(Editor’s note: This is Part 2 of the series “EHR and HIM Transitions in a Time of Mergers.” Part 1, “Redesigning HIM to Support an Electronic Record Environment,” posted March 25.)
When Skokie Hospital, a relatively small, stand-alone Illinois facility with no electronic record system, joined the NorthShore University HealthSystem in 2009, NorthShore’s Health Information Management Department played an integral role in achieving what has been called “the fastest EHR transition in history.”
In 2012, Chicago-based CARE Communications Inc. completed a case study to learn how Skokie Hospital’s HIM functions and staffing were redesigned and integrated into a NorthShore System that now includes Evanston, Glenbrook, Highland Park, and Skokie Hospitals.
Based on interviews with Terri Bunsen, the NorthShore health information manager and privacy officer; Arnold Wagner, MD, chief medical informatics officer; and Tom Smith, chief information officer, now retired, the CARE research team presented two reports. The first report focused on the corporate commitment and change management processes that NorthShore utilized to overcome obstacles. This second report details the HIM department’s role in the transformation and the ways in which HIM functions were in turn impacted by the system-wide implementation of the EHR.
The Changing Face of NorthShore HIM
When Evanston, Glenbrook, and Highland Park transitioned from paper to the electronic document management system (EDMS), HIM roles changed and became more efficient but without significant downsizing of staff at any of the hospitals, Bunsen said. Major changes occurred when the HIM departments from all three facilities were relocated to an offsite location along with home health, billing, human resources, IT, and learning and development.
Prior to relocation, the HIM department at each facility had its own work flow for record processing. Now, work flows and most HIM functions, including scanning and indexing, were consolidated, and functions that could be performed from home offices such as coding were encouraged. Large HIM staffs working at the individual hospitals were no longer necessary.
Experiences from the three existing NorthShore hospitals were applied to the Skokie transition. In the first three months, every Skokie department was asked to estimate their staffing needs in a centralized, shared-services staffing model. HIM found that five fewer positions would be needed. “But we still needed the positions until we were up on the EHR,” Bunsen said. Employees whose jobs would be eliminated after go live were offered a bonus for staying on through the implementation.
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This was 2009, a difficult time for finding a job,” Bunsen recalled. “So everybody stayed and worked through the go live.” The Skokie staff stayed on site for more than a year to assist in the transition from paper records to the EHR.
Today’s organizational structure includes four managers, four supervisors, and a total of 74.9 FTEs for all four hospitals, half of them in coding, and slightly less than the former 89. Managers rotate and support all five locations (four hospitals and the now centralized HIM department).
HIM assigns four staff members to Evanston Hospital, the largest of the four facilities, and two to each of the remaining hospitals. Responsibilities vary with the focus of each facility. For example, at Highland Park, a smaller, community-based hospital, one person is assigned to ROI and birth certificates, and one does scanning. At Evanston, one full-time person does birth certificates; one does ROI; one does pre-admission testing document scanning; and the fourth person, as at the other three hospitals, goes to the nursing units and picks up what they scanned during the day or have yet to be scanned.
As patient data moved through the fully implemented EHR, nearly every HIM function was affected. Currently, those functions include:
Chart Deficiency
The surgical schedule is reviewed daily and compared to dictations received. Surgeons are notified immediately regarding missing dictation. All other deficiencies such as missing signatures/co-signatures and discharge summaries are electronically identified by the EHR software.
Coding
NorthShore employs 39 coder FTEs for its four hospitals, plus an as-needed resource pool as described below. Most coders work remotely. Outpatient coder responsibilities include some core measure abstraction. In organizing its coding resources staff, HIM emulated NorthShore’s Nursing Department by offering coders a flexible work schedule of four 10-hour days, only if they work one day on the weekend. That prevents “too much of a blip” in scheduling, Bunsen said.
Coders who lack the required two years of prior experience were able to be employed full-time on site as interns for six months and work their way through different tiers of pay as they met quality standards.
“The first month interns do nothing but re-code already completed records,” Bunsen explained, “while we get a feel for their level of skill and what they still need to learn.” Months two and three are spent on site doing real production with 100 percent quality checking. In the last three months, interns can work remotely with reduced quality checks.
The interns then join a HIM resource team, once again working their way through three salary levels. At the end of six months, they are eligible to fill vacant full-time positions or remain on the HIM resource team to fill in for vacations, sick leave, etc. Team members make a commitment to work six hours per week while also employed at other facilities.
Rapid advancements in the field of information technology present a special challenge for HIM managers, Bunsen said. NorthShore already has gone live with Clinical Documentation Improvement (CDI) and Phase 1 of Computer Assisted Coding (CAC); Phase 2 began early 2013. Via the natural language processor, the system will provide the coder with annotated images to help identify diagnosis and procedures to be coded or to draw their attention to information that they may then wish to query the physician about.
MPI/EHR Corrections
Following approval by a physician, a full-time nurse makes amendments to the EHR and also works with off-site attorneys on requests for records. The Master Patient Index (MPI) is maintained by four FTE’S.
“A triage staff in IT looks at all the messages coming in from NorthShore Connect, our patient portal,” Bunsen said. “They send messages to us when there is an amendment request.” Often patients are the best identifiers of demographic data entry errors. The number of patient-generated corrections has increased as a result of NorthShore’s campaign to urge patients to review their records for accuracy. Patients also identify incomplete, inaccurate, or missing information.
Release of Information
HIM will always have a presence at each hospital to respond to patients’ requests for copies of their records, Bunsen said. Nursing, ancillary departments, and concierge services all know that they should send patients to the on-site medical records staff.
Authorizations have been modified to provide a checkbox for the patient to indicate preference for an electronic (CD) or paper copy of their record. Nurses also may place an order that indicates whether the patient wants the after-visit summary sent electronically in addition to receiving a paper copy.
Scanning
“Although our goal is to eliminate scanning, we still have 14 FTEs,” Bunsen said. Scanning of paper documents is initiated at the point of service (inpatient floor) and outpatient areas such as physician offices. Inpatient documents still requiring scanning are processed in the HIM Department by the end of each shift. Outpatient documents such as test results and information needing to get into the EHR quickly are scanned on site. The remaining documents along with those from the ER are transported to the HIM department for scanning the next day.
Scanning also has been impacted by medical group expansions within the NorthShore System. Early medical group/NorthShore mergers involved paper records that were abstracted and scanned into NorthShore’s EHR. “Now we are bringing in big medical groups with their own EHRs, some involving multiple vendors and systems, and each requires new technology to get them into the NorthShore document imaging system,” Bunsen noted. Bunsen and NorthShore Risk Management determine what data is not part of the medical record and can be left behind and what is needed and must be stored.
Transcription
NorthShore HIM has outsourced transcription to a private vendor. The vendor is interfaced to the ADT system to help verify patient demographics. Dictation is transcribed in the vendor system, and the completed report is transmitted directly to the EHR. Documents transcribed include operative reports, discharge summaries, and history and physicals (H&P). The emergency and radiology departments adopted speech recognition with the dictator responsible for all editing
Keeping HIM at the Forefront
Full implementation of the EHR means physicians no longer need to come to the HIM department for assistance in IT usage, Bunsen said; however, HIM’s leadership role has been expanded to include subject matter expertise to the EHR Physician Advisory Committee, nursing councils, and other committees.
The Medical Records Committee, which serves as a conduit for physicians who want to have input into the EHR, oversees results from record audits for compliance with standards; makes recommendations regarding system changes to expedite record completion; and, as major upgrades and changes to the EHRs are rolled out, reviews them and provides advice as needed.
The EHR Physician Advisory Committee, chaired by the chief medical information officer, reviews and approves system changes and recommends any changes that impact the professional staff to the Medical Executive Committee.
While HIM may have a smaller physical presence at individual hospitals, HIM’s role has not diminished. “It has a more significant presence than ever,” Bunsen said.
Patty Sheridan is president and Sandy Meyers is health services research administrator, Care Communications Inc., and Eileen Pech is a research journalist.
