6/20/05
Managing the EHR: New Job Descriptions for HIM Professionals
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: For the past few months this column has been exploring job positions for HIM professionals that have emerged as a result of the transition from paper medical records to electronic health records (EHRs). (See Hands-on Help columns April 25 and May 23.) Today we would like to learn more about the new jobs that arise within HIM departments to manage document management systems.

Patty: Let's talk with Nicole Walker, RHIA, associate director, HIM at The University of Texas M.D. Anderson Cancer Center in Houston. Approximately 70,000 patients receive care there annually, and more than 12,000 patients participate in clinical research, the largest such program in the nation. They have about 2,500 to 3,000 clinic visits daily.

Leslie: Nicole, please tell us about your organization's EHR.

Nicole: We have several clinical information systems, managed through a portal, in which all authorized users access information via our "Clinic Station." The Clinic Station is a viewer, which enables users to log on through a single sign-on to view patient information. It is a homegrown system developed by one of our physicians. We started approximately 5 years ago and have been adding to it over the years.

Patty: What electronic systems are accessed through the portal at this time?

Nicole: The main components are laboratory, pathology, diagnostic imaging, radiology, transcribed reports, clinical schedules, demographics, cardiology and scanned documents.

Patty: It sounds like your organization has implemented document imaging, a component of electronic document management systems, as an integrated component of the EHR. If I understand correctly the document imaging component is its own application without interfaces to other clinical systems. It is not a repository for anything other than scanned documents. It is accessed via the portal, as are the other clinical applications. Because of the user interface used on the Clinical Station, it's transparent to users where the data actually resides.

Nicole: That's right Patty. M.D. Anderson Cancer Center utilizes document imaging for scanning and storing paper-based documents and does not receive data from other systems. As such, it is not a repository for data from other clinical systems.

Leslie: Please tell us about the impact of the EHR and specifically document imaging on the HIM department.

Nicole: Our physical environment has changed. We were able to get rid of the large file rooms. Our employee's work at computer stations now and all of our old paper records are stored off-site. They are retrieved mostly for research purposes.

Patty: Did you do any back scanning when you implemented document imaging?

Nicole: Yes, on a limited basis. The steering committee determined the historical documents needed for patient care in returning patients and for research purposes.

Another impact of the EHR on our department is that morale has increased and the work is a lot less physical. As you can imagine, records of cancer patients tend to be very large. The average medical record was approximately 6 inches, and we were pulling, carrying and re-filing more than 3,000 records a day.

Leslie: Did you reduce the number of full time equivalents (FTEs) as a result of implementing document imaging and other EHR components?

Nicole: To date, we have not reduced FTEs. We actually had to add additional resources when first starting the project. We do anticipate, however, reductions over time.

Patty: Did clerical staff see the change as an opportunity for them?

Nicole: Most of them did. Some retired, but many stayed and took advantage of the opportunity to grow. We created a new position of HIM associate with a higher skill requirement. Formerly classified as HIM specialists and senior HIM specialists, employees were given the opportunity to transition to HIM associates by first qualifying to be put on document management teams, and then meeting the defined productivity standards for 4 consecutive weeks. That made them eligible for promotion and a pay grade increase if all other factors were in order, such as attendance, etc.

Leslie: What kinds of new positions were developed for credentialed HIM professionals?

Nicole: We created three new positions: project analyst, forms analyst and quality control coordinator.

Leslie: How many project analysts do you have and what do they do?

Nicole: We have two project analysts, both of whom are registered health information administrators (RHIAs). They serve as liaisons to the clinics and ancillary areas. Their responsibility is to analyze existing methods and procedures related to information flow in the clinics to promote efficient and effective operations. When document imaging was being implemented, they collaborated with the clinicians and support staff to organize and develop new workflow. In essence, it was their job to make sure that the system would work well for each clinic. They provided training and made sure that everything worked perfectly for the users.

Patty: What is the key to their success in this function?

Nicole: It's all about forming good, collaborative relationships. They got to know people, to understand their needs and responded to their concerns. It was a big change for the users to go from paper to the computer and having a knowledgeable and patient resource made it easier for them. I believe that HIM is viewed very positively throughout the organization as a result of this approach. We are appreciated for the expertise that we bring to the organization.

Leslie: Do the project analysts work solely in the clinics?

Nicole: No, they are also our workflow experts in the HIM department. The things that they learned about workflow in the clinics drive the decisions that we make about our workflow. For example, by knowing how the clinic uses the patient record they brainstorm with us on how to best achieve our goals and meet the users' needs at the same time.

Patty: Please tell us about the forms analysts.

Nicole: We have two forms analysts. One is a registered health information technician (RHIT) and one does not have an HIM credential, but has extensive forms management experience in the oil and gas industry. They are responsible for analyzing proposed and existing patient care forms for standardization, improvement, simplification or discontinuance as appropriate.

Leslie: This sounds like a pretty important position whether you have paper or electronic documents.

Nicole: That's right Leslie. When we started the system we wanted to have a better forms control process, so we became a key player in the interdisciplinary documentation committee (IDC) to review new and revised forms. The existing medical record committee also reviews new forms. In addition, we wanted to realize the full benefits of document imaging by utilizing electronic forms management software. To achieve this goal, we created an electronic forms library. Now clinicians and clerical staff can print forms on demand or have them scheduled to print.

The forms analysts met with representatives from each clinic to identify what forms comprised a visit packet for various appointment types. We then programmed the visit packet information into the electronic forms management system. Today, when users print forms, they enter the patient's medical record number and the system generates the whole packet of forms or an individual form needed to document the care. Forms print with the patient's demographic information as well as barcodes. The barcodes indicate the type of document, the date the form was printed and the medical record number. By having these barcodes on the form it automatically sends the form to the proper place in the scanned online record. Today, because of electronic forms management, we have bar codes on about 69 percent of the forms.

Leslie: Do you ever anticipate a time when all forms will have bar codes?

Nicole: That will be difficult because we have some information, like correspondence, that comes from the outside.

Patty: You also mentioned a new position of quality control coordinator. What are the job responsibilities assigned to this position?

Nicole: Yes, we have one person, an RHIT, who is responsible for reviewing the quality of the document imaging process. He performs random sample audits and audits of individual performance. He follows up on customer complaints and provides statistics on scanning quality and indexing accuracy. These statistics are included in the key quality indicators on a consolidated report that goes to the assistant vice president.

The quality control coordinator also assists users who want to know how to find scanned documents. This is mostly for new employees or medical staff who are not yet familiar with the system.

Patty: What percentage of records does he audit?

Nicole: He audits 10 percent of our daily discharged records and also does a 25 percent random sample from the daily work we process from the outpatient clinics.

Leslie: What have been your biggest challenges in the 4 years since you implemented document imaging?

Nicole: The staff transition, training and communications were my biggest challenges. It was such a tremendous change for our staff as well as for our customers. Some of our users were very reluctant to give up the paper record. It took a lot of communication and finally the chairman of the medical record committee made the decision that we would not pull any more paper records. We implemented that policy clinic by clinic over a period of time. It was painful for some, but today we only have two physicians who actually still receive some paper records.

Patty: You have seen your department through a challenging transformation. Do you have any tips for your peers?

Nicole: Prepare and educate your staff and the users as early as possible, and keep open communications. Create a tight forms management process with a forms approval process that is interdisciplinary. Make sure you have champions. We had great physician champions and it made all the difference in the world.

Leslie: Nicole, thank you for so generously sharing your EHR journey and for helping us to better understand the new HIM positions that emerged.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president of Care Communications Inc., a national HIM consulting and staffing company headquartered in Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com .