Leading the Way to Information and Data Governance, Part 3

LESLIE: In September and October, 2013, we wrote a two-part column about the Information and Data Governance leadership journey of Melissa Martin, RHIA, CCS, CHTS-IM, Chief privacy officer and director of HIM at West Virginia University Hospitals (WVU Hospitals), a 531-bed tertiary care system. (Read part 1 and part 2.) In 2013 the information governance agenda was top of mind across her healthcare system. Melissa took a proactive role in advancing the HIM department’s role as stewards of health information by working with medical staff and administrative leadership to build on the information management policies and procedures of their existing plan to meet Joint Commission standards.

PATTY: To advance the information governance structure, Melissa’s old medical record committee had become the Legal EHR committee and expanded to include representatives from Quality, Compliance, and Legal. Melissa discussed some of their priorities regarding issues related to EHR documentation, such as copy/paste and accuracy of EHR content, and described the success of their dashboard, used by the committee to measure the success of their activities. Her plans for 4th quarter 2013 included getting an information governance (IG) gap assessment performed by a consultant to help them determine the future needs of the program. Let’s check in with Melissa to see how the she and her colleagues used the consultation to advance IG in 2014.

LESLIE: Melissa, what were the IG highlights of 2014?

MELISSA: In 2014 we made progress in two broad areas — the IG structure and in IG operational process. We spent a lot of time determining the needs and goals for restructuring IG, beginning in the last quarter of 2013, before, during, and following an external consultant assessment of the HIM department. We also spent time creating and revising IG functions. Decisions about the structure of IG in HIM and system-wide required serious and thoughtful analysis and discussion this past year. Our healthcare system consists of an academic medical center, three community hospitals, three critical access hospitals, and several physician practices. The organizational structure for operations is at the individual facility level rather than the systems level, with my department at the academic medical center also performing some functions across the entire system. We plan eventually to take a system level approach to all IG to minimize fragmentation and redundancy, but that will need to be phased in overtime, and coordinated with other shared services that move from operating strictly at individual facilities to working the system level.

PATTY: I see the wisdom of standardizing and centralizing IG across all the facilities and I understand it would take time to implement a system level IG structure if some critical departments are not yet functioning at the system level.

MELISSA: We are a hybrid right now. The committee structure is at the system level, and some departments like Information Technology (IT) are at the system level, but the HIM department employees work in and report up through the leadership in each facility, so we need to take into account the various reporting roles. There is a lot of complexity to understand and address.

LESLIE: What changes have you been able to make within your HIM department at the academic medical center?

MELISSA: As a result of the IG consultation, we added an IG manager job description, which was converted from the old HIM manager position, and we developed a new data content and integrity manager position, which was approved by executive leadership.

PATTY: As I recall from last year you had a staff of about 170, which included only 4 managers at that time. Have there been other changes as well?

MELISSA: Yes, we now have 217 employees (27 physician-based coders moved from individual departments and the one new manager of data content and integrity, and 19 new coders to support ICD 10 and our growing Community Practice Division.)These changes, along with the two new manager positions I described earlier, reflect the beginning of the department’s transformation toward having a central role in information and data governance. In addition to coding, transcription and the other core HIM functions for our academic medical center, we are already responsible for maintaining the accuracy of the MPIs across the system, and for supporting the Legal Health Record Committee in such governance activities as auditing compliance to the copy/paste policies and procedures.

LESLIE: Where does HIM fit in the reporting structure in your facility?

MELISSA: We report to Finance and Legal at present. However, while today we are responsible for coding, and other core HIM functions, as HIM evolves in the future to do work more with quality of care data, population health management data and reporting, informatics, and data analytics, there are several alignment options to consider.

PATTY: I think everyone is going to want HIM!

MELISSA: I certainly hope so!

LESLIE: You mentioned that in addition to the structural advances this year, you also made progress in operations. Would you elaborate on that for us?

MELISSA: Yes, we are more focused on solving issues around copy/paste. We improved the process with technology that allows us to audit more records, and the Legal Health Record Committee determined that the solution to getting better compliance to the copy/paste policies is through better training and education about the hazards of improper use of copy/paste. The medical staff is still divided on its use-the specialists want to get rid of it and the general practitioners are concerned that completely eliminating it will significantly hurt their productivity. So to be fair to everyone, we have taken the education path this year, making sure that all physicians are aware of and understand the need for the copy/paste policies.

PATTY: How have your auditing activities helped this past year?

MELISSA: We have some new insights into the problem. Our auditing process has shown that sometimes what appears to be copy/paste is actually a result of the use of template notes in the EHR by various services, an issue that will also be addressed in the coming year. We want to understand the root cause of the problem and work with the physicians to solve these problems before implementing sanctions that have been proposed by the committee. We have stepped up our auditing and education all year, and will not implement a sanctions policy until 2015, so that all physicians will have had ample opportunity to learn the policies. We also want to align the copy/paste sanctions with our enforcement of delinquent record policies, so as not to overwhelm the physicians with different systems to correct different problems. We want to be respectful of their time.

LESLIE: You had implemented dashboards in 2013 to measure a variety of critical indicators. Do they demonstrate improvement?

MELISSA: I am happy to report that there has been improvement in the dashboard results. For example, data quality and integrity in the MPI went from error rates of 7.89 at the beginning of 2013, to 5.34 at the beginning of 2014, and now at the end of 2014, the rates are down to 2.95. We met our goal to be under 3%, and we will continue to monitor and report these rates on our dashboard. We may set some new goals for 2015.

PATTY: What else is brewing for 2015?

MELISSA: We will implement privacy and security auditing processes for other System facilities and practices as they come up on our EMR, and enhance our system-wide coding auditing process. We have created “affinity groups” (i.e., representatives from key departments in each facility) to get their input into the auditing processes that we will eventually implement and start reporting results on the dashboards. Another new audit role that is emerging for HIM is auditing records in legal hold to determine who has accessed the records.

LESLIE: Are there other new functions emerging related to the legal health record?

MELISSA: Our EHR system has a “legal record print” feature for release of information or for sending information with patients who are being transferred to other facilities. One of our biggest complaints about it is that it is too much information for the users. The IT, Legal, and Decision Support departments have issues with interpreting the records, so they look to us for assistance. HIM can and should be assisting with interpreting the patient’s story that a record tells. It is also an entr‚e to data analytics work.

PATTY: Melissa, your department is already living some of the exciting the new roles of HIM. The importance of IG has increased recognition by the healthcare system’s leadership; you and your staff have been proactive in helping sort through some of the challenges, and at the same time you have demonstrated your capabilities and competencies in new and important information functions. Do you have any advice to share with your fellow HIM colleagues who want to provide leadership in IG as a pathway to transforming their HIM departments?

MELISSA: To those who are just getting started, I suggest beginning with the operational issues, such as MPI, copy/paste, and records retention-both electronic and the paper records. We can’t forget about the old paper records. Our policy is to retain them for 20 years, so we have to make sure they are secure, readily accessible, and properly managed. I found the use of a dashboard useful in tracking the IG issues. Here is a link to the dashboard that your readers might find helpful. Download Here However, don’t linger too long on these operational issues. Move quickly to figuring out the structure of the IG functions, and start to branch out beyond the EHR.

LESLIE: Sounds like a tall order!

MELISSA: As HIM professionals we need to get outside of our comfort zone, and soon, or we’ll start to see new departments or offices popping up in our organizations. If we don’t lead now, we will see new infrastructure, such as a data management office, a decision support, or a quality office-and other healthcare professionals will be leading and managing these functions as they mature. We know that HIM professionals have the competencies and deep subject matter expertise honed over decades of medical record management to lead the emerging IG and DG functions, however, the rest of the organization isn’t always on the same page with us. For HIM professionals working in a healthcare system, leading the transformation of HIM and its role within the organization should be our highest priority over the next few years.

PATTY: Thank you Melissa for your inspiring message.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president, Care Communications Inc., Chicago. You can follow Leslie and Patty on their Twitter accounts, @FoxatCARE, and @pattytsheridan. Leslie and Patty invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or ptsheridan@care-communications.com.

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