Two decades ago, a shortage of qualified medical coders led to a new concept—remote coding from home. Initially, the idea was met with skepticism by many experts in the field. According to a 2001 AHIMA article, “Remote Coding at Home: Tips for Success,” the list of issues was long—telecommuting policies and procedures, human resource considerations, departmental process changes, Internet training, hardware/software evaluation, remote access to other systems, and more. Yet, a beta test revealed an increase in productivity by approximately 20 percent and improved coder morale. Overall, a cost benefit analysis indicated a net savings/gain of more than $380,000 annually.
The health information management (HIM) profession has come a long way since skeptics insisted that remote coding would never happen. Today, the possibility of a permanent virtual HIM workforce is a consideration as the new normal evolves post COVID-19. How realistic is a plan to safely return onsite? What would permanent remote HIM departments look like?
In this virtual roundtable, three HIM experts share insights gleaned from their experiences during the initial COVID-19 outbreak. The focus is on challenges and best practices in coding, clinical documentation improvement (CDI), and release of information (ROI). The discussion was moderated by Beth Friedman, founder and CEO, Agency Ten22, a public relations, content management, social media, and digital marketing firm focused exclusively on the healthcare technology industry.
Bill Wagner, CHPS, CPCO, chief operating officer, KIWI-TEK
Mary S. McNerney, RHIA, chief brand officer, Enjoin
Angela Rose, MHA, RHIA, CHPS, FAHIMA, vice president, implementation services and corporate policy, MRO
Friedman: What immediate steps did your customers take during the initial COVID-19 outbreak and shelter-in-place orders? What rapid-response best practices were established in coding, CDI, and ROI?
Bill Wagner: I’m proud of our country’s HIM professionals for their ability to quickly change existing workflows and policies to adapt. They saw their patient volume drop by 70 to 80 percent within a couple of weeks. They had to cut staffing, figure out how to have the remaining staff work remotely, train the coders on new coding guidelines, and educate clinicians on how to document new telehealth visits and COVID-19 testing and treatment. Many of these encounters were not set up to be documented in the electronic health record (EHR) or coded in the chargemaster. Billing systems, not recognizing these new encounters, created large numbers of edits that required rework. New coding guidelines released by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) had to be adopted and incorporated into the coding process. Payers, experiencing the same issues, created huge numbers of denied claims. All of these issues fell on the shoulders of the HIM staff and they responded quickly.
Mary S. McNerney: Most of our customers sent clinical documentation specialists (CDS) home and all had to quickly adapt to new coding and telehealth guidelines. Documentation guidance became critical and we implemented The Breakroom to support coding and documentation teams that may have lost their physician advisors to direct patient care. They have also enhanced the software that was already in place in order to prioritize accounts. While many of our HIM colleagues have never been busier, overall volumes have decreased. As a result, many customers have furloughed employees and reduced work hours to meet lower volumes.
Angela Rose: Our customers moved at different paces, but we saw the closing of walk-in windows/front desks immediately and as the weeks progressed. About half of the departments transitioned from working onsite to either working from home or operating with minimal staff.
Our team analyzed and redesigned workflows to promote a contactless environment as much as possible. We provided multiple workflow alternatives to our customers to help them make the best decision for themselves and their patients. And, numerous educational resources were published including three webinars, along with articles to provide guidance for our customers and the general public.
Friedman: Now that COVID-19 is rising nationwide, what are you hearing from customers? What has changed from the initial HIM response?
Wagner: The elective surgeries have resumed and chronically ill patients have returned for treatment, but nowhere near the numbers that existed previously. Many patients are still hesitant to seek treatment and risk infection. Facility quarantine policies have reduced the number of patients that can be admitted at one time. Many of the aforementioned challenges have been addressed, but there are still thousands of coders out of work.
McNerney: Initially, adjusting to new and constantly changing coding guidelines was a challenge. Now that we’re past the learning curve, productivity levels have improved. One of the biggest struggles was handling queries—how to get physicians to complete queries in a timely, efficient manner. We’ve learned that some of our customers quickly created templates that make it easier for physicians to capture everything associated with COVID. Today with CDS and coders as “guardians of the data,” documentation and accurate code capture are vital as we continue to collect data to support COVID research.
Rose: HIM is considered essential so there is a mix. About half the staff remain as virtual as possible, but skeleton crews rotate working onsite—either by teams or by schedule—one to two times per week. I see very little difference from the initial HIM response because they continued to practice what was implemented initially. Some opened walk-in windows but have since reclosed them with no intention to open again this year, if ever.
Friedman: Beyond coding, CDI, and ROI, how have you seen HIM leadership shift and adjust? What are you hearing from HIM directors regarding the remainder of 2020? How has HIM management changed?
Wagner: There is a lot of uncertainty remaining. No one can accurately predict patient volumes by type of service or the staffing needed to accommodate those volumes. Financial budgets have been thrown out the window. That places a hold on normal planned expenditures for IT upgrades, training, education, expansion, and more. Everyone is basically dealing with immediate and short-term issues while adopting a wait-and-see attitude regarding longer-range needs.
McNerney: I agree. With the shift in volumes and uncertainty, HIM management will need to be flexible and adapt to an enhanced leadership style with a focus on communication and thinking outside the norm. As we have learned from some clients, with management and director levels alternating work schedules with a reduction in hours, the public health emergency (PHE) requires more connection with all employees and virtual support with resources and education. This will also dictate the need to focus on technology and efficiencies.
Rose: A lot of HIM leadership remain virtual. Many daily operations are managed from a virtual office. Some departments are choosing to remain virtual through 2020. Some offices are moving to a virtual environment permanently, which requires a change in management style and approach. It means taking measures to keep staff engaged, hold them accountable, and maintain current productivity levels from your home office versus onsite. Identifying new benchmarks for productivity and turnaround times must also be reassessed.
Friedman: Looking long term, do you believe completely virtual HIM departments will be permanent and why?
Wagner: I do not believe that this will happen completely in the near future. While the coding can be done all or mostly all from a home office, there will always be a need to connect with related functional areas in a more personal, face-to-face encounter. Even if the appropriate technology is in place, we cannot expect patients and clinicians to fully embrace such a radical change for some time. It will be a gradual evolution.
McNerney: We predict the future will be heavily virtual with some varied degree of returning onsite. Coders have been remote for quite some time, so a 100 percent permanent transition for CDS may take more time. In fact, some of our customers say they expect very little onsite or hybrid work for CDI specialists and coders in the future.
Rose: I think there will be a mix, and it will be dependent upon geographic location. Most likely, there will be a rotating skeleton crew, as mentioned above, for the foreseeable future. Now is the time for HIM leadership to think outside the box to identify not only the most efficient and effective virtual workflows, but also to reset expectations and drivers for success. As an industry, we will need to focus on what has been working in the past four months and what is sustainable into the future. We can also look at what’s not working and reshape it so that it works.
Friedman: Are there any HIM staff that must remain onsite and why? Or why not?
Wagner: I see a need for an onsite contact person for patients to access their records. HIM management will also need some representation to deal with the coordination required with other departments.
McNerney: For the most part, HIM staff continue to work remotely with the exception of a few staff members coming into the office once or twice a week. The communication between CDS and physicians is important and may require some face-to-face interaction. With new technology, it’s becoming easier to have a remote workforce. Weekly team meetings via a visual presence are a top priority.
Rose: From an onsite ROI perspective, walk-in windows/front desks can become completely virtual with the use of a kiosk to request records, or with the ability to submit a request online or use a phone app. Further evaluation will be required regarding staff assistance to help any onsite patients and pull non-electronic PHI (microfiche/film, paper records, etc.) to fulfill requests in a timely and compliant manner.
Friedman: What operational workflows, processes, procedures, management, and technology will need to be in place to support permanent virtual HIM departments for the next year or two?
Wagner: First and foremost is the security of the applications, technology, and workflow used to access PHI remotely. There are very stringent HIPAA requirements and recommendations for the remote office. The sharing and transmission of any PHI also represents a security risk. Virtual conferencing, especially if recorded, is another privacy and security risk that must be addressed.
McNerney: Measuring productivity will be critical going into the future. The companies that can monitor their workforce will be most successful in a virtual format. Also, resources to support telehealth as well as workflows and processes related to a possible increase in denials will need to be addressed.
Rose: Many of our employees are working at home, armed with secured equipment and updated policies and procedures. Here is a summary of a remote work checklist:
- Policy and Procedure: Workspace requirements, devices, disclosure of PHI, work schedules, incident reporting, productivity, remote access/confidentiality agreement and other related guidelines.
- Workspace: Private and secure. Power off smart homes during work hours.
- Devices: Sufficient inventory. Perform routine updates and maintenance on all devices, personal and organization owned.
- Connectivity: Functional, secure internet access.
- Authentication: Secure passwords and multi-factor access to your network.
- Communication: Messaging, meeting platforms, email, phone calls. Schedule regular calls, encourage video.
- Education and Training: Virtual sessions and learning modules. Provide reference materials and the most current information on the crisis.
Friedman: Futurecast HIM in a virtual world. What does the department and function look like if HIM departments become permanently virtual?
Wagner: First, the privacy and security issues mentioned previously would have to be in place. I can see a completely closed, protected enterprise system for telecommunication with other staff, CDI, clinicians, billing, etc. This would include instant screen sharing to resolve questions, queries, billing edits, and other matters. At odds with that concept is that the pandemic has shown us the importance of interoperability in improving patient outcomes. Unfortunately, increased sharing of data also dramatically increases risk in regard to the security of PHI. Balancing improved patient care with security is a difficult dilemma that will have to be resolved.
McNerney: As of now, I think most of our clients are unsure as to what the future of CDI and coding will look like. However, they are confident in their ability to support a fully virtual workforce, ensuring the privacy and security of PHI with employees working from home as a top priority. From a CDI perspective, our clients will continue to support accurate documentation and interaction with physician advisors, but this will most likely be handled at the supervisory or management level.
Rose: Here are three main points to consider if HIM departments become permanently virtual:
- A rotating skeletal crew or minimized schedules will still be required to manage onsite daily operations where paper still exists.
- ROI could be completely virtual if records are all accessible electronically.
- Human contact is important. Bring your team together quarterly or twice a year for team building, education and training, etc., once the pandemic is no longer a threat.
What Employers Need to Know and Do for Safe Worksite Re-Entry
1: Legal Considerations
- Secure HIPAA release consent
- Review confidentiality requirements
- Understand ADA and Title VII Accommodations
- Know compensability guidelines regarding testing
- Establish protocol for managing infected employees
2: Worksite Safety
- Form a re-entry team to manage planning
- Evaluate your physical space for safety
- Outline plans and employee resources
- Clearly communicate return-to-office plans to employees
- Maintain a feedback loop with employees
- Implement targeted testing protocol that is mindful of:
- Pre-existent employee health threats
- Risk associated with various roles within the organization
- Probability of transmission in each office environment
- Understand your test type options, including at-home test kits
- Use tech to manage the testing, results tracking and follow-up
This checklist was shared in a recent BioIQ webinar.
Beth Friedman (firstname.lastname@example.org) is founder and CEO of Agency Ten22.