5/22/2006
The Work Force Crisis: The Dilemma of Transforming the HIM Profession
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: The recent report distributed to American Health Information Management Association (AHIMA) members, "Building the Workforce for Health Information Transformation," is a powerful incentive for continuing to clarify the vision of the HIM profession's future (www.ahima.org). It is a report that creates a great deal of urgency around the need for a workforce in the health care industry that is fully trained and prepared to create, implement, maintain and use electronic health records (EHRs) to improve quality, safety and cost-effectiveness of health care. Although the dream of EHRs has languished in the hearts of many for more than 30 years, now that they are coming, fast and furious, is our profession ready for them?

Patty: Well, it does make one pause and reflect on the challenges ahead for the HIM profession. The report, created by AHIMA's Foundation for Research and Education (FORE), is a result of the AHIMA and AMIA hosted workforce summit last November. It had broad representation of industry stakeholders from academia, professional associations, provider organizations, business professionals and government officials. When so many well-informed people take the time to carefully examine an issue like this, it definitely gets my attention.

Leslie: One reason the summit was convened is because achieving the full benefits of the transition to EHRs is dependent on having a highly skilled, well coordinated workforce comprising specialists that cross the three health information professions: informatics, information technology and information management. The industry has been experiencing shortages in HIM for many years, and at this time the number of trained health information professionals in all three of the required domains is far from keeping pace with the growing need. The participants at the summit concluded that the work force shortage is a crisis that warrants immediate action.

Patty: The group's first recommendation advised adopting the vision of the report of the Institute of Medicine, "Crossing the Quality Chasm," which highlighted the important role of health care information technology to improve quality, safety and cost-effectiveness of care.

Leslie: That critical recommendation places the summit's objective of ensuring a trained health information workforce firmly in the realm of major adaptive work for all three health information specialties.

Patty: Why do you describe it as adaptive work?

Leslie: In recognizing the interdependence of the three health information specialties, the urgency for defining how these three professions will work together in the health care industry increases significantly. According to Ronald Heifetz, author of the book Leadership without Easy Answers, there is an important difference between technical and adaptive problems. He writes that "different modes of action are required to deal with routine problems in contrast with those that demand innovation and learning. Adaptive work consists of learning required to address conflicts in the values people hold, or to diminish the gap between the values people stand for and the reality they face. Adaptive work requires a change in values, beliefs or behavior."

Patty: Do you see the three health information professions as having those kinds of gaps and differences?

Leslie: In consulting with health care organizations on the transition to EHRs, I do see a need for these three groups to realize that their boundaries are changing; their responsibilities and expertise overlap more than in the past, and more than ever they need clear and open lines of communications around common goals and objectives. However, in many health care organizations, I do not see a universal vision of electronic records; I do not see all three domains routinely collaborating or even having all three adequately represented at the EHR table. In some organizations I don't even see an understanding or recognition of the problem at the senior executive level. That does not bode well for the future of an interdependent health information workforce working together like a well-oiled machine.

Patty: Oh boy. It sounds like troubled waters lie ahead.

Leslie: It doesn't have to be that way Patty. It is a question of leadership. I mentioned Ronald Heifetz because I like the way he describes leadership.

Patty: And how is that?

Leslie: Heifetz views leadership as a process of mobilizing people to face important problems. Communities make progress on problems because leaders challenge and help them do so. Heifetz wrote, "In viewing leadership in terms of adaptive work, getting people to clarify what matters most, in what balance, with what trade-offs, becomes a central task."

Patty: I think those are the kinds of conversations that need to happen in health care organizations with regard to the three health information professions. However, this view may portend organizational change on the scale of structural transformation, which some people are not ready to face.

Leslie: Well, it is difficult work, especially because it has emotional aspects related to professional identity, organizational status and career ambitions. The professions are facing a classic dilemma. People may see it as "change or perish," as well as "change and perish."

Patty: Would you elaborate on that Leslie?

Leslie: Take for example the current debate within AHIMA about the concept of "inclusive membership." The AHIMA Board has brought forth a proposed bylaws amendment, which if passed by the House of Delegates will eliminate the category of associate member and enable anyone with an interest in the AHIMA purpose and commitment to the AHIMA Code of Ethics to be an active member, whether or not they have an AHIMA credential.

Patty: I see where you are going. Some members see this as an important strategy for making more porous the boundaries among the three health information professions, which might help in addressing the workforce needs, as well as the change from HIM to e-HIM®.

Leslie: Welcoming the other health information professionals and their leaders to join with us as equals in the quest to reinvent the way our industry collects, processes and uses health information is a clear position that we are willing to collaborate fully and equally in creating and optimizing the effectiveness of the new electronic health information environment.

Patty: That is one perspective. Another perspective is that allowing others equal status, which includes the right to vote and hold office without having earned an AHIMA credential, may dilute the value of HIM credentials.

Leslie: I am not sure that credentials and membership are the same issue.

Patty: That is another topic up for debate, but that is not the point I am trying to make.

Leslie: I know, I am just seeing if I can get into this debate with you. What is the point you are making Patty?

Patty: That adaptive work is very hard and that it is normal during adaptive work to have polarized viewpoints on industry topics that are deeply important to individuals. The online debate taking place in a number of AHIMA's Community of Practice forums is evidence that people are working hard to clarify and articulate what matters most to them, understand the trade offs and determine options to ensure the continuity of the HIM profession now and into the future. This sounds like the kind of adaptive work Heifetz is taking about.

Leslie: This discussion reminds me of something else I read in the Heifetz book. To illustrate the principles of leading adaptive change, he analyzed how Lyndon Johnson led the civil rights battle. Johnson first identified the adaptive challenge by asking two important questions: first, what issues are represented by the conflict—what were people really fighting about? And second, did the issues constitute a technical problem for which an authoritative response would suffice, or did the situation require an adaptive change? Is the conflict over values? Apparently he determined it was about values and he led the country in a way that allowed the issues to ripen and to be addressed without pushing us into another civil war. Had he intervened too soon, been too authoritative and not allowed the people to ultimately do the adaptive work, such significant social change may not have come about at that time.

Patty: As a leader he had his work cut out for him to evaluate the level of stress and make sure it didn't overwhelm the country. OK, I see some similarities to the adaptive challenge before the HIM profession, although in our case no one is fighting. We are just having good healthy debate, which should lead to those third alternatives—the innovative solutions that must emerge in adaptive work. Sometimes I think we are venturing into new, undeveloped territory, without a map or a compass.

Leslie: I don't think it is quite that scary. We all need to take some deep breaths and come to terms with the true nature of transition, especially a transition of the magnitude of EHRs. All transitions begin with an ending. It is normal to experience a sense of loss associated with endings and to go through a period of confusion as we search out a clear path for our future state. To use an analogy from nature, species that survive are flexible enough to adapt to changes in their environment.

Patty: Of course, but at the same time, we can all recognize and even be excited about the vision of a new e-HIM profession, one that requires every HIM professional to build on current competencies and develop some new ones. In a world where the patient and the family will soon be members of the documentation team, and where clinicians will be learning a vastly different way of interacting with health information and patients, we have little time left to make sure we adapt to this new world in a way that enables our nation to realize the full impact of health information technology.

Leslie: I think we can all agree that we have profound questions to think about, which have serious implications for the industry, for the association and for each one of us. For example, can we begin to think of ourselves as members of a wider health information care team? Do we truly need to differentiate the e-HIM profession from other health information professions? If so, to what extent do we need to differentiate e- HIM?

Patty: Yes, we must now expand our body of knowledge and continue working at redefining the HIM profession in relation to other information professions such as information technology and informatics. Perhaps some integration of the three information professions is in our future.

Leslie: It is important that as we go about our adaptive work, that we keep as top of mind that our outcomes must be directly related to meeting the needs of the health care industry and the citizenry we serve.

Patty: As HIM state and national volunteer leaders debate and make decisions on important future directions, I thought it might be appropriate to end our discussion this month with a quote from Dr. Murray Bowen: "There is the way I see it, the way you see it and the way it really is."

Leslie: No one said adaptive work would be easy.

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 .