Not so long ago, the health information management department at a hospital was called the "medical records department," and the legal medical record was paper.

But for HIM departments, even those recent times seem as remote as when dinosaurs rampaged across the landscape. The HITECH Act in 2009 put an industry already transforming itself via digitization into hyperdrive, and the act has in turn supported the next seismic wave-the Affordable Care Act.

Electronic health records and other information technologies keep hitting like tidal waves. Providers are preparing to corral their information into a form that will help them contend with millions of newly insured patients. They are learning to adjust to new treatment and payment models that compel wellness-based care delivered through better coordination with reimbursement based on quality and outcomes rather than fee-for-service. Supporting digitization and health reform are such initiatives as ICD-10, new HIPAA "operating rules" to better standardize claims and related electronic transactions, and strengthened privacy and security rules.

In the middle of the fray is the HIM department, responsible for the completion and integrity of the legal medical record. To do that, health information managers now have to understand the myriad information systems pouring into that record, be experts on the languages used to describe the reality of clinical treatments and financial operations, and be central planners of many new enterprise initiatives. Beyond that, they also are called to serve as coaches and confidants to fellow employees trying to navigate their way through the industry transformation.

So it's no real big surprise that "every HIM director is so much busier than they used to be, for sure," says Rachel Chebeleu, director of health information management and professional fee abstraction at the Hospital of the University of Pennsylvania in Philadelphia and a 23-year veteran who's been with the university for 21 of those years.

Wendy Mangin, director of HIM at Good Samaritan Hospital in Vincennes, Ind., has seen all the changes in health information management during a career coming into its fourth decade. Straight out of college, she joined the hospital 39 years ago and has been director for 29 years. "It's been a great challenge and a great ride."

In the past three years, the biggest changes have come from the technology side, Mangin says. The hospital went live with an electronic health records system in 2008 but continues to bring new applications live. And the biggest change in recent years has been implementation of computerized physician order entry, which was rolled out over a six-month period starting in late 2012. "That's really been a game changer for physicians, other hospital staff and HIM," she notes.

Physicians no longer just access data, they also enter it, and the task proved much easier for younger doctors right out of school who are accustomed to entering orders via computers. CPOE started with a select group of hospitalists and in retrospect, Mangin wishes the hospital had done a Big Bang, but didn't have the I.T. resources for it. The hospital's legal medical record has been electronic since 2008 with implementation of the EHR and scanning of such paper documents as consent forms and operative documentation. But some information continues to be printed and put on a paper chart, such as the medical history and physical, because that's what the Joint Commission and other accrediting or regulatory entities want, she adds. "They still want to see it on paper before the patient is taken to surgery."

For Laura Rizzo, a 31-year veteran, the biggest change since 2009 is the need to work much closer with the information technology department because of the push for electronic health records, health information exchange, and ICD-10 implementation. With records increasingly being automated and shared with other providers as well as patients, "we need to make sure we're not taking advantage of technology without appropriate security," says the corporate director of HIM at three-hospital WellSpan Health in York, Pa.

As provider organizations further consolidate, there is a need for a centralized HIM structure that can push standardized policies and procedures across multiple facilities and bring efficiencies of scale. That's one reason that Rizzo and some other HIM directors now are "corporate directors."

At Yale New Haven Health System in New Haven, Conn., coders are the first unit to be centralized within HIM as the organization starts to go live on its Epic electronic health records system by late 2013. But the delivery system also is moving toward supporting remote coders who follow standardized processes. Competition for good coders, especially with ICD-10 on the horizon, is fierce, says Cindy Zak, corporate director of HIM. "As this program grows, I see us being able to hire coders throughout the U.S."

Mangin doesn't view HIM departments elsewhere as competitors, except when it comes to recruiting coders. "It's the best time in the world to hire new graduates because they are coming out of school knowing ICD-10."

Planning, more planning

One reason HIM leaders-and their staff-are busier now is because there are so many initiatives and each of them requires a committee of hospital personnel to plan and execute, with HIM directors sitting at the table more often than in the past. Meaningful use and other HITECH programs, along with reform initiatives, fostered electronic documentation and the need to properly document care for quality reporting purposes.

"I feel like I'm working in a much more global environment because everything will affect the legal medical record," Mangin says. For instance, when new software such as a wound care information system comes in, HIM needs to know if it will link to the electronic legal medical record or how to otherwise get the data. HIM also needs to know what reports from the new system will look like and how to access them, then get them in the record. And Mangin now chairs a steering committee guiding the implementation of a patient portal in 2014, which will result in HIM being more involved individually with patients to educate them on using the portal.

HIM also supports clinical documentation improvement programs that assist providers in documenting more precisely by combing through records to give good examples of proper and improper documentation to the billing compliance and clinical documentation improvement departments, Chebeleu says. With the employer quality advocate Leapfrog Group, Joint Commission, US News and World Report and Medicare's Hospital Compare Web site leading the charge on measuring quality and safety, it also means HIM and quality improvement management staff members know each other a lot better these days, she adds. "We work with the quality department much more now than we ever did."

Competition among hospitals has increased with the proliferation of quality and safety ratings available about hospitals-particularly those of US News and World Report-and the higher profile role HIM plays in supporting those ratings, Chebeleu notes.

Coders are under the spotlight more than ever on how they code because what they code reflects on quality scores. When a coder is reviewing the documentation of a surgeon, for instance, it may not be clear if the intra-operative surgical laceration was accidental or incidental and the coder must track down the physician and get clarification. "We just want to code what really happened to patients," she adds.

HIM staff members also are getting more aggressive in efforts to get physicians to complete their clinical documentation in a timely manner, necessitated by continuing cuts in Medicare reimbursement and uncertainty about how Medicaid expansion will affect revenues. Hospitals that fail to minimize the revenue hit can find themselves in a tight financial situation and need to consider staffing changes or unable to make the capital expenditures they need, Chebeleu notes.

Many hospitals no longer wait to drop many of their bills at the end of the month, but work to have a consistent flow of billing throughout the month to have a more constant and regular cash flow into the organization. That's made timely clinician documentation for billing and quality reviews necessary to the point that Chebeleu herself sends e-mails to recalcitrant physicians or their secretaries to speed things up. "If we can't complete the coding because the physician didn't complete the operative report, that can really hold up a lot of money."

Higher stature

All the new initiatives in recent years have raised the stature of HIM departments, veterans say. Rizzo's position of corporate director of HIM at WellSpan Health reflects a realization that the department needs a higher stature necessary to ensure HIM needs are considered as new technologies come in, and to push through centralization of medical records policies and procedures within a delivery system.

But HIM can still find itself being the last to know about a new initiative. Rizzo, however, has a simple way of fixing that. "Sometimes you have to invite yourself to the table," she advises. "You have to have the initiative to do it. When you hear of things, reach out and say, 'I believe someone from my department should be there.'" The more HIM directors assert themselves at the table, the more they're seen as an integral voice in the process, Rizzo contends. She believes the point has been reached at WellSpan Health where the HIM department is now viewed as an automatic invite to planning sessions.

With HIM leaders becoming more deeply involved in influencing information governance policies, they also find that the teams they work with are changing as technology becomes more pervasive. For instance, communication with the I.T. department used to be related to running reports from HIM information systems.

Now, HIM works closely with the EHR staff, nurse informaticists and other I.T. personnel to ensure information systems support various documentation workflows, present information appropriately in the electronic legal record, and secure information being shared. With so much technology going in, I.T. projects are becoming a way of life, says Cindy Zak of Yale New Haven. And getting complacent can bite you. "Even s small project for staff lacking strong project management skills can be their toughest challenge."

Non-stop

Four years after the hard push for automation of the paper-mired health care industry began, there's still plenty to do. WellSpan Health recently completed implementation of speech recognition software in the transcription unit, and adding computer-assisted coding software starts this fall to aid in ICD-10 optimization. The delivery system has about 80 percent of inpatient records electronic after going live on electronic progress notes, which cut paper considerably.

As more I.T. comes into HIM sphere, so do new challenges. Implementing CPOE is a major initiative that affects many parts of a hospital and the department isn't immune to the impact, particularly to a facility with an electronic legal medical record.

The orders look different inside the electronic record post-discharge than they do during patients' hospitalizations in the ordering application and take some getting used to, says Mangin at Good Samaritan Hospital. Some physicians struggle with figuring out where to sign the orders and question how HIM could be sure that the orders being presented were their orders. These questions also arose in a paper world, so working closely with nursing staff is still needed to resolve issues.

But software that enables HIM staff to enter a documentation deficiency for a physician and for the physician to securely access from any location a chart that needs completion has dramatically declined the hospital's rate of delinquent charts, to 5 percent from about 25 percent. And the electronic legal record can generate a report at discharge showing physicians all of their unsigned orders requiring just one electronic signature versus signing multiple individual orders.

Electronic charting is live in the emergency department at Good Samaritan after a rollout that started in early 2013, but only a quarter of physicians use it, although all nurse documentation is electronic. The ED physicians continue to work with the vendor to improve the workflow and speed of charting. The rollout has been challenging for HIM because of the multiple ways physicians are charting-some in the EHR, some dictating and others using a paper check-off sheet.

In the HIT era, HIM departments need to elevate their game, Zak contends. With ICD-10 codes, hospitals will have to show through the diagnosis code that treatment was medically necessary-it has to be a more precise and accurate coding effort, or organizations are certain to see their payment denials going up post-discharge.

As responsibilities continue to expand and the jobs become more complex, HIM staff will be forced to earn more advanced degrees to qualify for leadership positions, Zak believes. Right now, an associate's degree is enough for working with an enterprise master patient index and coding, but the time is coming when bachelor's degrees will be required. And the HIM workforce will require much more expertise in such areas as information governance and integrity to handle high-value data. "We already prefer a master's for higher positions," she adds. But HIM departments won't need as many supervisors in the near future, she predicts, as management will use dashboards to track productivity and mistake levels. "HIM is life-long learning and we need to step it up and never stop learning."

Zak earned a project management certification while working as a consultant for 11 years. Coupled with a graduate degree, the certificate helped her develop skills that have proved invaluable since she returned to the HIM environment.

Zak is overseeing ICD-10 implementation across Good Samaritan, which means she needs not just management but emotional or "soft" skills as she engages and works with stakeholders to implement changes ahead. She's learned over time that project management isn't only about getting things done, but about change control, shareholder involvement, risk control and testing.

The View From AHIMA

Lynne Thomas Gordon served in health information management departments for 14 years, went into consulting and later served as associate vice president for hospital operations and director of the Children's Hospital at Rush University Medical Center in Chicago. Now, she leads the American Health Information Management Association and says HIM duties are becoming so specialized-with more than 60 distinct jobs-that the association encourages members to pursue credentials for certain skills, such as privacy and security compliance, as well as advanced degrees in informatics.

The single biggest change in HIM during the past several years has been the influx of information technology, Gordon says. "It's impacting everything and how work gets done. Everyone's being impacted by technology and it's just growing faster and faster."

Consequently, HIM leaders are becoming the go-to person on matters of information governance. Today, inpatient and ambulatory electronic health records are supporting data analytics and health information exchange (HIE) because of the data they hold. But the time is coming, Gordon believes, when the electronic legal medical record will support those activities because it contains information from so many systems.

But for now, HIE capability is lacking in health information management departments because of money issues, competing priorities such as ICD-10, privacy and security considerations, technical issues and the accuracy of patient data. There remain plenty of information governance issues to be resolved, Gordon says. For instance, how medications are abbreviated is not standardized. "What we're telling members is that we need to make sure we can compare apples to apples," she adds. "It's really hard to share data if everyone is not calling something by the same name."

While Gordon believes health information exchange is the next major hurdle for HIM, it's going to have to wait until the ICD-10 conversion is done. "But we have to turn information into knowledge," she says.

This story originally appeared in Health Data Management magazine. Published with permission.

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