HIM Coming of Age through Information Governance and Data Governance

Keep up with the latest on information governance as this key strategy emerges for addressing a myriad of information management challenges in healthcare. This blog will highlight the trends and opportunities IG presents for ensuring information is treated as an organizational asset.


By Robin Andrews, MEd, RHIA, CCS

 

Long ago, health information management (HIM) professionals were known as Registered Record Librarians (RRL) and Registered Record Administrators (RRA). Now, we are known as Registered Health Information Administrators (RHIA) and Registered Health Information Technicians (RHIT). Over time, the profession has evolved. But the valuable knowledge we possess—of documenting, indexing, classifying, and retrieval of information—is as relevant as ever. HIM is the practice of acquiring, analyzing, and protecting medical information—whether in digital or other forms—that is vital to providing quality patient care. HIM professionals plan information systems, develop healthcare policy, and identify both current and future information needs. We also apply the science of informatics to the collection, storage, analysis, use, and transmission of information to meet legal, professional, ethical, and administrative recordkeeping requirements of healthcare delivery.

We are the data analysts, archivists, and reporters of all care rendered to patients in a vastly changing environment. This new environment now encompasses home health-based visits, home visits, hospital visits, doctor office visits, home health agencies, surgical day centers, telemedicine, and many other healthcare verticals and services. If someone told me forty years ago, that the paper medical record would become obsolete and patients would not always be required to show up in person, I would have said, “There is no way possible!”

With all this evolution in healthcare delivery, name and focus are shifting to meet the demands of big data and to leverage that data for improved operational and clinical excellence, including patient care, satisfaction, and safety. We are now in an era where classification of patients’ diagnosis and treatment information are no longer stored in medical record shelving units, but in the form of data bytes. This processable data, previously reported to healthcare organizations on the green/white sheets of paper, is entered, processed, published, and stored in computer language format.

As a profession, we now are tasked with managing the continuous influx of data and information of all formats, complexities, and sources. We have also reached a point where managing this influx of data and information in siloes is not going to cut it. Our organizations need to enable a particular focus on data and information at the enterprise level by breaking down those siloes and increasing collaboration and standardization amongst the business units or departments. Internal and external partnerships will allow for areas of opportunity to be more easily identified and ensure that all business units or departments are working from the same standardized approaches through established policies and procedures.

The C-suite, executives who are focused and supportive of governing data and information, help to enable a culture where information governance (IG) embraces the opportunities for enterprise-wide improvements. IG is an ongoing program where “completed” (still ongoing) projects are continuously monitored and maintained, and new projects prioritized. Piece by piece, these organizations are improving their IG maturity.

For me, after one door closed, and the next door opened, a renewed energy and focused emerged, and I was able to create a small IG/data governance (DG) pilot plan in the hospital where I work. The pilot included a small group of frontline leaders, managers, and supervisory staff. As is said, “necessity is the mother of invention.” We had a need and used the AHIMA IG toolkit and free IGHealthRate assessment tool to create a charter and utilize an IG framework. The tools helped us to improve the process of managing the information and data to prevent loss of revenue, and satisfy regulatory and insurance requirements. The committee brought together leaders from several departments, and we were able to implement a process governing timely communication within the departments to prevent loss of revenue. The stakeholders who worked diligently on IG initiatives with the organization significantly contributed to the enterprise’s value creation processes—in particular, value-based purchasing, bundled payment methodologies, etc.

My first step was to identify the information of which I am the “owner.” A HIM Team Lead was assigned for each area: healthcare statics, data analytics, HIPAA/confidentiality, HIM content, format, ICD-CM/PCS coding performance, release of information, and maintenance of healthcare data and PHI. The team prioritized and performed IG/DG activities, using IG/DG methodologies in the IG/DG Toolkit. The HIM IG/DG teams require individual team members to reach out to areas outside of HIM for collaboration.

Ultimately, the goal is to expand the IG/DG initiatives enterprise-wide by leveraging the improvements, benefits, and return on investments made from the HIM IG pilot program—as well as expand the IG/DG initiative enterprise-wide. This decision comes from years of healthcare changes and looking at this change, from management to governance, is no different from all the rest. More often than not, the C-suite comes to realize that when you follow the health information, you find HIM professionals.

Today’s HIM professionals are the “Gatekeepers,” the abstractors, and the individuals with control over the release and maintenance of healthcare data and PHI. HIM professionals must embrace the new industry changes and recognize that our role is the same—but in the broader sense. It comes with a different name (Information Governance) and is practiced at an enterprise-wide level, reaching beyond the four walls of the traditional HIM department. Historically HIM has been responsible for data content, standards, and governance and HIM professionals have the skillsets to take on IG and DG so let’s compare HIM concepts, principles, and practice. See if you can find the similarities in the following side-by-side comparison:

HIM Current Role Information and Data Governance Role
Healthcare Statistics

 

Metadata Management/Data Architecture Management/Master Data Management/Data Analytics/Business Intelligence
Data Visualization for decision-making Data Governance, Data Architecture Management/Enterprise Content and Record Management/Data Standardization/Integration of Key Program Structures (DG, Enterprise Information Management, IT Governance)
Planning Research projects

 

Data Security/Metadata Management
Clinical Quality Management

 

Data Quality Management
Healthcare Data Analytics

 

Business Intelligence and Big Data/Master Data Management
HIM Confidentiality/HIPAA Data Security/Metadata Management
HIM Content and Format Content and Record Management/Standardization
ICD-10-CM/PCS Coding Terminology and Classification Systems Management

As the evolution of healthcare and the HIM profession continues to shift, HIM professionals must adapt to the changes and take on new roles by broadening our skill sets and using IG and DG best practices. Information governance is an initiative worth the time and resources. The initiatives we take and initiatives we use from IG and DG principles allow us to be more proactive and less reactive. It will enable us to leverage our information assets and use them more strategically through robust and repeatable processes, more profound insights, and improved collaboration. It is the future of the healthcare industry, and it gives us the ability to meet the ever-changing demands we continue to face year after year.

 

Robin Andrews is director, health information management at Norwood Hospital. Andrews is an AHIMA-approved ICD-10-CM/PCS trainer and an AHIMA Information Governance Practice Council member.

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