"It's a ton of work, but it's pretty clearly identified what we have to do," he says. "That's different from meaningful use."
There, not only does the health system have to coordinate coding with the electronic health record, but documentation has to evolve so that those standards are auditable.
"That's a job in itself," Fifer says.
Fifer says many of the changes under way at Spectrum Health would have been done eventually, but deadlines are ramping up efforts considerably. He cites the example of problem lists, which is one of the standards for achieving meaningful use designation.
For example, "what that means is in the EMR, that problem list is populated by physicians. It's as simple as that."
Simple, but not easy, because it involves significant culture change among physicians.
"The idea is spot-on, and this has happened informally for years with physician talking to physician, but it's not been documented. We're changing culture with that, and that's difficult."
Further, the standards mean the organization has to develop an audit trail so that when an investigator makes Spectrum Health prove that it complied with the standards, "we have a document we can pull out," says Fifer. "That audit trail process is a real challenge and time consuming."
Spectrum Health has developed scorecards that show leaders where it stands on achieving standards on both the hospital and physician sides. But the work has to take place physician by physician and practice by practice. And while the investment will pay off in the sense that meaningful use targets will be achieved and incentive payments will come from the government, Fifer says it's difficult to truly isolate the investment and whether it will pay off.
He says work on VBP standards is even more challenging because it is less specific than the other two.
"Most of the VBP criteria we really already are working on," he says. "In tracking our numbers and where we're close or short of the thresholds, we pay attention, but don't have to develop extra infrastructure to comply."
Regarding value-based purchasing, CHI's approach is strategic, says Rowan.
"As we look at the handoffs surrounding improving care, the idea is that when a patient has a problem, they don't experience four to five discrete events in our system," he says.
For instance, a patient might see a physician. Then, the patient might come in to the hospital for testing. Then he or she might be admitted and may need follow-up care and lab work in between.
"We need a clinical person who looks at [the patient] across all five events," he says. "Meaningful use is about that, but when you come in, we shouldn't be scratching our head on what started this whole thing out on the ambulatory side, and we shouldn't have to do expensive things like taking new imaging."
While larger systems like CHI and Spectrum rely on developing or hiring internal expertise on the big three, at Baptist Health System in Birmingham, AL, a smaller system with four hospitals, the compliance push is using outside as well as internal resources, says Alan Bradford, Baptist's chief human resources officer.
"On the revenue side all the VBP formulas continue to be refined. If you miss any of that detail, you're really going to cripple yourself on your revenue, so we've leaned on internal and external resources to make sure we fully understand our obligations," he says.
Of the three, ICD-10 might be the easiest to understand, at least procedurally, but that doesn't make compliance any less challenging.
"We have a pretty detailed plan, and each component has its own milestones," Bradford says. "We're on target with ICD-10 because we have an education and training component for both the clinician and revenue cycle team."
Baptist is also working on training what Bradford calls super-users on the IT side who can help clinicians and revenue cycle team members reconcile errors.
Further, Bradford says he doesn't see a future need for additional coders to handle the complexity involved in ICD-10 compliance, but he says the organization will probably have to reorganize its coding staff to include more specialized coding competencies that reside within a few people as opposed generalists who can operate in any clinical theater.
Fifer, of Spectrum Health, does see additional costs from the conversion.
"ICD-10 absolutely affects labor costs," he says.
He says he's seen high estimates of what ICD-10 implementation will cost from other organizations that range as high as $30 million–$40 million.
"That seems high, and it all really comes down to what you count. But when we went through budgeting—and we're pretty conservative—the request was to spend an additional $4 million annually on infrastructure to deliver ICD-10 results," Fifer says.
Spectrum Health pared that back significantly by redeploying people within the organization as opposed to hiring consultants, but the transition costs will still be $1 million annually, and that's without tracking time spent on retraining.
"What we don't know is what ICD-10 will do to coding productivity," he says.
What will mitigate those investments is a likely increase in productivity from computer-assisted coding. At least Fifer's hoping so.
"Absent that, I would expect a decrease in productivity by 30%–50%, and I don't know if I could find that many coders in the future."
Janice Jacobs, a director with IMA Consulting of Chadds Ford, PA, says she thinks labor costs associated with coding will increase permanently.
"Coders' methodology is changing dramatically and it requires more time to assign codes, so even after the learning curve is over and they're recertified, they only regain about 85% of initial productivity," she says. "On the other hand, we will be talking about computer-assisted coding more and more. This will not eliminate the coder, but will move them into an audit role and may alleviate some of the loss in productivity."