Physicians have seen the computerization of health care in our lifetimes. Undoubtedly, computers and other medical technology have improved the quality of health care tremendously. However, some aspects of this computerization have been stumbling blocks rather than aids to physicians and their patients. In this article, I describe some of the “curses” that have resulted from the codification of health care. I also describe an information system developed for the orthopaedic surgeons at Baylor University Medical Center (BUMC) that seeks to correct some of the limitations of administrative data and offers an opportunity to improve patient care and our individual practices. This story is a personal one. Before I went to medical school, I used my English and engineering degree to sell computer systems for IBM. Back in the 1950s, the systems were basically punch card applications, although soon afterward tape-based systems and sequential processing were developed. In my sales pitch, I stressed how, for the first time, data could be entered once, verified, and then never entered again. The computer systems were so expensive that only the largest companies could afford to rent the equipment (the equipment was never sold in those days). After a stint in the US Army, I attended medical school. As a young physician in the late 1960s, I entered notes on my bills such as “fractured tibia and fracture care.” All diagnoses and procedures were described verbally. Around this time, however, insurers began requiring standardized codes instead of descriptive language on billing information. The first codification system was the Bertillon Classification, or International List of Causes of Death, developed before the turn of the 20th century. It subsequently became known as the International Classification of Diseases (ICD). The World Health Organization updates this list, which is now in its 10th edition. The volume listing the codes is well over 1000 pages long. The American Medical Association published Current Procedural Terminology (CPT) in 1966, drawing on the input of its physician members. The codes are derived from medical specialty nomenclatures. In 1983, the Health Care Financing Administration (HCFA) adopted the CPT code for its Common Procedure Coding System. The fifth edition of CPT codes should be released in fall 2002. HCFA became frustrated with the large number of ICD and CPT codes and developed a limited lexicon of 432 diagnostic-related groups (DRGs) to facilitate reimbursement and case-mix analysis for hospital providers. The number of DRG codes was subsequently expanded. These codes in particular lack the specificity to be of value in clinical research or patient care. Physicians are severely limited in their ability to codify the procedures we do. An extensive process is required to develop a coding change for new procedures and innovative changes. The majority of procedures include a “global period and set of included services” that is automatically included in the “global” charge. Procedures are done on individual patients, however, and the individual variations—e.g., age, associated conditions, previous procedures, altered surgical site, and many others—are difficult, if not impossible, to codify in the limited lexicon. Complications, which are inherent in our profession, are viewed as inferring liability, and the result is underreporting. Complications should, rather, be acknowledged and considered an opportunity to find out what went wrong, allowing us to continue to improve care. The codes for “evaluation and management” services are thought by the profession to be so restrictive that, to date, the rules have not been finalized. Careful evaluation and management is the basis of our profession, in my opinion greatly undervalued, and probably impossible to codify and value except after the fact. How many business managers would tolerate being paid only after reducing their productivity to a limited number of 5-digit codes provided by a third party?
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May 9, 2009
Jeffery Funk 
Open Access