For HIM and CDI professionals, 2018 looks to offer a gift of the tremendous opportunity for success.
By Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS for ICD10 Monitor
For movie buffs, the film Darkest Hour offers a tremendous view into the early days of World War II, when the fate of Western Europe hangs on the shoulders of newly appointed British Prime Minister Winston Churchill, who must decide whether to negotiate with Hitler or fight on against incredible odds.
As we embark on our new year, it is very inspirational and motivational to remember the words of Churchill: “victory at all costs, victory in spite of all terror, victory however long and hard the road may be; for without victory, there is no survival.”
There is no new year’s hangover in the world of health information management (HIM) – only striving for Victory! The healthcare industry represents 17.9 percent of the nation’s gross domestic product, and it is still growing – and this will surely dominate the news in 2018, as it has for much of the past decade.
Some 2018 areas of focus for exploration and learning for HIM and clinical documentation improvement (CDI) professionals include the following:
Clinical Documentation Integrity in the Outpatient Settings
Where there is confusion in the industry, there is an opportunity for HIM/CDI. There is no roadmap to success in this area, and there are only one or two technology enablers.
Given the confusion, HIM and CDI can assess their organizational needs and determine how to measure improvement associated with planning efforts. Every provider organization is different, so there is no right or wrong approach, given current initiatives and obligations, workflow, and staffing. Learning about the different reimbursement models for observation, the emergency department, outpatient clinics, and physician practices is vital. Reach out to understand what payer contracts your organization has and how much risk-adjusted reimbursement is involved. You can create CDI programs to target these areas that need a concentrated effort on clinical documentation accuracy. HIM and CDI must be proactive in all denial mitigation and avoidance programs. Understanding the reimbursement requirements gives you the opportunity to enhance your electronic health records (EHRs) and templates, and to build physician education and CDI programs.
Provider organizations have made a significant investment in technology during the past few years, and one of the biggest involved EHRs. Take the time to research, learn, and understand how machine learning, natural language processing (NLP) engines, cloning detection, artificial intelligence, and data mining can create meaningful analytics applied to result in your organization being able to make more timely and accurate decision-making, which can drive real behavioral change. Think about how much improvement and time-saving you would have in one area, such as physician office CDI! The opportunities are endless, but you need to understand the details and leverage the investment that your organization has already made in its EHR.
Securing the Internet
Following a year marked by major, industry wide cybersecurity breaches and a 525 percent increase in medical device cybersecurity vulnerabilities reported by the government, HIM professionals now must heed the national call to action to maintain data privacy. Never before have we seen such a need to secure the thousands of connected medical devices on the healthcare enterprise provider networks and protect our patients. Cybersecurity threats are real in the Internet-connected medical devices that are playing critical roles in such tasks as patient care, medical records, and billing. HIM must work with IT to secure and lock down each connected device that represents a potential door for cybercriminals. Who better than HIM professionals to rise to the occasion?
Privacy and Security of Health Information
HIM professionals play critical roles to ensure compliance with legal mandates relevant to the privacy and security of patient information. This has proven to be challenging, considering a constantly changing legislative and regulatory environment. Most notable, and of greatest familiarity to the public, are the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. As mentioned, HIM professionals have a renewed focus on privacy and security given the rising presence of patient information breaches. Patients may have no idea how vulnerable they are to cybersecurity threats due to unprotected networks, patient portals, EHRs, and medical devices outside of the walls of the hospital. Even copiers and fax machines are often not included in the inventory of equipment holding patient identifying information that is not secured. HIM professionals are known privacy experts, and they now have to answer the call to create governance programs, monitor breaches, and prevent cybersecurity incidents. Such incidents must be treated as a “non-natural” disaster, resulting in the investment of more time, planning, governance, and training of personnel and the medical staff.
Patient Experience and Consumerism
As the healthcare industry transitions from pay-for-volume to pay-for-value, HIM professionals must make strategic investments to improve the patient experience within their organizations. Healthcare providers have succeeded in making administrative tasks easier and more convenient for patients. Just think of what you can do online: now patients can pay bills and schedule appointments online via email or text. 2018 will be all about redesigning the patient experience so that patient satisfaction and outcomes can be tracked and measured. Because of the knowledge of identifying management, coding, and coded data, healthcare organizations can now utilize the expertise of HIM professionals to redefine the customer-centered relationship. Bravo to the HIM companies that have made the investment to champion clinical documentation integrity, maintenance and preservation of authenticated patient information, and the appropriate release of information. Healthcare also has an opportunity to learn from other industries (consumer products, financial services, and hospitality, as examples) how to more effectively target, serve, communicate with, and retain patients.
The transition to pay-for-value will continue, and it ultimately will involve the growth of the Medicare Advantage population, wherein keeping patients healthier is critical to controlling costs. The tremendous opportunity for HIM and CDI professionals in the Medicare Advantage conversation is to understand if their organization has acquired physician practices, and of those, how many are paid “at risk,” according to the Medicare Advantage contracts. These physicians have an immediate need for a CDI program in the physician’s office to target the clinical documentation requirements for ICD-10 diagnosis coding and to optimize the hierarchical condition category (HCC) system.
Analytics will also be used more widely in 2018 by providers and payers in creating incentive programs for reimbursement. Payers will use analytics to reward providers based on their history of delivering quality outcomes. These collaborative efforts can only be done with the expertise of HIM professionals, as the goal of the initiative is to raise the overall standard of care while reducing costs and increasing patient satisfaction. Who better to be a driver for this success than HIM professionals with a strong expertise in coding and classification? A successful transition to value-based care requires that market players and consumers move beyond transaction-based treatment to the holistic health of populations, from treatment to prevention/wellness, and from individual to population health. The only path to success is to rely on the data in the EHRs, which should be standardized and monitored by HIM, and the data created through coding and used in analytics. The creation of a health information governance program of rules, standards, and guidelines, created by HIM professionals, is a must if your organization is going to rely on accurate analytics.
Analytics that can help uncover patterns of fraud, waste, and abuse in health information represent a key goal for HIM professionals. Check out the American Health Information Management Association (AHIMA) Body of Knowledge and read the groundbreaking research conducted by AHIMA and the Office of the National Coordinator for Health Information Technology ONC from 2001-07. Now is the time to renew the HIM professional focus on this problem, and to seek to understand and discover new ways to deploy people, processes, and technology to decrease the potential for fraudulent activity. Fraud is a significant drain on the U.S. healthcare system.
Ten years ago, estimates by government and law enforcement agencies placed annual losses as high as $170 billion due to fraud, so you can only imagine how this has grown since. Healthcare fraud is a serious and growing crime nationwide, linked directly to the nation’s increasing healthcare outlay. Fraud is also a moving target, shifting to new and more sophisticated schemes to mask aberrant behavior. Fraudsters have a ripe opportunity to exploit healthcare information systems due to lack of governance and security needed for appropriate protection of patient data. This is an area where HIM professionals have deep domain knowledge and expertise.
Disaster Recovery for HIM
Natural disasters create devastation that lasts long after they pass. Events such as hurricanes and wildfires can wreak havoc on health systems, both in the short and long terms. Health systems that conduct proactive scenario planning can increase the pace of recovery following such disasters and avoid making premature decisions that could do harm. HIM must be involved in business continuity planning and disaster recovery of patient information systems.
Learn all you can about Blockchain Technology
A distributed ledger (also called a shared ledger, or referred to as distributed ledger technology) is a grouping of replicated, shared, and synchronized digital data geographically spread across multiple sites, countries, and/or institutions. There is often no central administrator or centralized data storage. A blockchain facilitates secure online transactions, which should represent to HIM professionals a new area to embrace and learn all that you can. A blockchain is used to record transactions across many computers so that the record cannot be altered retroactively without the alteration of all subsequent blocks and the involvement of the network. Why? Well, there are some dramatic improvements that are predicted in the healthcare industry with blockchain technology, so you will want to be a leader in this area. Some of its features include:
- Interoperability: Blockchains could enable data exchange systems that are cryptographically secured and irrevocable. This would enable seamless access to historic and real-time patient data while eliminating the burden and cost of data reconciliation.
- Claims processing: Blockchain-based systems can provide realistic solutions for minimizing medical billing-related fraud. By automating the majority of claim adjudication and payment processing activities, blockchain systems could help eliminate the need for intermediaries and reduce administrative costs and time required of providers and payers.
- Privacy and cybersecurity: Blockchain-enabled solutions have the potential to bridge the gaps of device data interoperability while ensuring security, privacy, and reliability.
We can only learn about blockchain technology from other industries and dream about the possibilities. This is a must for HIM professionals in their journey of lifelong learning.
Be aware of dramatic reductions in workforce in the HIM/CDI industry going forward. HIM directors and management are experiencing job eliminations these days in the context of hospital restructuring, as well as the elimination of HIM and CDI lines of business for companies serving the healthcare industry due to lack of demonstrated value. Job growth in the sector slowed dramatically in 2017, especially during the second half of the year, and unfortunately, the outlook for 2018 is bleak. Admissions and lengths of stay continue to fall as more care moves to outpatient settings. Pressure to keep price increases low remains strong. Margins are narrowing, so HIM professionals must think fast and be loud in differentiating themselves and demonstrating value to their organizations. All HIM and CDI professionals must assess their organizations’ ambulatory clinical documentation integrity in the facility-based outpatient settings and hospital-owned physician practices.
Ten years ago, the nation’s former healthcare IT chief urged HIM professionals at the annual meeting to “continue to lead” and to make their efforts “larger, louder and faster.”
“You are at a flexion point,” David J. Brailer, MD, told an audience of hundreds of AHIMA members.
HIM professionals have made progress, but once again are being called to be “larger, louder and faster” – and to prove to the industry the value of health information management.