by Deborah Robb, BSHA, CPC, RMAI, RPI
Medical practices are facing changes in information management and technology. HIM professionals can help manage today’s needs and tomorrow’s transition to electronic systems.
The coming years do not bode well for the status quo at medical practices. In late 2008 the Medical Group Management Association asked practice administrators to identify their top challenges. Rising operating costs and declining reimbursement topped the list.1 Following was selecting and implementing an electronic health record (EHR) system. Change is pervasive, and many practices are ill prepared for the future, especially those lacking information management and technology support.
The challenge is more daunting since many practices are already struggling with day-to-day record management needs. In a separate survey of 47 small to medium practices, respondents identified challenges ensuring HIPAA compliance, supplying adequate clinical documentation for coding, and keeping track of patient charts (see table on page 46).2 For many practices, simply providing secure, appropriate record storage is a constant struggle. Other medical practice experts report that patient charts cannot be found in 30 percent of visits and that three out of every 10 tests are re-ordered because results are not available.3
HIM professionals can lend a hand. They can bring record management skills to paper-based practices and initiate and guide the organization’s move to electronic record systems. HIM professionals can see the big picture—scheduling, office visit, precertification, documentation, coding, and payment. They can identify red flags and recommend where improvement is needed and how the practice can best achieve it.
The experiences of four medical practices offer insights on how HIM professionals can help physician practices manage the paper-based practice, plan for electronic systems, implement systems, and support a completely electronic environment.
Key Issue in Small Practices—Storage and Retrieval
For the past 15 years Catherine Stemple, RHIT, has been office manager of Barbour County Family Medicine, a rural outpatient family practice in Philippi, WV. She oversees coding, manages record storage, and maintains HIPAA compliance. The practice is part of United Physician’s Care, a network of providers throughout north central West Virginia and western Maryland.
“For the most part, our office runs smoothly despite the fact that we’re still in a paper environment,” says Stemple, who has been with the practice since the doors opened in 1993. “Our main issue is the vast volume of records over 15 years.”
The practice keeps one year of active charts and stores records for the prior 14 years off-site in Clarksburg, 40 miles away. Retrieval is managed by routinely reviewing the schedule a month in advance. “We keep an ongoing list and make periodic trips to the storage site to retrieve records,” Stemple says.
Teresa Ramsey can relate. Ramsey, RHIT, is a medical transcriptionist with Tygart Valley Orthopedics in Elkins, WV, not far away. “Though we have a secure, well-organized storage facility, being off-site is a problem,” she says. “We keep one year of charts in the office, which means continually retrieving records for a patient’s two-year follow-up visit. For walk-ins, we have to retrieve records on the spot. This occurs often, as we see approximately 60 patients a day.”
Practices with HIM expertise are able to better manage medical record storage and retrieval problems. Not only can they keep patient charts more organized and accessible (e.g., through efficient systems for periodic purging, processing retrieval requests, and training staff on procedures), they fully understand the importance of meeting record storage and retention mandates.
Credentialed HIM professionals can help practices evaluate options, ensure compliance, and make cost-effective record retention decisions. Finally, HIM professionals in small practices can research, help determine cost justifications, and support the movement to electronic records.
Preparing for Health IT
Both Stemple and Ramsey look forward to their practices’ eventual transition to electronic practice with a mix of excitement and apprehension. Electronic record systems have the potential to alleviate many present-day concerns from small and medium-sized practices, but the barriers to successful implementation are significant.
For many small practices like Tygart Valley Orthopedics, taking the initial step is cost prohibitive. Initial outlays can be steep for a small practice, and the time required to implement the system may mean lost revenue. “It’s the cost and reluctance to change what seems to be working,” Ramsey says. “Until it impacts [providers] directly, they resist making the investment even though it could save time in the long run.”
HIM professionals can help in three distinct areas: demonstrating a return on investment, providing training and support, and migrating clinical documentation and legal records to the new electronic environment.
First and foremost, an HIM professional in a small to medium-sized practice can become informed on all aspects of electronic records—cost, benefits, impact on workflow and efficiency, and revenue potential. “We have to show providers how they can save time, reduce operating cost, and sustain quality of care,” says Stemple, who acknowledges the financial challenges in an environment of declining reimbursement and increasing operating costs.
She believes, as some studies suggest, that the benefits are largely contingent upon the internal efficiencies of the practice and the ability to make educated decisions that are conducive to successful implementation. That is a key area where the HIM professional can add value to the practice.
Overcoming the learning curve through education and support for physicians and staff will be equally important. “We’re not IT people, but we’re essential in terms of content, documentation, and workflow,” Ramsey says. “The challenge will be the IT component. I’ll need to be trained and educated so I can train personnel and provide support.”
Stemple recognizes the opportunity to demonstrate the value of her position to the practice. “Our knowledge serves as a valuable resource to help others understand the importance of proper documentation, confidentiality, professionalism, and optimal care as we move toward [an electronic system].”
HIM in Practice: Traits for Success
- Leadership ability-fundamental to educating personnel and advocating for best practices and products to ensure quality care, documentation, and accurate records
- Knowledge of the field-continuing education and training to keep abreast of changes, convey information to others, and serve as a valuable resource
- Documentation expertise-a core qualification that affects all levels including patient care, billing, and reimbursement
- Credentialing, education, and experience-necessary to meet an increasing demand for experienced, HIM personnel in a candidate-driven market
- Ability to assume multifaceted roles as administrator, educator, researcher, consultant, mediator, and practitioner
- Adaptability to rapidly changing environments-flexible, open to change, able to quickly assimilate new information
Key Issues with Medical Records
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Secure Record Storage
Lack of Clinical Documentation for Coding
HIPAA and Regulatory Compliance
Processing Requests for Patient Charts
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Source: HealthPort. “Key Issues with Medical Records.” Customer survey, 2008. Results may not total 100 due to rounding.
Implementing the EHR
Resistance to change is often an issue in IT adoption. Some providers and staff will not be comfortable with the new system. HIM professionals can help gain buy-in during planning and implementation by taking on increased responsibility as a researcher and educator. Importantly, HIM also can promote acceptance of the system by ensuring the quality of documentation and the production of an accurate record.
For Whitney Gregg, HIM manager of St. John’s Clinic in Springfield, MO, an electronic record is fast becoming a reality. The system is making its way to 170 clinics on a rolling schedule that started in April 2008 and is slated for full implementation in early 2009.
St. John’s is a physician-led and professionally managed multispecialty group practice encompassing more than 500 physicians and 140 midlevel and allied health practitioners in southwest Missouri and northern Arkansas. The record system includes information from multiple locations and sources, including records at the various clinics. Gregg manages HIM for all clinics, oversees a staff of 25 transcriptionists, manages supervision and training, and participates in creating policy and procedures and coordinating privacy and HIPAA security.
Gregg has a unique perspective, having worked in a privately owned physician practice prior to joining St. John’s. When she first came on board in 2002, each clinic managed its own records. In 2004 her department assumed responsibility for records in all 170 clinics. At that time, there was no uniform system for purging and storage.
“I suddenly found myself with responsibility for creating a system to address the needs of all the clinics,” says Gregg. “But the biggest challenge moving into a large environment was compliance . People simply didn’t know the right thing to do.” As a result, she spent several months traveling to each clinic to conduct training and ensure follow through with procedures.
One of the first steps in migration to the electronic record system was centralizing patient charts. Physician practices traditionally store patient charts in the primary location of care for each patient. “Before HIM took over individual clinics at St. John’s, finding missing charts was like detective work,” Gregg says. To address the problem, she implemented a procedure checklist system to keep track of charts and conducted training for managers and staff in each clinic.
Once records were more organized, Gregg could create a system for purging old patient charts and deciding which records to upload or integrate into the new system. This required cleaning out and organizing a centralized warehouse containing 250,000 records.
“It took a year to complete. Now, it’s down to a science,” she says. “We know exactly where records are for medical and legal purposes.” Gregg oversees annual scanning of a year’s worth of records from each clinic and has a centralized request process in place for record retrieval.
Finally, compliance was a major issue when HIM took over all clinics in 2004. Since then, the organization has implemented a program created by its health system privacy and security committee and reports virtually no compliance problems.
Gregg is pleased with the results. “Program requirements include mandatory training, electronic logs on all records in storage areas, and secure access to storage. Personnel in all clinics are well educated, and they know the procedures. We have a good system in place, with sanctions for not following through.”
With a 16-year track record in HIM, Gregg has amassed a wealth of knowledge, which provides a broad perspective for guiding efforts to move her organization toward electronic practice. “HIM professionals are natural leaders in so many areas of practice,” she says. “The HIM side is often the last side anyone thinks of in terms of leadership capacity. In reality, the HIM professional can anticipate potential problems before they occur—and envision the solutions.”
A CIO Perspective
Pinehurst Surgical is a multispecialty surgical practice comprised of nine specialty centers and 54 providers located in Pinehurst, NC. The practice has used an electronic record system since 2006. According to CIO Phyllis Schuck, the biggest challenge once a practice goes electronic is ensuring data accuracy when multiple people post data and codes into the system. Both HIM and health IT report to Schuck. “It’s a great fit in terms of workflow development and crossover,” she says. “We have good processes in place to ensure an accurate record.”
In physician practices, staff wear many hats. For the HIM manager at Pinehurst, this means not only managing medical records but also playing a key role in defining the designated record set for litigation (i.e., legal record), conducting HIPAA training, and serving on a clinical leadership committee whose goal is to involve nurses in identifying problems and working together to find the best solutions.
Schuck affirms the importance of HIM skills in the electronic world. “I strongly support having someone with medical record expertise on board. The leadership, skills, and qualities of the HIM professional are more essential than ever.”
Changing Practice, Future Roles
The Medical Group Management Association (MGMA) predicts a dramatically changing environment for medical practices. Environmental factors that will have an impact in the next decade include changes in practice financing and reimbursement, advancements in information technology, and work force issues. In each case, HIM professionals offer help in preparing for, and thriving under, these new environmental pressures.
The transition away from traditional reimbursement models and toward pay-for-performance reimbursement will constitute a major paradigm shift for physician practices. Additional reimbursement and revenue are available if practices meet quality criteria and submit mandated reports. For practices, the question will be whether the reimbursement is worth the effort. The additional responsibility and accountability may be more than some small practices are willing to bear.
For example, if a patient within the practice is diagnosed with diabetes, the entire group must meet the quality criteria for diabetic patients across the board in order for the practice to participate in pay-for-performance initiatives. It will be more important than ever to make sure data are captured accurately and applied to the bill so the physician receives correct reimbursement. For the HIM professional, this means more responsibility and accountability for ensuring the potential for increased revenue for the practice.
Increasing overhead and declining payment rates will also squeeze practices. Rural practices will be hit hard, with fewer opportunities than larger and urban practices to disburse costs among multiple clinics and increase the volume of patients on a daily basis. HIM professionals must be proficient in identifying ways to gain efficiencies and cut costs, and it may be necessary to take on more roles if personnel leave and are not replaced.
Despite MGMA’s projection that half of practices (most of them large) will use electronic record systems, providers are concerned about the cost of electronic records, and it’s hard for them to see long-term benefits.
A 2008 survey of 2,758 physicians found that 16 percent had purchased an electronic health record system but not employed it, and 26 percent planned on buying one within the next two years. 4 Two-thirds of respondents without EHRs cited affordability as the reason. Other barriers included complexity of choosing a product, concern about return on investment, and worries that the system will become obsolete quickly.
HIM professionals can help by researching what comparable organizations are doing. “Hardcore statistics say a lot to leadership,” says Gregg. “When we provide meaningful data in terms of workflow and financial benefits, we demonstrate our value to the provider and the practice.”
The HIM perspective is also vital to ensuring a secure, legal record in an environment where so much can be overlooked or forgotten. “Our leadership is fundamental to educating personnel and advocating for procedures and products that enable the organization to provide quality care and documentation, and to ensure a complete, accurate EHR,” adds Gregg. She believes that more and more success stories will encourage practices to take the journey that will propel them to a higher level of patient care and return on investment.
MGMA also foresees that staff loyalty will be low, resulting in frequent turnover and employer unwillingness to fund employee education and association memberships. At a time when many industry changes are making education and professional development a high priority, HIM professionals, particularly in small practices, may be faced with paying for their own education.
And while there may be great benefit in bringing HIM talents and skills to a practice, there is limited funding. Most small practices can’t afford to hire a credentialed HIM professional. Smaller practices may opt for an HIM consultant. As a result, there will likely be more opportunities for HIM professionals to deliver services to medical practices on a consulting basis.
In a time of great change for medical practices, HIM professionals must be ready to change, also. To be successful, they must be creative and adaptive to a constantly changing environment that requires the ability to assume leadership in multifaceted roles—administrator, educator, researcher, consultant, and practitioner.
How HIM Professionals Can Help
- Keep track of patient charts
- Develop an organized, centralized system with records properly labeled and filed
- Implement a “checks and balances” process
- Hire conscientious, efficient office staff
- Ensure secure record storage
- Ensure well-organized, climate-controlled storage facility
- Provide multilevel security for access
- Improve clinical documentation for coding
- Develop good working relationship with providers, being open to addressing issues and looking at impact on reimbursement
- Build a solid, dedicated team that works well together
- Ensure HIPAA and regulatory compliance
- Conduct mandatory training on policy and procedures for all personnel
- Implement sanctions for failure to follow through
- Provide routine updates on compliance to keep staff updated on changes
- Define legal record set
- Process requests for patient charts
- Create a system to ensure proper authorization for accessing records
- Train staff on policy and procedures, clearly establishing who has legal access
- Integrate records into electronic health record system
- Create a system for purging old charts and deciding which ones to upload electronically
- Establish guidelines for scanning records periodically
- Develop a centralized request process for record retrieval
- Require electronic logs on all records in storage areas
- Train staff on procedures
- Pope, Christina, and James Margolis. “Medical Practice Today: What Members Have to Say.” MGMA Connexion, July 2008. Available online at www.mgma.com/WorkArea/showcontent.aspx?id=20074.
- HealthPort. “Key Issues with Medical Records.” Customer survey. 2008.
- Technology CEO Council. “A Healthy System: How Improved Information Management Can Transform the Quality, Efficiency, and Value of Americans’ Health Care.” 2007. Available online at www.cspp.org.
- DesRoches, Catherine M., et al. “Electronic Health Records in Ambulatory Care—A National Survey of Physicians.” New England Journal of Medicine 359, no. 1 (July 3, 2008): 50–60.
Deborah Robb (firstname.lastname@example.org) is physician practice management consultant at HealthPort.
"Addressing Problems in Practice: How Health Information Professionals Lend a Hand"
Journal of AHIMA