What keeps hospital CEOs (or CIOs, CFOs and COOs) up at night? It's a topic nearly every health care magazine, blog and quite a few conferences have addressed in some shape or form. And while the list of C-suite concerns is perhaps too long and unwieldy to print, the list of resulting "to do" items for HIM departments can be even longer.

That's where key performance indicators (KPIs) come in. For the last two columns, our hybrid medical records roundtable talked about the staffing-related surprises and challenges they faced while transitioning to a paperless environment. Now we're tackling KPIs, which is a topic very near and dear to hospital leadership and their teams. Why? Because in a complex, fast-paced, often maxed-out environment, KPIs provide a focused snapshot of the hospital's operations--where it is meeting objectives, and where it isn't.

For the next few columns, we'll look at how KPIs change in a hybrid environment and what HIM directors should anticipate when faced with a hybrid environment. To begin our discussion, let's speak with two panel members about their current KPIs and what changes will occur during the hybrid phase.

Brandwein: What are your existing KPIs as they relate to HIM?

Beth Kost-Woodrow, RHIA, chief privacy officer and executive director, WellStar Health System, Atlanta: Our five HIM departments have always monitored a variety of typical things such as delinquent record rate and discharged-not-final-billed (DNFB). We knew going into an electronic environment, that staffing by position within HIM would be an important indicator of progress. So we also determined what the projected staffing for each position should be before our transition even began.

Overall, our KPIs reflect our mission to maintain the highest level of quality and patient safety. We evaluate each technology system against this criterion: Can it provide strategic value and help us achieve higher quality and safety?

Glennda Gore, RHIA, vice president, corporate compliance and risk management; former HIM director, McAlester (OK) Regional Health Center: Much like Beth mentioned, our KPIs revolve around running the HIM department as smoothly as possible and supporting our hospital's mission to provide high quality care. Some examples of our KPIs include turnaround times for release-of-information (ROI) requests, quality indicators for coding and abstracting, delinquencies and DNFB.

Brandwein: As you transition from paper to electronic, the traditional HIM KPIs may be difficult to maintain. Will you adjust the existing KPIs, and what new KPIs may be added during system implementation and training?

Kost: Yes, when you're in a hybrid environment, traditional KPIs will have to be modified. HIM staff will lose productivity as they try to manage paper processes and simultaneously learn the new system. Getting behind is not in their nature!

Physicians may be vocal about disliking the system and the new processes it requires. Their dissatisfaction and ramp-up time to learn new chart completion and record viewing processes may slow everyone down. Finally, as your executives hear these sentiments, it opens the door for them to question your electronic medical record's (EMR's) value. So re-evaluating and even perhaps re-setting KPIs is a smart idea.

We took a serious look at our existing KPIs and made some adjustments to accommodate for a productivity slow-down. For example, we changed our DNFB goal due not only because of our electronic record implementation and the impact on coders, but also the introduction of present-on-admission codes and  MS-DRGs. We are consistently re-evaluating where it should be post-implementation.

In addition, we developed a few specific KPIs that have helped us optimize the new HIM department, manage staff expectations and even maintain executive support for our e-enablement internally. As I mentioned above, the first was staffing by position. By evaluating this data as well as our vendor's baseline productivity standards, we were able to make several staffing model changes as we evolved with the system.

We also developed a new KPI around system availability and downtime. We began monitoring the percentage of time that each of our systems is up and available. This KPI will take on more significance when we're completely electronic.

Other new KPIs include system printing volumes. We monitor who is printing out of the system and the number of pages they print. It is a best practice not to print out of the system at all unless absolutely necessary. This KPIs helps us identify individuals who may need training on the best ways to use the electronic capabilities vs. printing. Similarly, we monitor the number of physicians who are using the system so we can see who may need additional training.

It's also important to monitor the percentage of deficiencies created by the system rather than a human being. By doing this, we recently discovered another way to streamline a process through automation. We found three forms that are almost always on a record and must be signed. We decided we could automatically assign a deficiency to that document.

Finally, we're monitoring turnaround time from discharge to the time each record is available in the system for viewing.

Gore: We are still in a transition phase but plan to focus more on delinquency rates before, during and after implementation. We expect to see a large decrease in this KPI when we're completely electronic. We currently have the old "doctor box" system, which means that the record sits in one doctor box before moving on to another. With an EMR, all users will have simultaneous access.

Soon we will be moving our coders offsite and give them the ability to work from home. We'll tweak our KPIs to enable better tracking of at-home coding productivity. Additionally, we hope our remote coding function will enable us to have a more consistent and robust team of coders, and we'll be closely monitoring staffing to ensure we're seeing improvements.

Brandwein: I think it is unanimous! Managing KPIs during the hybrid phase can go a long way to help executives rest easier while seeing the value of the HIM department and its efforts to take the hospital completely paperless. Stay tuned, as next month we'll explore the various reporting mechanisms our panelists use to communicate their current, new and upcoming KPIs as a way to communicate milestones, justify new resources, and demonstrate return on investment with electronic records.

Aaron Brandwein is divisional vice president for HealthPort, formerly SDS. He is responsible for HealthPort's EDMS tecnology division and currently serves on the AHIMA Exhibit Advisory Committee and has spoken at numerous AHIMA national and state conferences on the topic of electronic and hybrid records.