by Kevin Heubusch
Health information management professionals offer contemporary physician practices a lot of expertise. In the coming era, they offer even more.
Sometimes overlooked in the talk about information technology is information management. For all the benefits that IT offers physician practices, managing the information that they collect, retain, and report can make the biggest impact on how smoothly and productively practices run.
Information managers can be the missing link between a practice’s clerical staff and its clinical staff.
As they always have, they can optimize coding and reimbursement, making certain the practice is correctly compensated for the services it provides. And they do more.
Increasingly HIM professionals are bringing data management expertise to a new era in physician practices—electronic records, increased payer scrutiny, and quality reporting initiatives.
Where Are the HIM Professionals?
If professional information managers have so much to offer physician practices, why aren’t more employed there?
“I think the first thing is awareness,” says Greg Fraser, MD, medical director of information systems and informatics at Mid-Valley IPA in Salem, OR. “I’m pretty sure that a lot of physicians aren’t aware of the fact that there are people out there who have special credentials in coding or in information management that can help them.”
Money—always an issue in the small practice environment, particularly—is another barrier, Fraser says. Physicians in small practices may be aware that there are people who can help them with health IT, compliance, and reimbursement, but they don’t feel they can devote the resources to it.
“In primary care there is a bit of a crisis of confidence right now.” Fraser says. “And so the idea of having to do more things that are going to cost more money is something that they don’t accept very readily.”
That can be the prevailing attitude even when physicians suspect they are not getting full reimbursement. It may only be when cash flow becomes a crisis that they look for specialists in coding and reimbursement.
Perception can be a barrier, too. Physicians who are aware of HIM may perceive it as a limited clerical role—represented by the person at the hospital who nags them to complete their records.
“Physicians often meet HIM professionals in the hospitals where they practice,” says Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, an HIM consultant to physician practices. “The HIM professional in the hospital has a role to fill to keep the hospital not only compliant but within Joint Commission standards. So physicians tend to see HIM professionals as more concerned with other people’s needs than their own. They feel that within their own practice that they don’t deal with those things and don’t need that person.”
For HIM professionals to work with practices they must build bridges with the physicians, says Kuehn. “We have to convince the physician that we have knowledge they need and that we are on their team. That means saying, ‘I work for you. I’m here to help you have a better quality medical record, help your productivity, and make your life easier.’”
HIM professionals do that by easing time crunches and boosting productivity through effective management. They improve reimbursement by helping create quality records that substantiate the care that physicians bill. They reduce denied claims through better documentation, and that may even lower malpractice premiums.
“You have to correct any misconception that HIM is not there to help,” Kuehn says.
From Practice Managers to EHR Consultants
Currently HIM professionals are most likely to be found in large practices. A number of major influences on practices, however, will increase the need for information management expertise in smaller groups as well.
Physicians employed in large medical groups have an expectation that the group is going to take care of information management and IT needs, Fraser says. Larger groups thus are more likely to employ HIM professionals. Kuehn agrees, noting that the larger a practice gets, the more it begins to organize by departments run by supervisors and directors. When groups get to that larger scale, she says, they are more likely to turn to HIM professionals.
The growth of large medical groups is a trend Fraser believes will increase the movement of HIM professionals into physician practices.
Right now, full-time employment in smaller practices likely takes the more general form of the practice manager, who is responsible for a range of duties such as overseeing medical office billing and compliance. HIM professionals can step in as practice administrators without difficulty, Kuehn says. Some have clinical training, as well.
Fraser agrees that HIM professionals fit the practice manager role nicely. He also sees a growing opportunity for them to consult across multiple practices at the group level. The value for physicians comes in sharing consulting expenses, of course. That can be a more feasible proposition than hiring someone full time.
HIM professionals in such a role could help on EHR system selection and implementation; all aspects of quality documentation; creating and maintaining a legal health record; and privacy and confidentiality related to health IT.
Looking to the near future, Fraser sees the opportunity for physician practices to call on HIM professionals to help them navigate personal health records, health information exchange, and all the issues around privacy, stewardship, ownership, and sharing of records, he says. “It’s a new world for doctors. Certainly in medical school or residency there was no discussion of it. Things are changing rapidly.”
Expertise in Two Areas of Change
HIM training cuts across any number of applications. But physicians are facing two particular areas of change where HIM professionals can offer unique and focused expertise.
Electronic Health Records
“There are changes coming that make the need [for HIM] more acute,” Fraser says. “The primary one on my mind is electronic health records.”
It has become apparent through the early years of the EHR that how a system is implemented and applied is as important as the product itself. The make-up of the practice itself is a big determinant of success. Fraser says, “A practice’s culture brings up a host of issues that doctors will need help with, whether they realize it or not.”
HIM professionals can help in documenting and assessing workflow and transition in advance of implementation, thus preventing problems that come from failing to prepare adequately.
Stacie L. Buck, RHIA, CCSP, LHRM, RCC, CIC, is the vice president of Southeast Radiology Management in Stuart, FL. She says that HIM professionals know the right questions to ask. They can start with the practice’s goals—what it wants the new system to accomplish—and then work backward to ensure that the work patterns and the IT will deliver that.
This is especially important when participating in quality reporting or employing clinical decision support. HIM professionals in these situations fill a common gap in the practice’s knowledge between the clerical staff and the clinical staff, she says.
Kuehn says this is a critical gap. In a smaller practice, there may be someone who handles the records and someone who works with the computer, she says. Each likely has additional responsibilities. There is no one available with the knowledge and time required to install an EHR. Both resources are required in large amounts.
“That’s where I see HIM as starting to make headway into those smaller practices,” Kuehn says. “An HIM person can come in and fill the role of the integrator. They bring the knowledge of all kinds of different areas. Many have change management experience and project management experience. They can come in and do an evaluation and have time to lead the project—to get it installed. I’ve seen many professionals who have stayed on after implementation.”
Different Views of the Same Record Can Cause Miscommunication
Physicians and HIM professionals may approach the health record from different directions. Understanding their shared goals requires good communication.
This most often arises when physicians resist queries for additional information, Buck notes. “Sometimes there’s pushback, because they feel that everything they need clinically is there, so why are you asking them for additional information?” But HIM professionals look at the record for coding and reimbursement, for compliance, and from the perspective of a legal record.
Stephen Levinson, MD, believes that relating documentation back to the physicians’ standard of care helps clear away miscommunication.
“Quality, compliance, and liability protection are all part of the same milieu, all based on standard of care,” says Levinson, who practiced as an ENT and consults on health IT and documentation improvement. “We should all be focusing on these areas, and we should all be very comfortable with each other in finding common ground for success in these areas.”
A coder, he says, works on the “same foundation, the same platform, the same language that the doctor does.” Levinson believes that although some physicians with limited exposure to coding in their training may not perceive this relationship, such physicians need to appreciate that compliance principles are actually a codification of the quality care principles physicians learn in their training.
Working together with coders and information management professionals helps physicians identify issues related to both quality and compliance and to develop solutions that efficiently and effectively enhance both.
The bottom line, Levinson says, is that “we’re all on the same team.”
Greater Documentation Requirements
Perhaps the area where HIM professionals show practices the quickest return is in coding for reimbursement.
“My impression is that most physician practices under code; they don’t capture all of their charges,” Fraser says. “Some of this is related to their fear of Medicare audit and uncertainty of whether they are meeting the documentation guidelines. I think that HIM professionals are better placed than anyone to help figure all of that out and make sure they are doing things properly and appropriately and give them some comfort over that.”
It’s not unusual for physicians to be removed from the daily functions and finances of their practices, Buck says. They are focused on taking care of patients, and they leave coding and reimbursement issues to staff. Often staff lack coding and reimbursement expertise, and physicians may be losing thousands, possibly hundreds of thousands, of dollars to which they are entitled, according to Buck. An HIM professional can turn that around, ensuring that physicians get the correct compensation for the services they deliver, through accurate coding and managing and appealing denials.
Requests for coded data beyond reimbursement are growing. More and more insurers are asking for different types of data, says Kuehn. They are not just asking for the data that goes on the claim. PQRI is one example, she says.
Kuehn says the CMS initiative may not live on in its current form, but there will be data submission requests that billing data will not handle. “I think that’s a huge challenge that looms over the head of physician practices,” she says.
“In larger physician practices that have robust IT infrastructure—no problem,” Kuehn says. “They’ll be able to handle that in their regular course of business. It’s the smaller practices that will have the problem. They may have someone who’s supported in their work by an IT vendor, but without their own IT person they’ll have to pay someone to set this up. That’s a challenge for a small group.”
Kuehn doesn’t envision that the smallest practices would ever be exempt from reporting requirements. That would leave too many holes in the data. “I just don’t see that insurance companies or the government—the two major players who could demand data in the future—would allow a small group to not participate.”
HIM professionals also can help practices respond to stepped-up scrutiny from payers. Physician offices were an early focus of the CMS recovery audit contractor program, though contractors backed off because the dollars weren’t there, Buck says. But as the program expands, it likely won’t remain so discretionary.
Doctors may be blindsided by a RAC audit, Buck notes. “They are going to need qualified staff in place to manage these requests and submit written appeals,” she says. The ideal candidate for the job has initimate knowledge of coding and reimbursement rules and can assist clinicians with documentation improvement.
Pay-for-performance also will require new types of data capture and reporting. Kuehn has experienced the complications already in practices that have voluntarily taken part. “I’ve seen a lot of physician practices really struggle with that—in trying to understand it and figure out the process for reporting.”
The current programs are “definitely flawed,” she says, but in one form or another they will continue. “Something is going to become mandatory eventually—we’re moving in that direction,” Kuehn says. She believes HIM professionals are ideally suited for figuring out the programs and the optimal processes for collecting and reporting the right data with minimal interruption to the practice.
Perhaps the greatest disruption coming to data reporting is the switch from ICD-9 to ICD-10. The two code sets different significantly, and making the transition will require planning and education.
That switch, and others, may introduce a whole generation of HIM professionals to physician practices.
Kevin Heubusch (firstname.lastname@example.org) is editor-in-chief of the Journal of AHIMA .
"Physician Practices and Information Management: HIM Professionals Offer Value in Changing Practices"
Journal of AHIMA