79th Annual Conference Capitalizing on Our Strengths June 1 ─ June 4, 2014
Capitalizing On Our Strengths: HIM Leadership Through Information Governance Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, & AHIMA Approved ICD-10-CM/PCS Trainer and Ambassador June 2, 2014
Agenda • Overview • The HIM Story • Introduction to Information Governance • HIM Roles as Data Stewards • Information Governance • Coding Compliance • Embrace New Technology: CAC Readiness • Summary • Q & A
The Future of HIM From this point forward… we must accept one another as equal shareholders of a partnership called “The Future of Health Information Management”
HIM Story • Our story as Health Information Management (HIM) professionals is one of protecting and managing health information. • Our primary ethical obligation is to protect patient privacy and confidential information which includes: • Oversight of disclosure of information; • Management of health information systems and health records; and • the quality of information.
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
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.
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.
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 establish standards so that healthcare providers have the guiding principles for patient documentation.
HIM Story: Governance Now AHIMA called for “Unified Data Governance Principles that will help promote accuracy and consistency and reduce ambiguity”
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
What is Information 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
Information Governance / Embrace Technology Successfully automating the entire coding workflow requires integrating People, Process and Technology
Value of Information 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
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
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.
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.
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.
Governing the Clinical Documentation Integrity Chain EHR CODING DOCUMENTATION CDI ANALYTICS COMPLIANCE PATIENT ENCOUNTER QUALITY REPORTING
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.
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.
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.
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.
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
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.
Data Stewardship is Not an Afterthought • 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.
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.
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.
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
The HIM Professional is Key to Successful Information Governance Information Governance a Critical Role for HIM • 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
Information Governance: Coding Compliance 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.
Information Governance: Must Include Your Coding Compliance Plan It does not matter if your medical record is paper-based, hybrid or electronic, a high-integrity Coding Compliance Policy should be written and updated at least once per year as part of your information governance framework. Your core designated clinical documentation set for coding should to be used as the key constant source of clinical documentation by your coding professionals as they conduct all the medical coding for your organization.
Coding Compliance Begins with Defining Your Core Clinical Documentation Record Set Coding Compliance Policy: • Do you have this? • Job descriptions, productivity expectations, quality monitors in place? • Dust it off and complete an evaluation now. • Test it to the upcoming challenges in clinical documentation and associated coding that face the health information management (HIM) professional staff of 2014 in your organization.
Coding Compliance Begins with Defining your Core Clinical Documentation Record Set Your Coding Compliance Policy must identify medical record documents and clinical documentation that require a mandatory review by your coding staff and/or the outsourcing providers of coding for your organization.
Coding Compliance DEFINING YOUR CORE CLINICAL DOCUMENATION RECORD SET Defining your “Core Clinical Documentation Record Set for Coding Compliance” is a critical success factor for CAC! Available at nuance.com Available at ahima.org
Coding Compliance Begins with Defining Your Core Clinical Documentation Record Set Defining your “Core Clinical Documentation Record Set for Coding Compliance” is a critical success factor for CAC!
What is CAC? • Computer-assisted coding is a solution based on technology that offers gains in efficiency and coding workflows, and improves quality of coded and clinical data. • CAC has been defined by the American Health Information Management Association (AHIMA) as “…the use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare practitioners.”
WhyShould I Consider CAC? It could be a mitigation strategy for: • Coding Compliance • Transition to ICD-10 • Incomplete documentation • Incomplete or incorrect coding • Sequencing errors leading to financial loss • Not understanding complexity of data (severity and Mortality risks) • Data integrity at risk
CAC Benefits • Reduce AR days and DNFB • Reduce HIM labor and outsourcing costs
Assess Your Current State • Evaluate, Update and/or Create a Coding Compliance Plan. • Identify your core clinical documentation record set for coding compliance. • Understand the types of clinical documentation capture. • Know the technology that will be affected by CAC and/or other ICD-10 preparations within your organization. • Review your current workflow for ICD-9 coding.
Know Your CAC Readiness • Understand the different types of clinical documentation capture. • Know the technology that will be affected by CAC within your organization. • Review your productivity standard. • Assess your process for coding compliance. An upfront assessment can yield long-term benefits to your Information Governance program.
Call to Action: HIMSharpen your Information Governance SkillsEmbrace Population Health Management