May 2014

Hospital Schooled
By Selena Chavis
For The Record
Vol. 25 No. 5 P. 14

Some facilities are looking to higher education partnerships to shore up coding staff levels, even if it means developing an in-house training program.

The effects of supply and demand—perhaps the most basic economic principle—are wreaking havoc on HIM recruiting and retention efforts. It’s a challenging situation, as multiple clinical and regulatory initiatives require a heightened focus on high-quality coding resources while an experienced and available workforce continues to decrease.

HIM departments have faced an ever-worsening shortage of qualified coders for several years, and while no one can accurately predict the extent of the deficiency, some industry estimates point to a nationwide shortage as high as 30% to 50%. The situation has been compounded by several factors, including a growing population of older adults who will require more health care services and an aging coder workforce that the industry may lose to retirement over the next decade.

Further exacerbating the situation is the transition to ICD-10. According to Anna Wheeler, MPH, RHIA, CCS, system services director of coding with Memorial Hermann Health System in Houston, ICD-10 presents an unprecedented challenge to HIM resources—even with the deadline being extended to October 1, 2015. “Productivity will decrease. Industry estimates suggest that it will never come back fully to where we are with ICD-9,” she notes, adding that daily workflows under the new coding system are expected to require additional coding resources, while preparation and training for the transition will intensify the situation. “Hospitals have to maintain the production side [of coding] while training for ICD-10.”

Faced with ongoing recruiting challenges and the seemingly forever-looming ICD-10 deadline, Memorial Hermann made the strategic decision to develop partnerships with nearby universities to recruit and train graduating seniors with bachelor’s degrees in HIM. The organization has taken the initiative to create its own formal inpatient coding education program that is carried out on site and administered by internal staff.

Because such programs provide a win-win situation for hospitals seeking qualified employees and university graduates looking to land that first job, it’s an idea many in the industry believe will spread. Mary Worsley, MS, RHIA, CCS, an associate professor and program coordinator for the health information and informatics programs at Miami Dade College in Florida, says the school has established similar key partnerships with local hospitals such as Baptist Hospital of Miami, Palmetto General Hospital, and Mount Sinai Medical Center. The program, which allows students to participate in internships, provides needed on-the-job experience for students and opportunities for hospitals to identify potential new hires.

“[Health care organizations] are reaching out to colleges and universities because they have realized they need to get HIM students trained,” she notes. “They find that students are eager to learn and easier to train on ICD-10.”

The ICD-10 Conundrum
When it comes to ICD-10, the HIM recruitment challenge for many hospitals is a double-edged sword. While lean staffing models already place significant strain on coder productivity, the coming regulatory transition will only heighten the need for hospitals to continue to do more with less.

Regarding coder shortages, Worsley suggests that past attitudes about hiring qualified and experienced coders have limited hospitals’ ability to identify appropriate new hires. Simply put, inpatient coding departments have been reluctant to dedicate resources to internships and training programs that could open a larger pool of potential candidates. “Productivity does lag when you have students in hospital internship programs, but there are benefits in the long run,” she explains.

Now faced with the complexities of the ICD-10 transition, HIM managers are changing their outlook on the benefits of in-house training, especially in light of the fact that some coders who have been in the industry for many years under ICD-9 are reluctant to learn the new system. Worsley points out that it’s much easier for a coder to transfer from ICD-10 to ICD-9 than from ICD-9 to ICD-10.

At Lake-Sumter State College in Leesburg, Florida, the HIM program’s advisory committee features representatives from all large and many medium-sized health care facilities and physician practices, including two accountable care organizations. The college partners with each entity to offer low-priced continuing education training for existing staff members who need to be up to speed on ICD-10 coding and documentation requirements. Graduates also can visit specialist sites, contract to help a practice make the ICD-10 transition, and fill open coding positions as long as they have obtained their RHIT or CCS credentials.

“Our community attracts a large retirement population, which means a large medical community to serve the needs of older citizens. ICD-10 is intimidating to many providers because they hear rumors or facts taken out of context, so they are seeking leadership and education to help them prepare,” says Brandy Ziesemer, RHIA, CCS, an ICD-10-CM/PCS trainer and an HIM program manager and associate professor at Lake-Sumter State. “All of these partners have approached the college for help preparing for and learning the ICD-10 coding system as well as notifying us when they have openings for graduates who have been taught ICD-9 and ICD-10 coding systems.”

Getting Started
According to Ziesemer, building trust between providers and faculty is the first step toward getting an effective recruiting and training partnership off the ground. She adds that health care organizations often need to be educated on the value of using graduates or students to help prepare for the upcoming documentation and workflow challenges. “It’s easier for graduates to get jobs with experience, but partnerships also provide a good resource for partners who are willing to hire an inexperienced but strong worker to code,” Ziesemer says.

Memorial Hermann got its training program off the ground by reaching out to the University of Louisiana at Lafayette and Texas State University, alma maters of the current HIM staff. Memorial Hermann representatives met with professors from both universities to discuss how to best introduce students into their chosen profession. “I had ties to Louisiana-Lafayette, and others had ties to Texas State,” Wheeler says. “We decided that targeting four-year graduates would be the best option for an inpatient coding environment.”

Following on-site interviews at Memorial Hermann’s Houston hospital, eight graduates were chosen from an applicant pool of 23 to participate in the first training program that began last July. Candidates who enjoyed reading (there would be many medical records to peruse) and had a predilection for working from home were a step ahead of the competition. Applicants also had to provide details about their interest in the coding profession and their ability to adjust to an evolving work environment. “Given the six months allotted to train graduates, we felt the HIM graduates would have the basic skills in coding necessary to transition to inpatient coding,” Wheeler says.

Ziesemer says selecting students with the appropriate attributes is critical to success in high-level HIM environments. “Students must understand how to professionally communicate with physicians and management with confidence,” she notes. “Not all students or graduates are able to tackle these projects with minimal supervision, so we send the less prepared students to more established types of practicum sites and explain what they need to do before we feel confident they can help local entities prepare for and transition to ICD-10.”

Building a Program
Establishing attainable goals and objectives must form the basis of any successful internship program, Worsley says. “Some internships have elaborate goals that are not reachable,” she says, adding that both colleges and health care organizations must be realistic about what situations students can be exposed to in a given time frame.

Nevertheless, Worsley points out that partnership programs must provide depth to their training so that students gain the ability to work in real HIM environments. “One program asked for students, but all [the students] did was file,” she recalls, emphasizing that effective programs must allocate internal staff resources to adequately train students. “If they don’t, they are wasting the college’s time and their own time.”

Memorial Hermann’s program provides six months of on-site training in both ICD-9 and ICD-10 coding. The objective is to teach ICD-9-CM coding at a hospital level while incorporating ICD-10 education. Current members of the inpatient coding staff served as mentors to the inaugural eight trainees, answering questions about the coding profession in general and guiding the newcomers through day-to-day operations. For example, the trainees became familiar with workflows, attended educational meetings, and experienced computer-assisted coding implementation.

To help with training, Memorial Hermann employed AHIMA’s Web-based Coding Assessment and Training Solutions and Precyse’s ICD-10 online modules. In addition, Faye Brown’s ICD-9-CM Coding Handbook and Coding Clinic served as centerpieces for chapter-specific discussions.

Following the completion of each chapter-specific guideline, trainees were given a list of actual medical records to code online that were applicable to the most recently read chapter. The instructor reviewed any coding errors, discussed the rationale behind the code selections, and answered student questions related to the exercise.

After three weeks, trainee progress was measured, and those demonstrating a greater understanding of coding were allowed to advance in the program. After five weeks, it was determined that the students could be divided into three levels of coding expertise. Subsequently, adjustments were made to train the students based on the rate they were able to master concepts and their ability to code accurately.

Students also were given assignments based on their progress. For example, one student, who was coding all types of inpatient records with greater than 90% accuracy, was placed on prebill review. Within seven weeks of classes, three other trainees were placed on prebill review, with the remaining four students attaining that level three months into the program.

By the end of the six months, Wheeler says all trainees were coding independently while maintaining quality and productivity standards. After one year, trainees—who are required to make a two-year commitment to Memorial Hermann—are advised to sit for the CCS exam as an inpatient coding specialist.

Challenges and Opportunities
The ability to train and recruit future HIM professionals in a real-life setting generally is a winning proposition. In fact, partnerships between academic institutions and health care organizations can be invaluable on several fronts. “Both parties learn and develop their skills better, and employers learn about potential employees,” Worsley says.

To be successful, these programs must be willing to dedicate the appropriate resources, including finding the ideal candidate to spearhead the initiative. Worsley says selecting the appropriate instructor can make or break the program. “We were looking for an experienced HIM professional with both prior teaching experience and actual coding experience in a large acute care facility,” she says. “We searched for a balance between teaching experience and strong technical coding skills.”

Wheeler says don’t expect the arrangement to come cheap, noting that department budgets will take a hit from training costs. The salaries of new graduates and a qualified instructor, along with material costs stemming from the purchase of PCs, education materials, and online tools, can add up quickly, she notes.

At Memorial Hermann, matters were complicated by the logistics of identifying appropriate and safe low-cost housing for graduates who made the commitment to relocate to Houston for the six-month training program.

Nevertheless, the program’s benefits outweighed any inconveniences and financial concerns. With unbilled days at fewer than two, HIM workflows at Memorial Hermann are keeping inpatient coding current. Wheeler also points out that raising staffing numbers to their optimum level has greatly reduced overtime, even in the midst of conducting ICD-10 training throughout the organization.

In addition to those benefits, Memorial Hermann believes it is now sufficiently staffed to handle any productivity declines related to the introduction of ICD-10. The numerous achievements have more than offset any hardships endured, Wheeler says, noting that expectations were met. “We satisfied our main objective, which was to be fully staffed,” she says.

Apparently, hospital leaders took notice. “Based on how successful the program was, Memorial Hermann is reviewing an educational model with a focus on outpatient coding,” Wheeler says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to health care and travel.