Vol. 12 •Issue 19 • Page 26
Designing the HIM Future
Where would you begin?
Don’t look now, but there are health information management (HIM) departments with windows, mobile storage, ergonomic office furniture and enough cabling for Internet access and an electronic medical record (EMR) system. Maybe you’re still crammed in the basement, but it can’t hurt to dream. Who knows, maybe someday you’ll be asked to consider things like workspace vs. storage needs, staff accommodations, computer cabling–even furniture–in redesigning your department. Where would you begin?
This Old HIM Department
Brandi L. Fowler, RHIA, CPC, health care market specialist for SPACESAVER Filing and Storage Inc. in Palmyra, VA, has helped a few basement dwellers make the transition to new or renovated digs in her job. Traditionally, she observed, “HIM departments are usually in the smallest, worst place in the hospital with no windows,” said Fowler. “It’s the last area that most architects think about when designing the building, and HIM directors are stuck squeezing 20,000 filing inches and 10 people in a small space.”
Lack of space is coupled with an ever changing HIM environment, due to technological advancements, downsizing and mergers. Liz Allan, RHIA, director of client programs for Deliverex, a SOURCECORP Company in San Jose, recalled changes at one hospital she worked at within a 10-year span. Each change affected the department layout. “When I first started, I had typewriters in my budget,” she said. “Two years later we all had dumb workstations.” Within two years, they too were gone. “We all had PCs and none of our Steelcase desks were functional. You would put them on the desk and there was no room for paperwork.” Of course, she added, that was when CPUs were horizontal. Allan temporarily gained space with the outsourcing of transcription, but a merger quickly took care of that. “You don’t anticipate these things when you take the job, no matter how much they say, ‘This is what we’re looking forward to.'”
Function for Today and Tomorrow
In Fowler’s opinion, the first thing to consider is the size of current operations. “It’s important for HIM directors to compare the retention schedule of their active medical records against the number of employees,” she volunteered. For example, “In a small facility, if they are able to keep five to 10 years of active records on their shelves and they have five full-time employees, they may opt to focus more on storage space than workspace.” But the scenario would be reversed for a larger facility, she added, with the focus shifting to maximized workspace. Of course, there’s the future to consider. “The HIM director has to look at how the facility is now, as well as how it’s going to grow.”
“I would hope that departments are able to plan for some electronic form of the record down the line and to maximize the people space,” said Allan. Fowler agrees, and her answer to meeting the needs of today and tomorrow involves flexibility of design.
“Obviously no equipment will last forever,” said Fowler. “I’ve seen my customers change part of their paper to microfilm reels or to CD ROM.” In some cases, they’ve eliminated paper.
“The key is to remember to purchase storage equipment that is easily reconfigured,” said Phyllis St. Michael, healthcare key account manager at SPACESAVER’s Ft. Atkinson, WI, office. “Our four-post shelving is certainly adjustable and can easily be reconfigured with no special tools.”
For departments with immediate paper needs that are moving toward the EMR, Fowler advocates mobile storage. Even if paper is eliminated altogether, “There is always going to be a department within a health care facility that can use a mobile system. It can be used for paper or pharmaceutical drugs or even lab slides,” she offered.
Of course, all of this functionality is worthless if you aren’t wired, according to Allan. “Put in as much cabling and electrical as you think you’ll need—and then add more. You’ll end up using it,” she stressed. Allan has observed that in older departments, “It drives the information technology folks nuts—every time you move someone they have to come in and snake cables and wires through the walls,” she said. “It’s not like you’re just unplugging and plugging in a typewriter, there’s all sorts of cabling for your PCs, modems, faxes, telephones and anything else you want to add down the road.” And address this up front, Allan advised, otherwise cost is a factor. “In my experience, it’s more cost effective to do it all at once, rather than paying the big bucks for a crew to come back in and run wires/cables after the fact.”
Considerations for The E-Department
Fowler also suggested that outside-the-box thinking should apply to designing an HIM department. “Even if you get your HIM department paperless, you have to consider where that record travels throughout the facility,” she offered. Ask yourself: “How do you transmit that paper up to the floor where the patient is going to be seen?” If physicians are no longer carrying charts with them to check on patients, “maybe there is a terminal in the room, or maybe they’re using a handheld device.” Whatever the case, she cautioned, an HIM director may be pulled into design debates out- side of her realm—to be forewarned is to be forearmed.
Yet for that growing handful of facilities plunging headlong into the electronic age, St. Michael warns that the paper trail may still lie ahead for them in some form. In addition to the paper-to-electronic transition phase, “Departments should consider the Health Insurance Portability and Accountability Act (HIPAA) component that requires third-party business associate agreements. Are these agreements going to be paper based and kept in a file in the HIM department?” she asked. Storing these documents, along with consent forms and privacy right disclosures, will be an issue in an otherwise “paperless” environment.
A Cube of One’s Own
Cables and wires enable the electronics within a department, but Allan also points to the staff members who must function in this new environment. “Technology really changes the way people work,” she volunteered. With e-mail, the Internet, electronic desk references and EMRs, “Employees don’t get up from their desks as often as they used to, so you really need a nice ergonomic site for them to sit at eight hours a day.”
And there are other trends. “I deal a lot with furniture in the health care market,” noted Fowler. “Recently, the trend is toward freestanding furniture and changeable workstations.” File cabinets have wheels, and if there’s an overhead mounted cabinet, “It can easily be taken down and moved into another area within the department.”
Cubicles themselves may be more modular, but their use has remained consistent. “There’s a lot of Dilbert jokes about cubicles, but at the same time, they do hide the clutter,” said Allan. “Especially in an HIM department. Even with the technology, there’s still so much paper, and it also gives the employee a sense of their own territory.”
Still, “cube farms” are not without their critics. Kirsten Lagatree, author of Feng Shui at Work, calls a cubicle-filled room a rat maze. In addition, “For many, working in a cubicle means working in an alienating environment,” she wrote in “Feng Shui for Cubicles” (posted July 10, 2001, www.techtv.com).
Another drawback is a kind of nesting syndrome that Allan observed to be less than conducive for employee training. “Cubicles can make it more difficult when you have to cross train staff, because people don’t necessarily want to get up and leave their space to go work in somebody else’s space.” Allan suggested using lower walls so that workers aren’t distracted by traffic, but if they stand up, they can still look across the room without feeling boxed in.
Sub-departments of HIM
Finally, a department design also hinges on the services it offers, Allan stressed. For example, if HIM handles the release of information (ROI) function in-house, there are some unique considerations. “Put ROI at the front of the department to serve your customers, but also try to make it somewhat private so people can ask questions without the entire department overhearing them,” she advised.
Another consideration is whether to establish an incomplete chart room. “Every medical records department has an area where physicians complete their charts. A lot of hospitals are trying to keep an incomplete chart room separate from the active medical records department because that record is not ready to be filed away in the chart room yet,” said Fowler. If the space is not there, or the hospital anticipates the use of an EMR down the road, “You can use a mobile system to keep those incomplete charts separate, and still provide workspace for your physicians, hopefully to get them to dictate their charts so you can get it sent through the department and get your reimbursement quicker.”
Redesigning for HIPAA’s Sake
With the emphasis on mobility, the question of security is unavoidable. Wheels are great, until a cart of charts gets wheeled right out of HIM. But is that really a concern? “HIPAA privacy regulations aren’t some brand new concept about securing patient information,” said Fowler. “And nowhere in HIPAA does it say you have to lock down filing cabinets.” Rather, Fowler emphasized making every reasonable effort.
Nonetheless, she has customers taking extreme measures. “Some facilities are going to do everything they can to make sure their charts are secure, and that may mean ripping out all of the wood filing cabinets they have now and putting in a lockable mobile system or using a cabinet with receding doors.”
On the other hand, “The Office of Civil Rights did emphasize that covered entities may need to make certain adjustments to their facilities to minimize access,” noted St. Michael. “This includes isolating and locking filing cabinets or record rooms,” she specified. “Access to protected health information should be limited,” and in her opinion, “few approaches work better than high-density mobile storage to control that access.”
With the only constant being change in HIM, the main themes in redesigning hinge on flexibility, but other areas of focus include HIPAA, in addition to Occupational Safety and Health Administration and Americans with Disabilities Act standards. And, lest we forget, feng shui.
Linda Gross is an assistant editor at ADVANCE.