Editor's note: this practice brief supplants the January 2005 practice brief "The HIM Role in Patient Safety and Quality of Care."
Achieving high quality, cost-efficient healthcare requires collaboration among all healthcare professionals and stakeholders. Currently the quality of healthcare tends to be inconsistent, disorganized, and inefficient, with some patients receiving excellent care, while others receive substandard care.
Drug safety, medical mistakes, healthcare-acquired conditions, information system constraints, and fragmented delivery systems are just some of the many issues affecting healthcare quality and safety. Addressing these challenges requires organizations capture valid and reliable data that can be transformed into useable information to aid in developing change strategies.
Converting data into meaningful information for decision making calls for the expertise of credentialed HIM professionals. HIM professionals possess unique knowledge and expertise to enable strong partnerships with clinical and executive teams to advance the quality and safety of patient care delivery. In addition, effective HIM practices enable accurate data assignment, capture, analysis, trending of healthcare operations and patient safety, and output of objective data for decision making.
This practice brief outlines the critical functions HIM professionals perform in the delivery of safe, high-quality patient care.
HIM's Role in the Use of Healthcare Data
Since 1999 the Institute of Medicine has published several reports outlining the quality and safety issues that negatively affect the healthcare system. To eliminate these problems healthcare organizations must demonstrate greater diligence in capturing information that supports a more accurate measurement of healthcare quality, such as determining how adverse events (i.e., injuries caused by medical management, not the underlying disease) actually occur in hospitals.1
Existing data from administrative, laboratory, clinical registry, and electronic health record (EHR) systems can provide the necessary information to improve patient safety and quality. Effective HIM practices facilitate the aggregation of data from multiple sources to enable the capture of data once so it can be repurposed many times.2
A 2009 PricewaterhouseCoopers report notes that data must be transparent and overseen by honest brokers or stewards to gain everyone's trust.3 HIM practices facilitate data stewardship by promoting the adoption of guidelines for data access, use, and control, as well as principles and guidelines for the standardization of content and definitions. The report goes on to say that the industry needs to shift focus from data transactions to quality and outcomes, which will require a new data architecture that enables multiple systems to operate together.
The HIM professional is not, by trade, an information technologist; however, the two disciplines of information management and information technology must collaborate to manage the increasing volumes of electronic data. HIM professionals must be active participants in the entire EHR lifecycle, leveraging their knowledge and expertise in records management, confidentiality and security, workflow, terminology and classification systems, standardized data sets, and health information exchange.4 Appendix A in the online version of this practice brief outlines areas of collaboration for HIM and IT professionals.
The expansion of IT and electronic documentation is improving the capture and quality of healthcare data, leading to safer and more reliable care delivery systems. In order to continue advancements in these areas, organizations must facilitate the flow of information among different parties. In addition, leveraging electronic data from numerous sources and integrating it into a centralized repository can help improve the quality and consistency of patient care delivery.5
Numerous roles and responsibilities are emerging as data are standardized across organizational systems. HIM professionals are experts in data content standardization and have the necessary skills and competencies to advance improved validation, capture, analysis, and output of information for quality and patient safety initiatives. HIM professionals can play a critical role when quality and safety conversations and decisions are made.
Essential HIM practices that must be considered part of quality and safety initiatives include:
- Data governance, which is the foundation of information management rules. Data governance involves a group of dedicated individuals that make information management decisions and develop a structure to enforce rules involving technology training and education, auditing, and compliance. It includes an inventory of the organization's resources and how they are managed, organized, and controlled, as well as the process for the application of the rules to the applicable information resources in the information inventory. Appendix B in the online version of this practice brief provides more detail on HIM's role in data governance.
- Data standardization, which is an important element in data stewardship that affects the use of data for quality and patient safety programs. Data stewards are the glue that holds a governance program together.6 HIM professionals can advocate for and obtain leadership endorsement so that standardization of data content becomes a strategic aim of the organization (see appendix B). Creating, utilizing, and maintaining a data dictionary not only standardizes definitions and ensures consistent use, but also facilitates a common understanding of an organization's data quality when developing reports and analyzing information.7 This will assure the end user that the information used for decision making is consistent and comparable.
- Data capture validation and maintenance, which are the fields where HIM professionals are at the forefront. However, there has never been a greater need for sharing this knowledge than right now. Collaborating on these efforts will help create an environment where the integrity and quality of data are preserved. HIM's role in data capture, validation, maintenance, information retrieval, analysis, and reporting are further outlined in appendix C in the online version of this practice brief.
- Data capture, analysis, and output, which require critical thinking about healthcare performance expectations to draw informed conclusions from measurement data. The ability to measure the quality of patient care accurately and efficiently is central to enabling clinicians provide excellent care, including improving patient outcomes, reducing infection rates, preventing serious adverse events, controlling near misses, and standardizing treatments using evidence-based medicine. With the adoption of EHRs, HIM professionals are in a unique position to evaluate the data in the EHR and other source systems that feed into the enterprise-wide data warehouse (see appendix C).
HIM's Role in Quality and Safety Initiatives
The Centers for Medicare and Medicaid Services (CMS) has begun transforming from a payer of services into an active purchaser of higher quality, affordable care by creating incentives that encourage healthcare providers to deliver higher quality care at lower total costs. This is the underlying principle of value-based purchasing, which is occurring not just within Medicare and Medicaid, but with other payers and at the national, state, and local levels.
CMS has released results from three demonstrations that showed the benefits of paying for improved performance and outcomes. In total, these demonstration projects awarded more than $53 million to hospitals and physician practices.8
However, achieving these pay-for-quality goals requires improved documentation throughout the healthcare system. The age-old adage "if it isn't documented, it wasn't done" is as appropriate as ever. The responsibility lies with HIM professionals to monitor the quality of documentation while working collaboratively with other members of the healthcare team to maintain the clinical accuracy and completeness of the data. These efforts will be the key to identifying system and process problems within the realm of patient safety and quality of care.
While the ultimate goal is delivering safe and improved patient care, it cannot be ignored that errors made during hospitalization result in greater costs (such as increased length of stay, need for higher level of care, and additional procedures). A study published in the April 2011 issue of Health Affairs estimated that approximately one in three people in the United States will encounter some kind of mistake during a hospital stay.9 A separate study in the same issue estimated the annual cost of medical errors to be $17.1 billion in 2008 dollars.10 A conservative method of review indicated 1.5 million measurable medical errors occurred in 2008.
Patient safety and compliance issues represent a major factor in data integration. Through the use of clinical decision support and electronic documentation, healthcare-associated infections, falls, and other negative healthcare-associated events can be more quickly identified, tracked, monitored, and eliminated.
The desire to improve the quality of healthcare has prompted increased use of performance measures. These measures examine the outcomes of interventions for evidence of improved health and are used to hold providers accountable for the quality of care.
Yet tension exists regarding the capabilities of the current science of quality measurement, with physicians and researchers questioning the validity of the data used. The authors of a third article in the April 2011 issue of Health Affairs offer five recommendations to advance quality measures, such as ensuring the validity of measures and evaluating performance over time.11 All of the recommendations lend themselves to HIM practices. As quality measures are developed, HIM professionals can provide the expertise to ensure that any new measure is feasible, quantifiable, and measureable.
With their skill sets, HIM professionals are ideal candidates to lead patient safety and quality improvement initiatives while at the same time playing a pivotal role in the information capturing process and system improvement measures. Patient safety initiatives require all forms and types of data capture, many of which are already managed by HIM in paper and electronic formats. For example, HIM professionals are able to provide data related to serious adverse events, present on admission indicators, and hospital-acquired conditions.12 They are equipped to analyze and interpret these data and participate in the patient safety teams that conduct root-cause analyses and develop action plans for improvement.
HIM's Role in a Rapidly Changing Landscape
HIM professionals will play an integral role in the rapidly changing healthcare landscape.
Evolving Data Specifications
As data and classification systems evolve, HIM professionals will be invaluable to ensuring the appropriate interpretation and conversion of healthcare data related to many uses, including patient data, organizational effectiveness and efficiency, policy making, and reimbursement systems. For example, the implementation of ICD-10-CM/PCS and other terminology systems such as SNOMED CT will necessitate a better understanding of how data are collected, analyzed, and reported to ensure information is understandable and useable.
Secondary uses of health data to evaluate and improve healthcare outcomes and costs have received increasing emphasis. Quality measures are now an integral part of value-based purchasing initiatives at the federal, state, and local level.13 In addition, quality and patient safety measures include a variety of coded data variables as part of their definition.
As the industry begins leveraging more complex coding systems, organizations must determine how to trend data over time and compare data captured using other methods and sources. Changes in code definitions, time variances, code combinations, and data sources must all be taken into consideration when analyzing data.
Experts in all the healthcare classification and clinical terminology systems will be a valuable and irreplaceable resource when managing and interpreting data from a wide variety of sources.
Evolving Measurement and Payment Models
Strategies for managing rising healthcare costs are highly dependent on clinicians and consumers having reliable access to accurate and complete patient information for informed decision making and improved efficiencies. Early studies of patient-centered medical homes, a new patient care delivery model, have attributed improved outcomes to use of EHRs that link all elements of the broader healthcare system.14
Transitions from one setting to another are a particularly vulnerable time for patients. One study found that 12 percent of patients suffered an adverse drug event after being discharged from the hospital.15 Seamless flow of patient information among providers and with patients is critical to achieving the dual goals of high quality and high value care.16
The Affordable Care Act of 2010 established a variety of transitional care programs and services to improve quality and reduce costs, including the National Strategy for Quality Improvement in Health Care, the meaningful use program, and the Medicare Shared Savings Program.17 HIM professionals play an essential role in facilitating the transfer of information, such as medical history, medication lists, and test results, from one clinician to another.
HIM professionals make a difference by advancing the effective use of personal health records or patient portals and serving as a health information advocate on behalf of patients. Consumer access to health information can greatly enhance safety, facilitate patient engagement, and improve continuity of care.18
The Affordable Care Act also authorized CMS to contract with accountable care organizations, in which physicians, hospitals, payers, and other providers collaborate and become clinically and financially accountable for healthcare delivery in their communities. One focus of ACOs is the measurement of longitudinal outcomes and costs. HIM professionals are uniquely qualified to identify, capture, and analyze relevant data residing in all the data sources that will comprise the patient's care record.19
Another approach to delivering improved patient care, especially for people with chronic health conditions, is the patient-centered medical home. This model combines prompt access to primary care and an ongoing relationship with a primary care provider or team with adoption of health IT and improved coordination of care.20 With their combined knowledge of health IT and the expertise to extract information from multiple sources, HIM professionals are perfect candidates to facilitate the patient-centered medical home model's success.
Ten years after the Institute of Medicine's report "Crossing the Quality Chasm," progress has been made toward reaching the six dimensions of care; however, much work still remains. Leveraging HIM professional expertise as a key partner in a multidisciplinary patient care team enables effective management and use of healthcare information to further advance improvements in quality and patient safety systems.
- Dentzer, Susan. "Still Crossing the Quality Chasm-Or Suspended over It?" Health Affairs 30, no. 4 (Apr. 2011): 554–55.
- AHIMA. "Statement on Data Stewardship." December 2008.
- PriceWaterhouseCoopers. "Transforming Healthcare through Secondary Use of Health Data." 2009. www.pwc.com/us/en/healthcare/publications/secondary-health-data.jhtml.
- AHIMA. "HIM and Health IT: Discovering Common Ground in an Electronic Healthcare Environment." Journal of AHIMA 79, no. 11 (Nov.–Dec. 2008): 69–74.
- Bochantin, Felisha, et al. "HIM Expertise Critical for the Advancement of Quality and Patient Safety Initiatives." August 2011, Journal of AHIMA. http://journal.ahima.org.
- Marco, David, and Anne Marie Smith. "Understanding Data Governance and Stewardship, Part 3." Information Management, November 2006. www.information-management.com/issues/20061101/1066745-1.html.
- Clark, Jill. "Tools for Data Analysis: New Toolkit Provides Resources for Health Data Analysts." Journal of AHIMA 82, no. 2 (Feb. 2011): 40–41.
- Centers for Medicare and Medicaid Services. "Medicare Demonstrations Illustrate Benefits in Paying for Quality Health Care." Press release. December 9, 2010. www.cms.gov/DemoProjectsEvalRpts/downloads/PGP_Press_Release.pdf.
- Clausen, David C., et al. ''Global Trigger Tool Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured." Health Affairs 30, no. 4 (Apr. 2011): 4581–89.
- Van Den Bos, Jill, et al. "The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors." Health Affairs 30, no. 4 (Apr. 2011): 4596–603.
- Pronovost, Peter J., and Richard Lilford. "A Road Map for Improving the Performance of Performance Measures." Health Affairs 30, no. 4 (Apr. 2011): 569–73.
- Eramo, Lisa A. "HIM, Quality, and Safety: Data Collection and Analysis Skills Offer a Natural Role in Patient Safety." Journal of AHIMA 81, no. 4 (Apr. 2010): 48–49.
- Giannangelo, Kathy, and Linda Hyde. "Retooling Quality Measures for ICD-10." Journal of AHIMA 81, no. 6 (June 2010): 56–57.
- Bates, David W., and Asaf Bitton. "The Future of Health Information Technology in the Patient-Centered Medical Home." Health Affairs 29, no. 4 (Apr. 2010): 614–21. www.cimit.org/images/events/ciw/IT-in-Patient-Centered-Medical-Home.pdf.
- Forster, Alan J., et al. "The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital." Annals of Internal Medicine 138, no. 3 (2003): 161–67.
- Moreno, L., D. Peikes, and A. Krilla. "Strategies to Ensure HITECH Supports the Patient-Centered Medical Home." AHRQ publication no. 11-0013. Agency for Healthcare Research and Quality, February 2011. www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/ahrq_commissioned_research.
- Naylor, Mary D., et al. "The Importance of Transitional Care in Achieving Health Reform." Health Affairs 30, no. 4 (Apr. 2011): 746–54.
- Eramo, Lisa A. "HIM, Quality, and Safety."
- White, Susan, Crystal Kallem, Allison Viola, and June Bronnert. "An ACO Primer." Journal of AHIMA 82, no. 6 (June 2011): 48–50.
- "Patient-Centered Medical Homes." Health Affairs. September 14, 2010. www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=25.
Four appendixes are available in the online version of this practice brief in the AHIMA Body of Knowledge at www.ahima.org:
AHIMA Task Force on Healthcare Quality and Patient Safety:
Alexandria Berretoni, CCS-P
Felisha Bochantin, BS, CPC, CPC-H, CPC-I
Teresa Brown, RHIT
Rebecca Busch, MBA, RN, CCM, CBM, CPC, CHS-III, CFE, FIALCP, FHFMA
Jaime Chapman, RHIT, CCS
Tina Cobia, RHIT
Marie Colin, RHIA
Vicki Delgado, RHIT, CTR
Terri Hall, MHA, RHIT, CPC
Mary Lou Hilbert, MBA, RHIT, LHRM
Kelly Hugo, MBA, RHIA
Linda Hyde, RHIA
Sheila Johnson, RHIT, CCS
Crystal Kallem, RHIA, CPHQ
James (Bob) Lantis, MHA, MS, RHIA
David Mozie, PhD, RHIA
Sandra Nunn, MA, RHIA, CHP
Mark Palen, PMP, CPHIMS
Catherine Porto, MPA, RHIA, CHP, CPEHR
Deborah Reed, RHIT, CCS-P, CCP-P
Lisa Roat, RHIT, CCS
Matthew Schuller, MS, RHIA
Deborah Slanicky, RHIT, CPHQ
Patrice Spath, MA, RHIT
Alison Stangeby, RHIA, CCS, CPC
Stacy Vaughn, RHIT, CCS, CCDS
Alison Viola, MBA, RHIA
Valerie Watzlaf, PhD, RHIA, FAHIMA
Traci Waugh, RHIA
Margaret Williams, AM
Sue Woodham, RHIT
Jane DeSpiegelaere-Wegner, MBA, RHIA, CCS, FAHIMA
Angela Dinh, MBA, RHIA, CHPS
Patience Hoag, RHIT, CHCA, CCS, CCS-P, CPC
Prepared by (original)
Beth Hjort, RHIA, CHPS
Don Asmonga, MBA
Don Mon, PhD
Carol Quinsey, RHIA, CHPS
Harry Rhodes, MBA, RHIA, CHP
The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.
† Indicates an AHIMA best practice. Best practices are available in the AHIMA Compendium, http://compendium.ahima.org.
"HIM Functions in Healthcare Quality and Patient Safety"
Journal of AHIMA