HIT Standards for HIM Practices Being Developed for an Interoperable World

On Tuesday afternoon during the Interoperability Track, the AHIMA Standards Team and fellow HIM professionals will feature a session on enabling functional interoperability in healthcare. Linda Bailey-Woods, RHIA, CPHIMS, Sandra Huyck, RHIT, CCS-P, CPC, CPC-H, Lee Wise, MS, RHIA, CHCO, and AHIMA Standards Team staff Diana Warner, MS, RHIA, CHPS, FAHIMA, and Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA, will discuss a ground-breaking AHIMA initiative on guiding the development of health information technology (HIT) standards in healthcare.

HIM professionals often encounter many challenges as they transition from a paper-based to an electronic system. Hoping to help with these vexing issues, AHIMA and Integrating the Healthcare Enterprise (IHE) collaborated to promote standards for effective use of health information systems, including electronic health record (EHR) systems.

IHE International (www.ihe.net) is the not-for-profit membership-based international collaborative of HIT vendors, professional associations, and governmental entities to develop, test, implement, and use interoperability standards in healthcare for all health information needs.

On September 18, 2015 AHIMA and IHE published the white paper “HIT Standards for HIM Practices,” available online at http://qrs.ly/lb4vec0, which unveiled an approach for cross-collaboration between HIM professionals, standards developers, and HIT vendors to support the capture, management, sharing, and use of electronic health information.

The AHIMA-IHE white paper:

  • Outlines a methodology to engage HIM professionals in defining their needs for HIT products
  • Offers a detailed analysis of HIM business requirements and best practices related to information governance principles in healthcare
  • Specifies use cases for HIT capabilities needed to support HIM practices
  • Defines a roadmap for adoption of interoperability standards to support HIM practices in healthcare.

 

An AHIMA task force of HIM professionals provided expertise to standards developers at IHE for aligning HIM practices and capabilities of health information systems through HIT standards for functional interoperability (i.e., defined the “rules of the road” for information sharing).

The white paper—part of AHIMA’s globally-focused information governance (IG) initiative—marks the first time HIT vendors and HIM professionals have formally worked together to ensure that interoperability will be addressed from an HIM perspective.

“Identifying HIM practice needs and a means to address them in standards is the first step in achieving our shared goal of the interoperability and overall governance of health information,” said Deborah Green, MBA, RHIA, chief innovation and global services officer at AHIMA. “We’ve created the methodology and the roadmap for developing interoperability standards to support information governance. These ensure that HIM principles and practices are represented when crafting standards for interoperability in collaboration with HIT vendors, professional associations, and government entities.”

Nineteen HIM subject matter experts (SME) guided the development of the white paper. During the public comment period in July, over 140 comments were received from the HIM community. They were addressed in the final version of the paper.

Below are some of the quotes from HIM SMEs on the completion of the white paper.

“This is such a positive step forward for all of us and our profession. I am feeling very grateful for having had the opportunity to work with all of you and contribute to this beginning work on Standards,” said Lori McNeil, from Boston Children’s Hospital. “I am so proud of AHIMA for moving this forward and keeping our profession on track!”

“This was a great experience and to be part of this publication demonstrates our commitment to ensuring that the integrity of a person’s health record is maintained to the highest standard,” said Elisa R. Gorton from St. Vincent’s Medical Center.

The white paper specified business requirements under the IG principles of information availability, integrity, and protection as well as defined the HIM practice checklist of best practices (work processes) under these principles. The white paper also included five use cases to detail for the standards developers’ HIM activities (actions) supporting documentation for the episode of care. These use cases are:

  • Use Case 1: All documents in the episode of care record are accounted for
  • Use Case 2: Episode of care record is complete and closed
  • Use Case 3: Release of information (ROI) to external requestor
  • Use Case 4: Audit for the episode of care record
  • Use Case 5: Audit for the ROI

 

The AHIMA-IHE effort will continue in 2016. The task force will focus on specifying business requirements and HIM practices checklists for the information governance principles of information accountability, compliance, retention, disposition, and transparency. The new use cases will be developed on data quality, copy and paste, patient registration, patient matching, and transition of care.

“It is imperative that HIM and HIT professionals work together so HIM practices are included in HIT standards for IG,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. “Together, we can achieve interoperability of health information.”

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