Remember the title "medical record librarian?" It accurately reflects the early days of health information management (HIM), when the primary responsibility was to maintain and track clinical records. As technology and healthcare have advanced, however, the role of the basement-bound librarian has evolved into that of full-fledged data manager and information gatekeeper.
This profound transformation continues to elevate the importance of HIM professionals. From Meaningful Use to accountable care, there has never been more pressure to collect and use healthcare data to lower costs and improve care quality. In an environment now dedicated to breaking down traditional data silos, HIM already offers a uniquely cross-functional perspective.
Unlike the quality manager who reviews data only with an eye toward quality indicators, or the director of finance whose focus is limited to the revenue cycle, HIM professionals understand the role of data from all angles. HIM knowledge bridges conventional boundaries to include process improvement, quality assurance and reporting, medical records, regulatory compliance and revenue cycle management.
For this reason, HIM specialists are in the best position to ensure that information not only meets institutional needs, but also conforms to all federal and state regulatory guidelines. The critical responsibility for auditing and validating data now rests squarely on HIM shoulders. Three key data functions - capture, control and analysis - are now evolving to fulfill a variety of new interdisciplinary requirements. As a result, the HIM perspective is becoming increasingly valuable to the future delivery of healthcare.
Ensuring Effective Data Capture
The days of physicians hand-writing notes and sending them off to a transcriptionist for inclusion in the medical record are rapidly dwindling. Today, direct documentation into an electronic health record (EHR) at the point of care is considered the gold standard. Yet even with provider-entered EHR documentation, hospitals and health systems still must ensure that the right information is being documented accurately.
The familiar adage "not documented, not done" has taken on a new twist since the arrival of EHRs and the associated upsurge in payer audits. Documentation must not only be available, it must also accurately reflect the salient aspects of each patient encounter. Recognizing when documentation is at risk requires both a broad knowledge of clinical processes and an understanding of payer and regulatory requirements.
HIM professionals are among the few with the background necessary to assess documentation against all of the clinical needs, quality initiatives, payer uses and regulatory requirements for which it might be necessary. For example, while information technology (IT) staff can see whether specific EHR data fields are complete, they typically cannot tell whether the information in those fields is relevant for coding or quality measurement purposes. By contrast, HIM staff can use their understanding of the data being entered to drive beneficial clinical documentation improvement (CDI) efforts.
Furthermore, coding functions appear to be moving along much the same path as transcription. In the sense that voice technology and speech recognition software have made it possible for transcriptionists to become "editors" rather than "typists," computer-assisted coding (CAC) and other tools are enabling HIM professionals to step into new roles as code "validators."
All of these changes in the way data is captured are heavily dependent on technology. It is important, therefore, for HIM to work together with IT to ensure technology supports the appropriate and useful collection of data - whether via participation in vendor selection or by offering assistance with EHR template creation. All this adds to the significance of HIM professionals' viewpoint on data capture.
Controlling Data Integrity
Editing and auditing health information has long fallen within the purview of HIM. As larger and larger amounts of data are captured electronically, however, ensuring the integrity of that data will become an even bigger part of the HIM role. While EHRs make data collection faster and easier, providing solid quality control requires an understanding of where the data comes from, where it is going and how best to protect it.
Consider, for example, the fact that many of the Meaningful Use criteria encourage patient access to health data. These new rights and responsibilities must be carefully weighed against stringent Health Insurance Portability and Accountability Act (HIPAA) regulations that govern privacy and security. The ability to walk this "records-release tightrope" increasingly will require the skill of HIM staff versed in regulatory compliance, in addition to clinical workflows and IT capabilities.
It will be up to HIM experts to bring this same knowledge to the development of inward-facing data control policies and procedures as well - such as those regulating the appropriate use of "copy-and-paste" features within the EHR.
Promoting Accurate Data Analysis
Ultimately, most of the change occurring in healthcare today is aimed at using data to derive financial and patient care benefits. This requires the efficient and effective analysis of data; analysis that promises to create profound shifts in HIM.
As patients evolve into healthcare consumers with the freedom of choice, peer comparisons - among providers, hospitals, health systems and payers - are expected to grow in importance. As true data managers, HIM professionals must be prepared to play a key role in ensuring the relevance and accuracy of data revealed to patients, payers and other providers.
Hospitals will need the right data, the right analytical tools and the right HIM resources to review all data points if they wish to fully meet financial and quality benchmarks. Hospitals and health systems that look only at financial data, for instance, will fail to identify opportunities for clinical quality improvements. However, by comparing internal data against publicly reported peer data, institutions gain the information they need to implement initiatives capable of driving operational efficiencies and patient care improvements.
Continuing the Evolution
Most healthcare organizations have come to the realization that data is the underpinning of clinical, financial and operational change. They recognize that public reporting and transparency are important to future viability. Data "librarians" are no longer necessary; data "managers"; however, are indispensable.
HIM professionals are uniquely qualified to help usher in the new era of data-driven healthcare. Merely collecting data provides no assurance that it is good data. The role of gatekeeper is essential to ensuring that healthcare information is appropriate, reflective of reality and useful.
As health information stewards, HIM professionals must remain the custodians of data integrity. HIM is not just a cost-center now; it has become part of the lifeblood of healthcare.
George Abatjoglou is CEO of IOD, a leading provider of integrated HIM solutions for hospitals, IDNs, healthcare systems and clinics. Shiny B. George is the senior director of health information management at Thomas Jefferson University Hospitals, Philadelphia.