By Mary Butler
When the once-dominant retailer Sears filed for bankruptcy in 2018, many attributed its decline—and that of brick and mortar retailers in general—to the existential threat of Amazon and online retail. While Amazon played a role in the demise of Sears, it’s far from the whole story. After all, Sears practically invented online shopping’s precursor, the mail-order catalog, which allowed price-conscious consumers to do their shopping at any time of the day. Retail analysts say other mistakes such as failing to assess the risks posed by big box retailers, a poorly executed acquisition of Kmart, and a failure to continue anticipating consumer behavior—an area where the company excelled in its heyday—led to its bankruptcy.
What these factors have in common is that they stem from a failure of leadership and lack of imagination. Plenty of analysts agree that Sears could have recovered from its early missteps if management had recognized and addressed problems earlier on. Other competitors, such as JC Penney, Kohl’s, and Home Depot, have survived the dramatic shift in the retail landscape, proving that it can be done with the right people at the right time.
Healthcare and health information management (HIM) are staring down a similar crossroads of change, also spurred by new technology and a morphing professional landscape. Electronic health records (EHRs), computer-assisted coding (CAC), natural language processing (NLP), and the push for “HIM without walls” have all changed the way HIM professionals do their jobs. AHIMA has taken notice, launching initiatives like HIM Reimagined that call on HIM professionals to supplement their current skills with continuing education and new credentials.
All these changes have put a strain on HIM professionals and their leaders, who are now tasked with motivating the workforce while managing the anxiety that accompanies change. However, if HIM leaders really listen to and engage with members of their workforce—and act on what they learn in the process—the industry can and should thrive during times of change. But that doesn’t mean it will always be easy.
Change is central to the nature of HIM—after all, HIM professionals were originally known as medical librarians. Now, however, one could be forgiven for mistaking HIM as an information technology role or unexpectedly finding HIM professionals working in clinical areas. The biggest recent change is the use of EHRs and the transformation that comes with digitizing nearly every piece of information about a patient. With EHRs came health information exchange (HIE), patient portals, querying of databases, and an increase in regulations such as HITECH, MACRA, and the 21st Century Cures Act. Other factors, like an increased focus on artificial intelligence in healthcare and the move to ICD-10-CM/PCS, have also been sources of anxiety for many.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, an independent HIM coding consultant, admits that the profession’s response to EHRs was perhaps a little flat-footed. “There are benefits to EHRs and a big one for me is legibility in coding—it’s huge to have such a big change in 20 years,” Bryant says. “But at the same time, I feel we weren’t as prepared for the depth of the change. Technology is one of those areas where we don’t know about hidden capabilities. Just as with the telephone, and iPhones, we didn’t originally see the impact they would have. And I think we’ve missed the boat a bit with EHRs.”
An individual’s reaction to change varies from person to person. In the years and months leading up to ICD-10-CM/PCS, there was a lot of talk about coding professionals who planned their retirements around it in order to avoid the hassle. Others thrive on change. Christine Methany, RHIA, CHPS, CHTS-IM, HIM director and chief privacy officer at West Virginia University Medicine (WVU Medicine), recalls a conversation she had with a former employee that had transitioned to a career in education but wondered if HIM was still a viable option.
“I started talking about changes in technology and how patients and consumers are becoming more active in their care and diagnoses, as well as population health. After talking to me and naming those things she said, ‘That’s enough to keep my appetite wet because technology is constantly changing,’” Methany says.
Good leaders must be prepared for the gamut of reactions to upheaval, according to Bryant. Some employees react with fear and suspicion and don’t trust the messenger, and leadership actions can make or break the change while it’s occurring. Allowing fear to creep in can create new ethical concerns, particularly in the coding realm, Bryant says.
Fear can create dishonest behavior and dishonest emotions, and can manifest itself in the form of such practices as upcoding, the “unbundling” of codes, using more codes than are appropriate, or intentionally misinterpreting documentation to bill for a higher level of services.
“We’re also seeing ethical issues around querying, leading queries, using the EHR in ways that aren’t allowed or are leading a physician. Drop-down menus, shaded-out boxes next to diagnoses. All of that is tied to reimbursement. And because we are a very code-dependent healthcare system, the role of ethics in coding are actually more important today than they’ve ever been before,” Bryant says.
She has also found that ethical problems develop when HIM is absent from a larger organizational initiative or development.
“I’ve often seen in my career new departments and service lines develop, new medicine developed. HIM leadership needs to step in and say: ‘We have a new business line?’ HIM needs to go in and check that out [from a CDI standpoint] and make sure there’s nothing leading, nothing inappropriate,” Bryant says. “We need to ask how it’s going to be coded, processed, all that needs to be in place due diligence-wise. In HIM there’s a role for us that we’re not utilizing. We need to be the leader in those kinds of things.”
Keep Calm, SWOT On
Naturally there is a good way and a bad way for leaders to guide their organizations through change, which can come in many forms, from new software to new workflows, new EHRs, annual coding updates, or even mergers and acquisitions—with the latter leading to fears about job security. Additionally, HIM professionals are frequently told they need to update their skills, credentials, and degrees in order to stay relevant in the future. Any one of these events can distract employees from the task at hand.
WVU Medicine’s Methany took a project management class and used the techniques she learned to tackle a major source of employee dissatisfaction in her workplace. Ever since her department had implemented a new worker productivity database, she heard complaints about it. Everyone in her HIM department, which had 237 employees at the time, had to use the tracker, which left many feeling like Big Brother was looking over their shoulder. At that time, the tracker had been in use for 10 years and was still meeting resistance.
Methany decided to solicit feedback from 10 percent of her employees and asked her assistant to schedule 30-minute one-on-one interviews with staffers, for a total of 23 interviews. This gave them the opportunity to ask Methany any question they had about the database or any other concern. Then in turn, she appointed each of them to be liaisons for their own separate corners of the HIM department. The liaisons could hold additional training sessions and brainstorm on ways to improve the use of the database, increase its effectiveness, and identify ways it improved their job performance. Methany was also very deliberate in her selection of liaisons, in some cases choosing individuals who had an “axe to grind” with the system.
“I figured that if I could make myself their champion, they would spread the word… I felt that because it was such a bone of contention with folks at the grassroots, if they could hear more about it from their peers, it was better than me saying ‘We’re working on it,’” Methany says.
Every liaison conducted a SWOT (strength, weakness, opportunity, threat) analysis of the tool, and Methany laid out a roadmap, developed a milestone schedule, and wrote a charter governing the project.
“By the time we got through the project they started performing and I took a backseat role. They started forming subgroups, by the end of the project we were still using the same product but made changes that gave us a lot of wins,” Methany says.
A Little Empathy Goes a Long Way
Workforce worries beyond new platform or software changes—including concerns about future career prospects, layoffs, or the need for more education—require a more deft leadership approach. One reliable way for managers to approach this is to try to put themselves in their colleagues’ shoes, and doing this properly takes strong communication skills.
Mary Ellen “Emmy” Clancy, MHA, CCS, CMPE, CPC, CDEO, CPMA, revenue cycle, coding, and operations consultant with Emmy Award Healthcare Consulting, describes herself as a “why” person—if she can understand “why” a change is being made, she’s more accepting of it. It’s in that spirit that leaders should be as transparent as possible when explaining decisions.
“The more you can share the better,” Clancy says, especially when dealing with layoffs or restructuring of services. “As understanding creeps in, it’s easier to stomach what’s happening.”
The first step when communicating change, she says, which addresses the “why” factor, is to use phrases such as “We couldn’t stop this from happening,” or “We can’t afford not to do this,” and “We have to do this because the regulations require it,” she says.
The second step, Clancy says, is that leaders need to ask their employees what leadership can do to offset the impact of the change—for example, offer to be references for those whose jobs are terminated. “That sends the message that you care and that this is personal for everyone,” Clancy says.
It is also vital to provide as much advance notice regarding changes as possible, and to celebrate and communicate successes just as well as negative changes. “It’s easy to have good news, but sometimes we’re not good with saying why this happened. ‘It’s a result of all the good work you guys have been doing,’” Clancy says.
Sandra Finley, president and CEO of the League of Black Women, specializes in training leaders on a type of transformative change management developed by the military known as VUCA, which is an acronym that stands for volatility, uncertainty, complexity, and ambiguity. Finley and a co-presenter did a training session on VUCA and leading through change tailored for HIM professionals during the 90th annual AHIMA Convention and Exhibit in September 2018. Because of its origin in the military, VUCA addresses plenty of thorny questions and has tactics for navigating ambiguity, which is useful as the HIM industry confronts a future with a lot of unknowns. Finley compares VUCA’s approach to communication to a car or phone’s GPS system.
“It [GPS] tells you where you are and what it understands about distances between where you are and where you’re trying to get,” Finley says, noting that the strategy is constantly course correcting. “It is an inferred promise that it will not leave you… even if it takes you through somebody’s backyard. For leaders, the underlying promise has to be as clear as it is for the Marines. We will not leave you. And that is the thing that’s most frightening to people who have to turn the steering wheels of their career over to other people.”
Employers can execute strategies like this through simple steps, which many companies but especially academic medical centers can do, such as reimbursing employees for continuing education programs.
“I haven’t worked anywhere in maybe the past eight years that didn’t have some form of tuition reimbursement,” says Shannan Swafford, RHIT, CHDA, CCS, manager of coding process improvement at BlueCross BlueShield of Tennessee. “It’s a viable way to make a loyal and smarter workforce. You might lose those folks after some education, but if you’re investing in your employees they should stay loyal.”
Swafford has worked consistently in HIM—but in a number of different areas, including Tennessee’s regional extension center, which was funded by the Office of the National Coordinator for Health IT to help advance the “meaningful use” EHR Incentive Program. She’s also worked as a clinical analyst for the Cancer Treatment Centers of America, where she did a lot of work with analytics, and now she’s overseeing the implementation of an end-to-end data content governance program across Blue Cross Blue Shield of Tennessee for ICD-10, HCPCS, and CPT coding. Since so much of her work has been with technology, she’s witnessed a lot of resistance to change, a common occurrence when learning any new technology.
“As leaders, it is often uncomfortable to know some of the things we know due to the privilege of information provided from key decision makers. One key element is to be open to answering all questions, even the really difficult ones,” Swafford advises. “Another is being aware that change is scarier for some than for others and all they want is to understand—so tell them. And, if you don’t know, tell them you don’t know. Be honest and be kind!”
Delventhal, Shoshanna. “Who Killed Sears? 50 Years on the Road to Ruin.” Investopedia. October 15, 2018. www.investopedia.com/news/downfall-of-sears/.
Isidore, Chris. “Here’s what’s killing Sears.” CNN. February 12, 2018. https://money.cnn.com/2018/02/12/news/companies/sears-downfall/index.html.
Peterson, Hayley. “Inside Sears’ death spiral: How an iconic American brand has been driven to the edge of bankruptcy.” Business Insider. January 8, 2017. www.businessinsider.com/sears-failing-stores-closing-edward-lampert-bankruptcy-chances-2017-1.
Mary Butler (firstname.lastname@example.org) is associate editor at the Journal of AHIMA.
Butler, Mary. “Weathering the Storm—How to Lead Through the Chaos of Change.” Journal of AHIMA 90, no. 1 (January 2019): 12-15.