What We Mean When We Say Health Information Improves Healthcare Outcomes

Let’s talk first about each of your professional backgrounds. Dr. Marc, you’re the health informatics and information management department chair, and the health informatics graduate program director at the College of St. Scholastica, and Dr. Sandefer, you’re the vice president for academic affairs. How did you both end up at the College of St. Scholastica?

David Marc: My pathway intersects with Ryan. I have a bachelor’s degree in biology and psychology, and then I went on for my master’s in biological sciences. I was always interested in research, and I worked for a research lab where I was the resident data scientist. During my master’s, I took a course in health informatics, and I found my people there. So I decided to go for my PhD in health informatics.

That’s where I met Ryan, while he was also getting his PhD in health informatics. We got to know each other while working on a couple of projects together, and he said, “Hey, you seem to be kind of good at this data stuff. Do you want to teach at The College of St. Scholastica as an adjunct faculty?” And I said, “Yeah, sure, I can give it a whirl.” So I did.

Then, six months later, they had a position open up, and I was nearing the end of my doctoral studies, so I pursued that opportunity. I was hired as the health informatics graduate program director where I started the health informatics graduate program at the college. Ryan was the chair of the department at that time, and then Ryan moved into a new position at the college, and I took his role as the chair of the department.

Ryan Sandefer: I have a background in political sciences and health services research. I got my master’s degree in political science, and I went into a research role at the University of Wyoming. I was doing a lot of research, consulting, telemedicine, and telehealth technology projects, which gave me a real orientation to help health information technology and opened up a lot of pathways for me, kind of like David. We were working within the field without really knowing we were with our people, so to speak.

So, I had an opportunity to take a job at the College of St. Scholastica as a research scientist. I was working on some implementation projects in rural hospitals, on trying to drive outcomes improvements related to efficiency, utilization, data quality, different projects with speech recognition, other tools, and technologies. I had a role here at the college doing research, and ultimately became a faculty member, and then a department chair.

Then, ultimately, I got promoted up to higher levels of administration at the college, where I am now. And thank goodness, because it gave David—someone who really knows what he’s doing—a chance to take the reins down there in the health informatics program. I have my PhD in health informatics as well.

Tell me a bit about the health informatics master’s program at the college.

Sandefer: One of the things we know from our practice within industry is that the continuum of health informatics is pretty wide. We have all kinds of different competencies that are required. David and I felt very strongly that we needed to create a program that was very experiential, very hands-on, and very data-focused.

We wanted to make something that was applied because we felt that was something missing and a great need within industry. We’d both been working a lot with health information management professionals in the teaching we’d done, and we knew early on that health information management professionals were really a target audience for us in terms of their deep knowledge of classification systems, data utilization within organizations, and compliance, but there was a real need for technical knowledge within analytics.

So, we wanted to have it be broad enough to be applicable for many roles but deep enough in the analytics area so people can make an immediate and real impact on their organization or within their disciplinary area.

That’s the way we’ve approached our master’s program here at the college—really making sure that it was applied, that it was focused on data, and that it provided an opportunity for interdisciplinary collaboration. We knew we wanted to target within health information professionals because it was a real need for the industry, but we also wanted to make sure that we could make it broad enough to attract clinicians into our program to provide deep knowledge and learning among the cohorts that are coming into the program.

And that has come to fruition, so we’re really excited about the work that’s happening. We launched the program in 2014, and the program continues to grow. We’re very excited about the trend. And not only the trend and the numbers, but also the trend and the professional backgrounds of the individuals. It keeps getting more and more diverse, which is strengthening it.

Marc: We’ve always had a decent number of medically trained professionals in the Master of Science in Health Informatics Program. What’s happened since the start of COVID-19 is we’ve seen more clinicians, nurses, physicians, pharmacists, lab technicians, physical therapists—a number of different clinical professions—interested in health informatics, and I think it’s this balance between the requirements of what it means to be a professional in a clinical profession, and there’s a lot of burnout happening. They’re looking for ways of enacting change still, but maybe that’s less direct interactions with patients and more about the processes, the data—ways of enacting change in other ways through technology. That seems to be a continuing movement; our percentage of students with clinical backgrounds is continuing to rise.

Why do you think it’s important for the profession to elevate itself from a mostly baccalaureate level to higher degrees?

Marc: At the College of St. Scholastica, we have two separate programs: We have a Master of Science Program in Health Information Management and Master of Science Program in Health Informatics. What we’re seeing are the master’s programs—whether it’s health informatics or health information management—employers are looking to hire people who are trained to be in these leadership roles within the organizations. They are looking to make decisions that are efficient, effective, and evidence based; that their employees have the skills to make those data-driven decisions; that they understand the healthcare landscape; that they know how to manage people—that balance between soft skills and technical skills is incredibly important.

So, I think what the employers are finding is that by investing in people with a higher level of education, they have greater success in finding those candidates who have that training that is needed to lead teams. I think that’s probably what’s happening in the workforce. That’s what we’re finding too with our discussions with our alum who are in those management roles; they’re looking to hire people, and they want people who have those leadership qualities as much as the required hard skills.

Sandefer: I’m going to say this, not only to toot our own horn, but also to tee up what I want to say about why we need to change. The College of St. Scholastica was the first college in the country to offer a four-year degree in health information management back in 1934; it was medical record science. We’re also the first to offer a master’s degree because we saw the industry need at that time. So, we’ve had a master’s in HIM for well over 20 years, and we were the first to do that, which was very cutting edge at the time. I still think it is. Obviously, there are a lot more programs now that are being offered.

I think this is just another part of that continuum, this trend of trying to advance. Most healthcare organizations, if you have management in the title, they’re shifting to needing more and more education as a prerequisite to be in those roles. Change is constant, and the complexity of healthcare today is much more complex than it was five years ago, than it was 10 years ago. Organizations are looking for highly skilled individuals, and there’s a relationship between higher education, critical thinking, and the ability to lead effective change within organizations. Things aren’t getting any easier, and the pandemic has only demonstrated the importance of being able to leverage information as an asset.

The better skilled people you have, to manage people, data, and processes, the more effectively you’ll be able to respond to significant challenges facing your organization or department. So, I think that that’s what’s happening.

It’s very important that we are seen as a profession that is prepared to lead change, and part of that preparedness is being seen as having the knowledge, skills, abilities, and educational background to be seen as a member of the team. Right now, every other profession is having the same conversation. Many of them are not talking about moving from associate’s to bachelor’s—many of them are moving from master’s to doctorates. So, where can we show our relevancy the most effectively? Part of that is just the proportion of our profession that is master’s prepared.

For someone thinking of getting a master’s degree in either health information or health informatics, can you talk about the differences between them?

Marc: We get that question all the time. The best way to understand it is that for health information management, that word “management” is important. You’re managing people, processes, and policy that is related to healthcare information, data, and technology. So, it’s the management of the people and the processes that predominates that profession.

Health informatics tends to focus more on technical skills. It’s a different interaction with data; you tend to be doing more of the analysis of that data. Developing technologies tends to be an important aspect. Health informatics, just generally speaking, does require more advanced technical skills in computer information systems, data analytics, data science, databases, and so forth.

Those who tend to be more interested in technology, they tend to go more into the health informatics side of things; those who tend to be more interested in the management of people or developing policy or operating procedures within an organization tend to go the HIM route.

Sandefer: I view it like a Venn diagram. There are competencies and skills that HIM professionals and informatics professionals share, but informatics is truly defined as the interaction between people and technology. So it’s really driven by technology and the interaction between people and computers, whereas HIM is not necessarily that, although there is a relationship.

The intersection of computer science, statistics, data, and healthcare is where informatics lives. HIM is a bit broader and really focuses on the management of people, technology, data, and revenue—managing risk more than so than just technology.

We often talk about improving outcomes when we talk about health information. When we say “outcomes improvements” in healthcare in the context of health information, what does that mean exactly?

Marc: We have a triple aim of cost effectiveness, cost efficiency, and quality of care.

When we’re thinking about outcomes, the outcomes could be related to the quality of care that healthcare organizations are providing. For example, what are the readmission rates for a hospital, as a measure of quality? What are the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) measures, which would measure patient satisfaction—that’s a quality outcome related to the clinical care that’s being delivered.

Cost is another aspect; there are outcomes related to cost.

And then efficiency: time to care; what are the emergency room wait times? Those are all important outcome metrics.

So, when we’re talking about outcomes improvement, simply what that is, is making improvements on those measurable outcomes. You need to measure change. You don’t want to see things worsen. You want outcomes improvement. You want to see those measures to eventually have some sort of measure or marked increase or improvement.

Sandefer: If healthcare is good at one thing, it’s good at collecting information at a very discreet level on almost everything, whether it’s counting gloves used or whatever. The problem is that some of our outcomes are awful within healthcare. They’re truly awful, especially when you think about that comparatively. So, it’s extremely important for us from a values perspective that we value quality of care.

The reason why we got into this business is to actually help people. We want to make a significant impact on patient outcomes largely, but we can’t do that if we can’t collect information and measure what it is that we’re doing so that we can actually improve it. I think we know that we have a lot of work to do. Even though we’re very advanced, we have a lot of work to do in terms of what care we’re providing, how we’re providing it, and to whom we’re providing it when.

And then, in particular, we have major disparities by all kinds of different factors—socioeconomic status, race, geographic location. These are things that we know. We know that there are drivers in some of these quality areas that we can have an effect on. We need to collect this information and present it.

This is why informatics is important. Some of it is just about how that information is presented, to whom, and for what desired effect. If we can’t put information in front of those people who are having an opportunity to change their behavior, whether that be a nurse, a physician, or a CEO—for example, around the timeliness of care from an emergency department perspective, or the frequency of C sections before a certain date and in the pregnancy, or whatever—if we don’t present that information in such a way that will actually have an effect and that we can trend track trends on, we won’t be able to make those improvements that we say we value.

Is “improvements” always an objective value, or is there a level of subjectivity when it comes to “outcomes improvements”?

Marc: It’s up to leadership to define in healthcare organizations. Nowadays, in a lot of hospitals, morale is an important outcome. How you measure morale effectively can be difficult. So, there are decisions and outcomes that could be more subjective in nature that are still very important outcomes. How you respond to not just data, but also feelings and reactions that may not be as objective, I think that is important and very much a reality.

However, in healthcare, we do like to measure things. So, we like to have a data point to be able to see a change of. When we talk about something subjective, there is oftentimes an attempt to develop an objective measurement of that. That could be through employee satisfaction surveys then creates some kind of key performance indicator or measure that they want to have a benchmark for employee satisfaction. If that survey is falling below that line, then leadership might respond or do something different in response to that data point.

Sandefer: I honestly think this is a really good question, because there are quite a few really reliable measures of quality, right? We have tons of measures within healthcare that we calculate and we report, and in fact now they’re embedded within quality improvement or pay-for-performance programs. They’re being used not only as mandatory reportable measures, but also they’re tied to the hospital’s value based care programs and the readmission reductions programs, and so on. These are built within those for incentive-based payments.

But you’re right, some of the questions being utilized in there are, while they are objective from the standpoint that they’re asking patients their perceptions on things, some of them are questionable in terms of the reliability and validity of whether that measure really is a quality indicator for nurse communication to direct patient outcomes for whatever the diagnosis would be.

But to David’s point, morale is a good one. How do you objectively measure morale? How do you measure empathy? How do you measure the level of empathy that your caregivers are showing to patients? I don’t know.

Marc: We do have objective measures where there is a significant level of subjectivity in how we get to a number. Like in long-term care with the surveys that are done; you might get one surveyor who gives you a score and a different surveyor who gives you an entirely different score. There is a level of subjectivity in our objective attempts.

How can someone on the individual level impact health outcomes? How can they assure the work they do is relevant and meaningful?

Sandefer: The most important thing they can do is show up. Education provides an opportunity to open doors, and once you’re in the organization, once you have a position, it’s very important to show up, be at the table, and be a contributor, because most of the time, organizations are looking for people to step up and do work.

The knowledge, skills, and abilities of these HIM and HI professionals—these people are skilled individuals who have a lot of individual knowledge to be put to work, and they need to make sure that their voices is at the table and contributing because, most of the time, there’s no right answer.

It’s about working collectively as a team to drive change. What’s the priority of your organization? What do you see in your region in terms of a need of the community? What are those disparities within your community that we could actually measure effectively and present to the board?

Whatever the case would be, that voice of and knowledge around what data we have, where is it located, how reliable is it, and how it can be put to work for the benefit of the organization and the community we’re serving—without that voice at the table, you’re adding to the problem not adding to the solution.

Marc: We train our students how to think critically about problems with regards to outcomes improvement.

You can look longitudinally at data from where it’s collected, where it’s stored, how it’s collected, to its eventual use and destruction of that data. Health information management professionals are really at the center of that; they need to ensure that data is collected in a meaningful way, it’s stored securely, and it’s stored in a way that the data can be accessed for outcomes improvements and being able to respond to that data. Then it’s the appropriate reports are ran around that data, that the data is then interpreted correctly, and that it is only in the hands of the people who need it.

So, there are a lot of aspects of health information management professionals. The outcomes would exist, but you wouldn’t have any data to respond to.

Outcomes aren’t direct, and certainly not immediate. So, is it often the case where people are working in this field and they don’t get to see the how the data is implemented? In other words, they might be working toward these outcomes, but they don’t actually get to see the outcomes. Is that a challenge?

Marc: Yeah, I think so. A lot of times, the HIM professional is asked to support a process of acquiring data for some purpose in developing a report or tracking on some outcome, but they may not be the ones to make the decisions or respond to that outcome or be involved in the conversations related to that outcome. So, I think that can be a challenge within some organizations.

With that being said, though, I think there are many instances where that isn’t the case. The health information management professionals who are in leadership roles, they might be the ones making sure that the information is being understood in a correct way and leadership is responding to it in a responsible and effective way. I think it really depends on the individual within an organization.

Sandefer: Think about it from a technology implementation standpoint. We have a need, we implement a new system, that system is utilized ideally to serve a purpose, whether that be to collect more accurate information or to be assistive to a caregiver. But I think the bigger problem is the other way around.

Oftentimes, health information professionals or informatics professionals are brought in way late in the game, and they’re asked to try and measure something with information that’s already collected without the advice and expertise of the individual on the front end to say “This is the way it should be collected.”

I’ll give you an example. I was working on a project where we were trying to standardize quality measures across five rural critical access hospitals for the purposes of a data exchange, so that they could get relevant numbers across multiple communities to make meaningful sense of it. All five institutions had implemented their systems in such a way that it was collecting the information different enough where it was impossible to aggregate that information. We came in way late trying to standardize, and it took months and months and months of in-depth conversations on data granularity that no one wanted to be having at that point, simply because there wasn’t that coordinated and collective approach from the front end. So, that’s the problem; there’s all this waste of resources to try and standardize something way too late.

How do you solve for that problem?

Sandefer: I think this is a systemic problem. How do you train your leaders to make sure that you have well representation across the institution and at the table.

That’s how we deal with it at the college, making sure that we have the right voices. If we have something about student retention, we want to make sure that we have a good collection of faculty, student affairs, finance, etc., around the table.

It’s the same in healthcare. Ultimately, you’re looking at the chief information officer to hold people accountable for doing that. There is a part of that issue with data integrity. This is what AHIMA was focused on for so long, whether we call it data governance, information governance, whatever we call it, there aren’t best practices out there to ensure that the information we’re collecting and the way we’re utilizing it has value and integrity. That’s why you have these programs in place.

On the other side, we also hold responsibility for this, and we have an obligation to act. We have a responsibility as professionals to step up and try to articulate what value we bring to the table. I think, historically, we’ve had problems with making sure our voices are heard—at the department level, at the division level, at the institutional level.

I’ve heard it a hundred times at the House of Delegates or otherwise, that we want AHIMA to let our organizations know who we are. How do we articulate who we are to our organizations? And what opportunities do we need to grow as professionals? Whether that be through professional development, whether that be through mentoring, whether that be through formal academic education, etc.

Sooner or later, informatics professionals are going to have to be responsible to step up and take more senior leadership positions within organizations if that value is going to be understood, shared, and acted on.

It’s become easier for organizations to not see the value in HIM professionals the longer the pandemic goes on, because there’s more and more remote work that’s driving people who can work remotely out, and of those individuals who are not likely to stand up to begin with, it’s compounding the problem from a physical geographic location of where you’re working.

I don’t know how to articulate that very well, but I’m concerned about it. I’m concerned about the further you get in distance from individuals who are responsible for enacting change, what does that do to the profession as a whole?

Marc: With regards to health information management professionals being at the table, there’s a personal responsibility to put yourself in that position to find those opportunities and take advantage of them. And also with organizations that have leaders who recognize the potential of their employees and the skill sets of their employees in where they can have a return on the investment of hiring HIM professionals.

I do feel like there still is a level of education that is needed for healthcare leaders to really understand what HIM is, and we’ve been talking about this for years. They’re never going to know until unless HIM professionals step up and actually make themselves known and valued.

As the world continues to change—you’ve mentioned some recent changes—what are the health information roles of the future?

Marc: I think that population health is going to continue to expand. I think what COVID-19 has done is illustrated how, as a community or population, we need to be responsive to data. And that’s opened the door for responding to data in other ways. That role of HIM professionals in supporting population health efforts will continue to expand. Also, I think that it is related to a greater need for more technical training for HIM professionals to have the skill set needed to work with data effectively.

Sandefer: I would echo the data piece. There’s a major need there, and there will continue to be a major need for, risk management. All this involves data analysis, but risk management from the perspective of staffing, revenue cycle, pandemic response, and pandemic planning—all of these things are heightened right now when you’re thinking what’s the role of a human resource informatician.

Because that’s really what we’re dealing with right now: How do you actually put the puzzle together from an HR perspective to keep the doors open, to keep the revenue flowing, and to ensure that quality? You’re going to need some individuals with significant skill to try and navigate those waters. There’s a lot of risk right now and ongoing, given the burnout factor of employees and the relative risk of what that burnout could mean financially for individuals and organizations, which are in a pretty precarious space right now.

The margins aren’t great to begin with, and when you start talking about giving up elective surgeries for prolonged periods of time, there’s a lot of risk to the organizations financially; there’s a lot of risk to the organizations from a compliance and quality perspective. And what are these other, subjective measures around how you track morale and empathy, and then what is the long-term probability of significant negative impacts if those things aren’t controlled?

There’s a huge opportunity for information professionals to play a role in those discussions, and those roles aren’t currently defined. I think people are doing them ad hoc, but long term, I think this will be an area of any organization’s pandemic response plan: How do you have these sorts of individuals at the ready?

What do you see as the way to keep pace with that future of healthcare?

Marc: We are attempting to always respond to the needs of the workforce, and we pay particularly close attention to those needs. So, a lot of our scholarly work as faculty is an evaluation of where we are at as a profession and as a workforce. We attempt to change and adjust to change by making sure our students are getting the training that’s needed to prepare them. That’s been a part of our academic history and our tradition that we uphold.

Sandefer: As informaticians, we have many opportunities to look for a professional home, and we look at AHIMA as our as our professional home because of the history there, but also the applied nature of what the profession does in terms of the deep knowledge and understanding of data and information and how it should be used for many perspectives within organizations. We try and lift that up; we expect our students to be engaged professionally.

We’re trying to make every aspect of our curriculum that we can be applied and experiential. If they’re going to be conducting research, we expect it to be applied and practical, and drive change for an organization or be helpful for an organization that is trying to apply change. So, we look to AHIMA for resources and guidance on that as well. We’ve been partners on that for a long time.

When we think about utilizing technology in the VLab, and the AHIMA Health Information Body of Knowledge, for example, we’re looking to the guidance of the profession to help drive and provide resources within our curriculum that we can use prepare people for the workforce to be the next change agents. We’re excited about that ongoing partnership into the future.

Do you have expertise relevant to improving outcomes, preparing health information for the future, solving problems with health information and health data analysis, or leading healthcare organizations? AHIMA is accepting proposals for two upcoming conferences—the Assembly on Education (AOE) and the AHIMA22 Conference.