HIM Role as the Data Stewards

1. HIM Role as the Data Stewards Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS & AHIMA Approved ICD-10 CM/PCS Trainer & Ambassador Senior Director of HIM Innovation

2. Agenda • Overview • The HIM Story • AHIMA Position Statement • Introduction to Information Governance • HIM Roles as Data Stewards • The Infrastructure of policies, roles and progress indicators • Summary: Our HIM Call to Action • Q & A

3. HIM Story • Our story as Health Information Management (HIM) professionals is one of protecting and managing health information. • Our primary ethical obligation to protect patient privacy and confidential information which includes: • Oversight of disclosure of information; • Management of Health information systems and health records; & • the Quality of information.

4. Ensuring Clinical Documentation Integrity Patient Safety Compliance Medical Necessity CMI Accurate Clinical Documentation Care Summary Severity of Illness Discharge Summary POA/HAC Core Measures Outcome Measures

5. HIM Story: Historical Position Statement on Data Stewardship, Approved November 2008 • AHIMA called for a nationwide effort among the healthcare and information technology industries, relevant government agencies, federal legislators, employers, and consumers to establish or identify and authorize a national health data stewardship entity (NHDSE). • A NHDSE would: • Ensure that rules for standards are established for uniform and consistent data and HIT would enable the HIE. • Coordinate the bodies that support the life cycle and collection of data exchanged over electronic and other HIE systems and the data stored in a variety of repositories or registries.

6. HIM Story: Historical Position Statement on Data Stewardship, Approved November 2008 In 2014, we still do not have universal authoritative source, law, or regulation that addresses and defines stakeholder rights and responsibilities and further ensures consistency and integrity in data collection (including common data definitions), distribution, and storage that allows for appropriate use of such data. There is a clear need in the healthcare industry to move toward a standard approach to developing the policies for a uniform and consistent method for health data integrity and exchange that transitions the concept of data ownership to that of access, use, and control of data.

7. Introduction to Information GovernanceData Stewardship

8. HIM Story: Information Governance Now On October 1, 2012 AHIMA called for Improved Health Information Governance to Unify Standards for EHRs Use to ensure the technology fulfills its promise of guiding better, more efficient patient care. AHIMA is ready to work with the HC industry to est. standards so that healthcare providers have the guiding principles for patient documentation.

9. HIM Story: Information Governance Now “Unified Data Governance Principles will help promote accuracy and consistency and reduce ambiguity” Lynne Thomas Gordon, AHIMA CEO

10. What is Data Governance? Making strategic and effective decisions regarding the organization’s information assets. Includes: • Defining roles and responsibilities for data • Establishing data quality policies • Creating metadata management practices • Arbitrating shared data questions • Release of Information

11. Value of Data Governance • The current “age of accountability” demands compliance • Data integration initiatives • Mergers and Acquisition (M&A) conversions • Master Data Management (MDM) • Data Warehousing • Release of Information • Insight into Profitability and Attrition • Compressed project delivery schedules

12. Benefits of Data Governance • Advances goal of making organizational data accurate, timely, relevant and high quality • Reduces duplication and associated costs including potential errors • Increases confidence in data

13. Information Governance • Govern health information environment; lead the development of organizational & compliance policies, processes, decision-rights & responsibilities • Protect and assure the ethical use of health information

14. Information Governance • Information governance provides parameters based on organizational and compliance policies, processes, decision-rights and responsibilities. • Governance functions and stewardship ensure the use and management of health information is compliant with jurisdictional law, regulation, standards, and organizational policies. • As stewards of health information, HIM roles and functions strive to protect and assure the ethical use of HIM.

15. The HIM Professional’s Key to Successful Information Governance • Data or Information governance is the high-level, corporate, or enterprise policies or strategies that define the purpose for collecting data, ownership of data, and intended use of data. Accountability and responsibility flow from governance. • The Information Governance plan is the framework for the overall organizational approach to data governance.

16. The HIM Professional’s Key to Successful Information Governance Data stewardship focuses on the people, policies, processes, and tools that manage the quality of data. • It is the operational component that complements the data governance plan and ensures that data are fit for its intended purposes.

17. HIM Role as the Data StewardsValue to Your Organization

18. HIM Role: Health Data Stewardship • To ensure the knowledgeable and appropriate use of data derived from individuals’ personal health information. • A central concept of data stewardship is accountability. • The role of data steward should be a formal responsibility within the organization for assuring appropriate use of health data, and with liability for inappropriate use. • Health data stewardship supports the benefits to society of using individuals’ personal health information to improve understanding of health and health care while at the same time respecting individuals’ privacy and confidentiality.

19. The HIM Professional is Key to Successful Information Governance Health data stewardship has taken on great practical urgency because of • the increase in availability of electronic health data; • growing recognition of the value of electronic data in improving health care and population health; • the acceleration in the use of information and communication technology; and • awareness of the potential risks associated with incorrect or inappropriate uses of health data

20. The HIM Professional is Key to Successful Information Governance Information Governance • Our expertise in Information Governance is our sweet spot. • Information or Data governance is the high level organizational framework or enterprise-wide infrastructure of accountability and responsibility that define the purpose for collecting data, ownership of data, and intended use of data. • One of the critical success factors within the domain of Data Governance is Data stewardship which addresses the detail of data quality management, everything from process workflow, policies and procedures to project management within this space.

21. The HIM Professional is Key to Successful Information Governance Information Governance • Information governance provides a foundation for the other data-driven functions in AHIMA's HIM Core Model by providing parameters based on organizational and compliance policies, processes, decision rights, and responsibilities. • Governance functions and stewardship ensure the use and management of health information is compliant with jurisdictional law, regulation, standards, and organizational policies. • As stewards of health information, HIM professionals strive to protect and ensure the ethical use of health information.

22. Clinical Documentation Integrity is Patient-centric A Document of high integrity is the center of your CDI efforts Physician & Clinical Documentation Clinical Documentation Specialist Health Information Management

23. The HIM Professional is Key to Successful Information Governance Why Now? • Many healthcare organizations have embraced data quality for years, it not decades, but the planning component of data governance is a relatively new concept. • Formal data governance requirements are being driven by the explosion of electronic data, the consolidation in the healthcare provider arena, and the increased focus on data sharing within and across local, regional, and state levels.

24. Data Quality Management Model

25. The HIM Professional is Key to Successful Information Governance Data Quality Management Domains Application: The purpose for the data collection Collection: The processes by which data elements are accumulated Warehousing: Processes and systems used to archive data and data journals Analysis: The process of translating data into information utilized for an application

26. Data Stewardship is Not an Afterthought • Understanding the relationships between data is often difficult, and the rewards of adequately resourcing data stewardship are not always self-evident. It is often shuffled aside when its impact is not understood. • A well thought out Information Governance Model that addresses many of the issues and clearly articulates organizations, systems, inputs, updates, appends, ownership, access, and reporting capabilities is the first step in an effective data governance program. • Information Governance acts as a framework for data that will be used to drive clinical and operational information and decisions; it is the blueprint for building a solid data structure. • This blueprint should also include details about which systems generate which data, where data flow and how, and how data will be used.

27. HIM Profession NOW • Healthcare leaders face many challenges: • ICD-10-CM/PCS transition • Achieving meaningful use (MU) • Launching accountable care organizations (ACOs) • Value-based purchasing programs • Assuring the sustainability of health information exchanges (HIEs) • Maintaining compliance with multiple health data reporting and clinical documentation requirements As a result, the need for more rigorous data quality governance, stewardship, management, and measurement is greater than ever.

28. HIM Responsibilities • Establish one point of accountability for each data element • Establish common vocabulary to help users know they have the right data and maintain the values for common reference data • Explain nature of electronic health information – ease of ability to transmit and share • New and greater uses of health data • Increasing secondary use of health data

29. The HIM Professional is Key to Successful Information Governance Example: Coding Compliance Policies Organizations using diagnosis and procedure codes to report healthcare services must have formal policies and corresponding procedures in place that provide instruction on the entire process—from the point of service to the billing statement or claim form. Coding compliance policies serve as a guide to performing coding and billing functions and provide documentation of the organization’s intent to correctly report services. The policies should include facility-specific documentation requirements, payer regulations and policies, and contractual arrangements for coding consultants and outsourcing services.

30. Compliance Patient Care FinancialIntegrity In EHR Self-editing In EHR MT-editing Narrative Feedback • Value-Based Purchasing • Coding/CMI On the Go • Meaningful Use • Quality Reporting • Documentation Integrity EHR On an MFP On a PC With a RIS/PACS At a DictationStation

31. The HIM Professional is Key to Successful Information Governance • HIM professionals are the Data Stewards • HIM professionals protect and manage Health Information • Both handwritten and computerized medical records contain personal and private information that we must protect and safeguard. • This is who we are, it is all data stewardship

32. Clinical Documentation Integrity The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.

33. Call to Action:Information Governance

34. HIM Call to Action: Information Governance • Our Challenge: Put your stake in the ground and let it be known in your organization that you are the steward of the data • Your organization can count on you and the HIM team for world-class Information Governance • Unified Data Governance principles will help promote accuracy and consistency and reduce ambiguity

35. The HIM Professional is Key to Successful Information Governance HIM Role Must Transition from Management of Paper to Management of Data Integrity • Position HIM as part of the leadership team with the implementation of these technology initiatives • Drive development of standards: • Patient identity management • Protocols for amendments and retractions • Naming conventions for forms and templates • Build in time between phases for improvement/optimization • Design 24/7 real-time data integrity and clinical documentation improvement processes • Communicate the importance of and changes to legal medical records in electronic environments

36. The HIM Professional is Key to Successful Information Governance New Unique, Innovative HIM Roles are Emerging • Identity Coordinator/MPI Coordinator • Content Management Coordinator (working with IT on doc) • EMR Integrity Specialist • Compliance Analyst (privacy and documentation audits) • Applications Systems Analyst • Regulatory Analyst • Regulatory Manager • Associate Director for Record Design & Management • Making Data Healthy Manager • Physician Educator

37. The HIM Professional is Key to Successful Information Governance Information Governance a Critical Role for HIM • HIT Thought Leaders were surprised to see the survey results reporting little increase in HIM’s role in Information Governance • Many agreed this was due to the fact that providers aren’t yet using the information to the degree that they will have to in the future • In addition, as clinical outcomes data increases in importance with VBP, Information Governance will increase in importance • This is an evolving area and AHIMA should work to stay ahead of the curve to help members lead this effort

38. AHIMA HIM Core Model POLICY Health Information Governance and Stewardship S T A N D A R D S Data Capture, Validation & Maintenance Information Analysis, Transformation & Decision Support Information Dissemination & Liaison R E S E A R C H Health Information Resource Management and Innovation Quality and Patient Safety EDUCATION

39. Future HIM Roles • ICD-10 and CAC • Compliance and reporting for Meaningful Use audits • Evidence-based medicine and knowledge management • Data and information governance • Managing patient identity integrity • Patient advocacy and engagement • Drivers of clinical documentation improvement • HIE at the hospital, market, and state levels • Legal Medical Record and eDiscovery • Cross-venue coordination of coding and quality metric reporting

40. Biggest Challenges • Reconciling/replacing disparate systems between facilities, practices, etc. • Data governance (who defines data, determines data flow into warehouse/decision support systems, ensures data integrity?) • Access to data: decentralized access throughout an organization OR centralized analytical team? • Timeliness of data to assist “real time” decision making • Both across entire core continuum

41. In Summary: Clinical Documentation Integrity • Integrity of health information is an obligation of HIM • HIM professionals must assume a leadership role in transforming these functions • Now is the time to analyze and visualize documented and undocumented intra and interdepartmental HIM functions to understand the current and future state of the HIM department while ensuring HIM best practices and standards are consistently maintained

43. Thank you

44. Contact Information Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS AHIMA Approved ICD-10-CM & PCS Trainer AHIMA ICD-10 Ambassador 678-291-1223 (office) 770-367-5156 (mobile/voicemail) Bonnie.Cassidy@Nuance.com

45. References • AHIMA. "Data Quality Management Model (Updated)." Journal of AHIMA 83, no.7 (July 2012): 62-67. • AHIMA Board of Directors. "New View of HIM: Introducing the Core Model.“ • American Health Information Management Association. "Developing a Coding Compliance Policy Document (Updated)." Journal of AHIMA (Updated March 2010). • AHIMA. “Statement on Data Stewardship.” November 2008. Available online at www.ahima.org/dc/positions

46. References • Cassidy, Bonnie S. "Teaching the Future: An Educational Response to the AHIMA Core Model." Journal of AHIMA 82, no.10 (October 2011): 34-38. • Fernandes, Lorraine; O’Connor, Michele. "Data Governance and Data Stewardship: Critical Issues in the Move toward EHRs and HIE" Journal of AHIMA 80, no.5 (May 2009): 36-39. • Moseley, Marty. “Agile Data Governance: The Key to Solving Enterprise Data Quality Problems.” Information Management. Special report, September 18, 2008. Available online at www.information-management.com/specialreports