 84.5% Incomplete cases 662 333 % of Incomplete 18.3% 15.5%
Wrong principal diagnosis coding/no principal diagnosis coding found By evidence 2009 2010 % Error of Audit cases (n=3619) By evidence % Error of Audit cases (n=2151) 303 8.4 130 6.0 Wrong Comorbidity coding 18 0.5 8 0.4 Incomplete coding 230 6.4 125 5.8 Use ICD 10 for diagnosis 30 0.8 17 0.8 No external cause coding 56 1.5 38 1.8 Not clear diagnosis/no diagnosis Categories of Incompleteness 84 2.3 34 1.6 Note: Some cases have more than 2 Categories of Incompleteness
Bumrungrad International: Lesson Learned Reasons for errors Not carefully check the ICD 10 before selection Not aware of or not have enough knowledge such as external cause especially trauma cases or comorbidity Remember the ICD 10 by heart but mistyped ICD 10 search engine is difficult and confusing, not users friendly/error prone for users.
Using G11 instead of G80.9
Pharyngitis A50.0 Early Congenital Syphilis J02 Pharyngitis
Bumrungrad International: Lesson Learned What do we do to improve? Inform the errors to doctors (group and individual) Re-Training Implement Electronic Clinical Note with Clinical Decision Support System Communicate with EMR vendor for better search engine Using other user friendly search engine
Bumrungrad International: Lesson Learned Conclusion Doctors are capable of using the ICD 10. Key success factors Leadership Physician s champions Start with small group Training and education 24 hours support team Feed back process/ communication Good/user friendly EMR software with CDDS
Contrast Media in Cardiac CT Imaging