Comments of the American Health Information Management Association (AHIMA) Pursuant to the Town Hall Meeting at HIMSS

March 8, 2004
Jonathan G. Javitt, MD
Chairman, Health Care Delivery and Information Technology Subcommittee
President's Information Technology Advisory Committee
Office of Science and Technology Policy
Executive Office of the President
Re: Comments of the American Health Information Management Association (AHIMA)
Pursuant to the Town Hall Meeting at HIMSS

Dear Chairman Javitt:

I am sending this letter in response to your request for submission of additional comments following the recent town hall meeting conducted at the HIMSS meeting in Orlando, FL. AHIMA was not able to offer verbal comments at that time and we appreciate PITAC's desire to hear our thoughts regarding:

  • The barriers to the implementation of health information technology and electronic health records
  • How the federal government involvement can assist in overcoming these barriers.

The exhibit hall at HIMSS certainly underscored the breadth and depth of business investments in healthcare information and communication technology (ICT). Having watched this industry develop over the past twenty-five years there is no question that today's ICT solutions are finally capable of supporting-even transforming-many clinical and businesses processes and, ultimately, improving patient care. But, in order for this to happen, the barriers that restrict progress must be overcome.

Barriers to Implementation of Healthcare IT and the EHR

We believe that there are four barriers to implementation that must be acknowledged and addressed through cross-industry, public-private collaboration:

  1. Vision. The industry and the public need a guiding vision of where we are headed and some tangible milestones by which to measure progress. The NHII vision developed by the NCVHS is a major contribution, but it is not widely understood. The importance of electronic health records as key building blocks for the national healthcare information infrastructure is not well understood. Electronic health records are the basis for family, longitudinal and personal health records and the source of information for research, public health and cost effective administration. Without full deployment of the electronic health records, the NHII will be cumbersome and unsustainable. A clearer vision would help all stakeholders to communicate a common message throughout the industry, like Canada's Health Infoway, which has been built upon a national vision and has garnered much support throughout that country.
  2. Standards. Standardization of technology and information will accelerate the deployment of systems and interoperability-and will save money. But the development and adoption of standards in the US is slow, and at times even competitive. Also, our culture is one of customization and the importance of standards is not well understood in health care outside the small circle of organizations that has been engaged in their development. There is need for more effective communication regarding the importance, impact, and mutual benefits of standards in order to gain widespread support for standards initiatives.
  3. Change Leadership. Transitioning from paper to electronic practice impacts every work process in a health care organization. So much of the current discussion is focused on ICT solutions, but it is the process and workflow changes that hang us up. As anyone who has ever implemented a new system knows, it is the “power user” that gets the results. The same system in two organizations can produce vastly different returns on investment depending on the leadership and level of integration between the system and the staff. This is not technological change. It is process and a people change.
  4. Third-party Payer Participation. Engaging the private health insurance industry is crucial. Many of today's health record policies and practices are designed to meet the information requirements of third party payers-coverage, substantiating medical necessity, reimbursement, adjudication-but these payers are not engaged in any meaningful way in this change effort. In fact, as seen in their recent opposition to ICD-10-CM and ICD-10-PCS, they do not acknowledge the benefits provided by improved information standards and tools, many of which accrue to their organizations. They also do not conform to data and code set standards and their policies impair the quality of data. They too must modernize if we are to maximize return on investment.

How the Federal Government can help Overcome Barriers

  1. Remove outdated regulations that hold back innovation in health information management. There are many outdated regulations that stand in the way of improving administrative processes that will improve productivity. The Medicare Conditions of Participation (COP) are a good example. These impose medical record keeping practices that are outmoded. The Joint Commission on Accreditation of Healthcare Organizations has modernized its Information Management Standards, but the COP have not kept pace. The COP has been slated for revision for years.
  2. Adopt ICD-10-CM and ICD-10-PCS. Publish the Notice of Proposed Rule Making (NPRM) as soon as possible for adoption of ICD-10-CM and ICD-10-PCS and implement new code sets as soon as feasible. It has been four months since the NCVHS wrote its letter recommending adoption to Secretary Thompson and still there is no indication of when the NPRM will be out. ICD-10 is important for 3 reasons:
    • The US is out of step with all other developed countries that have already adopted the 10 th edition of the ICD. Other countries use it to classify the incidence of disease as well as the causes of death. The US is using ICD-10 for cause of death reporting only and ICD-9 for disease reporting. Our national data systems are being rendered useless. At a time when SARS and other epidemics are just an airplane flight away, the US must be part of the world health data community. I might add, that many countries rely on US analytical tools based on codes and groupers. This edge is being lost by the inexplicable delay in coming in line with contemporary code sets.
    • A map between SNOMED-CT and ICD-10-CM needs to be built to derive full benefit from SNOMED. This map is the crosswalk from the clinical reference terminology to the classification system. It makes no sense to build a map to an obsolete classification system. The electronic health record will permit automated assignment of ICD codes. However, the construct and greater specificity offered by ICD-10-CM and ICD-10-PCS will greatly facilitate this application.
    • Availability of computer-aided coding applications would relieve the shortage of expert coders and enable them to perform other critical data management roles in the electronic health information management environment.

    It will take several years to realize full benefit from the improved aggregate databases. For example, coded data based on ICD-10 would permit improved underwriting and payment methodologies, more precise research sampling, tracking and trending of patient outcomes and costs and more useful performance data for consumers.

  3. Invest in workforce development. The Bureau of Labor Statistics forecasts the need for a 49% growth in the number of trained health information workers by 2010. AHIMA has just completed major workforce research that lays out new competencies needed to manage health information in an electronic environment. This means additional training for the current workforce and retooling college curricula to educate future workers. Other health professions face a similar challenge and AHIMA is working with other allied health groups to pass an Allied Health Reinvestment Act. As stated above, preparing the work force to be change agents is a critical element of advancing change.
  4. Build consensus. Establish a unit at the appropriate level in the federal government that is authorized and funded to bring stakeholders together to build a consensus or, at least, focus the discussion around the national healthcare information infrastructure. This vision should clarify and effectively communicate the relationship between the NHII and the EHR. We are not suggesting that the federal government fund the implementation of the NHII. Rather, we are merely stating that the federal government is in the best position to formulate a national vision with broad stakeholder input.
  5. Create incentives and programs. There needs to be stimulus to encourage adoption of voluntary standards. In addition, the government should adopt standard data definitions, particularly those that the private sector is required to submit to the government. The Consolidated Health Informatics project is a useful start and should be leveraged as guidance to the healthcare industry. In addition, the government should provide incentives for the industry to agree on data standards for data interchange and the electronic health record. For example, there is confusion in the industry about the relationship between the Continuity of Care Record (CCR) and the electronic health record (EHR) standard. In fact, those standards can be harmonized, but there is little impetus to do so without such incentives. The use of incentives is preferable to a regulatory approach.

AHIMA is encouraging the full deployment of ICT through its e-HIM (electronic health information management) initiative and by participating in standards and collaborative efforts. Our e-HIM initiative is designed to promote migration from paper to electronic records and deliver measurable cost and quality results from improved information management. Our nearly 40,000 practicing health information management professionals work in 30 types of health care organizations and in 200 job titles. Mobilizing this workforce for change is one way we are helping to make such change a reality.

AHIMA appreciates this opportunity to comment to PITAC. We look forward to working with you in the future. If you have any further questions at this time, please contact me at the above address and phone (312) 233-1166 or by e-mail .


Linda L. Kloss, MA, RHIA
Chief Executive Officer

Cc: Melanie Brodnik, PhD, RHIA, 2004 AHIMA President