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March 26, 2012

HIM Plays a Central Role in Safety, Quality Issues
By Elizabeth S. Roop
For The Record
Vol. 24 No. 6 P. 14

HIM professionals are well positioned to make significant contributions to hospital performance.

Whether it’s captured via pen, pencil, touchpad, or keyboard, accurate patient information is central to reducing medical errors and improving patient safety. As the keeper of the master patient index (MPI), HIM is uniquely positioned to advance quality initiatives by ensuring the data used to make care decisions are clean, accurate, current, and readily available.

“Push for quality records and everything else goes hand in hand with that. If you document properly and have correct patient identifiers and demographics on every page, it will lead you down the garden path toward better quality of care,” says Timothy Skero, Sr, RHIA, director of clinical information services with Sharon Regional Health System in northwestern Pennsylvania. “The medical record is the complete story of the patient. You need to tell that story as accurately as you possibly can.”

That holds true whether a facility has made the transition to an EHR, is in the process of doing so, or is still functioning in a primarily paper environment. In fact, if anything, the transition to EHRs and electronic MPIs (eMPIs) has upped the ante for HIM in terms of maintaining data integrity to facilitate a safer care environment.

Every Tool in the HIM Arsenal
Currently paper based, Sharon Regional has an eMPI in place and expects to have an EHR up and running by May. In preparation and as part of a larger focus on patient safety, the HIM department requested that the 241-bed hospital undertake a comprehensive MPI cleanup to eliminate duplicates and system overlays.

While the cleanup was “like a sigh of relief,” Skero notes that it was just the first step. Keeping it clean and finding new and better ways to utilize patient data to identify and mitigate potential safety issues are the real battles—ones HIM is best suited to fight in both the current paper and future electronic environments.

“We will utilize every tool we have available to try to eliminate every [issue] we can,” he says.

For example, the “do not use” abbreviation list maintained by HIM is a resource that is making the transition from paper to electronic along with Sharon Regional’s medical records. It is currently printed on all order forms as a reminder to clinicians not to use potentially dangerous abbreviations and will also be embedded in electronic order screens.

In addition, the transcription staff is trained to notice anomalies that could signal the potential for adverse reactions, medication allergies, etc. When an issue is identified, it goes directly to the health system’s patient safety advocate for management.

Skero’s department is also overseeing a concurrent documentation improvement program as part of Sharon Regional’s emphasis on quality improvement. Two registered nurses review all Medicare charts while patients are still in-house and call attention to anything that may impact the quality and safety of care.

“As far as monitoring, they’re doing it in real time. Their main focus is on document improvement to make sure doctors are documenting severity of illness, risk, and mortality up front,” says Skero, adding that in many ways, HIM has become a support arm for the patient safety team. “Normally, [issues] are caught concurrently while the patient is still in the hospital. Generally, I’m showing them something they’ve already seen.”

Meeting the Hybrid Challenge
Sharon Regional is not alone in straddling the paper and electronic worlds. The majority of hospitals today operate in a hybrid environment where patient information is scattered across the enterprise in both paper and digital formats.

It is here where HIM can have perhaps the greatest impact on error rates and overall quality and safety. With its unique blend of clinical, technological, and data management expertise, HIM can be a valuable resource as hospitals establish strategies for making the transition to EHRs in a way that enhances safety and improves care.

“In the hybrid world, things are extremely difficult. Clinicians may not be capturing all of the necessary information or it may be captured on different media. We need to make sure that the media used is presenting information appropriately and completely to the provider to make sure the patient gets the proper treatment,” says Karl J. Koob, MS, RHIA, CPEHR, FAHIMA, a clinical assistant professor and HIM department chair with the University of Kansas Medical Center. “This is extremely critical. As the industry continues to move forward, that hybrid environment is where HIM support will be critical.”

Koob cites the example of an HIM department within an academic medical center that developed a quick reference list highlighting the correct placement of information within a hybrid medical record to guide the conversion from paper to digital. Because of its clinical and data knowledge, HIM can also play a significant role in the development of clinical pathways, as well as in performance and quality improvement programs, to bridge the paper and electronic worlds.

“Better information doesn’t always equal more technology. Sometimes it’s about making it less complex and paying attention to the user interface, which are areas where a lot of errors can occur,” Koob says. “[In the meantime], we are still validating data going into the systems, questioning anything that doesn’t sound right, and making sure that everything is complete. Just because it’s electronic doesn’t mean they’ve filled in all the blanks.”

The key, he adds, is for HIM to step up and be noticed for its “responsibilities in the area of keeping the whole organization pointed toward patient safety, quality, and performance improvement.”

Leveraging Technology
HIM’s new responsibilities in the realm of patient safety don’t end when the transition to electronic is complete. If anything, the department’s role transitions right along with the patient record. It must become even more vigilant and adopt new strategies to ensure inconsistencies, inaccuracies, or other integrity issues don’t creep into the system via multiple new entry points.

Quality improvement in an electronic environment “begins with us because HIM is the keeper of the enterprise master patient index. We are the key link to all the electronic components” of patient information, says Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and privacy officer for HealthPort, which provides release-of-information services and audit management and tracking technology. “We are keeping that enterprise document clean [and] validating the quality and integrity of information coming into the medical record.”

Bowen suggests installing quality checkpoints at every stage of the data continuum, particularly at points of entry. Data should be continuously analyzed and validated. Any records that indicate possible patient safety issues should be flagged for additional evaluation so appropriate action can be taken. Most importantly, this should be done prior to discharge.

The real challenge stems from the fact that a hospital that has deployed information systems across the enterprise can easily have 40 or more data entry points. Further, the typical eMPI system will be used by more people than had access to the registration systems, many of whom have limited understanding of how the eMPI works.

Validation in an electronic environment is also more problematic. In a paper-based environment, information is typically keyed into a patient record by someone specially trained in the process and is therefore validated at the point of entry. That doesn’t happen when data are being entered by clinicians and others with little or no medical records training. As a result, a single error can make its way across the enterprise before it is identified—assuming it ever is.

“It becomes even more convoluted if you’re trying to do enterprise access, where you’ve merged outpatient ancillary, inpatient, and physician offices that are not traditionally in the MPI,” says Bowen. “You’ll find that will increase the error rates, so you have to clean it before it gets into [the system].”

For facilities that outsource to transcription or other data management vendors, Bowen recommends HIM establish clear policies that dictate when information should be flagged as potentially problematic. Doing so ensures that the department is alerted to the need for further validation.

Too often, she says, vendors simply trust that the data they are sent are correct. In actuality, they can serve as a second point of validation “to make sure there is no breach in the MPI. Send it back to the partner site so they can see if it’s an overlay of information. Have a conversation and engage all the people who are using the information. Work with them so they understand the importance of alerting the controllers of the patient index” to potential issues.

Bowen notes that while technology can enhance quality and safety by streamlining data entry, it can also introduce an entirely new set of challenges that HIM is best suited to resolve. For example, if all the key data elements are not properly authenticated at the time of registration to ensure the record is correct, it can result in overlaid information.

The process of separating electronic data is far more complex than its paper counterparts. In particular, the same issue may need to be corrected in multiple systems.

“We used to just open a paper folder [and] fix it. In the olden days, when a paper record came to us, it was what it was. We knew that was all the information. We authenticated it and could then say we were the custodians,” says Bowen. “Now, when you make a correction, you have to identify if the source system is updated and corrected. It’s not just fixing it once; it could be many times. So technology has helped the job but also made it more difficult.”

Answering the Call
As care and reimbursement models continue to evolve, pressure will continue to increase on hospitals and healthcare organizations to find more innovative ways to reduce errors and improve safety and quality. Because of its longstanding role as the keeper of patient data and its ability to function effectively on both the clinical and IT sides, HIM must assume a leadership role in the process. Along with establishing appropriate data governance policies dictating how information is collected, validated, and corrected, HIM should work closely with patient safety, risk management, and quality assurance to educate everyone who touches patient information on how it impacts care outcomes.

Regardless of whether it’s an electronic or paper-based setting, reducing medical errors and improving patient safety are responsibilities for which HIM is uniquely qualified. While some have yet to embrace the profession’s evolving and increasingly important role in the new healthcare environment, many HIM professionals are actively pursuing ways to impact quality initiatives.

“HIM touches all the components, from patient care and safety to compliance and billing,” says Bowen. “That’s the one thing that HIM brings to the table that another discipline may not. We are embedded into all the processes, and we know them from beginning to end. We know the life cycle of patient data, so there is no one better equipped to impact safety and quality.”

— Elizabeth S. Roop is a Tampa, Florida-based freelance writer specializing in healthcare and HIT.


HIM and Quality Benchmarking
HIM is well positioned to impact more than just internal quality and safety initiatives. Its role as keeper of patient data also means it is ideally suited to influence the quality indicators that are taking on new importance in today’s performance-based healthcare environment.

“HIM is getting out of the department, taking a more holistic approach, getting involved at the level that patient care is documented, and supporting the accuracy of patient information to which decisions are based,” says Susan Gatehouse, RHIT, CCS, CPC, managing director and principal of Gatehouse Consulting, Inc, which provides reimbursement, clinical documentation improvement, ICD-10 education, and coding quality review services. “[It] has a tremendous role in helping hospitals submit accurate data by working with performance improvement on areas that have been identified as subpar in terms of patient safety indicators.”

She notes that HIM’s perspective is one in which information is reviewed and coded after the patient has been discharged. When patient safety scores are low, too often the focus is on coding accuracy when the real problem may lie upstream with clinical documentation or interpretation of clinical or coding guidelines, which in today’s environment can often conflict.

Rather than assuming a defensive position, HIM should take advantage of the situation to identify areas where additional training or education could drive improvements in quality scores. By working with the performance improvement and/or quality committee, HIM can educate clinicians and others on how coding is driven by documentation, which can be influenced by care guidelines and clinical pathways. This will ultimately lead to improvements across the board that will impact indicators.

“You can see the lightbulb go off when you’re in those meetings. It’s two different worlds,” says Gatehouse. “You would never get to that point unless you sit down and see it from another person’s perspective. It’s such a great learning opportunity for both parties. The HIM professional is exposed to patient care guidelines and standards in place for certain conditions. Conversely, performance improvement becomes knowledgeable about the challenges coding guidelines set forth with some of the quality indicators.”

While clinical documentation will likely always be a challenge, HIM must take charge of finding ways to improve it from a specificity and accuracy standpoint, Gatehouse says. Closing the knowledge gap so everyone understands how data impact patient safety indicators should be a priority, she notes.

Surveillance technologies can be leveraged to more quickly flag cases that may impact indicators by continuously scanning clinical documentation for preprogrammed edits that may signal patient safety or core measure issues. This enables those cases to be evaluated while the patient is still in-house, netting treatment decisions that reduce or eliminate the risk of adverse events. The end result is that benchmarks are met.

“It’s about the quality of care, but also about the quality of data,” says Gatehouse.