Summer 2022

Thoroughly Modern HIM Directors
By Susan Chapman, MA, MFA, C-IAYT
For The Record
Vol. 34 No. 3 P. 18

A shifting landscape has helped redefine the core essentials necessary for a successful career.

As the health information landscape transforms, HIM directors are finding that their skill sets need to evolve. With that in mind, the education of new entrants into the field and the ongoing education of seasoned HIM professionals are also in flux. HIM professionals and those who educate them need to stay flexible as new advances in technology, changes in regulations, and other factors impact the HIM director’s role.

Evolving Skill Sets
Karen Youmans, MPA, RHIA, CCS, president and CEO of YES HIM Consulting, a national HIM coding and auditing consulting organization, notes that HIM’s evolution has been particularly apparent to HIM directors over the last decade. “I would say one of the biggest changes is with technology, with the EHR. The changes going from paper to scanning to the EHR, so we have to be much more in tune with IT departments than ever before, especially with compliant remote access,” she says.

Pamela Oachs, MA, RHIA, CHDA, FAHIMA, an assistant professor in the health informatics and information management department and the director of the HIM undergraduate program at the College of St. Scholastica, says that although EHRs have been in use for quite some time, staying current with technology is still important. “There are also everchanging compliance [standards] and regulations, and HIM directors do need that knowledge base and skill set regarding any regulations they oversee, including privacy, security, revenue, and audits,” she says. “Additionally, the more common and enhanced use of spreadsheets and data analytics to help with decision-making, those are probably newer in terms of integrating technology, especially in the area of gathering and analyzing data.”

According to Youmans, it’s becoming more common for HIM directors to be well-versed in hospital finances. “You always have the CFO concerned with the discharge, not final billed (DNFB) balance—when a provider has discharged a patient, but the facility hasn’t submitted a final bill,” she explains. “It’s one of the biggest revenue killers for health care providers. The number of skilled coders that you can contract with has become fewer over time. So, there is always a concern about the number of coders vs quality and accuracy vs productivity.

“The DNFB is also about analysis,” Youmans continues. “An HIM director, then, needs analytical skills. If the CFO asks why the DNFB is so high, go back and show the monthly/quarterly trends. A one-time snapshot is not the true picture. It’s a marathon, not a sprint. HIM directors have to be able to analyze trends, not a one-time fix. They need to go back to the CFO and say, ‘Here’s where we’re going; yes, today we’re high, but look at the trend.’ Being able to convey that is important.”

Because HIM directors and CFOs interact more frequently, Youmans believes the former require strong communications skills. “CFOs don’t want to know every detail. They just want to know how things will improve and change, and HIM directors have to be able to say things succinctly. Sometimes those skills can be taught and learned, but sometimes they’re innate,” she says. “Part of it is experience and part of it is personality traits.”

Coupled with solid communications skills is the need for broad clinical knowledge. “With the payer side of things, many payers have their own set of clinical criteria. A payer may, for instance, have their own criteria for sepsis. It’s not up to the HIM professional to make the actual decision, but they need to know when to send that information to a physician or a physician advisor,” Youmans says.

Stephanie Donovan, EdD, MBA, RHIA, dean of academic operations and faculty development, and faculty chair of Health & Human Services at Peirce College (Peirce), a Philadelphia-based private, nonprofit institution that offers online-only education to adult students, says that the entry-level educational requirement for HIM directors has remained relatively consistent over the years, noting that more often than not, the RHIA credential is a requirement.

To take the RHIA exam, students must have completed a program accredited by the Commission on Accreditation for Health Informatics and Information Management Education or meet one of the other eligibility criteria. “And part of the requirement for the individual to maintain the RHIA credential is to earn continuing education units [CEUs] in a number of HIM-specific domains,” Donovan says. “We need to stay current. For example, an RHIA must earn 30 CEUs every two years, with at least 80% of the total CEUs required earned in an HIM domain that includes clinical foundations, data structure, content and information governance, evolving topics, and health law and compliance, among other topics. We must report our CEUs to AHIMA during the certification cycle to maintain the RHIA credential.”

Donovan, who is the current president of the Pennsylvania Health Information Management Association, points out that a large culture shift has taken place in HIM in which diversity, equity, inclusion, and belonging are top of mind. “While we’re all expanding our understanding of technological competencies like telehealth and artificial intelligence, at the same time, we’re uplifting each other and becoming more equitable and inclusive in our practices and raising the bar of how we’re committed to equity,” she says.

For example, during a recent meeting on gender-affirming care, Donovan learned that the more accurate term regarding personal pronouns has shifted from “preferred” to “correct.” “What does that mean, not only in patient care but also in how we relate to one another as colleagues, as humans? As we grow in those areas, we can feel uncomfortable, a feeling that is rooted in fear of not getting it right, of inadvertently offending a patient or colleague. We’re learning, then, how to advance this work in a way that is meaningful, respectful, and impactful. We have to invite the right people to the table to guide us along the way and be constantly willing to learn,” Donovan says.

Qualification Shifts
While aspiring HIM directors need a four-year degree and the RHIA credential, Donovan points out that many individuals at the director level continue their education and earn master’s degrees, where they learn those sought-after communications and analytical skills.

“Hands down, communication skills have been, and remain, a priority, that includes both verbal and written communications,” Donovan says. “Interpersonal skills and emotional intelligence continue to be a current topic of focus, essentially self-awareness, which goes to interpersonal skills. Successful HIM directors need to be appropriate and professional in meetings and e-mails as well as in their interactions with colleagues in general. They take steps to solve problems by appropriate means, having a chat or making a phone call when the situation calls for that type of interaction over one that involves e-mail. And when we’re doing most of these transactions through Google chat or e-mail, I think we’ve lost touch a bit with professionalism and etiquette. We’ve lost touch with that, but how we show up, even in those remote situations, matters.”

Donovan consistently hears from advisory board members that employers appreciate employees with good attitudes and growth mindsets. “Of course, the foundational skills are important, but employers want employees who are open to trying new things and have a willingness to learn,” she says. “They want innovation and curiosity over rigid points of view.”

Oachs points out that HIM directors’ tools and methods have evolved, even if some of their tasks have been in place for some time. “HIM directors have always been involved in problem solving, data sharing, helping others do that as well—all of that is the same,” she explains. “The way they do it may be different. Project management and leadership skills are now required. Employers know that our graduates are going to have some of those technological skills and knowledge to find things out about regulations and technology. What employers really need is someone to jump in, take the lead on projects, and not sit back and wait to be asked about such things. That’s something we’re working to offer our students so that they’re prepared to lead.”

Donovan agrees that the entry-level qualifications for new HIM directors have not significantly shifted academically, but the evolution of skill sets and tools is being driven, in part, by employers and what they want to see. Donovan explains, “I had a workforce development meeting with a large hospital in our area, and they’ve intensified their requirement of written communication skills, for instance. Customer service also continues to be an area that employers prioritize and value, especially as we are delivering more services virtually. Telehealth is huge right now, and there is no indication that telehealth was simply a Band-Aid at the height of the pandemic, poised to disappear.”

The COVID-19 pandemic has prompted unanticipated changes that move beyond the proliferation of telehealth. Chief among them is managing a remote workforce. Donovan says many remote workers do not have the appetite to return to the physical workplace as pandemic restrictions have eased. While some health care professionals must be onsite, others can continue to do their work from home or another remote location.

In general, Donovan says, the industry is experiencing a shift away from a physical workplace when possible. “Given these changes, what does it look like to show up for work in a virtual environment?” Donovan asks. “We have to remind employees to use appropriate Zoom backgrounds, for instance, and dress professionally. From a manager’s perspective, it would be managing that workforce, not just from a productivity and quality standpoint but also regarding morale. It’s uncharted territory and requires a lot of effort.”

Another aspect of the transforming HIM field is the experience requirement for entry-level employees. For example, most of Youmans’ clients require a minimum of three years’ coding experience. “Some want five years. We hire new graduates as trainees and have offered different programs over the years,” she explains. “But in a hospital, they typically do not have the staff to mentor, train, and test them and perform 100% secondary reviews, etc. Hospitals don’t have the resources to do that, and we try to fill that role.”

Because employers want experience beyond education, well-qualified candidates who have graduated from strong programs are unable to land jobs. “We’ve hired six new graduates over the last three years and we’ve mentored them. We anticipate hiring more new graduates in the near future,” Youmans says. “What we know is that you can do great in school and on standard exams, but the real-world situations may not be as cut and dried. It takes experience and time to transition what was learned from a book and apply it to the real world.”

How Changes Reshape Education
As requirements for HIM directors evolve, education must keep pace. AHIMA performs skill-set analyses and communicates with educational institutions about what courses and clinical requirements must be added to their curricula. “It’s a formal analysis every few years. It is a formal process and, of course, each director of a program would then have to go to the curriculum committee of their university to implement AHIMA’s changes,” Youmans says. “It can take a while, but institutions do listen to AHIMA. There may be some internal red tape within an institution, but they do ultimately incorporate what they’ve been asked to do.”

“At Peirce, we recently implemented the 2018 AHIMA Health Information Management Curricula Competencies Model,” Donovan says. “The most recent competencies were created to align HIM education with the skills and knowledge required to meet long-term future HIM workforce needs. Each academic level comprises six common domains, representing the areas of mastery important for all HIM students and practitioners, regardless of academic degree. That required a complete remapping of competencies across the curriculum. There is a second piece of that. Those competencies must live in the curriculum at the appropriate learning level. The question is are we teaching our students the appropriate competencies at the appropriate level. We’ve got to make sure that the prerequisite, supporting body of knowledge has a meaningful progression across the program.”

The progression Donovan describes impacts how student learning is assessed. “We have to ask ourselves, ‘Do we have the appropriate assessments in place at the course level? What do those assessments look like? Are students performing or underperforming? If it’s the latter, why? How can we improve that?,’” she says. “I would say, generally speaking, that assessment is the purview of each academic institution. In some instances, we look at the pass rate of the RHIA exam as the benchmark for student achievement in a specific domain. But it’s really important not to look solely at the end-of-course grade for student achievement. We also use score reports from AHIMA that tell us how many graduates took the RHIA exam during a specific time period and how our students performed in each domain as compared to the national average.”

Donovan notes that while current student retention remains strong at her institution, student enrollment in Peirce’s HIM degree programs has recently decreased, a change that is consistent with postpandemic national higher education enrollment trends. Youmans believes that one way to increase enrollment is to reach out to students as they are just beginning to consider their career choices.

“The average age of a coder is about the mid-50s, and fewer people are going into this profession,” Youmans says. “I think we need to work with middle- and high-school counselors. Now, the field is so technologically and clinically focused that if someone has that background or interest and wants to go into the medical field yet doesn’t want direct patient care, we can promote our profession. We’re not reaching the masses like we really should. To remedy that, we should be building awareness of what is available by reaching out to that next generation of potential leaders in HIM.”

— Susan Chapman, MA, MFA, C-IAYT, is a Los Angeles-based writer, yoga therapist, and well-being coach.