December 10 , 2007

Going the Distance — HIM Departments Enter the Winner’s Circle Through High-profile Initiatives
By Selena Chavis
For The Record
Vol. 19 No. 25 P. 10

Visit three facilities that have reaped the benefits of the HIM professional’s expanding role.

Kudos. Applause. A job well done. Those words are being echoed in healthcare facilities across the nation as HIM departments are being recognized for their leadership in taking healthcare to the next level.

And industry professionals agree it’s a trend that’s not going to change as HIM professionals are increasingly setting the standard for electronic health record adoption, as well as advocating for quality patient records and patient access.

“We’ve always had multiple responsibilities across so many areas of health … that hasn’t changed,” says Maria Stolze, RHIA, vice president of HIM at Parkview Health, an Indiana-based healthcare system encompassing eight inpatient facilities and more than 6,200 employees. “What has changed is other people’s awareness of what we contribute to healthcare.”

From notable achievements in creating more efficient models for dictation and transcription to improved revenue cycles and decreased chart delinquencies, a number of HIM departments have spearheaded projects that have made significant improvements in the way health is delivered in their respective facilities. No longer are these professionals centralized in a single department behind closed doors. Now, they are making an impact on clinicians, staff, and patients by applying their expertise across complex healthcare organizations.

Highlighted in this article are three departments that stand out for their efforts, as well as the secrets behind their success.

Southwest Medical Center
Located in Lafayette, La., Southwest Medical Center is a 140-bed hospital with approximately 85 physicians serving on its staff. In June, the organization’s chart delinquency rate reached 29%, its highest level ever. The number reflected delinquencies for 670 charts.

With a visit from The Joint Commission nearing, HIM Director Kathy Boone knew the organization had to take action. “The Medical Executive Committee (MEC) felt we did not have enough meat in our bylaws to deal with physicians who had delinquent charts,” she recalls. “We decided to put some teeth into this effort.”

And the results proved to have significant bite as a new policy was enacted allowing the hospital to suspend the admitting and surgical privileges of any physician whose charts were more than 60 days delinquent. “A lot of area hospitals were talking about suspension but [their bylaws] didn’t have the teeth. We just felt we had to go forward,” Boone notes.

Before the new policy, physicians who had a delinquent medical record of more than 90 days would report to the MEC for corrective action. According to Boone, the physician would often fail to show up, and the committee would not take the needed follow-up action.

The new policy now dictates that medical records should be completed within 30 days following discharge.

Initially, Boone says one full-time employee was dedicated to the physicians’ incomplete area. This specialist was in charge of mailing out a series of letters notifying physicians of pending problems. Now that the new system has been up and running for a while, Boone notes that it does not require full-time hours.

According to the new policy, a courtesy letter is mailed to physicians whose charts are one to 29 days old; a warning letter for up to 59 days; a suspension letter for records that are 60 to 89 days old; and, at 90 days, a letter relinquishing all hospital privileges is mailed. The physician would also be reported to the National Practitioner Data Bank and the State Board of Medical Examiners.

Boone says the results have been nothing short of amazing as the delinquency rate plummeted to 7% after the program was implemented in July. “It’s really changed the efficiency of the department,” she says, adding that, so far, the organization has not had to suspend any privileges. “Out of 13 years, this is one of the best projects that has impacted department morale and relations with physicians.”

While most physicians now believe it’s a good policy, Boone acknowledges that tensions ran high at first. “The [correspondence] was referred to as the ‘ugly letter.’ We had to tweak the wording some,” she notes. “It’s still hard for some of the staff [throughout the hospital]. They don’t want the physicians to be upset.”

After the doctors were notified of the policy changes, letters of explanation were blown up to several feet high and placed in the physician lounge, surgery department, and incomplete chart room. The MEC also established a policy that a physician in danger of suspension would be contacted by phone in addition to the mail.

Boone suggests that simple organization within the HIM department also made a difference. Before implementation of the new policy, delinquent charts would be placed on a shelf after coding in no particular date order. Now, charts are placed in order of date, and the department has set a goal that the specialist would not get more than three days behind before another clerical person would be pulled to help.

Effective communication with physicians and hospital staff was key to the endeavor’s success, Boone says. “You really need administration support and MEC support. You really can’t move forward without those pieces,” she says.

Parkview Health
“We knew we had an issue with ambulatory claims,” recalls Brenda White, RHIA, the HIM project manager at Parkview Health who spearheaded a recent initiative to improve the ambulatory revenue cycle for the healthcare system.

That was the starting point for a major revenue cycle restructuring centered around new technology and new processes. Ambulatory billing was chosen first due to the organization’s complex multicampus environment, as well as the complex rules governing outpatient prospective payments and medical necessity guidelines, Stolze notes.

“There was nothing but opportunity to improve,” she says, pointing to issues that continually surfaced over incomplete diagnoses, missed charges, and inefficient communication methods.

And the results were immediate and significant. Within a few months of making major workflow changes, the organization was able to eliminate coding and editing delays equating to nearly $1.5 million in revenue.

With new technology provided through 3M software, as well as new guidelines and expectations for turnaround time, the organization was able to communicate needs to other departments in a more timely manner and identify problems earlier in the game. “We were already using other 3M tools,” White notes, adding that the addition of new technology was not the complicated piece of the project. “It worked similar to the rest of the product.”

Changes to how the medical necessity edits were completed proved to be the challenge. Before the reengineering, Stolze says medical necessity edits would be identified by patient accounting (PA) after billing. Then, the process would involve medical necessity forms being faxed to various departments in the hospital, many of which were already facing time constraints for other duties.

By redesigning the workflow so that coding identified the medical necessity edit before it reached PA, the organization was able to bill $514,903 in 5.2 calendar days instead of an average of 22.4 calendar days. Along the same lines, the workflow changes allowed the organization to improve the turnaround time for outpatient coding edits from 30.5 calendar days to 4.2 calendar days.

Kathy Holleran, Parkview’s director of health information services (HIS), adds that interfacing with and educating various departments also proved to be a challenge. “There were so many departments that we had to get our arms around … and get a timely response from them,” she says.

White concurs, adding that regular small group meetings with high-volume departments such as radiology, laboratory, and emergency proved crucial to the process. “We also had to meet more often with patient accounting and finance,” she recalls.

As part of the new workflow process, a communication tool within the software component notifies departments or physicians about needed information and then requires a 24-hour turnaround for delivering the components. “Previously, PA hadn’t set an expectation for getting information back to them,” Stolze says.

Using an interdisciplinary team to reengineer the process was a necessary component to make the project successful, White suggests. “You have to have the right people involved in the project,” she says, pointing to the needs for diversity and expertise from a number of disciplines. “You also need organization leadership, buy-in, and support. We were trying to change our processes across multiple facilities, and it was being done through indirect leadership.”

Leading the charge to reengineer revenue cycle management at Parkview meant working as a team with other departments. “Management of revenue cycles absolutely requires multidisciplinary participation. This was a major change for many departments, not just HIM. [We] had to embrace change because it was for the betterment of Parkview,” Stolze says.

The interdisciplinary team made the decision to approach the project by phases to avoid the onslaught of too much change at once. “We knew if we pared it down, we would still get 80% of the return, and we would get it sooner,” she explains, acknowledging that initially they still underestimated everyone’s learning curve. “You’re asking a group of people to assume knowledge they’ve never had before. We wouldn’t have seen return on investment if we tried to do it all at once.”

In Parkview’s case, Stolze is quick to acknowledge that the project would have been unsuccessful without a manager. “I’ve had the benefit of having a project manager in my area,” she says. “I would not attempt anything that involves this much change without a project manager.”

Those overseeing the Parkview project included the HIS director, project manager, coding manager, and coding compliance coordinator; a core technical team comprised of the 3M project manager, Parkview IS analyst, 3M interface specialist and an interface consultant; and other key resources in the organization including the finance manager, PA billing manager, and PA billing supervisor.

Richmond State Hospital
Founded in 1890, Richmond State Hospital is a public behavioral health facility operated by the state of Indiana that provides psychiatric and chemical dependency services. A nuance to behavioral health, treatment plans for long-term care have to be completed at 30-, 60-, and 90-day intervals, according to Kerry Moore, director of HIS.

“When I came to the department, they were handwriting the [treatment] plans and then sending them to transcription,” she recalls. Recognizing the need to streamline the process, Moore set out to develop a method for making the treatment plans electronically accessible to all clinicians and HIS staff in the absence of an electronic health record.

Using the organization’s local network and resources available through Microsoft Word, Moore established processes and protocols for electronically maintaining plans. Minus the costs associated with training and development, Moore points out that the cost for the project was also a huge plus—it was free.

The turnaround time for getting plans completed went from a two- to three-month backlog to less than three days. “[The results] were huge, and it definitely impacted our quality of care,” she says, noting that early on, there was significant resistance. “Now, I don’t think anybody would suggest going back to what we were doing before.”

Along with workflow efficiencies, Moore notes that the make-over has also changed the role and skill set of the transcriptionists to some degree. “Transcription now serves more of a proofreading and editing function,” she says.

Moore also took on the challenge of implementing a digital dictation system for the organization’s 11 doctors. When doctors used handheld dictation machines, transcriptionists frequently had difficulties understanding them on the tapes, and the devices often would get damaged. Recognizing that there would be an up-front financial investment for the new system, Moore acknowledges that “it took a long time for me to convince administration to do it.”

The new system has created a number of efficiencies within the HIM department—the most obvious being the ability of transcriptionists to get information within seconds instead of hours or a full day. The organization is also saving costs associated with replacing handheld devices and tapes.

Overall, the projects have created better cohesiveness between transcription and the clinicians. “We’ve earned a lot more respect,” Moore 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 healthcare and travel.