Day two of the AHIMA (American Health Information Management Association) conference in Atlanta kicked off early Tuesday, October 28 with a breakfast panel called, “HIM’s Current and Future Role in the Documentation Value Chain.” This discussion, moderated by past AHIMA president, Bonnie Cassidy, began with a brief overview presented by Health Business Group’s David Williams, who shared top findings from their new survey of 800 healthcare providers called, Clinical Documentation Trends in the US, 2013-2016. Panelists included: Laura Rizzo, director, HIM, WellSpan Health; Jaime James, MHA, RHIA, senior director, Health Information Management Services, Banner Health; David Williams, president, Health Business Group; and Bonnie Cassidy, senior director of HIM Innovation, Nuance.
The survey points to four trends:
- A significant proportion of clinical documentation in the U.S. is done using electronic health records (EHRs), with adoption highest among physician practices vs. hospitals.
- Providers use a mix of clinical documentation methods today, including transcription, front- end speech recognition, keyboard/mouse entry into EHRs and paper charts. Paper will mostly go away in the next three years.
- Despite the investment in EHR technology, approximately 50 percent of those surveyed lack confidence that their EHRs provide a complete picture of a patient’s clinical story. This level of confidence was higher in IT respondents than with HIM professionals.
- Integrated Delivery Networks (IDNs) create a lot of change in the industry and for HIM professionals. Approximately 66 percent of physician practices that affiliate with IDNs changed their clinical documentation method and 53 percent changed their EHR.
Changes and opportunities in preparing for 2014:
- Ambulatory practices/clinics: While more hospitals are consolidating and snatching up physician practices, these pose both a challenge and an opportunity for HIM leaders as greater oversight is needed in managing clinical documentation across the expanding organization. For example: One audience participant said her California-based health system had brought on 25 clinics and added a hospital in the past year.
- Data integrity management: HIM departments are developing “copy/paste” policies and best practices for clinical documentation beyond just ICD-10 to preserve integrity across the enterprise. Both WellSpan and Banner have added a data integrity positions to help impact data governance and standards for quality and compliance.
- Clinical documentation improvement (CDI) initiatives are vital and impactful when you focus physicians on the quality of documentation vs. coding requirements.
- HIM is expanding in scope and importance: By owning the content, HIM can have a seat at the table in shaping strategies for data integrity, privacy and security of data, and ultimately patient care for an organization.
HIM leaders are ready for ICD-10 and face escalating core measure reporting as well as other industry pressures. “ICD-10 gave us an opportunity to look at how and why we were documenting,” said Jamie James, senior director of Banner Health. “Next we can determine what tools we want to give providers to enhance clinical documentation and assess what they need from a quality perspective and what specificity is needed.”
Health Business Group, a leading healthcare strategy firm, conducted the Clinical Documentation Trends in the US, 2013-2016 study sponsored by Nuance Communications, Inc. Results are available for complimentary download at www.nuance.com/go/hbgreport.