Keeping Information Clean: New Information Governance Efforts Challenge HIM to Sort Out Dirty Data

By Mary Butler

In a hurry to deliver two dozen artisanal doughnuts to your office one Monday morning, the bicycle delivery man takes a spill in rush hour traffic. One dozen glazed pastries tumble out of the bakery box onto the sidewalk, collecting some dirt but still looking edible (five second rule!). The other dozen, customized and individually wrapped in a separate box, survives unharmed.

Upon delivery, your office mates decide to ditch the box of glazed treats because who knows what kind of bacteria live underfoot. They can, however, trust the doughnuts that are safely wrapped—and feel comfortable sharing and passing the doughnuts around, even to coworkers who didn't kick in for the delivery fee.

That extra layer of protection—the wrapper plus the box—boosts the confidence of everyone who comes in contact with one of those doughnuts throughout their (likely) brief lifecycle.

Health information and data typically have a much longer lifecycle and deserve greater protection than everyone's favorite breakfast carb, which is why health information management (HIM) experts are making a hard push for information and data governance. To make the concept of information governance as it pertains to health information and data more accessible, Linda Kloss, RHIA, CAE, FAHIMA, president of Kloss Strategic Advisors and former CEO of AHIMA, has referred to information governance as an "accountability wrapper." The wrapper is what keeps the data "safe" or "clean," Kloss says.

Over the last several years, healthcare leaders have been too focused on technology acquisition and not focused enough on the content and data they've collected with that technology. As a result of that rapid adoption of technology—primarily in the form of electronic health records (EHRs)—the healthcare industry is starting to see signs of an approaching information crisis, Kloss says.

"So we see breaches, we see an increase in medical identity theft, we see errors in electronic records that are very hard to tease out or back out. And all of these are symptomatic of rapid adoption and not [having] an adequate policy and governance infrastructure," Kloss says.

As a result, healthcare leaders are starting to take information governance seriously and are starting to devote multidisciplinary teams to developing governance initiatives. But in many cases, it may be up to HIM professionals themselves to make sure they're involved.

Why is this a Problem Now?

Healthcare leaders are starting to get on the information governance bandwagon now because they're realizing that the industry has to make up for lost time, Kloss says. Information governance efforts have been happening successfully in industries such as banking and finance for years. As providers prepare for ICD-10-CM/PCS and continue down the health IT path laid by the "meaningful use" EHR Incentive Program, they need to start thinking about the information they're collecting with these new tools as an asset. Information governance is, therefore, asset management.

"Think about the plumbing infrastructure and the water going through that plumbing," Kloss explains. "Information governance is about managing that flow of water, what is it, where is it going, who has access to it, what faucets can be opened," Kloss says. "It's not just a matter of buying new technology to solve this problem. Information governance is really asset management, through effective policy, the whole array of management tools, technology being just one of them."

Mary Reeves, RHIA, administrative director of medical information services at Vanderbilt University Medical Center, agrees that the EHR push has helped spur the demand for better governance.

"I think all of a sudden we have this incredible amount of information, and people are recognizing that not only is it important to install an electronic record and make it operational, but to also understand the content and management of the information within the electronic record," Reeves says. "And that doesn't just automatically happen as a result of installing and implementing an EHR system. As in any information system, you have to have management of the data, and someone responsible for the integrity of the information."

Improving the Health Record and Data

One of the core focuses of information governance is improving the quality and integrity of the patient health record and general health data.

Kloss says the HIM role is evolving from one that takes an archival view of a patient's record—one that looks at the record after a stay, organizes it, and checks its completeness—to a role that manages a record's downstream impact.

"What happens now, in a digital world, [is] that information is readily accessible [and] getting pulled forward to new stays. Our management gets shifted from the archive to getting it ready to store, to starting information management, to information capture," Kloss says. She emphasizes that HIM professionals have a responsibility to manage that data accurately and make sure that everyone who uses it down the line understands its intricacies.

Jane Thorpe, JD, says information governance plays a major role in maintaining a legally sound health record, especially when it comes to tracking any requests for disclosures and e-discovery. Providers must know what information they are releasing and whether that information meets the minimum necessary rule. Having those policies and tracking procedures in place to organize, store, and maintain data ahead of time is part of a sound information governance program.

"On the front end, as an attorney in private practice, we would get calls from providers all the time saying 'Police are at the door and they would like this information.' Or, 'We've been subpoenaed and asked for this information,'" Thorpe explains. "So it can lead to this case-by-case decision making process that can be very stressful, very resource intensive, and also lead to a concern that you're not making the right decision because you're making it so quickly."

When Reeves began working on information governance at Vanderbilt, one of her first projects was determining what should be part of the electronic legal health record.

"Your documentation and your record is very critical for regulatory compliance. Documentation in the record is a significant part of revenue cycle and reimbursement within an organization," Reeves says. "…There are multiple uses for the medical record, so all of that ties together in doing it for compliance and how governance is linked to that."

Another information governance task Reeves oversees in her department is health record corrections, a key step in preventing duplicate health record numbers. Reeves says she gets a monthly report of every correction a staff member has made to a health record.

"We don't want everybody that uses the electronic record, or every user, to go in and make corrections and deletions. That, to me, is not an appropriate way to manage data integrity within the record," Reeves says. "They may be deleting inappropriate information from the record. We have a policy that governs that."

Enter HIM Professionals

HIM professionals are perfectly suited for information governance roles, but it can be hard for executive management and CIOs to recognize that since, in other industries like financial services and insurance, governance is seen as an IT function.

For providers to implement information governance programs well, it must be a collaborative effort, according to Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and privacy officer at HealthPort. HIM professionals are skilled at piecing together data from multiple provider systems, such as the radiology, laboratory, emergency departments, and then managing that flow of information—and not just on the front end. All of these skills are vital for information governance projects. "You hear about this in nursing informatics all the time," Bowen says. "Nursing informatics is only about how it assists the nurse during the clinical caregiving process. Once it leaves that process, they don't care where it flows. But HIM does know that."

HIM professionals need to assertively convince executive management and senior technology officers that HIM is vital for any information governance efforts, Bowen says. "So you've always got to bring it back to HIM and look at it from a compliance umbrella. Bring these domains together. It's not one domain specific. It's got to be the collaboration," Bowen says.

Seth Katz, MPH, RHIA, was recently named assistant administrator, information management and program execution, at Truman Medical Centers in Kansas City, MO, after previously serving as the system's HIM director. Katz is part of a 20-person information governance team at Truman, which he estimates has as many as 50 contributing individuals in total. Katz is one of several HIM employees at Truman working on its information governance program, which he is optimistic about.

"What we want to get to [over] the next couple of years is a formal data governance enterprise across the entire organization," Katz says. "There are five data governance policies across the organization and we have clear owners of each that are empowered to make changes, whether it's a database steward, whether it's someone who's in charge of our data dictionary, any of those pieces. All of that's put in place. So it's a long-term project obviously, a couple year's worth, but we're really excited."

For HIM professionals who see the need for information governance programs, but don't see enlightened administrators, Katz encourages them to get involved and start talking to an administrator or CIO. Most importantly, speak up. "The first thing is you've got to read up on it and say, if we haven't looked at one [information governance team], we really have to. As an organization, this is important for us. If you have started one, get a seat on it. Explain the virtues your background brings," Katz says.

HIM professionals are a good fit for information governance programs for many reasons, according to Katz. "[The] HIM profession has clinical knowledge, IT, business, educational knowledge—HIM is the epicenter of all of those different functions of a hospital and that's a huge plus to have. It's good to have some strategy background because it's good to support your strategic goals. I think that's a huge piece. Experience with an EHR is crucial," Katz says.

When Reeves is looking for people to work on information governance teams, she typically looks for credentialed health data coordinators and someone who has broad experience with an EHR and a strong grasp of workflow. Reeves says the ideal candidate must be able to ask: "How did that information get into the electronic record?" and "Who is documenting that in the electronic record?" Having the ability to audit and follow that check through to its completion is an important skill set, she says.

Governance is the Future of HIM

HIM professionals overwhelmingly believe that information governance is their new domain, and the future of their profession. Stephanie Luthi-Terry, MA, RHIA, FAHIMA, director of eHIM business solutions, health information for Allina Health in Minneapolis, MN, agrees. She has been working on Allina's information governance program for two years, and says it's still in its infancy but will continue to evolve and improve. Governance also is the key to keeping HIM relevant in the future.

"If you go back to the question of why we're even around, it's because HIM professionals manage information. That has always been our core strength and competency," Luthi-Terry says. "…It crosses that chasm between a medical record professional process to that technology. We're migrating to that enterprise data content management role. I believe truly that is where HIM lands, and where our strength is and will be for the future."

Reeves says HIM professionals need to make information governance a priority, and that doing so has the potential to create new job opportunities. "The use of information, and governance of it, is the future of healthcare. Transcription and traditional roles are changing," Reeves says. "We don't see as much transcription now as [we] did in the past. We must create our future. To me it's so logical that we do this, this is our expertise."

While there is consensus that information governance is the future of HIM, many in the industry have expressed a desire for the need of a set of industry standards. However, nobody seems to agree on just exactly who should issue the standards. "There's got to be some structure to it," Bowen says. "We need to have some standards built at the national level."

Bowen explains that the lack of standards is a roadblock that inhibits the industry, causing it to "put the cart before the horse." Thorpe also says she's been hearing a lot of debate on this issue.

"My sense is that, like most things, this would benefit from some public/private collaborative effort to take into consideration all the various circumstances and scenarios that need to be addressed from a governance perspective because it does look different from the point of view of different organizations," Thorpe says. Improved governance policies could pave the way for lower healthcare costs, quicker decision making, reductions in unnecessary procedure duplications, and fewer hospital readmissions. "I think as the amount of information continues to grow, the technologies that are available that allow more rapid sharing of this information governance is absolutely critical because without governance, it doesn't take many occurrences or data breaches to really set back movements," she says.

Thorpe says that with information as sensitive as an individual's health information, frequent data and privacy breaches have the potential to hurt the push for electronic records. "The more we're able to enable health information exchange with providers, with payers, with patients, the more great benefits," Thorpe says. "I think we'll get higher quality of care. Providers will be able to share information in real time, I think you'll have a much more empowered and engaged patient base."

Mary Butler (mary.butler@ahima.org) is associate editor at the Journal of AHIMA.