HIM's Professional Shake-Up Wake-Up: Moving Beyond Reality 2016 and 'Reimagining' HIM for a Quickly Changing Healthcare Industry

By Mary Butler

Health information management (HIM) and coding professionals intent on keeping their jobs and their skills relevant would do well to study the career prospects of medical transcriptionists, their healthcare documentation brethren. As providers started transitioning to electronic health records (EHRs), fueled by the “meaningful use” EHR Incentive Program and aided by natural language processing, the need for medical transcriptionists started to dwindle, especially for those who did not update their skills.

In 2013, AHIMA and the Association for Healthcare Documentation Integrity (AHDI) collaborated on a pair of surveys assessing the needs of transcriptionists and transcription managers. The surveys revealed an “overwhelming need” to identify transition plans and career paths for transcriptionists. Seventy-three percent of managers and supervisors indicated they did not have a plan in place, and 87 percent indicated a need to identify skill and knowledge gaps when working with EHRs.¹

According to the US Bureau of Labor Statistics, employment of medical transcriptionists is expected to decline by three percent between 2014 and 2024 (the average growth rate for all occupations is seven percent). Cheryl Braunreiter, MBA, RHIA, CHPS, director of HIM at ProCare Health in Wisconsin, says her transcription department shrunk from 75 transcriptionists—prior to the implementation of an EHR and Dragon natural language processing—down to 3.5 transcriptionists in five years.

Desla Mancilla, DHA, RHIA, senior director of academic affairs at AHIMA, says the path of medical transcriptionists should serve as a warning to HIM professionals, particularly to coding professionals who can expect to see demand for coding jobs shrink, too, thanks to technology such as computer-assisted coding (CAC). And just as with transcription positions, coding jobs are increasingly being outsourced or given to offshore coders.

Nancy Kadish, MS, RHIA, FAHIMA, vice president of clincial research and data abstraction at CIOX Health, is a member of AHIMA’s Council for Excellence in Education (CEE), a small group of elected AHIMA leaders including educators, practitioners, and industry consultants seeking to guide the HIM community through improvements in education, coursework, and curricula of associate, baccalaureate, and graduate HIM programs.

The CEE has examined the considerable parallels between the transcription and HIM/coding career paths. Kadish predicts that coding professionals, whose primary job is deciding code assignment, may very well see their jobs morph. But healthcare “will always need individuals that can understand how those codes are assigned, who know how to read records and analyze the data, and explain it to other users and stakeholders,” she says.

It’s up to the individual to keep their skills diversified and make sure they evolve with the industry, she says. The shifts taking place in coding are representative of what’s happening in HIM at large, warn HIM education and workforce experts. To help HIM professionals expand their influence in the workplace and prepare HIM students for a job market increasingly reliant on technology and informatics, the CEE is working on a follow-up to “Reality 2016,” a framework launched in 2006 aimed at guiding HIM into the future by promoting the acquisition of new skills and advanced degrees.

The Reality 2016 framework is being updated this year and will be called “HIM Reimagined: A framework for transforming health information management.” This initiative serves as a professional wake-up call to the shake-up currently facing HIM departments and professionals. HIM Reimagined will provide guidance on how to take the newly updated HIM competencies and use them in the profession (not just academia) to get the HIM jobs of the future, as well as ensure the profession remains relevant.

This is not just meant for freshman HIM students—even the most seasoned HIM professionals, Mancilla says, need to take note of the recommendations in HIM Reimagined and make sure they have the skills to remain relevant in healthcare.

New Competencies First Step Toward a New HIM

It’s now or never for HIM students and professionals with a vested interest in ensuring that the industry keeps up with the numerous changes going on in healthcare. A new emphasis on informatics, data analytics, information governance, clinical documentation improvement, Big Data, project management, value-based purchasing, and other payment reforms require a bigger investment in education for skills building. These themes will be a big part of the HIM Reimagined framework. Fortunately, AHIMA and educators are standing by, prepared to help both practitioners and students keep the profession thriving amidst massive change. To succeed, however, individuals need to invest in themselves.

Assisting with this shift in the HIM industry are new academic competencies developed by the CEE and released in 2014, says Michelle Millen, MSCPM, RHIT, interim dean of academic affairs at Collin College and chair of the CEE. The changes, which will be fully implemented in all accredited HIM programs by 2017, focus training and education on emerging HIM areas like information governance, data analytics, and informatics.

So far, educators have been accepting and enthusiastic about the new academic competencies. “I think that it was time for us to push that envelope a little bit to enhance and solidify those areas that weren’t present in the last curriculum. I think it’s been going well,” Millen says.

Understandably, there have been questions from educators who have asked for assistance. To address questions, Millen’s been involved in face-to-face meetings and webinars with other educators. “And certainly there is always room for improvement and we’ll take that into consideration when we work on the next phase of the curricular competencies… but I think it was well received,” she notes.

These academic competencies are really HIM professional competencies that all HIM professionals need to know to ensure continued relevance in a changing healthcare world. While the curriculum changes were developed separate from the HIM Reimagined initiative, the new competencies will help the initiative meet its goals. To strengthen HIM’s position in healthcare organizations the CEE beefed up several HIM curricular competencies and added others, focusing on areas such as research, budgeting, and strategic and organizational management.

These areas were added to ensure students can keep up with an increasingly automated work environment, even though the competencies don’t correspond directly to automation, Millen says. She says the goal of these competencies is to help students develop an overall skill set that enables them to manage business, clinical, and information systems that are integrated across an enterprise.

Making students aware of the interdependence of these separate systems was important to the CEE. Giving students a broader understanding of research applications and methodologies was also a priority, given the industry’s focus on improving outcomes through data and research.

“For example, at the associate’s level we added the competency of ‘being able to explain common research methodologies and why they’re used in healthcare.’ That was something we didn’t [previously] address at the associate level. At the baccalaureate level, one of the new competencies is ‘applying principles of research in clinical literature evaluation to improve outcomes.’ At the graduate level we added ‘analyzing principles of research and clinical literature, as well as creating an evidence-based practice body of knowledge,’” Millen explains.

Another new competency centers on HIM professionals knowing how to use “enterprise-wide information assets in support of organizational strategies and objectives.” The CEE wanted to make sure an understanding of this is captured at the associate’s level. Other new areas the CEE honed in on are cultural diversity, data analysis, and vendor contract management.

Putting ‘Reality’ in the Rearview, ‘Reimagined’ in the Windshield

The new competencies that are being applied within academia by 2017 are designed to give students the skills needed to remain relevant in the new healthcare environment in areas like informatics, information governance, revenue cycle, and data analytics. HIM Reimagined goes one step further and will examine and lay out for both HIM educators and professionals just how those new competencies/skills should be applied in the workforce, discussing what the new HIM workforce will be, where the new jobs are, how HIM professionals and students can get those jobs, as well as what new skills they will need in order to be successful and remain relevant in healthcare.

So much in the industry has changed since Reality 2016 was developed that Millen says it became apparent that the group needed to take a harder look at data analysis, informatics, and information governance and update Reality 2016 with HIM Reimagined. “In addition to that you’ve got the areas that have created some real challenges for our healthcare entities, things like privacy, security, data breaches, again very much a part of the HIM skill set,” Millen says. “We saw all of this and said ‘We’ve got to come up with some overarching goals, some tenets that we want to highlight for educators to make sure we continue to provide quality education that is representative of the credentials that AHIMA offers.’”

If HIM professionals don’t up their skill level in the areas Millen and others have mentioned, there are other healthcare professionals poised to move in and grab the jobs in those domains. Clinical professionals are increasingly moving into informatics, with nurses finding natural homes in nursing informatics and bioinformatics, just as IT professionals can easily step into roles with health information systems. And, since HIM is often housed in a hospital’s business office, billing jobs previously held by people with an HIM background can be usurped by individuals with more business skills, Millen warns. Also, in some facilities nurses have filled clinical documentation improvement jobs instead of coding professionals.

Millen says it’s important to remember that HIM professionals understand the clinical and business processes that occur from the moment a patient is admitted to the hospital to when the patient is discharged, and when the patient and their insurer are billed for service. HIM professionals are relevant because they have a complete understanding of how this cycle works.

HIM Reimagined seeks to answer questions arising as a result of a changing healthcare and education landscape, Mancilla says. “As we look at the ‘four Ps of healthcare’ in the future, as reported by a recent Deloitte paper—Predictive, Participatory, Personalized, Preventive—we know HIM professionals’ involvement with healthcare users will increase,” Mancilla says. “Hence, HIM Reimagined will, by necessity, address how HIM professionals must advance their skill set to more effectively communicate with and guide consumers.”

Use of electronic data and technology systems will play a big part in the HIM Reimagined recommendations. “Continual technology advancements and the data made available for decision making as the result of technology requires both students and practitioners to be better able to interpret, present, summarize, and use data to positively impact healthcare,” Mancilla says.

HIM Reimagined will offer a long-term and phased implementation plan to ensure the HIM profession is equipped both academically and professionally to further advance individuals and the HIM profession to a place of increased relevance in the future.

The Disappearing HIM Department

With the transition from paper to electronic records, the elimination of paper has also meant that HIM departments have physically downsized as well, with coders, transcriptionists, and clinical documentation improvement (CDI) specialists now being able to work off site and clerical filing roles being phased out. Seth Katz, MPH, RHIA, assistant administrator, information management and program execution, at Truman Medical Centers, says that when he first started at Truman in 2006 the system was still using paper records and HIM staff pulled 1,200 charts per day. He says meaningful use and the EHR boom gave the HIM department a chance to redefine itself. “The opportunity to rebrand who you are doesn’t come along very often… We don’t do anything the way we did 10 or even six years ago,” Katz says of the era that preceded going live with an EHR.

Truman isn’t alone. HCA Healthcare, which has about 165 hospitals, has transitioned the HIM departments of those facilities into eight regional “shared service centers,” run by the HCA subsidiary Parallon Business Solutions. Each hospital in the system has a tiny HIM department which is headed by a HIM leader, comprised of no more than eight people who fulfill primarily clerical functions as well as some transcription and release of information (ROI) tasks. The rest of the traditional HIM duties, including additional transcription, coding, ROI, document imaging, deficiency management, and others, are overseen by one HIM chief executive officer (COO) at each of the eight shared service centers. The COOs, including Cindy Nichols, RHIA, vice president of HIM at Parallon Business Performance Group, preside over an almost entirely remote workforce.

Nichols says HCA started moving to this model in 2008 when one group of hospitals realigned its HIM department during an EHR integration. The final group of hospitals that aligned its HIM department into a shared services center finished its transition in 2012.

Although this setup is nontraditional right now, Nichols expects to see HIM departments of the future go in this direction, especially as technology enables people to work remotely. There still are hospitals that use paper records, and as long as there is paper, there will be a need for onsite people to chase it down, according to Nichols.

She says that this organizational structure feels very “transactional” in nature, making an understanding of quality and workflow design a necessary skill for those working in this environment. There are so many data and records handoffs—when charts are sent from coders to billers, for example—that are harder to verify virtually than in a hospital.

Working in a remote environment, with “more of an eye toward the transactional business components of HIM, one skill set we have to have is being cost efficient and working with data,” Nichols says. “And my personal opinion, I don’t know if our average HIM graduates are getting that kind of exposure in their schooling, so they can come out and hit the ground running in this type of environment.”

That concern is exactly what the CEE hopes to address with the new HIM academic competencies, which, in part, center on these exact skills, and eventually HIM Reimagined.

HIM Skills Get a Reboot

HIM professionals are increasingly finding they must update their skills and certifications to not just keep their jobs but keep HIM going as a profession. ProCare Health’s Braunreiter says having her HIM department moved to the revenue cycle department was a catalyst for more education.

“When I have my monthly meetings with the finance directors, I really need to be able to understand and talk their language when it came to finance, which is why I went for MBA versus other master’s degrees. I looked at where I was in my career and where I wanted to move it,” Braunreiter says.

Braunreiter says she’s seen HIM departments become so transformed by technology—watching the transcription department go from 75 FTEs down to 3.5 over five years is just part of it—that she feels she must always be advocating for the importance of her own knowledge and HIM in general.

For example, since HIM was moved into revenue cycle, she has fewer privacy and security responsibilities, but because of her HIM background and her healthcare privacy and security (CHPS) credential, her facility’s compliance officer seeks Braunreiter out for questions.

She’s also concerned that HIM will cede some ground to their IT and information systems counterparts, which is prompting her to seek out the certifications offered by her EHR vendor, Braunreiter says. “In fact when I talked about going to [the vendor] myself and getting the certifications, the IT people are trying to convince me not to do that,” Braunreiter says. “‘We do that,’ they say. But I think ‘How can I tell you what I need if I don’t understand it as well as you?’”

Medical transcriptionists have had to diversify their skill sets, too, in order to protect their jobs, according to Linda Brady, CAE, the chief executive officer of AHDI, the professional member association for transcriptionists formerly called the American Association for Medical Transcription.

The transition to EHRs and voice recognition technology such as Dragon have shifted the focus of transcriptionists. Because of this, Brady says that the association now prefers the term “healthcare documentation specialist” to “transcriptionist.” Now, these specialists receive training in natural language processing, speech recognition editing, and quality assurance, since that’s where their duties are headed.

To help define the role of healthcare documentation specialist, AHDI has released new job titles and job descriptions for roles such as “HIM analyst,” “documentation integrity auditor,” and “EHR documentation trainer,” Brady says. “These are just a few examples of how some medical transcriptionists are starting to evolve into these different roles, in addition to many continuing on with speech recognition editing.”

As Seth Katz indicated, a profession doesn’t often get the chance to rebrand; but HIM now has that chance, something that is recognized by HIM Reimagined. Mancilla agrees, saying that with such vast change afoot in healthcare “now is a perfect opportunity to rebrand not only yourself, but the HIM profession as a whole.”

Note

^[1] Person, Carol and Minnette Terlep. “Transitioning Transcriptionists.” Journal of AHIMA 84, no. 7 (July 2013): 44-46. 

Reference

Deloitte. “Healthcare and Life Sciences Predictions 2020. A bold future?” Deloitte Centre for Health Solutions. 2014.

Mary Butler (mary.butler@ahima.org) is associate editor at the Journal of AHIMA.