By Mary Butler
Human beings have been fascinated by birds—their flight patterns, colors, and songs—for centuries. In the ancient world, “augurs,” Roman practitioners of “augury,” looked for clues about the past and future by observing birds in flight, hoping for omens. Modern bird watchers, sometimes known as “birders,” study them for less mystical purposes, such as the chance of spotting a rare one, identifying which winged creatures might be creeping toward becoming endangered, or just for the sake of observing their beauty. Every diligent birder carries with them a list, binoculars, and a field guide to help document proof of every discovery and keep score.
Though it might seem at first that birders and health information management (HIM) professionals don’t have a lot in common, they face many of the same challenges. Both need to be vigilant about species—or job roles and technologies—facing extinction and both operate in environments where regulation is a fact of life. Birders and HIM professionals have to be constantly mindful of habitats and whether those habitats offer protection from invasive species.
Like birders, HIM professionals accept that change, regulation, and growth have a natural progression, even when Mother Nature—or the hand of government—gets in the way. In the HIM world, 2014 was a tumultuous year—another delay in ICD-10-CM/PCS implementation; stumbling blocks and technical challenges in implementing the “meaningful use” Electronic Health Record (EHR) Incentive Program; the ever-present threat of government audits; continuing the implementation of new HITECH-HIPAA protocols; and realizing that information governance (IG) is going to become a huge priority.
That’s why HIM folks need to take a cue from birders: grab a checklist, a field guide, and let the Journal of AHIMA be your augur.
HIM Fights for Implementation in 2015
Non-birders loathe the nuisance that is the common grackle, which are characterized by their shiny black metallic and purple sheen. They can carry disease and foment fears of avian flu, but most people hate them for unattractively decorating their cars. Like any species, however, their existence is vital to maintain harmony in the ecosystem. And while the ecosystem can adapt to stressors, too many hits can cause it to collapse.
The same can be said for ICD-10-CM/PCS. In order to maintain the modern healthcare ecosystem, which needs accurate disease and coded billing data to keep up with regulations and monitor public health, a more sophisticated code set is a must. For many providers and payers who had spent millions of dollars getting ready for the expected October 1, 2014 implementation date, the ICD-10 delay enacted by Congress in April was a major setback.
In a letter to the Centers for Medicare and Medicaid Services (CMS), AHIMA and other organizations reminded the agency that the cost of a one-year delay to the healthcare industry could be as much as $6.6 billion.
Angie Comfort, RHIA, CDIP, CCS, AHIMA’s senior director of HIM practice excellence, coding services, says payers and providers are weary and fearful of another delay, especially those who have already spent their budgeted training dollars in preparation for the 2014 deadline.
“Hospitals and physician practices don’t have a lot of budget when it comes to education. If they spend their entire education budget in 2013 with an expectation of going live in 2014, then they aren’t going to have anything to spend in 2014,” Comfort says.
In the year ahead, provider organizations must spend the extra time on doing end-to-end testing with as many of their biggest payers as they can, keep training physicians on documentation improvement, and dual code claims as much as time allows.
Comfort encourages hospital and physician practice staff to “once a week, once every two weeks, code some charts with ICD-9 and ICD-10. Just to see what you may be missing down the road, as far as documentation goes… dual coding not only provides those coders with hands on education, but it also helps the physicians,” she says.
Comfort says she expects to see the use of computer-assisted coding (CAC) programs pick up speed during the delay. She also dismisses speculation within the industry that coders are going to be replaced by technology, namely CAC systems.
“Coders’ role is evolving. They’ll still need to know the guidelines, they will still need to code, there’s not any type of computer system that can replace an individual with that knowledge,” Comfort says. “If you can offset your productivity decrease from ICD-10, too, with CAC, it should come out in the wash.”
Privacy and Security
Hunting Down HIPAA Compliance
As hunters and birders know, there are strict rules regulating water fowl such as ducks, geese, and game such as pheasants, grouse, and woodcocks. Hunters face fines and penalties for exceeding the maximum number of animals they’re allowed to kill. In the HIM world, privacy and security officers know all too well the burden of complying with myriad regulations—and the significant penalties if they don’t.
Privacy and security professionals spent 2014 continuing efforts to ensure compliance with the HITECH-HIPAA Omnibus Final Rule, which for the first time in September 2013 required business associates of covered entities to be compliant with HIPAA, changed breach notification protocols, and extended individuals’ rights to obtain restrictions on certain disclosures of protected health information to health plans if services are paid for out-of-pocket, among other requirements.
In 2012 covered entities responded to audits under Phase 1 of the HIPAA audit program, which centered on their compliance with the law. The about-to-begin Phase 2 audits will have auditors for the first time looking into organizations’ business associates as well.
Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA, director of HIM practice excellence at AHIMA, says that Phase 2 audits—conducted by the US Department of Health and Human Services’ Office for Civil Rights (OCR)—is one of the highly anticipated privacy and security stories for 2015.
“Phase 2 of OCR HIPAA audits are going to be important in 2015,” Rose says, “especially because it is the very first time business associates will be audited.”
Rose noted that at the September 2014 AHIMA Convention and Exhibit in San Diego, CA, officials from OCR said they have identified the organizations that they plan to audit in 2015, but as of press time had not officially notified the organizations.
For the most part, targets for OCR scrutiny have been chosen at random, but some are done in response to complaints, particularly if news of a big data breach makes it into the media. That might spark an audit. Organizations should make sure they have a complete list of all of their business associates with whom they share PHI, should they be subject to an audit.
Healthcare Moving from the ‘Why’ of IG to the ‘How’
The Eurasian collared dove, notable for its mocha feathers and a dark narrow band across the back of their neck, is considered an invasive species in some birding circles. Transported by humans from the Bahamas to the United States in the mid-1970s, the birds quickly made their homes here, threatening to overtake the population of native doves. Hunters are encouraged to shoot the birds to keep their numbers low.
Information governance (IG) in the healthcare world has the same task as these hunters. With so much healthcare data being generated and stored, and becoming hard to access, HIM professionals are well-positioned to keep information and data from becoming invasive in its own way.
AHIMA took a major step in helping HIM leaders take charge of IG in their organizations with the 2014 release of its “Information Governance Principles for Healthcare (IGPHC),” as well as a benchmarking white paper exploring the state of IG readiness across healthcare organizations. According to AHIMA, IGPHC is a set of “comprehensive principles that can be applied in all types of organizations across the healthcare ecosystem.”
Lydia Washington, MS, RHIA, CPHIMS, a senior director of HIM practice excellence at AHIMA and a member of AHIMA’s IG Task Force, says IG is really picking up momentum in that HIM leaders clearly see the need for it. At AHIMA’s most recent convention in September 2014, Washington says the IG-related sessions were packed, and several HIM leaders volunteered to be pilot sites once the IG Task Force develops their forthcoming IG maturity model this year.
The maturity model, according to Washington, will help interested organizations complete a self-assessment to figure out their current IG capabilities and improve their processes.
“We want to see where people are, have people able to assess where they are, and ideally from that assessment develop a plan as to how they move into governance within their organization,” Washington says.
Part of what’s driving the need for IG, Washington says, is a recognition among providers that they implemented electronic health records (EHRs) too quickly—they put a lot of data into the EHR, but are struggling to get it back out in a meaningful way due to a lack of standards.
“Conditions change, the practice of medicine changes, payment changes, almost anything, the EHR has got to be a little more malleable in order to meet those requirements,” Washington says. “That requires a governance process as well. You’ve got to have a [governance] body somewhere that makes adjustments as needs come up.”
Data Analyst Skills Increase in Demand
Wood ducks, extremely common and abundant in number, are a favorite of hunters and birdwatchers alike due to the sheer beauty of their colorful, iridescent plumage. This water fowl saw a decline in the late 19th century, but preservation efforts have made them more popular and prevalent than ever.
Likewise, the preservation of data, in the eyes of health informaticians and health data analysts, is rapidly becoming more important than ever as they find ways to harness the beautiful and abundant data for improvements in healthcare.
Julie Dooling, RHIA, CHDA, a director of HIM practice excellence at AHIMA, says that the industry has long been saying that “data is king” and “it’s all about the data,” but the current healthcare environment is finally putting these calls to action to the test.
“Now you’ve got the Affordable Care Act, you’ve got the payment bundling and you’ve got the value-based purchasing (VBP) and the accountable care organizations (ACOs)… Healthcare organizations are trying to figure out how they can find the value in their data,” Dooling says. She adds that organizations are generating so much data these days it can be very challenging to know what needs to be analyzed.
Because of this, interest in AHIMA’s certified health data analyst (CHDA) credential has gone way up. While it’s still largely HIM professionals seeking the credential, says Dooling, who teaches CHDA exam preparation courses, she’s seeing more interest from those who work in the role of “analyst” across many different healthcare sectors.
But HIM practitioners have the upper hand when it comes to deciding how and where data are analyzed in healthcare settings.
“When it comes to knowing where the data originated, where it gets populated, where it gets managed and archived, and where it lives for its final disposition—that’s the HIM professional, and there’s nobody that knows that information like we do,” Dooling says.
She adds that jobs for data analysts are increasingly in demand, which has spurred interest in the CHDA credential. A recent Department of Labor report confirmed this. According to analysis of a Department of Labor report titled “Hospital recruiting efforts shift to data and outpatient services” published in Healthcare Finance in September 2014, “when hospitals are hiring, they are looking for more techies and analysts to help crunch the data required by accountable care models.”
Data Standards and Interoperability
Interoperability Remains a Struggle, Standards Needed
The snowy owl has achieved celebrity status among avid birders. The snowy owl migration pattern reaches far into the US, making this regal raptor something of a ubiquitous winter resident of the northern states—and an enthusiastically welcomed, though less frequent, sight in some not-so-northern states.
HIM professionals are working hard to build a health IT infrastructure that makes health data exchange ubiquitous across the country. But right now, as the country continues learning how to flap its wings, the coverage of that infrastructure remains inconsistent.
In a report to Congress from the Office of the National Coordinator for Health IT (ONC), provider participation in meaningful use—the federal incentive program that encourages interoperability of EHRs across states—is robust, but interoperability is lagging.
According to the report, 42 percent of hospitals electronically shared clinical care summaries outside their systems, an increase of 68 percent since 2008. Fifty-five percent of hospitals shared radiology reports outside of their systems, and 57 percent shared laboratory reports. Four in 10 physicians reported electronically sharing any patient health information with other providers, with 14 percent indicating that they share patient information with providers outside their organization.
Authors of the report called on the industry to promote “existing technical standards and developing new standards critical to the development and success of an operational and connected health system.”
To that end, AHIMA members and staff will be sitting on ONC committees designed to address the interoperability problems the industry faces.
Michelle Dougherty, MA, RHIA, CHP, the senior director of research and development for the AHIMA Foundation, has been appointed to ONC’s Health IT Policy Committee’s Implementation, Usability and Safety Workgroup. Linda Kloss, MA, RHIA, FAHIMA, a consultant and former CEO of AHIMA, was recently appointed to ONC’s newly convened Privacy and Security Workgroup, which is a subgroup of the Health IT Policy Committee and is replacing the previous Privacy and Security Tiger Team.
According to Diana Warner, MS, RHIA, CHPS, FAHIMA, a director of HIM practice excellence at AHIMA, all eyes will be on these groups to see how they tackle current interoperability challenges.
One of the barriers to true interoperability, Warner says, is a “patchwork of laws” across states. Laws governing health issues such as sexually transmitted diseases, mental illness, or pregnancy among emancipated minors, have different privacy protection state to state. “That’s some of the stuff that they [members of the ONC workgroups] have to look at or we’ll never get interoperability,” Warner says.
Additional Checklist Items for 2015
Birders often have multiple checklists operating at the same time—one for birds in the backyard, one for birds they’ve spotted in their own state, city, or even North America. Successful HIM professionals, likewise, must keep lists in order to juggle and respond to competing priorities.
Additional checklist items that every HIM professional should be tracking in 2015 are:
- Clinical Documentation Improvement (CDI). At AHIMA’s most recent convention, the CDI Roundtable, which normally attracts 40 attendees, brought in 120 attendees. Lou Ann Wiedemann, MS, RHIA, CHDA, CDIP, CPEHR, FAHIMA, AHIMA’s vice president of HIM practice excellence, says it’s a misnomer that interest in CDI is being driven by documentation needs for ICD-10. “Truly, if you do CDI for the right reasons, CDI is about quality of care and patient safety,” Wiedemann says. “Accurate reimbursement will follow. If you’re trying to sell CDI as a reimbursement tool, as a profit margin, it’s never going to go.”
- The return of Recovery Audit Contractor (RAC) audits will require extensive documentation improvement, especially in light of CMS issuing new criteria for a “two-midnight” hospitalization. This is a potential game changer for HIM professionals who have to produce patient records for an audit.
- Patient matching. In February 2014, ONC released a report on the current state of patient identification and matching system programs. The findings in the report drew on information provided by AHIMA representatives involved in an environmental scan. Patient matching best practices are key to ensuring patient safety, as well as reducing medical identity theft. Wiedemann noted that healthcare fraud is one of the leading types of white collar crime. This type of fraud is often perpetrated when an individual uses a family member or friend’s insurance card to receive services. There’s almost a 40 percent chance that “someone who commits healthcare fraud has already committed credit card fraud,” Wiedemann says. AHIMA is currently developing a white paper on patient matching in response to ONC’s ongoing efforts.
- Copying and pasting in EHRs. In March 2014, AHIMA released a position statement on the practice of “copying and pasting” information in an EHR, a practice that can lead to medical errors or perpetuate fraud. AHIMA’s Diana Warner, MS, RHIA, CHPS, FAHIMA, says AHIMA is working on another white paper about copying and pasting, also known as “cloning,” to recommend standards that EHRs should integrate to prevent copy/paste from occurring. Warner is working with the international community, via the International Standards Organization Technical Committee 215 (ISO/TC 215) on Health Informatics on developing a standard for the appropriate use of copy and paste functionality in EHRs.
New Care Models Take Flight in 2015
The Affordable Care Act has forced the healthcare industry to adapt to an influx of new patients while at the same time preparing to meet the needs of aging Baby Boomers. The industry is responding the same way that many grassland species of birds such as Baird’s sparrow, Henslow’s sparrow, and Grasshopper Sparrows have had to adapt to grassland farming practices and federal regulations.
One of the most closely watched parts of US healthcare reform has been the implementation of Medicare’s ambitious accountable care organizations (ACOs), the medical home model, and value-based purchasing (VBP) initiatives. The programs are intended to lower costs by better coordinating care and carefully monitoring the health of individuals enrolled in these programs. The programs’ success is largely reliant on the capabilities of health information exchanges (HIEs) and the interoperability of the data being exchanged.
The Social Security Act requires that ACOs define processes that promote evidence-based medicine and patient engagement; report on quality and cost measures; coordinate care; employ telehealth; conduct remote patient monitoring; and be fully EHR capable. All of these responsibilities fall right into the HIM professional’s wheelhouse.
In October 2014, both the Centers for Medicare and Medicaid Services (CMS) and the eHealth Initiative (eHI) released financial and quality results reflecting ACO programs’ performance. According to results posted by CMS about the Pioneer ACOs and the state of HIE development, during the first year of the ACO program health spending slowed as much as seven percent among some ACOs and accelerated as much as five percent for others. In the second year, health spending dipped as much as 5.4 percent among those that reduced patients’ medical bills and accelerated as much as 5.6 percent where costs grew, according to an analysis by Modern Healthcare. Nine ACOs exited the program, however, after recording increased costs.
The eHI report “Post HITECH: The Landscape of Health Information Exchange,” which surveyed 106 US health information exchange organizations (HIOs), paints a more upbeat picture of ACOs. According to the report, 64 respondents (51 percent) are supporting an ACO, 52 HIOs are supporting a patient-centered medical home (41 percent), 21 HIOs are supporting a state innovation model (SIM) grant (17 percent), and 12 HIOs are supporting a bundled payment initiative (9 percent).
However, the federal funding that helps support these initiatives will be running out. “Next year  will be critical to the success of these groups, particularly as they try to find funding for interoperability,” said eHI CEO Jennifer Covich Bordenick, in a press release.
The challenge for HIM professionals in the era of health information exchange and care coordination efforts is working to increase interoperability and make sure the data being generated are safe and reliable.
“All of these records they [HIOs] are collecting from patients in ACOs, medical homes, and VBP, you’re going to have to protect all that stuff along with all the other stuff you’ve got to protect,” says Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA, a director of HIM practice excellence at AHIMA.
Dimick, Chris. “HITECH Omnibus Rule Compliance Begins Today.” Journal of AHIMA. September 23, 2013. http://journal.ahima.org/2013/09/23/hitech-omnibus-rule-compliance-begins-today/.
Evans, Melanie. “CMS posts long-awaited Pioneer ACO quality and financial results.” Modern Healthcare. October 8, 2014. www.modernhealthcare.com.
Office of the National Coordinator for Health IT. “Report to Congress: Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information.” October 2014. www.healthit.gov/sites/default/files/rtc_adoption_and_exchange9302014.pdf.
Mary Butler (firstname.lastname@example.org) is associate editor at the Journal of AHIMA.
"The Year Ahead"
Journal of AHIMA