By Mary Butler
As the old canard goes, "if all you have is a hammer then everything looks like a nail." Which is to say that specialists in a given area tend to only consider their specialty and miss the big picture. To personally disprove the idiom, one ideally has multiple tools in their toolbox—as tempting as it is to swing a hammer at everything—since every task requires a more nuanced approach.
Health information management (HIM) professionals are no exception. Their toolboxes need to be stocked with a variety of gadgets and accompanying skills for dealing with the various ways health data can run amok throughout a healthcare organization.
A single tool, like a hammer, didn't fix all the roadblocks and challenges HIM professionals faced in 2015—and the same will go for 2016. RAC audits will start picking up steam again this year, ICD-10-CM/PCS implementation still carries many unknowns, information governance is becoming an ever more important task, and evolving reimbursement and payment models are accelerating the need for data analysts and clinical documentation improvement programs.
A well supplied workbench and toolbox will ensure that HIM professionals are prepared for the work ahead this year. Here are a few tools to grab that will help build a successful 2016.
Measure, Then Measure Again with Data Analytics
Without a tape measure even the most minor home repair or home decorating projects are impossible. Assembling an IKEA dresser? Better measure to make sure it fits the space. Cutting a board for a shelf? You know the saying: measure twice, cut once. Measuring what you have so you know what is and is not needed saves valuable time and money.
Data analytics is the measuring tape of healthcare. And in 2016, that tape measure will be more important than ever. As ICD-10 data starts coming in, providers are going to need data analytics programs and analysts to measure and compare that data with their legacy data, says Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR, FAHIMA, vice president of practice excellence at AHIMA. This will help providers identify DRG shifts that may have resulted from the code set switch. "It's hard to sift through all the data and determine what's important and what isn't," Wiedemann says.
In addition to optimizing new ICD-10 data, providers are dealing with the move to accountable care organizations (ACOs) and value-based purchasing, reimbursement models that reward efficiency and the health of a given participant's population. A picture of both an organization's efficiency and population health is not possible without well-measured analytics.
"ACOs are going to continue to be the things to look for. Healthcare is going to go retail because it's all about getting the bang for your buck," Wiedemann notes. "It's going to be about the facilities that can deliver all the experience at a low cost. Those are the ones [facilities] that are able to survive."
When Wiedemann says that healthcare is going "retail," she is referring to the fact that physician practices and hospitals are increasingly reporting public quality metrics that allow consumers to comparison shop for healthcare services. Likewise, hospitals will be changing the way they market their services by emphasizing their quality and value, much like retail chains. As hospitals become part of ACOs, maintaining good outcomes becomes especially important.
"All of those things are going to come into play, so it's important to understand and know your data, know your survival rate, mortality rate, and for which doctors. If you're an ACO and you're dragging the rest of the group down, you can't afford to lose that group," Wiedemann says.
Providers will also be facing a workforce challenge in managing the crush of data. There is still a shortage of healthcare data analysts that can help providers derive meaning from electronic health records (EHRs) and ICD-10, public health, billing, and enterprise data. Without good data analysts, providers "don't know what they don't know," Wiedemann says.
Patching and Sealing Leaks Crucial to Privacy and Security
Duct tape might work in a pinch if one is sealing a leaky pipe or drafty window in a dorm room. But caulk, applied dexterously with a caulk gun, is the true home repair expert's best friend. Whether one is sealing a pipe or bathtub surround, caulk, which is formulated with one or many sticky substances, can provide an airtight environment that when used right prevents leaks of all kinds.
Privacy and security officers are the caulkers of the health IT world, tasked with looking for leaks in data privacy and security and applying policies, software patches, and encryption technologies to stanch a dribble or flood of protected health information (PHI) from leaking out and falling into the wrong hands—as it did in record numbers in 2015.
The biggest data breach came early in February 2015 when Anthem, the nation's second largest insurer, was hacked, compromising the data of 80 million policy holders. "The major lesson is that you could be super diligent and have everything in place and in order, and it [a breach] could still happen to you," says Angela Rose, MHA, RHIA, CHPS, FAHIMA, a director of HIM practice excellence at AHIMA.
As providers tighten up their encryption and security protocols in the wake of several high profile 2015 breaches, Rose says they should also be prepared for phase two of the Department of Health and Human Services Office for Civil Rights' (OCR) HIPAA audits, which were hotly anticipated before being delayed in 2015. Rose says 2016 will likely be the year things will get moving again, as indicated by Deven McGraw, OCR's new deputy director of health information privacy, in recent media interviews.
The audits will be done at random and will for the first time include business associates. McGraw said in an interview with the Information Security Media Group that the HIPAA audits will be narrower in scope than the 2011 and 2012 round of audits, and may not include on-site visits.
Rose also says to keep an eye on the legislation known as the "21st Century Cures Act," which at press time had only passed the US House of Representatives but had not been acted on by the US Senate. As written, the law would change, among other things, how PHI is shared for research purposes. Rose says that with 2016 being a presidential election year, it's hard to predict what will happen to the legislation, through privacy experts will be watching carefully.
CDI Offers Torque Behind Reimbursement Reforms
A monkey wrench is one of the most versatile objects one can have on their workbench, in their car, or under the sink for quick use. Adjustable and heavy duty, a monkey wrench can assist with the needed torque to loosen or tighten everything from lug nuts to shower heads with precision and efficiency. While you may be able to change a flat tire without one, the tire would likely fall off down the road due to the loose nuts.
Clinical documentation improvement (CDI) specialists play a similar role. A patient's record could be coded and sent in as a claim, but without a CDI specialist's guidance and tweaking the claim could become unscrewed due to the stress placed on it somewhere within the revenue cycle or under the scrutiny of a RAC audit. In 2015, CDI specialists played a major role in helping physicians tighten up the accuracy of their documentation in preparation of ICD-10, and that work will continue into 2016 and beyond.
Patty Buttner, RHIA, CCS, CDIP, CHDA, a director of HIM practice excellence, coding and data standards, at AHIMA, says it's important to keep in mind that documentation isn't important just for reimbursement. Coded data abstracted from EHRs gets reported out for numerous purposes, such as patient safety indicators and quality indicators, which impact expanding value-based purchasing initiatives. It'll be increasingly important for CDI specialists to ask physicians whether certain conditions were present on admission, and to document accordingly.
Buttner says the Centers for Medicare and Medicaid Services' (CMS) 2016 Inpatient Prospective Payment System's (IPPS) Proposed Rule contained some proposals CDI specialists should keep their eyes on. One of those proposals calls for a new payment methodology for joint replacements. Under the proposal, CMS would pay for joint replacements through a shared bundled payment, spanning from before the procedure takes place until the patient is fully recovered. That way, if there are any complications before, during, or after the procedure, such as infections acquired in the hospital or rehabilitation facility, all of the providers are penalized monetarily.
"It's an interesting model," Buttner says. "If they go with that for joint replacements, I'd think other payers would jump onto that wagon as well."
Information Governance Cleans Up a Multitude of Messes
ShopVacs are typically considered fixtures in the maintenance environment for a reason—they can suck up dust, paint chips, and dog hair and can even sop up wet messes of all kinds. Neat freaks love their attachments that allow them to vacuum the drapes and crumbs in the couch cushions. You can use it in every room of the house, plus the yard and garage.
Likewise, information governance (IG) can help clean up all the various data messes located across a healthcare organization, and needs participation from every department of the organization to fully work. When used effectively by attaching it to the right departments, IG can improve data collection and use in a way that helps the organization as a whole function better. In 2015, AHIMA's IG work went a long way toward helping healthcare facilities achieve IG by building on the Information Governance Principles for Healthcare (IGPHC)TM, a set of eight healthcare-specific IG principles adapted in part from ARMA's Generally Accepted Recordkeeping Principles, and creating the Information Governance Adoption Model (IGAM). The IGAM is comprised of 10 competencies rooted in the IGPHC as well as the established body of standards, best practices, and legal/regulatory requirements that surround IG in healthcare. The IGAM has been deployed to healthcare-based pilot sites that have volunteered to test drive AHIMA's strategies for IG.
AHIMA is also launching a number of IG-related projects in 2016, including IG HealthRate, an online tool that allows organizations to evaluate their IG readiness according to the 10 competencies. HealthRate is also tied to the IG consulting services AHIMA launched in 2015—which will likely grow this year as more organizations implement formal IG programs, says Kathy Downing, MA, RHIA, CHPS, PMP, senior director of information governance at AHIMA.
"We might have organizations that want us to come in and do a gap assessment and say ‘What are our areas where we really need to focus on IG?'" Downing says. "We'll come on-site and help develop an IG project plan on what to focus on. If they had a HIPAA breach, we'll come in and do an assessment on everything privacy and security—that's one area where you might see a gap analysis."
Last year AHIMA co-sponsored a second IG survey and white paper that gauged IG readiness in providers. AHIMA will be using the results of that survey to help guide its IG efforts throughout this year. For example, one of the takeaways from that survey, Downing says, is the sense that HIM professionals would feel more comfortable asserting their IG knowledge if they had an IG-related credential.
"Based on the findings of this white paper AHIMA is investigating an IG credential and its value to healthcare," Downing says.
ICD-10 Codes are the Nuts and Bolts of Healthcare
(And Coders are the Socket Wrenches)
Nuts and bolts are absolutely fundamental to any project. Almost nothing can be built or repaired without them, so they come in dozens of sizes and combinations to create something much larger than themselves. Foundations, walls, and cabinets would crumble without them.
Healthcare, too, would fall apart without the nuts and bolts of ICD-10-CM/PCS. Coders are also vital, serving as the specialty socket wrenches that are employed to fit just the right bolt. Services might be rendered, but they couldn't be documented or billed for in any meaningful way without codes and coders. The data also couldn't be tracked for data analytics and research.
Now that the battle to get ICD-10 implemented was won last year, coders and providers in 2016 are dealing with the realities of the new system. As of press time early reports on ICD-10 showed few problems and early success, with many providers breathing a sigh of relief. CMS reported at the end of October 2015 that since the transition on October 1 claims had been processing normally, with only 10 percent of claims being rejected—a rate that nearly equals CMS' historical baseline rejection rate in ICD-9. Only .09 percent of those claims were rejected because of invalid ICD-10 codes, according to CMS.
"The biggest surprise I've heard of is that the productivity for those that have educated their staff over the past two years [on ICD-10] have not seen a huge productivity decrease," says Angie Comfort, RHIT, CDIP, CCS, a senior director of HIM practice excellence at AHIMA. "Yes, some decrease has been realized, but nowhere near the rumored 50 percent."
Wiedemann says that by November 2016 the industry will have a better idea as to how much the new ICD-10 data has affected reimbursement and can then gauge the impact on coders.
"Keep in mind there's been a code freeze. Nobody's had new codes," she says, noting that coders can expect to see 600 to 800 new ICD-10 codes come out later this year when the code freeze ends. Before the code freeze, coders could usually expect 100 or so new codes each year.
"Turn around in November and you'll get all of the reimbursement guidelines regarding what's a complication, what's a major complication, based off of these ICD-10 codes," Wiedemann says.
She notes that in addition to the 600 to 800 new ICD-10 codes, which will be released in September and go into effect in October, the annual update of CPT codes will be released at about the same time. This will produce a crunch time wherein coders and billing departments will be learning how to apply all these new codes and figure out what that means for their reimbursement.
More Tools for 2016
It would take a heavy duty vise grip to fit all of the other HIM topics the industry will have its eyes on this year in one article. Here are a few additional items to squeeze onto the HIM workbrench.
Informatics is one of AHIMA's strategic pillars for a reason. Wiedemann says organizations have more healthcare data than they know what to do with, and only the ones that know how to handle it through information governance and informatics will survive. "Successful groups will know their biggest payer, where their patients come from, how many patients have chronic disease that could be managed on an outpatient volume, etc. One in four organizations predict that the biggest trend in informatics will be in public health trending," Wiedemann says.
Consumer engagement will continue to be a major trend in 2016, with the proliferation of thousands of new patient mobile applications being released every month. Wiedemann notes that with over 1.5 million apps in the Apple Store, healthcare industry experts can expect consumers to "go appy" with their health. Millennials, Wiedemann says, are less concerned about privacy with app use, which creates challenges for providers and developers. "Outpatient services will continue to expand; as well as the use of scribes in these settings," says Crystal Clack, MS, RHIA, CCS, a director of HIM practice excellence at AHIMA. "Consumers are more informed with their healthcare and therefore want more transparency and education on how to navigate through the healthcare maze for themselves and loved ones. Telemedicine is growing by leaps and bounds."
There are additional privacy concerns that Rose is keeping a close eye on in 2016—specifically, release of information rules. "We're waiting on the OCR to release some guidance on charging for electronic PHI which will prove helpful to the industry, especially ROI vendors, with pricing," Rose says. "AHIMA just responded to a request for comment to the OCR on this."
Keeping Things Level with Standards
There's no tool a perfectionist loves more than a level. For a person with obsessive-compulsive tendencies, hanging pictures or mounting shelves on a wall would be a nightmare without a level, which provides visual confirmation that everything is lined up and standardized. In the HIM world, health IT standards function as a level, trying to keep vendors and providers operating in a somewhat uniform fashion when building interoperable EHRs and using protocols that are accepted industry-wide. AHIMA's Standards Team was busy in 2015 trying to guide the discussion on standards within the HIM community. Their focus in 2016 will shift from building awareness to advocating for the actual use of health IT standards.
AHIMA submitted comments to the Office of the National Coordinator for Health IT (ONC) following the January 2015 release of the agency's Interoperability Roadmap. Since then, AHIMA has worked with Integrating the Healthcare Enterprise (IHE)—an international initiative to promote the use of standards to achieve interoperability in health IT—to release their joint white paper "Health IT Standards for Health Information Management Practices."
"Our strategy this last year has been working on education and awareness as well as participating in standards work. We can't just educate and make people aware and not participate," says Diana Warner, MS, RHIA, CHPS, FAHIMA, a director of HIM practice excellence at AHIMA. In the year ahead, Warner says the Standards Team is going to work with AHIMA's Information Governance Team and incorporate the IG competencies and adoption model "into our white papers and continue our work with standards and aligning HIT standards for HIM practices." Also this year, Warner says, the hope is to move beyond awareness of standards, and focus on socializing key concepts—pushing HIM professionals to recognize that they use standards every day and that standards impact their life.
"Our number one goal is to guide the development of standards and information governance for functional interoperability in collaboration with HIT vendors." Warner says.
Mary Butler (firstname.lastname@example.org) is associate editor at the Journal of AHIMA.
"Stocking HIM's Workbench for the Year Ahead"
Journal of AHIMA