March 2013

Hello EHR, Good-Bye HIM? — Rethinking the Role of HIM Professionals in an Electronic Environment
By Lisa A. Eramo
For The Record
Vol. 25 No. 5 P. 18

Melissa M. Martin, RHIA, CCS, chief privacy officer and HIM director at West Virginia University Hospitals (WVUH), knew she had to think strategically if she planned to transition most—if not all—of the HIM staff members into new roles after the hospital implemented an EHR. Complicating matters, she also had to keep in mind the institution’s financial interests.

“Imaging systems and electronic health records are very expensive. Sometimes leadership is looking for ways to get a return on investment,” she says. “They may say, ‘OK, now that we are electronic, we should eliminate all clerical positions.’”

As an early adopter of computerized physician order entry and optical imaging, WVUH always had been ahead of the curve. The hospital also employed a chief financial officer (CFO) who, according to Martin, was particularly interested in leveraging HIM knowledge and expertise during technology implementations.

Prior to implementing optical imaging in 2004, the HIM department had 79 full-time employees (FTEs). One year later, the number was the same, although many clerical positions were transitioned to higher-level, more technical roles, Martin says.

For example, within a few weeks of implementation, the hospital transitioned nearly one-half of its medical record assistants (ie, individuals who file and pull records) to scanning-related roles. Martin says she knew at least one year in advance that the decrease would occur, and she wanted to plan proactively. “As positions became vacant, we either didn’t fill them or if we had to fill them, we went with temporary services so that we didn’t harm anyone at the time of the transition,” she says.

The hospital also transitioned analysts who flagged paper records for signatures to more technical roles. “We knew we were going to see a decrease [in staff] in this area, so we started working with our medical staff affairs department so we could start performing core measures audits,” Martin explains.

Existing staff members were encouraged to take classes to develop the skill set necessary to work with the new technology. Martin says the transition required minimal training. “The medical staff affairs department was hiring multiple nurses to perform clinical abstraction for core measures. All we needed to do was ask one of those nurses to train our staff,” she says. “It was a matter of five or six training sessions of where to look in the record to abstract the information. The department didn’t need to keep hiring nurses to do the job.”

Thinking strategically helped maintain crucial HIM staff members throughout WVUH’s makeover to a postdischarge EHR, according to Martin. “We didn’t add any FTEs for a couple of years, but in my opinion, we elevated our profession,” she says. “We elevated the roles of the staff and helped them in many cases increase their salaries by thinking ahead instead of just slashing and burning positions.”

Shifting Roles
WVUH took a similar approach when it began its journey toward a complete EHR in 2008. “I wanted us to be smart about how we handled it, and I wanted to do the right thing for the organization,” Martin says. “As a manager, director, or administrator, nobody wants to have to go to an employee and say, ‘I’m sorry, but your position is being eliminated.’”

The hospital placed the HIM function at the center of its EHR implementation. In 2008, it introduced the EHR in the revenue cycle department (including HIM) before rolling out the technology in its inpatient and ambulatory settings in 2009 and 2010, respectively. “Your No. 1 risk with implementing an EHR from a revenue cycle perspective is the accounts receivable,” Martin says. “If you can’t get accounts coded and billed, then you’ll have big problems.”

Like many hospitals nationwide, WVUH began to look for a return on investment. Transcription was one of its first targets. Martin says a consultant suggested the possibility of eliminating the function completely in an effort to cut costs. “The CFO who was here at the time came to me and said, ‘What do you think? Can we really eliminate transcription?’” she recalls. “To answer the question, I had to ask a question back to leadership: ‘Are we going to require all physicians to perform direct documentation in the system even when it gets difficult and the workflow isn’t perfect yet?’”

At the time, WVUH employed 27 transcriptionists. “We felt like the fair thing to do was to budget for a decrease in transcription by five FTEs for the year that we were going live. We knew ahead of time, and nobody was harmed in the process. It was all done through attrition or desired voluntary reduction in hours,” Martin says.

After implementation, several transcriptionists moved into roles in which they oversaw the partial dictation process, including training physicians on how to use the system. “This was an opportunity to take people who were performing more of a traditional transcription role and give them something more,” Martin explains.

Transcriptionists weren’t the only employees facing potential changes. WVUH worked with a consulting company to perform workflow and staffing evaluations. “[The company] pushed the idea of eliminating a whole lot more staff,” Martin says. “They were looking at the financial numbers and at what the market was saying that an EHR is supposed to be able to do. But they weren’t necessarily involved in the operations. If anything, it probably made us think harder about what we should do and how we should justify positions.”

As hospitals migrate to a hybrid record and eventually to an EHR with a document imaging solution, they can—and should—expect to see a reduction of FTEs, usually because of attrition, says HIT consultant James H. Braden, MBA, adding, however, that hospitals should not get lured in by EHR vendor promises to reduce staffing. “A vendor will often support its business proposition and return on investment metrics with unrealistic and/or ill-advised FTE reductions,” Braden says. “The actual metrics of the net FTE impact and redistribution of HIM staff resources should be the product of an objective and dynamic staff analysis spread over a defined period of time.”

Tracking productivity is paramount, Martin says. “This enables HIM directors to plan from a budgetary perspective for potential eliminations or changes in roles,” she says. At WVUH, all HIM staff members have tracked their time and productivity since 1999.

Ultimately, the HIM department has grown—not shrunk—since implementation of the EHR. WVUH currently employs 120 HIM FTEs, approximately one-half of whom work from home.

Martin attributes much of this growth to an increase in coders, something she says will probably continue indefinitely as the hospital moves toward ICD-10. “We won’t see a decrease in coding on the hospital side, even with computer-assisted coding live. We’re using three to five contract coders at this point,” she says. “The projections for the learning curve with ICD-10 is somewhere between a 30% to 60% reduction in productivity. Everyone hopes that within six to 12 months, we’ll start to gain that back, but I think in reality, there will be a certain amount that you’ll never get back just because of the specificity and complexity.”

The growth is also the result of adding two privacy managers who assist with security audits—a task that may fall under IT’s purview in some hospitals—as well as a recovery auditor coordinator and several staff members who facilitate the auditing process. The HIM department also grew to include certified EHR trainers and an applications analyst, both of which are traditional IT positions. “As clerical positions came out of our budget, more technical positions were needed,” Martin says.

Many hospitals decide to revamp, not eliminate, HIM positions to accommodate an electronic environment, Braden says. “Most of the HIM roles and functions are not eliminated, but rather they morph to support vitally important functions such as clinical code editing/abstracting, hybrid record management, transcription editing, document deficiency management, decision support, identity management, and disclosure from the legal EHR,” he says.

Other EHR-related positions into which HIM staff may move include system analyst, EHR trainer, interface monitor, or data analyst, says Angela Dinh Rose, MHA, RHIA, CHPS, director of HIM solutions for AHIMA. “IT may say, ‘Oh, this is our area and our function,’ but it goes back to the data and the information that’s passing through the record. That’s what HIM is there for,” she notes.

Still, Rose says she’s heard many stories of hospitals that have adopted an EHR and then eliminated or significantly reduced HIM FTEs in order to outsource all HIM functions. “I’ve heard of a lot of directors’ positions being eliminated, and the assistant director or manager of operations can run what’s needed in an electronic environment,” she says. “I think organizations put themselves at a major disadvantage by not keeping or including HIM professionals who are already there, who know the organization, and who know the flow of the data.”

Outsourcing HIM Functions
However, outsourcing isn’t detrimental at every facility. For example, at MedStar St Mary’s Hospital, a 95-bed facility in Leonardtown, Maryland, no formal on-site HIM department exists because the hospital outsourced all its functions after implementing its EHR in 2008.

Richard Braam, CPA, MBA, vice president of finance at MedStar St Mary’s, says outsourcing the department was one of the best decisions the hospital ever made. “We’re geographically challenged. We’re in a relatively rural area and we’re on a peninsula, so staffing has been really hard,” he notes. Outsourcing the department resulted in a reduction of 19.5 FTEs.

Transcription had been particularly difficult to manage. Prior to the EHR, MedStar St Mary’s employed four transcriptionists and two independent contractors. It also worked with an outsourcing company when volumes surged. Outsourcing the entire transcription function allowed the hospital to ensure consistency as well as the rapid turnaround time to which physicians were becoming accustomed, according to Braam.

Coding was another challenge. “We’re in a community of approximately 100,000 people, so it was difficult for us to find qualified and certified coders,” Braam says. “Joining the MedStar system allowed us to access system resources, so inpatient coding is now performed through [an outsourced] shared-services arrangement. The electronic record allows coders to access the system from anywhere. We took advantage of the functionality to go with outsourcing.”

Then there was the question of how to handle release of information. As recovery auditor requests started to skyrocket, Braam says the hospital decided to completely outsource the release of information function just so it could keep up with the volume. The outsource company currently employs two individuals, both of whom work on site. Braam says patient requests for information actually may start to decline once the hospital activates its patient portal.

Although MedStar St Mary’s decided to outsource its HIM functions, it did try to retain current staff members when possible. For example, it tried to move several individuals who had previously performed paper filing into scanning-related roles. However, it also had hired an outsourcing company at the same time and realized that it didn’t need that many FTEs devoted to the task, Braam says. One staff member with a background in phlebotomy was able to move back into that department, and another currently oversees the scanning function and works with the contract company. For the most part, however, staff members were eliminated.

One year after go-live, MedStar St Mary’s HIM director resigned. Braam says the hospital tried to fill the position, but none of the applicants had detailed EHR experience. “After nine months of trying to recruit, I sat down with the hospital’s president one evening and said, ‘Let’s think outside the box here. Do we really need this position, and can we realign things?’” Braam says. “Literally within 15 minutes, we mapped out what we landed with. Frankly, I think it has worked quite well. We haven’t had any sort of gaping issues.”

However, not filling the HIM director position meant that several other directors, most of whom serve in clinical roles, would need to take on additional responsibilities to manage the HIM outsourcing contracts and processes. For example, the director of risk management and compliance—a nurse—oversees the outsourced release of information function.

“If it’s potential or pending litigation, [this director] is involved anyway, so we’re actually happy that she knows who is requesting the record,” Braam says. “She, more than anybody, is adamant that the information being released is absolutely accurate. She understands the clinical ramifications [of inaccurate information]. She’s also the compliance officer, so she’s acutely aware of the HIPAA concerns.”

Two data technicians in the performance improvement department, who are overseen by a nurse, manage transcription and were hired after the EHR implementation. “Our performance improvement department oversees our Joint Commission preparedness, so it seemed like a natural fit for this function,” Braam says. “Our clinical data gurus all work in this area, so that was actually a pretty good fit.”

Both data technicians, one of whom is in the process of pursuing a formal HIM education, monitor the transcription interface, perform chart analysis for completeness, and work with physicians to obtain signatures. “We have a very high level of clinical knowledge involved in these functions, which I think is very beneficial,” Braam says. “We were also blessed that we had folks with a can-do attitude who were willing to take these things on.”

Outsourcing the HIM department has certainly had its perks, one of which pertains to ICD-10. “Our only concern around ICD-10 is the training of our own clinical staff,” Braam says. “As others right now are scrambling to try to figure out system remediation, we’re trying to work with our physicians to make sure that their clinical documentation will really allow the coders to maximize coding under ICD-10.”

Although MedStar St Mary’s HIM structure is somewhat unconventional, The Joint Commission doesn’t mind. “Other than asking for the delinquency report, they didn’t really fixate on [the HIM department structure] that much,” Braam says when discussing the hospital’s most recent survey experience.

Thinking Outside the Box
Still, many experts agree that HIM professionals should be at the forefront of any EHR implementation and that they play an important role regardless of the department in which they work. “The HIM professional is best suited to assume critical roles in the management, use, privacy, security, and integrity of the EHR,” Braden says, adding that in some hospitals, this may involve moving HIM professionals into other teams, business units, or reengineered organizational structures, such as IT, decision support, or compliance.

Martin agrees: “It’s frustrating for me when I hear people say that HIM jobs are being eliminated because I know that there’s so much potential and so many opportunities. There’s a whole new aspect to the medical record from a data governance and information integrity perspective. To me, that’s what we’re going to be talking about over the next five years.”

Strategic planning is the best defense, Martin says. “If you don’t step outside of your traditional roles, you will find yourselves eliminating a lot of positions,” she explains. “When the rubber starts to hit the road and you need to have your return on investment, it’s very easy for leadership to say, ‘These positions have to go away,’ and you haven’t had time to think about how their roles could change rather than be eliminated.”

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and healthcare regulatory topics.