With clinical documentation integrity (CDI) professionals playing a key role in efforts to “flatten the curve” of the COVID-19 pandemic, the American Health Information Management Association (AHIMA) has developed tools designed to ease administrative burdens during this difficult time.
AHIMA’s two new COVID-19 CDI query templates will help CDI professionals ensure the integrity and quality of a patient’s health record. With data being such an important element in the fight against COVID-19, the new templates provide a clear guideline of what critical data needs to be obtained to accurately document for the virus. The templates are similar to those CDI professionals use to document other diseases.
“I feel immense pride when I see the important work CDI professionals are doing during this pandemic,” said Wylecia Wiggs Harris, PhD, CAE, AHIMA CEO. “We believe these clear, concise, and compliant templates will make it easier for CDI professionals to document this virus, which in turn gives courageous medical providers more time to focus on patient care.”
The new templates are designed to capture high-quality documentation to support the continuum of care in this complicated healthcare environment. Clinical documentation integrity is critical during the pandemic because it can impact research efforts to curb COVID-19 and provides government and healthcare leaders with key information for their decision-making processes.
Despite gains in medical technology and the use of electronic health records (EHRs), medical errors related to patient identification continue to pose significant, and in some cases, fatal risks for patients across the U.S.
Medical errors are the third-highest cause of death in the U.S., with 250,000 deaths per year, according to a Johns Hopkins University report.
Mismatched patient records and duplicate patient records are the two biggest forms of error that can lead to misidentification, according to a study by the Pew Charitable Trusts and Massachusetts eHealth Collaborative. Misidentification may result in the wrong surgery or medication, duplicate or unnecessary testing, unintended surgery, inaccurate prescriptions, and higher medical costs. The study also found medical errors occur more frequently within urban health systems where patients are more likely to be seen at more than one medical facility.
The Pew study cited patient misidentification as a nationwide crisis, with matching rates as low as 50 percent in some healthcare facilities.
We must do better.
The collective outcry of our patient population demands we do more. Our patients deserve more. As CEO of the American Health Information Management Association (AHIMA), and with the full support from our Board of Directors, I will continue to advocate for the adoption of a nationwide patient identification solution that addresses the need to accurately identify patients as they move through our healthcare systems.
We are not there yet, but help is on the way.
In June of last year, the U.S. House of Representatives passed an amendment to the Labor-HSS Appropriations bill that removed a ban prohibiting federal dollars from being used to adopt a national patient identifier. In December 2019, when Congress passed the 2020 spending package, language was included to address patient safety, and efforts in furtherance of a nationwide patient identification strategy:
Patient matching: The general provision limiting funds for actions related to promulgation or adoption of a standard providing for the assignment of a unique health identifier does not prohibit efforts to address the growing problems faced by health systems with patient matching. The agreement encourages HHS to continue to provide technical assistance to private-sector-led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information.
At the AHIMA19: Health Data and Information Conference, leaders in health information management (HIM) shared innovations in healthcare and addressed issues affecting patient access to their health records including the privacy, accuracy and interoperability of that information.
The annual meeting for the American Health Information Management Association (AHIMA), AHIMA19, also highlighted inspiring stories of perseverance, empowerment and shared details of AHIMA’s global leadership.
Patient advocate Doug Lindsay shared his gripping story of transitioning from a wheelchair to walking again; Alexandra Mugge, deputy chief health informatics officer at the Centers for Medicare & Medicaid Services (CMS), outlined the benefits of interoperability and patient access; healthcare innovators pitched their ideas to a panel of experts for a $5,000 prize; and exhibitors and industry speakers shared their spectrum of knowledge with attendees gathered from across the globe.
Nearly three thousand HIM professionals gathered for the annual conference in September, held at Chicago’s historic McCormick Place, the largest convention center in North America.
Information and Inspiration
Speakers addressed clinical documentation, data ownership, patient access to their medical records, interoperability and cybersecurity. These presentations provided important insights and updates on technology to help HIM professionals continue leading the industry in improving healthcare and changing lives.
Mugge told the crowd that interoperability and greater access to medical data is integral to improving healthcare outcomes for payers, patients, and providers.
“We believe electronic data exchange is the future of healthcare, and interoperability is the foundation of value-based care,” Mugge said. “Patients should know that the way they interact with the healthcare industry is changing. Patients are no longer passive participants in their care, they now have the ability to be empowered consumers of the healthcare industry through access to data that puts them in the driver’s seat to make the best and most informed decision about their health.”
Mugge assured attendees that privacy and security safeguards would remain in place as HIM professionals help shape the landscape of interoperability.
Lindsay found his own way to improve his health, seemingly against all odds. He was bedridden and home-bound for 11 years because of a debilitating illness that forced him to drop out of college at 21 years old.
Although Lindsay’s body was limited, his mind was strong and he was determined to walk again, and to live again.
That determination led Lindsay to create a surgery for what he learned was bilateral adrenal medullary hyperplasia. He then assembled a team of experts to perform the surgery, which eventually led to his recovery.
The American Health Information Management Association (AHIMA) sent a joint letter to Congressional leaders today voicing concerns that certain provisions of the Office of the National Coordinator for Health Information Technology’s (ONC’s) recent 21st Century Cures Act (Cures) proposed rule on information blocking jeopardizes goals to foster a healthcare system that is interoperable, patient-engaged and reduces burdens for those delivering care.
The letter, co-signed by seven organizations representing the nation’s clinicians, hospitals, health systems and experts in health informatics and health information management, outlines several recommendations aimed at furthering the objectives of Cures, while ensuring that the final regulations do not unreasonably increase provider burden or hinder patient care.
“We support the intent of the Cures Act to eradicate practices that unreasonably limit the access, exchange and use of electronic health information for authorized and permitted purposes that have frustrated care coordination and improvements in healthcare quality and efficiency,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “However, in light of the lessons learned from the meaningful use program, we believe it is crucial that we get this right. We look forward to discussing the details of these recommendations with congressional staff and ONC.”
Recommendations outlined in the letter include:
Additional rulemaking prior to finalization: ONC should seek further input from impacted stakeholders on issues including modifying the information blocking proposal to ensure that the requirements and exceptions are well-defined and understandable, and clinicians, hospitals and health information professionals are not inappropriately penalized if they are unable to provide a patient’s entire electronic health information through an application programming interface (API).
Enhanced privacy and security: The proposed rule does not sufficiently address Cures’ directives to protect patient data privacy and ensure health IT security. It is imperative that the Committee continues its oversight of privacy and security issues that fall outside of the Health Insurance Portability and Accountability Act (HIPAA) regulatory framework. This includes ensuring certified APIs include mechanisms to strengthen patients’ control over their data—including privacy notices, transparency statements and adherence to industry-recognized best practices.
Appropriate implementation timelines: ONC should establish reasonable timelines for any required use of certified health IT (CEHRT). Providers must be given sufficient time to deploy and test these systems, which must take into account competing regulatory mandates.
Revised enforcement: The U.S. Department of Health and Human Services should use discretion in its initial enforcement of the data blocking provisions of the regulation, prioritizing education and corrective action plans over monetary penalties.
For additional information on these recommendations, click here.
Signatories of the letter include:
American Health Information Management Association (AHIMA)
American Medical Association (AMA)
American Medical Informatics Association (AMIA)
College of Healthcare Information Management Executives (CHIME)
Federation of American Hospitals (FAH)
Medical Group Management Association (MGMA)
Five startups in the health information management (HIM) field pitched their ideas for a new product, service or business that harnesses health data and information to advance healthcare at the AHIMA19: Health Data and Information Conference. The winner, Drugviu, presented their population health platform that empowers communities of color to use their data to improve health outcomes.
The American Health Information Management Association’s (AHIMA) Pitch Competition, hosted in collaboration with MATTER, the health technology incubator based in Chicago, underscored the conference’s focus on innovation and change. The event served as an opportunity to inspire creative thinking at AHIMA19 and provide startups with a platform to present their health data and information solutions to a group of leading HIM experts.
Only six percent of clinical trials and research involves minorities. Drugviu, which received $5,000 for winning the competition, aims to end this under representation and improve health outcomes among minority communities by sourcing more minorities into clinical trials, providing education tailored to people of color and empowering people to share their medication experiences with their online community engagement platform.
“This award money will allow us to pursue our mission of expanding the data set of medication and health experiences to include minorities,” said Drugviu CEO Kwaku Owusu.
“Innovations that help connect people, health systems and ideas are key to improving health outcomes,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “With the inaugural AHIMA pitch competition, we’re putting the power to impact health in the hands of enterprising HIM professionals who are developing solutions to advance the healthcare industry. We congratulate Drugviu on their impressive platform to engage more minorities in clinical trials and research.”
Valhalla Healthcare received second place, winning $2,500 for its product Allevia, a fully patient-driven, AI-powered intake solution that automates clinical documentation for healthcare providers. Uppstroms received third place and $1,500 for their machine-learning application that addresses upstream social risk for promoting better health.
Additional semi-finalists included:
Smarter Health: A digital health startup aimed at transforming the way people collaborate to improve value-based healthcare
Tapcloud: A remote patient monitoring and engagement platform that helps patients and their clinicians achieve better health outcomes
“The best solutions to improve the healthcare experience are developed through collaboration between entrepreneurs and industry leaders,” said MATTER CEO Steven Collens. “Winning this competition is a great recognition for Drugviu and gives them the opportunity to work closely with leading health information professionals to further develop their solution.”
The American Health Information Management Association (AHIMA) recognized recipients of the 2019 AHIMA Triumph Awards at the Appreciation Celebration at Chicago’s Navy Pier during the AHIMA19: Health Data and Information Conference. This honor is presented to members who have demonstrated excellence in their dedication and service to the health information management profession.
“The AHIMA Triumph Awards recognize the contributions of health information management (HIM) leaders who have enriched the field by preparing future HIM professionals, encouraging fresh HIM talent and leadership and contributing to our knowledge base,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “We are pleased to honor the following individuals with these awards.”
Distinguished Member Award
Cassi L. Birnbaum, MS, RHIA, CPHQ, FAHIMA, was named Distinguished Member, AHIMA’s highest honor. Birnbaum has been a dedicated volunteer for more than 30 years and has served as a past Board president/chair of AHIMA and as an AHIMA director. She led and guided the industry and profession through a successful transition to ICD-10, information governance, analytics, informatics and CDI strategies. She is currently employed by the University of California San Diego (UCSD) Health System as system-wide director of HIM/revenue integrity, as well as adjunct faculty member for San Diego Mesa College and UCSD Extension academic programs.
AHIMA is proud to have selected the Ohio Health Information Management Association (OHIMA) as the recipient of the 2019 AHIMA Advocacy Triumph Award. OHIMA advocated for the HIM profession by creating a short, animated video showcasing the diverse job settings, skills and functions that make up the HIM profession to aid potential students, human resource departments and the general HIM profession in understanding the field. Kristin M. Nelson, MS, RHIA; Lauren W. Manson, RHIA; and the OHIMA Board are credited with leading this strategic advocacy project.
Marquetta M. Massey, MBA, RHIA, was honored with the Educator Award. Massey has been an instructor at Central Piedmont Community College (CPCC) in Charlotte, N.C. since 2012 and a program chair since 2015. In 2018, she received a CPCC award for “Best Instructional Video” based on her use of creative teaching tools and methods used in her online courses. Massey is recognized for her “student-first” stance and persistent and widespread use of technology to enhance her students’ learning experience. As a mentor and active member, Massey encourages students to become involved with AHIMA and their local state association.
Emerging Leader Award
Kenneth H. Lugo-Morales, MS, RHIA, received the Emerging Leader Award. Lugo-Morales directs the Health Information Management Department at the San Jorge Children and Women’s Hospital in San Juan, Puerto Rico, where he has successfully implemented a committee resulting in greater chargemaster accuracy and improved documentation and coding outcomes. He is a former president of the Puerto Rico Health Information Management Association (PRHIMA) and is a CSA Delegate to the AHIMA House of Delegates.
Patricia S. Coffey, RHIA, CPHIMS, CPHI, was honored with the Innovation Award. She is currently employed by the National Institutes of Health (NIH) as chief of the HIM department in the Clinical Center. Coffey helped influence NIH gender identity efforts, cutting-edge patient engagement and efforts to facilitate the collection and management of critical research data while ensuring the integrity of clinical data and patient information. Before transitioning to electronic medical records was a national initiative, she positioned the HIM department at NIH to transition to a completely paperless medical record.
Chrisann K. Lemery, MSE, RHIA, CHPS, FAHIMA, received the Leadership Award. She has served in various leadership capacities including president, past president and board member of the Wisconsin Health Information Management Association (WHIMA) and secretary of the AHIMA Board of Directors and Speaker of the House of Delegates. Lemery served on the award-winning HIPAA Collaborative of Wisconsin (HIPAA COW) Board of Directors as well as government-appointed committees addressing electronic health records and medical record copy fees. She has given more than 70 presentations sharing her knowledge.
Tressa A. Lyon, RHIT, received the Mentor Award. Lyon is currently the HIM manager at Norman Regional Hospital in Norman, Okla., and a member of the executive board for the Oklahoma Health Information Management Association (OkHIMA). She has been involved with professional committees and projects including the Medical Decision-Making Committee, the Patient Portal Committee and the Outcomes and Efficiencies Team. Lyon serves as a mentor for many colleges and universities in Oklahoma and through OkHIMA.
Rising Star Award
Laura A. Shue, MPA, CHDA, CPHIMS, was awarded the Rising Star Award. Shue received a master’s in public administration with a concentration in healthcare administration from Eastern Michigan University. She earned her CHDA in 2012 and CPHIMS in 2016. Shue currently serves as the HIM operations director for Michigan Medicine where she has engaged in wide-scale efforts to reduce medical record delinquencies and improve EHR functionality, and has advocated for quality, data management, data analytics and management development. She is currently president-elect of the Michigan Health Information Management Association (MHIMA).
Access to data and the interoperability of health information has the power to change the face of healthcare, according to Alexandra Mugge, deputy chief health informatics officer at the Centers for Medicare & Medicaid Services (CMS).
Addressing leaders in health information management (HIM) at the AHIMA19: Health Data and Information Conference, the American Health Information Management Association’s (AHIMA) annual conference, Mugge outlined CMS’ Interoperability and Patient Access Initiative efforts and what the agency will focus on next.
“We believe electronic data exchange is the future of healthcare, and interoperability is the foundation of value-based care,” Mugge said. “CMS is dedicated to advancing interoperability throughout healthcare.”
Emphasizing that the privacy and security of health records underpins all CMS activity on interoperability, Mugge pointed to several initiatives in 2019 aimed at improving data exchange among providers, payers and patients, including:
The CMS interoperability and patient access proposed rule addressing new policies to expand the exchange of information across all aspects of healthcare
The Office of the National Coordinator for Health Information Technology (ONC) 21st Century Cures Act proposed rule
The Blue Button 2.0 initiative, an application programming interface (API) containing four years of Medicare Part A, B and D data for 53 million Medicare beneficiaries that allows patient access to their health information.
Looking ahead to 2020, Mugge said CMS will focus on addressing challenges to patient matching, updating provider directories, expanding data elements to be standardized and incorporating behavioral and public health social determinants in healthcare.
HIM professionals are essential to ensuring access to health information where and when it is needed, Mugge said, adding that HIM professionals are responsible for shaping the data that ultimately comes together as a part of a patient’s complete healthcare picture.
“CMS is a valued contributor to our ongoing support of interoperability and its benefits to patients, providers and payers,” said Wylecia Wiggs Harris, AHIMA CEO, PhD, CAE. “AHIMA stands in alignment with the goals of interoperability in helping people to live healthier lives and creating access to health information that empowers people to impact health.”
The digitization and expansion of access to data and health information will continue to change healthcare, making this an exciting time in the industry, Mugge added.
“Patients are no longer passive participants in their care, they now have the ability to be empowered consumers of the healthcare industry through access to data that puts them in the driver’s seat to make the best and most informed decisions about their health,” Mugge said. “And providers who have historically been forced to work with incomplete information can now unlock large amounts of data about their patients that will improve care.”
This new technology is being added as an online component to AHIMA’s most popular textbook Health Information Management Technology: An Applied Approach, Sixth Edition and was announced during AHIMA’s 2019 Assembly on Education Symposium/Faculty Development Institute (AOE/FDI). AOE/FDI is the premier conference for health information and informatics educators and the primary forum for leadership in HIM education.
“We are thrilled to add this advanced tool to our flagship textbook which will provide personalized learning experiences to HIM students,” said AHIMA CEO Wylecia Wiggs Harris. “As a leader in HIM, we take pride in delivering the best education possible to students entering the field who will play a crucial role in furthering the profession.”
The adaptive learning model uses artificial intelligence backed technology to provide a customized experience to each learner. It presents progressive content and allows students to receive follow-up in areas in which they need additional guidance. This approach is based on each learner’s individual needs to fill skill gaps and build greater competency, quickly, and effectively in key areas.
“We are very pleased to partner with AHIMA in offering personalized adaptive learning features in its flagship textbook. Adaptive learning meets learners where they are—helping them gain the knowledge and skills they need to practice with greater competence and confidence in their abilities.” said Ulrik Juul Christensen, M.D., Area9 Lyceum CEO.
The online adaptive learning online component will be available for purchase in March 2020. More information will be available soon on AHIMA’s website.
When hiring professionals for clinical documentation improvement (CDI) programs, managers seek candidates with a background in both clinical and health information management (HIM) knowledge—challenging a common perception that a clinical background alone is sufficient, according to a recent survey by the American Health Information Management Association (AHIMA).
Respondents also said that while registered nurse and certified coding specialist are the most frequently required credentials, one of the highest preferred is AHIMA’s certified documentation improvement practitioner (CDIP) credential, indicating a growing understanding of the value and need for a higher level of educational certification, according to the research.
The article, “The State of CDI,” in the April issue of the Journal of AHIMA, analyzes key takeaways from the AHIMA survey conducted by the AHIMA Clinical Documentation Improvement Practice Council and performed to identify the current landscape and practices in the CDI industry.
The survey examined the type of organizations where CDI employees work, the departments under which teams are managed, professional backgrounds and the common credentials of CDI professionals.
Results found that most CDI programs fall under the HIM department. More than half of survey respondents also stated they hire HIM and certified coding professionals for positions in their CDI programs.
“The advancement of CDI programs and practices is essential to the delivery of quality patient care,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “The survey results show that not only do managers in these programs understand CDI professionals must have both a coding and clinical background, but that it’s becoming increasingly important for these professionals to have advanced credentials. With their knowledge and experience, HIM professionals are well positioned to lead the CDI path forward.”
The survey also examined the type of health records reviewed by CDI programs, with inpatient records accounting for the majority. The second-highest was a combination of inpatient, outpatient and professional records reaffirming that the industry is beginning to shift toward CDI reviews of outpatient health records. Full survey results are available to members here.
Seeking to recognize a healthcare delivery organization that takes an outstanding and innovative approach to health information management (HIM), the American Health Information Management Association (AHIMA) is calling for applications for the eighth annual Grace Award.
Interested applicants can submit their entries via ahima.org/grace through May 31.
Ninety years ago, Grace Whiting Myers acted on a sincere conviction to improve the quality of our nation’s health records by founding the association now known as AHIMA. The idea was simple–that advancements in the collection and organization of health information will invariably help to improve public health. As a tribute to Myers’ prescient vision, AHIMA’s annual HIM award bears her name: The Grace Award.
Past winners of the Grace Award regularly demonstrated transformative journeys toward new and innovative HIM practices that also delivered better patient outcomes.
“AHIMA is excited to open nominations for an organization that is taking innovative and novel approaches to using HIM to deliver high-quality care to patients,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “This process furthers an industry dialogue about innovation and excellence and invites us to learn from each other.”
The 2019 award will be presented at AHIMA’s Health Data and Information Conference in Chicago, September 14-18.
A committee of judges, representing healthcare delivery organizations, health information professionals and HIM associations, selects the Grace Award. This year’s judges are:
(CHAIR) Sandra Pearson, RHIA, CHDA, MHA, CPEHR, CDI & Data Governance Director, SCL Health