The Impact of COVID-19 on Health Information Management

The COVID-19 pandemic radically altered multiple facets of daily life we had previously taken for granted—shopping at a grocery or retail store, eating at a restaurant, visiting friends and family, attending school in person, and travelling, among others.¹

The pandemic’s impact on the US healthcare system was epochal, the effects of which will reverberate long after COVID-19 ceases to be a public health emergency.

The virus has exacted a crushing toll on healthcare workers, with nearly 2,000 dead² and many thousands more infected. Hospitals and health systems across the country, many of which were operating on thin margins before the pandemic, face unprecedented financial pressure as elective visits and procedures are delayed or cancelled.

The destruction caused by COVID-19 did produce green shoots. Notably, telehealth services, which were rapidly deployed and scaled in the early months of the pandemic, as well as the ability of so many hospital departments to transition daily operations to remote environments.

With encouraging news regarding vaccines and improved treatments, now is a good time for reflection on the victories and shortcomings of the past 12 months.

We already understand much of what could have been done better, including improved data quality. Public health officials’ struggle to provide timely and valid information to the public regarding reasonable expectations on testing and treatment and the politicization of basic health protocols (i.e., mask-wearing) as infringements of individual liberties.

However, the degree to which we holistically, critically, and transparently assess healthcare’s response to this pandemic will define our success in responding to the next pandemic. For the purposes of this article, let’s focus on the health information management (HIM) response.

HIM and COVID-19: Lessons Learned

Privacy. HIM professionals are the custodians of healthcare data, ensuring its acquisition, structure, governance, access, and security. The HIM professional’s work is to guard and use data responsibly, ensuring the patient’s privacy and the integrity of the data being used.

However, the emergence of the pandemic forced HIM professionals to balance the sometimes mutually exclusive concepts of patient data privacy and addressing a global public health concern. Data was needed to evaluate the disease’s risk and spread, which could potentially compromise patient privacy.

For example, in March 2020, the Office for Civil Rights (OCR) published a special bulletin noting that the HIPAA Privacy Rule permits covered entities to disclose the protected health information of individuals infected with or exposed to COVID-19 to law enforcement, paramedics, and public health authorities without the individual’s authorization.³

Interestingly, the accuracy, consistency, and integrity of the data on people infected with COVID-19 were often fraught with issues due to an immediate need to collect data without the implementation of a robust governance strategy.⁴

Coding. The implications of properly coding a virus during a pandemic are crucial to understanding disease incidence and spread. If inaccurate coding occurs, impacts on the reported rates of positive infections may be drastic.

Guidance for diagnostic coding of COVID-19 was released in March 2020 by the Centers for Disease Control and Prevention (CDC).

The CDC adopted ICD-10-CM code U07.1 on April 1, 2020, for COVID-19, which was placed in a new chapter—Chapter 22—titled Codes for Special Purposes.⁵

Section U00-U49 is for the provisional assignment of new diseases of uncertain etiology or emergency use. Under the CDC’s guidance, the U07.1 code was only to be used for confirmed cases of COVID-19—meaning when an individual tested positive for the virus.

In cases where a provider documents “suspected,” “possible,” “probable,” or “inconclusive” COVID-19, guidance was not to assign code U07.1. Instead, coders assigned a code(s) explaining the reason for encounter (such as fever) or Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases.”⁶

Furthermore, when COVID-19 met the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients.

If COVID-19 did not meet the definition of principal or first-listed diagnosis (e.g., when it developed after admission), code U07.1 was used as a secondary diagnosis. Simply put, if a patient has COVID-19, use code U07.1.

At present, there is no other COVID-19 ICD-10-CM code to report a positive infection. AHIMA does offer guidance on coding COVID-19 with ICD-10-CM as new information is continually being released.⁷

As a population, our inherent desire is to trust shared data, but mistakes happen. HIM professionals must maintain their best effort in validating a COVID-19 diagnosis and coding accurately.

Technology. In response to the public health emergency, virtual patient services, especially telehealth, were adopted with a speed and scale unprecedented in modern medicine. Despite obvious advantages and the necessity for remote care, telehealth has inherent risks, including the exacerbation of the digital divide, poor software engineering, and the potential for security breaches.⁸

In its March 2020 bulletin, the OCR announced that it would exercise its enforcement discretion and not impose penalties for HIPAA violations against healthcare providers that, in good faith, provide telehealth using non-public facing audio or video communication products, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.⁹

Certainly, this stance helped accelerate the adoption of telehealth services. However, continued and significant investment in technology development is critical to fully realize telehealth’s potential.

Government needs to support the health technology industry’s development and testing of safe, agile, and accessible telehealth solutions. Healthcare organizations must coordinate with professionals and patients to ensure the full availability of telehealth solutions, that data is kept private and secure, and that solutions are intuitive, flexible, and tailored to organization needs.¹⁰

During the pandemic, clear communication within a healthcare organization was pertinent to ease the stress and anxiety of employees in a time of rapid change. Faltering communications at some healthcare organizations resulted in inconsistent adoption of policies and practices.

Altogether, the call to action for HIM professionals focuses on preparation. Creating policy to prepare for appropriate collection and use of data, adopting technology with proper oversight and direction, and utilizing communication standards that ease the stress of employees are guiding policies and practices that will position organizations for future success during uncertain times.

Performance Excellence

To comply with basic health protocols, many HIM professionals were required to work remotely and often had to take on tasks outside of their primary responsibilities, such as registration and screening.¹¹

The Baldrige Self-Assessment for performance excellence offers foundational components healthcare organizations can use to be a sustainable, patient-focused, high-performing organization.

The following management principles are intended to improve the overall performance of an organization:¹²

• Leadership: How senior leader’s actions and an organization’s governance system guide and sustain performance
• Strategy: How the organization sets strategic objectives and determines key action plans, with the flexibility to change if circumstances require it
• Customers: How patients and other customers are engaged, including how they are listened to, how their expectations are served, and how relationships are built
• Measurement, analysis, and knowledge management: How the organization effectively uses, analyzes, and improves data and information to support key organization processes and its performance management system
• Workforce: How the organization enables its workforce to reach its full potential and how it is aligned with the organization’s objectives
• Operations: Aspects of how the organization works, including the design and delivery of services, innovation, and operational effectiveness to achieve organizational success that persists well into the future
• Results: Examines the organization’s performance and improvement in its key business areas, including patient satisfaction, healthcare outcomes, workforce satisfaction, financial and marketplace performance, operational performance, governance, and social responsibility

Using the Baldrige assessment criteria as a framework for evaluating an organization’s response to the COVID-19 pandemic, clear improvement opportunities exist.

Broadly, the ability to respond to a crisis requires leaders to develop organizational plans that focus on their employees’ best interest, adopt clear, well-communicated processes central to the mission of the organization, and identify ways of measuring their results to illustrate what is working and where further improvement is needed with great commitment to their customers.

The Road Ahead

The greatest takeaways from COVID-19 for healthcare illustrate the propensity for failure with obvious flags for improvement. The fact that the healthcare workforce experienced the highest unemployment rate in more than 10 years during the pandemic exemplifies one failure.

As shown in Figure 1, just over 10 percent of the healthcare workforce was unemployed in April 2020. As of August 2020, the unemployment rate for healthcare workers rebounded to 5.4 percent. On average, the unemployment rate in healthcare is around 3.6 percent.

Figure 1: Unemployment rate of healthcare workers in the United States.

[caption id="attachment_17903" align="aligncenter" width="1024"] Source: Bureau of Labor Statistics, 2020¹³[/caption]

The role of the HIM professional has taken on greater significance in the wake of COVID-19. Between collecting accurate information, keeping that information private and confidential, supporting the analysis of data to understand a public health crisis, developing and communicating the processes and procedures around data governance, central tasks for HIM professionals will help to positively position organizations.

In future pandemics, we need to ensure that appropriate data governance strategies and necessary technologies are established in preparation.

As the custodians and stewards of healthcare data, HIM professionals have a responsibility to the public to be proactive in our preparation for pandemics. After learning these lessons, we must act.

Notes

1. Pew Research. “Most Americans say coronavirus outbreak has impacted their lives.” March 30, 2020. www.pewsocialtrends.org/2020/03/30/most-americans-say-coronavirus-outbreak-has-impacted-their-lives.
2. National Nurses United. “Sins of Omission.” September 2020. https://act.nationalnursesunited.org/page/-/files/graphics/0920_Covid19_SinsOfOmission_Data_Report.pdf.
3. US Department of Health and Human Services Office for Civil Rights in Action. “Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19).” March 28, 2020. www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf.
4. Fernandes, Lorraine, Kerryn Butler-Henderson, and Marci MacDonald. “The Impact of COVID-19 on the Work Life of HIM Professionals: An IFHIMA Survey.” Journal of AHIMA. July 23, 2020. https://journal.ahima.org/the-impact-of-covid-19-on-the-work-life-of-him-professionals-an-ifhima-survey.
5. Centers for Disease Control and Prevention. ICD-10-CM Tabular List of Diseases and Injuries. Addenda. April 1, 2020. www.cdc.gov/nchs/data/icd/ICD-10-CM-April-1-2020-addenda.pdf.
6. Ibid.
7. AHIMA and AHA FAQ: ICD-10-CM/PCS Coding for COVID-19. Journal of AHIMA. September 1, 2020. https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/.
8. Agboola, Stephen and Joseph Kvedar. “Telemedicine and Patient Safety.” Perspectives in Patient Safety. https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety.
9. US Department of Health and Human Services Office for Civil Rights in Action. “Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19).” March 28, 2020. www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf.
10. Blandford, Ann et al. “Opportunities and challenges for telehealth within, and beyond, a pandemic.” August 10, 2020. The Lancet Global Health. www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30362-4/fulltext.
11. Fernandes, Lorraine, Kerryn Butler-Henderson, and Marci MacDonald. “The Impact of COVID-19 on the Work Life of HIM Professionals: An IFHIMA Survey.”
12. National Institute of Standards and Technology. Baldridge Performance Excellence Program. Baldrige Health Care Criteria for Performance Excellence Categories and Items. www.nist.gov/baldrige/baldrige-criteria-commentary-health-care.
13. Bureau of Labor Statistics. “Labor Force Statistics from the Current Population Survey.” 2020. https://data.bls.gov/pdq/SurveyOutputServlet.

David T. Marc (dmarc@css.edu) is chair of the department of health informatics and information management at The College of St. Scholastica in Duluth, MN.

Matthew Blow (mblow@css.edu) is pursuing a Masters of Health Informatics at The College of Saint Scholastica.

Shauna Overgaard (sovergaard@css.edu) is an assistant professor of health informatics at The College of Saint Scholastica.