“Data is like the air we breathe. We share it and if it’s not kept clean, we all suffer,” said Deborah Green, MBA, BS, RHIA, executive vice president, operations and COO, AHIMA. Green, the first of three panelists to address the crowd at a Nuance-sponsored AHIMA14 breakfast panel, explained that we all need information we can trust to help patients. She agrees with fellow panelists, Juana Colon, RHIA, corporate director of health information management for Orlando Health and Dr. Richard Garcia, MD, MPP, MHA, emergency department director, Beverly Hospital in California, that while HIM professionals are on the forefront of safeguarding clinical documentation integrity, we all have to get engaged in cleaning it up.
A recent AHIMA survey of healthcare providers found that US hospitals have some work to do when it comes to information governance: 65% of those surveyed recognize the need for formal information governance, but only 35% said that their facilities have a comprehensive strategy to date. There’s no question that the need to create standards and policies to control the input/output of information has grown since the influx of electronic health records (EHRs), but as the survey shows, most sites need help in understanding how and where data flows across an enterprise, as well as the functional teams and guidelines to properly manage the quality of that information.
Here are recommendations for safeguarding healthcare data through information governance:
- Create a steering committee. Collaborate across functional teams on an approach and practices that create better data and knowledge across the healthcare system. This committee should reflect clinical, financial and operational areas, representing many different groups across the healthcare organization. Collaboration is essential in order to agree to a clear owner of the patient record, identify distinct steps to ensure everyone manages data properly within the organization, and to create an accountability framework with consistent checks and balances.
- Define an information governance strategy. How are you controlling what gets in and out of records, and what gets shared in and outside the organization? Create standards to manage information throughout its entire lifecycle. Root out accuracy issues and mitigate the biggest risks by delivering data you can trust. This will also support compliance, patient safety and changing payment models.
- Leverage educational tools. AHIMA has created new industry-wide tools and resources for information governance, including a framework and a maturity model designed to help organizations identify where they stand today and what steps they need to take in order to better manage information safely, securely, and properly.
- Update policies & procedures. Most hospitals have adopted and communicated a set of policies to employees to serve as a guide for decision making and outline actions to keep teams aligned with the goals and values of the organization. Many hospitals and healthcare organizations never updated these to address EHRs, hybrid records, and information exchange across numerous inpatient and outpatient care areas, and public and regulatory agencies. Updating these policies and procedures is essential to effectively manage use of information across an enterprise.
- Re-visit how you manage and retain records. Hospitals used to store decades of paper records, which took space, time and money. Now things have changed and much of that information is contained in EHRs. First, define where the legal record resides and then have updated policies for storage and disposal of records. For example, at Orlando Health, Colon said the legal health record resides in HIM and they keep these for 10 years. They used to store them for much longer, but with EHRs and new technologies, there’s no longer the need.
- Embrace being the gate keepers of all the data. HIM professionals play an integral role in data management, so it makes sense that they become the gatekeeper of data within a healthcare organization. This requires a willingness to move to a philosophy of HIM “without walls,” breaking down barriers between medical staff, coders, quality, case management, compliance and HIM teams to manage and release information within the organization. This culture of information exchange is becoming increasingly important as data is being communicated more widely outside the organization to support quality care, audits, and regulatory compliance across clinical and financial areas. HIM directors are well-positioned to play a central role.
These steps will help you get started with information governance to build a framework for data accuracy and accountability so you can trust the data flowing in and out of your organization.