By Amy Czahor RHIT, CDIP, CCS; Ginna Evans, MBA, RHIA, CPC, FAHIMA; Beth Friedman, BSHA, RHIT; and Erin Head, MBA, RHIA, CHDA, CHTS-TR
The healthcare industry’s move from paper to electronic health records (EHRs) has spanned two decades. The implementation of ICD-10 took four years. Now the shift from fee-for-service to value-based reimbursement is upon us. Like most large healthcare initiatives, full realization of value-based reimbursement will occur over time.
With their historic announcement in January 2015, Medicare set clear goals for “transitioning from volume to value.” They are currently targeting 90 percent of all payments to be tied to quality or value by 2018. Today’s efforts include programs such as hospital value-based purchasing, hospital readmission reduction, and the Bundled Payments for Care Improvement (BPCI) initiative. Tomorrow’s programs will bring even more changes for how we document, code, bill, and manage health information.
As value-based care and reimbursement emerges, savvy HIM professionals are rising to the challenge. This roundtable article highlights three HIM leaders who are taking great strides to thrive in a value-based healthcare environment.
Beth Friedman, BSHA, RHIT, Founder, Agency Ten22: Briefly describe your organization’s initial steps away from fee-for-service and toward value-based reimbursement.
Amy Czahor, RHIT, CDIP, CCS, RecordsOne: Prior to joining RecordsOne in 2015, I was the regional director of clinical documentation improvement (CDI) for a 24-hospital health system. The system unveiled a strategic plan to move from volume to value in 2012. Value-based programs have been front and center for HIM, quality, and CDI teams ever since. Within the CDI ranks, focus shifted from case mix index to outcome measures.
Our biggest challenge was how to increase CDI efforts and case reviews for value-based programs without doubling or tripling staff. The answer was technology—software to identify cases for CDI review across the enterprise. Specifically, we used technology to find the right patients—cases with potential diagnoses falling into our value programs including severity of illness, risk of mortality, hospital-acquired conditions, and patient safety indicators.
Ginna Evans, MBA, RHIA, CPC, FAHIMA, AHIMA-Approved ICD-10 CM/PCS Trainer, Emory Clinic: In 2013, a vision was fulfilled to develop a Coding Education Department. The department was created to work with coders, physicians, and other areas with their specific coding and documentation needs. The first area of focus for this department was preparing for ICD-10.
Now in its third year, the department has grown to ten coding educators who continue to provide ICD-10 coding classes and deliver specialty-specific presentations to physician groups within the Emory Clinic. This same team of coding educators has rolled out a Provider Shadowing Initiative as we move toward value-based reimbursement.
Erin Head, MBA, RHIA, CHDA, CHTS-TR, Parrish Medical Center: Our focus has been on quality of care, not quantity of visits. The hospital began participating in the BPCI program in 2015 for three Medicare populations: major joint replacements, heart failure, and cardiac arrhythmias. We track these cases across the entire care continuum to monitor costs, reduce readmissions, ensure quality care, and improve health literacy for patients and their families.
As the only hospital certified by The Joint Commission as an integrated care network in the US, our goal is to treat BPCI patients at lower-than-average costs, share responsibility with their families, and bring the entire community into our value-based efforts.
Friedman: What specific tasks are you and your HIM department helping with?
Czahor: Like most HIM departments, ours was part of enterprise revenue cycle. However, in the wake of value-based reimbursement, the CDI area of HIM now functions under the quality umbrella. The department plays a stronger role in ensuring record quality as the downstream impact of data errors extends further into patient care, quality, and outcomes.
Evans: During my first twenty-plus years in HIM, patient financial services (PFS) and medical records maintained a love-hate relationship. It was always us against them. Three years ago I transferred into the Patient Financial Service Department since my role within HIM was being eliminated. These past three years in PFS for a large health system physician clinic have been the ideal opportunity to share my HIM skills with the former “enemy.”
The first step was to assign members from our coding education team to each service line (Internal Medicine Specialties, Primary Care, Surgery, Hospital Services, Orthopaedics and Neurosciences, Specialty Services). This step was invaluable as we migrated to ICD-10 and is now paving the way for value-based reimbursement through our Provider Shadowing Initiative as mentioned above.
As part of this initiative, we work with physicians in each specialty to observe workflow, observe processes, see how they document their notes, and audit the documentation. We are now reviewing notes to provide direct physician feedback. We suggest how physicians could capture additional diagnoses that would better show true patient acuity in value-based models and for specific patient populations. Each service line also has a dedicated revenue cycle analyst that can generate and analyze reports as well as trend denials with coding educators to provide feedback to the service line areas.
Head: Our HIM team is currently involved with value-based programs in two ways: patient identification and patient portal education. Working closely with CDI specialists, we use coding and DRG data to designate which Medicare patients will be part of bundles. We’ve created an internal registry for these high-risk populations—to know when patients need extra help and to ensure CDI specialists know the correct ICD-10 coding guidelines for each case.
A new position within HIM was also created: patient portal coordinator. This person engages registration, medical groups, patients, and families in an ongoing dialogue about correct use and management of their health information. Specifics of the new customer service role include:
- Teaching registration and physician office staff how to discuss portal access and usage with patients and their families.
- Participating in discharge planning rounds to keep the conversation going.
- Managing a customer service kiosk within HIM for patients and families to access the portal.
Friedman: Please share three specific skills HIM professionals bring to value-based initiatives.
Czahor: HIM professionals have always been champions for patient data. In the past, our focus was on quantity—we’d ensure the H&P was in the chart. The same data stewardship skills shift to qualitative analysis to support value-based initiatives. For example, HIM professionals must now ask, “Does the H&P documentation support medical necessity?”
The move to value-based reimbursement will also require HIM’s strength in interdisciplinary communication to interface with clinicians and add value to case conversations. Complex case reviews will require deep knowledge of the record—a valuable HIM skill.
Evans: Health information management is truly the heart of healthcare. HIM professionals bring a wealth of knowledge to the table, managing information collected to provide continuity of care for patients. Our educational skill set is unique—anatomy, physiology, coding, management skills, to name just a few.
The first skill necessary for value-based reimbursement is communication. HIM professionals have long worked with the physicians and many other care providers. Most importantly, we have the communication skills to work with the providers. These skills allow us to educate providers on the need for quality documentation as we move toward value-based initiatives.
Secondly, data analytics continues to grow in the HIM world. Clinical coders are critical. They have the ability to take written documentation and turn it into numbers (codes) which are then captured within large databases and queried for business insights and intelligence. Little data becomes big data. Long data tells the story of a patient over their lifetime. Both will help us organizations as they shift from fee-for-service to value-based reimbursement.
HIM professionals are also capturing patient medical information to identify high-risk and high-cost patients. Our unique ability to manipulate data and look at trends and to share information with physicians, insurers, and others is critical as we move toward population health management.
Lastly, health information management is the heart of healthcare. We must use our strong leadership skills, particularly change management, to lead this process to ensure a smooth transition. The next few years will bring many opportunities and HIM professionals need to continue lifelong learning and reach beyond their comfort zone. Don’t be afraid to step beyond the walls of HIM. As an HIM professional, be the leader of the transition to the value-based care payment model for your employer. We have so much to offer.
Head: HIM professionals offer data analytics skills, portal knowledge, and coding accuracy. HIM will be tasked with abstracting data, running reports, and presenting results. Organizations will rely on HIM professionals to keep coding data accurate—and to decipher it and help identify patients at risk. Finally, HIM skills can bridge the gap between health literacy and the community. With knowledge of patient portals, HIM professionals can explain to patients and families, “Here is your information and this is how you use it.”
About the Authors
Amy Czahor RHIT, CDIP, CCS
Vice President, Optimization & Analytics Services, RecordsOne
Ginna Evans, MBA, RHIA, CPC, FAHIMA
Coding Education Coordinator, Internal Medicine Specialties
Emory Healthcare – Emory Clinic
Beth Friedman, BSHA, RHIT
Founder, Agency Ten22
Erin Head, MBA, RHIA, CHDA, CHTS-TR
Director of Health Information Management and Quality, Parrish Medical Center
The views expressed in this article are solely the author’s and not representative of Parrish Medical Center or any other affiliated organization.