By Mary Butler
Prior to the 2010 signing of the Patient Protection and Affordable Care Act (ACA) by President Obama, nearly anyone who had interacted with the American healthcare system could agree that it was, in many ways, broken. Millions of Americans were uninsured—due to either pre-existing conditions, lack of employer-backed options, or gaps in Medicaid eligibility. Healthcare professionals—from physicians to payers—were also frustrated by the system’s inability to allow them to provide care for patients clearly in need.
But anyone who was paying attention to the news at the time, both before and after implementation of the ACA (also known to many as Obamacare), could see how fearful politicians and the American populace were of such a sweeping overhaul of the system. Everyone was certain “why” reform needed to happen, they were just very scared about “how” it would happen. To explain the “how,” federal officials held town hall events, unleashed healthcare “Navigators” to every state to explain the sign up process, and undertook a massive marketing campaign to dispel myths.
So far, ACA has withstood Supreme Court challenges, congressional efforts to repeal it, and the early crash-and-burn of the program’s centerpiece website, Healthcare.gov. Both critics and supporters of the law agree that it’s far from perfect. While the legislation’s merits will continue to be debated and dissected for years to come, anyone looking to effect major change at an institutional level would do well to study the ACA’s history—health information management (HIM) professionals included. It can be a challenge to move from the “why” of an initiative to the “how”—something many in HIM are currently facing with their move to information governance practices.
AHIMA Leads the ‘How’ of IG
Currently, HIM professionals are poised to enact comparable changes by implementing information governance (IG) programs in their hospitals and other healthcare facilities. For the last two years, AHIMA has been helping these providers by actively promoting the “why” of IG. It has done so by surveying the state of IG practice, generating IG white papers, identifying best practices, conducting live and virtual events, and planning educational products.
Just as the ACA’s Navigators helped Americans sign up for insurance coverage, AHIMA has begun shepherding providers into the “how” of IG. To help achieve actual implementation of IG practices, AHIMA developed resources such as the Information Governance Principles for Healthcare (IGPHC)™, available online at http://research.zarca.com/survey.aspx?k=SsURPPsUQRsPsPsP&lang=0&data. And a yet-to-be-released IG maturity model will help providers self-assess their IG maturity and readiness. AHIMA credits ARMA International for sharing their Generally Accepted Recordkeeping Principles, which provides guidance in the governance of information, to help develop the IGPHC and maturity model for the healthcare industry.
AHIMA’s ultimate vision relates to what IG will do for healthcare, says Deborah Green, MBA, RHIA, executive vice president, chief innovation and global services officer, at AHIMA. “With widespread adoption, and movement toward high levels of IG maturity, we envision that IG will ultimately and consistently ensure reliable and trusted data and information,” Green says.
Mature IG programs, in the long run, will help ensure the safe use of health IT, enable evidence-based healthcare practices, improve effective coordination of care across the healthcare continuum, and reduce costs, according to Green.
The draft IG maturity model is a five stage model for self-scoring an organizations’ current adoption of IG. The model contains “maturity markers” by stage, specific to essential functions of IG. Maturity markers at lower levels indicate an organization that can be characterized as fragmented and technology-oriented. Markers at the higher levels indicate that an organization can be characterized as holistic and business-driven in approach. Prioritization of remediation steps can be undertaken based on the degree of risk to the organization, Green explains.
Is Healthcare Ready for IG?
There have been several IG pioneers in healthcare that launched and implemented IG or IG-like programs simply because a business or organizational need was identified. In many ways, the healthcare industry has been involved in IG for decades without calling it IG.
Jaime James, MBA, RHIA, senior director of HIM at Banner Health, based in Phoenix, AZ, says IG has been going on in her organization for nearly 10 years in some form or another. Banner has created teams over the years to deal with the biggest health IT initiatives, such as the enterprise master patient index (EMPI), electronic health records (EHRs), and HIPAA compliance. When James joined Banner eight years ago she was on the EHR team, which has since transitioned into the enterprise information management (EIM) committee. Its members comprise of individuals from departments including risk management, compliance, legal, and health information management services. James said Banner is introducing concepts related to IG through this committee.
“So we have all of these HIPAA, security, EMPI, EIM teams, and our IT governance structure for EMRs. [We’re talking about] how do we pull it all together under one information governance umbrella? There’s recognition that we have IG going on, versus a formal structure,” James says.
She hopes that AHIMA’s IG maturity model will help the organization put these disparate teams together under one IG umbrella. While AHIMA advocates for an IG framework that operates from the top down—with leadership and the C-suite jump-starting efforts—James said her facility has been doing the reverse. They’ve started multiple projects at the small department level in an effort to build a case strong enough to take to the C-suite.
People who are experts on IG and healthcare agree there’s a growing interest in how to begin and structure IG efforts. According to a recent survey into IG readiness, which was completed by AHIMA and Cohasset Associates, 44 percent of survey respondents indicated that over the past 12 months IG advancement has begun in their organizations. However, nearly one-third (32 percent) of survey respondents reported no progress in their organizations, with another 24 percent indicating that IG simply is not yet an organizational priority.1
Consultant Karen Lawler, RHIA, CHPS, principle adviser at KJL Consultants, says the healthcare systems she advises have come to her for help in framing what they’re already doing into a full-time IG project. When organizations reach out to her, their motive is usually function-based. For instance, their quality scores and metrics may be low, or they’re having trouble with their patient portal implementation. These problems become opportunities to start IG projects.
“When I look at a department, I say ‘What is your core business, what is your scope of service? How do you look at information as an asset and how do you see your role in it as the HIM professional? That is your job, to protect patient information,’” Lawler says. “Build a governance structure on the goals you want to accomplish.”
Michele O’Connor, MPA, RHIA, FAHIMA, director of sales operations, identity and information governance at QuadraMed, says that despite what surveys may show healthcare has been ready for IG for decades. “I think we continue to want to take shortcuts and we know what we need. We already have this in place, and now we’re moving on to the implementation,” O’Connor says.
Those shortcuts she’s referring to include record retention and disposition policies that HIM departments typically set up, “but they’re not coordinated across the organization and they’re not tied to organization-specific initiatives but rather tied to systems that are up for specific purpose. And most importantly, I don’t really see a broad C-suite involvement,” she adds.
Five Steps for Moving Forward With Information Governance
Healthcare systems with and without formal IG infrastructures can still proceed with IG activities that improve operational efficiency and deliver quality care. However, LifePoint’s Joe Ponder points out that the most successful programs tend to be those that are both dedicated to IG and widely supported by the business.
“An organization can have a successful IG program without an IG department. However, in my experience, if IG becomes just another hat for someone already tasked with a myriad of responsibilities, it becomes difficult to introduce organizational changes that are transformational in nature,” Ponder says.
With that in mind, here are some basic IG tenets that can help move any healthcare organization down the path of IG.
- Streamline Master Patient Indices: With mergers and acquisitions rates at an all time high, having a uniform process of positively identifying patients thrown into databases that aren’t interoperable is critical.
- Information Mapping: Understand the critical information assets of the business, including data ownership and management.
- Information Retention: Establish clear standards for retaining critical and valuable information while allowing disposition of the rest.
- Information Planning: Establish a go-forward strategy surrounding how you want data to be stored and managed, closely tying the management of that information to retention schedules.
- Storage Management (Electronic and Paper): Improve the processes that are used to store and archive information to promote recall, usage, and destruction.
Pleading Your IG Case
When the Obama administration pitched the idea of healthcare reform to the American public, it started with informal discussions in individual voting districts, publishing editorials in newspapers, and appealed to young people on social media networks like Facebook and Twitter. When it came time for legislators to vote on the law, their constituents had plenty of time to evaluate the law’s proposals and let their representatives know how they felt. Additionally, since the ACA is being rolled out over a period of several years, stakeholders have had time to adapt and anticipate changes headed their way.
HIM professionals should take the same tack in pitching IG to the C-suite and other departments by making a business case for it, says O’Connor. To do that, however, a leadership chain or task force must be established in order to include the right people across the enterprise. Potential task force members include individuals from IT, legal, compliance, security, and HIM.
She notes that an IG program should aim to braid together all of the relevant information one needs for a patient, including clinical data, social data, and business and financial data, and make it accessible to whoever may need it at any time.
“I’m a fan of start small and think big in terms of enterprises. Start to create this culture. Determine what your blueprint is and where you expect to go,” O’Connor says. Once that blueprint—or framework—is laid, the next step is making those proposals measurable. It’s also important to keep in mind that IG projects don’t have an end date—they are continuous, O’Connor emphasizes.
LifePoint Health, a Tennessee-based provider network serving rural communities, tackled IG by establishing an IG council, the formation of which was led by LifePoint’s legal department.
“This provides a solid foundation for building out an IG program, because some of the core challenges faced by most IG programs typically surface when litigation activities are underway,” says Joe Ponder, vice president of information governance at LifePoint Health.
The council, which includes members from the legal, compliance, IT, HIM, finance, human resources, and other departments, meets once a month. To start an IG program, Ponder says, IG needs to be a priority for the business. “Ironically, one of the main drivers for IG has been the impact of not having an IG program,” Ponder says. “It can be hard for the business to understand the value that can be realized from well-managed data, but easy for them to see the impact of improperly managed data. Furthermore, it can be difficult for the organization to harness the real power and see the value of information if they don’t understand the data, if it isn’t mapped, managed, retained, etc.”
New Survey Shows IG Adoption Lagging in Healthcare
AHIMA and Cohasset Associates recently conducted a new survey to measure the readiness of healthcare professionals to address the technical and strategic demands they face, as well the opportunities that manifest as they work to advance information governance (IG) in their organizations. The survey and subsequent white paper was underwritten by Iron Mountain and Nuance.
The survey went to healthcare and industry professionals such as clinical and non-clinical leaders, officers, directors, and managers in both provider and non-provider settings, as well as AHIMA members.
The chart below represents the survey question “What is your involvement in your organization’s information governance (IG) oversight body, such as a council, committee or working group?”
The survey reveals that progress in IG is relatively immature in healthcare. For example, the survey found that 40 percent of respondents’ organizations do not have an IG council, committee, or working group, and have no plans to establish one.
Practical IG Examples
Early initiatives of the ACA were almost imperceptible to everyday consumers. Those include pay-for-performance programs, the creation of accountable care organizations, and the ability of adults to keep their children under the age of 26 on their own insurance policies. However, once the insurance marketplace and mandates to purchase insurance hit the scene, Americans had a more tangible sense of how the law would affect them.
Institutional IG programs function this way, too. Ponder emphasizes that the key to successful IG is not the creation of new practices and policies that support governance, but rather integrating newly defined practices throughout the culture of an organization.
Like many large integrated delivery systems, LifePoint is rapidly acquiring new hospitals and practices, which presents the challenge of trying to standardize the patient records that come with each acquisition. With the help of policies created by their IG council, LifePoint developed a strategy for managing those newly acquired paper and electronic records.
LifePoint started this process by focusing on simplifying retention schedules. “We decided that our legacy schedules were too detailed and needed some enhancements to reflect the growth and change that has occurred throughout LifePoint Health since they were first drafted,” Ponder says. “We have put a lot of effort into simplifying these schedules to ensure that they are easier to understand and implement. Furthermore, we have started working with our preferred records management vendors to integrate these new schedules into their physical records management solutions to ensure that paper records are being properly managed and destroyed.”
KJL Consultants’ Lawler says a common IG activity she’s been involved with is patient portal governance—that is, getting patients to sign up for a portal and interact with it. The first step, says Lawler, was taking a step back and asking: who are the owners of this process? “What type of messaging do we need to collaborate on and control, and what kind of consistent process do we need to develop? The great opportunity for the HIM team was truly to own what we already do. We already communicate with patients about patient information and take it to that next step. And it’s been very successful. The reported metrics of how the patients are engaged have tripled,” Lawler explains.
Furthermore, Lawler says that to get IG off the ground, HIM professionals and their colleagues just need to continue what they’re already doing and take it up a level. For instance, one IG-related project that Lawler took on was managing the master patient index of 30 different physician practices.
“I said to my CIO at the time, ‘The HIM team can do this, but we’ll be spending a lot of time doing corrections. Wouldn’t it be better if we spend a lot of time doing corrections, but if we went out there with a model globally to instruct people how to do patient identification and own a piece?’ So we did that. And I did that in partnership with the director of patient access,” Lawler says. “Now over 300 people have that training toolkit. It made a difference when we went live, enterprise wide, all marching to the same beats.”
While true IG should involve a variety of healthcare professionals across an enterprise, HIM is well suited to lead the effort, especially as IG initiatives fall increasingly under their purview.
“Governing our information will not replace managing it and there will still be HIM and HIM roles,” says AHIMA’s Green. “… There will certainly be multiple new and evolving roles in information management, and data and information governance. We do believe that IG in healthcare must encompass all information, not just health and/or clinical information.
“We also believe that HIM professionals who are qualified to be senior leaders can certainly lead information governance.”
1 AHIMA and Cohasset Associates. “Information Governance in Healthcare 2015 White Paper.” Preliminary results, unpublished.
Mary Butler (email@example.com) is associate editor at Journal of AHIMA.