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How to Balance Privacy, Security and Quality with Offshore Coding: Three Critical Caveats for HIM – HIM Scene

Posted on October 4, 2017 I Written By

The following is a guest blog post by Sarah Humbert, RHIA, ICD-10 AHIMA Certified Trainer, Coding and Compliance Manager, KIWI-TEK. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Prior to ICD-10 there was a shortage of domestic coders, making offshore services a necessity for many organizations. But in a post ICD-10 environment, experienced U.S. coders are more readily available and accessible. Domestic coding services are still considered best practice by most HIM professionals. In fact, 72 percent of hospital respondents outsource more than half of their coding needs according Black Book’s October 2016 Outsourced HIM Report.

While acceptance of offshore coding services has grown there are important caveats for HIM professionals to know according to the Black Book report. Price isn’t everything when it comes to protecting your patient’s privacy and your organization’s financial performance. Additional offshore concerns continue to be reported by U.S. hospitals and health systems:

  • Increased audit costs
  • Higher denial rates
  • Missed procedure codes

As Black Book states, it is imperative for offshore coding companies to tighten processes in three key areas: privacy, security and quality. With ransomware on the rise, hospitals, health systems and medical groups have greater levels of responsibility to fully assess their business associates—especially those using protected health information (PHI) offshore.

Because of these concerns and those mentioned above, HIM professionals must carefully explore, vet and secure detailed service level agreements prior to even considering the offshore option. This month’s blog lays out three critical caveats to consider and weigh against the proven value of domestic coding services.

Verify and Test Privacy and Security for Offshore Coding

The first step for HIM professionals is to understand the annual attestation requirements. Originally required by CMS for Medicare Advantage (MA) plans, the following annual attestations have become best practice for healthcare provider organizations and other covered entities (CEs) working to protect PHI.

  1. Provide notice to CMS—30 days prior to beginning the contractual relationship—that offshore contractors will be used, providing CMS an opportunity to review and raise an objection if warranted.
  2. Sign an annual attestation to accurately report to CMS the use of any offshore contractors.

For example, if a hospital wants to use a coding or billing company with personnel located offshore, it must submit the initial notification, receive no objections from CMS, and then annually attest that protections are in place with the offshore vendor.

Beyond the two-step attestation process, HIM professionals must take the following five precautionary steps with all offshore HIM services vendors.

  • Discuss any offshore contacts with your legal counsel and the vendor prior to signing.
  • Include language to indicate that onshore vendors will not subcontract with offshore vendors or coders.
  • Make sure your vendors are aware of attestation rules and take precautions to safeguard PHI.
  • Obtain cybersecurity insurance that includes coverage for potential breaches of offshore data.
  • Identify any other clinical services that may be provided offshore, such as coding audits, and consult your legal counsel to determine if that service should be identified in the attestation.

Rigorous due diligence of offshore coding vendor privacy and security safeguards ensures HIM professionals are doing their part in reducing PHI breaches and ransomware attacks in healthcare. Six states went a step further by prohibiting Medicaid members from sending any PHI offshore: Arizona, Ohio, Missouri, Arkansas, Wisconsin and New Jersey. If your state provides healthcare services in any of these states, additional review by legal counsel is mandatory.

Watch Offshore Coding Quality

The second area for concern with offshore medical record coding services is accuracy.

Offshore coders are mostly former nurses or other well-educated candidates. Although global coding staff speak English and are highly competent, they may not be well trained in self-directed chart interpretation.

Our clients often report international coding accuracy concerns and the need for additional audits, higher denials and missed procedure codes—especially as global coders expand beyond relatively simple and repetitive ancillary testing and radiology cases. In fact, 22 percent of HIM executives continue to shy away from a non-U.S. workforce, according to Black Book.

When it comes to coding quality, here are five recommendations to measure, monitor and manage accuracy prior to engaging an offshore coder.

  • Confirm who is actually doing your coding initially, and after each month into the services engagement.
  • Know global coders’ credentials, testing results and accuracy scores.
  • Verify that less experienced coders aren’t engaged following the initial work assignment.
  • Conduct a minimum of monthly coding audits to quickly identify and correct any negative trend or patterns.
  • Refuse to accept lower quality standards for offshore coding.

Re-evaluate Your Options

The medical record coding industry has shifted. Now is the time to re-evaluate the risks and returns of offshore coding services—keeping privacy, security and quality top of mind.

About Sarah Humbert
Sarah serves as the manager of coding and compliance at KIWI-TEK, a 100% domestic coding and audit services company. She is responsible for coding quality control—accuracy, turnaround time and compliance.

Sarah oversees all coding processes, including coders’ performance, credentials and recurrent testing. She is a member of AHIMA, IHIMA, CHIMA, and she is also a Certified ICD-10 AHIMA trainer. Sarah has worked in a variety of health information management positions for Health Care Excel, MedFocus and St. Vincent Health System.

KIWI-TEK is a proud sponsor of Healthcare Scene. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Preview of #AHIMACon17 – HIM Scene

Posted on September 7, 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.

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

I thought it might be interesting to check out the #AHIMACon17 conference hashtag for the AHIMA Annual Convention to get an idea of what the hot topics were going to be going into the annual convention. Unfortunately, there wasn’t much conversation happening on the hashtag yet. Here’s a sample of a few things I found and some of my commentary about each.


I’m excited to hear Viola Davis as well. I’m sure she has some amazing stories. It’s not clear to me her connection to healthcare, but I’m all about hearing the stories of successful people. I hope they let her tell her story and not try to have her be a healthcare speaker. Ironically, the MGMA Annual Conference is happening at the same time as the AHIMA Annual Convention about 45 minutes away. Viola Davis is keynoting both. I’m not sure if they planned this together or if it’s just coincidence. Either way, I guess I get 2 chances to hear Viola, but trying to manage both events is hard.


This tweet from Ciox made me laugh. There’s a lot of things in healthcare that are still stuck in the 80s. As Mr. H from HIStalk likes to say, Healthcare is where old technology goes to die. There’s certainly some modernization that could happen at about every healthcare organization.


This tweet is ironic after the above tweet talking about the need to modernize. I wonder how many in the AHIMA community are familiar with NLP based technology. For those not familiar, NLP stands for natural language processing. It can be used in a variety of ways, but in the AHIMA world it’s most commonly used to analyze medical records and assess if the documentation matches the coding. It’s pretty amazing technology. I also love seeing NLP used on narrative sections of a note to identify granular data elements that could be used to better inform clinical decision support tools. Do many HIM professionals care about this technology? Are they using it? I think I’ll ask when I’m at the event.


I think security will be an extremely hot topic this year. Given HIM’s role in doing release of information (ROI), it’s always had an important role. In fact, they have a pre-conference Privacy & Security Institute that I’ve heard a lot of great things about. I’m hoping to go this year if they let press attend.

Will you be at #AHIMACon17? What do you expect to be the hot topics? Are there sessions you absolutely must attend? Who’s going to throw the best party? I hope to see many of you at the conference!

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

Can HIM Professionals Become Clinical Documentation Improvement Specialists?

Posted on April 21, 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.

Most acute care hospitals have implemented a clinical documentation improvement (CDI) program to drive appropriate reimbursement and clarification of documentation. These roles typically live (and should live) within the HIM department. Clinical Documentation Specialists (CDS) work closely with the medical staff and coders to ensure proper documentation and must have an understanding of coding and reimbursement methodologies along with clinical knowledge.

Certain aspects of the CDI or CDS role require in-depth clinical knowledge and experience to read and understand what documentation is already in the chart and find what is missing. Some diagnoses may be hiding in ambiguous documentation and it is up to the CDS to gather consensus from the medical staff to clarify through front-end queries. There are many tools available to assist in this process by creating worklists and documentation suggestions based on diagnosis criteria and best practices. The focus of CDI is not entirely on reimbursement, although it is a nice reward to receive appropriate reimbursement for the treatment provided while obtaining compliant documentation for regulatory purposes.

Determining or changing the potential DRG prior to discharging a patient provides a secondary data source for many healthcare functions such as case management, the plan of care, decision support, and alternative payment models. For these reasons, a CDS must know the coding guidelines for selecting a principal diagnosis that will ultimately determine the DRG.

Inpatient coders also have the foundational skills to perform this role. Coders and HIM professionals are required to have advanced knowledge of anatomy and physiology, pharmacology, and clinical documentation. Therefore, to answer my original question “Can HIM professionals become Clinical Documentation Improvement Specialists?”, the answer is absolutely. But I will say that it depends on the organization as to whether nursing licensure and clinical experience is required in the job description.

Some organizations have mixed CDI teams consisting of coders and nurses while others may allow only nurses to qualify for this role. The impact of who performs the CDS role in the CDI program all lies in the understanding of the documentation, knowledge of coding guidelines, and detective work to remedy missing or conflicting documentation.

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

10 Awesome Things About HIM Professionals to Celebrate HIP Week

Posted on April 6, 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.

April 3-9, 2016 is known as Health Information Professionals (HIP) week. This annual event is a great time for celebrating accomplishments and touting the diverse skills of HIM professionals. I came up with a list of great things for us to brag about during HIP week and every day:

  1. HIM Careers: There are roughly 180,000 HIM professionals in the United States. There are 15 nationally recognized professional credentials available for HIM. (Keep spreading the word so we are recognized when asked what we do for a living. We are not just Medical Records!)
  2. Information Governance: HIM professionals are the gatekeepers of health information and are perfectly apt to take on new exciting roles in Information Governance and Data Analytics.
  3. Advocacy: HIM professionals are in Washington, DC this week advocating for a unique patient safety identifier- My Health ID. Be sure to sign the petition to remove the ban that prevents HHS from working on this important endeavor.
  4. ICD-10: ICD-10-CM and ICD-10-PCS coding classification systems were successfully implemented in October 2015 and are providing more specificity and detail to health data for documentation quality improvement and secondary data usage.
  5. Job Growth: There is a projected job growth of 18-26% in HIM positions in 2016. Source: Monster.com
  6. Remote Coding: Many medical coding professionals are able to work remotely from home.
  7. Social Media: A new hashtag for HIM social media conversations was started this week- #HIMsocial.
  8. Networking: We have great networking opportunities in HIM – conferences, online forums, and social media are great ways to learn and share information. Lifelong friendships and strategic relationships are always waiting to be made.
  9. HIPAA: HIM professionals ensure protected health information is kept secure and released only to the correct individuals who have a need to know. This  protects healthcare consumers and prevents fines of millions of dollars for healthcare organizations annually.
  10. Versatility: HIM professionals are versatile and can provide many benefits to different healthcare settings including hospitals, physician offices, EMR vendors, auditors, and insurance providers among many others.

Happy HIP Week to all! Celebrate your success and that of our great HIM community!

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

Keeping Telehealth in Compliance

Posted on December 9, 2015 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.

Telehealth, or telemedicine, promises to create better opportunities for increased access to healthcare. It makes perfect sense to meet patients where they are instead of requiring them to travel sometimes long distances for adequate care. We know that some diagnoses and treatments will definitely require an office or hospital visit but staying healthy, keeping compliant with medications, and maintaining chronic diseases could easily be addressed with telehealth.

Technology and EHR advances are already making many healthcare tasks easier and more convenient such as remote coding and web-based training. Smart phones and secure texting are being used by interdisciplinary teams to conveniently reach members of the team for coordination of care. Telehealth fits right into the mix using technology to bridge the geographic distance and gaps in patients’ access to care.

As with all healthcare operations, we must remember the sensitive nature of the subject matter at hand. Many try to cite HIPAA compliance as a potential barrier to adopting new technology. In contrast, HIPAA laws are being updated inline with the technology changes and we are able to securely exchange information by following the rules and taking appropriate measures to safeguard protected health information.

In order to successfully use telehealth, providers must work with health information technology professionals to ensure the technical and physical safeguards are in place for transmitting information to and from patients. Information must be kept secure and private which will continue to challenge health IT and HIM professionals. Patients must feel comfortable trusting that their personal information will be protected in the telehealth format just as it is in other media formats.

Other key concerns with telehealth are payment and insurance coverage. While telehealth will reduce the costs of healthcare, there is still a need for reimbursement to cover the provider’s time and expertise provided through a telehealth “visit” and the technology needed. There are many new conversations going to Congress in the near future to address the need for funding for telehealth particularly in rural areas. One of these is a bill referred to as the Telehealth Innovation and Improvement Act introduced recently. Until the benefits, cost savings, and effectiveness of telehealth can be understood by the Federal Government, we will continue to see the slow adoption rate. Once these issues are addressed and Government funding becomes available, there will be explicit guidelines and criteria for providers to meet in order to be in compliance with the payment structures.

We continue to strive for the best possible methods of meeting the needs of healthcare consumers in today’s technology driven society. We must marry the best of both worlds to provide convenient and cost-effective access to healthcare with secure and confidential methods of transferring protected health information. All of this will come with a price tag and will require the successful collaboration of health IT, HIM, and compliance professionals.

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

HIM Professionals and the Patient Portal

Posted on October 21, 2015 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.

One of the hot topics in healthcare that has been consistently developing and growing over the past few years is the patient portal. Since many different EMRs and portal platforms are used across hospitals and physician offices, each facility is left to develop policies and procedures for what will be released through the portals and how they will be used. There are no specific standards for patient portals, aside from those needed to meet Meaningful Use requirements, which results in different experiences and functionality for end users.

HIM involvement with patient portal implementations has been a little spotty over the years from what I gather from my peers. I heard someone say we “missed the boat” on patient portals. I don’t necessarily agree but I do see inconsistencies in the level of HIM involvement. When it comes to developing policies governing the content that will be released through the portal, HIM professionals are the experts on this initiative. HIM professionals have always been the stewards of the medical record and keeping release of information processes secure and appropriate. There has been a focus on encouraging patients to keep a personal health record long before EMRs and patient portals came to exist. So how could some HIM professionals get left out of the patient portal process?

My first assumption is that patient portals came to exist mostly, although not solely, as a result of Meaningful Use initiatives. If you have had similar experiences to mine, you have witnessed Meaningful Use initiatives typically being handled by IT professionals. As a result, patient portals have fallen under that umbrella from a technology standpoint but I see great opportunities for HIM professionals to be involved to optimize the content shared for the end users. Since the main intent of patient portals is to encourage patients to be engaged in their own care, these portal initiatives have much more benefit beyond attesting to Meaningful Use and should be incorporated into organizational strategic plans for patient engagement.

There has been a lot of discussion around the struggle of increasing patient portal participation. A common factor in patient portal adoption is the lack of patient competencies in using the technology involved. Some patient populations do not frequently use computers, email, or mobile applications which are all a part of the patient portal functionality. To address this at my facility, we created a position within the HIM department to coordinate all patient portal functions including enhancing the user experience by creating frequently asked questions and answers, troubleshooting issues that patients may have when attempting to login, and resetting portal passwords as needed among many other initiatives. Policies were developed to address who can have access to the portal information, how the patients confirm their identity to log in, what is released, and the duration of the availability of the information. We have an interdisciplinary team that contributes to the patient portal process but having the point person reside in the HIM department makes the most sense for governing the entire concept.

One thing to remember is that patient portals do not eliminate the need for traditional release of information processes because we release information to many different requestors for different purposes. The portal does not include every patient document due to the sensitive nature of some results therefore requests for entire charts and abstracts are still necessary in some cases. Patients should participate in the portal for the personal benefit of being proactive in their own healthcare but they should not expect it to replace release of information. I encourage HIM professionals to be involved in the patient portal process in an administrative capacity. The strides made with patient portal optimization are key in optimizing the transition to health information exchange (HIE) concepts which also require heavy HIM involvement.

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

Ensuring Quality Throughout the Evolution of Clinical Documentation

Posted on October 14, 2015 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.

Throughout my HIM career, I have seen many different methods of capturing clinical documentation. We are always looking for solutions to get accurate and complete clinical documentation into the medical record in a timely manner with minimal disruption to the provision of care. The processes for gathering documentation have evolved with advances in technology and HIM professionals have been very involved in ensuring the quality of the documentation.

When I first began working in an HIM department, we had a Transcription department with hospital-employed transcriptionists and a management team devoted to medical transcription. Quality reviews were performed regularly and the transcriptionists had an ongoing relationship with the physicians to provide feedback and get clarifications. As part of this department, there were file clerks in charge of filing the transcribed documents onto the paper medical records throughout the day and into the night. When I think back on these practices, it seems like an entirely different lifetime from today’s practices yet it really wasn’t that long ago.

Over time, transcriptionists began to disappear from hospitals as the task became outsourced. Vendors have offered to do the job for less cost and they guaranteed a high quality rating of the transcribed reports. However, transcribed reports often still come back to the medical record with blanks and anomalies that must be corrected by the dictating clinician which can delay the documentation reaching the chart. It’s important to review documents to make sure there are no obvious errors that may have been misinterpreted by the transcriptionist or the back-end speech recognition system.

Many are still relying on outsourced transcription as a major source of capturing documentation but this is evolving as EHRs have created new opportunities for documentation. EHRs provide documentation tools such as templates to import data into the notes and allow for partial dictation for the narrative description. The negative side of this is that copy and paste is used frequently due to the ease of grabbing documentation from the rest of the EHR and pasting it into the note to save time. Clinicians using copy and paste may not realize that the information could be outdated or it could be against company policies. This now requires quality reviews to monitor the use of copy and paste and the relevance of the documentation to maintain the integrity of the medical record. This should be incorporated into chart audits or other quality review processes.

Front-end speech recognition tools are popping up frequently as an additional tool to capture documentation. A concern with this is the shift from having quality reviews performed by the transcriptionist to now relying on the clinicians to edit their documentation as they dictate. Many are creating positions in HIM departments to perform quality reviews on the documentation to not only ensure the documentation is in the record in the adequate timeframe but making sure the documentation is accurate for each patient. It will be interesting to see how clinical documentation continues to evolve as new methods of capturing documentation are developed and deployed. No matter how the information gets into the medical record, HIM professionals still have the ultimate responsibility to ensure the quality of the documentation for patient care and appropriate reimbursement.

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

Is More Data Driving Less Individualized Healthcare?

Posted on September 16, 2015 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.

Many would agree that the goal of most healthcare professionals is to promote individualized treatment and care for every person who comes through an organization’s doors. Unfortunately, healthcare professionals and leaders are compulsorily focused on meeting regulatory requirements and capturing tons of data which may lead to less focus on individual patients. Unique personal characteristics can get lost in the big data of healthcare that is focused on producing aggregate trends and scores. 

HIM professionals are getting more and more involved in the collection of data and the use of this data for impacting clinical care decisions. While we are not the providers of clinical care, we still play a big role in the data life-cycle and its affect on population health. The fact that HIM professionals are not involved in direct patient care is beneficial to an organization because we can focus on gathering, measuring, and analyzing raw data that is returned to the clinicians in the form of information. Turning this data into meaningful information allows the clinicians to make positive impacts on individual patient outcomes and control healthcare costs by removing some administrative burdens. 

Key regulatory agencies such as The Joint commission are looking for an individualized plan of care for each patient. Meanwhile, Meaningful Use initiatives are pushing for a more statistical approach to capturing the same data on each patient to drive an aggregate snapshot of a patient population. Objectives for aggregate data and composite scores can overlook some individual nuances and take valuable time away from the patient’s one on one time with a clinician. This can put clinicians in a tough spot balancing between all of the different competing requirements.

HIM professionals are here to help find the balance between these objectives by assisting in the development of documentation templates and automated workflows. Pulling data forward in the EMR and minimizing duplicate entries are ways to successfully achieve this. In a perfect world, clinicians should be able to focus their time on gathering data about each patient’s particular condition and individual socioeconomic factors of health. Required regulatory data fields should be easy to find with prompts and they should make sense for a clinician’s normal workflow. These requirements should not be an excuse for non-individualized healthcare.

The quest for individualized healthcare can be difficult when clinicians are bogged down with checklists and requirements. What I hope to see more of in the future is better utilization of HIM professionals’ skills in support of individualized care and regulatory outcomes measurements. This results in a more streamlined workflow for clinicians, more data and information at their fingertips, and ultimately better outcomes for each individual person.

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

What’s Information Governance and Why Does It Matter in Healthcare?

Posted on August 19, 2015 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.

I recently spent some time explaining Information Governance (IG) and its importance to one of our executive leaders. She asked me to explain IG in 3 sentences or less to help her understand. Well, that was actually pretty difficult. It is complicated to summarize such a large, all encompassing framework that is IG but I believe I made the case effectively: “Information Governance is the umbrella that houses every transaction of information (not just medical records) within the organization and covers many different departments and tasks. It is much more than data governance. IG covers everything from monitoring the generation of data, protecting the information, controlling access to information, capturing revenue, governing the content and quality of the information, promoting population health, making decisions from data, and sharing the information internally and externally.”

Perhaps my explanation was less concise than she was looking for but IG is just that complex. I was happy to have the floor and to be able to discuss this topic with someone who can help me make an impact within the organization with a little education and guidance. I did not wait to be asked about IG. This topic is something of importance to me as an HIM professional and it’s also important to the successful operation of healthcare therefore I look for ways to insert the topic into everyday conversation at my organization. I welcome the opportunity to discuss IG.

This concept of governing information is not new; especially not to HIM professionals. Healthcare IG is becoming the new brand for the tasks we have done in HIM for decades. As more and more health information has become automated, IG has emerged as the necessary solution to the growing presence of raw data and increased electronic accessibility. I agree that governing health information and data in an electronic world is different from the paper-based records of the past but the foundation and concepts are the same. Managing information in the form of thousands of pieces of data takes technology and data analytics skills that HIM professionals are adapting and learning every day. We must take the new technology and the wealth of data and use it for the good of healthcare.

IG is really not so daunting when you start to apply it to everyday organizational workflows. It’s what HIM professionals know best. AHIMA has adapted ARMA’s generally accepted recordkeeping principles and has written a collaborative white paper to help us better understand what IG is in today’s data-driven healthcare environment. This is great for educating the HIM workforce and creating talking points for discussing IG within our organizations. If senior leaders and other healthcare professionals don’t understand IG and why an organization needs a structured approach, it is up to HIM professionals to start the conversation to introduce everyone to the principles of information governance and how HIM can lead the cause.

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

Why and Who Should Ensure Quality Health Data?

Posted on August 12, 2015 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.

Contrary to common belief, technology does not own health data. Data exists as a result of the input of multiple sources of information throughout each patient’s healthcare continuum. The data does not exist only because of the technology but rather because of the careful selection of meaningful data items that need to be captured and at what frequency (ie. instantly, daily, weekly, etc.).

We in healthcare collect granular data on anything ranging from demographics, past medical, surgical, and social history, medication dosage and usage, health issues and problem lists, disease and comorbidity prevalence, vital statistics, and everything in between. We collect data on financial performance with benchmarks and reimbursement trends using individual data elements from accounting transactions. Healthcare organizations have been collecting the same or similar data for decades but never before have we been able to operate with such efficiency as we do now thanks to advances in technology.

We have become so data rich in the healthcare environment in a short amount of time and this data continues to multiply daily. But are we still information poor? When we continue to generate data but fail to aggregate the data into quality information, we are essentially wasting bandwidth and storage space with meaningless and disconnected data.

Every time patients have interactions with healthcare providers and facilities, data is generated. Over time, the data that is generated could (and should) be used to paint a picture of trends in patient demographics, population health, best practices in care, comorbidities and disease management, payment models, and clinical outcomes. This information becomes useful in meeting regulatory requirements, overcoming reimbursement hurdles, clinical quality initiatives, and even promotional and marketing material for healthcare organizations. This data could have opposite effects if not properly governed and utilized.

It goes back to the saying “garbage in, garbage out.” If the data cannot be standardized or trusted, it is useless. Input of data must be controlled with data models, hard-stops, templates, and collaborative development of clinical content. Capturing wrong or inconsistent data in healthcare can be dangerous to the patients and healthcare quality measurements as well as leading to unwanted legal actions for clinicians.

So who is the right person for the job of ensuring quality data and information? I have seen bidding wars take place over the ownership of the data and tasks surrounding data analysis, database administration, and data governance. Information Technology/Systems wants to provide data ownership due to the skills in the development and implementation of the technology needed to generate and access data. Clinical Informatics professionals feel they are appropriate for the task due to the understanding of clinical workflow and EHR system optimization. Financial, Accounting, Revenue Integrity, and Decision Support departments feel comfortable handling data but may have motives focused too heavily on the financial impact. Other areas may provide input on clinical quality initiatives and govern clinician education and compliance but may be primarily focused on the input of data instead of the entire data lifecycle.

When searching for an appropriate home for health data and information governance, organizations should look no further than Health Information Management (HIM) professionals. Information management is what HIM does and has always done. We have adapted and developed the data analytics skills needed to support the drive for quality data abstraction and data usage (just look at the education and credentialing criteria). HIM departments are a hub of information, both financial and clinical therefore governing data and information is an appropriate responsibility for this area. HIM also ensures an emphasis on HIPAA guidelines to keep data secure and in the right hands. Ensuring quality data is one of the most important tasks in healthcare today and trusting this task to HIM In collaboration with IT, Informatics, and other departments is the logical and appropriate choice.

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