Small Organization Making Mighty Strides with IG

By Betty Rockendorf, MS, RHIA, CHTS-IM, CHPS

Ministry Door County Medical Center (MDCMC) is a 25-bed critical access hospital in Sturgeon Bay, WI that offers many services, from inpatient and outpatient care to rehabilitation services, emergency department and urgent care, six clinics, and a skilled nursing facility. So, how does a smaller organization such as MDCMC make strides with information governance (IG)?

At MDDMC, IG begins with the Provider Integration Team, a branch of our former “Medical Records Committee.” Membership is comprised of approximately five physicians who attend on a regular basis, the Chief Information Officer, IT analysts, HIM Director, Chief Medical Quality Officer, Quality Manager, Vice President of Patient Care Services, and Director of Clinic Operations. The team meets weekly because there are so many decisions to be made at this stage in our journey. Business conducted includes approval of any new or updated forms, consideration and approval of electronic health record (EHR) change requests, standard content, or any new content for the EHR. The team has a charter which serves as a unifying authority so that individual departments ore areas are not making changes or decisions unilaterally. Though this team is specifically designated as an “Information Governance Team,” we anticipate the current team will evolve and grow into a broader IG team.

We are taking small steps and found it necessary to begin with a focus on EHR governance, which is a priority for us as we strive to meet “meaningful use” EHR Incentive Program requirements and provide tools that are user-friendly for our medical staff and safe for our patients. Successes so far include our Statewide Health Information Network, which enables us to create and send continuity of care documents, and of the implementation of a patient portal that provides 24/7 access to health information. Integration of other systems is in process and requires oversight, as well as testing and validation, to ensure quality and integrity.

Other teams within our organization bring together all the various areas mentioned in the opening paragraph, and this is particularly important in a small organization offering such diverse care settings. Senior leaders oversee the executive committees and keep their hand on the pulse of IG throughout the organization. They seek input or participation as needed from medical staff, department directors, and managers. Coordination is necessary to ensure regulatory compliance in all the various care settings. For instance, the Revenue Cycle Committee meets monthly and pulls in directors and managers from all the various service/care settings. Another example is our critical access hospital and rural health clinic annual policy review. We review policies each month, so that by the end of the fiscal year, we’ve been through all of them. An annual meeting is held with both Board and community members present.

We are in the midst of converting to a new EHR platform that combines both acute and ambulatory into one complete package. The ultimate goal as we journey to this combined EHR is to have standard content with structured data fields where they are most needed and to optimize the value of the EHR by best utilizing its many capabilities. We found from previous experience that substantial changes to standard content make it more difficult to manage upgrades, maintain data integrity, and can greatly hinder data retrieval. Structured data is important when retrieving information for core measure reporting, ensuring the integrity of the information in the EHR, and maintaining patient safety. Smaller organizations require information governance as much as larger organizations, if not more. If the scales tip in the wrong direction at a small organization, it will likely be readily apparent and can have drastic consequences. The structured data will benefit the organization by having information readily available for real-time decision making. In the past, reports were retrospective, which caused costly delays in decisions regarding services. In today’s rapidly changing healthcare landscape, time is of the essence.

Larger organizations typically have many resources, including human resources. For us, there are fewer people to do the work and those people generally wear more than one hat. The decision to hire a consultant came as a direct result of that—we simply didn’t have the manpower to do this alone. Another challenge is getting busy physicians to take time away from seeing patients to come to meetings. Recognizing the importance of having physician input (having learned from experience how unhappy the medical staff can be when they are not included in decisions which affect their workflow), organizational leadership has made it worth their while to participate and these physicians are truly invested in improving the use of the EHR through their participation on the Provider Integration Team. This meant fairly compensating the physicians for their administrative time and offering them flexibility in their schedules, not penalizing them for decreased patient visits on any given day, and certainly ensuring that they get their time off. We respect and support work-life balance for our physicians and schedule meetings on days when they are working.

Information flows to the Provider Integration Team from multiple work groups who review the options and make recommendations. The health information management department works closely with IT staff, reviewing and approving content for the EHR. The HIM Director also works with the Ambulatory EHR Workgroup to review the needs of the clinic practices. Our nurses in acute care also form a strong team investigating ways for physicians to capture and integrate nursing documentation into their reports (if they choose to do so), making it flow smoothly without the need for re-documentation or double work.

Utilizing IG principles helps us maintain healthy teamwork and a healthy balance. It’s an ongoing journey and there is much more to do, but we are off to a good start! We have policies in place to address all the principles outlined in AHIMA’s Information Governance Principles for HealthcareTM (accountability, transparency, integrity, protection, compliance, availability, retention, and disposition). Current committees may be a bit spread out, but do address:

  • Governance of clinical and operational information in order to improve quality of care and patient safety
  • Improve population health
  • Increase operational efficiency and effectiveness
  • Reduce costs
  • Reduce risk

We are working toward establishing one committee that encompasses the broad scope of IG.

Though we may be small, we are making mighty strides with IG. Information governance is a team effort. It’s important to have support for the cause from senior leadership, as well as dedicated physicians, IT and HIM professionals, and clinicians to lead the way. No matter what the size of the organization, the information assets are proportionately valuable.

Betty Rockendorf ( is director of health information management and privacy officer at Ministry Door County Medical Center, based in Sturgeon Bay, WI.

Original source:
Rockendorf, Betty. "Small Organization Making Mighty Strides with IG" (Journal of AHIMA website), March 10, 2016.