AHIMA’s 4 Key Takeaways Go Beyond ICD-10 outlined by Rita Bowen, Senior Vice President of HIM and Privacy Officer at HealthPort
Believe it or not, McCormick Place, Chicago’s super-sized convention center was buzzing with more than ICD-10 talk last week. HIM professionals debated and discussed a number of important topics related to healthcare IT including privacy, data governance and meaningful use. Here are some of the questions and concerns I along with my colleagues overheard during sessions and in the exhibit hall.
CIOs and HIT vendors take note and check-in with your HIM Directors. Many of the discussions involve you!
Ramp Up Privacy
Perhaps it’s the new HIPAA privacy and security audits. Or maybe it’s those massive breaches posted seemingly daily on HHS’s wall-of-shame. Regardless of the cause, AHIMA attendees were keenly focused on privacy while in Chicago for their 84th National Convention and Exhibit.
Attendees bombarded speakers with questions regarding dates for the final privacy rule. The answer was consistent: soon. Most felt it would be after the upcoming presidential election, but only time will tell. As the industry continues to wait three proactive steps were recommended to prepare.
- Conduct an in-depth review of the proposed rule
- Compare existing privacy procedures to day-to-day practices. Ascertain if employees are really “walking the walk” of privacy
- Update mobile device policies and procedures. Strive to make hospital-owned devices for “hospital only” business
Implement a Data Governance Program
Data governance is a new term for some, but a long-standing role and responsibility for HIM. Maintaining accurate records and spot-on patient information is a core tenant of patient safety and legal medical record keeping. HIM professionals have been doing it for years.
However, as medical records morph into patient data, the job of governance gets complicated. EHRs can be a hotbed for information errors. And once erroneous data is captured it spreads like an air-borne virus; fast and furious.
A strong data governance program reduces errors, mitigates risk and improves patient safety. Furthermore, Meaningful Use Stage II can never be accomplished without effective data governance. Here are a few steps to get started.
- Establish a data governance team and ask HIM to lead the charge.
- Create a complete inventory of every information asset and assign a data steward to each system.
- Define each data element (data dictionary) and determine the effectiveness, usability, life span, and political outcome of each element.
- Plot data flow for every element within and between information systems.
- Formalize policies for data management and audit compliance.
- Monitor and manage the “cut and paste” feature within EHR documentation.
Establish Meaningful Consent in HIEs and ACOs
Another hot topic among AHIMA attendees was the need for clear patient consent to support ubiquitous information sharing in HIE and ACO environments. While IT professionals grapple with the technical ins and outs of information sharing, HIM professionals debate meaningful patient consent and the consent process. Questions include:
- “Who” is obtaining patient consent for information sharing?
- “How” is the patient being informed?
- “What” processes and procedures are in place to protect patient privacy as information is moved forward within an HIE or ACO?
A federal rule for HIE privacy and re-disclosure of information is critically important. HIMSS asked Congress for harmonization of federal and state privacy laws during their recent 2012 Policy Summit and in 2008, AHIMA published a practice brief addressing their concerns. Perhaps it is time for an update!
[See also: Health Information Exchange Is The Foundation for ACOs]
Survive the Barrage of Audits
The onslaught of recovery audits from Medicare, Medicaid and other payers can’t be denied. AHIMA attendees know it and AHA’s RACTrac 2Q Survey results confirm it. However, HIM professionals carry the most burdensome piece of audit; they must receive and responding to auditor requests for records.
The strategy for many AHIMA attendees was clear: focus efforts on preventing audits up-front to reduce cost and minimize revenue disruption down the road. The mantra to improve clinical documentation as a first step in reducing denials and mitigating audit risk was repeated at every booth and in every session. Additionally, these topics were discussed in relation to recovery audits:
- Pure volume is driving providers to move from Excel spreadsheets to audit management software and tools.
- Many organizations are centralizing the audit management function.
- In addition to hospital records, auditors are beginning to request physician office records.
Overall, AHIMA is a conference every HIT professional should enjoy and HIM professional attend. The confluence of regulatory pressures and data management requirements show no sign slowing down. And this doesn’t even include our biggest mandate: ICD-10!
Featured image credit: http://farm7.static.flickr.com
