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August 1, 2005

The Role of a Lifetime
By Kate Jackson
For The Record
Vol. 17 No. 16 P. 18

The electronic medical record appears set to take center stage in the healthcare industry over the next 10 years. To gain a starring role in this long-running production, HIM professionals need to step forward and show that they’re more than understudies.

Are HIM professionals making their voices heard and bringing their unique expertise to the planning and implementation of electronic medical records (EMRs)?

According to Michelle Dougherty, RHIA, CHP, professional practice manager at the AHIMA, the answer is yes ... and no. “We have many members who have been called out by their bosses to participate and who are actively involved, yet we hear as well that there are many members who won’t come to the table, aren’t interested, or don’t have the time,” she says.

Shifting the Balance
“It’s critical for HIM department managers to understand their organizations’ EMR initiatives and IT [information technology] plans, and if they have not been involved, they must recognize their need to be at the table,” says Dougherty. The role of the HIM department changes in an automated environment, she observes, and HIM specialists must understand the changes if they want to have an impact on their future and the facility’s future. “They need to get involved now,” she urges.

In many cases, it takes a great deal of assertiveness to insert yourself in the process and it’s often necessary to push yourself into a workgroup. “Let’s say there’s a big steering committee. Getting on that steering committee might not be possible, but there may be some workgroups or subgroups that are implementing different types of technology,” Dougherty says. “Campaigning and working to get on some of those groups and proving yourself there may be an excellent way of getting a foot in the door.”

Another way, she adds, is by staying on top of the available professional resources, such as articles in trade publications and AHIMA’s Practice Briefs. Then use that type of collateral to get on some teams and begin to raise HIM issues pertinent to electronic records.

HIM professionals may have to overcome a reluctance to join implementation teams, suggests Dougherty. Once they recognize these obstacles, they need to make a plan to overcome them. “For example, if you’re hesitant to get involved because you think you don’t speak the language, then it’s important to do something about it,” she says.

There are various remedies, such as college courses, AHIMA’s online course, articles, and Web sites, all with a wealth of information to supplement your education. “It’s not necessary to be an information technology expert, but it is necessary to speak the language to a point and be able to converse,” Dougherty says. Paying more attention to technical lingo is a step in the right direction.

Dougherty says another issue is that HIM professionals tend to take a tactical, task-oriented approach to things. The workload and types of jobs done in the HIM department foster that sort of thinking. “It’s important to start shifting your way of thinking from tactical to strategic, especially in a management position,” she advises. It’s necessary in this arena, she says, to start thinking more about the bigger picture and avoid digging in and trying to get right to the bottom of how to do something. “That kind of approach shuts off the thinking process. Instead, try to think strategically first about where you want to go. Or help the organization think strategically about where the electronic record can let them go and what some of the key issues might be,” she says.

Battling the Hierarchy
Dougherty has been dumbfounded to find a common comment emerging from chief information officers (CIOs) and technical consultants in workgroups: They can’t even drag HIM staff to the table to discuss EMRs. What was the problem? she wondered. “Was it a time issue? Were they overloaded? Were they uncomfortable with the topic? Did they not see how important it would be strategically to the department to be involved?”

Looking into the matter, she discovered that the HIM manager may be an impediment. “HIM professionals who have said that they are very involved often report to the CIO or to someone who has the information technology department under their purview,” she says. “For those professionals, it might seem natural to pull HIM into the process.”

She notes that a barrier may exist when the HIM manager reports to the chief financial officer or an individual whose focus, priority, and purview is not on technology or the EMR. “When individuals whose focus is financial are responsible for HIM departments, the last thing they want is a shift in focus in the HIM department from revenue toward technology,” she says. Because the HIM manager’s finance-oriented bosses don’t see the value of giving HIM a voice in technology implementation, they don’t give them the latitude to get involved in the projects, Dougherty explains.

Tooting Your Own Horn
Once they find a voice, it’s important for HIM staff to champion their role in the process, announce their strategic vision, and present key areas they need to oversee. “We’ve heard for a few years that with electronic medical records they’ll be no need for HIM departments because we’ve been so entrenched in the paper process,” observes Dougherty. “So one of the things that HIM has to do by getting involved in the EMR and the movement toward going paperless is to show that they can get rid of the paper, that they’re not married to the paper.”

There’s a perception, she notes, that electronic records don’t require management—that somehow, magically, technology will manage the records. “It’s not true. Electronic records still need to be managed,” she says, “and HIM staff has to communicate to others their continued role in record management.”

One overlooked area for HIM staff in an EMR environment concerns legal issues surrounding the medical record. “In the current atmosphere, everyone is concerned with information gathering and managing the patient at the point of care. What’s lacking is concern about the functionality for the back end or the downstream uses of the medical record,” says Dougherty.

Concern has been expressed only for what happens at the point of care, not for what happens after the patient leaves the facility. Often, she says, there is no functionality in place for the paperless record—for the electronic health record to be the legal business record that will stand up in court. Numerous legal issues—such as defining the legal record in an electronic or hybrid environment—must be dealt with on an ongoing basis, and it’s the HIM staff that has the expertise to manage these issues.

However, Dougherty observes that HIM managers who champion this role may encounter some resistance. “People don’t get it; they don’t know why it’s important. It’s a very hot topic,” she notes.

If facilities want to eliminate paper, their electronic record systems must be able to stand as the legal records. That fact alone argues for continued and considerable involvement of HIM management in planning and implementing electronic records. Because HIM management has always taken care of these downstream uses of the record in the paper world, it’s an often-overlooked functionality that will continue to be needed in the electronic world. “Teams are now waking up to the fact that they need to start having HIM people at the table and that these issues need to be addressed. As our members are championing these issues, that’s a message they need to bring out. They need to be seen as the key individuals in records and data management,” says Dougherty.

Facilities often see the electronic record as the domain of the IT department. “The IT department deals with the technology—the infrastructure, the network, and the physical and technical security,” says Dougherty. “What’s usually lacking is the data analysis and data management that HIM can provide.” As these roles become increasingly recognized, the HIM department will change. “It will be less clerical and more professional,” she says.

Case in Point
Dougherty points to Anne Tegan, MHA, RHIA, HRM, director of data and record services at Children’s Hospitals and Clinics in Chicago, as an example of an aggressive champion of HIM’s role in an EMR environment. “She [Tegan] got the ball rolling and created a transition plan and showed her facility how important HIM is to [its] electronic medical records initiative,” Dougherty says.

Tegan has been employed at Children’s since it began talking about an EMR and became involved in the process in 1996. “We started doing an RFP [request for proposal] with a number of different vendors, and I worked with a group that included the IT director, our vice president, and our medical director of informatics,” Tegan recalls. She says this was the core team that developed standards and goals, determined outcomes, and constructed the framework for implementation.

Tegan had to lobby to some extent to be included, but the vice president at the time of her initial involvement was aware of HIM’s expertise. She’s reported to a number of different people over time, however, and has had to continue to lobby for ongoing involvement and be proactive in asking questions and getting her voice heard.

“If you hear that something is going on or that a new product is being delivered, you need to ask tough questions and have to speak up with your concerns,” she says. “And when you do speak up, you must have a positive solution to any problems that you identify.”

Such behavior is not always easy, and it’s sometimes downright uncomfortable, she observes. It can be uncomfortable, she says, because it can thrust HIM into conflict—a position it typically tries to avoid. “It could be perceived that we’re trying to butt into an area that we shouldn’t be involved in and that we’re perceived as having knowledge only about the paper record, not the electronic record,” Tegan observes. If HIM staff doesn’t embrace the conflict, they could be left out, which would hurt their careers and the integrity of the medical record. “We have the greatest information about the medical record content and design,” Tegan explains. “We have a good understanding of the documentation workflow and we’ve always been able to communicate with the caregivers. We understand the concerns of the physicians and the nursing staff and we can translate that information to the IT technical staff.”

Sometimes the lack of inclusion in EMR development is just a matter of oversight. Planners merely overlook HIM and fail to understand their unique and critical role. “We have a depth of understanding about what physicians and nurses do, how they document, and what their documentation problems are,” Tegan says. “We’re generally the only people that really understand the importance of regulations, of making sure that everything is in order for the drug commission and CMS [Centers for Medicare & Medicaid Services], and of the role of documentation in coding and reimbursement.”

As Dougherty says, Tegan sought support from others, including the medical director of informatics, and advises that it’s crucial to network within your organization and gain the support of those who understand the importance of documentation. Speak up, she says, develop and maintain liaison relationships, and get as many people as possible to support your position and uphold your role.

Once records are online, says Tegan, there may be some decrease in the number of HIM staff, but the department certainly won’t be eliminated. HIM has a significant role to play both in the transition to electronic records and the ongoing management of those records. Many facilities are living in the hybrid world of part-electronic and part-paper records, and HIM staff is often performing dual functions. There will be a decline in the need for medical records personnel to print and file documents that are now online, but there will be a continued need for HIM expertise in the medical record management workflow, streamlining documentation, and defining the legal record.

Planning for Change
Tegan says HIM’s role in the move toward an EMR includes creating a vision—“trying to envision what the EMR will look like within your organization and what its impact will be in your department. What is missing in your organization? Who is responsible for the reconciliation of data? Do you have an HIM professional responsible for access to the record or is it an IT security person?”

Technical people can understand the background of security, she says, but do they really understand all the rules about who should have access to what portions of the EMR? That’s a definite role of HIM, she insists.

“It’s a whole new frontier, and HIM people are at the center of that because we’ll be involved with all aspects,” Tegan says. “There are new opportunities for HIM professionals coming up every day as we move along the path of the EMR. We have an orientation to detail that many others don’t have, and we have to translate our skills into the electronic world.”

— Kate Jackson is a staff writer at For The Record.

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