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Themes and Lessons from AHIMA 2011

October 19, 2011
by Joe Bormel
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Three issues are competing for attention: MU, EHRs, and ICD-10

Themes and Lessons from AHIMA 2011

As promised (link), I’m here to share a few of the major messages that resonated during this convention. So without further ado, here are my notes, grouped by subject area. I'll try to share the names of the presenters where I can, since the presentations and audio are available to AHIMA members. If you have trouble accessing a reference, ask your organization's AHIMA member; if they attended the conference, they have the same access that I used. In some cases, the AHIMA staff has posted videos of presentations on the organization’s YouTube channel. I love social media, don't you?

Meaningful Use

This would seem to be the place to start, given the immediacy of MU. The topic came up in the majority of presentations. Providers said that three issues compete for resources and attention, MU, the EHR, and ICD-10. We have a tendency to forget or fail to see the common management and change management components, since all three are concerned with improving information capture and the quality of that information for overlapping purposes. That said, the managers and directors involved often have very independent perspectives, needs, and budgets.

I highly recommend an article, " Meaningful Use - Notes From the Journey," by Chris Dimick, JAHIMA October 2011. Dimick covers "results so far," including that early attesters greatly exceeded the MU requirements thresholds. Probably not surprising is that those organizations that were underway when the program was announced do better than those starting cold. Apparently those shrink wrapped, pre-packaged, slam-them-in approaches haven't delivered attestations. Dimick addresses real world challenges like reproducing records for patients. He notes that current provider workflows often don't support this since the chart isn't ready when the patient should be able to leave. All-in-all, this nine-page article is a wonderful framing of where we are today as an industry with MU. Articles from Bonnie Cassidy (link) and Lynn Thomas Gordon (link, page 23) are also highly recommended.


- ICD-10 will be an economic battleground between the payers and providers, despite the public posturing that the move will be revenue neutral. Providers and Payers who don't arm themselves with retrospective and concurrent (i.e. dual coding) skills, data, and modeling will leave money on the table, as well as overpay or be overpaid. One healthcare delivery organization has already spent 30,000 hours on ICD-10, between training, analysis, and outside review of its operational plan.

- Creating a code in ICD-10 will often require information that is either not captured today, or captured today utilizing language that is not allowed in ICD-10. For example, if a code requires indication of laterality such as a limb bone fracture, i.e. right, left, both, or unspecified, a code cannot be determined without that information. It was noted by several speakers that, if the "unspecified" code is used, some payers will deny the claim. For more on this, I recommend Lynn Kosegi/NLP, “The Silver Bullet” presentation ( link).

- The revenue opportunities and risks with the move to ICD-10 dwarf the MU incentive dollars by one or two orders of magnitude. Every organization with its eyes open has its best and brightest people managing this risk. See my notes section on competing initiatives.

Competing Initiatives

- Life within hospitals is especially chaotic these days. I just touched on MU and ICD-10 transitions, each of which present distinct challenges. What can quickly get lost is that the hospital EHR roll-outs, both inpatient and community, were in progress over a seven to ten-year period before MU and ICD-10 were contemplated. Although there are synergies, such as improving physician documentation and CPOE related ordering practices, there are plenty of cases where sub-projects compete for resources, create incompatible deadline issues, and expose “single-threadedness” or bottleneck performance limits.

- There are many project deliverable "crossover" issues between HIM, its information stewardship, and other initiatives within a health system. These deliverables can clearly improve quality measures, and many other MU-related EHR functions, such as problem lists, MPI integrity, and patient portals. The need to assemble a thoughtful, comprehensive, and staged approach for an enterprise is obvious. It’s also extensive planning work. Most HIM professionals with whom I chatted privately have concluded that the only available option is to muddle through with tactical approaches. If there are clever ways to kill two birds with one stone, they are recognized as overly ambitious relative to local experience.

Human Backdrop

Another theme that came up often was the disappearance of many face-to-face interactions throughout our health systems. As the world moves more and more online, remote workers and remote patients are becoming frequent. It's become practically impossible for people in the HIM area to have an informal, face-to-face dialogue with physicians.

One practice in past decades was for the HIM professionals to set up a station outside the physician's weekly Grand Rounds meetings. This gave physicians an easy opportunity to resolve chart signing deficiencies that fit into their workflows. Now, with distance learning, obtaining CME's online makes these meetings less critical and less frequent. Of course, with the trend toward increasing the use of hospitalists, this simply puts non-hospitalists at a further relative disadvantage, i.e. being absent from all important informal interactions. Moving from a clerical world to a fully self-service one forces more email communication, without the benefits of a pre-established face-to-face relationship.

Interesting Observations

- Many insightful HIM attendees express their names using three words, sometimes hyphenated, in far greater apparent frequency than age, gender and professionally role-matched peers. This is an extremely smart practice, since, for example, there may be a dozen Mary Smith(s) in Mary's community, but only one Mary Thomas Smith.

- One of the plenary speakers was Stephen M.R. Covey, speaking on the topic of Trust and author of “ The SPEED of Trust: The One Thing that Changes Everything.” He is the son of Steven R. Covey of “Seven Habits of Highly Effective People” fame, and his arguments and practical behavioral recommendations clearly resonated with the attendees. Covey told the story of a street vendor who doubled his revenues by trusting his customers, letting them pay and take their own change with essentially a public access cash register. The point was that there is a dividend to trusting people. It was the right topic delivered to the right audience. You probably couldn’t find a more trustworthy group of people than the HIM professionals attending a convention in Salt Lake City!

- CDI, or Clinical Documentation Improvement, was a recurrent theme in many educational sessions and exhibitor offerings on the show floor. Apparently, there are two competing philosophies on how to structure such programs. A nurse manager from a very large health system described for me the less common approach she uses. The CDI focus is built in a MS-DRG blind fashion. In other words, they don't look for documentation elements that help them substantiate a higher reimbursement as the priority. Instead, they focus on elements that create a more accurate and precise clinical story. Sure, there are a lot of times when they overlap. But, she told me, the credibility that comes from a clinical quality framework is a big deal, compared to a predominately financial one.

I subsequently presented this approach to three CDI managers of other provider organizations. They said that they understood the concept, but it was uncommonly deployed for two reasons. One, CDI initiatives must justify their ROI explicitly and manage to that. Second, for some service lines, there isn't a significant difference in blinding the relationship between CDI and DRG-awareness to the physicians. This may be purely a difference between representing oneself authentically verses having the appearance of spin.

To Whom Should HIM Report?

Wow. What a fascinating topic. A Maestro Strategies recent survey (still preliminary) showed that the single, highest volume model is reporting to the CFO. Most presenters who raised the topic favored the COO, with clinician leadership at least in a dotted line reporting model. The explicit, albeit controversial, shared opinions were that their CFOs simply don't understand or value clinical quality, whereas COOs, even those with no clinical background, do value the quality implications of the HIM function.

I think this is fascinating, in part because of the parallels with, for example, to whom do CMIOs report ( most CMIOs report to the CIO, link to Vi Shaffer's 2009 Gartner/AMDIS study here, page 13). Most report to the CIO, then the CMO, and third the CEO/COO/Other categories. This survey indicates that CFOs and COOs aren't even near the top of the list.

The implications for change are becoming more evident with the evolution of care delivery and its transformation. Many more observations to share in subsequent blog posts. Stay tuned and please post a comment as I’d like to know your thoughts.

Joe Bormel, M.D., MPH
CMO & VP, QuadraMed

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