JANUARY 2019 Weathering the Storm

HOW TO LEAD THROUGH THE CHAOS OF CHANGE

19_January.indd 1 12/14/18 2:56 PM Welcome TO THE DIGITAL EDITION OF THE JOURNALOF AHIMA

Slideshow: HIM Jobs of the Future While change can bring uncertainty, HIM experts identify emerging roles for the profession in this slideshow illustrated by Catherine and Sarah Satrun.

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19_January.indd 1 12/14/18 2:57 PM Contents January 2019

Departments

pg. 16 There is a growing need to develop HIM’s professional visibility, which can be accomplished by highlighting one’s expertise through writing.

Cover 12 Weathering the Storm Departments How to Lead Through the Chaos of Change 5 President’s Message Be Heard, Be Fearless By Mary Butler 6 Bulletin Board Features 11 Inside Look 16 Why You Need to Write for Your Profession Navigating Change with Courage As Change Transforms HIM, Professionals Must Leverage Better Information Sharing 42 Calendar By Ryan Sandefer, PhD, and Amy Watters, EdD, RHIA, FAHIMA

20 The Business Reality of HIM Outsourcing: Explained 43 Keep Informed By Susan Carey, MHI, RHIT, PMP, FAHIMA 44 Volunteer Leaders

48 Addendum Spring Forward, Fall Back… Over a Record Keeping Cliff

19_January.indd 2 12/14/18 2:57 PM Contents January 2019 Vol. 90, no. 1

Working Smart Quizzes

AHIMA members may earn continuing education credits 24 Mitigating Security Risks Associated with by successfully completing the following quizzes at Wireless Infusion Pumps https://my.ahima.org/store By William R. Shenton, JD 15 “Weathering the Storm” 28 General Data Protection Regulation and Domain: Management Development Research in the United States By Shamsi Daneshvari Berry, PhD, MS, CPHI, and “Why You Need to Write for Your Profession” Jill Flanigan, MLS, MS, RHIT 19 Domain: Management Development

In Pursuit of Comparable Coding Audit 30 41 “IPPS Final Rule Changes for Fiscal Year 2019” Benchmarks Domain: Clinical Data Management By Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA

32 Drivers for Solid Information Management Expanding in Healthcare By Deborah Green, MBA http://journal.ahima.org

Practice Brief Featured Content 34 Ensuring the Integrity of the EHR (Part One)

HIM’s Year Ahead Coding Notes Industry experts review health information hot topics to watch 38 Components of an Effective Outpatient in 2019. Coding Compliance Policy Program By Daniel Land, RHIA, CCS; Julie Davis, CPC, COC, CRC, CPMA, CPCO, CDEO, CPC-I; Monica Watson, RHIA, CCS, CCS-P, CPC, CPMA, CIC, CRC, CDEO; Faith McNicholas, RHIT, CPC, CPCD, PCD, CDC; and Sue Bowman, MJ, RHIA, CCS, FAHIMA Slideshow: HIM Jobs of the Future While change can bring uncertainty, HIM experts 40 IPPS Final Rule Changes for Fiscal identify emerging roles for the profession in this Year 2019 slideshow illustrated by Catherine and Sarah Satrun. By Moira Hunger, RHIT

Journal of AHIMA Blogs: Code Cracker Facilitated by AHIMA coding experts, Code Cracker’s monthly blog posts explore challenging areas and documentation opportunities for coding professionals.

19_January.indd 3 12/14/18 2:57 PM AHIMA CEO Wylecia Wiggs Harris, PhD, CAE ADVERTISING REPRESENTATIVES MCI USA EDITORIAL DIRECTOR Anne Zender, MA Jeff Rhodes EDITOR-IN-CHIEF Chris Dimick Phone: (410) 584-1940 ASSISTANT EDITOR/WEB EDITOR Sarah Sheber [email protected]

ASSOCIATE EDITOR Mary Butler Allison Zippert CONTRIBUTING EDITORS Sue Bowman, MJ, RHIA, CCS, FAHIMA Phone: (410) 584-1941 Patricia Buttner, RHIA, CDIP, CCS, CHDA, CPHI [email protected] Tammy Combs, RN, MSN, CCS, CCDS, CDIP Kathy Downing, MA, RHIA, CHPS, CPHI, PMP AHIMA OFFICE 233 N. Michigan Ave., 21st Floor Melanie Endicott, MBA/HCM, RHIA, CHDA, CCS, CCS-P, Chicago, IL 60601-5800 CDIP, FAHIMA (312) 233-1100; Fax: (312) 233-1090 Kristi Fahy, RHIA Jewelle Hicks AHIMA ONLINE: www.ahima.org Lesley Kadlec, MA, RHIA JOURNAL OF AHIMA: [email protected] Dawn Paulson, MJ, RHIA JOURNAL OF AHIMA MISSION Donna Rugg, RHIT, CCS, CDIP The Journal of AHIMA serves as a professional development tool Gina Sanvik, MS, RHIA for health information managers. It keeps its readers current on Robyn Stambaugh, MS, RHIA issues that affect the practice of health information management. Maria Ward, MEd, RHIT, CCS, CCS-P Furthermore, the Journal contributes to the field by publishing work that disseminates best practices and presents new knowledge. ART DIRECTOR Graham Simpson Articles are grounded in experience or applied research, and they represent the diversity of health information management roles and EDITORIAL ADVISORY BOARD Linda Belli, RHIA healthcare settings. Finally, the Journal contains news on the work Gerry Berenholz, MPH, RHIA of the American Health Information Management Association. Carol A. Campbell, DBA, RHIA, FAHIMA Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FAHIMA EDUCATIONAL PROGRAMS Diane A. Kriewall, RHIA The Commission on Accreditation for Health Informatics and Information Management Education (www.cahiim.org) accredits Glenda Lyle, RHIA degree-granting programs at the associate, baccalaureate, and Daniel J. Pothen, MS, RHIA master’s degree levels. For more information on HIM career Tricia Truscott, MBA, RHIA, CHP pathways and CAHIIM accreditation, visit www.ahima.org/careers. Carolyn R. Valo, MS, RHIT, FAHIMA

Journal of AHIMA (ISSN 1060-5487) is published monthly, except for the combined issues of July/August and November/December, by the American Health Information Management Association, 233 North Michigan Avenue, 21st Floor, Chicago, IL 60601-5800. Subscription Rates: Included in AHIMA membership dues is a subscription to the Journal. The annual member subscription rate is $22.00 for active and graduate members, and $10.00 for student members. Subscription for nonmembers is $100 (domestic), $110 (Canada), $120 (all other outside the U.S.). Postmaster: Send address changes to Journal of AHIMA, AHIMA, 233 North Michigan Avenue, 21st Floor, Chicago, IL 60601-5800. Notification of address change must be made six weeks in advance, including old and new address with zip code. Periodical’s postage is paid in Chicago, IL, and additional mailing offices.

Notice of Policy Editorial—views expressed in articles contributed to the Journal of AHIMA are those of the author(s) and do not necessarily reflect the policies and opinions of the Association, editorial review board, or staff. Articles are not to be construed as endorsing any particular product or service. Advertising—products, services, and educational institutions advertised in the Journal do not imply endorsement by the Association.

4 / Journal of AHIMA January 19

19_January.indd 4 12/14/18 2:57 PM President’s Message

Be Heard, Be Fearless

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA

AS AHIMA TRANSITIONS into our strat- patients to use. As different interven- egy reset, it is more important than ever tions are used to treat the patients, the to keep our passion for the HIM profes- system learns through algorithms built sion strong, as well as align our passions by our students and faculty which in- with what is best for our profession and terventions are best and provides that association. So, how do we find our information to the healthcare providers voice in HIM? so that they can adjust their treatments. Performing community service like this Forming Relationships can help new graduates find jobs. One of Sometimes we find our voice byform - our former students on this project and a ing relationships with others to create recent graduate of our master’s program a collective network. Let’s think of what said that during the interview process we, as HIM professionals and members prospective employers were impressed of AHIMA, can achieve together. Let with his work on the project. He now each of our voices be heard, positive- works for IBM. ly supporting our HIM profession. Be fearless. Raise your voice often, so that together we can make AHIMA and our How do we find our HIM profession the best it can be. voice in HIM? Undertaking Research Sometimes we find our voice through research. It is so important for all of Helping Others Find Their Voice us to embrace research, both as learn- We may also find our voice and passion ers and as conductors, in areas such by helping others find theirs. One of as coding productivity and quality, our HIM students came to me when he computer-assisted coding, information was just about ready to graduate and integrity, leadership roles, privacy and told me that the letter we sent to him security, and more. Research provides about the HIM profession, when he was the knowledge to form the foundation of undecided about his major, changed our profession. his life. He said he had no idea what he wanted to major in and was contemplat- Community Service ing leaving college. After he received our Community service is another route letter, his whole life changed, and he is to discovering your passion and culti- working in the HIM field as a systems vating your voice. One of our commu- analyst and truly enjoys what he does. nity service projects at the University So, continue to reach out, pay it forward, of Pittsburgh includes working closely and tell others about our profession. with the Focus Pittsburgh Free Health Guide others, because it may change Center and with our HIM students to a life and give someone the voice they create new technologies, such as a need to be successful. Remember: Be mobile app called imHealthy that col- heard and be fearless. ¢ lects wellness assessment data from the community and a web portal that Valerie Watzlaf (valerie.watzlaf@ahimaboard. displays the wellness data results in a org) is vice chair of education and associate pro- user-friendly format for physicians and fessor at University of Pittsburgh.

Journal of AHIMA January 19 / 5

19_January.indd 5 12/14/18 2:57 PM Bulletin Board what’s happening in healthcare

Report: Accurate Patient Matching Key to Value-Based Care, Quality The costs of not having a nationwide information in a facility where they’ve tion currently exists that could achieve strategy for patient identity manage- been seen before. Another survey perfect—or even near-perfect—match ment in the healthcare system are found that a patient matching strategy rates for all patients, but actions can high—both financially and in terms of helped a provider improve its match- be taken to better link records. Third, patient safety, according to a new re- ing rate to 98 percent. But one salient although some opportunities exist to port from the Pew Charitable Trusts. takeaway from the report is that pa- make meaningful, incremental progress However, there are short-term, tient matching is a big enough prob- in the near term, more robust change medium-term, and long-term strategies lem that it requires a nationwide strat- will require the use of new approaches that individual providers can use to egy and no single method can achieve and technologies.” increase the success of their matches. perfect matching rates. Pew also hosted a panel discussion Pew notes that one reason patient “First, regardless of the approach with patient matching experts dis- matching rates are difficult to study taken, a nationwide strategy will require cussing the report’s results, and pan- is because health systems often have coordination to identify the needed best elists focused on standardization over different ways of calculating their own practices; commitments from health technology as a means for improving rates. One survey cited by Pew found care organizations and technology de- rates, FierceHealthcare reported. that matching rates within the same velopers to implement agreed-upon “We talk about standards and stan- facility can be as low as one in five standards; and patient involvement,” dardization,” said Shaun Grannis, di- patients being incorrectly matched to the authors wrote. “Second, no solu- rector of the Regenstrief Center for

Physicians Report Use of Scribes Reduce Healthcare Bets Big EHR-Caused Burnout on Blockchain A common complaint among phy- documenting after-hours and on Almost half of global healthcare com- sicians is that their implementation weekends. panies have launched blockchain initia- of an electronic health record (EHR) There will be an estimated 100,000 tives, according to a new report. A survey has decreased both their produc- medical scribes working in the US by conducted by PricewaterhouseCoopers tivity and patient communication, the year 2020, according to a 2015 (PwC) found that 49 percent of the 74 since they must spend so much estimate by the American College of global healthcare companies it con- time focused on documenting en- Medical Scribe Specialists published tacted are developing, implementing, or counters through a computer and in a recent U.S. News and World piloting blockchain projects. less on patients. Report article. Physicians who use Blockchain itself is basically a decen- To combat this issue, an increas- scribes also report more specific doc- tralized ledger of all transactions in a ing number of physicians are turn- umentation through the scribe that network. Using blockchain technology, ing to medical scribes—paraprofes- can then translate into more accurate participants in the network can con- sionals who transcribe clinical visit reimbursement, fewer denied claims, firm transactions without the need for information in EHRs in real time un- and better patient care through the a trusted third-party intermediary, ac- der physician supervision. A recent higher level of detail included in the cording to PwC. study conducted by a group of physi- record. The PwC report states that health- cians and published in JAMA Internal “Using a scribe is amazing and care companies are using blockchain Medicine found that “use of scribes does help with job satisfaction,” for the secure management of supply was associated with significant re- said Jennifer Sewing, DO in an chain data, enrollment and provider ductions in electronic health record AAFP News article discussing data, back office functions, payment documentation time and significant scribe use. “It definitely helps with functions, data collection, and research improvements in productivity and all of the EHR-related issues that and development. job satisfaction” among the group of we deal with daily. I have more time “Companies that are slow to change physicians participating in the study. to talk to patients without worrying may lose out to ones that use the tech- More specifically, the use of scribes about all of the boxes that need to nology to cut costs and increase effi- led to physicians spending less time be checked.” ¢ ciencies,” the report states. ¢

6 / Journal of AHIMA January 19

19_January.indd 6 12/14/18 2:57 PM Biomedical Informatics, during the MA, told TechTarget that momentum is panel discussion. “The fact that stan- growing to improve matching. The Food and Drug Administration has dards help is not in question. Which “If a medical center is paid based on launched the new open source standards we get to is the question.” outcomes, it’s imperative to gather as MyStudies app that allows patients to submit real-world data and research- For example, Regenstrief analyzed much data about a patient as possible ers to use the data for improved drug Indiana databases and found that stan- from all their sites of care,” Halamka told development. dardizing the patient’s last name and the publication. “Without patient match- their address yielded the highest matching, it’s impossible to improve quality Data from the American Hospital Associa- ing rate. If providers could all agree and reduce total medical expense.” tion’s Information Technology Supple- to standardize these two elements, it Halamaka supports increased use ment Survey reveals that 93 percent of non-federal acute care hospitals would help address patient matching of methods such as biometric devices have already upgraded to the federal issues until a national effort is applied. like palm scanners, the establishment government’s 2015 Edition Health IT Additionally, health IT experts warn of a national patient identifier, and the Certification Criteria. that success with value-based care addition of non-healthcare-related programs could be compromised with- referential matching data to master Gartner has named the top strategic out suitable patient matching methods. patient indexes, such as voting place, technology trends organizations need to explore in 2019, including au- John Halamka, MD, CIO at Beth Israel which will work 90 percent of the time, tonomous things (robots and drones), Deaconess Medical Center in Boston, according to TechTarget. ¢ augmented analytics (machine learning), and artifical intelligence-driven development.

The Leapfrog Group, a national healthcare nonprofit that rates quality and Consumers Increasingly Using Online safety, has expanded its public reporting to outpatient and ambulatory Medical Records surgery settings. Healthcare consumers are becoming increasingly comfortable with accessing their health records online. That was the overall conclusion when the Office of the Na- The Office of the National Coordinator for Health IT and the Office for Civil Rights tional Coordinator for Health Information Technology (ONC) recently analyzed data (OCR) have updated their popular from the National Cancer Institute’s 2017 Health Information Trends survey, accord- Security Risk Assessment Tool to ing to Health Data Management. The upward trend in use of patient portals and make it easier to use and apply more similar technologies is likely to continue, with industry forces in motion, such as the broadly to health information risks. provisions of the 21st Century Cures Act, to improve patient access to electronic health information, according to Health Data Management. The data analyzed in- A study by IBM showed that organizations who have proactive data cluded consumer access and use of online health records, use of smartphones recovery plans can reduce the cost and tablets, and use of health-related electronic monitoring devices. According to and frequency of data breaches by 30 the survey, 52 percent of consumers have been offered the chance to access their percent. records online—an increase of 24 percent since 2014. ¢ According to the 2017 Global Informa- Reasons for Online Record Access tion Security Workforce Study, women make up only 11 percent of the current 85% View test results cybersecurity workforce. 62% Perform health-related tasks A survey of healthcare IT executives 48% Use secure messaging by CHIME and KLAS found that 18 percent of provider organizations had 39% To inform treatment plan medical devices impacted by malware or ransomware in the last 18 months, 23% Update/correct medical record although few of these incidents resulted in compromised protected 17% Download online medical record health information or an audit by the 14% Transmit record to other entity Office for Civil Rights. ¢

0% 20% 40% 60% 80% 100% Source: Bazzoli, Fred. “Individuals’ use of online medical records is on the rise.” Health Data Management. October 21, 2018. www.healthdatamanagement.com/list/individuals-use-of-online-medical-records-is-on-the-rise. Journal of AHIMA January 19 / 7

19_January.indd 7 12/14/18 2:57 PM Bulletin Board what’s happening in healthcare

Budgets Low, Confidence High for Medical Device Security Almost half of healthcare information and firewalls, but there are many de- CYBERATTACKS COST HEALTHCARE technology (IT) professionals do not vices—like medical monitoring equip- ORGANIZATIONS $6 MILLION PER YEAR: have a separate or sufficient budget ment—and no one is thinking about REPORT for securing connected medical de- securing them.” Meanwhile only 21 www.barkly.com/ponemon-2018-end- vices, according to HealthITSecurity. percent of survey respondents report- point-security-risk com. And while 41 percent reported ed that their organization’s connected A report from the Ponemon Institute this issue to Propeller Insights in a re- medical devices receive preventative stated that 56 percent of healthcare cent survey conducted on behalf of maintenance based on device usage organizations have been compromised by an endpoint cyberattack in the last Zingbox, 87 percent of respondents as opposed to a fixed schedule. year. These attacks originate in remote reported confidence that their con- “Despite the recent progress of the devices connected to a network, such nected medical devices were safe from healthcare industry, the survey ex- as a laptop, tablet, or smartphone, the threat of a cyberattack. Further- emplifies the continued disconnect and are estimated to cost the average more, 79 percent of respondents said between perception of security and healthcare organization $6.5 million a year, according to the survey. that their organization has real-time in- the actual device protection available formation about which devices are vul- from legacy solutions and processes,” HOSPICE AGENCIES LACK CONFIDENCE IN nerable to attack, and 69 percent said said Xu Zou, CEO and co-founder of PASSING AUDITS they feel traditional security solutions Zingbox. www.optimahcs.com/blog/hospice- used on laptops or desktops were also Zou stated that adopting the latest survey-shines-light-clinical-documen- adequate to secure connected medical Internet of Things technology and re- tation-vulnerabilities/ devices. viewing and updating processes that Recently the Office of Inspector Gen- According to Jon Booth, Bear Valley could be a decade old or more are eral recommended that the Centers Community Hospital District IT direc- steps that organizations can take to be for Medicare and Medicaid Services strengthen their survey process as part tor, “Most organizations are thinking prepared when the next cybersecurity of guidance on improving the Medicare about antivirus, endpoint protection crisis hits. ¢ hospice program. As regulators ramp up their investigations in hospice quality, compliance, and other deficien- cies, hospice agencies are growing concerned. An independent survey by New Team Seeks to Boost HHS Optima found that nearly half (46 percent) of respondents showed a lack of Cybersecurity Practices full confidence in their ability to survive Following concerning reports about a within HHS by identifying and making a federal audit without facing penalties lack of strong cybersecurity best prac- actionable recommendations to address or loss of productivity. tices in the Department of Health and cybersecurity vulnerabilities and threats,” MOST MEDICAID DATA BREACHES STILL Human Services (HHS), the Office of said OIG, according to the article. One CAUSED BY MISTAKES Inspector General (OIG) has formed a area likely to come up is the state of the https://oig.hhs.gov/oei/reports/oei-09- multidisciplinary team of auditors, evalu- technology upon which many of HHS’s 16-00210.pdf ators, investigators, and attorneys from current efforts rely—much of it is aging An Office of Inspector General re- various agencies to help address the and outdated. The team will address port reviewing state Medicaid data issue, according to an article from Heal- the task of protecting HHS systems and breaches found that most of the 2016 thITSecurity.com. Members of the team data with IT controls, risk management, incidents affected a single individual represent agencies such as: and resiliency (ability to recover from an and typically were due to misdirected Office of Audit Services, Cyberse- incident) initiatives. Previous audits have letters and faxes, not hackers. The characteristics of these breaches var- curity and Information Technology found vulnerabilities in HHS and state ied widely, but they typically affected Audit Division Medicaid systems, including inadequate few beneficiaries; often resulted from Office of Evaluation and Inspections access controls, patch management, misdirected communications, such Office of Investigations, Computer data encryption, and website security, as letters and faxes; and exposed Crimes Unit according to the article. beneficiaries’ names and Medicaid or Office of Counsel More information on cybersecurity ef- other identification numbers. Breaches that resulted from hacking or other IT forts at HHS is available online at https:// incidents were rare, the report said. ¢ “The cybersecurity team aims to posi- oig.hhs.gov/reports-and-publications/ tively impact the cybersecurity culture featured-topics/cybersecurity/. ¢

8 / Journal of AHIMA January 19

19_January.indd 8 12/14/18 2:57 PM OCR Working on Potential HIPAA Changes The Office for Civil Rights (OCR) an- from healthcare stakeholders on end- nounced in October that it is actively ing the requirements that stipulate pa- working on several changes to HIPAA tients must sign a form acknowledging ARTIFICIAL INTELLIGENCE INFLUENCING requirements in an effort to increase they have received an organization’s HEALTHCARE information sharing and decrease Notice of Privacy Practices. In addi- www.ehidc.org/articles/machines- regulatory burden. Speaking at the tion, Severino said OCR is working on are-here Safeguarding Health Information: a proposal called for in 2009’s HITECH A joint report from the eHealth Initia- Building Assurance Through HIPAA Act to distribute HIPAA violation fines tive and Booz Allen Hamilton outlines how artificial intelligence (AI) is being Security conference on October 18 in to data breach victims, HealthITSecu- used to improve healthcare outcomes. Washington, DC, OCR Director Roger rity.com reported. Since 2017 Severino The white paper provides real world Severino said his agency is drafting said OCR has collected $45.4 million in examples of AI use in healthcare, as a notice of proposed rulemaking on HIPAA fines. well as discusses challenges to AI “good faith” disclosures of patient Sharing more OCR news, Severino adoption and outlines federal initia- data by healthcare providers in pa- said that a summary of findings from tives that are supporting AI. tient emergencies, such as an opioid Phase 2 of its HIPAA Audit Program AHIMA OFFERS REVENUE CYCLE TRAINER overdose, according to coverage of would be released by the end of 2018. VIRTUAL WORKSHOP the event by HealthITSecurity.com. The Phase 2 desk audits of 166 cov- www.ahima.org/events/2018Revenue These disclosures could be made ered entities and 41 business associ- CycleTrainerWorkshop without patient consent, and could ates were done to “identify best prac- Starting in February 2019, this exten- include notifying a patient’s family tices, uncover risks and vulnerabilities sive eight-week multifaceted learning and friends when they have suffered not identified through other enforce- experience prepares advanced-level an overdose. ment tools, and encourage consistent revenue cycle professionals to train Severino also said OCR will soon attention to compliance,” HealthITSe- others in industry best practices using AHIMA curriculum. Trainers discover submit a formal request for information curity.com reported. ¢ how to train others using established adult learning principles, and have an opportunity to do a live teaching demonstration during the workshop for valuable feedback.

Pediatric Patients are Susceptible to MOST WIRED SURVEY OFFERS INSIGHT ON Medication Errors in EHRs HEALTH IT USAGE https://chimecentral.org/wp-con- Dose-related medication errors in elec- able to EHR usability and safety chal- tent/uploads/2018/10/Healthcares- tronic health records (EHRs) continue lenges because of different physical Most-Wired—National-Trends- to plague the pediatric patient popula- characteristics, developmental issues, 2018-FINAL.pdf tion, a new study found. and dependence on parents and other The College of Healthcare Informa- Investigators analyzed 9,000 patient care providers to prevent medical er- tion Management Executives’ annual safety reports made between 2012 and rors,” the study said, according to an 2018 Healthcare’s Most Wired Survey showed that while 95 percent of 2017 from three different healthcare article from Health Data Management. participants’ clinicians regularly ac- institutions that were likely related to Investigators funded by the Pew Char- cess clinical information electronically, EHR use. Of the 9,000 reports, 3,243 itable Trusts and the Agency for Health- integration between electronic health (36 percent) had a usability issue that care Research and Quality concluded record (EHR) systems and patient- contributed to the medication event, that the Office of the National Coordina- monitoring equipment is still emerg- and 609 (18.8 percent) of the 3,243 tor for Health IT (ONC) should include ing—only 25 percent of organizations, for example, send data from their IV might have resulted in patient harm, safety as part of a pediatric-focused pumps directly to their EHR. ¢ the authors wrote in a study published voluntary EHR certification program. in Health Affairs. “These new findings reinforce pre- The most common usability chal- cisely why it’s imperative for the ONC lenges were associated with system to act swiftly to ensure safety is part feedback and the visual display. The of the EHR voluntary certification pro- most common medication error was gram. One patient harmed is one too improper dosing, the authors noted. many,” lead researcher Raj Ratwani “Pediatric patients are uniquely vulner- told Health Data Management. ¢

Journal of AHIMA January 19 / 9

19_January.indd 9 12/14/18 2:57 PM Ad Space

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2020.18

19_January.indd 10 12/14/18 2:57 PM Inside Look

Navigating Change with Courage

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer

NAVIGATING CHANGE CAN be excit- A few years ago, the cover of this ing—or it can be scary. It can be espe- magazine featured an image of a cha- cially hard to cope when you feel like meleon and the word “Adapt or Dis- you’re right in the middle of change and appear.” Amy Watters, EdD, RHIA, you don’t know how everything’s going FAHIMA, and Ryan Sandefer, PhD, to turn out. challenge readers to stand out in their In his sermon “Antidotes for Fear,” Dr. environment by sharing their knowl- Martin Luther King Jr. wrote about cour- edge in “Why You Need to Write for age: “Courage faces fear and thereby Your Profession.” “Instead of chang- masters it. Cowardice represses fear and ing color to camouflage, change your is thereby mastered by it. Courageous colors to vibrant hues that no one can men never lose the zest for living even ignore. Use your adaptability to stand through their life situation is zestless; out, display your skills, and tout your cowardly men, overwhelmed by the un- knowledge. Then publish your work,” certainties of life, lose the will to live. We they write. (By the way, guidelines for must constantly build dikes of courage to submitting an article to the Journal of hold back the flood of fear.”1 AHIMA can be found at http://journal. In the past year, as I’ve taken on a ahima.org/submission-guidelines/.) new job, relocated to a new city, and Outsourcing of HIM functions is a real- jumped into the work of AHIMA, I’ve ity due to pressure to reduce costs, but needed that courage. I’ve needed the it also prompts concerns about loss of courage to take risks. I’ve made sure control, quality, and compliance. Susan to hold on to my anchors—those im- Carey, MHI, RHIT, PMP, FAHIMA, tack- portant things in my life that have kept les this topic in “The Business Reality me grounded amid the chaos. And I’ve of HIM Outsourcing: Explained.” Carey been deliberate, understanding my op- advises that the issue can’t be dis- tions as I make decisions. cussed based on emotional reactions, The articles in this month’s Journal but that “outsourcing needs to be ap- each touch on different ways HIM pro- proached as a service, and healthcare fessionals can cope with change in our organizations need to evaluate whether careers and build “dikes of courage.” the particular service provider provides Leading, engaging, and motivating the value-add based upon the docu- others during times of change can mented needs of the organization.” She be a big challenge for managers. In advises HIM professionals to research “Weathering the Storm,” Mary Butler the risks, establish a governance struc- talks to HIM professionals about their ture to manage the outsourcing model, experiences leading through the chaos and understand and define the desired of change. One HIM director recom- future state they want. mends empathetically listening to oth- We’re not done with change. But I hope ers and putting yourself in their shoes. these articles will help you find your “Be open to answering all questions, courage. ¢ even the really difficult ones,” advises Shannan Swafford, RHIT, CHDA, CCS, Note in the article. “And if you don’t know, 1. King, Martin L., Jr. “Antidotes for Fear,” tell them you don’t know. Be honest in Strength to Love. Minneapolis, MN: and kind!” Fortress Press, 2010.

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HOW TO LEAD THROUGH THE CHAOS OF CHANGE By Mary Butler

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WHEN THE ONCE-dominant retailer Sears filed for bankrupt- have such a big change in 20 years,” Bryant says. “But at the cy in 2018, many attributed its decline—and that of brick and same time, I feel we weren’t as prepared for the depth of the mortar retailers in general—to the existential threat of Amazon change. Technology is one of those areas where we don’t know and online retail. While Amazon played a role in the demise of about hidden capabilities. Just as with the telephone, and Sears, it’s far from the whole story. After all, Sears practically iPhones, we didn’t originally see the impact they would have. invented online shopping’s precursor, the mail-order catalog, And I think we’ve missed the boat a bit with EHRs.” which allowed price-conscious consumers to do their shop- An individual’s reaction to change varies from person to per- ping at any time of the day. Retail analysts say other mistakes son. In the years and months leading up to ICD-10-CM/PCS, such as failing to assess the risks posed by big box retailers, a there was a lot of talk about coding professionals who planned poorly executed acquisition of Kmart, and a failure to continue their retirements around it in order to avoid the hassle. Others anticipating consumer behavior—an area where the company thrive on change. Christine Methany, RHIA, CHPS, CHTS-IM, excelled in its heyday—led to its bankruptcy. HIM director and chief privacy officer at West Virginia Univer- What these factors have in common is that they stem from a sity Medicine (WVU Medicine), recalls a conversation she had failure of leadership and lack of imagination. Plenty of analysts with a former employee that had transitioned to a career in agree that Sears could have recovered from its early missteps if education but wondered if HIM was still a viable option. management had recognized and addressed problems earlier on. “I started talking about changes in technology and how pa- Other competitors, such as JC Penney, Kohl’s, and Home Depot, tients and consumers are becoming more active in their care have survived the dramatic shift in the retail landscape, proving and diagnoses, as well as population health. After talking to that it can be done with the right people at the right time. me and naming those things she said, ‘That’s enough to keep Healthcare and health information management (HIM) are my appetite wet because technology is constantly changing,’” staring down a similar crossroads of change, also spurred by Methany says. new technology and a morphing professional landscape. Elec- Good leaders must be prepared for the gamut of reactions to tronic health records (EHRs), computer-assisted coding (CAC), upheaval, according to Bryant. Some employees react with fear natural language processing (NLP), and the push for “HIM with- and suspicion and don’t trust the messenger, and leadership ac- out walls” have all changed the way HIM professionals do their tions can make or break the change while it’s occurring. Allow- jobs. AHIMA has taken notice, launching initiatives like HIM ing fear to creep in can create new ethical concerns, particularly Reimagined that call on HIM professionals to supplement their in the coding realm, Bryant says. current skills with continuing education and new credentials. Fear can create dishonest behavior and dishonest emotions, All these changes have put a strain on HIM professionals and and can manifest itself in the form of such practices as upcod- their leaders, who are now tasked with motivating the workforce ing, the “unbundling” of codes, using more codes than are ap- while managing the anxiety that accompanies change. Howev- propriate, or intentionally misinterpreting documentation to er, if HIM leaders really listen to and engage with members of bill for a higher level of services. their workforce—and act on what they learn in the process—the “We’re also seeing ethical issues around querying, leading industry can and should thrive during times of change. But that queries, using the EHR in ways that aren’t allowed or are lead- doesn’t mean it will always be easy. ing a physician. Drop-down menus, shaded-out boxes next to diagnoses. All of that is tied to reimbursement. And because we Identifying Threats are a very code-dependent healthcare system, the role of ethics Change is central to the nature of HIM—after all, HIM pro- in coding are actually more important today than they’ve ever fessionals were originally known as medical librarians. Now, been before,” Bryant says. however, one could be forgiven for mistaking HIM as an in- She has also found that ethical problems develop when HIM formation technology role or unexpectedly finding HIM pro- is absent from a larger organizational initiative or development. fessionals working in clinical areas. The biggest recent change “I’ve often seen in my career new departments and service is the use of EHRs and the transformation that comes with lines develop, new medicine developed. HIM leadership needs digitizing nearly every piece of information about a patient. to step in and say: ‘We have a new business line?’ HIM needs to With EHRs came health information exchange (HIE), patient go in and check that out [from a CDI standpoint] and make sure portals, querying of databases, and an increase in regulations there’s nothing leading, nothing inappropriate,” Bryant says. such as HITECH, MACRA, and the 21st Century Cures Act. “We need to ask how it’s going to be coded, processed, all that Other factors, like an increased focus on artificial intelligence needs to be in place due diligence-wise. In HIM there’s a role in healthcare and the move to ICD-10-CM/PCS, have also for us that we’re not utilizing. We need to be the leader in those been sources of anxiety for many. kinds of things.” Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, an independent HIM coding consultant, admits that the profession’s response Keep Calm, SWOT On to EHRs was perhaps a little flat-footed. “There are benefits to Naturally there is a good way and a bad way for leaders to EHRs and a big one for me is legibility in coding—it’s huge to guide their organizations through change, which can come in

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many forms, from new software to new workflows, new EHRs, made, she’s more accepting of it. It’s in that spirit that leaders annual coding updates, or even mergers and acquisitions— should be as transparent as possible when explaining decisions. with the latter leading to fears about job security. Addition- “The more you can share the better,” Clancy says, especially ally, HIM professionals are frequently told they need to update when dealing with layoffs or restructuring of services. “As under- their skills, credentials, and degrees in order to stay relevant standing creeps in, it’s easier to stomach what’s happening.” in the future. Any one of these events can distract employees The first step when communicating change, she says, which from the task at hand. addresses the “why” factor, is to use phrases such as “We WVU Medicine’s Methany took a project management class couldn’t stop this from happening,” or “We can’t afford not to and used the techniques she learned to tackle a major source do this,” and “We have to do this because the regulations require of employee dissatisfaction in her workplace. Ever since her it,” she says. department had implemented a new worker productivity da- The second step, Clancy says, is that leaders need to ask their tabase, she heard complaints about it. Everyone in her HIM employees what leadership can do to offset the impact of the department, which had 237 employees at the time, had to use change—for example, offer to be references for those whose the tracker, which left many feeling like Big Brother was look- jobs are terminated. “That sends the message that you care and ing over their shoulder. At that time, the tracker had been in that this is personal for everyone,” Clancy says. use for 10 years and was still meeting resistance. It is also vital to provide as much advance notice regarding Methany decided to solicit feedback from 10 percent of her changes as possible, and to celebrate and communicate suc- employees and asked her assistant to schedule 30-minute cesses just as well as negative changes. “It’s easy to have good one-on-one interviews with staffers, for a total of 23 inter- news, but sometimes we’re not good with saying why this hap- views. This gave them the opportunity to ask Methany any pened. ‘It’s a result of all the good work you guys have been do- question they had about the database or any other concern. ing,’” Clancy says. Then in turn, she appointed each of them to be liaisons for Sandra Finley, president and CEO of the League of Black their own separate corners of the HIM department. The liai- Women, specializes in training leaders on a type of transfor- sons could hold additional training sessions and brainstorm mative change management developed by the military known on ways to improve the use of the database, increase its ef- as VUCA, which is an acronym that stands for volatility, uncer- fectiveness, and identify ways it improved their job perfor- tainty, complexity, and ambiguity. Finley and a co-presenter mance. Methany was also very deliberate in her selection of did a training session on VUCA and leading through change liaisons, in some cases choosing individuals who had an “axe tailored for HIM professionals during the 90th annual AHIMA to grind” with the system. Convention and Exhibit in September 2018. Because of its ori- “I figured that if I could make myself their champion, they gin in the military, VUCA addresses plenty of thorny questions would spread the word… I felt that because it was such a bone of and has tactics for navigating ambiguity, which is useful as the contention with folks at the grassroots, if they could hear more HIM industry confronts a future with a lot of unknowns. Fin- about it from their peers, it was better than me saying ‘We’re ley compares VUCA’s approach to communication to a car or working on it,’” Methany says. phone’s GPS system. Every liaison conducted a SWOT (strength, weakness, op- “It [GPS] tells you where you are and what it understands portunity, threat) analysis of the tool, and Methany laid out a about distances between where you are and where you’re trying roadmap, developed a milestone schedule, and wrote a charter to get,” Finley says, noting that the strategy is constantly course governing the project. correcting. “It is an inferred promise that it will not leave you… “By the time we got through the project they started perform- even if it takes you through somebody’s backyard. For leaders, ing and I took a backseat role. They started forming subgroups, the underlying promise has to be as clear as it is for the Marines. by the end of the project we were still using the same product We will not leave you. And that is the thing that’s most fright- but made changes that gave us a lot of wins,” Methany says. ening to people who have to turn the steering wheels of their career over to other people.” A Little Empathy Goes a Long Way Employers can execute strategies like this through simple Workforce worries beyond new platform or software changes— steps, which many companies but especially academic medical including concerns about future career prospects, layoffs, or centers can do, such as reimbursing employees for continuing the need for more education—require a more deft leadership education programs. approach. One reliable way for managers to approach this is to “I haven’t worked anywhere in maybe the past eight years that try to put themselves in their colleagues’ shoes, and doing this didn’t have some form of tuition reimbursement,” says Shan- properly takes strong communication skills. nan Swafford, RHIT, CHDA, CCS, manager of coding process Mary Ellen “Emmy” Clancy, MHA, CCS, CMPE, CPC, CDEO, improvement at BlueCross BlueShield of Tennessee. “It’s a vi- CPMA, revenue cycle, coding, and operations consultant with able way to make a loyal and smarter workforce. You might lose Emmy Award Healthcare Consulting, describes herself as a those folks after some education, but if you’re investing in your “why” person—if she can understand “why” a change is being employees they should stay loyal.”

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Swafford has worked consistently in HIM—but in a number com/news/downfall-of-sears/. of different areas, including Tennessee’s regional extension Isidore, Chris. “Here’s what’s killing Sears.” CNN. February 12, center, which was funded by the Office of the National Coor- 2018. https://money.cnn.com/2018/02/12/news/companies/ dinator for Health IT to help advance the “meaningful use” sears-downfall/index.html. EHR Incentive Program. She’s also worked as a clinical analyst Peterson, Hayley. “Inside Sears’ death spiral: How an iconic for the Cancer Treatment Centers of America, where she did American brand has been driven to the edge of bankruptcy.” a lot of work with analytics, and now she’s overseeing the im- Business Insider. January 8, 2017. www.businessinsider.com/ plementation of an end-to-end data content governance pro- sears-failing-stores-closing-edward-lampert-bankruptcy- gram across Blue Cross Blue Shield of Tennessee for ICD-10, chances-2017-1. HCPCS, and CPT coding. Since so much of her work has been with technology, she’s witnessed a lot of resistance to change, Mary Butler ([email protected]) is associate editor at the Journal of a common occurrence when learning any new technology. AHIMA. “As leaders, it is often uncomfortable to know some of the things we know due to the privilege of information provided from key decision makers. One key element is to be open to Journal of AHIMA Continuing Education Quiz answering all questions, even the really difficult ones,” Swaf- Quiz ID: Q1919001 | EXPIRATION DATE: JANUARY 1, 2020 ford advises. “Another is being aware that change is scarier for HIM Domain Area: Management Development some than for others and all they want is to understand—so Article—“Weathering the Storm” tell them. And, if you don’t know, tell them you don’t know. Be honest and be kind!” ¢ Review Quiz Questions and Take the Quiz Based on References this Article Online at https://my.ahima.org/store Delventhal, Shoshanna. “Who Killed Sears? 50 Years on the Road Note: AHIMA CE quizzes have moved to an online-only format. to Ruin.” Investopedia. October 15, 2018. www.investopedia.

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AS CHANGE TRANSFORMS Cycle HIM, PROFESSIONALS MUST LEVERAGE BETTER INFORMATION SHARING By Ryan Sandefer, PhD, and Amy Watters, EdD, RHIA, FAHIMA

Health Information Exchange Coding Professional Development CDI

Privacy and Security

Patient Matching 16 / Journal of AHIMA January 19 Leadership

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THE MAY 2014 cover of Journal of AHIMA featured an im- ten blend in behind the scenes, not drawing the attention age of a chameleon and the words “Adapt or Disappear.” their work so often deserves. HIM professionals have been This hyperbolic warning for health information manage- driven by managing records, ensuring compliance, using ment (HIM) professionals was delivered in the context of the pain-staking detail to verify information integrity and main- rapid change impacting healthcare through advancements tain financial health. What has now become clear is that the in technology, organizational structures, and hiring prac- characteristic of camouflage is no longer a strength for the tices. The pivot point for the industry was the widespread profession, but a vulnerability. adoption of the electronic health record (EHR). The Journal One of the greatest strengths of the HIM profession is its of AHIMA article, by Mary Butler, notes: “While the EHR focus on improving the information practices within the hasn’t changed the need or demand for HIM professionals’ healthcare industry. The profession is known for develop- skills, it has drastically changed the way those skills are ap- ing, using, and adapting industry practices that are sound plied and has accelerated the need for professionals to add for ensuring organizational compliance to standards and new electronic-based abilities.”1 guidelines, increasing the integrity of data collection, and The methods, tools, and techniques for how health infor- protecting health information. The profession is not known mation is collected, managed, and used internally and exter- for evaluating and sharing these best practices widely with nally has changed drastically in the last few years, and the audiences. HIM professionals think their best asset—the skills of health information professionals are not keeping ability to innovate HIM practice for organizational benefit— pace because of this speed of change. Because of this, it is has not been leveraged through information sharing. Many extremely important that HIM professionals share their col- in HIM think the profession needs to evolve and the easy next lective best practices in this new era of HIM. One way to do this is by writing articles for magazines and websites on HIM best practices—an act that both improves the profession and the professionals themselves.

Adapting to the New HIM through Shared Best Practices Butler’s article continues with a sense of optimism: “It isn’t too late. There is still time for HIM professionals to adapt to the new healthcare environment and prosper in its opportunities.”2 The purpose of including the image of the chameleon was to drive home this point of adaptation, something to which HIM professionals are no strangers. Just to expand on this a bit, it is important to demonstrate how adaptable (and amazing) chameleons are by providing a few fun facts: They have the fastest tongues of any animal (0-60 mph in 1/100 of a second), which increases their ability to catch food. Their eyes operate independently and provide a complete 360-degree field of vision. Essentially, they have the ability to run and process two computers and monitors simul- taneously. They can change color to match their surroundings, becoming their own camouflage.3

It is this last trait that chameleons are most known for and one that historically has also been a trait of HIM professionals. Chameleons have an amazing ability to blend into their surroundings by changing their color and avoiding attention. Like chameleons, HIM professionals have been known for adapting so well within their organizations that they of-

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step is to share what is working (or not working) within one’s strate the HIM professional’s value to the broader health- organization through publishing. care enterprise.

Publishing is Your Duty Those who have any hesitation about their ability or inclina- The first thing you might ask yourself is, “Why do I need to pub- tion to publish should start by asking these questions: lish?” This article could spend considerable time documenting Do I have a particular area of interest or expertise in a the myriad benefits of publishing, but the authors will leave it topic area? at these five points: Could others benefit from my knowledge? 1. It’s your duty! The HIM Code of Ethics states that it is a Is there a gap between my knowledge and what’s happen- HIM professional’s obligation to contribute to the Body ing in practice? of Knowledge, as they should “advance health infor- Do I want to grow professionally? mation management knowledge and practice through continuing education, research, publications, and pre- Writing is a Process sentations.”4 If you answered yes to any of these questions, then publishing 2. The profession and practices are changing rapidly, and should be in your future. Now that you’ve been convinced to these practices need to be evaluated for efficacy. publish, here are a few steps to begin the process. 3. There is increased competition for HIM-related positions, and thus documenting HIM expertise is critical. There are Identify and Choose a Topic many personal benefits to publishing, such as career op- This first step can be daunting. A good way to start is by do- portunities, networking, professional growth, and more. ing some brainstorming. Think about topics or areas of inter- 4. There is a need to develop and maintain HIM and profes- est and/or experiences you’ve had. Are there projects you’ve sional visibility, and this can be accomplished through worked on that others could learn from? Have you implement- highlighting one’s expertise. ed something innovative at your organization? Have you ad- 5. Perhaps most importantly, it is mission-critical to demon- dressed a significant issue through the use of data? What are

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you interested in? your thoughts to begin the writing process. You may also be- Take five minutes of brainstorming time to jot down any top- gin collecting your data if necessary. If you plan on publish- ic ideas that come to mind, without overthinking it, and with- ing a research article that involves human subjects, approval out judging your ideas. Use that list to find books and articles from an IRB will be required. This must be determined before related to some of those topics. Is there a particular aspect of your research begins, so be sure to factor that step into your the topic that piques your interest? Is there a gap in the litera- process. Once your research is complete, is it is time to start ture that your contribution could address? writing. Talk to friends and colleagues about your ideas. They can often provide a perspective you haven’t thought of or may even Publishing Helps HIM Stand Out be able to help you with your topic. As you learn more about HIM professionals, it is time for action. Look to the traits of each topic, continue to refine your ideas so they are manage- the chameleon, but instead of changing color to camouflage, able. The more you read and talk about your topic, the easier change your colors to vibrant hues that no one can ignore. Use that will be. The most important thing is to pursue a topic you your adaptability to stand out, display your skills, and tout are interested in. Writing about something you are passionate your knowledge—then publish your work. about makes the process much more enjoyable and culmi- It is critical that HIM professionals use their skills to survey nates in a better end product. the landscape to detect threats. HIM professionals must use their capacity and agility to obtain resources and opportuni- Collaborate When You Can ties, and must acknowledge that what HIM professionals do— Publishing is a great opportunity to collaborate with other how we are making an impact that is meaningful within the professionals, both within and outside of the HIM disci- HIM profession and also for the industry at large—is vital to the pline. As you are exploring topic ideas, consider colleagues future of healthcare. Historically, HIM professionals have used at your organization or other professionals you have worked their camouflage skills to adapt to rapidly changing environ- well with that could serve as co-authors. Perhaps the HIT/ ments largely unnoticed. Moving forward, HIM professionals HIM program at a local college is looking for opportunities need to draw upon this chameleon-like attribute to draw atten- for their faculty or students to collaborate with practicing tion to themselves and the entire HIM profession. ¢ professionals. Sometimes undertaking a research and writing project with a partner can make it more manageable, not Notes to mention the valuable networking opportunities that may 1. Butler, Mary. “Adapt or Disappear: AHIMA’s Reality 2016 arise through the partnership. has a New Mission to Transform the HIM Workforce through Education—or Else.” Journal of AHIMA 85, no. 5 Identify Resources (May 2014): 24-29. http://bok.ahima.org/doc?oid=300443. Once you have chosen your topic, you’ll want to conduct a 2. Ibid. more structured review of the literature and resources that ex- 3. Mancini, Mark. “10 Colorful Facts About Chameleons.” ist to ensure there is enough information available to support Mental Floss. September 23, 2016. http://mentalfloss. you in your topic choice. Think about where you can access the com/article/85956/10-colorful-facts-about-chameleons. resources you need, such as the library at your organization, 4. AHIMA. “Code of Ethics.” October 2, 2011. http://bok. online databases, AHIMA’s HIM Body of Knowledge (bok.ahi- ahima.org/doc?oid=105098. ma.org), or even the local library. Ryan Sandefer ([email protected]) is assistant vice president for academic Build Support affairs and associate professor, and Amy Watters [email protected]( ) is as- Again, make sure you’re talking to people about your project, sociate professor and HIM graduate program director at the College of St. particularly if you need data and resources from your organi- Scholastica. zation or others. Express the importance of your project and what it can contribute to the organization, the HIM profession, Journal of AHIMA Continuing Education Quiz and healthcare. Quiz ID: Q1929001 | EXPIRATION DATE: JANUARY 1, 2020 HIM Domain Area: Management Development Begin the Research, Start Writing Article—“Why You Need to Write for Your Profession” Now that you’ve chosen your topic, identified your resources, and obtained support for your project, you are ready to begin the research for your publication. The main activities at this Review Quiz Questions and Take the Quiz Based on point are reading, obtaining Institutional Review Board (IRB) this Article Online at https://my.ahima.org/store approval (if necessary), collecting/analyzing data, and writing. Continue exploring the resources you identified and read as Note: AHIMA CE quizzes have moved to an online-only format. much as you can about your topic. Take notes and organize

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19_January.indd 19 12/14/18 2:58 PM The Business Reality of HIM Outsourcing: Explained By Susan Carey, MHI, RHIT, PMP, FAHIMA

OUTSOURCING, WHETHER DELEGATING work to compa- vice providers to set expectations, manage risks, and achieve nies within the US or to other countries (offshore outsourc- agreed-upon results. Coding, release of information, and tran- ing), has become a strategic consideration and business scription are functions that are now being typically consid- model in many areas of the healthcare industry, including ered for outsourcing within the HIM realm. Understandably, healthcare IT, health information management (HIM), and HIM practitioners’ response to outsourcing has been mixed, revenue cycle management. as concerns with loss of control and ownership, quality, and Historically, outsourcing was utilized to provide the staff compliance are typical. In addition, great uneasiness comes augmentation needed to complete large initiatives occur- when outsourcing is with a company in another country or a ring outside of normal day-to-day operations, such as the US-based company that utilizes resources located in another recent transition to ICD-10. Outsourcing was also used as a country. Former Navy SEAL and current CEO of Force12 Me- method to catch up operationally by sourcing supplemental dia Brandon Webb summed up why many service providers staff to assist in a specific project or to gain small wins by are moving offshore in aBusiness Insider article. “Economies paying less to manage one or two non-core functions. Over are incentive driven, and the current incentives in America time, outsourcing has evolved into a business strategy that are driving more and more business owners to cut American healthcare executives utilize to cut costs and allow resourc- workers in favor of cheaper hires in Asia, eastern Europe, and es to focus on core business functions. elsewhere… This trend will continue until leaders and policy- At the system level, organizations are starting to view out- makers in US government adopt practical tax and employment sourcing service providers as partners and solutions vendors laws that bring back strong incentives to hire Americans,” instead of just staffing firms. Organizations are including Webb said.1 more performance criteria and metrics in contracts with ser- C-suite executives are navigating through several chang-

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es and shifts that influence or impact organizations’ finan- or a lack of cost effectiveness can be demonstrated, there is not cials, making cost cutting a necessary strategy and out- a battle to be fought. The issue remains a theoretical battle due sourcing an attractive objective. Some of these changes and to personal stakeholder preferences and emotion, which will shifts include: continue to be considered the root cause of opposition to the The healthcare industry is experiencing more consoli- model. Outsourcing cannot be debated based on stakeholders’ dation between insurers and providers. Declining reim- feelings about the model—whether the outsource company bursements and increasing legislative and regulatory uses offshore resources or not. The risks of outsourcing need burdens have led to consolidations to provide opportuni- to be researched and documented and respectfully presented ties for reducing inefficiencies in care and improvement of to the C-suite. And, frankly, there is more risk with partners care coordination. who do utilize offshore resources, due to differing laws, regu- Addressing the opioid abuse crisis and the out-of- lations, and cultural barriers. That said, both outsourcing and control spending caused by the issue is necessary to offshore outsourcing models need to be assessed for risks, improve the lives of those who suffer from substance such as: abuse. The cost of inpatient hospitalizations related to Poor security the opioid abuse crisis reached $15 billion in 2012, qua- Hidden costs drupling since 2002.2 Improper or lack of communication With the shift from volume-based payment to value-based Poor resource management payment, the measurement of the patient experience is of Unbalanced work distribution/dissemination greater focus to the provider as patient experience scores Lack of technology are publicly reported. Customer loyalty can lead to higher Quality problems revenue. High turnover rates Navigating through the challenges of the expansion of Legal problems Medicare Advantage plans is a balancing act. These plans reimburse at a lower rate, but with more plans there will These risks cause apprehension for HIM practitioners due to be more patients and this could make up the gap. Health the threat to patient health information (PHI) confidentiality, reforms related to Medicaid and Medicare continue to privacy, and security. Researching and documenting breaches loom and create uncertainty and angst related to reim- and the penalties that have occurred through outsourcing and/ bursement. or offshore outsourcing should be completed, and not just when an opportunity to outsource arises. HIM practitioners should What does all this mean to HIM practitioners? From their be doing this work and communicating their findings to the C- view as leaders in healthcare settings, it means that the ta- suite on a routine basis. Service providers, whether using off- ble may not be set the way they think it should be set. But to shore resources or not, are taking the necessary steps to address change it, HIM practitioners need to pull up a chair and edu- and mitigate these challenges. However, these service providers cate the others at the table. should be mandated to respond to a security assessment and a Outsourcing is a business strategy that is being relied upon risk analysis to be reviewed by the organization’s IT resources by more and more C-suite executives as part of being fiscally and legal resources. In a 2016 article on offshoring PHI, Erin responsible and providing appropriate stewardship to their Whaley, a partner at Richmond, VA-based Troutman Sanders, organizations. The benefits of outsourcing non-core functions said: “The reach of OCR’s [Office for Civil Rights] enforcement are tangible, and agreements are being implemented for IT power hasn’t really been tested. They haven’t gone after any off- services, HIM services, and revenue cycle management, as shore business associates as far as I know. Part of it may be that well as expanding to human resources. Time and energy spent they don’t have the resources or appetite to do that—they’ve got to dissuade leaders from entering agreements with outsource enough to deal with domestically. Or maybe there just hasn’t companies may be futile. Instead, time and energy should be been a big enough event yet to warrant them doing that. That’s focused on thoroughly vetting service providers to determine kind of an interesting gray area in the law, and we don’t know whether they use offshore resources or not, and to ensure they what OCR would do.”3 This is something to consider when en- can provide efficiencies, quality, compliance, service levels, gaging a service provider who utilizes offshore resources or is and innovation. an offshore provider. C-suite executives are blessing outsourcing models with or Outsourcing needs to be approached as a service, and health- without key stakeholders being on board. The battle of using care organizations need to evaluate whether the particular ser- offshore resources is one that can be fought. But it is a com- vice provider offers the value-add based upon the documented plex issue and not one that can be easily fought or won by HIM needs of the organization. In order to demonstrate issues with practitioners. Nor can rhetoric between the outsource com- outsourcing, stakeholders need to approach the relationship panies debating the use of offshore resources win the battle. as a partnership versus an “out of sight out of mind approach Until issues with outsourcing are proven and communicated, with a contract.” In addition, the quality aspects need to be

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highlighted, stressed, and communicated. There needs to be a Transcriptionists have evolved into support specialists for governance structure established to manage the outsourcing training clinicians on speech recognition, building smart model. “Vendor management and governance is emerging as a phrases and templates. Release of information staff are pro- top business priority,” according to an article by The Outsourc- cessing requests much more efficiently due to technology. ing Institute.4 “Organizations are recognizing that effective Coding professionals are evolving into data miners and audi- oversight of service delivery is essential to managing multi-ven- tors as the use of artificial intelligence equips the provider to dor service delivery models, to achieving anticipated value and document accurately in real time. All these examples increase benefits from outsourcing and to complying with increasingly productivity or shift resources. How will the future healthcare stringent regulatory compliance requirements.” trends continue to influence coding, release of information, A first step is to ensure that the organization has developed the and transcription? Here is a look at some likely possibilities for business case prior to outsourcing. In an article in HFM maga- future outsourcing trends of which HIM professionals should zine, Steve Scharmann, a vice president of finance and revenue be aware when assessing outsourcing: cycle operations with Dignity Health, said that before Dignity Increased adoption of artificial intelligence Health started outsourcing, the company identified several Continued push for interoperability revenue cycle metrics where they wanted to see a lift, such as More exchange tools will emerge cash-to-net ratio, accounts receivable (A/R) days, denials as a More effort/focus on security event prevention percent of net revenue, and other areas.5 “When we set up our Hackers become extremely sophisticated current outsourcing relationship, we turned those metrics into service level agreements (SLAs), which we regularly monitor,” Outsourcing is a viable business strategy, and in some cases Scharmann said. “To determine the appropriate measures, we service providers are offshoring the work. HIM practitioners started with the HFMA MAP keys and compared those with our should stay up-to-date on breaches within the outsourcing organization-specific pain points to pinpoint the most relevant model, follow Office for Civil Rights responses to breaches, and measurable metrics.” keep up with cybersecurity issues in outsourcing models, In the same HFM article, Don Dadds, vice president, patient and communicate this information to the C-suite periodi- access for OSF Healthcare, said he believes when it comes to cally. In addition, HIM practitioners should define the future outsourcing that “fundamentally, you must do your due dili- state landscape at their organizations so that future partner- gence and find partners that are proven and truly have the ships are thoroughly vetted and managed. ¢ knowledge and technology to meet your needs.”6 Scharmann also recommended measuring over time. “We have a number Notes of SLAs with our vendor, and some carry bonus potential if the 1. Webb, Brandon. “A Navy SEAL-turned-CEO explains why vendor over performs,” he said. “We have 11 SLAs that have companies are outsourcing in droves.” Business Insider. bonus potential and several other key performance indicators August 3, 2015. www.businessinsider.com/a-former-na- (KPIs) we regularly measure.”7 vy-seal-explains-why-companies-are-outsourcing-in- The future state need for outsourcing HIM functions and the droves-2015-8. requirements that a service provider needs to offer should be 2. Feeney, Susan. “Major Shift in Healthcare: The Top defined by HIM practitioners, who are the business owners of Changes to Know in 2018.” Kindred blog. March 22, 2018. those functions. How will the current technology, systems, and www.kindredhealthcare.com/resources/blog-kindred- integrations advance and influence workflow in the future? The continuum/2018/03/22/2018-healthcare-trends-to- following are current state trends that are impacting HIM op- watch. erations, and this impact needs to be assessed when consider- 3. Miliard, Mike. “Think offshoring PHI is safe? You may not ing whether or not to outsource—specifically, how each trend be covered if a business associate breaches data.” Health- impacts the service provider. care IT News. October 12, 2016. www.healthcareitnews. Coding considerations: com/news/think-offshoring-phi-safe-you-may-not-be- Computer-assisted coding covered-if-business-associate-breaches-data. Computer-assisted practitioner documentation 4. The Outsourcing Institute. “Vendor Management.” http:// outsourcing.com/category/bpo/vendor-management- Release of information considerations: bpo. Health information exchange 5. Optum360. “Key Considerations for Revenue Cycle Out- Electronic health records sourcing.” HFM. September 1, 2018. www.hfma.org/Con- Risk/liability of ePHI and PHI on foreign networks/content.aspx?id=61738. figurations 6. Ibid. 7. Ibid. Transcription considerations: Speech recognition Susan Carey ([email protected]) is system director, HIM, Templated documentation at Norton Healthcare.

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Mitigating Security Risks Associated with Wireless Infusion Pumps

By William R. Shenton, JD

WIRELESS INFUSION PUMPS must provide a steady inflow ated with infusion pumps for some time and has a webpage of life-saving or life-sustaining medications, but these critical dedicated to this issue.4 Mitigating risks to wireless infusion devices come with significant risks that every healthcare orga- pumps has received more attention recently. In October 2018, nization must address. To operate effectively and efficiently, the FDA issued a draft update of its 2014 guidance concern- infusion pumps often must be linked to a network and to the ing Premarket Submissions for Management of Cybersecu- internet, which brings the risk of malicious manipulation rity in Medical Devices.5 In November 2018, the FDA issued a that can result in patient harm, data breaches, and can even “FDA In Brief” document highlighting its oversight efforts for expose an entire organization’s computer system to ransom- infusion pumps and other medical devices.6 ware. Federal regulatory agencies have put attention on these The FDA guidance is directed at manufacturers of all types key security issues, leading to conclusions on practical take- of medical devices and provides information to manufacturers aways for healthcare organizations. about cybersecurity issues that the FDA will examine in future The risks of wireless medical devices have received dramat- pre-market reviews of devices. However, the guidance has help- ic attention, including an episode of the TV series Homeland, ful information about issues that healthcare organizations cur- where a hacked cardiac pacemaker was manipulated to assas- rently face in deploying and maintaining wireless devices, dis- sinateW the vice president. While the portrayal in the Homeland cussed later in this article. episode may have been dramatized for effect, it reflects very real In August 2018, the National Cybersecurity Center of Excel- security concerns. lence (NCCoE) finalized the draft guidance it first issued last year on securing wireless infusion pumps.7 The NCCoE guid- Government Issues Warnings, Guidance ance is targeted for clinical and administrative leaders, as well Networked medical devices have been on the cybersecurity as the IT staff who run their networks. The 375-page report has radar screen for some time and received attention in the 2017 detailed information about technical measures to secure infu- report from the Health Care Industry Cybersecurity Task Force.1 sion pumps. For a good visual representation of the suggested The report identified a number of patient risks that can result system architecture consult the second page of NCCoE’s Sum- from inadequate security on medical devices, including unau- mary, which is linked on the webpage where NCCoE’s guidance thorized alteration of data or operating parameters and denial is available.8 The guidance stresses that the architecture for of service attacks which can render a device inoperable and lead these solutions uses commercially available hardware and soft- to exfiltration of patient data. ware and was developed with input from the vendors. In September 2017, the Food and Drug Administration (FDA) A fundamental takeaway from NCCoE is the need to come to issued a recall for almost a half million pacemakers.2 In that grips with common vulnerabilities of these devices, listed in Ap- same month came news about infusion pumps’ vulnerability.3 pendix B of NCCoE’s guidance, including: The FDA has been issuing guidance about the risks associ- Infusion pumps may stay in service beyond the point at

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19_January.indd 24 12/14/18 2:58 PM which they can be easily updated or patched. continuously update this inventory with detailed informa- Infusion pumps will store sensitive patient information, but tion, including the manufacturer of each device and contact may lack the ability to encrypt it either at rest or in transit. information; the departments or locations within the orga- Infusion pumps with external or removable media height- nization where each type of pump is typically used and their en the risk of inappropriate disclosure of information, as typical use cycles; and whether the manufacturer has issued well as the introduction of malicious software. software updates or patches and documentation that patches were installed. Appendix C in the NCCoE Report contains a concise list of Another obvious but still important issue highlighted by NC- recommendations and best practices, but emphasizes that CoE is establishing a secure area where devices not in use may the threat landscape is constantly evolving. NCCoE is invit- be stored, which remains reasonably accessible to the clinical ing comments on its guidance. To comment or to learn more, staff who must employ them. including how to arrange a demonstration of its example implementation, contact NCCoE at [email protected]. Technical Safeguards In the meantime, there are a number of basic practical steps The FDA draft guidance in October recommends that device that organizations can implement which are suggested by the manufacturers begin providing customers with a list of the NCCoE and the FDA. They revolve around the three overarch- hardware and software components of a device, so that custom- ing domains of security in the HIPAA Security Rule: the physi- ers can understand when a publicized vulnerability might affect cal, the technical, and the administrative. their deployed devices. While this is not yet a FDA requirement, it is not too early to collect and maintain that information as part Physical Security of the device inventory. The first step in the NIST Cybersecurity Framework is iden- The NCCoE guidance spotlights the repository of vulnerability tify, which entails a concerted effort to identify every wire- management data maintained at the National Vulnerability Da- less infusion pump in the organization (along with other tabase as a source of this information.10 wireless devices).9 Each organization will want to create and Since infusion pumps often are deployed for years, there must

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be a program to assess, update, and patch them on an ongoing ba- damental principle that devices should not be deployed with sis. But patching should follow a systematic approach. Guidance default passwords or other manufacturer-installed settings that on software vulnerabilities and patching software issued in June would expose them to malicious attacks. 2018 by the US Department of Health and Human Services’ Office The ability to carry out these protective measures must be fac- for Civil Rights emphasized the importance of confirming that a tored into the process of acquiring new devices, and the FDA has patch has not compromised the functionality of a device and of highlighted a number of important features for manufacturers making sure that the clinical staff is oriented appropriately.11 to implement in a checklist on page 13 of its draft guidance. The The FDA draft guidance in October 2018 also mentions the checklist identifies important features that should be considered concept of segregating some devices on the organization’s net- by healthcare organizations in purchasing wireless devices. work to limit the negative impact of an exploit of an older device The FDA’s draft guidance in October 2018 also emphasizes that can no longer be patched or updated effectively. NCCoE the value of information sharing about risks and vulnerabilities recommends implementing media access address filtering to among the user community. Among the Information Sharing limit access to medical devices by unauthorized actors attempt- Analysis Organizations (ISAOs) established to facilitate timely ing to infiltrate the organization’s network through an exposed sharing of information about cybersecurity threats is the Health ethernet port on the device. Information Sharing and Analysis Center.13

Administrative Policies Stay Tuned as Threats Evolve The human element is critical to cybersecurity and this arena is While the guidance from the FDA and NCCoE contains impor- no different. Securing wireless infusion pumps and other wireless tant cybersecurity tools that are ready to be implemented now, it devices will involve clinical and IT staff working collaboratively is important to stay tuned as cybersecurity threats evolve. ¢ to develop procedures that will ensure reasonable, workable physical and technical safeguards are implemented and can be Notes followed without disrupting patient care. On its Medical Device 1. Department of Health and Human Services (HHS). “Health webpage, the FDA recommends establishing teams of clinical, Care Industry Cybersecurity Task Force Report on Improv- management, and IT personnel who work collaboratively to de- ing Cybersecurity in the Health Care Industry.” June 2017. velop and refine policies and respond to incidents, and the FDA www.phe.gov/Preparedness/planning/CyberTF/Docu- website has several webpages targeted at the various clinical, IT, ments/report2017.pdf. and management disciplines that have responsibilities for the ac- 2. Food and Drug Administration (FDA). “Class 2 Device quisition, deployment, or use of infusion pumps.12 Recall Accent family of pacemakers.” November 2018. The NCCoE guidance highlights the importance of role-based www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRes/res. access to the devices, limiting access to particular functions on cfm?ID=158779. an infusion pump solely to persons whose job functions require 3. Paganini, Pierluigi. “Hackers can remotely access Smiths them to use those functions. NCCoE also emphasizes the fun- Medical Syringe Infusion Pumps to kill patients.” Secu-

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rity Affairs. September 11, 2017.https://securityaffairs.co/ tional Cybersecurity Center of Excellence. August 17, 2018. wordpress/62918/hacking/syringe-infusion-pumps.html. www.nccoe.nist.gov/projects/use-cases/medical-devices. 4. FDA. “Infusion Pump Risk Reduction Strategies.” August 9. National Institute of Standards and Technology. “Cyberse- 22, 2018. www.fda.gov/MedicalDevices/Productsand- curity Framework.” www.nist.gov/cyberframework. MedicalProcedures/GeneralHospitalDevicesandSup- 10. National Institute of Standards and Technology. “National plies/InfusionPumps/ucm202498.htm. Vulnerability Database.” https://nvd.nist.gov/. 5. FDA. “FDA In Brief: FDA proposes updated cybersecu- 11. HHS’ Office for Civil Rights. “June 2018 OCR Cybersecu- rity recommendations to help ensure device manufac- rity Newsletter.” www.hhs.gov/sites/default/files/june- turers are adequately addressing evolving cybersecurity 2018-newsletter-software-patches.pdf. threats.” October 17, 2018. www.fda.gov/NewsEvents/ 12. FDA. “Infusion Pump Risk Reduction Strategies.” August Newsroom/FDAInBrief/ucm623624.htm. 22, 2018. www.fda.gov/MedicalDevices/Productsand- 6. FDA. “FDA In Brief: FDA’s increased inspections of MedicalProcedures/GeneralHospitalDevicesandSup- medical device manufacturers and targeted risk-based plies/InfusionPumps/ucm202498.htm. approach leads to improved compliance.” November 13. Health Information Sharing and Analysis Center (H-ISAC). 21, 2018. www.fda.gov/NewsEvents/Newsroom/FDAIn- Home page. https://nhisac.org/. Brief/ucm626428.htm. 7. National Institute of Standards and Technology and Na- William R. Shenton ([email protected]) is a partner at Poyner tional Cybersecurity Center of Excellence. “Securing Spruill LLP in Raleigh, NC. His areas of expertise include health and hos- Wireless Infusion Pumps in Healthcare Delivery Organi- pital law, civil litigation, and administrative law, and his practice includes zations.” August 2018. www.nccoe.nist.gov/sites/default/ advising and representing healthcare facilities and individual providers files/library/sp1800/hit-wip-nist-sp1800-8.pdf. in federal and state regulatory compliance issues, certificate of need issues, 8. O’Brien, Gavin et al. “Securing Wireless Infusion Pumps.” administrative appeals, compliance issues, HIPAA, and state and federal National Institute of Standards and Technology and Na- civil litigation.

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General Data Protection Regulation and Research in the United States By Shamsi Daneshvari Berry, PhD, MS, CPHI, and Jill Flanigan, MLS, MS, RHIT

THE EUROPEAN UNION (EU) protects the personal informa- tal, economic, cultural or social identity of that natural per- tion of EU citizens through the General Data Protection Regu- son,” the regulation states.5 This personal data can be used lation (GDPR),1 which went into effect on May 25, 2018 and re- for research purposes but is subject to conditions unless it placed the Data Protection Directive.2 The GDPR details some would “seriously impair” the research aims.6 The purpose is new rights of EU citizens and other European Economic Areas to minimize the amount of personal data used in research. (EEA) such as Norway, Iceland, and Liechtenstein.3 Although there are similar privacy efforts in the United Specifically, it impacts the right to: States, there are some additional constraints that raise is- Know who is processing one’s data, what data they are sues when it comes to international research involving the looking at, and why they are doing it EU or EEA. Request an organization to inform one of the personal In addition, certain categories of personal data are consid- data it has in its system ered especially sensitive and receive additional protection Request that personal data gets sent and exchanged be- under Article 9 of the GDPR. Processing data described un- tween providers der Article 9 is prohibited unless a specific exception applies. Have information deleted from specific systems The special categories include, “data revealing racial or ethnic T Be asked before a company processes one’s data origin, political opinions, religious or philosophical beliefs, or Be informed of a data breach trade union membership, and the processing of genetic data, Have clear, straightforward language in privacy policies4 biometric data for the sole purpose of uniquely identifying a natural person, data concerning health, or data concerning a The key to these new rights is that they apply across the EU, natural person’s sex life or sexual orientation… .”7 In legal ter- regardless of where the data is stored or processed. The law minology, a natural person is one who is a human as opposed also applies to non-EU companies—including those in the to a corporation. US—who collect or process the personal data of an individual Under the GDPR, there are three main differences from the residing in the EU when the data is collected or processed. This previous directive that affect research. First, a person must means even US companies and healthcare organizations can consent in accessible language to have their personal data be covered by the law. used.8 They have the right to withdraw from the study as well as “be forgotten,” which involves erasing their data from the sys- GDPR and Personal Data tem—not just eliminating it from processing.9 Therefore, any The regulation covers personal data that can be identified study must receive consent from all participants unless the directly or indirectly through a “name, an identification data set is anonymized. (Pseudonymized data, under Recital number, location data, an online identifier, or one or more 26, is considered personal data.10) Thankfully for researchers factors specific to the physical, physiological, genetic, men- there is a workaround that individuals can consent to “areas

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of research.” Additionally, Recital 51 also allows for medical Winton. “Does GDPR Regulate Clinical Care Delivery by research that is in the public’s interest.11 US Health Care Providers?” The National Law Review. Consent must be explicit for all categories of personal data February 26, 2018. www.natlawreview.com/article/does- that may be processed during a research study. Organiza- gdpr-regulate-clinical-care-delivery-us-health-care- tions engaged in research may be prepared to obtain clear providers. consent for the use of health data, but if in the course of re- 4. Cornock, Marc. “General Data Protection Regulation search data on ethnicity, sexual orientation, or other protect- (GDPR) and implications for research.” Maturitas. May ed categories is collected then researchers must ensure that 2018. www.maturitas.org/article/S0378-5122(18)30036- they obtain explicit consent for the use of data in any of the 7/fulltext. special categories.12 5. Rumbold, John Mark Michael and Barbara Pierscionek. The GDPR-covered person has the right to be forgotten, also “The Effect of the General Data Protection Regulation known as the right to erasure. This may occur if consent is on Medical Research.” Journal of Medical Internet Re- withdrawn, when the data is no longer needed, or other cir- search. February 24, 2017. www.ncbi.nlm.nih.gov/pmc/ cumstances where the data is required to be erased to comply articles/PMC5346164/. with other regulations or if there has been a violation of the 6. Official Journal of the European Union. “General Data data protection regulation.13 Protection Regulation 2016/679/EU.” Second, data sharing outside the EU is allowed as long as the 7. Ibid. rights of the individual are not lessened in the country receiv- 8. Ibid. ing the data.14,15 In other words, if you are sharing EU medical 9. Cornock, Marc. “General Data Protection Regulation data within the United States, the data must be HIPAA-com- (GDPR) and implications for research.” pliant as well as GDPR-compliant. 10. Rumbold, John Mark Michael and Barbara Pierscionek. Third, data must be portable.16,17 This means that the individ- “The Effect of the General Data Protection Regulation on ual must be able to get a copy of their data that is in a common Medical Research.” machine-readable format. Article 20 of the GDPR describes 11. Official Journal of the European Union. “General Data the right of portability. The individual can request the data be Protection Regulation 2016/679/EU.” provided directly to another entity that will control the data. 12. Ibid. The need to be able to provide the data copy will influence how 13. Ibid. the organization stores the data.18 14. Rumbold, John Mark Michael and Barbara Pierscionek. “The Effect of the General Data Protection Regulation on GDPR and the United States Medical Research.” If you are based in the US, the GDPR applies to you if you are 15. Cornock, Marc. “General Data Protection Regulation using research subjects in the EU and EEA or are recruiting (GDPR) and implications for research.” subjects in that region.19 However, data is not just personal 16. Official Journal of the European Union. “General Data data because it involves a citizen of the EU or EEA. The data Protection Regulation 2016/679/EU.” must be collected on them while they are located in the EU or 17. Cornock, Marc. “General Data Protection Regulation EEA. Therefore, if an EU citizen travels to the US and requires (GDPR) and implications for research.” healthcare, the GDPR does not apply.20 It would only apply if 18. Official Journal of the European Union. “General Data the individual was recruited to use that healthcare system Protection Regulation 2016/679/EU.” while still in the EU and EEA or if they were followed up with 19. Broccolo, Bernadette M., Daniel F. Gottlieb, and Ashley by a physician or researcher after returning to the EU.21, 22 Winton. “Does GDPR Regulate Clinical Care Delivery by If the GDPR does apply to research, one important differ- US Health Care Providers?” ence in comparison to HIPAA is the higher standard applied 20. Rumbold, John Mark Michael and Barbara Pierscionek. to de-identification. A data set is not considered de-identified “The Effect of the General Data Protection Regulation on if there is any reasonable way to directly or indirectly identify Medical Research.” the individual or if a key code exists.23 ¢ 21. Ibid. 22. Broccolo, Bernadette M. et al. “Does GDPR Regulate My Notes Research Studies in the United States?” The National Law 1. Official Journal of the European Union. “General Data Review. February 5, 2018. www.natlawreview.com/article/ Protection Regulation 2016/679/EU.” April 27, 2016. does-gdpr-regulate-my-research-studies-united-states. https://publications.europa.eu/en/publication-detail/-/ 23. Ibid. publication/3e485e15-11bd-11e6-ba9a-01aa75ed71a1/ language-en. Shamsi Daneshvari Berry ([email protected]) is an assistant professor at the 2. Ibid. University of Mississippi Medical Center. Jill Flanigan ([email protected]) is 3. Broccolo, Bernadette M., Daniel F. Gottlieb, and Ashley an assistant professor and HIM coordinator at Middlesex Community College.

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In Pursuit of Comparable Coding Audit Benchmarks By Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA

PEOPLE LIKE BENCHMARKS. They like to know how they becoming more common to incorporate the nuances of are doing in comparison to someone else. In health infor- well-established reimbursement methodologies and com- mation management (HIM), a common benchmark is the de pliance requirements. facto standard of 95 percent accuracy rate for medical cod- Record-over-record accuracy considers the number of re- ing. HIM professionals regularly measure coding accuracy cords with correct coding divided by the total number of and compare accuracy rates for medical coders in facilities cases reviewed. Sometimes referred to as the “all right/all within a health system. External benchmarking of coding wrong method,”2 the non-weighted record-over-record cal- accuracy, however, is more difficult. This is partially due to culation is useful for binary audit elements (such as DRG data privacy requirements as well as concerns for potential accuracy) but makes it challenging to achieve a high score exposure to non-compliance in healthcare claims data. But when multiple audit elements are considered on each re- of equal concern is how coding accuracy rates are calculat- cord. In contrast, weighted record-over-record calculations ed and the comparability of the data from one healthcare can account for multiple audit elements and present a more system to another. achievable overall score. It has been suggested that coding accuracy is subjective To illustrate the differences, the author of this article ap- Pand must be measured within the context of a given facil- plied each method to the same random sample of 25 inpa- ity.1 This article focuses on this challenge and compares tient cases. The 25 cases included a total of 475 ICD-10-CM data derived from various methods for calculating coding diagnosis codes and 68 ICD-10-PCS procedure codes. A com- accuracy rates. parison of the accuracy rates derived from each methodology is presented in Table 1 on page 31. Comparison of Coding Accuracy Rates The variety of bolded accuracy rates in Table 1 demon- The most common methods of calculating coding audit results strate how much accuracy rates vary, depending on how the are either per code or per record, and the statistical equation rate is calculated. For this particular sample of 25 cases, the applied may include weighting of audit elements. Results can diagnosis coding appears to be slightly stronger than pro- vary widely and may or may not be comparable depending on cedure coding, according to the non-weighted code-over- which method is used. code rate (92.42 percent). However, the three DRG changes Code-over-code accuracy considers the number of codes were all due to diagnosis code changes and several of the that are originally assigned correctly divided by the total secondary diagnosis codes changed were MCC/CC (major correct codes. Historically, a non-weighted code-over-code complication or comorbidity/complication or comorbidity) approach was favored because code variances are counted designated codes. In fact, the majority of the findings were equally with no judgement on the importance of a particu- diagnosis code changes, additions or deletions, a fact that is lar code variance. But weighted scoring mechanisms are better reflected in the weighted code-over-code rate (87.68

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Table 1: Comparison of Accuracy Calculations

Calculation Method Diagnosis Accuracy Procedure Accuracy NON-WEIGHTED CODE-OVER-CODE • Numerator = Total number of original 92.42% 91.18% codes assigned correctly (=439 correct original codes/475 total codes) (=62 correct original codes/68 total • Denominator = Count of correct codes codes) WEIGHTED CODE-OVER-CODE • Principal diagnosis codes and MCC/CC codes are 87.68% 92.59% given twice the weight of additional diagnosis codes • (76 original principal/ MCC/CC codes • (13 original principal procedure • Otherwise, the numerator and denominator are correct*2) + 346 original additional Dx codes correct*2) + 49 original calculated as above codes correct = 498 additional procedure codes • (93 principal/MCC/CC codes correct*2) + correct = 75 382 correct additional Dx codes = 568 • (13 principal procedure codes • 498/568 = 87.68% correct*2) + 55 correct additional codes = 81 • 75/81 = 92.59% NON-WEIGHTED RECORD-OVER-RECORD • Numerator = Total number of cases correct on all (or Overall case rate = 28% specified) audit elements as originally presented (=7 cases with no errors on any audit element/25 cases) • Denominator = Number of cases DRG accuracy rate = 88% (=22 correct original DRGs/25 cases) WEIGHTED RECORD-OVER-RECORD • Highest weight: principal diagnosis, secondary di- Overall record accuracy = 91.6% agnoses, POA, principal procedures, or discharge (=2,290 points scored based on original codes/2,500 possible total points) disposition codes that change the DRG • Modest weight: secondary diagnosis codes that change the SOI, ROM, or HCC • Lowest weight: Non-MCC/CC secondary diagnosis, secondary procedure codes, POA, and discharge disposition changes that do not impact DRGs • No weight: educational code notes

percent). 25 cases, taking into consideration, for example, two cases Analysis of procedure coding detailed results is also more with risk of mortality (ROM) changes and one case with an consistent with the weighted code-over-code rate (91.18 inaccurate discharge disposition (none of which impacted percent compared to 92.59 percent). The six procedure code the DRGs). errors were primarily the addition of reportable procedures; Non-weighted accuracy rates are particularly useful to appropriate, but not impactful on reimbursement or quality. measure performance on specific codes or groups of codes There were far fewer procedure codes, making the denomi- in a code set. They are useful for both internal and external nator smaller, thus increasing the statistical impact of the benchmarking because the calculation is based on objec- changes in a non-weighted code-over-code rate. The non- tive code counts. In contrast, weighted accuracy rates al- weighted record-over-record accuracy rate (28 percent) il- low for more sophisticated benchmarking that incorporates lustrates the difficulty in achieving accuracy when multiple defined priorities, which is extremely useful as follow up audit elements must be met on each record. This calcula- action plans depend on the types and severity of errors. tion is very useful, however, to measure whether the single Weighted accuracy rates are presently limited for external DRG audit element is correct on a case—or not (88 percent). benchmarking due to the lack of standardization in the The weighted record-over-record calculation is more complex but presents a more thorough overall analysis of the Continued on page 47

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Drivers for Solid Information Management Expanding in Healthcare By Deborah Green, MBA

EVERYTHING THAT IS done in healthcare revolves around data due to its objectives of “better care for the individual, better and information. From new sources of data to new technologi- health for populations, and lower per capita costs” has fueled cal advancements, the drivers and needs for solid information transformation in healthcare.1 From value-based purchasing to management have not only grown but have become reinforced disruption driven by large-scale changes to major technology by and intertwined with technology megatrends and macro- advances, one is hard pressed to identify a healthcare change level forces. All of these forces rely on trustworthy, accurate, and that is not related to the Triple Aim. The three aims cannot be protected information, which cannot be ensured without sound accomplished, however, without trusted data and information. and comprehensive information management. The ability to meet those challenges and leverage the trends and forces of to- Data, Analytics, and AI day and tomorrow depends on how prepared organizations are Rising data volume and managing the difficulties of efficiently to manage the swarms of data and information. and effectively preparing the data and using it to make data- driven decisions is not new. The inter-relation of data and Using Information Management to Meet New Demands analytics is also not new. Now, given the high demands for ad- Data and information, when appropriately managed and lever- vanced analytic tools, the healthcare industry is seeing AI lev- Eaged, will give organizations new and uncharted insights that eraged to provide augmented analytics and give organizations they didn’t have in the past. Better information management new insights into their data, which helps respond to the popu- practices will help these organizations meet each demand de- lar theory that “you don’t know what you don’t know.” AI can scribed below: help find knowledge in data while information is maximized 1. Triple Aim through strong information management, data governance, 2. Data, Analytics, and Artificial Intelligence (AI) analytics, artificial intelligence, the Internet of Things (IoT), 3. Digital Health and Disruption and digital health. 4. Internet of Things (IoT) Distribution of data access, tools, and development of work- 5. Automation and AI force capabilities through data governance will help to foster a 6. Regulatory Compliance data culture in the organization. 7. Cybersecurity Threats 8. Disruption, New Models, and New Entrants Digital Health and Disruption There are a number of healthcare initiatives that are focused on Triple Aim improving the health of the population. An Ernst and Young ini- This driver is placed first in the above list intentionally. Apart tiative called “Health Reimagined” envisions a model of digital from its adoption as key to America’s national healthcare strat- health with broad use of apps, sensors, wearables, virtual care, egy, the Institute for Healthcare Improvement’s Triple Aim, prevention, and real-time intervention, supported by Big Data

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and advanced analytics. controls in a more proactive manner to ensure information is “Healthcare is being disrupted,” writes David Roberts, Ernst and protected and secured in all phases of its lifecycle. Young’s Global Health Leader, on a company blog post.2 “Cost inflation has become unsustainable, driving healthcare systems Disruption, New Models, and New Entrants and payers to seek new approaches, including incentives that em- Technology advances, innovation, and the need to reduce health- phasize value. These cost pressures are exacerbated by changing care costs are enabling new entrants into healthcare and new demographics, rising incomes in emerging markets, and an im- models for service delivery. Disruptors change the status quo in minent chronic disease epidemic. The rapid rise of digital health— healthcare and allow for innovations to surface in new ways. mobile health, Big Data, and analytics—is enabling real-time, cost- One of the most notable disruptions was the nonprofit ven- effective interventions. Companies beyond healthcare are entering ture announced in early 2018 by Amazon, JP Morgan Chase, and the fray, providing new sources of competition and collaboration.” Berkshire Hathaway. This venture, with a goal of reducing health- New technology is no doubt driving digital health. As a result, new care costs for its collective employees, includes durable medical sources of data are generating exponential amounts of data that re- equipment and medical supplies, a mail order retail pharmacy, a quire solid information management to extract its true value. Prop- pharmacy benefit manager, and telemedicine or in-home care.4 er management will provide the solution for more effective delivery Another large-scale disruption was the CVS acquisition of Aet- and monitoring of care through digitized health, lower healthcare na. This is seen as a major disruption given Aetna’s prominence costs for both patients and providers, and overall healthier popula- as an insurer, serving 45 million in the US, and CVS’s omnipres- tions—again, helping to meet the goals of the Triple Aim. ence as a retail pharmacy and operator of its MinuteClinics. Of the US population, 76 percent live within five miles of a CVS. This Automation and AI acquisition is expected to reduce costs given the key advantage of Automation and AI will allow organizations to unlock greater in- the “complete picture of members’ health status” from the com- sights into their data and information. To do that, new technologies bined pharmacy and benefit data.5 In this example, the impor- and data governance initiatives should be implemented to ensure tance of data and information cannot be overstated. It is the value the data are “fit” for in-depth analysis. Access to the capabilities of of the information that yields the anticipated value of quality care, automated processes and AI is an asset that can’t be denied. Each health of the covered populations, and the reduced costs. will enable informed and data-driven decision-making in all areas of the organization as well as throughout the information lifecycle. Focus on Strategic Planning Efforts Over the past five years, drivers for information management Regulatory Compliance have intensified or evolved and new drivers have emerged. It Regulatory compliance will continue to be a major driver of good is expected the future will unveil drivers that have yet to make information management and organizations must be diligent their debut. It is essential to get to a mature state with informa- in compliance efforts given new regulations and changes. The tion management to address these challenges and give organi- outcomes of litigation, information submitted for mandatory re- zations a competitive advantage. ¢ porting, and meeting compliance demands all hinge on having accurate and timely information that can be easily accessed and Notes shared as appropriate. It is important to have a collaborative effort 1. Institute for Healthcare Improvement. “The IHI Triple between legal teams, IT, and the business units to ensure necessary Aim.” www.ihi.org/engage/initiatives/TripleAim/Pages/ information can be accounted for when needed for legal purposes. default.aspx. 2. Roberts, David. “How EY is Reimagining Healthcare.” Ernst Cybersecurity Threats and Young. January 8, 2018. www.ey.com/en_gl/health/ Cybersecurity risk and threats represent serious challenges in how-ey-is-reimagining-health-care. healthcare and will continue to drive the need for strong infor- 3. Barker, Ian. “4.5 billion records compromised in first half mation management practices. In the first half of 2018 there were of 2018.” BetaNews. October 2018. https://betanews. 945 data breaches across all industries, compromising 4.5 billion com/2018/10/09/4-5-billion-records-compromised-2018/. records. This represented an increase in compromised records 4. Haslehurst, Robert and Joseph Johnson. “As Amazon Turns by 133 percent. This volume of compromised data equals 25 mil- Its Gaze to Healthcare, the Industry May Be in for a Wild Ride.” lion records per day, or 290 records per second. These records are FierceHealthcare. October 22, 2018. www.fiercehealthcare. composed of medical, credit card, financial, or other records with com/sponsored/did-you-know-72-u-s-adults-go-online-to- personally identifiable information. Only one percent of the com- find-health-information-and-did-you-know-41. promised records were protected by encryption.3 5. Liss, Samantha. “‘Nowhere to hide’ for rivals after block- Given this alarming information, healthcare organizations buster CVS-Aetna deal.” Healthcare Dive. October 11, must have a holistic view of their IT landscape to ensure that ad- 2018. www.healthcaredive.com/news/nowhere-to-hide- equate protections are in place to mitigate potential risks. Col- for-rivals-after-blockbuster-cvs-aetna-deal/539396/. laborative information management positions organizations to identify all areas of opportunity and to implement security Deborah Green ([email protected]) is an executive consultant.

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practice guidelines for managing health information

Ensuring the Integrity of the EHR (Part One) Editor’s Note: This Practice Brief supersedes the August 2013 “Integrity of the Healthcare Record: Best Practices for EHR Documenta- tion” and the May 2015 “Assessing and Improving EHR Data Quality” Practice Briefs.

NEARLY 20 YEARS have passed since the landmark release of Journal of AHIMA. The second installment of this Practice Brief the Institute of Medicine’s (IOM) report To Err is Human: Build- will discuss specific systems and functionalities, initial and on- ing a Safer Health System. This report estimated the number of going training, and recommendations for ongoing efforts to people dying in hospitals yearly due to preventable errors to be maintain integrity of the EHR. at least 44,000. John James, in the September 2013 Journal of Patient Safety, estimated that there were between 210,000 and Capturing Data at the Point of Care 440,000 preventable hospital deaths a year.1 The quality of clinical documentation at the point of entry is The goal of the electronic health record (EHR) is to help health- critical for all secondary uses of the data. EHR quality is depen- care professionals produce and use quality data for evidence- dent upon the data collected at the point of registration and fol- based knowledge management and decision-making for patient lows through with each participant in the patient’s care. Clinical care. The EHR has the potential to minimize medical errors if the documentation practices need to be developed and standard- data are accurate and meet quality criteria. EHRs are comprised of ized to facilitate data quality, accurate data capture, and encod- many different technologies. EHR governance by means of clear ing while reflecting the individuality of each patient. In an EHR, policies, standards, procedures, and functionalities should be es- it is imperative these content standards are built into the foun- Ntablished for all systems and applications that interface with the dation of the data capture tools. EHR, and define who owns and has responsibility for maintaining After building content standards into documentation tools, the and creating the data dictionary for each system and module. next critical step is training. The frontline clinical and adminis- Poor documentation, inaccurate data, and insufficient com- trative staff members who are creating entries in the EHR need munication can result in errors and adverse incidents.2 Inaccu- guidance to understand the data standards and definitions to rate data threatens patient safety and can lead to increased costs, make choices that accurately reflect the patient’s circumstanc- inefficiencies, and poor financial performance. Furthermore,- in es. Without understanding the importance and meaning of data accurate or insufficient data impedes reimbursement, payments, standards through appropriate training, data integrity will be strategic planning, and health information exchange (HIE), as lost. An example of a content standard is the Health Level Seven well as hinders clinical research, performance improvement, and (HL7) Reference Information Model (RIM), which is a visual quality measurement initiatives. The impact of poor data on pa- representation of clinical content as discrete objects and data tient care has increased with the implementation of ICD-10-CM/ elements that can be generated, shared, and used in a lifecycle PCS, the Promoting Interoperability Program (previously known of events between participants.3 as the “meaningful use” EHR Incentive Program), accountable Establishing consistent data models will ensure the integrity care organizations, and value-based purchasing. and quality of the data maintained in the EHR. A data model is With the continued advancement of EHRs there is increasing a representation of the data to be stored in a database and the concern that poor documentation integrity could lead to com- relationships between the tables and data fields which can then promised patient care, care coordination, quality reporting, be carried out using object-oriented or entity relationship ap- payment errors, and research, as well as fraud and abuse. Pro- proaches.4 viders and suppliers must rely on proper documentation to jus- AHIMA’s Data Quality Management Model, available online tify the validity of coded services when claims are rejected. As in AHIMA’s HIM Body of Knowledge, discusses the business the predictive analytic capabilities of third-party payers evolve, processes that ensure the integrity of an organization’s data the documentation within the medical record projects a greater throughout the information lifecycle, from collection, applica- focus on the integrity of data that supports billing functions and tion, and warehousing to analysis. revenue generation. This Practice Brief discusses the challenges of maintaining quality data in the EHR and offers best practice Ensuring Data Accuracy guidance for ensuring the integrity of healthcare data. Quality patient care and safety improvement goals can be en- This Practice Brief will be published in two installments, ap- hanced and better achieved through the application of docu- pearing in the January 2019 and February 2019 issues of the mentation guidelines and data standards. Documentation and

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data content within an EHR must be accurate, complete, con- Security of information—or access to create, use, and amend cise, consistent, timely, and universally understood by data us- data—begins with role-based access that is defined and en- ers. It must also support the legal business record of the organi- forced with administrative safeguards. Clear policies that define zation by maintaining these parameters. It is critical that both information access by a specific role or relationship to patient structured and unstructured data meet a standard of quality if type limits authority to enter, access, update, and delete data they are to be meaningful for internal and external use, such along with the means to audit such activities. A regulatory stipu- as continuum of care and secondary purposes. Factors such as lation of the Health Insurance Portability and Accountability Act ease of use and design can facilitate adherence to documenta- (HIPAA) defines the limitation of access to patient information tion guidelines and standards, as discussed in the Practice Brief with the minimum necessary rule, which states that staff should titled “Fundamentals of the Legal Health Record and Designat- only have access to the information they need to do their job. ed Record Set.” Technology can assist with access control, but there still needs Documentation policies and guidelines for both paper and to be coordination with individual stakeholders and processes electronic documentation must be established in compliance to ensure accuracy and availability of the data for patient care. with governmental, regulatory, accreditation, and industry Standards of terminology support consistency in data collection. standards, including those for accuracy, timeliness, copy func- The data dictionary ensures the consistent use of data elements tionality, and privacy and security. Organizational EHR gover- and terminology to improve the use of data and storage within a nance managing the use of best practice alerts and hard stops database management system. Data definitions should be clearly is recommended to ensure accurate and complete documenta- communicated to all staff accessing the record, especially those tion, while limiting overuse to avoid alert fatigue and delays in responsible for reporting data. The data dictionary can also be patient care. Strong facility controls and governance can help built into various information systems to promote data consisten- ensure documentation guidelines are followed and compliance cy throughout the enterprise. Information governance requires requirements are met. For example, consider the varying use of ongoing ownership and maintenance of the data dictionary. abbreviations and acronyms across facilities and states. If an ab- The development and distribution of standards of terminolo- breviation is used incorrectly or is not understood by the reader gy, including clinical vocabularies, classification code sets, and and then acted upon, it could have a negative impact on the nomenclatures, facilitates interoperability for the exchange of treatment of the patient. clinical data and to improve the retrieval of health information Data integrity policies and procedures must be created and from data storage. Barriers to interoperability and data quality followed. These policies may include, but are not limited to, result when there are inconsistent naming conventions, defi- registration processes, standards for handling duplicate re- nitions, varying field length for the same data element, and/or cords, and processes for addressing overlays (writing over one varied element values, which can all lead to problems such as person’s demographic information with another person’s infor- poor data quality and misuse of data in reporting. For example, mation). It is important to implement policies and procedures the date of a patient’s admission may be referred to as the “date to maintain the integrity of the data throughout the patient en- of admission” in one system and “admit date” in another. counter for all information entered into the EHR, whether by people or other electronic systems. Individuals dedicated to the HIM Role in Enterprise Information Management continuous auditing of the medical record, as well as automated The traditional role of the HIM professional as the legal custodian processes that monitor the EHR system proactively and identify of health records in terms of organization, content, maintenance, errors as they are created, play an important role in fine-tuning and authorized release has taken on new dimension with the ad- processes and ensuring the overall quality of the data. Alerts vent of electronic health records and the movement toward more may be built into the EHR to identify potential errors and bring comprehensive information governance approaches. these to the attention of the provider, others treating the patient, As data strategies incorporating data quality assurance to or staff who monitor the record for data integrity issues. ensure optimal data quality become necessary, the HIM professional’s role expands to include data governance. The im- Data Quality Best Practices portance of managing information as an asset means HIM To realize the advantages of the implementation of health infor- professionals would like to see their roles evolve to have an en- mation technology and HIE in the combined goals of improving terprise-wide presence that encompasses such duties as help- quality of care and ensuring the financial integrity of the orga- ing to bridge data gaps for clinical documentation and support- nization, best practices for ensuring quality healthcare data being operational information demands. come the foundation. Data quality should be a constant focus for HIM profession- Some key factors that must be considered for best practices to als. As the custodian of the health record, the HIM professional support data quality include: is tasked with authenticating and certifying the legal health re- Security of access cord for legal issues. Compliance with billing requirements ne- Data dictionaries (metadata) cessitates a medical record that supports the claims submitted. Standards of terminology Clinical documentation improvement supports the accurate Policy and procedures representation of a patient’s clinical status translated into coded Information governance data which advances to such secondary uses as quality report-

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ing, physician report cards, reimbursement, research, public on the role-based tasks, along with specific policies and proce- health data, and disease tracking and trending. dures for compliance with those tasks as well as associated re- Healthcare organizations must manage information as an sponsibilities related to computer system access and other equip- asset and adopt proactive decision-making and oversight. This ment within the department. For staff development training, can be achieved through information asset management, in- organizations may need to devote more strategy to ensure provid- formation governance, and enterprise information manage- ers and staff are well-informed about compliance and legal risks. ment (EIM) to achieve data trustworthiness. AHIMA defines The education program needs to clarify and reinforce that the information governance as “an organization-wide framework HIM documentation requirements and documentation guide- for managing information throughout its lifecycle and for sup- lines accepted and established for the paper record also apply to porting the organization’s strategy, operations, regulatory, le- the EHR. In addition, all regulatory and oversight agency require- gal, risk, and environmental requirements.”5 AHIMA further ments for documentation, such as for the Centers for Medicare defines EIM as “a subdomain of information governance that and Medicaid Services, The Joint Commission, the Accreditation includes the policies and processes for managing information Association for Ambulatory Health Care, the American Osteo- across the organization, throughout all phases of its life: cre- pathic Association, and Det Norske Veritas GL Health apply to ation and capture, processing, use, storing, preservation, and the electronic record as well. Periodic staff education, through disposition. It also includes management of enterprise prac- in-service and continuing education programs that focus on best tices for information sharing, release and exchange practices, practices for documentation to support the integrity of the health chain of custody, and long-term digital preservation.”6 The record, provide an opportunity to reinforce established policy multitude of federal and state health information exchange and introduce regulatory and guideline changes that necessitate initiatives require information governance and the integrity of new policies and procedures. EHRs to support confidence in record sharing. Documentation of the education activity as part of the physician, provider, or employee’s permanent medical staff or human Training is the Foundation for a Culture of Quality Data resource record verifies the employee participation and estab- The quality and integrity of the data element cannot be estab- lishes accountability for following organizational policy. In the lished and maintained without a human element, so an ef- event of any possible future issues regarding false or fraudulent fective and continuous training program becomes the driving entries, the organization will be able to demonstrate that due force in achieving a culture of data stewardship and compliance diligence was exercised in the training of its staff. throughout the organization. For health information systems, a comprehensive training Maintaining EHR Integrity program can provide the necessary skills for the workforce in To ensure a high level of integrity of the EHR, organizations achieving the work goals and objectives of the organization. Hav- should consider: ing sufficient test cases available in a system is key so all aspects Implementation of a formalized, organization-wide infor- of job requirements can be used in a test environment. Testing mation governance program and training should not occur in a production environment. For Desire and commitment to conduct business and provide the workforce, effective training provides the employee with the care in an ethical manner knowledge and tools in performing task completion according Purchasing systems that include functions and capabili- to established policy. For the organization, training and human ties to prevent or discourage fraudulent activity resource development—aligned with the strategic plan—benefit Implementing and using policies, procedures, and system the organization by ensuring maintenance of a workforce pos- functions and capabilities to prevent fraud sessing the skills for current and future organizational needs. Inclusion of an HIM professional, such as a record content Achieving an effective training program requires planning to expert, on the IT design and EHR implementation team to assess training needs through analysis. Once the assessment is ensure the end-product is compliant with all billing, cod- completed, the next step is to develop a plan with training ma- ing, documentation, regulatory, and payer guidelines terials and mode of delivery, then test the effectiveness of the plan, implement the training activities, monitor the effective- Ensuring EHR integrity is a fundamental practice. Organiza- ness, and, finally, revise as needed.7 tions should use the guidelines within this Practice Brief as well as the detailed checklist in Appendix A, available online in AHI- Opportunities for EHR Policy Training MA’s HIM Body of Knowledge at http://bok.ahima.org to assess The timing of training is an additional important factor to con- compliance. sider. Training for use of an EHR and its component devices and software is a multifaceted process, starting with new employee HIM’s Evolving Role orientation. This instruction sets the foundation by introducing The role of the HIM professional is evolving from managing the the employee to the basics of the administrative, physical, and content of the health record to managing overall EHR data stan- technical safeguards in place in the organization and the expecta- dardization and harmonization, both within the organization tions of the employee related to information use and governance. and with external organizations through health information ex- Departmental orientation for new employees requires a focus changes. The new role of the HIM professional will involve leader-

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ship in the development of information and/or data governance tion. Chicago, IL: AHIMA Press, 2016: pp. 752–753. programs, EHR quality models within the organization, and an 8. Dimick, Chris. “Health Information Management 2025: expansion of auditing and monitoring programs. Audit programs Current ‘Health IT Revolution’ Drastically Changes HIM will help identify points throughout the data collection process in the Near Future.” Journal of AHIMA 83, no. 8 (August that are at risk. HIM professionals can contribute positively to all 2012): 24-31. http://bok.ahima.org/doc?oid=106207. these efforts through their understanding of the processes underlying the clinical and financial data streams that comprise the References EHR. Many HIM professionals will continue to find a natural mi- Davoudi, Sion et al. “Data Quality Management Model gration to leadership roles in technology departments or vendor (2015 Update).” Journal of AHIMA 86, no. 10 (October environments to share their knowledge from another perspective. 2015): expanded web version. http://bok.ahima.org/ HIM professionals have always worked to ensure data in the doc?oid=107773. health record meets quality standards for accuracy, timeliness, Williams, Adrian. “Design for Better Data: How Software and consistency, and completeness. The ability to use these skills Users Interact Onscreen Matters to Data Quality.” Journal of reinforces the importance of HIM engagement in auditing and AHIMA 77, no. 2 (February 2006): 56-60. http://bok.ahima. monitoring documentation practices contributing to critical org/doc?oid=62323. EHR design decisions, as well as discussions surrounding data collection, data management, and data analysis and reporting. Prepared By Information governance programs, along with HIM steward- Shamsi Berry, PhD, MS, CPHI ship, ensure the use and management of health information Angela Campbell, MSHI, RHIA is compliant with jurisdictional law, regulations, standards, Jill Flanigan, MLS, MS, RHIT and organizational policies. As stewards of health informa- Dawn Paulson, MJ, RHIA, CHPS, CPHI tion, HIM roles and functions strive to protect and ensure the Barbara Ryznar, RPh, MSHI, RHIA, CPHI, CPHIMS, CAPM ethical use of health information.8 The migration of healthcare Jami Woebkenberg, MHIM, RHIA, CPHI, FAHIMA records from paper to electronic puts HIM professionals in a unique position to lead efforts to evaluate and improve EHR Acknowledgments data, which will be central to the acceptance of the EHR and Melanie Endicott, MBA/HCM, RHIA, CDIP, CHDA, CPHI, the migration to a future state with new technologies and in- CCS, CCS-P, FAHIMA teroperability. Cheryl Ericson, MS, RN, CDIP, CCDS See the February 2019 Journal of AHIMA for part two of this Kristi Fahy, RHIA Practice Brief. ¢ Elisa Gorton, RHIA, CHPS, CHC Tammy Love, RHIA, CDIP, CCS Notes Ann Meehan, RHIA 1. James, John T. “A New, Evidence-based Estimate of Patient Mari Pire-St. Pierre, RHIA, CPHI Harms Associated with Hospital Care.” Journal of Patient Donna Rugg, RHIT, CDIP, CCS-P, CCS Safety 9, no. 3 (September 2013): 122-128. http://journals. Clarice Smith, RHIA, CHP lww.com/journalpatientsafety/Fulltext/2013/09000/A_ Anny Yuen, RHIA, CDIP, CCS, CCDS New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx. 2. Kohn, Linda T. et al. To Err Is Human: Building a Safer Additional Acknowledgments Health System. Committee on Quality of Health Care in Additional acknowledgments for individuals that have worked America, Institute of Medicine. National Academies Press, on previous versions of the information contained in this Prac- 2000. tice Brief are available in the online version of this Practice Brief 3. Orlova, Anna. “Overview of Health IT Standards.” Journal in AHIMA’s HIM Body of Knowledge. of AHIMA 86, no. 3 (March 2015): 38-40. http://bok.ahima. org/doc?oid=107579. 4. White, Susan. A Practical Approach to Analyzing Health- Read More care Data, Second Edition. Chicago, IL: AHIMA Press, Appendices Available Online 2013. http://bok.ahima.org 5. Empel, Sofia. “Way Forward: AHIMA Develops Information Two appendices are available in the online version of this Practice Brief Governance Principles to Lead Healthcare Toward Better in AHIMA’s HIM Body of Knowledge: Data Management.” Journal of AHIMA 85, no. 10 (October • Appendix A: EHR Integrity Checklist 2014): 30-32. http://bok.ahima.org/doc?oid=107468. • Appendix B: Case Scenarios 6. AHIMA. Pocket Glossary of Health Information Manage- ment and Technology, Fifth Edition. Chicago, IL: AHIMA Correction Press, 2017. The Practice Brief in the November-December 2018 Journal of AHIMA 7. Oachs, Pamela K. and Amy Watters. Health Information was published with the incorrect title. The correct title is “Redisclosure Management: Concepts, Principles, and Practice, Fifth Edi- of Protected Health Information (PHI).” The Journal regrets the error.

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Components of an Effective Outpatient Coding Compliance Policy Program By Daniel Land, RHIA, CCS; Julie Davis, CPC, COC, CRC, CPMA, CPCO, CDEO, CPC-I; Monica Watson, RHIA, CCS, CCS-P, CPC, CPMA, CIC, CRC, CDEO; Faith McNicholas, RHIT, CPC, CPCD, PCD, CDC; and Sue Bowman, MJ, RHIA, CCS, FAHIMA

EFFECTIVE CODING COMPLIANCE policies and programs HCPCS Coding Guidelines impact all areas of health information management (HIM). CPT Coding Manual Instructional Notes and Guidance Implementation of a compliance program can be a multi- CMS’ Medicare Physician Fee Schedule tiered process. Building on the Office of Inspector General’s National Correct Coding Initiative (NCCI) Edits (OIG) recommendation for a step-by-step approach for a com- NCCI Policy Manual for Medicare Services pliance program, this article details important considerations NCCI General Correspondence Language and Section- when developing and implementing a voluntary compliance Specific Examples (For NCCI Procedure to Procedure program in the outpatient setting.1 (PTP) Edits and Medically Unlikely Edits (MUE)) CMS’ Claims Processing Manual Chapter 12 (Professional 1. General Policy Statement Fee Coding) The first step should be a general policy statement about the CMS’ indices for National Coverage Determinations and commitment of the organization to correctly assign and report Local Coverage Determinations codes. The following is a sample policy statement: CMS’ Transmittals and MLN Matters articles “Memorial Medical Center is committed to ethical, accu- Erate, and consistent code reporting in accordance with all 3. Define Requirements for Coding Professionals regulatory requirements and the American Health Informa- It is incumbent upon the individual organization to define the tion Management Association’s Standards of Ethical Coding. requirements for all parties with responsibilities related to All reported codes will reflect actual services provided as code assignment, including: substantiated by consistent and complete provider medical Credential/certification requirements and maintenance record documentation.” Measurement of proficiency for a specific coding discipline(s) 2. Coding Tools and Resources Defined minimum years of experience with code assign- It is important for coding professionals to have access to the ment for a specific outpatient coding discipline(s) (facility following coding tools and resources: or professional fee coding) ICD-10-CM Official Guidelines for Coding and Reporting Minimum continuing education requirements American Hospital Association’s (AHA) Coding Clinic Identification of those parties who can perform code as- American Medical Association’s CPT Assistant signment, including but not limited to coding staff, auditors, CPT Coding Guidelines educators, clinical documentation improvement (CDI) pro- Centers for Medicare and Medicaid Services’ (CMS) fessionals, and managers responsible for decision-making

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processes and operations, as well as HIM/coding students 10. Identify Optional Codes Develop a procedure to identify optional codes gathered for 4. Querying for Proper Documentation statistical purposes by the facility—such as external causes of When the health record documentation used to assign codes morbidity codes and CPT Category II codes—and clarification is conflicting, imprecise, incomplete, illegible, ambiguous, of the appropriate use of activity codes. or inconsistent, providers must be queried for clarification and completion or amendment of the record where neces- 11. Escalation Policy sary. Adding documentation to a record must follow stan- Create a clearly defined escalation policy to follow when dard protocols in accordance with the applicable laws and there is a coding dispute between a coding professional and regulations. See the AHIMA Practice Brief “Guidelines for a physician. Achieving a Compliant Query Practice” for additional guidelines on appropriate query practices. Provider organizations 12. Review of Claim Denials must decide internally whether outpatient setting queries A review of claim denials will help an organization identify for ICD-10-CM clarification will be conducted. However, it is a significant risk area and improve its cash flow by submit- important to note that incomplete documentation results in ting correct claims that will be paid the first time they are a lack of specificity of code assignment for outpatient proce- submitted. Initial focus must be directed to those risk areas dural cases. that have been problematic for the practice such as coding and billing. 5. Designate Relevant Coding Guidelines Develop a procedure for processing claim rejections that Official coding guidelines for inpatient, outpatient, and phy- must be routed to a coding professional for clinical documen- sician reporting are different and should be clearly stated as tation and medical code selection review. For example, the such. For example, an organization that is developing facility- coder must review claims that are rejected due to invalid diag- specific coding guidelines for emergency department services nosis or procedure codes, determine and document the cause should designate that the coding rules or guidelines are appli- (such as failure to update the practice management system cable only to this specific setting. with the codes from the latest fiscal year), and ensure that appropriate action is taken. 6. Payer-Specific Reporting An effective outpatient coding compliance policy document 13. Clarifying Statement on Code Assignment and should address payer-specific reporting requirements. Reimbursement Include a statement clarifying that codes will not be assigned, 7. Inaccurate Code Corrections modified, or excluded solely for maximizing reimbursement The document should address procedures for correction of in- or circumventing payment reduction. accurate code assignments in the clinical database and agencies to which the codes have been reported. 14. Avoid Over-Reliance on Electronic Coding Tools Coding staff should not rely solely on the use of encoders 8. Audit Plan within the organization. Current coding manuals must be Each organization should have a defined audit plan to help en- readily accessible, and the staff must be educated appro- sure code accuracy and consistency over time. The audit plan priately to detect inappropriate logic or errors in encoding should include corrective action plans for areas of risk that software. When errors in logic or code crosswalks are dis- have been identified through audits or other forms of coding covered, they are reported to the vendor immediately by the quality monitoring. coding supervisor. Many clinical settings are implementing and utilizing 9. Process for Coding New Procedures, Unusual electronic coding tools to assist in gaining efficiency in the Diagnoses coding process. These tools should only be used in an as- Develop a process for coding new procedures or unusual di- sistive capacity and not as a replacement for the current agnoses. official coding manual. Electronic tools may have errors in Research the anatomy/physiology related to the new pro- mapping or the decision tree process, and they may even cedure or unusual diagnoses to enhance understanding have outdated information. prior to querying. Use the additional information to determine the most ap- 15. Require Full Encounter Documentation propriate diagnosis or procedure code. If a code still can- The coding compliance policy should require that the entire not be identified, documentation should be sent to the AHA for further clarification on the matter. Continued on page 47

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IPPS Final Rule Changes for Fiscal Year 2019 By Moira Hunger, RHIT

THOUGH HARD TO believe, a new fiscal year (FY) is already – 346, Minor small and large bowel procedures. well underway. The Centers for Medicare and Medicaid Ser- The second quarter 2017 issue ofCoding Clinic that set vices (CMS) released the final rule for the Hospital Inpatient guidance for spinal fusions and fixations created around Prospective Payment System (IPPS) on August 17, 2018. All 100 codes that were eventually considered clinically in- changes were effective with discharges beginning on October valid by CMS. As of October 1, 2018, these codes were de- 1, 2018 and will end with discharges on September 30, 2019. leted from ICD-10-PCS. Clocking in at almost 2,000 pages, the IPPS Final Rule was MS-DRG 685, Admit for renal dialysis, has been deleted a hefty read. All information on FY 2019’s IPPS Final Rule, in- completely. All associated codes are to be moved to MS- cluding tables, can (and should!) be accessed on the CMS web- DRGs 698 – 700, Other kidney and urinary tract diagnoses. site. The entire IPPS Final Rule with all of its charts and tables CMS and 3M tackled the messy and complicated assign- for FY 2019 can be found at www.cms.gov/Medicare/Medi- ment of codes to MDC 14, Pregnancy, Childbirth and the care-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019- Puerperium. The logic for the entire GROUPER in this cat- IPPS-Final-Rule-Home-Page.html. egory was rewritten so that it simplified and streamlined Please bear in mind that this article is by no means a com- the assignment of the proper MS-DRG to be in line with Tprehensive discussion of the changes enacted this year, but the existing tiered severity structure that we’re all famil- rather a short overview of some of the coding highlights. iar with in other parts of ICD-10-CM/PCS. In the end, this required deleting 10 existing MS-DRGs and establishing MS-DRG Changes 18 new MS-DRGs. As pointed out in the Federal Register entry, ICD-10-CM/PCS and CMS also removed dilation and curettage procedures MS-DRG are both imperfect systems and are constantly being from MDC 14 and directed them to the appropriate MS- monitored and revised. To that end, the IPPS Final Rule brought DRGs in MDC 13, Diseases and Disorders of the Female both MS-DRG and ICD-10-CM/PCS changes, including: Reproductive System. All pacemaker insertion procedures, even pacemakers Codes R65.10, Systemic inflammatory response syn- considered to be “leadless,” will be grouped together in drome (SIRS) of non-infective origin without acute organ MS-DRGs 260 – 262, Cardiac pacemaker revision except dysfunction and code R65.11, Systemic inflammatory re- device replacement. sponse syndrome (SIRS) of non-infective origin without Twelve procedure codes regarding repair and reposition acute organ dysfunction have been re-assigned from MS- of the intestines will be moved from MS-DRGs 329 – 331, DRG 870/871 to MS-DRG 864, which has been retitled to Major small and large bowel procedures, to MS-DRGs 344 read “Fever and Inflammatory Conditions.”

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The various changes for FY 2019 bring us to a total of 761 MS- cipal Diagnosis antepartum? Postpartum? Were there any DRGs in version 36. procedures done? New non-delivery MS-DRGs were consolidated into the following: GROUPER Logic in MDC 14 MS-DRG 817, Other Antepartum Diagnoses with O.R. Pro- The initial analysis of MDC 14, Pregnancy, Childbirth and cedure with MCC the Puerperium, revealed that the current structure of “de- MS-DRG 818 Other Antepartum Diagnoses with O.R. Pro- livery with complicating conditions” was not accurately re- cedure with CC flecting the intended MS-DRG structure of “tiers of severity,” MS-DRG 819, Other Antepartum Diagnoses with O.R. Pro- so CMS went back to the beginning and completely changed cedure without CC/MCC the GROUPER logic. The existing MDC was broken out into MS-DRG 831, Other Antepartum Diagnoses without O.R. “groups” of types of procedures—either delivery, abortion, Procedure with MCC or other. Antepartum diagnoses were separated and received MS-DRG 832, Other Antepartum Diagnoses without O.R. their own separate MS-DRGs. Those procedures that were Procedure with CC considered non-essential to a delivery were moved to other MS-DRG 833, Other Antepartum Diagnoses without O.R. MDC groups. This includes dilation or aspiration curettage Procedure without CC/MCC (including for retained placenta) and, more surprisingly, re- pairs of third- and fourth-degree vaginal lacerations. These Coding professionals are encouraged to read this section, include repair of anus, rectum, and the anal sphincter. CMS II.F.10, in the Federal Register entry for a more complete ex- argued that these specific procedures, as opposed to repair of planation and two excellent flowcharts illustrating the revised the perineum muscle, could be expected to require a separate GROUPER logic. operating room episode from the delivery. Once the definition of what does and does not constitute New Technology a “delivery” was established, the question of how to fit the Nine new items have been included as eligible for new tech- current model of tiers of severity had to be applied. What is nology add-on payments in FY 2019: the starting point? Once the GROUPER sees a Principal Di- VYXEOS™ agnosis from MDC 14, where does it go next? CMS settled on GIAPREZA™ asking the GROUPER if there is a delivery code. Yes? What VABOMERE™ kind? Is there a sterilization done during the encounter? Are ZEMDRI™/Plazomicin there other procedures done that do not fall into the MDC 14 Remede® System procedure list? Using this logic, the new delivery MS-DRGs AndexXa™ in MDC 14 are: Sentinel® Cerebral Protection System™ MS-DRG 783, Cesarean Section with Sterilization with MCC Aquabeam® MS-DRG 784, Cesarean Section with Sterilization with CC Kymriah®/Yescarta® MS-DRG 785, Cesarean Section with Sterilization without CC/MCC Defitelio®, ZINPLAVA™, and Stelara® remain eligible for new MS-DRG 786, Cesarean Section without Sterilization with technology add-on payments as well. MCC MS-DRG 787, Cesarean Section without Sterilization with Meaningful Measures CC CMS consolidated the number of measures hospitals are re- MS-DRG 788, Cesarean Section without Sterilization quired to report under the various quality and value-based without CC/MCC purchasing programs. All measures under the Inpatient MS-DRG 796, Vaginal Delivery with Sterilization with Quality Reporting (IQR), Readmissions Reduction, Hospi- MCC tal-Acquired Conditions (HAC), and Value-Based Purchas- MS-DRG 797, Vaginal Delivery with Sterilization with CC Continued on page 46 MS-DRG 798, Vaginal Delivery with Sterilization without CC/MCC MS-DRG 805, Vaginal Delivery without Sterilization with Journal of AHIMA Continuing Education Quiz MCC Quiz ID: Q1939001 | EXPIRATION DATE: JANUARY 1, 2020 MS-DRG 806, Vaginal Delivery without Sterilization with CC HIM Domain Area: Clinical Data Management Article—“IPPS Final Rule Changes for Fiscal Year 2019” MS-DRG 807, Vaginal Delivery without Sterilization without CC/MCC Review Quiz Questions and Take the Quiz Based on Non-delivery DRGs received similar logic if the GROUPER this Article Online at https://my.ahima.org/store “sees” an abortion principal diagnosis on the chart. Was there an operative procedure done? If so, the GROUPER as- Note: AHIMA CE quizzes have moved to an online-only format. signs the current MS-DRG of 770 or 779. No? Was the Prin-

Journal of AHIMA January 19 / 41

19_January.indd 41 12/14/18 2:58 PM Calendar

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18 19 Faculty AHIMA Development Foundation Webinar: Webinar: Preparing for Apprenticeships: Continuing An Effective Accreditation Workforce Site Visit Planning Model for Employers 20 21 22 23 24 25 26

27 28 29 30 31

AHIMA Annual Conference

2020 Atlanta, GA October 13-17

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PMS 7625 and black A Look Ahead Keep Informed Upcoming AHIMA Institutes, Seminars, Workshops, Resources and News from AHIMA and Webinars Recertification Policy, Education Domain FEBRUARY Changes Delayed 12 AHIMA Foundation Webinar: Apprenticeships: The recertification timeline cycle changes and new A Tool for Career Seekers CEU domains that were previously set to become effective on November 1, 2018 have been delayed. 13 Faculty Development Webinar: Teaching The Commission on Certification for Health Infor- Presence Online matics and Information Management (CCHIIM) 20 Revenue Cycle Trainer Virtual Workshop, Online seeks to ensure strategic alignment and an effec- 27 Revenue Cycle Trainer Virtual Workshop, Online tive, error-free implementation when these changes take place. The previously published information allowed for an individual to report in the CEU Center UPCOMING INSTITUTES, SEMINARS, (starting on November 1, 2018) using either the new domains or the existing domains until December 31, WORKSHOPS, AND WEBINARS 2019. The revised plan will be to use only the new March 6 Revenue Cycle Trainer Virtual Workshop, Online domains starting on January 1, 2020. March 12 AHIMA Foundation Webinar: Apprenticeships: An After further discussion, CCHIIM has decided to Effective Workforce Planning Model for Employers re-evaluate the proposed revisions that were previously announced about the recertification timeline March 13 Revenue Cycle Trainer Virtual Workshop, Online (changes related to the grace period and revocation March 19 Faculty Development Webinar: Tips for Developing period). At this time, it is undetermined whether any Community Partnerships with Industry revisions will be made. Additional communication will be distributed throughout the year leading up to March 20 Revenue Cycle Trainer Virtual Workshop, Online the January 1, 2020 implementation date. March 27 Revenue Cycle Trainer Virtual Workshop, Online April 9 AHIMA Foundation Webinar: Apprenticeships: An Developing a Team You Can Trust Effective Workforce Planning Model for Employers AHIMA’s Train the Trainer program is designed to April 15–16 CAHIIM Accreditation Conference, Chicago, IL transform distinguished health information management professionals into skilled trainers. This Febru- April 16 Faculty Development Webinar: CourseShare and ary, qualified candidates can participate in an ex- Educator Resources tensive eight-week training program that prepares May 14 AHIMA Foundation Webinar: Apprenticeships: A advanced-level revenue cycle professionals to train Tool for Career Seekers their team in industry best practices using a gold- June 11 AHIMA Foundation Webinar: Apprenticeships: An standard AHIMA curriculum. The program starts Effective Workforce Planning Model for Employers February 20. Learn more at www.ahima.org. July 9 AHIMA Foundation Webinar: Apprenticeships: An Effective Workforce Planning Model for Employers AHIMA Welcomes New and Returning Signature Partners July 12-13 CSA Leadership Symposium, Chicago, IL AHIMA is pleased to announce July 27-31 Assembly on Education/Faculty Development GeBBS as a continuing Signature Institute, Atlanta, GA Cornerstone Partner and August 13 AHIMA Foundation Webinar: Apprenticeships: A University of Cincinnati HIM Online Tool for Career Seekers as a new Signature Luminary Partner. AHIMA thanks GeBBS September AHIMA Foundation Webinar: Apprenticeships: An and the University of Cincinnati 10 Effective Workforce Planning Model for Employers HIM Online for their commitment to the association and the HIM profession. The Check www.ahima.org/events for the latest schedule of Signature Partner Program is dedicated to partnering institutes, seminars, and workshops. with industry sponsors for the advancement of HIM. As the role of HIM in the transformation of healthcare delivery continues to expand, industry professionals look to leaders, such as AHIMA’s Signature Partners, for resources to help them increase their effectiveness and efficiency every step of the way.

19_January.indd 43 12/14/18 2:58 PM AHIMA Volunteer Leaders

AHIMA BOARD OF DIRECTORS President/Chair CEO, AHIMA TERM ENDS 2020—DIRECTORS Jennifer Mueller, MBA, RHIA, FACHE, FAHIMA Valerie J. Watzlaf, PhD, MPH, RHIA, FAHIMA Wylecia Wiggs Harris, PhD, CAE Treasurer Vice President and Privacy Officer Vice Department Chair of Education and Chicago, IL Seth Jeremy Katz, MPH, RHIA, FAHIMA Wisconsin Hospital Association – Information Associate Professor (312) 233-1092 Associate Chief Information Officer Center University of Pittsburgh [email protected] Truman Medical Center Fitchburg, WI Pittsburgh, PA (913) 526-4987 (920) 285-9232 (412) 383-6647 TERM ENDS 2019—DIRECTORS [email protected] [email protected] [email protected] Jill S. Clark, MBA, RHIA, CHDA, FAHIMA Director of Coding Services and Senior Secretary Godwin I. Okafor, MSHI, RHIA, FAC-P/PM President/Chair-elect Consultant, e4 Kim D. Theodos, JD, MS, RHIA Program Manager Ginna Evans, MBA, RHIA, CPC, CRC, FAHIMA Red Lion, PA Assistant Professor US Department of Veterans Affairs Coding Educator, IM Specialties Division (610) 357-4582 University of Louisiana at Monroe (404) 822-1708 Emory Healthcare [email protected] (318) 245-1776 [email protected] Decatur, GA [email protected] (770) 845-5730 Dwan Thomas Flowers, MBA, RHIA, CCS, CDIP Board Advisor [email protected] HIM Consultant Melinda A. Wilkins, PhD, RHIA, FAHIMA John P. Hoyt, FACHE, FHIMSS (904) 607-6610 Professor and Program Director, Health Executive Vice President Emeritus Past President/Chair [email protected] Informatics and Health Information HIMSS Diann H. Smith, MS, RHIA, CHP, FAHIMA Management Chicago, IL Vice President Karen S. Scott, MEd, RHIA, CCS-P, FAHIMA Arkansas Tech University (312) 590-9019 Texas Health Resources Senior Training Specialist/Owner (479) 970-1434 [email protected] Arlington, TX TruCode/Karen Scott Seminars and Consulting [email protected] (682) 236-7803 Bartlett, TN [email protected] (901) 233-7245 TERM ENDS 2021—DIRECTORS [email protected] Sharon Easterling, MHA, RHIA, CCS, CDIP, CRC, Speaker of the House of Delegates FAHIMA Shawn C. Wells, RHIT, CHDA President Director of Health Information DocBytes University of Utah Health Charlotte, NC Salt Lake City, UT (704) 779-8095 (801) 503-5596 [email protected] [email protected]

2019 CHAIRS OF AHIMA VOLUNTEER GROUPS Advocacy and Policy Council Annual Convention Program Committee Engage Advisory Committee Privacy and Security Program Committee Seth Johnson, MBA, RHIA Sandra Joe, MJ, RHIA, FAHIMA Yvette Humphries Beth A. Kost-Woodrow, RHIA [email protected] [email protected] [email protected] [email protected]

Daniel Utech, RHIA, CHPS CDI Summit Program Committee Fellowship Committee Tanya Srdanovic, MPA, RHIA, CHPS [email protected] Genee Askew Linda Galocy, MS, RHIA, FAHIMA [email protected] [email protected] [email protected] AHIMA Grace Award Committee Professional Ethics Committee Sandra Pearson, MHA, RHIA, CHDA, CPEHR Lisa Campbell, PhD, RHIA, CDIP, CCS, CCS-P New Graduate Leadership Committee Vong Miphouvieng, MHA, RHIA, CHPS [email protected] [email protected] Todd Norden, RHIA [email protected] [email protected] AHIMA Triumph Awards Committee Clinical Coding Program Committee Renae Spohn, MBA, RHIA, CPHI, CPHQ, FNAHQ, Megan DeVoe, CCS Nominating Committee FAHIMA [email protected] Ralph Morrison, RHIA, CPC [email protected] [email protected] Lance Smith, MPA, RHIT, CCS-P, CHC, COC, CPMA [email protected]

2019 CHAIRS OF AFFILIATE VOLUNTEER GROUPS AHIMA Foundation Commission on Accreditation for Commission on Certification for Health Council for Excellence in Education Diann H. Smith, MS, RHIA, FAHIMA Health Informatics and Information Informatics and Information Management Keith Olenik, MA, RHIA, CHP (682) 236-7803 Management Education Karen Collins Gibson, MSA, RHIA, FAHIMA (816) 392-5796 [email protected] Stuart M. Speedie, PhD, FACMI [email protected] [email protected] (651) 249-1350 [email protected]

2019–2020 HOUSE OF DELEGATES Speaker of the House of Delegates Speaker-elect of the House of Delegates Envisioning Collaborative House Leadership Shawn C. Wells, RHIT, CHDA Christine Williams, RHIA Aurae Beidler, MHA, RHIA, CHPS, CHC Becci Conroy, RHIA, CCS-P, OHCC Director of Health Information Health Information Management Document [email protected] [email protected] University of Utah Health Integrity Manager Salt Lake City, UT UW Health Shawn C. Wells, RHIT, CHDA Christine Williams, RHIA (801) 503-5596 Madison, WI Director of Health Information Health Information Management Document [email protected] [email protected] University of Utah Health Integrity Manager Salt Lake City, UT UW Health (801) 503-5596 Madison, WI [email protected] [email protected]

2019 PRACTICE COUNCIL AND TASK FORCE VOLUNTEER CONTACTS Clinical Documentation Improvement Clinical Terminology and Classification Privacy and Security Chinedum Mogbo, RHIA, CDIP, CCS, CCDS Faith McNicholas, RHIT, CPC, CPCD, PCS, CDC Dana DeMasters, MN, RN, CHPS [email protected] [email protected] [email protected]

44 / Journal of AHIMA January 19

19_January.indd 44 12/14/18 2:58 PM AHIMA Volunteer Leaders

COMPONENT STATE ASSOCIATION PRESIDENTS Alabama Iowa New Jersey Utah Lakesha Kinnerson, MPH, RHIA, CPHQ Jacinda Barth, RHIT Fran DiLorenzo, RHIA Carolyn Russell, RHIA [email protected] [email protected] [email protected] [email protected]

Alaska Kansas New Mexico Vermont Kara Anderson, CCS-P, B.Ed, CPC, CPC-I Richard Ryan, MHS/HCEd, RHIT Erica Lopez, RHIA Sarah Donaldson, MS, CCS-P [email protected] [email protected] [email protected] [email protected]

Arizona Kentucky New York Virginia Lisa Hart, MPA, RHIA Dustin Ginn, MA, MHA, RHIA Jeffery Youngs, RHIT Kathleen Scott, RHIA [email protected] [email protected] [email protected] [email protected]

Arkansas Louisiana North Carolina Washington Sara Daniel, RHIA, CHES Kristy Courville, MHA, RHIA Mary Gregory, RHIT, CDIP, CCS, CCS-P, CPC Paula Dascher, RHIA [email protected] [email protected] [email protected] [email protected]

California Maine North Dakota West Virginia Maria Caban Alizondo, MOL, RHIT, FAHIMA Sheri Conley, RHIT, CPC Laurie Peters, RHIA, CCS Vickie Findley, MPA, RHIA [email protected] [email protected] [email protected] [email protected]

Colorado Maryland Ohio Wisconsin Shandra Duncan, RHIT, CHTS-T To be determined Krystal Phillips, RHIA, CHTS-IS Elizabeth Rockendorf, RHIA, CHPS, CHTS-IM [email protected] [email protected] [email protected]

Connecticut Massachusetts Oklahoma Wyoming James Donaher, RHIA, CDIP, CCS, CCS-P Bibi Von Malder, RHIT Tressa Lyon, RHIT Sarah Reynolds, CCS [email protected] [email protected] [email protected] [email protected]

Delaware Michigan Oregon Kimberly Seery, RHIT, CHDA, CDIP, CCS, CPC, CRC Shawn Armbruster, RHIA Crystal Clack, MA, RHIA, CDIP, CCS [email protected] [email protected] [email protected]

District of Columbia Minnesota Pennsylvania Toni Jackman, MS-HIS, MTM, RHIA Ryan Johns, RHIA, CHPS Margaret Stackhouse, BSB/IS, RHIA, CPC [email protected] [email protected] [email protected]

Florida Mississippi Puerto Rico Rae Freeman, RHIA, CHPS, CDIP, CCS-P Lorie Mills, RHIT, CCS Amarylis Del Hoyo, RHIA [email protected] [email protected] [email protected]

Georgia Missouri Rhode Island Karen Searcy, RHIA, CPC Brenda Fuller, RHIA, CHC Patti Nenna, RHIT, CPEHR [email protected] [email protected] [email protected]

Hawaii Montana South Carolina Lari Anne Kamei, MBA, RHIA Rebecca Conroy, RHIA, CCS-P, OHCC Teresa Huss, MHS, RHIA, CPC-H [email protected] [email protected] [email protected]

Idaho Nebraska South Dakota Jamie Sand, EdD, RHIT, CCS Tina Mazuch, MS, RHIA, CCS Jamie Husher, MS, RHIA, CHPS [email protected] [email protected] [email protected]

Illinois Nevada Tennessee Tricia Truscott, MBA, RHIA, CHP, FAHIMA Zheila Smith, CDIP, CCS Shannan Swafford, DHA, RHIT, CHDA, CCS [email protected] [email protected] [email protected]

Indiana New Hampshire Texas Lynette Thom, RHIA, CDIP, CCS Pamela Varhol, MS, MBA, RHIA, CAHIMS Penny Crow, MS, RHIA [email protected] [email protected] [email protected]

Email changes to your listing to [email protected]

Journal of AHIMA January 19 / 45

19_January.indd 45 12/14/18 2:58 PM AHIMA Thanks Its Loyalty Program Members Advertising Index The AHIMA Loyalty Program offers organizations the opportunity to better align their marketing outreach with AHIMA’s print, AHIMA...... 10, 23, inside back cover content, and information channels while delivering year-long exposure to AHIMA’s 103,000+ health information professionals. HCPro, an H3.Group brand...... inside front cover To learn more about the AHIMA Loyalty Media Program and position your organization for success, contact: Healthcare Cost Solutions...... 15 Jeff Rhodes, 410-584-1940, [email protected] or Allison Zippert, 410-584-1941, [email protected] Medical University of South Carolina...... 17 Mitchell Hamline School of Law...... 27 EXECUTIVE LEVEL MRO...... back cover

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Continued from page 41 (“IPPS Final Rule Changes for Fiscal MANAGER LEVEL Year 2019”) ing (VBP) programs were evaluated for administrative burden, outcome improvement, and duplication within the four programs. This review led to the removal of 18 measures; 21 measures that were in multiple programs have been consolidated to one program, which is being referred to as “de- duplication.” Healthcare-associated infection measures will still be removed from the IQR, but that has been delayed until December 31, 2019.

Post-acute Care Transfer and Special Payment Policy Discharges to hospice care were included in the list of post- acute care transfer payment adjustments. No new MS-DRGs were added to the post-acute care transfer policy, but two MS- DRGs have been added to the special payment policy list: MS- DRG 023 and MS-DRG 024. ¢

Reference Department of Health and Human Services. “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims.” Federal Register 83, no. 160 (August 17, 2018). www.gpo.gov/fdsys/pkg/FR-2018-08-17/ pdf/2018-16766.pdf.

Moira Hunger ([email protected]) is a certified coder/ DRG analyst at Community Hospital Anderson.

46 / Journal of AHIMA January 19

19_January.indd 46 12/14/18 2:58 PM Continued from page 39 (“Components of an Effective Out- ance program in the inpatient setting. ¢ patient Coding Compliance Policy Program”) encounter or episode of care be reviewed to ensure that the Note key elements of medical record documentation are present 1. Department of Health and Human Services. “Publication and then assign appropriate diagnoses, procedures, and mod- of the OIG Compliance Program Guidance for Hospitals.” ifiers. It is not appropriate to focus on one part of the medical Federal Register 63, no. 35 (February 23, 1998). https://oig. record, such as the final assessment, without ensuring that the hhs.gov/authorities/docs/cpghosp.pdf. full medical record has been finalized. Outpatient care settings should consider clinical documen- References tation areas as part of the outpatient coding compliance poli- AHIMA. “Guidelines for Achieving a Compliant Query cy, including: Practice (2016 Update).” January 2016. http://bok.ahima. Authentication of physician orders for services ordered org/PB/QueryCompliance. Clinician visit/encounter notes AHIMA House of Delegates. “American Health Information Documentation for why the service was ordered Management Association Standards of Ethical Coding Presence of test results, therapies and medications, etc. (2016 version).” December 2016. http://bok.ahima.org/ CodingStandards. Effective Coding Compliance Program Offers Benefits AHIMA House of Delegates. “Ethical Standards for Clinical Benefits of an effective coding compliance program include Documentation Improvement (CDI) Professionals the establishment of processes to meet regulatory require- (2016).” Approved June 2016. http://bok.ahima.org/ ments, submission of accurate claims for appropriate re- doc?oid=301868. imbursement and correction of reimbursement errors, and improved coding quality. Improved operational efficiencies Daniel Land ([email protected]) is director of revenue integrity and more reliable data for reporting and research will also and compliance review services at MedPartners. Julie Davis (julie@r-da- flow from a compliance program. The most successful coding vis.com) is a Medicare consultant at Optum. Monica Watson (monica. compliance programs are comprised of clear, sound guide- [email protected]) is director of coding services at Centauri lines and procedures with good mechanisms to detect, cor- Health Solutions. Faith McNicholas ([email protected]) is man- rect, and prevent coding errors. It’s an evolving process that ager, coding and reimbursement, practice management at the American needs to be continually reviewed and enhanced. Academy of Dermatology. Sue Bowman ([email protected]) is An upcoming article in the July 2019 issue of the Journal of senior director, coding policy and compliance, HIM practice excellence AHIMA will discuss considerations for an effective compli- at AHIMA.

Continued from page 31 (“In Pursuit of Comparable Coding ticle observe “…this evolution produced numerous defini- Audit Benchmarks”) tions, whose common theme is continuous measurement of weighting used in the equation. one’s own performance and comparison with best-perform- ers to learn about the latest work methods and practices in Recommendations for Setting Benchmarks other organizations.”3 HIM professionals should continue When determining the methods for calculating coding accu- to pursue useful coding accuracy measurements internally racy and analyzing and interpreting benchmarks, HIM profes- but also seek and voluntarily contribute to external bench- sionals should be mindful of the following: mark data for continuous improvement in the medical cod- Collect data at a detailed level for each audit element to ing function. ¢ ensure source data is sufficient to calculate the results in multiple ways Notes Clearly define the numerator and denominator for an ac- 1. Chapman, Susan. “Best Practices in Coding Audits.” For curacy rate and collect data consistently the Record 30, no. 1 (January 2018): 10. Use weighted and/or non-weighted methods intentionally 2. Humbert, Sarah. “How to Choose the Right Coding Au- and consistently dit Method.” Journal of AHIMA 89, no. 3 (March 2018): Interpret accuracy results within context, considering 18-19. how the rate was calculated 3. Ettorchi-Tardy Amina, Marie Levif, and Philippe Mi- Voluntarily collaborate with other healthcare systems to chel. “Benchmarking: A Method for Continuous Quality advance development of external benchmarks Improvement in Health.” Healthcare Policy 7, no. 4 (May 2012): 101-119. A literature review of benchmarking in healthcare highlights how benchmarking approaches have evolved in the Mary H. Stanfill [email protected]( ) is vice president of consul- healthcare industry. The authors of a Healthcare Policy ar- tant services at United Audit Systems, Inc.

Journal of AHIMA January 19 / 47

19_January.indd 47 12/14/18 2:58 PM Spring Forward, Fall Back… Over a Record Keeping Cliff

MOST HOSPITALS WEATHERED THE DREADED Y2K glitch with nary a problem, but nearly 20 years later, for even the largest electronic health record (EHR) vendors, turning the clock back for daylight saving time is a bridge too far. “It’s an hour where you’re sort of flying blind,” said Mark Friedberg, MD, a senior physician policy researcher at the Rand Corp. in a Kaiser Health News article, regarding the hour that some hospitals revert to paper records or shut down their EHR system when clocks change for daylight saving time. Some hospitals keep their systems running but re-enter information that might have disappeared during the time change. The issue goes beyond just being annoying for clinicians, turning systems off for an hour can delay wait times in emergency departments and delay the entry of key information such as vital signs. But while some advocate for updating their EHRs to work around the glitch, it’s simply not financially possible for some providers who are often locked into contracts, according to Kaiser Health News. Others agree that while the issue is perplexing, there are other problems physicians would like to see fixed first. One possible non-tech answer may be for more states to choose what California voters have done: drop daylight saving time altogether. In November, voters in that state elected to drop the “spring forward, fall back” song and dance, joining other states such as Arizona that has chosen to do the same. Although voters made this decision in the voting booth, the proposal still faces votes by both houses of the California Assembly. Still, as Friedberg told Kaiser, “I shudder to think … what does it [the EHR] do with leap years?” ¢

48 / Journal of AHIMA January 19

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