Clinical Documentation Improvement

LESLIE: In the February Hands-on Help column, “The New Normal: Are You Ready for 2014”, we promised to address some of the priorities we are hearing from our HIM colleagues. The two most frequently mentioned priorities are ICD-10 training and improving clinical documentation.

PATTY: Enough about ICD-10! Let’s talk about clinical documentation.

LESLIE: A lot of people link the impetus for clinical documentation improvement to the ICD-10 transition.

PATTY: Of course they do, accurate clinical documentation is important for high quality ICD-10 coding, but the HIM role in clinical documentation is a much broader imperative. In the HFMA’s Executive Survey: Clinical Documentation Meets Financial Performance published in November, 2013, 91 of the 126 respondents indicated that “transition to the ICD-10 code set is the top clinical documentation priority for organizations”. This finding was closely followed by “optimizing reimbursement” as the next top priority. Improving the accuracy of clinical documentation was cited as the greatest opportunity for financial improvement.

LESLIE: So healthcare executives see the connection between quality clinical documentation and accurate ICD-10 coding, and they conclude that better quality documentation leads to better reimbursement. That may or may not always be true in our current transaction-based reimbursement system. Better quality documentation will be more compliant, protecting provider organizations from potential financial losses due to government or third party payer audits, but more accurate documentation does not necessarily lead to more reimbursement, just more accurate reimbursement.

PATTY: True, they may not be seeing the whole picture. The importance of quality clinical documentation is many faceted. In a transformed healthcare system compensated under emerging models of population-based health management, physicians and administrative executives must make clinical and business decisions based on a deeper knowledge of their patients’ health and healthcare experiences. The databases that they need to mine for their business intelligence start with individual patient health records and extend across all systems in the organization that contain patient health information.

LESLIE: So the bigger picture is the growing importance of the quality of clinical information across the enterprise and across the care delivery continuum.

PATTY: That’s right, Leslie. Our HIM colleagues who are leading Information and Data Governance in their organizations are creating the urgency needed to engage executives, physicians and departments throughout their organizations in developing the best data practices that will be the foundation of their business intelligence data now and well into the future. We first addressed this issue in September and October of 2013, in a two part Hands-on Help column, “Leading the Way to Information and Data Governance”

LESLIE: As I have learned more about the need for good information and data governance programs to assure data quality throughout a healthcare system, I see more than ever that the HIM profession’s body of knowledge is the cornerstone of successful information and data governance in healthcare. After all, it all starts with the patient’s health record. In a practical eBook being released in April 2014 by Care Communications Press, Information and Data Governance: What Every HIM Professional Needs to Know, Kathy Johnson, RHIA and Lisa Fink, MBA, RHIA, CPHQ, FAHIMA provide a primer on information and data governance, and describe the role of HIM.

PATTY: Johnson and Fink state that “A strong enterprise-wide information governance program focuses on data integrity at the front end of data’s life cycle while also managing the larger use of that data.” That alone makes a strong case for the central role of HIM professionals in assuring healthcare data quality and it is the reason that I see this as core to the modern HIM profession.

LESLIE: They further support their premise by citing AHIMA’s nine characteristics of data quality: “accuracy, accessibility, comprehensiveness consistency, currency, definition, granularity, precision, relevancy, and timeliness”. HIM professionals have always had responsibility for assuring that patient health records met these criteria, and that responsibility is more important than ever.

PATTY: The digitized nature of patient health information in the 21st century enhances the importance of the data quality characteristics because to deliver quality care today, providers can and must leverage in real time the most massive body of medical knowledge ever accumulated.

LESLIE: Yes, and that brings me back to Information and Data Governance. The deep subject matter expertise of HIM professionals in clinical data quality is foundational for developing enterprise-wide Information and Data Governance policies and procedures, and for implementing and managing programs that will assure data quality in the age of ‘Big Data.”

PATTY: “Big Data” is on the agenda of most healthcare policy makers, regulators, and leaders of healthcare organizations. We all recognize the need to better understand healthcare at the macro level in order to improve the health of our nation and to reduce the cost of healthcare. Mining Big Data will be exciting.

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LESLIE: Equally as important, clinicians and executives on the front lines of our delivery system need the best data they can get at the bedside or point of encounter, and at the enterprise level to manage their healthcare organizations today. Just moving healthcare delivery from the fragmented silos that have existed for so long, to managing the health of individuals over their lifetimes requires a dramatic shift in how all healthcare professionals accomplish their work. This paradigm shift includes new approaches to global data management as well as the more granular processes by which an individual or business unit creates and manages data.

PATTY: You are describing a change that goes way beyond the mechanics of creating and managing policies and procedures; a successful Information and Data Governance program affects everyone in the enterprise. If we were just dealing with a technical change it would be hard enough. But we are talking about adaptive change here. When we challenge long held beliefs or habits, for example, trying to standardize definitions of data elements across professions, across the enterprise, across the continuum of care, we touch some sensitive nerves and can expect reactivity. Change leadership for adaptive change takes courage, fortitude and perseverance.

LESLIE: It also takes collaboration. We are not suggesting that HIM professionals create these programs alone. This is large scale change. It takes a team. An executive sponsor, a project leader, and representatives of as many of the healthcare professions and shared service departments as one can reasonable get involved. However, the HIM profession is central to the effort. HIM professionals already work with all clinical and administrative groups in a healthcare organization, perhaps having more awareness of the needs and responsibilities of all departments for information and data governance.

PATTY: Let’s wrap this discussion up by connecting the dots. We started with our curiosity about the priorities of HIM professionals and related their 2014 priorities to the results of the HFMA survey of healthcare executives. They seem to be in sync: successfully transition to ICD-10 and improve clinical documentation. However, to achieve the goals of their priorities, a deeper strategic issue must be addressed. HIM professionals and healthcare executives need to think as broadly as possible-to see Information and Data Governance as an essential strategy to accomplish the critical priorities they have identified.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president, Care Communications Inc., Chicago. You can follow Leslie and Patty on their Twitter accounts, @FoxatCARE, and @pattytsheridan. Leslie and Patty invite readers to send their thoughts and opinions on this column to lfo[email protected] or [email protected].

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