October 15, 2007

HIM Professionals: RHIOs’ Missing Asset
By Elizabeth S. Roop
For The Record
Vol. 19 No. 21 P. 18

It would seem to be an ideal partnership: an organization designed to facilitate the exchange of health information and experts well-versed in best practices for doing just that. Then why aren’t more HIM professionals involved in the formation of regional health information organizations?

At the heart of any regional health information organization (RHIO) or health information exchange (HIE) is patient data. As such, it is reasonable to expect that HIM professionals are actively recruited by these organizations for their unique expertise in all aspects related to health information.

Yet the primary focus of many RHIOs and HIEs remains on the technology required to facilitate the exchange of data rather than the data itself—a situation unlikely to change unless and until the HIM profession inserts itself into the process at the local, regional, and national levels.

“When you think about health information exchange, the first thought is that it is a technical process and not an information management process. That is why the HIM profession has to take the initiative,” says Don Mon, PhD, vice president of practice leadership at the AHIMA. “Protecting privacy and confidentiality, obtaining consents and authorization, the release of information process—these are the kinds of things that have to be brought to the forefront. If the HIM profession doesn’t take the initiative, then it could boil down to a technical process that may not have the best practices for exchanging health information to support it.”

The Need for HIM
One challenge that HIM must overcome to insert itself into the RHIO/HIE process is a lack of awareness among organizers about the assets the profession brings to the table in terms of managing the data exchange process.

“It goes back to the fact that a lot of RHIOs and other HIE projects are really driven by physicians. They are trying to do something to connect disparate organizations. If you look at who is writing the grants [to fund exchanges], it tends to be the provider, the practitioner who is driving it, and the first thing they think of is getting the IT infrastructure into place,” says Beth Haenke Just, MBA, RHIA, president and CEO of Just Associates. “That’s fine, but when those types of endeavors get started or initiated, there are core HIM-related data exchange issues that have to be addressed early in the process. The HIM professional is the one to do that, but until they step up to the table to volunteer, they aren’t going to be able to.”

HIM professionals are in the best position to address questions regarding privacy and confidentiality of information that will cross the exchange, as well as identify the most effective way to link medical records between disparate healthcare organizations.

Determining the accuracy of the data to be exchanged and establishing processes and procedures to manage the release of information (ROI) between multiple facilities are other assets attributed to HIM professionals.

Getting HIM involved early in the development lets RHIOs and HIEs answer critical questions about the accuracy, validity, and integrity of clinical data, as well as what data needs to be exchanged and in what time frame. It also helps guide technical decisions in areas such as field mapping.

“Because we understand the content of the data, we can look at [fields to be mapped] and say when it doesn’t make sense. An IT person is going to say that the data went through because they didn’t get an error message,” says Just. “The successful linking of records is the second biggest challenge for RHIOs, next to sustainability. But it is not described as an HIM issue; it is described as a technical issue.

“The reason it is an HIM issue is that you don’t know what you don’t know. If you are connecting records in a database from disparate organizations and you don’t have the critical eye that our profession brings to the data itself, you don’t know that you’re not linking 70% [of the data] that should be linked or that you’re overlaying records that should not be linked,” she adds. “IT folks tend to look at it [from the perspective] that they are getting information in and the records are linking. They aren’t looking at the qualitative aspects. That is what HIM brings to the table.”

Mon also points to proper use of the master patient index (MPI) and resolving the patient identification challenges RHIOs and HIEs face when data flow from one institution to another as additional areas of strength HIM brings to the process.

HIM professionals can also leverage their expertise and understanding of clinical data to guide RHIOs and HIEs in establishing policies and procedures necessary to govern the exchange and use of the health information being shared.

“It is not necessarily the volume of information that is being exchanged but handling the differences in various policies and procedures of the participating entities. There has to be a common agreement among the entities about the policies for privacy, security, and confidentiality. Different organizations might have different levels, so it is important to form a RHIO-level set of policies and procedures for doing the actual health information exchange,” says Mon.

For example, policies governing whether shared data can be used for purposes other than patient treatment, payment, or operations, or if participating entities can create their own databases with shared information are “key sets of policies and procedures that have to be agreed upon by the health information exchange in the earliest stages,” says Mon.

One RHIO That “Gets It”
The Bronx RHIO, which was established in late 2005 with funding from its member institutions and a $4.1 million New York State grant received in 2006, is one organization that saw the wisdom of involving HIM from the beginning.

The Bronx RHIO encompasses 80% of the healthcare providers in Bronx, N.Y., as well as one half of the borough’s practicing physicians and two thirds of its residents. Its founding stakeholders operate a combined total of more than 3,200 acute care beds, respond to more than 600,000 annual emergency department visits, and provide 4.5 million ambulatory care visits per year.

According to Barbara Radin, the RHIO’s executive director, the challenges of establishing the policies and IT infrastructure to effectively exchange data across multiple institutions made getting HIM involved in the early stages of the RHIO’s development critical from a variety of perspectives.

“Really, the RHIO is another level of HIM in my mind,” she says. “The questions that HIM becomes really critical in helping us sort through are things like when data is really complete for sharing, what data is out there, where it is, and how we find it. The other piece that is really important is helping us sort through the identity question.

“All the things that HIM departments do, as far as interacting with patients and physicians, now have to be translated to the RHIO world,” Radin adds. “They are the resource in terms of helping us figure out how to do that.”

One area where HIM has been particularly valuable has been working with the Bronx RHIO’s technology partners, including consulting firm Emerging Health Information Technology, information integration and interoperability software provider dbMotion, and enterprise MPI solution provider Initiate Systems, Inc., to create a scalable, secure information exchange based on valid, accurate data.

Because HIM already plays a key role within individual institutions in terms of addressing challenges such as patient identification and duplicate records and the Bronx RHIO essentially multiplies those issues across 12 data-sharing sites, it made perfect sense to bring HIM and IT together to resolve any issues from the outset.

“We had the HIM people sitting in rooms with us for days looking at potential matches and identifying where the issues were so we could fine-tune those algorithms to ensure we are getting as precise a match as we can,” says Radin. “We looked at a set of data that was thousands of records and, literally, sat in a room and looked at matches and asked if it was really a match, not a match, maybe a match, and why. … You need to give that feedback to the software developers so they can build their algorithms to pick [certain pieces] of information up on a regular, consistent basis. HIM [professionals] are in that data every day, all the time, and understand the complexity of it in a way no one else does. If you can’t and don’t involve them, you’ll lose a huge amount of information that really is critical.”

The depth of familiarity and understanding of the data and key processes, such as ROI and consent, that HIM brings to the Bronx RHIO has enabled the organization to address significant challenges early in the process before the first site goes live.

Radin also notes that HIM’s work will be far from done once the RHIO begins exchanging data. She anticipates that it will play a key role in determining how the system will impact workflow, as well as in identifying and addressing future challenges as they arise.

HIM professionals “have an expertise and a wealth of knowledge to bring to the process and ignoring that would be detrimental,” she says. “I would hope that [other RHIOs] are involving their HIM departments the way we are. If they aren’t, they are going to have to or they are going to fall on their faces at some point. … We can’t do this without them.”

Inviting Themselves to the Table
While a small but growing number of RHIOs and HIEs are following the Bronx RHIO’s example and bringing HIM into the fold early, many others are not.

That is why the AHIMA is undertaking a state-level project, funded by the Office of the National Coordinator of Health Information Technology, to examine not only how individual states are approaching the formation of RHIOs and HIEs but also identify how HIM can and should be involved.

So far, two models for participation have emerged. One takes advantage of the career opportunities created within the information exchange organization itself, which operates separately from the institutions participating in the RHIO. The second features HIM professionals within participating entities stepping up and volunteering to participate as part of the resources their facilities contribute to the RHIO or HIE.

The AHIMA has also published several reports on state-level RHIOs and HIEs and is working to put its members in touch with initiatives as the association becomes aware of them, says Mon. “We notify [our members] of emergent discussions and encourage them to get involved,” he says. “We also encourage our state associations to take a leadership role in health information exchanges that are being formed within their state, and we provide a toolkit for our members [to access] as they want to learn more or need more tools as they become involved.”

Just applauds the AHIMA’s work to encourage HIM involvement but says it must also happen at the local level, where individual HIM professionals need to create their own seats at the table by educating RHIO stakeholders and their employers on the value they bring to the process.

“RHIOs don’t know what HIM brings to the table. I think they will eventually learn it, hopefully,” she says. Until then, “We should be inviting ourselves to the table. That takes volunteer time. People have to be willing to do it, and the organizations they work for have to be willing for them to be gone during the day. … It’s a matter of HIM stepping up to the plate and being leaders.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.