By Chris Dimick
Editor’s note: This month’s practice brief, “HIM Functions in Healthcare Quality and Patient Safety,” outlines the critical functions HIM professionals perform in the delivery of safe, high-quality patient care. Here, members of the AHIMA quality and safety task force that authored the brief encourage HIM professionals to increase their roles in quality and safety efforts and offer suggestions for getting involved.
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Information has always been a lynchpin of quality healthcare. Physicians and other caregivers must have comprehensive and accurate data to diagnose and treat patients.
This was true in 1751 when the first US hospital was built in Philadelphia, and it is still true today. Florence Nightingale championed the collection of outcome statistics in the 1860s, and Dr. Ernest Codman reiterated the value in 1910 when he advocated that hospitals should follow every patient they treat long enough to determine whether or not treatment has been successful. Using data for decision making remains a vital element of high quality patient care.
What has changed over the years is the volume and scope of the data.
Prior to the 1990s information systems were designed to support the quality requirements of an individual organization. Patient health records primarily documented the care given by clinicians in that one organization. Performance measurement statistics only reflected the organization’s experience. Healthcare providers were self-contained islands of information. This meant that data definitions and other factors associated with data governance were left to the discretion of the organization.
At the start of the twenty-first century the demand for quality care rose very quickly. Technological advancements have led to large centralized databases containing performance measurement data from multiple organizations. Patient information is being exchanged within and across healthcare communities. Providers are no longer islands of information, and this has created new data standardization, capture and validation challenges.
HIM professionals possessing technological, clinical content, and privacy and security expertise are ideally positioned to help healthcare organizations leverage information to improve patient care quality and safety. Major national initiatives are occurring in two general areas: reimbursement and the adoption of health IT.
The Cost-Quality Connection
Healthcare spending in the US has continued its precipitous increase for several decades. It increased 44 percent in the last decade, comprising an increasing share of family, state, and federal budgets. Despite these spending increases, some highly recommended patient care practices are only carried out 60 percent of the time. While there have been some improvements in patient care over the past years, disparities in access and quality still persist.
Increasing concern about the cost, quality, and access to care has led government and private payers to implement programs linking quality of care to reimbursement. In 2008 the Centers for Medicare and Medicaid Services initiated plans to reduce payments to healthcare providers when patients suffer hospital acquired conditions. CMS has also established the Recovery Audit Contractors (or RAC) program and intends to implement a value-based purchasing program.
Private insurers are taking similar steps that link reimbursement with quality and safety expectations. These initiatives have elevated the importance of high quality and safe patient care at the provider level.
Automation has long been recognized as an important factor in reducing human errors in work processes, including those involving delivery of healthcare. Numerous studies have substantiated the positive effects of health IT on quality and safety improvements.
HIM professionals possess the expertise—particularly in data capture and validation, diagnosis and procedure coding, data quality management, and decision support—to help organizations use information and automated technologies to reduce costs and improve quality. The linkage of reimbursement and provider performance has created new opportunities for HIM professionals to apply their analytic skills to help their organization remain financially healthy while maintaining high quality patient care.
EHRs and Quality Care
Through the “meaningful use” incentive program, the federal government is encouraging providers to adopt and effectively use electronic health record (EHR) systems.
Overall, the goal in the development and use of EHRs is to enable effective and measurable improvements in the health of individuals and fully involve them in the process. The Office of the National Coordinator for Health IT describes three central themes in the meaningful use of EHRs:
- Complete and accurate information. Providers will be in a better position to manage and advocate for patients when they have access to a patient’s entire complete and accurate health history.
- Better access to information. Complete and accurate electronic health information will facilitate the ability of multi-dimensional teams to diagnoses and treat patients.
- Patient empowerment. With access to their health information, patients will be better able to manage their own care and communicate with their providers.
The ability to measure the efficacy of treatment decisions and patient outcomes will further the ability to improve patient safety. Ultimately, “quality healthcare depends on the availability of quality data”—a statement that summarizes the most significant contributor to meaningful use in an EHR environment.
Improving Patient Safety through Better Information
It is estimated that 80 percent of serious medical errors involve miscommunication between caregivers when a patient is transferred or handed off. This is just one example of how patient safety can be comprised when health information is not complete, accurate, and accessible.
Since August 2009 healthcare systems throughout the country have been partnering with the Joint Commission Center for Transforming Healthcare on a project designed to end potentially harmful communication breakdowns during patient transitions. In the measurement phase of the project, participating hospitals found that an average of 37 percent of hand-off communications were defective, with the receiving caregiver unable to safely care for the patient.
By improving the completeness, accuracy, and accessibility of patient information through targeted solutions that included the use of information technologies, project participants were able to reduce defective hand-offs by an average of 52 percent.
Examples of HIM Involvement
With their data management experience, HIM professionals are integral to an organization’s quality infrastructure. Information support and technical consultation in areas such as data quality are absolutely essential HIM roles. Illustrated below are examples of how HIM expertise is helping to advance quality and patient safety improvement initiatives.
Ashley Ketterer, RHIA, a new HIM professional, works in the quality department at Hillman Cancer Center in Pittsburgh. Her responsibilities include reviewing patient charts to determine compliance with quality oncology practices and surveying patients to discover whether expectations are being met.
Ketterer and other members of the quality team work collaboratively with managers and staff at all levels to measure performance and determine best practices. Recently she assisted clinicians in setting patient wait time expectations for receipt of medications and treatments. Now she routinely collects and analyzes data to determine the cause of unexpected delays and reports results to the departments.
At UAB University Hospital in Birmingham, AL, HIM staff priorities include gathering accurate data for performance measurement databases and identifying potential quality problems, according to department director James Lantis, MHA, MS, RHIA. Examples of how the department supports these goals include the following:
- All cases in which a hospital acquired condition (HAC) is identified by coders undergo a second review. This review is done to confirm presence of the HAC and determine if it is attributed to the correct clinician(s). In support of the facility’s patient safety improvement efforts, cases in which the HAC was not present on admission are referred to the medical staff for professional practice evaluation and also to the patient safety office.
- All charts of patients with the principal diagnosis of congestive heart failure are reviewed to ensure that the discharge medications listed in the instructions given to the patient match those listed by the physician in the discharge summary. Cases that fall out of this review are reported to the hospital’s government and regulatory affairs department and the quality council.
Health record transcriptionists at Carilion Clinic in Roanoke, VA, are instructed to be on the look-out for anything in a report that is outside the norm. Their senior manager, Teresa Brown, RHIT, receives notification of these reports and refers the cases to the risk management or performance improvement department.
Out-of-the-norm situations include operative notes detailing a procedural error, consultation reports describing a patient’s allergic reaction to a hospital-dispensed medication, or progress notes that mention a patient fall. HIM professionals involved in any type of record review for coding or abstracting purposes can also be on the look-out for situations needing referral for further investigation.
Ways to Get Involved
HIM professionals seeking to be involved in advancing quality and patient safety in their organizations must actively seek out collaboration opportunities. Whether in a provider setting or within one of many healthcare stakeholders (e.g., insurance plan, health information exchange, durable medical equipment, pharmacy management services, etc.), quality initiatives will always benefit from HIM expertise. To further advance the HIM professional skill set, AHIMA provides certifications as a Certified Health Data Analyst (CHDA) and Certified in Healthcare Privacy and Security (CHPS).
To ensure inclusion in quality and patient safety improvement initiatives, HIM professionals must voice their concerns and desire to assist and share their unique knowledge with the appropriate people. They can consider any of the following opportunities:
- Contact the individuals responsible for patient or resident quality and safety to explore ways that HIM can be beneficial in their improvement projects
- Ask to be included as a member of the organization’s patient safety or quality improvement committees
- Include discussions of patient or resident safety and quality in department meetings to heighten staff awareness of these issues
- Work closely with other departments to ensure patient care documentation is appropriate, consistent, complete, timely, and meets the needs of everyone involved in the patient’s care
- Collaborate with clinicians and IT professionals to configure information systems that are capable of meeting internal and external performance measurement data requirements
- Be a patient care advocate and advance patient centered care by encouraging the development and use of an electronic personal health record for patients and their families
- Join AHIMA Communities of Practice that bring quality and patient safety issues to the forefront and discuss information management issues with likeminded colleagues
HIM professionals have long been dedicated to improving the quality and safety of patient care. HIM expertise was essential when these initiatives were conducted primarily within organizations. Now that initiatives have expanded to include shared performance measurement databases and information transfer among providers, effective data governance and the role of the HIM professional are even more important.
- Spiegelhalter, David J. “Surgical Audit: Statistical Lessons from Nightingale and Codman.” Journal of the Royal Statistical Society, Series A (Statistics in Society), 162, no. 1 (1999): 45–58.
- Berwick, Donald M., and Maureen Bisognano. “Health Care Services.” In Joseph M. Juran and A. Blanton Godfrey, eds., Juran’s Quality Handbook, 5th ed. New York, NY: McGraw-Hill, 1999.
- Council of Economic Advisors. “The Annual Report of the Council of Economic Advisors.” February 13, 2006.
- Agency for Healthcare Research and Quality. “National Healthcare Quality Report.” 2011.
- Agency for Healthcare Research and Quality. “National Healthcare Disparities Report.” 2011.
- Slovenky, Donna J., and Nir Menachemi. “How Information Technology Can Improve Patient Safety.” In Patrice L. Spath, ed., Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 3rd ed. San Francisco, CA: Jossey-Bass, 2011.
- Office of the National Coordinator for Health Information Technology. “Electronic Health Records and Meaningful Use.” 2011.
- Nancy Staggers, Charlene Weir, and Shobha Phansalkar. “Patient Safety and Health Information Technology: Role of the Electronic Health Record.” In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Washington, DC: Agency for Healthcare Research and Quality, 2008.
- AHIMA. “Assessing and Improving EHR Data Quality.” Journal of AHIMA 78, no. 3 (March 2007).
- American College of Surgeons. “TJC Tackles Miscommunication among Caregivers.” Bulletin of the American College of Surgeons 96, no. 1 (Jan. 2011).
Felisha Bochantin, BS, CPC, CPC-H, CPC-I, senior data analyst, Ingenix
Teresa Brown, RHIT, senior manager of transcription, Carilion Clinic
Rebecca Busch, RN, MBA, CCM, CBM, CPC, CHS-III, CFE, FIALCP, FHFMA, president and CEO of Medical Business Associates, Inc.
Vicki Delgado, RHIT, CTR, director of health information management, Specialty Hospital of Albuquerque
James Lantis, MHA, MS, RHIA, administrative director of health information management, UAB University Hospital, Birmingham, AL
Patrice Spath, MA, RHIT, healthcare quality specialist, Brown-Spath & Associates
Valerie Watzlaf, PhD, RHIA, FAHIMA, associate professor, department of health information management, University of Pittsburgh
"Advancing Quality and Patient Safety Initiatives"
(Journal of AHIMA),