When the Doctor Calls: Opportunities in Ambulatory Care

It wasn't too long ago that physicians could hire a file clerk to handle simple filing tasks and doctors themselves decided how patients could view their records. But today doctors' information needs are much more complex.

Just look at how many credentialed HIM professionals are bringing their expertise to ambulatory care settings, which include physician practices, free-standing community health clinics, and hospital outpatient departments. According AHIMA's 2005 member profile data analysis, 14 percent of respondents say they work in physician offices and more than 17 percent say they work in an ambulatory care setting.*

Privacy regulations, new transaction code sets, complex payment issues, compliance with local medical review policies, and especially adoption of the electronic health record (EHR) all require knowledge of HIM fundamentals. HIM professionals are well positioned to offer their expertise to physicians, whether as employees or consultants.

"This is a great opportunity for HIM professionals to share their knowledge and expertise," says Margaret Stewart, RHIA, president of Morgan Stewart Health Information Services in Norcross, GA. "We must be assertive in our involvement. Most practices would welcome the advice and information."

Take a look at some of the problems physicians face, and how HIM professionals can help.

Making EHRs More Palatable

Adopting the EHR is posing many challenges to physicians. As entrepreneurs, doctors are concerned about the bottom line, disruptions to their work, and whether patients (their clients) perceive a smooth or bumpy transition. The main barrier is cost, says Cheryl Gregg Fahrenholz, RHIA, CCS-P, president of Preferred Healthcare Solutions, LLC, a Bellbrook, OH, practice management and consulting firm that works with large physician networks and outpatient facilities. "As physicians' income shrinks due to tighter reimbursements, it's very difficult to convince physicians to invest in new software," says Gregg Fahrenholz.

Another challenge is redesigning workflow. Physicians perfect their workflow to remember whom they saw and what they did. EHR implementation can disrupt their way of working. A successful EHR implementation will take each physician's working style into consideration. Physician acceptance is individual and personal, says Susan P. Hanson, MBA, RHIA, FAHIMA of TerraStar Consulting, a Nashua, NH-based consulting firm. Hanson is helping organize an Institute on "EHR in the Physician Office" at the 2005 AHIMA 77th Convention and Exhibit in San Diego, CA.

"Physicians are trained to be good diagnosticians," says Hanson. "One of the individuals that I worked with applied these same diagnostic skills to the analysis of the documentation process with the EHR. He concluded that there were too many 'clicks.' I provided him with advanced training encouraging him to redesign his workflow to optimize the software's functionality."

A big barrier to widespread adoption of the EHR is the lack of data content standards in physician practices. Unlike hospitals, in physician practices there's not even a consensus around what paper medical records should contain.

Doctors end up trying to define the data content standards at the same time that they begin moving to an EHR, which can bog down EHR efforts. Before beginning the technology adoption process, HIM professionals can help physicians identify basic data content standards and create consistency in record formats between physicians in their group.

In addition, there are literally hundreds of EHR systems for physician practices on the market. Physicians are concerned about whether their EHR systems will perform as promised, according to Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, president of Kuehn Consulting, LLC, in Waukesha, WI.

Certification of EHR products will help accelerate adoption of EHRs by removing some of the risk of buying a new system. The Certification Commission for Healthcare Technology (CCHIT) was formed in July 2004 by AHIMA, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. A pilot of the certification process for ambulatory care EHR products is under way. Check www.cchit.org for more information.

"Right now we don't have any 'Good Housekeeping seal of approval' and I think the CCHIT certification will make physicians feel much more comfortable," says Kuehn. Doctors may need help in learning about the certification, understanding what it means and what kind of assurances it gives.

Expediting Information Flow

Doctors need HIM professionals' organization, release of information, and privacy skills. In large physician practices, the amount of patient information shared or accessed can be mind-boggling-upwards of 1,000 charts can be pulled in a single day! This heavy traffic often surprises HIM professionals who switch from a hospital setting to an ambulatory care setting. The Health Insurance Portability and Accountability Act (HIPAA) privacy rules have confused doctors about when and with whom they can share information. In addition, doctors rely on receiving in a timely manner test results, specialists' reports, and other information from outside entities.

E-mail is another tricky area, says Kathy Cleary, RHIA, HIM director at the Austin Diagnostic Clinic in Austin, TX, a clinic with more than 115 providers in several locations. After some physicians attempted to communicate through unsecured e-mail with patients, her clinic began a pilot project to provide secure messaging between doctors and patients.

Another big hurdle is the lack of consensus in the United States on what the legal medical record is. AHIMA and other healthcare organizations are lobbying for the EHR to be the legal record. If paper records persist as the legal standard, then doctors and others will be forced to maintain the EHR in paper format.

"We've always said the legal record is what you see in the computer, and the paper file is an archive file or another volume," says Cleary. "We still have a hybrid record because some information can't be electronically transmitted. In some cases we use scanning to bring information into the EHR. We continue to pursue additional electronic connectivity."

This year AHIMA launched a new e-HIMâ„¢ practice work group "Defining the Legal EHR," which will identify key conformance criteria that will ensure that the EHR is universally accepted as the legal health record.

Finding Common Touch Points

AHIMA members can help create change and raise their professional profiles by offering their expertise. To do so, members will need to step forward and gain doctors' trust.

If you are working in an ambulatory care setting, "start networking to find people who are supportive," advises Cleary. "These might be the risk manager, office managers, or physicians with an interest in HIM. Volunteer for committees on quality management, risk management, or anything involving process improvement." This will increase your visibility in the organization and help you identify projects that need your expertise.

If you work in an HIM department at a hospital, you may begin to get calls from doctors wondering how they can set up an EHR in their practices. Before they call, learn about physician practices. Kuehn suggests taking a tour of a small office with three or four physicians and then taking a tour of a larger one. She recommends that HIM professionals read two books: Electronic Health Records: A Practical Guide for Professionals and Organizations by Margret Amatayakul, which will help readers understand the EHR from an organization's perspective. The other book is Electronic Health Records: Transforming your Medical Practice by Amatayakul and Steven Lazarus. (Physicians will find the case study at the end of Chapter 10 particularly helpful in visualizing what life will be like in the EHR environment.)

Another excellent resource is the MGMA-AHIMA Smart Pack. AHIMA teamed up with the Medical Group Management Association to offer a collection of practical articles and papers entitled, "Implementing an Electronic Health Record in Physician Practices."

Participate in the Ambulatory Care-Physician Practice CoP and the EHR CoP. If you consult in this area, check the Consulting CoP for ambulatory care topics.

Follow the Centers for Medicare & Medicaid Services demonstration project called Doctors' Office Quality-Information Technology (see www.doqit.org). This initiative promotes adoption of EHRs by small and mid-sized physician practices by educating doctors on EHR system solutions and alternatives and by providing implementation and quality improvement assistance.

The American Academy of Family Physicians (AAFP) has created the online Center for Health Information Technology (www.centerforhit.org) which contains many reference resources and links to projects of interest.

At the hospital, consider having EHR implementation as a topic for a monthly or quarterly medical staff meeting or for grand rounds, which sometimes covers coding or other operational issues. "It's just as important a topic as any clinical topic that the physicians would hear," says Kuehn. AHIMA members can make the presentation with a doctor who has successfully implemented an EHR in his or her practice.

Suggest that interested physicians read up on change management or organizational change. "Physicians don't always understand that they need to be the leader in the implementation effort. They have to be totally engaged and comfortable, then the staff will follow," says Kuehn. AHIMA's Renaissance for the 21st Century program uses a book called The Heart of Change, Real-Life Stories of How People Change their Organization, by John Kotter and Dan Cohen.

Become respected as a valuable HIM resource. "If you demand and earn respect, you will get it and will be turned to as the expert," suggests Stewart, who will speak on HIM challenges in ambulatory care at this year's AHIMA Convention. Include all your staff physicians on updates and critical information. For example, as soon as the new ICD-9-CM codes are released, copy and place these in your physicians' boxes or send through interoffice mail. Pass along information about any EHR activities, including any regional health information organizations (RHIOs) being formed in your state. Consider inviting physicians or their staff to HIM meetings.

Even as a patient, take note of what occurs when you or a family member visits any physician or ambulatory setting, says Stewart. Examine the handwritten questionnaire they give out at the beginning of the visit. Ask about the data the practice is maintaining on you as a patient, as well as the record systems the practices uses.

"Keeping the healthcare settings as independent 'islands' has led to the problems we face today," says Stewart. As HIM professionals reach out to doctors, we can facilitate interaction and strengthen the healthcare industry.

*Profile respondents were able to indicate more than one work setting.

Source: AHIMA Advantage 9:5 (August 2005)