Free Hospital EMR and EHR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to Hospital EMR and EHR for FREE!

A Look Into the Future of HIM with Rita Bowen – HIM Scene

Posted on June 14, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

One of my favorite people in the HIM world is Rita Bowen. She is currently Vice President, Privacy, Compliance and HIM Policy at MRO, but she has a really impressive HIM resume previous to MRO and a deep understanding of the evolution of HIM and their role in healthcare.

With this experience in mind, I was excited to interview her on the current state of HIM and where HIM is heading in the future. Here are the list of questions I asked Rita if you want to skip to a specific question or you can just watch the full video interview embedded at the bottom of this post.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

The Disconnect Between Patient Experience and Records Requests – HIM Scene

Posted on April 19, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

This week I met with one of the digital marketing team at a children’s hospital. We had a great conversation about the hospital website and the way the hospital’s website represented the organization to the patient. Plus, we talked about how patients choose to interact with the hospital through their website. There are a wide variety of patient requests through the website, but one of those requests was a request for their patient record.

It wasn’t really a surprise that this digital marketer didn’t really know the details of what’s required for a patient to make an appropriate medical record request from his hospital. In his defense, he didn’t usually answer the questions, but just created the website that collected the questions. However, it was quite clear that the workflow for any medical records request was to send it to their HIM department and let them figure it out.

Most organization then have their HIM staff play phone tag with the patient to explain how to make a proper records request which will allow them to release the information to the patient. The progressive organizations might send the patient an email. However, many of them will then ask the patient to mail, drop off or fax in the official records request. If this sounds painful, I can assure you that it’s as painful as it sounds.

This illustrates the massive disconnect between creating a great patient experience and most organization’s current records request process. Please note that I’m not blaming the digital team at hospitals for the issue and I’m not blaming the HIM people for this problem. I’m blaming the disconnect between the two organizations because the only way to solve this problem is to have both organizations involved.

The best patient experience would actually be for the patient to go to their patient portal and download their whole record. Maybe we’ll get their one day, but there are hundreds of systems in a hospital where a patient’s data is stored. So, it’s going to take a while for us to reach the point where a patient can self-service their data requests.

Since I’m not holding my breath on this amount of data sharing happening between disparate systems, I’m more interested in making the current processes so it’s a seamless experience for the patient. If you can model a medical records request on paper, then you can do it digitally. To their credit, I’ve seen a few organizations working on this. In fact, their system is part education about records requests and part getting the information that’s needed to fulfill a records request.

It’s time that HIM and a hospital’s digital and tech teams come together to make the process for requesting records a seamless patient experience. And if you think using a fax machine is a seamless experience for patients, then you’re part of the problem.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

A Look at the HIM World with Dr. Jon Elion from ChartWise Medical Systems – HIM Scene

Posted on April 5, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Healthcare Scene had a chance to interview Dr. Jon Elion, founder and president of ChartWise Medical Systems where we asked him about some of the big happenings in Health Information Management (HIM) and how world of HIM is evolving. Dr. Elion offers some really great insights into the HIM profession. You can watch the full video interview embedded at the bottom of this post or click on one of the questions below to hear Dr. Elion’s answer to that question.

Find more great Healthcare Scene Interviews.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

HIM’s Role in Healthcare Security and Privacy – HIM Scene

Posted on November 30, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

One of my go-to experts on healthcare privacy and security is Mac McMillan, CEO and Co-Founder of CynergisTek. He’s built a really great company that focuses on privacy and security in healthcare and he’s a true expert.

While at AHIMA 2016, I talked with Mac about the role that HIM plays in healthcare privacy and security. We also talk about where healthcare privacy is heading and which part of healthcare privacy and security doesn’t get enough attention. I also asked Mac to make a big 20 year prediction on what will happen with privacy and security in healthcare.

Check out our interview with Mac McMillan, CEO and Co-Founder of CynergisTek:

We shot a number of other videos at AHIMA 2016 which we’ll be posting shortly. If you enjoyed this video, be sure to Subscribe to Healthcare Scene on YouTube and watch our full archive of Healthcare Scene interviews.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Will Medical Coders Be Needed in the Future? – HIM Scene

Posted on October 26, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

After spending time with so many HIM professionals at the AHIMA Annual conference, I’ve come back thinking about the future of medical coders. No doubt, many HIM professionals are moving well beyond medical coding into other areas such as healthcare analytics, clinical documentation improvement (CDI), EHR optimization, and much more. However, there’s still a massive need for high quality medical coding and the HIM professionals that provide that service.

As we look into the future, the techie in me feels like medical coding should be automated. Why are we paying people to do medical coding? Why can’t that be automated and be done by robots? It’s not like medical coding is a particularly fun job. I’m sure there are some times it’s fun working on unique cases, but it can be quite monotonous and tedious. Why not have a computer do it instead?

What I’ve learned over the years is that medical coding is more art than it is science. Certainly there are some clear cut cases where it’s basically science. However, a large part of what a coder does isn’t set in stone. There’s some artistic licence if you will, or at least some interpretation that has to happen in order to code a visit properly. Computers aren’t good at interpretation, but humans are.

The other reality is that doctors don’t produce perfect documentation. If they did, then we probably could code a robot to code a patient visit. Since there are nuances to every physician’s documentation, we’re going to need humans that interpret those nuances as part of the coding process. I don’t see this changing in our lifetimes.

One word of caution. Many people fall into the trap that we need automated robot coding to be perfect for it to accepted. That’s just not the case, because human coders aren’t perfect either. In fact, there’s some research that human coders aren’t as good as we thought they were at coding, but I digress. The reality is that automated coding just has to be better than humans, it doesn’t have to be perfect. Even with this said, I don’t see it happening for a while.

What we do see happening now is a collaboration between humans and computers: computer assisted coding. While we don’t have to worry about computers replacing humans in medical coding, we do need to focus on ways that technology can make the work humans do better. That’s a powerful concept that we’re starting to see happen already.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Integrating CDI Efforts Across Inpatient and Outpatient – HIM Scene

Posted on October 19, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

One of the main topics HIM professionals have been discussing for a couple years is around CDI (Clinical Documentation Improvement). These programs have taken all sorts of shapes and sizes. Some are completely human driven. Others are largely tech driven, but most are a mix of the two. In fact, most CDI programs have gotten quite sophisticated and are really impacting the bottom line of healthcare organizations.

While most healthcare organizations realize that there are benefits to CDI, most of them have restricted these programs to the inpatient environment only. This was illustrated to me really well when I ran into a transcription vendor from India. It was his first time attending AHIMA and he was considering new areas of business including CDI. When we talked about CDI, his first comment was that he’d only ever seen CDI in hospitals, not in the ambulatory world.

While this is the case today, one HIM expert at AHIMA told me that one of the next big frontiers for CDI is going to be outpatient CDI. She went on to tell me that it’s fertile ground that could really benefit every healthcare organization. However, she also suggested that there shouldn’t be two CDI programs: 1 for inpatient and 1 for outpatient. Instead, CDI should be an integrated effort across inpatient and outpatient.

Clinical documentation improvement is only going to become more important in healthcare. Certainly, most CDI projects were started as a way to improve reimbursement. That’s a good goal and a benefit of a high quality CDI project. However, over time CDI is going to become even more important to an organization’s value based reimbursement efforts. In fact, if your clinical documentation isn’t accurate your reimbursement will really suffer. How can you keep a patient healthy if you’ve documented the wrong information for a patient?

How is your organization approaching CDI? Are you doing CDI in both inpatient and outpatient?

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Looking Forward to #AHIMACon16 – HIM Scene

Posted on October 12, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

As we prepare to head to the 2016 AHIMA Annual convention (see our full list of conferences we attend), we’re excited to talk about how we’re planning to expand HIM Scene to include as many HIM voices and perspectives as possible. HIM Scene will still be hosted here on Hospital EMR and EHR and will still have its own email list where HIM professionals can receive great HIM related content from thought leaders across the industry. However, we’ll be using HIM Scene to share a wide variety of people and perspectives.

The HIM industry is an amazing group of devoted people and that really comes through at every AHIMA annual convention I attend. Plus, HIM has a lot more influence than many people realize. So, we’re happy to do what we can to raise the voices and perspectives of HIM professionals here at HIM Scene.

Looking forward to the AHIMA Annual convention next week in Baltimore, we’re excited to learn about a number of important topics. Here are a few we’ll be sure to report on in future HIM Scene posts:

ICD-10 – A year after implementation, I’m really interested to hear the real stories of how ICD-10 has impacted healthcare organizations for good and bad. I bet there will be a lot of stories that haven’t been shared. I’ll also asking the HIM professionals I meet what they think the impact of the end of the ICD-10 grace period will have on healthcare. I wonder how many will have stories of ICD-10 improving care versus stories of ICD-10 for reimbursement.

Information Governance – This is an eternally hot topic in HIM, but it always continues to evolve. This is particularly true as records have gone electronic. This year I wonder how many people have been involved in some sort of health data sharing project. Information governance can get pretty tricky as healthcare organizations start to share data with each other electronically.

HIPAA Privacy and Security – A really hot topic given all the HIPAA breaches and ransomware incidents in healthcare. I’m sure I’ll find a number of HIPAA privacy officers that will share some good insights into how they’re dealing with these security and privacy challenges. I’m afraid many of them will give me exasperated responses about how their leadership isn’t taking it serious enough.

Informatics – I’ve been really intrigued with HIM’s role in healthcare informatics. Once you dive in, it makes since why HIM would be involved, but I don’t think most people saw that at first. What’s also been interesting to watch is many HIM professionals who’ve kind of shunned their involvement in healthcare informatics. We’ll see if many are still in that position or if most HIM professionals are starting to embrace and participate in the informatics efforts of their organizations.

What hot topics will you be looking for at the 2016 AHIMA Annual Convention? The AHIMA 2016 theme is to “Inspire Big Thinking to Launch Our Future.” We’ll be sure to report back any big thinking we hear from people we meet.

ahima-2016

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Managing Health Information to Ensure Patient Safety

Posted on August 17, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Electronic Medical Records (EMRs) have been a great addition to healthcare organizations and I know many would agree that some tasks have been significantly improved from paper to electronic. Others may still be cautious with EMRs due to the potential patient safety concerns that EMRs bring to light.

The Joint Commission expects healthcare organizations to engage in the latest health information technologies but we must do so safely and appropriately. In 2008, The Joint Commission released Sentinel Event Alert Issue 42 which advised organizations to be mindful of the patient safety risks that can result from “converging technologies”.

The electronic technologies we use to gather patient data could pose potential threats and adverse events. Some of these threats include the use of computerized physician order entry (CPOE), information security, incorrect documentation, and clinical decision support (CDS).  Sentinel Event Alert Issue 54 in 2015 again addressed the safety risks of EMRs and the expectation that healthcare organizations will safely implement health information technology.

Having incorrect data in the EMR poses serious patient safety risks that are preventable which is why The Joint Commission has put this emphasis on safely using the technology. We will not be able to blame patient safety errors on the EMR when questioned by surveyors, especially when they could have been prevented.

Ensuring medical record integrity has always been the objective of HIM departments. HIM professionals’ role in preventing errors and adverse events has been apparent from the start of EMR implementations. HIM professionals should monitor and develop methods to prevent issues in the following areas, to name a few:

Copy and paste

Ensure policies are in place to address copy and paste. Records can contain repeated documentation from day to day which could have been documented in error or is no longer current. Preventing and governing the use of copy and paste will prevent many adverse issues with conflicting or erroneous documentation.

Dictation/Transcription errors

Dictation software tools are becoming more intelligent and many organizations are utilizing front end speech recognition to complete EMR documentation. With traditional transcription, we have seen anomalies remaining in the record due to poor dictation quality and uncorrected errors. With front end speech recognition, providers are expected to review and correct their own dictations which presents similar issues if incorrect documentation is left in the record.

Information Security

The data that is captured in the EMR must be kept secure and available when needed. We must ensure the data remains functional and accessible to the correct users and not accessible by those without the need to know. Cybersecurity breaches are a serious threat to electronic data including those within the EMR and surrounding applications.

Downtime

Organizations must be ready to function if there is a planned or unexpected downtime of systems. Proper planning includes maintaining a master list of forms and order-sets that will be called upon in the case of a downtime to ensure documentation is captured appropriately. Historical information should be maintained in a format that will allow access during a downtime making sure users are able to provide uninterrupted care for patients.

Ongoing EMR maintenance

As we continue to enhance and optimize EMRs, we must take into consideration all of the potential downstream effects of each change and how these changes will affect the integrity of the record. HIM professionals need prior notification of upcoming changes and adequate time to test the new functionality. No changes should be made to an EMR without all of the key stakeholders reviewing and approving the changes downstream implications. The Joint Commission claims, “as health IT adoption becomes more widespread, the potential for health IT-related patient harm may increase.”

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Value Based Reimbursement: Another Challenge for HIM Professionals

Posted on August 3, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

How many times have you heard something along these lines: “HIM professionals must stay relevant and current with the continuous healthcare changes.” I must sound like a broken record to my team but it is absolutely true! HIM professionals provide the bridge between clinical data and reimbursement methodologies through CDI, coding, documentation integrity, and health data analytics to name a few. It has been proven time and time again that these HIM skills are vital to healthcare organizations but these skills must also be adapted and be put to good use each time a new guideline or rule is introduced.

Value-Based Reimbursement is an area that continues to grow with the push for quality patient outcomes and healthcare savings with potential penalties for excessive costs and poor quality of care. Reimbursement incentives that are tied to quality of care make perfect sense and HIM professionals need to take the plunge into these initiatives. By marrying departments and cross-functioning teams, we are able to generate proactive data and improve performance.

At my facility, I oversee the HIM department as well as the Quality department because we work closely together and will continue to have an even closer relationship throughout healthcare reform. This is becoming very common in the industry.

In this roundtable article for the Journal of AHIMA, we each outlined how we are bringing HIM to the table for Value Based Reimbursement initiatives and maximizing the tried and true skills of HIM professionals.

I have said it before and I will continue to say it: Always keep your finger on the pulse of healthcare and stay relevant by taking on these new challenges!

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Are We Outgrowing HIM Systems?

Posted on July 15, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

We have changed and adapted to a rapid influx of electronic medical records and data over the last several years and it’s no surprise that some systems have struggled to keep the pace. Electronic medical records (EMRs) are in a state of constant revision to make sure patient care, clinical functionality, and data security measures are keeping up with our needs. It seems there are software application solutions or enhancements to almost every task we do in healthcare and these systems are also constantly evolving.

I don’t know of any healthcare application system or workflow that has remained static year over year and because of this, it is important for us to stay on top of vendors and keep an eye on current and future needs of HIM workflows. Clinical Documentation Improvement (CDI) is one of those areas that has been evolving since it first came on the scene and it is currently undergoing yet another face-lift. We realized there were many revenue opportunities hiding within inpatient clinical documentation and found that we could maximize reimbursement with a little detective work and physician education along with sophisticated software tools. Many are exploring the idea of CDI for outpatient levels of care. This means we will need software applications, interfaces, and expanded CDI workflows to extend these opportunities to outpatient documentation. Have you thought about what you will need from your vendors to adapt or upgrade current systems and how much will need to be budgeted for?

As we work to implement computer assisted coding (CAC) programs, we see opportunities to increase coder and CDI productivity and capture even more quality documentation by using discrete EMR data to our advantage. But are these CAC systems ready to be pushed to the limits to enter unchartered waters? I personally do not have a CAC success story to tell as of yet, but I am exploring the options and hoping that these systems have matured more than when we first explored them a few years ago.

That’s the beauty of technology in healthcare; if a product does not meet your needs, there may be other options already on the market or rapidly developing new technologies on the horizon. A vast amount of data may be held hostage in our systems if we do not maximize our EMRs and applications and set our standards high in a quest for knowledge. We can’t rely 100% on technology to dictate what we do which is why we need to be the visionaries and demand more from our systems in order to accomplish new and exciting things in HIM.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.