1/3/2006
EHR Goals Accomplished in 2005: Part 2
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: The transition to e-HIM® and electronic health records (EHRs) continues to be a primary focus of HIM leaders in health care facilities around the country.

Last month we checked in with two of the three people we spoke with in January of 2005 to see how they progressed on their 2005 EHR goals, and to talk about the priorities for this year. We caught up with the third person, Susan Carey, RHIT, division director of HIM at Norton Health Care, a five-hospital health care system in Louisville, KY, in early December. She too has had an interesting and productive year of progress toward her goals.

Patty: Susan, please share with our readers how your year went–the accomplishments and lessons learned.

Susan: It has been a busy, but most interesting and challenging year for me. I enthusiastically had planned to launch my e-HIM strategy last January, however, I quickly realized that we had more work to do on our infrastructure as we were still on two different platforms. So in 2005 we upgraded two of our hospitals to the latest version of our vendor's system and a third will be upgraded in early 2006. Then all five hospitals will be using the same software applications so we can have consistency in the reporting of data and the performance of other functions.

Leslie: Well, that certainly makes sense. As you create and standardize e-HIM processes, you want the HIM staff in all five hospitals working from the same playbook, all using the same tools.

Susan: That's right, Leslie. We also had other issues to address. With everyone on the same version of the system, I determined that 60 percent of our medical record is electronic and 40 percent is still paper. I am identifying what part of the paper record won't eventually be part of our vendor's electronic system, and what we will do to transition all documentation from paper-based to electronic.

We still need to plan exactly how and when we will be paperless. Our EHR strategy still needs tweaking even though we have a clear vision.

Patty: What is that vision, Susan?

Susan: Our vision is to be an integrated delivery network (IDN) that shares information with everyone in the system, using the same technology. While the vision is clear, we weren't clear enough about our needs when we first went live with the system. Sometimes it is hard to understand exactly what is and is not included in these large complex systems.

Leslie: Would you do anything differently if you could do it over again?

Susan: I do think we should have gone department by department looking closely at the documentation processes to determine our workflow needs more precisely and anticipate what types of documentation would remain on paper and what the migration would look like based upon our vendor's EHR functionality timeline. We could then have engaged our vendor in a planning session around the gaps in our processes and current EHR functionality.

Patty: Were there other issues besides the technology?

Susan: Yes, we had organizational and staffing issues that we needed to think through and resolve. I had to calculate and justify the anticipated HIM staffing levels and expenses through the transition period. Because we will be working in a hybrid environment for longer than I would have hoped, I had to help others in the organization understand the impact on staffing, especially when substantial handling of paper records is still in the mix of HIM practice. There is a tremendous variability in HIM staffing and practice among hospitals in an EHR transition. For example, workload in HIM is affected by case-mix, and HIM department functions, procedures and processes vary across hospitals, all of which make comparative staffing statistics of limited value in HIM.

Leslie: What is the biggest challenge you see in the skills area?

Susan: We are on the cusp of looking at how the skill sets in HIM need to change and will be working with human resources to identify skills and for doing retraining as needed. I must be able to show how the HIM skill set is evolving.

As we become more electronic, the number of FTEs may be reduced eventually, but the skill set levels are increasing and career paths look different.

Patty: Earlier you mentioned the hybrid record, how are you handling the question of the legal record?

Susan: Thanks for asking about that Patty, because that took a lot of time, thought and discussion this year as well. We defined our legal record as the hybrid record, part electronic and part paper. We do not print the electronic portions of the record. That was a giant step forward for us.

Patty: How did you accomplish the "no printing" decision? That has been a struggle for some of our colleagues in other hospitals.

Susan: I sold the benefit of not printing. I emphasized that there would be no time lapse for results reporting because we eliminate printing in the HIM department and going to the floors to chart results. When we print results in the HIM department, there can be a 24-hour gap. Now, physicians can get their results as soon as they hit the system. Helping staff on the floors understand that printing documents creates more work for them and us, encouraged people to support the no printing policy pretty quickly. It has also helped the physicians to get more and more comfortable working with records in an online environment.

Leslie: So it sounds like people are gradually getting used to the electronic environment.

Susan: Yes, I think they are coming around. Another area that has helped increase physician comfort levels with electronic work is our e-signature system. We have been successful in getting just about full compliance with e-signature. I am able to demonstrate to the organization that the more work that we accomplish in an electronic environment, the more efficient we are becoming, and the closer we are to realizing our EHR strategy and vision.

Leslie: Does your reporting organizational structure support your move toward e-HIM?

Susan: It absolutely does. I report to a physician who is the assistant vice president (AVP) of clinical affairs. We work closely with the chief medical informatics officer (CMIO). Both of these physicians report to the chief medical officer, so we have very strong clinical leadership for the EHR. The CMIO works closely with the vendor on system functionality and workflow for physicians, getting input from the medical staff. The AVP is continuously communicating on our progress and next steps to the physicians, making sure that they are always in the loop. Both of these physicians have been invaluable in supporting us as we implemented e-signature, and they fully support the paperless vision.

Patty: It sounds like you have the physicians really well covered. How about other disciplines?

Susan: We may have a little gap with the quality management and compliance staff, but we have a meeting planned in January to get more key executives involved. The meeting will include the VP of legal, the VP of quality, the AVP, the CMIO, the chief information officer and myself.

Leslie: Susan, what is the purpose of the meeting?

Susan: I want the executives to be involved in strategic conversations about the direction they want to see for e-HIM in this organization, eventually leading to a clear e-HIM strategy. As the EHR evolves, all users, including our own department staff, will need to develop new processes for accomplishing their work. The impact of EHRs is so widespread throughout the organization; we must get these conversations started as soon as possible. Their input on developing our roadmap from HIM to e-HIM is essential to our moving forward.

Patty: How are you preparing for this first meeting?

Susan: I am in the process of reviewing all of the AHIMA e-HIM practice briefs. To get the conversation started, I plan to summarize the articles for the group and talk about the impact of e-HIM on Norton, both the benefits and the challenges.

Leslie: So let's summarize the lessons learned that you want to share with our readers.

Susan: Well, there are many lessons learned, but here are a few that really got reinforced for me this year.

First, the EHR vision and strategy has to be clear and well known throughout the organization before you can create the e-HIM strategy and roadmap.

Second, we have to know more about what the vendor is offering now and in the future, and how their developmental timeline will be coordinated with our roadmap. That's how we will be able to determine interim solutions; such as if an interim clinical application is needed to realize quality or productivity gains sooner.

Third, I really need to understand the EHR vision of all stakeholders, so I can determine my priorities and know how hard I should push to create urgency in others. For example, I would like to see a provider-patient e-mail component to our system. We need to understand the needs and wants of our population so that as we move forward with our EHR and e-HIM strategy, we are gaining maximum competitive advantage. We have very savvy patients today, and more and more they want access to their health information. We have to make sure their vision of the future is also top of mind as we move forward.

Patty: What are your goals then for 2006?

Susan: I want to get our transcription strategy nailed down and determine whether or not we will implement voice recognition technology. I want to complete the revision of all HIM job descriptions and the re-grading that is necessary. And, I want to map out the EHR/e-HIM roadmap, complete with timeline and a more clearly defined role for HIM in the future.

Leslie: How do you see the role of HIM changing?

Susan: We need to assess the value of centralizing more of our functions. For example we have a central MPI for the five facilities and the physicians' offices. Release of information is another function that might be centralized, along with registration and pre-admission processing. We also need organizationally to tease apart the information technology (IT) functions from the HIM functions at the operational level. I would like to see the IT functions come into HIM rather than HIM going into IT.

Patty: The changing organizational structure around HIM functions is a very interesting topic, and is being approached in many different ways.

Leslie: Hmmm, that sounds like a topic we should address in this column this year.

Patty: Susan, we will check in with you again next year to talk about your progress. Thank you for once again sharing your experiences with our readers.

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 .