By Lesley Kadlec, MA, RHIA
In an effort to begin to answer basic questions related to the state of information governance (IG) in healthcare, AHIMA invited several different types of organizations from across the country to participate in a case study analysis.
Below are the results of the de-identified IG case study that focuses on a “four hospital integrated delivery system.”
Executive Information Governance Program Sponsor
CIO and Chief Quality Officer
This organization is an integrated healthcare system and the region’s largest healthcare provider. They provide services to patients throughout their region through four hospitals, more than 48 outpatient clinics, and more than 1,500 affiliated physicians.
The organization is a recognized leader in the adoption of electronic health records (EHRs), with a system-wide implementation that allows its hospitals and physicians to offer integrated, coordinated care throughout the region.
Information Governance Program Description
This organization started its information governance program to tie together information from the EHR at four hospitals that fall under the umbrella of the corporation. Each hospital is a separate legal entity, and these hospitals did not share common data prior to the implementation of their EHR. In order to ensure that information was reliable for patient care, as well as to ensure patient safety, an EHR workgroup was established. This group led to the further establishment of the clinical governance program.
Prior State Analysis
Prior to the initiation of the information governance program, each of the hospitals in the system operated independently as a separate legal entity. This led to problems getting data and being able to respond quickly to requests for release of information, quality reporting, core measures, and meeting contracted, quality required for pay-for-performance.
HIM staff had participated in the implementation of the EHR, but they did not have a voice in how the EHR-generated data was being used. HIM leadership recognized that a framework was needed.
Physicians were complaining of there being too much clutter in the EHR. Also there were complaints of too much “garbage” in the record, and physicians were saying they could not get to the heart of the patient’s complaints. They wanted to have a mechanism to understand the patient’s story. Some physicians wanted to use “progress notes” for everything without entering any discreet data. There was a dependence on scanned documentation, both clinical notes as well as business documents. Scanned documents could not be found in the “notes activity” within the electronic health record, meaning physicians had to search multiple tabs to find information while providing patient care.
Information Governance Drivers
The information governance program was started to meet reporting requirements for core measures and quality initiatives. The data that was being pulled was felt by staff to be inaccurate or incomplete, and the lack of data integrity was leading to patient safety concerns.
Physicians could not tell the patient’s story with the amount of clutter in the EHR. Filters were not usable and problem lists were not being maintained. Eight to nine years after the EHR’s implementation, HIM staff was being bombarded with scanned documents, both clinical documents as well as business documents, all of which needed to be maintained. But the record volume was making it difficult to find what was needed to manage patient care. Another driver was related to legal cases that emerged when release of information requests were sent with incomplete information.
The quality team was challenged because they had no real guidance available to them on what was appropriate data that should be pulled for core measures. HIM staff was asked to provide guidance and develop policies on documentation, problem list use, and appropriate use of templates with structured data to ensure that data could be pulled effectively for quality reporting.
The organization is a part of the regional health information exchange (HIE) and the CIO and the privacy officer represent the organization on the exchange.
The system’s president/CEO was instrumental in getting the information governance program initiated. The hospital CEO for each individual organization was asked to champion the project locally. The enterprise CIO and Chief Quality Officer were given authority to manage the umbrella program, and the Chief Nursing Officer was enlisted to provide guidance from a patient safety perspective. Physicians were supportive because they were program drivers with the desire to achieve pay-for-performance measures as well as wanting the development of more patient-centered care. Nurses were identified from within the system to work with the Chief Nursing Officers to take on a leadership role in the program.
HIM professionals have a governing voice, and the legal department also participates to ensure that they are guiding decision making. They developed a program charter, and used existing staff in the governance program. A fundamental element for success has been empowering staff to bring forward suggestions for improvement.
Prior to implementation, there were multiple distinct organizations that all had individual identities. There were three different models in place for physician staffing: employed physicians, community physicians, and one facility was physician-owned. The system also utilized medical students and residents.
Executive leadership focused on making the program physician driven to harmonize the various physician groups and put guidelines in place that applied to all physicians in the organization.
A physician workgroup was pulled together as a part of the information governance program. The goal was for the workgroup to evaluate all existing templates and standardize them for patient care, core measure and quality reporting, and to ensure patient safety.
By making physicians the drivers of the change, the organization was able to show the importance of information governance and gain physician buy-in. Physicians are now happy with the ownership they have over the information in the record, and they are now taking responsibility to ensure that the policies and information governance structure is enforced.
Information Governance Program Structure
This organization has a centralized approach to information governance within the organization. There is a centralized authority led by the CIO and chief privacy officer with a secondary group of leaders from across the organization that provides control and decision making authority for information obtained at the enterprise level. There are subgroups with responsibilities for data within their respective business areas, and additional staff can be brought into the program to design workflows, documentation flow sheets, order sets, and other items as needed.
Components addressed with the information governance structure include access, security, and confidentiality; information integrity and quality; information design and capture; content and records management; and information required for participation in the regional health information exchange.
The organization recognizes that everything in healthcare is changing, and they are preparing to react to this change. It is this organization’s stance that if they have to measure something, then they need to know how to get the necessary information out of their systems.
The organization is working on making sure that they are able to keep up with requirements for the Centers for Medicare and Medicaid Services’ “meaningful use” EHR Incentive Program, core measures, pay-for-performance, hospital-acquired conditions reporting, ambulatory care requirements, and preventive screening notifications.
They are currently working on information governance policies and procedures, and while some fundamental policies are in place, most is still a work in progress.
Impact of the information governance program on the organization has included:
- Centralization of decision making for information use and dissemination
- Executive leadership has driven the organization to be aligned with its strategic initiatives
- All employees are expected to think about data in terms of how it affects the patient
As part of the initiative, filters were set for scanned images to make it easy to filter out business documents from patient care documents. Physician leadership was able to get buy in from primary care physicians for them to “own” the problem list. Other filters were built to make it easier to find what was needed for patient care and to reduce concerns over patient safety when necessary information could not be found.
One of the intangible benefits realized from the initiative is the ability to get all levels of the organization to participate in the program while it is still being developed. Leadership has recognized that they can still be aggressive in moving the program forward while they continue to think it through in terms of development.
There has been a need to go back at times and work through challenges, but that has been seen as a positive for the organization because it has helped staff uncover their talents and become a more aggressive and progressive organization. In addition, flexibility has been key since it is recognized that the program outcomes are not always as expected. But by approaching the governance program with the best intention and by thinking about how it affects the patient, there will be knowledge and wisdom gained along the way, organization staff feel.
This organization recognized the need to bring together information from all of their affiliated hospitals which, prior to the organization of their information governance model, had operated independently from one another.
The key drivers for formalized information governance in this organization included:
- The need for accurate data for core measure reporting
- A desire for better integrity of information in the EHR
- A concern for patient safety
- Identified gaps in their release of information and documentation processes
The CIO and chief privacy officer were essential to getting buy-in for the information governance program. Health Information Management staff have a governing voice in the information governance program, including holding responsibility for developing and monitoring compliance with information governance policies. Physicians also have a voice in the governance program, and this has helped with buy-in from physicians across the organization.
Overall the information governance program has brought executive level staff from within the organization together to achieve the goal of a unified health system that is prepared to meet the upcoming challenges that they expect to see in healthcare.
"State of Health Information Governance in Healthcare: Case Study—Four Hospital Integrated Delivery System"
(AHIMA, February 2014)