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December 2013

A New Day for ROI Workflows
By Selena Chavis
For The Record
Vol. 25 No. 16 P. 14

Greater data exchange presents new challenges and opportunities to the release of information function.

The need to access patient records can come from a seemingly endless list of sources. As the industry moves toward greater health information exchange (HIE) and patient engagement, and information moves more quickly through the care continuum, HIM departments may feel increased pressure from release of information (ROI) requests.

It’s a significant trend that most HIM professionals agree has the potential to impact care delivery in a positive way. “The way we look at it is that patients have always had access to their information,” says Lisa Ferrante, RHIA, vice president of business development for Star-Med, a Delaware-based health and information management services company, adding that it’s vital for patients to be more engaged in their care. “The challenge is for health care providers to ensure privacy of that information as it changes hands.”

As electronic requests from stakeholders—ranging from patients and other health care providers to payers and government agencies—become heightened, the ROI process must evolve to include processes that ensure compliance with state and federal regulations and the secure transfer of information.

Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and privacy officer for HealthPort, says some confusion may exist about the role of HIEs and patient portals in the ROI process. “Patient portals may not contain the entire medical record despite their long-term goal to encompass a patient’s entire health record, regardless of where the care was received. HIEs securely share only very specific information, such as lab values and emergency visits,” she explains. “Both initiatives were designed to increase quality of care, public health, and patient engagement but will not replace the need for release of information functions within the health care industry. They are merely an alteration of current workflows.”

Jonathan Arkin, vice president of business development for HealthPort, adds that some of the confusion stems from IT departments, where a lack of understanding about the ROI process can create situations that lack proper management and administration. “IT doesn’t understand that HIEs are primarily designed for coordination of care,” he says. “Similarly, patient portals have a limited scope; they are presented by the EMRs and generally limited to very specific clinical information. What concerns me most is the lack of oversight with HIE. Whereas the ROI function requires validation of authorizations, prior review to ensure proper release, and other security features, HIE seems to be a bit of a free-for-all from an access perspective. This should be very concerning for compliance.”

Under the auspices of the Office of the National Coordinator for Health Information Technology, a pilot program currently is under way in cooperation with the University of Texas (UT) at Austin and Jericho Systems Corporation to address privacy in this evolving age of dynamic patient review. The program is designed to identify best practices for increasing transparency of data exchange for patients while safeguarding their privacy decisions, a critical issue going forward for success with HIEs and patient portal initiatives, according to David Staggs, JD, CISSP, chief technology officer for Jericho Systems. “There is a lot of concern about ROI as HIE grows,” he notes, pointing out that patient concerns regarding how consent is passed through the system increases skepticism about HIE.

As HIEs and patient portal initiatives progress, many professionals believe that workflows for the ROI function ultimately will look very different than they do today. “One of the most important things to remember is that this whole ROI process is morphing and will continue to morph into something very different than what we have now,” says Diane Ferry, RHIA, MS, president and CEO of Star-Med.

Complications for HIM Gatekeepers
“An informed patient is a better patient,” Ferrante notes, pointing out that better information exchange between providers and patients can only benefit care delivery models. While current industry trends advance patient engagement across the continuum, she suggests that their success will hinge on policies and procedures that ensure authorized access.

Increased patient access to health data is a double-edged sword, Arkin says. Instead of access running through HIM, it often extends beyond the department’s scope of control through the proliferation of electronic record technology. “While there is certainly a benefit for coordination of care, there is also much to be concerned about due to the increased regulations that have accompanied the increased access,” he explains, adding that the fallout already is occurring in the form of major data breaches. “The industry is not able to keep up from a regulatory perspective. It won’t be surprising to me when we hear a story about some crime ring that was able to position itself as an HIE participant and literally ping providers throughout the country to gain access to personal health information.”

Arkin also is concerned about the shifting roles across HIM and IT, noting that IT’s role seems to be growing exponentially in correlation to HIE movements. “Discussions at C-level meetings focus on how HIEs will streamline care delivery and lower cost while also improving quality. However, these initiatives don’t always correlate,” he says. “Depending on the hospital or system, I have witnessed HIM stripped of some of its power when they should be key stakeholders.”

In the end, Arkin notes that it may take some hard lessons learned before HIM’s role is elevated to where it needs to be in the greater discussion. “The federal government is pushing HIE via the big carrot-and-stick approach,” he says. “Providers are chasing the meaningful use incentives. However, if you really dig into the regulations, you will notice many ways for the government to position themselves to recover monies through compliance initiatives.”

The Need for Transparency
With so much convoluted in terms of control and jurisdiction over access to information, better patient engagement also may need to translate into greater patient control and responsibility in the ROI process. According to Staggs, transparency will be critical going forward. “Adding transparency would provide patients with more certainty and get more to opt in,” he says, noting that there must be some flexibility on HIM’s part to allow patients to have a say in the decision-making process about what information can be released.

The pilot program currently under way between UT at Austin and Jericho Systems focuses on giving patients more control and providing transparency. Essentially, patient consent databases that include automated policies determine who can access patient information and exactly what information is available for release. When a request is made, patients are notified directly so they can track who is accessing their data.

“What we are looking at is taking information that is external to a system—like a patient information repository—and using it alongside a policy-based CDA [clinical document architecture] document,” Staggs explains, citing the use of standards compatible with the Nationwide Health Information Network. “Patients can actually say, ‘Release everything but my psychiatric record.’”

Essentially, once a request for a patient’s clinical data is made to a provider’s EMR, the system contacts a patient information repository, where the patient has submitted automated policies surrounding ROI. The system releases the information based on the rules associated with the data, and the patient is sent a notification of the request.

Currently, researchers engaged with the pilot program are examining how a patient consent directive for a simulated patient record is retrieved and matched to a patient’s identity as well as how the patient is informed of the access request.

Changing the Culture
As the concept of ROI and more patient control over the process continues to evolve, what effect will it have on HIM?

Bowen emphasizes that HIM directors need to take a leading role in education and apply change management techniques as ROI workflows continue to change. “Sometimes you have to assist people with unfreezing from the status quo,” she explains. “Do this by explaining or painting a picture of the difference between status quo to the desired goal. The HIM leader must become a motivator for the journey and then, upon arrival, refreeze new processes and procedures throughout the organization for the success of the stated goal.”

Arkin points out that HIM will need to consider an expanded focus on customer service because more patient knowledge means more questions. Instead of hiding behind the scenes in the hospital environment, HIM professionals must become more visible as more patients become engaged in their care, he says. “HIM is becoming the front line of the provider, so an expanded role would be a good course of action,” he says, adding that patient satisfaction is a focal point for all health care organizations in today’s report card and rating climate. “As patients gain more power, they demand more services, more choices, and more quality. Let’s face it: The baby boomers are entering their retirement years. This is a large generation; they generally have money, they are demanding, and they engage in technology.”

Bowen adds that as HIM departments become more engaged in conversations with patients, leadership should review its current design to ensure there is ample private space for such conversations to take place. Considerations regarding the appropriate level of trained and educated HIM professionals also will need to come into play to ensure there is enough availability to accommodate requests.

Simply put, as patients become more engaged in care, increased requests for record amendments may begin to overwhelm HIM. “As patients more actively read the information contained within their health record, they may note discrepancies and request that those discrepancies be amended,” Bowen says. “Without a well-designed information data governance plan, which includes mapping of all source systems, the amendment process could become an overwhelming task.”

Expanding and Elevating HIM’s Role
The article “Opportunities for HIM Involvement in the HIE Landscape” posted online in January 2013 in the Journal of AHIMA mentions three keys to data integrity: the data must be collected, entered, and queried correctly.

Experts agree that boosting HIM’s role will be critical to the success of future ROI functions to ensure information integrity and data oversight. For example, Bowen points out that HIM professionals are excellent resources to assist with the design and patient engagement processes associated with the patient portal. “The first step is for HIM professionals to join C-level discussions around data governance and data integrity,” she says. “HIM’s ability to analyze, interpret, and create innovative solutions is needed by every health care organization and HIE initiative.”

According to Bowen, communication and data content standards are the keys to successful information exchange, making HIM professionals key players in the process as they help health care organizations use data standards to enhance the utility and value of the information exchanged. “It is imperative that HIM professionals utilize their voice in their facility and community discussions as initiatives regarding sharing of data are being discussed,” she says.

Arkin cautions that while greater patient engagement certainly has its advantages, it also may create more litigation if ROI is handled incorrectly. He believes HIM expertise will be critical to navigating the future of information access. “We already live in a very litigious environment, where people are marketed to on a daily basis that they may have been wronged,” he notes. “The regulatory environment around access is already burgeoning, and compliance is truly a cost center. As providers struggle to contain costs, they will have to make very difficult decisions in the area of risk management.”

Many challenges lay ahead on the road to greater patient engagement but, in the end, Bowen believes that overcoming roadblocks will be well worth the effort. “Better informed patients lead to stronger compliance with their own wellness programs and ongoing lifestyle changes for healthier outcomes,” she says. “Organizations that embrace this philosophy also become active partners within their patient communities and true advocates for improved health and maintenance.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to health care and travel.