Implementation of ICD-10-CA and CCI in Canada

Lori Moskal, CCHRA (c)

Introduction

The Canadian implementation of The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) and The Canadian Classification of Health Interventions (CCI) began in 2001 with five provinces and one territory. In 2002, Canada's two most populated provinces moved to adopt the new classifications, and it is anticipated that by 2006, all 10 provinces and 3 territories will have adopted the new classifications. As Canada is a bilingual country, ICD-10-CA and CCI are produced in both official languages, English and French.

Background

Since 1979, a variety of medical classification standards have been used to collect national and provincial statistics on death, illness, surgical procedures, and treatments. More recently, the two classification standards in use were ICD-9, with its companion surgical classification The Canadian Classification of Diagnostic, Therapeutic and Surgical Procedures (CCP) and ICD-9-CM. In December 1995, the Conference of Deputy Ministers of Health and Chief Statistician of Canada approved the recommendations to adopt the newly published International Statistical Classification of Diseases and Health Related Problems-Tenth Revision (ICD-10) and a revised or new CCP. For the purposes of morbidity data collection, Canada produced a clinical modification to ICD-10 the ICD-10-CA and a new classification tool for interventions the CCI.

Methods

The education program is composed of four modules. It was designed to deliver as much information as possible with a minimal disruption to work priorities. The provinces did not want their coders to be away from their desks for more than two days, considering that a backlog already existed in many sites. The four modules are:

• Self-learning package that contains a comparison of ICD-9 and ICD-9-CM to ICD-10-CA; explanation of the generic structure and concepts used in CCI; and a brief introduction to using electronic reference material. The new classifications are distributed in electronic format only.
• Two-day workshop that takes place in a computer lab where each participant is seated at their own computer;
• Online case studies for further practice following the attendance at the workshop
• Optional one-day refresher that is offered six months following the computer lab

History

Two key challenges are:

• Natural resistance to change
• Shortage of health record professionals

The typical health record professional in Canada is female, 40-50 years old, and has been in the profession for 20 years or more. A good portion of the coding is done quickly and well, but is also done by memory. As the classifications have been relatively stable for many years, switching to new classifications means that coding staff must forget all those memorized codes. We found that many people had become unfamiliar with the alphabetical index and had to be re-taught how to find codes. Also, switching to an electronic medium created angst among coders. Many coders in Canada were familiar with abstracting software, but had not had much exposure to a Windows-based product. They were also not very comfortable using software to find codes, and some had not used a mouse prior to the initial phases of implementation.

Several provinces indicated that they experienced difficulty in filling job vacancies due to a shortage of health record professionals in Canada. Staffing coverage for vacation and sick relief is an ongoing problem, so that in many facilities a backlog of coding existed prior to the introduction of the new classifications.

Trends

The implementation of ICD-10-CA/CCI in an electronic environment is a major commitment of time, energy, and resources and, an ongoing process.

Productivity levels following the implementation of the classifications were impacted. The specific time line to return to pre-ICD-10-CA and CCI productivity levels varied from one institution to another but averaged six months overall. Health record professionals were tasked with learning new classifications, new software, and a new abstract. We did find that coders familiar with Windows products made the transition quicker than those who were less comfortable in the electronic medium.

In an effort to maintain comparability during the implementation period, the Canadian Institute for Health Information (CIHI) developed a modified ICD-9 based grouper (using ICD-10-CA and CCI conversions). This grouper will be in use until 2006 when an ICD-10-CA and CCI data-based grouping methodology is available. The phased introduction of ICD-10-CA and CCI is having a significant impact on Canada's ability to provide comparable data from year to year and across jurisdictions. Analysis of this impact has identified five major factors contributing to the difficulty in the interpretation of data grouped using the modified ICD-9 based grouper. These include:

• Structure of new classifications in comparison to predecessor classifications
• Coding rule/standard change
• Conversion process issues
• Coding or conversion errors
• No identifiable rationale for variations in the case volumes and expected lengths of stay. There were a number of Case Mix Groups (CMG(TM)) where the types of cases within a group remained relatively stable and it was only the volumes and lengths of stay that significantly changed.

Discussion

The many benefits to adopting the new classifications outweigh the challenges of implementation.

1. Canada now has a single set of classification standards. Historically, a variety of classifications had been in use, which presented obstacles in compiling national databases and conducting interprovincial comparisons. A single set of standards eliminates these obstacles and reduces the inefficient resources spent on supporting two sets of standards. The same classifications are used for all inpatient and hospital based ambulatory care.
2. Ongoing maintenance and updating. ICD-10-CA and CCI are expandable, dynamic, comprehensive and clinically relevant, as CIHI has established a regular updating cycle for the classifications. Maintenance and enhancements are based on input from the following sources:
   • WHO modifications to ICD-10
   • Coding Query Service
   • Special interest groups
   • Review of other international classifications
     (for example, ICD-10-AM, ICD-10-CM)
   • Public submissions
3. ICD-10-CA and CCI have a more comprehensive scope. ICD-10-CA moves well beyond the traditional causes of death and hospital admission. The expansion of content and specificity to conditions and situations that are not diseases are particularly relevant for use of the classification outside the hospital setting. The CCP, originally developed in the 1970's, was designed primarily for use in the acute, inpatient setting. Its scope was heavily weighted toward surgical procedures. CCI was developed to provide a classification that would capture the activities and services of the whole health-care system in Canada. It endeavors to provide a comprehensive range of interventions and has codes for everything from specific immunizations to heart-lung transplants. CCI has more than 17,000 codes as compared with approximately 3,500 in CCP.
4. International comparability. As a member state of WHO, Canada is governed by its nomenclature regulations, which make ICD-10 the international standard for reporting of illness and death. Statistics Canada began using ICD-10 to report mortality statistics in 2000. The adoption of ICD-10-CA for morbidity applications has Canada in sync with other countries around the world.
5. More effective structure and presentation. Structural changes introduced in ICD-10-CA contribute to its effectiveness. The alphanumeric structure more than doubles the number of available codes. CCI's structure uses a prefix to define broad types of interventions. This prefix is part of the intervention and allows the user to identify the type of intervention (e.g. therapeutic, diagnostic, obstetrical) at a glance. The "built-in" hierarchic structure allows data aggregation and analysis to an extent that was not easily done with the previous classifications.

Strategies

There are several critical success factors to the implementation of new classifications:

1. A comprehensive plan
• Provincial, regional, or local committees were struck that involved key stakeholders in the process either in an advisory or a task based capacity. Roles were defined and objectives established.
• A provincial leader/project coordinator or team oversaw the whole plan.
• An environmental assessment or scan was done.
• Needs were identified along with the resource requirements.
• Funding responsibility and source of these resources was identified.
• Monitoring processes were established.
2. Commitment to the project
• A broad range of industry sector stakeholders were involved--all levels of government and their agencies, professional associations, colleges and universities, healthcare facilities (management, service providers, support), vendors both computer (hardware/software) and CIHI
• Every level of stakeholder, from the CEO to the front-line, was engaged in the process at some time
3. Communication, communication, communication
• Every venue of communication needs to be employed.
• It is critical to keep all stakeholders, in the various loops, informed at all times with frequent written updates on progress, next steps, issue identification and resolution.
• It is important to touch base on a regular basis to ensure all feel supported in the process. Asking "How's it going" to anyone and everyone along the implementation line builds trust and support and, is often the first avenue for flagging issues that may impact on the successful completion of the project.
4. Computer readiness: hardware, software, and computer literacy of end users
• A detailed evaluation and plan for this aspect of the project is fundamental.
• Together with the vendor, define target dates for all deliverables and check in frequently to see if they are on target. Build contingencies into your plan. Unexpected glitches in making the transition to any new hardware or software are rarely an exception.
• Facilities with a high degree of computer literacy in the end-users, prior to the change, felt the transition was smoother. The learning curve wasn't as steep, and the return to normal coding volumes was achieved in less time.
5. Education targeted to the needs of each stakeholder--presentations, access to materials, workshops
   Key target audiences in this process were:
• Industry leaders and decision makers to achieve buy-in and support for this major undertaking in various sectors
• Hospital-based physicians to facilitate buy-in, changes in documentation and broad support
• Vendors of abstraction software to facilitate transition to a new standard and address internal needs
• Health record administrators and respective associations and colleges to achieve full integration of these new standards into coding practices
6. Successful tool
• CIHI products included the Implementation Tool Kit, the Self-Learning Package (SLP), the two-day Basic workshop, bulletins and fact sheets
• Development of provincial trainers/resource personnel--CIHI staff trained provincial representatives in each province/territory who later assisted CIHI staff in each two-day workshop
7. Ongoing support
• CIHI has an online coding query service that was established in June 2001 in time for the first provinces adopting the new classification
• Refresher courses, and continuing education are offered in all jurisdictions
• "What's New?" teleconferences held with the release of updated versions of the classification

Results

Overall, health record professionals in Canada would not go back to the previous classifications. ICD-10-CA and CCI have been described as "interesting, exciting, and fun."

Conclusion

The adoption of ICD-10-CA and CCI provides Canadians with a data source that is comparable across jurisdictions and reflective of current clinical knowledge and practices in Canada.

The release of the ICD-10-CA/CCI-based grouping methodology in April 2006, should allow decision makers and researchers to take full advantage of the increased diagnostic and procedural specificity in the new classification systems.

References

Renahan, Mea, Heick, Caroline, Moskal, Lori. "Impact of ICD-10-CA and CCI on Interim Grouping Methodologies in Canada" presented at WHO-FIC meeting in Cologne, Germany, October 2003

Renahan, Mea. "Implementation of ICD-10-CA/CCI in Canada: A Continuous Journey." July 2002.

Moskal, Lori, "The Implementation of New Morbidity Classifications in Canada" published in the Health Information Management Journal , a publication of the Health Information Management Association of Australia, March 2002.

Canadian Institute for Health Information. CCICD-10 Canada-Implementation Tool Kit - CIHI 1999.