by Chris Dimick
On the third anniversary of the hurricane, staffing shortages still plague some HIM departments, and many EHR implementations remain on hold.
In a matter of hours, 400,000 medical records were reduced to pulp.
Dorothy Jones, RHIT, health information supervisor at Medical Center of Louisiana in New Orleans, thought removing the bottom rows of records in her hospital’s basement storage facility would be enough to guard against Hurricane Katrina’s punch August 29, 2005.
She didn’t expect a levee break would send water gushing into the basement and up to the first floor ceiling. Every paper record was destroyed.
Jones was evacuated from her hospital by boat two weeks after the storm. Her hospital was shuttered.
Jones wasn’t alone. Many hospitals in the New Orleans area lost thousands of medical records due to flooding and the slow rot of mold that followed.
Hurricanes Katrina and Rita, which followed less than a month later, left a broken healthcare network in New Orleans—damaged facilities, scattered staff, and destroyed records. Three years later, every HIM department is still dealing with the impact. Most physical facilities have been repaired, but the operations are still recovering as the city slowly welcomes back patients.
Lingering Staffing Shortages
Hospital officials say that inflated costs for supplies in the region, unadjusted Medicare rates, and an increase in uninsured patients have the major New Orleans hospitals operating at a loss each year since Hurricane Katrina.
In a June 16, 2008, letter to the editor of the Times-Picayune newspaper, Touro Infirmary chairman Stephen Kupperman wrote that the five hospitals that provide 90 percent of healthcare in the New Orleans region are projecting a loss of $130 million in 2008. Those hospitals are lobbying for federal and state relief money.
East Jefferson General Hospital is one of those five. It is facing financial hardships even though it never closed or flooded during the storms. Financial troubles in New Orleans today center on the secondary effects of the hurricanes. “We are losing money every month, salaries are rising… the salaries in New Orleans are astronomical now,” says Stacy Collins, MHIM, RHIA, director of HIM at East Jefferson.
The rising wages reflect an attempt to attract and keep workers. HIM departments, like other departments, faced a shortage in employees following the storm. While the shortages have since disappeared for some facilities, others are still not fully staffed three years later.
The majority of the population left the city due to the storm, and most healthcare facilities closed for weeks following it, scattering employees even further. Facilities have since had to work hard to entice employees back to the battered city.
At Touro Infirmary, more than half of staff did not initially return after evacuating, says Sandy McCall, RHIA, director of HIM. Some couldn’t get back to the city; others had no home to return to. By the time some facilities reopened, some former staff had started new lives in a different state. “Most people had lost everything, from their schools to their house to their grocery stores,” McCall says.
The need for hospital staff proportionally increased as more residents and relief workers came into New Orleans. In the first year after the storm, workers were in such high demand that in some cases HIM departments were competing with fast food restaurants for employees. Some fast food restaurants were offering $11–$13 an hour, comparable to clerical jobs in HIM departments, McCall says.
Struggling with Wage Increases
The work force shortages have resulted in a large pay raise for entry-level HIM positions across the region.
“There have been significant increases in wages, especially for my coders,” says Shelia Gorden, RHIT, HIM director and chief privacy officer at Tulane University Hospital and Clinic, based in New Orleans. Meeting those increases have necessitated some creative budget juggling.
Some of the openings created by evacuated employees were filled by skilled HIM professionals from other facilities who lost their jobs due to Katrina. Several damaged hospitals never reopened, leaving staff looking for work. This was the case with McCall, who worked at Memorial Tenant Medical Center before the storm. She came to Touro Infirmary as the director of HIM eight months after the storm closed her hospital and put her house eight feet under water. She then hired several of her old employees from Memorial to fill staffing holes.
As one of the first hospitals to reopen, Touro was in the position to claim displaced HIM professionals. This was also the case for East Jefferson, based in the nearby suburb of Metairie, which never closed.
“There were so many hospitals that closed. We were really the only hospital in New Orleans proper that was open, and everybody had lost their jobs in the city,” McCall says. “So we had the advantage of getting… the best of the best.”
Finding skilled HIM professionals was not as easy for other facilities. The national coder shortage was made worse by the hurricane. Tulane had seven open coding positions as of July 2008. One of the positions at a satellite facility has been open since the hurricane hit in 2005. As a result, Tulane has offered grant money to pay for employee coding education and RHIT preparation. The grants are in part an attempt to grow skilled HIM staff that can fill long-vacant positions, Gorden says.
East Jefferson faced staffing shortages in the first year following the storm. But as people returned to the city, Collins says her department was gradually restaffed. It helped that most of her staff had homes to return to, as they lived in areas that had not flooded.
The biggest issue at East Jefferson is getting money for wage increases, Collins says. While HIM entry-level wages were initially raised, East Jefferson, like many area hospitals, put a freeze on pay raises due to dire financial situations. This past June the freeze was temporarily lifted and raises distributed.
Hopes for a Model Network Postponed
IN THE MONTHS FOLLOWING the storm, some stakeholders began an effort to rebuild the New Orleans healthcare system as a model for the future. With so many facilities starting over, the group offered a plan to implement sweeping changes and cutting-edge IT for all state healthcare facilities.
In 2006 the Louisiana Department of Health and Hospitals—at the recommendation of the US Department of Health and Human Services (HHS)—created the Louisiana Health Care Redesign Collaborative to draw up a plan. The collaborative issued its final concept paper in October of that year. Proposed initiatives included moving the state’s primary care physicians to the medical home model and implementing interoperable electronic health record systems.
But today hospitals in the areas affected by the hurricanes have not seen the collaborative’s plans come to fruition. Hundreds of millions of dollars have been sent to New Orleans–area hospitals from both federal and state agencies, but the money has largely gone to rebuilding facilities and merely keeping their doors open.
Even as late as May 2008, federal assistance was being directed toward staffing. That month an additional $19.1 million in assistance from HHS was targeted to facilities “facing serious and ongoing financial pressure to compete for workers in highly competitive post-storm labor markets,” according to an HHS press release. The money is intended to help bridge the gap until Medicare payments can be adjusted to local wages. The preceding May, $195 million in grants to the Gulf Coast region was targeted to “provide direct patient care and attract good health care workers.”
Efforts to redesign the state’s healthcare system began again last year. The Coalition of Leaders for Louisiana Healthcare formed to resurrect the earlier efforts to expand coverage and introduce EHRs into Louisiana’s hospitals. Members include area providers and medical associations; they are an independent effort, not acting under state or federal direction. Time will tell what the group’s efforts bring.
Little Money for Health IT
Though all HIM departments didn’t face the decimation of medical records that occurred at Jones’s facility, most lost at least some records due to water or subsequent mold. An initial challenge after the storm was recovering those records as best they could.
At Touro, HIM operations manager Melanie Hidalgo and her staff donned hazmat suits and undertook a “search and recovery” sweep of the entire hospital for personal health information. Many HIM professionals at other facilities did the same, as mold thrived in the humid air of temporarily closed hospitals.
A lesson was clear in the aftermath of the storm: most electronic records were safe and ready to be used once the hospital opened.
Tulane took this lesson to heart. The hospital and its clinics greatly increased the amount of dictation done by physicians upon reopening, Gorden says. Done electronically, the dictation notes could be easily accessed in the days after the storm. Gorden has seen a 50 percent increase in the number of physicians dictating information from patient visits. General use of all of Tulane’s electronic systems has also increased due to the storm. “[Physicians] realized that even if they can’t physically get to that paper record, they can get to the information that is available electronically,” Gorden says.
Still other hospitals have put any EHR system implementations on hold until their financial situation brightens. Many had plans to implement EHRs prior to Hurricane Katrina. Touro, which prints documents for the record post-discharge, planned to add to their EHR system pre-Katrina. But money is now an issue, and the target date for their proposed EHR system was pushed back to 2009.
“All of our monetary resources are really needed elsewhere,” McCall says. “Every hospital in New Orleans is struggling financially, so we’ve had to really put that on hold a little longer than we wanted to. Had Katrina not hit three years ago, we would have had a functioning electronic medical record and forms management.”
The hurricane also delayed the implementation of an EHR at East Jefferson General Hospital. Initially set for go-live in October 2005, the enterprise-wide EHR system didn’t launch until July 2006, when work shortages began to subside, Collins says.
Though a costly endeavor, the implementation has helped the hospital recover from the hurricane, Collins says. Her coding turnover has been eliminated due to the new ability of coders to code from home. Some positions were eliminated due to changes in workflow. The EHR helps get the bills out the door faster, which is good for a struggling facility, Collins says. “I think if we wouldn’t have installed this system, we would be in a lot worse shape than we are now,” she says.
The hospitals that implemented health IT have had to raise their own money, setting aside funds as an investment in recovering lost revenue. Millions of dollars in federal aid have come to the region, but despite initial hopes that the region would be rebuilt as a model health IT network, the money has been required to provide direct care, help pay salaries, and cover the gap in Medicare payments, which have yet to be adjusted for local conditions.
Disaster Planning Enhanced
In the years since the 2005 hurricanes, HIM departments have used the experience to enhance their disaster preparedness plans. At Touro, the HIM department has laid out a strategic plan that lists exactly what it will do as a hurricane tracks toward the facility.
One revised policy centers on a procedure for sending medical records with patients as they are evacuated to a different facility—something many patients in New Orleans hospitals were forced to do after Katrina.
The Touro HIM team has run several drills on this procedure, each successfully. “We have built it on what we learned in Katrina,” McCall says. “There is nothing better than experience to really refine our policies and procedures.”
At Tulane University Hospital, the HIM staff is now considered essential personnel during a hurricane. Typically nursing would handle any records requests during a storm, which are minimal since the hospital usually receives no patients, Gorden says. But after the levees broke and patients started arriving, the HIM department was needed.
HIM presence was even more necessary when Tulane began evacuating patients to other hospitals, their original medical records in tow. “It was a great lesson learned the hard way,” Gorden says.
The facility itself is also better prepared after digging its own well and building large generators with ample fuel on the second floor of a parking garage. HIM staff have been cross-trained, which ensures a fully functioning department even if everyone can’t report back to work.
At East Jefferson, the new EHR system was designed to accept submissions of inpatient beds in the emergency room. The change was made after the hospital—one of only a few metro-New Orleans area hospitals to stay open during and after the disaster—had at one time had 30 patients in the emergency department waiting for an empty room.
East Jefferson has added two backup plans for their dictation and transcription process in case their normal processes are affected by a hurricane or other disaster.
At the Medical Center of Louisiana, now called LSU Interim Hospital, policy has been changed to completely remove all medical records on lower levels and place them on the second floor, a lesson learned after losing all their records to flooding. “We pray that we never have to do this, but if it comes to it we will be prepared to move the records completely out,” Jones says.
Not Normal, but “Workable”
Even with advancements, many New Orleans-area HIM departments are not back to normal.
Today, Jones’s HIM department is up and running, operating in the women’s department of the former Lord and Taylor retail building. The HIM department has been housed there since 2005, with the clinical operations in a separate facility and service community clinics scattered over a two-mile span. “The challenge is trying to get all the medical records that they need to those different facilities,” Jones says, who has significantly reduced staff since the storm.
With most facilities operating far below the bed levels they once had, fewer positions are needed. This helps with staffing shortages. The Medical Center of Louisiana operated 575 beds and had an HIM department of about 170 employees in August 2005. Today it has 230 beds and 34 HIM employees.
Several hospitals remain closed, driving more patients to remaining facilities that are working with fewer resources. The impacts of the storms are still evident in the New Orleans streets. Touro gets several calls a day from people who lost everything in the storm and are searching for birth records and other personal information.
Though Medical Center of Louisiana facilities are somewhat scattered, there is talk about moving all departments into one newly built facility, Jones says. There is also talk of implementing an EHR at the facility, partly to avoid a repeat of the massive loss of paper records that occurred during Hurricane Katrina.
For now, Jones has devised an HIM workflow plan that gets the job done. Though not ideal, her system works. But more staff are needed to get the department functioning as it was on August 28, 2005. “I don’t think things will be normal for quite a long time,” Jones says. “Because we have two different sites, it will not be normal. But it will be workable.”
Chris Dimick (firstname.lastname@example.org) is staff writer at the Journal of AHIMA.
"Long Recovery: HIM Departments Three Years after Katrina"
Journal of AHIMA