h.i.m. in the age of e.h.r. joseph ng, md chief medical information officer at john t. mather...

H.I.M. IN THE AGE OF E.H.R.

JOSEPH NG, MD

CHIEF MEDICAL INFORMATION OFFICER AT JOHN T. MATHER MEMORIAL HOSPITAL

CRITICAL CARE INTENSIVIST

PROGRAM DIRECTOR, TRANSITIONAL YEAR RESIDENCY

INTRODUCTION

• EHRs are reshaping the work of healthcare professionals

• Improving healthcare delivery

• Enabling payment reform

• Huge effect on HIM professionals

• New day to day demands

INTRODUCTION

• Accelerated change in the HIM environment

• Physical records are being phased out

• More stringent regulatory directives

• Multiple versions of the medical record

• Multiple pieces of the record in multiple systems

• Analyst, I.T. specialist, and HIM professional all-in-one

INTRODUCTION

• Envision and develop new opportunities

• Engage and drive change

• Redefine the role of HIM professional

STATE OF ELECTRONIC HEALTH RECORDS (EHR)

• EHR adaptation is at all time high

• 59% (6 out of 10)

• 5 fold increase compared to 2008

• Increase of 34% in 2013 compared to 2012

INFORMATION EXCHANGE

• 41% of Hospitals are able to SEND and RECEIVE secure electronic messages containing PHI

• Printing out records

• Faxing

• Mailing

OFFICE OF THE NATIONAL COORDINATOR (ONC)

HITECH WORKFORCE DEVELOPMENT PROGRAM

• The HITECH Act authorized ONC to establish the Community College

Consortia to Educate Health IT Professionals Program.

GOVERNMENT IS COMMITTED

• Meaningful use payouts

• March 2014, $22.9 Billion dollars

• $14.3 billion to eligible hospitals

• $8.6 billion to eligible providers

• March 27, 2015 – EPCS rollout in NYS and Ohio

E-PRESCRIBING

E-PRESCRIBING

• I-STOP

• EPCS – Electronic Prescribing of Controlled Substances

• Starts March 2015 for NYS and Ohio

• Needs 2 factor authentication for controlled substances

HUGE AMOUNTS OF TRAINING NEEDED FOR USERS

WHAT DOES THIS MEAN FOR THE HIM PROFESSIONAL???

ENTERPRISE INFORMATION MANAGEMENT GOVERNANCE IS CRITICAL

CURRENT STATE

• EHRs are rapidly replacing paper records

• Volume and sources of data is overwhelming the information management capacity of most healthcare organizations

• What is your source of truth as a legal record when information is coming from all systems

• What is your institution’s policy to aggregate all this information?

• Who is the final manager of all this information? Who releases the information?

CURRENT STATE

• HIM manage health records

• Departments would manage their piece of information

• Problematic

• Difficult to integrate all these pieces of information

• Impossible to piece together patient course

• Hinders an organization’s ability to implement, oversee, and enforce standardization

• Data is being managed to varying levels of completeness, quality and accessability

CURRENT STATE

• LIJ – So many facilities – So many workflows – So many levels of usage

• Physician Documentation is at varying levels of usage

• Paper in chart, dictation

• Medication Reconciliation

• CHSLI – Same problems

• Consults are not on EHR

• Trickle down from Good Samaritan to St. Charles may take years

CURRENT STATE

• Mather – Community Hospital, Stand alone

• Competing priorities – Limited staff resources

• Multiple systems trying to communicate with each other

PROBLEMS

• Increasing cost due to inefficient storage practices

• IT cost to manage dozens of applications

• Exposure to preventable risk

• Unauthorized access

• Lack of trust hinders effective use

• Multiple versions of chart (some updated, other not)

• Question of accuracy

FUTURE STATE

• Information is managed as a strategic asset

• Correctly aggregated information can increase the bottom line

• Value Based Purchasing

• Prevent loss of capital due to law suits

• Governance is integral

• How information is managed needs to be clear

• Adds value to the information obtained

• Improves decision making capabilites

• Information Management needs to be an enterprise-wide function

• Everyone on the organization must “Buy-In”

THE ENTERPRISE MODEL FOR INFORMATION GOVERNANCE

Information Governance

Design and Capture

DESIGN AND CAPTURE FUNCTIONS

• Beginning of the Information Management Life Cycle

• Architecture

• Content Definitions

• Standards

• Reference Terminologies

• Mechanisms that improve efficiency and quality of data collection, downstream information use, interoperability and reuse

• Ideally data should be captured once and used for a variety of purposes

THE ENTERPRISE MODEL FOR INFORMATION GOVERNANCE

Information Governance

Design and Capture

Access and Use

INFORMATION ACCESS AND USE FUNCTIONS• Advances and supports critical data use

• Support to:

• Clinical and business process owners

• Patient access to health information

• HIM role

• Educate users about data characteristics

• Reliability and accuracy

• Collaboration to build trust in data for population health management, community, and public health

THE ENTERPRISE MODEL FOR INFORMATION GOVERNANCE

Information Governance

Design and Capture

Access and Use

Life Cycle Management

LIFE CYCLE MANAGEMENT FUNCTIONS

• Defines and maintain designated record sets

• Legal health records and other types of records

• For:

• Business needs of the organization

• Legal and regulatory requirements

• Management of plans and processes

• Storage

• Retention

• Disposition of medical and business records

THE ENTERPRISE MODEL FOR INFORMATION GOVERNANCE

Information Governance

Design and Capture

Access and Use

Life Cycle Management

Privacy, Confidentiality, and Security

PRIVACY, CONFIDENTIALITY, AND SECURITY FUNCTIONS

• Protect PHI

• Information is only available to authorized persons

• For Authorized purposes

• Risk assessment and audits

• HIPAA compliance

• Complicated by expansion of users

• Expansion of access points

• Mobile

THE ENTERPRISE MODEL FOR INFORMATION GOVERNANCE

Information Governance

Design and Capture

Access and Use

Life Cycle Management

Privacy, Confidentiality, and Security

Integrity and Quality

INFORMATION INTEGRITY AND DATA QUALITY FUNCTIONS

• Data needs to be:

• Accurate

• Reliable

• Up-To-Date

• Consistent

• Fit for use

INFORMATION INTEGRITY

• Begins with data architecture, definitions and relationships

• How is data compiled and sorted?

• Legal record? Define it…

• How does the paper in the chart combine with the data in the EHR to form the legal record?

• Provenance or lineage of data

• Processes for error correction and amendments

• Analysis of medical record for completeness – this process now needs to be redesigned for real-time, electronic systems

• Signing orders both in HIM system and EMR

EXCELLENCE IN HIM – NEEDS TO:

• View information as an asset that must be deliberately managed

• Encompass patient records and other clinical and business data

• Implement and continuously improve on the component functions reflected in the model

• Encompass the life cycle of information and records

• Be guided by effective governance and stewardship focused on “getting it right”

• Measureable and sustainable improvement over time

•Forward thinking HIM leaders understand the need to transition from traditional HIM to an enterprise view of

information

ERRORS

• HIM leaders have been left out of critical decisions such as EHR selection

• Find workarounds for information and records management shortcomings

• Unique understanding

• Information contents and records

• Information flow

• User needs

• Compliance

BLURRING OF THE LINES

• Joining of I.T. / I.S. / H.I.M.

• Need to understand the basics of:

• How the information is stored

• How it is retrieved

• What technical processes occur in the background to obtain the output

• Example: Siemens E-HIM/Soarian AND Allscripts

• EMR Data Aggregation into report Integration into the HIM system

• When information is updated – versioning – When does that occur?

• Out of sync with patient’s course – Have to wait until patient is discharged

COMPETITION

• Priorities

• Transition to ICD-10

• Demonstrating meaningful use

• Strengthening privacy and security

• Budget constraints

• All hinder progress the Holy Grail of Enterprise Information Management

• Solution: Outsource resource heavy low-value functions so that you can “Keep your eye on the ball” and shift staff to new roles for higher-value work

MAKE YOUR INSTITUTION SUCCESSFUL AT INFORMATION MANAGEMENT

• Break from paper

• Outsource records storage

• Production functions

• Transactional work

• Make a case for electronic information management

• Understand the state of information and records management across your institution

• Organize for governance

• Extend support for appropriate governance

• Collaborate

• Measure results

• Cost savings

• Operational improvement

• Risk reduction

• Educate

• Enterprise information management needs to be built and improved over time

• Raise awareness

• Explain how everyone is involved to improve and reach the goal

HOW DO YOU LEVERAGE HIM SKILLS?

• Unique and valuable skill set

• Assume managerial and subject matter expert roles

• Realize that you all have the knowledge for theses roles already

• They rest on foundational HIM competencies

• However to adjust to the changing landscape – further training or even an advanced degree

• Rapid adoption of technology and volume of data have made challenges more complex and costly

• To get support and buy-in from senior leadership, concepts of EIM need to be relayed as organizational goals and translated to dollars saved, performance improved, and risks mitigated

• SELL HIM’s NEW ROLE

EPILOGUE – WHAT ABOUT ELECTRONIC HEALTH RECORD MANAGEMENT (EHRM)?

• Reminder: EHRM requires that HIM be part of the decision-making and planning throughout the entire life-cycle of the EHR

• Lack of involvement will mean hundreds of hours of re-working

• Not only involvement in implementation but in maintenance and even in disposal

• Someone has to know what records to keep from a defunct EMR and for how long

• Make critical decisions about rollout to avoid maintaining a hybrid system

HIM LEADERSHIP – BACK TO GOVERNANCE

• HIM professionals are ideally suited to provide the institution with the leadership to ensure the EHR is optimally managed

• BUT – you need to get involved sooner rather than later!

• HIM professionals, with their training are best suited to make sure standards are consistently applied across various systems

• Maintain information integrity

NEW RESPONSIBILITIES FOR THE HIM PROFESSIONAL

• Patient Portals

• E-mail communications

• Personal Health Records

• Maintenance of scheduling of appointments

NEW RESPONSIBILITIES, NEW BENEFITS

• Charts get completed in a timely manner

• Chart analysis

• Coding

• Able to code from home

• Dynamics of the job

• Availability of charts online

ARE HIM PROFESSIONALS BEING EDGED OUT?

• Hopefully with what I’ve presented to you so far, you can see the growing need for people who possess the expertise in this room

• Not only is the prediction that HIM professionals won’t be needed, wrong

• They are going to be in a much more visible role

• Transformation of the HIM role

QUALITIES NEEDED TO MANAGE THE PAPER RECORD ARE THE SAME REQUIRED TO MANAGE THE EHR

• Attention to detail

• Ability to compare competing data sources and reach conclusions about data accuracy

• Project management

• Categorization of data

• Data reporting

• Evaluating, understanding and interpreting regulatory standards

BLURRING OF THE LINES… RECAP

• HIM will interact and overlap with HIT (health info tech)

• Clinical informatics overlap

• HIM department should have a close and ongoing relationship with HIS department

• Understand each others lingo

• Comprehend complexities of making things happen in each other’s department

• New hires are those that have HIM and HIT experience

HIM ROLES WILL MOVE FROM TASK ORIENTED ROLES AND SKILLS TO:

• Analytical thinking

• Process design

• Project management

• Cross-operational management / leadership

• Change management

• Planning and implementing new systems

• Educating providers and administrators

• Solving strategic and operational problems

• Developing/installing/operating clinical and financial applications related to the medical record

WHAT NEW ROLES ARE AVAILABLE?

• Enterprise Information Management Leadership

• Privacy / Security Officer

• Revenue Cycle Management

• Data Quality and Integrity

• Clinical Vocabulary and Classification

• Compliance and Risk

• Information Policy and Standards

• Records Life Cycle Management

• Information Access and Release

• Health Data Analyst

• Data Dictionary

• Patient Information Advocates

• Health Information Exchange

• What you choose to do depends on your skills and interests

RESOURCES

Transition and Change Management Books

• Lundin, Stephen C., Harry Paul, and John Christensen. Fish! A Remarkable Way to Boost Morale and Improve Results. Hyperion, 2000. (And other Fish! books by the same authors.)

• Johnson, Spencer. Who Moved My Cheese? An Amazing Way to Deal with Change in Your Work and in Your Life. Penguin Putnam, 1998.

• Carnegie, Dale. How to Stop Worrying and Start Living. Pocket, 1990 (revised edition).

• Bridges, William. Managing Transitions: Making the Most of Change. Perseus, 2003.

• Kotter, John, and Dan S. Cohen. The Heart of Change: Real-Life Stories of How People Change Their Organizations. Harvard Business School Press, 2002

RESOURCESE-HIM Practice Guidelines

These standards can be found at www.ahima.org/infocenter/ehim:

• “HIM Practice Transformation”

• “Delving into Computer-assisted Coding”

• “The Strategic Importance of Electronic Health Records Management 

• “Core Data Sets”

• “The Complete Medical Record in a Hybrid EHR Environment”

• “Implementing E-Signatures”

• “E-mail as a Provider-Patient Electronic Communication Medium and Its Impact on the Electronic Health Record“

• “Electronic Document Management as a Component of the Electronic Health Record”

• “Core Data Sets for the Physician Practice Electronic Health Record”

• “Speech Recognition in the Electronic Health Record”

REFERENCES

• Redefining the Role of Healthcare Information Management in the New World of Information Governance; Iron Mountain; Linda Kloss

• Visioning e-HIM: A Process for Imagining—and Anticipating—HIM’s Future; Patty Thierry Sheridan, MBA, RHIA, Michele D’Ambrosio, MBA, RHIA, Kerry Heinecke, RHIA

• Redefining the Role of Health Information Management in the New World of Information Governance; Linda Kloss, 2013

• AHIMA Work Group on Electronic Health Records Management. "The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the EHR". Journal of AHIMA 75, no.9 (October 2004): 80C-E.

• AHIMA e-HIMTM Task Force. "The Strategic Importance of Electronic Health Records Management.“ Journal of AHIMA 75, no.9 (October 2004): 80A-B.