How ICD-10 is like 'Game of Thrones'

Unexpected plot twists are just one commonality
By Mike Miliard
07:21 AM
Nick van Terheyden

A lot has been said about ICD-10 over the years, along the winding and surprise-packed road toward the looming Oct. 1, 2015, compliance date. But few have said much about the code set's parallels with one of HBO's biggest hit shows.

[See also: ICD-10 'storm' posing dilemmas for health information management strategies]

Nick van Terheyden, chief medical information officer at Nuance Communications, is one person who sees the battle to finally transition to those 68,000 clinical codes as having some things in common with the intrigue and power dynamics of the Seven Kingdoms.

On Tuesday, Sept. 30, at the AHIMA Convention and Exhibit, van Terheyden offers a discussion titled, "Game of Documentation: Winter is Coming – Surviving ICD-10."

[See also: ICD-10 cost a 'crushing burden' for docs]

Sure, he admits, part of the rationale behind that title is "getting people excited and interested," making a sometimes rather dry topic more engaging to his audience. But the parallels between the move toward ICD-10 – and the clinical documentation improvement upon which it depends – and George R.R. Martin's fantasy epic are real, says van Terheyden.

"As you look at the series and some of the challenges the characters face, it seemed like there were a lot of similarities between the ICD-10 changes that are being implemented," he tells Healthcare IT News.

"I think people's perception of those challenges relate to Game of Thrones and the battling of those folks against adversity, and the need for creating allies within a world that is constantly changing, constantly dealing with challenges. To me, there was a clear relationship," van Terheyden adds.

When van Terheyden first submitted the idea for his AHIMA presentation, he "expected us to be very close" to the original Oct. 1, 2014 switchover deadline, he says. But thanks to the compliance date pushback that surprisingly found its way into the Sustainable Growth Rate/"doc fix" bill on Capitol Hill this past spring, here we are "a little over a year out again," he says.

Indeed, just as – spoiler alert! – Ned Stark and Oberyn Martell discovered, unexpected plot twists have seemed to play a big part in the ICD-10 journey.

But the overarching theme of this momentous, industry-wide transition, says van Terheyden, is that, "much as you see in the Game of Thrones universe, separately we're not as strong, but together we're stronger."

That's especially true when it comes to clinical documentation improvement, on which van Terheyden will focus during in his presentation. He aims to show how CDI strategies can move beyond merely focusing on compliance and monitoring to make sure clinicians are documenting in a manner that fulfills coding and billing objectives.

"What's happened in many instances is that physicians have been left on the sidelines observing – or being asked to do certain things – and don't necessarily feel engaged," says van Terheyden.

"We're all in this together," he says. Docs must be central participants. "Pulling them into the fold, helping them understand why this is important, helping them (with) the modifications in their behavior to adapt to this new coding system" is key to ICD-10 success.

Thankfully, technology is helping make this much easier, he says.

"The big change that's occurred – and the big positive boost in all this – is natural language processing," says van Terheyden, "or as we term it, clinical language understanding."

Technology such as Nuance's "analyzes the content real-time with the physician's documentation," he says. "One of the things that happens in most CDI processes is the feedback to the clinician occurs sometime – could be hours, could be days, even weeks – later."

But most clinicians, they're on this diminishing logarithmic curve of knowledge: 'If you ask me now, I'll know. If you ask me in a few hours or days, I'm decreasingly likely to know the answer to the question you're asking me. I've got to reactivate all that knowledge and remember.'

By offering "real-time feedback that educates," says van Terheyden, "physicians are getting education at point of documentation – the best form of education you could ask for." Moreover, "it frees up the resources we've got – the very limited CDI specialists and coding specialists – to focus on the more complex cases we have that our technology may not be able to detail," he says.

NLP technology has traditionally been less than ideal – requiring repeated emendation and revision to ensure the spoken word is translated correctly into text. Has the technology evolved in the past few years?

"Oh, it's almost indescribably so much better," says van Terheyden. "One of the great things about this technology is the massive learning curve." In Nuance's case, that's thanks to a cloud-based platform.

"Every time someone uses our technology, it gets uploaded securely in the cloud, we process it and return it," he says. If a clinician enters a note or code erroneously, "we know instantly because if it's wrong somebody doesn't use it, they don't take action on it."

As of now, Nuance is processing "more than a billion transactions per month in the cloud, and we're learning from that interaction," says van Terheyden. "If it's right and you use it, you know that it's right, and if it's not, you either re-dictate or discard it and we input that into the system.

"Our learning curve has really escalated: We're certainly north of about 93 percent accuracy on average, across a number of modalities," he says. That's "helping people on the back-end, that we focus all the high-quality, high-accuracy feedback to the clinician and the evidence suggests that the response rate and the agreement rate is all very high."

Ultimately, van Terheyden says he wants his session to emphasize that "ICD-10 is not a negative implementation. It's a positive. I think we should see it as an improvement in the whole coding and understanding of what we're doing. I think it's a benefit to everybody in the system – patients, coders, physicians alike.

"Importantly," he adds, "you have to work together as a team to deal with it."

Not unlike, perhaps, the brotherhood of Night's Watch, guarding the northern border from White Walkers?