Members may read all stories online in the AHIMA FORE Library: HIM Body of Knowledge. Select features and practice briefs also are available publicly.

July 2009

Features

• Present on Admission: Where We Are Now, by Gail Garrett, RHIT
• Mortality Coding Marks 10 Years of ICD-10, by Chris Dimick
• Making the Most of External Coding Audits, by Cathy Brownfield, RHIA, CCS, and Donna M. Didier, MEd, RHIA, CCS
• Healthcare Standards Development: The Value of Nurturing Collaboration, by William Edward Hammond, PhD, Charles Jaffe, MD, PhD, and Rebecca Daniels Kush, PhD

In Addition

• Classifications without Borders, by Sue Bowman, RHIA, CCS, and Rita Scichilone, MHSA, RHIA, CCS, CCS-P, F-CHC

Practice Brief

• Managing the Integrity of Patient Identity in Health Information Exchange

Working Smart

• Documenting Data Loss, by Sandra Nunn, MA, RHIA, CHP
• Amendments to FERPA Regulations, by Laurie A. Rinehart-Thompson, JD, RHIA, CHP
• Preparing for ICD-10-CM, by Eric Rose, MD, FAAFP
• Parental Proxy Access via Web Portals, by Sheila Green-Shook, MHA, RHIA, CHP

Coding Notes

• New Guidance for Home Health Coding, by Ida Blevins, RHIA
• The Casting Conundrum, by Tanai S. Nelson, CCS, CCS-P, and Christina Benjamin, MA, RHIA, CCS, CCS-P

* * *

The World Health Organization maintains the Family of International Classifications, a suite of classification products that may be used in an integrated fashion to compare health information internationally and nationally. The International Classification of Diseases is published and maintained by WHO-FIC. ICD-10 is the current edition, and ICD-11 is in development.

Internationally endorsed classifications such as those in WHO-FIC facilitate the storage, retrieval, analysis, and interpretation of data; they enable the comparison of data within populations over time and between populations at the same point in time. Their use results in the compilation of internationally consistent data.

Accordingly, WHO-FIC seeks to

• improve health through provision of sound health information to support decision making at all levels;
• provide a conceptual framework of information domains for which classifications are, or are likely to be, required for purposes related to health and health management;
• provide a suite of endorsed classifications for particular purposes defined within the framework;
• promote the appropriate selection of classifications in a wide range of settings in the health field across the world;
• establish a common language to improve communication;
• permit comparisons of data within and between member states, health care disciplines, services and time; and
• stimulate research on health and the health system.

WHO has designated a number of collaborating centers to work with it in the development, dissemination, maintenance, and use of WHO-FIC. The WHO Collaborating Center for the Classification of Diseases for North America was established in 1976 to represent the US and Canada in international activities related to study and revision of ICD.

Now known as the WHO Collaborating Center for the Family of International Classifications for North America (abbreviated as NACC), it is located at the National Center for Health Statistics, a part of the US Centers for Disease Control and Prevention.

NACC works in close collaboration with two Canadian agencies: the Canadian Institute for Health Information and Statistics Canada. It maintains liaison with WHO on use, implementation, and maintenance of the FIC by the US and Canadian governments.

Nine WHO committees and reference groups contribute to maintaining the FIC:

• Update and Revision Committee
• Education Committee
• Implementation Committee
• Family Development Committee
• Electronic Tools Committee
• Mortality Reference Group
• Morbidity Reference Group
• Functioning and Disability Reference Group
• Terminology Reference Group

In addition to representatives from the collaborating centers who are members of the WHO-FIC network, other classification, health information, and clinical experts can be appointed by respective collaborating centers to represent their respective countries.

Representatives from AHIMA currently serve on three committees and reference groups: the Morbidity Reference Group, the Terminology Reference Group, and the Education Committee.

Morbidity Reference Group

The Morbidity Reference Group seeks to improve international comparability of morbidity data and the application of ICD in morbidity by analyzing and integrating needs deriving from statistics (e.g., hospital data), case mix (e.g., DRG systems), and clinical documentation (e.g., clinical terminology and electronic health records).

AHIMA’s participation helps provide the US health information management perspective to the process of developing and maintaining current and future versions of ICD and developing associated international usage rules.

While differences in national regulatory requirements and reimbursement systems inevitably lead to differences in clinical modifications of ICD and reporting rules, the goal is to minimize these differences and achieve international data consistency and comparability, to the extent possible, through international collaboration.

Sue Bowman, RHIA, CCS, AHIMA director of coding policy and compliance, currently serves on the Morbidity Reference Group and shares a US vote with Donna Pickett, MPH, RHIA, medical systems administrator at the National Center for Health Statistics.

The group:

• Identifies, discusses, and solves problems related to the interpretation and application of ICD to coding and classification of morbidity, including the establishment of standardised interpretation of the categories and the development of agreed definitions, coding rules and guidelines
• Develops recommendations for ICD-10 updates for forwarding to the Update and Revision Committee annually, through a democratic process that attempts to achieve consensus
• Supports the revision process for ICD by providing advice on morbidity-related issues and possible terminology linkage for morbidity coding
• Reviews possible morbidity applications of WHO-derived and related classifications, to inform recommendations for change to ICD
• Considers and supports statistical, epidemiological, reimbursement (including casemix), and clinical applications of ICD for morbidity purposes
• Constructs a database summarizing national applications of ICD for morbidity purposes
• Provides documentation of discussions and decisions in a database that can be used online and offline

The Morbidity Reference Group participates in the development of ICD-11, as do all of the committees and reference groups.

Terminology Reference Group

The Terminology Reference Group follows terminology and terminology systems developments and promotes awareness of the need to ensure and verify congruence between concepts underlying clinical terminologies and the WHO classifications.

The group first convened at the 2006 WHO-FIC meeting in Tunisia. Its establishment reflects the importance placed on the relationship between the classifications of WHO-FIC and the emerging clinical terminology initiatives around the world. Subsequent meetings were held in 2007 and 2008.

AHIMA director of practice leadership Rita Scichilone, MSHA, RHIA, CCS, CCS-P, F-CHC, serves as a US representative to the group. The group:

• Promotes awareness of the need to ensure and verify congruence between concepts in clinical terminologies and the categories available within the WHO-FIC products such as ICD and ICF
• Collaborates with the research community, healthcare providers, software developers, and health authorities
• Monitors and provides guidance for mapping between classification and clinical terminologies
• Guides the evolution of WHO-FIC products (e.g., ICD-11) so new work takes account of the content and formalisms used to construct and maintain clinical terminologies

Discussions between the International Healthcare Terminology Standards Development Organisation (IHTSDO) and WHO-FIC began in 2007 for harmonization of classification systems with the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT).

Education Committee

The Education Committee assists and advises WHO and the WHO-FIC Network in improving the level and quality of use of WHO-FIC in member states by developing an education, training, and certification strategy; identifying best training practices; and providing a network for sharing training expertise and experience. Its current work plans prioritize ICD and the International Classification of Disability, Functioning, and Health.

The Education Committee entered into a joint collaboration with the International Federation of Health Records Organizations (IFHRO) in 2001. IFHRO is a nongovernmental organization in official relations with WHO; AHIMA is its US representative. Together the Education Committee and IFHRO have developed an international training and certification program for ICD-10 coders and trainers. In cooperation with the WHO, they have been developing Web-based training tools for ICD-10 and the International Classification of Disability, Functioning, and Health.

AHIMA director of practice leadership Rita Scichilone serves as a US representative to the Education Committee. Its functions include:

• Assessment of the needs of users of the classifications, including those who provide source information, apply codes, conduct research or use the resulting data
• Identification of the learning objectives for educational approaches
• Inventory of existing educational materials and capacity
• Recommendations for learning content including development of core curricula
• Recommendations for best practices for promotion and delivery of educational material
• Harmonization, review, development, and maintenance of self learning tools.

References

Berg, Lars, and James R. Campbell. “Mapping SNOMED CT to ICD-10—A Joint Task of IHTSDO and WHO-FIC.” 2008.

National Center for Health Statistics. “WHO Collaborating Center for the Family of International Classifications for North America.”

World Health Organization. “Terms of Reference of the WHO-FIC Committees.”

World Health Organization. “The WHO Family of International Classifications.”

The Journal of AHIMA publishes four Buyers Guides a year: Consulting/Outsourcing (February), Transcription (April), Coding (July), and Software and Health IT (September).

Click on the image to view the guide

The definition will in part determine which providers are eligible to receive incentive payments for the use of health IT under the American Recovery and Reinvestment Act. Providers who are “meaningful users” of health IT can receive up to $44,000 in increased Medicare and Medicaid payments over five years.

Public comments are due June 26.

The proposed definition features a series of evolving objectives and measures for 2011, 2013, and 2015. The objectives are keyed to five healthcare outcomes policy priorities identified in a 2008 report from the National Priorities Partnership, convened by the National Quality Forum.

The workgroup recommends meaningful use support the following five goals:

• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and families
• Improve care coordination
• Improve population and public health
• Ensure adequate privacy and security protections for personal health information

The policy committee workgroup highlights several aspects of the proposal for feedback in particular. In a preamble to the draft, it writes:

“We seek specific stakeholder feedback on whether the recommended timeline of requirements is overly aggressive based on the current state of technology and the demands on new provider workflows, or not challenging enough to result in significant transformation, in light of the declining level of Medicare incentives in future years.”

The draft recommends that the definition of meaningful use vary by setting. Thus “some features and capabilities will be recommended as required in an ambulatory setting before similar functions are expected to be widely used in the hospital.”

The group also singles out measures reporting for feedback, noting that there are currently “considerable gaps in EHR-generated measures available to monitor key desired policy outcomes.”

The workgroup’s proposal will not be the final word on meaningful use. In fact, it won’t be its own final word—the group has already been asked to present revisions at the full committee’s next meeting on July 16. Ultimately ONC and the Centers for Medicare and Medicaid Services will weigh a range of input and develop a proposed rule later this year. That proposal will be open for public comment for 60 days.

updated June 17

While ONC’s draft description rightly stressed the delivery of IT assistance, the centers and their clients will require a wider range of expertise for the full preparation, deployment, and management of health information communications and technology. Different phases of EHR implementation and use require differing skills.

In its comments on the draft description, AHIMA recommended that the final program define core services that include a range of services to assist in EHR use throughout a system’s lifecycle.

This range of services includes workflow analysis, transition planning, data analysis, and training. The sample phases of an EHR lifecycle shown below illustrate the differing core services that users may require over the entire lifecycle.

In its proposal, ONC indicated it could begin requesting applications from potential regional centers as early as this summer, with grants awarded this fall.

 Sample EHR Lifecycle and Possible Core Services

AHIMA’s comments were in response to a draft description of the program published May 28 by the Office of the National Coordinator for Health IT. Specified under the American Recovery and Reinvestment Act, the program calls for a central Health IT Research Center with affiliated regional extension centers that provide direct assistance to providers. The centers will help providers meet requirements for receiving bonus Medicare and Medicaid payments under a separate ARRA provision.

AHIMA offered recommendations around four main comments:

Establish a clear and consistent set of goals:

• Define what constitutes a “region” for the regional centers
• Clarify the relationship among the regional centers and between the regional centers and the central Health IT Research Center
• Reconsider the proposed plan to issue multiple, closely spaced requests for proposals from organizations seeking to become regional centers 
• Consider mechanisms that ensure all providers are covered by qualified regional centers and that they are not penalized by any delay in accessing the services

Define a consistent set of core services delivered by an interdisciplinary team:

• Further define the minimum level of services the regional centers must supply
• Provide a consistent and uniform approach toward core services that addresses different functional components during each phase of an EHR implementation
• Consider critical areas of health IT implementation that are not just technical in nature and require specialized skills, such as workflow analysis, transition planning, data analysis, training, and customization (see related story for sample core services)

Clarify the governance and management structure:

• Define a clear and uniform structure for governance and management of the overall program, the regional centers, and the corresponding research center
• Discuss a coordinated, consistent, and standard approach toward program planning and service delivery of the regional centers and their relationship to the resource center
• Separate the research center’s research function from any management of the regional centers (the proposal seems to suggest that the research center will serve both roles)

Develop a sound program evaluation process that creates a learning community for sharing best practices with the resource center and among the regional centers:

• Create a uniform and consistent approach toward evaluating the program
• Develop a uniform measurement process that enables ONC to assess, evaluate, and make decision regarding future award programs, determining successful and unsuccessful regions, and defining areas that may need additional resources
• Provide detail on the evaluation process

In the draft program proposal, the Office of the National Coordinator indicated it could begin requesting applications from potential regional centers this summer, with grants awarded as early as the fall.

“The automated reviews are less burdensome on the provider, because there’s no request for medical records,” said Marie Casey, deputy director of the Division of Recovery Audit Operations at CMS, in the news item. “They’re also easier for the RACs to manage.”

The delay for medical necessity auditing is due to the complexity of the reviews. “We’re delaying because it’s more difficult,” Casey said. “We are really trying to ensure that when there is a difference of opinion [on the medical necessity determination of the case], the RAC clearly documents their rationale.”

The delay will also help CMS roll out an issue review team, a group comprised of members from various agency divisions that will look at policy questions, such as whether the RACs have been correct in the interpretation of coding guidelines. These teams will look comprehensively at the questions before approving new issues for RAC review, according to Kathleen Wallace, a CMS representative who spoke at a May 28 Region D RAC training session held in Helena, MT.

When record requests do come, they will start sporadically but eventually fall into a pattern, at least in Region D, said HealthDataInsights president and CEO Andrea Denko, during the Helena training session.

In addition to the summary report, the seven subgroups that comprise the collaboration are presenting their work through free webinars on Tuesdays and Thursdays this month. The sessions focus on the tools and processes developed by each group, as well as how individual, local, regional, and state-level stakeholders can use them.

Formed in 2006, the Health Information Security and Privacy Collaboration was charged with studying privacy and security issues associated with interstate electronic health information exchange. It is managed by RTI International under a contract with the Department of Health and Human Services. The third phase, scheduled to end in April, received a last-minute extension through July. RTI will add an addendum to the recent report to describe the work of the extension.

Material from all three phases of the HISPC project—including documents, tools, reports, and products—are available through Health and Human Services.

Exactly how HISPC’s body of work will live on, and how directly it is promoted, is unclear given the changes in HHS personnel and programming brought about by the new presidential administration and the American Recovery and Reinvestment Act. However, ARRA’s goal to promote the secure, widespread exchange of electronic health records certainly relies on overcoming the barriers to health data exchange between states that HISPC identified and worked toward resolving.

HIM professionals can play four important roles, the authors write:

• Advocating, designing, and testing PHR products that are sensitive to underserved populations
• Promoting PHR use within their communities
• Training both consumers and providers in PHR use
• Helping secure personal health information to both safeguard individuals and build the trust that will encourage consumer acceptance of health IT

See “Healthcare Disparities and the Role of Personal Health Records” by Jennifer Garvin, Barbara Odom-Wesley, William J. Rudman, and Rachelle S. Stewart.

For a look at the need to improve data collection in support of efforts to reduce disparities, see the April 2009 Journal feature “Data Collection and Reporting for Healthcare Disparities.”

Jane Cook, Cheryl D’Amato, Gail Garrett, Becky Ruhnau-Gee, Linda Hyde, and Natalie Novak sort out the relationship of POA, HACs, SREs, and “wrong” surgical site policies in “Understanding National Coverage Policies.”