Public Reporting: Are You Ready?
Public reporting is on the increase and requires organizational commitment and a substantial budget.
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Leslie: Data collection and reporting initiatives have exploded. The demand for the analysis of health data within and outside of health care organizations is moving at a pace faster than many organizations can handle.

Patty: Added to this increased momentum for health data is the growing EHR adoption rate. This growth creates even more data sources and increases the breadth and depth of data available for analysis. And the cost for organizations to participate in data collection and reporting initiatives is not cheap! It requires technology and the collaboration of clinical providers, most importantly physicians and nurses, as well as HIM and quality assurance professionals.

Leslie: This is a significant leadership issue for HIM professionals. The HIM role includes educating others on the uses of secondary data, identifying data sources within their organization to be used for public reporting and research initiatives, linking clinical documentation program efforts to public reporting and establishing guidelines for the use of the medical record in data abstraction.

Patty: HIM professionals may also play a role in mining data and participating on committees that discuss and/or oversee secondary uses of data.

Leslie: Looking at the big picture, it's good news that our health care system is using data to improve health care outcomes and inform the public. I have used HealthGrades several times when shopping for a health care provider. I have also used The Leapfrog Hospital Ratings, which include information on high risk treatment such as aortic valve replacements and a "safe practices score." They use a system similar to consumer reports with partial circles, full circles etc. rating the quality of the organization.

Patty: There are complexities to this issue that are discussed in the white paper, "Toward a National Framework for Secondary Uses of Health Data: An American Medical Informatics Association White Paper." The authors express concern around the misuses of secondary data, lack of confidentiality and security protections for non-covered HIPAA entities and an overall lack of national policies and standards.

Leslie: The absence of national policies leaves individual providers to determine how to best participate in public reporting activities and how to protect health information used for non-direct patient care.

Patty: On that note, let's check in with Barbara Siegel, MS, RHIT, FAHIMA, the director of HIM at Hackensack University Medical Center (HUMC) in northern New Jersey. HUMC is a 775-bed tertiary care teaching facility that is highly involved in a number of mandatory and voluntary public reporting initiatives.

Leslie: Barbara has been on the forefront of public reporting and she recently provided testimony on behalf of AHIMA to the Adhoc Workgroup for Secondary Uses of Health Data of the National Committee on Vital and Human Statistics (NCVHS). She really understands how data collection and reporting affects an organization and an HIM department.

Patty: Hi Barbara. Let's start off talking about some of HUMC's key public reporting initiatives.

Barbara: We are currently or have been involved in several important national and state initiatives such as: Premier's Hospital Quality Incentive Demonstration, (see sidebar below for more information), the Pursuing Perfection project led by the Institute for Healthcare Improvement (IHI) and funded by the Robert Wood Johnson Foundation and the State of New Jersey's data collection and reporting initiatives. We are also involved with The Leapfrog Group and HealthGrades rating programs.

Patty: What kind of data is New Jersey mandating?

Barbara: New Jersey's cardiac surgery hospitals are required to report data on each patient undergoing open heart surgery. New Jersey Department of Health's Open Heart Surgery Registry uses the data to create risk-adjusted mortality rates for each New Jersey hospital and surgeon performing coronary artery bypass graft surgery (CABG). Each year the data are reported in the cardiac surgery consumer report. We also report on infections.

Leslie: In addition to mandatory reporting, it looks like you are involved in several voluntary initiatives. How does HUMC decide on the initiatives?

Barbara: An internal HUMC group called the Champions meets once a month. This group is comprised mostly of physician leaders. My inpatient clinical data manager and I attend these meetings, which are largely around public reporting initiatives and disease management. A performance improvement coordinating committee also meets once a month, which includes senior executives. Many of the decisions to participate or not are made in this committee.

Patty: With so many reporting requirements where do you focus?

Barbara: We pay attention to HealthGrades as well as Leapfrog and ensure the data they post on their Web sites to the public are accurate. Our focus, however, is on collecting quality data for direct patient care as well as secondary uses. I have an interesting experience to share about public reporting and data quality.

We had a patient a couple of years ago that looked up HUMC's outcomes on the HealthGrades Web site. She was scheduled to have an orthopedic procedure. She almost didn't come here because at that time HUMC's ratings, for the procedure she was about to undergo, received a low rating. This prompted a review of the clinical documentation and coding. It was noted on review that Doppler ultrasounds were ordered routinely following surgery to detect deep vein thrombosis (DVT). Depending on how the orthopedic surgeon documented their findings, it looked like DVT was a complication of surgery when in fact it wasn't. The orthopods reviewed and changed their Doppler and documentation practices to accurately reflect the care provided. The HealthGrades rating now accurately reflects our outcomes in this particular area. Because HealthGrades relies on the Medicare Provider Analysis and Review data (MedPar), which does not reflect current data, it's important to catch these discrepancies as soon as possible.

Leslie: Did the patient proceed with her surgery?

Barbara: She did, but not until after she spoke with the chief of medicine who explained why the data wasn't accurate.

Patty: Do you have any issues related to confidentiality and security?

Barbara: Let's bring my HIPAA expert Pam Thomas, RHIA, systems manager, into this conversation.

Pam: The issue to be aware of is that some requestors of secondary data may not be covered under HIPAA or may not be HIPAA compliant. For example, there are a lot of payers contracting third parties to do quality reviews for them. The result is an increasing number of requests for data from organizations that aren't familiar to us.

Leslie: Don't these third parties introduce themselves when requesting data?

Pam: Not usually. We have to determine if they are entitled to the data and if they are working with an entity that is either a business associate of HUMC or covered by HIPAA and authorized to receive the data. The HIM release of information staff have to be able to recognize these requestors and go through a process to ensure that they are authorized to receive data. When the request is not for treatment, payment or operations (TPO) we scrutinize it to ensure authorization. We will work with our risk manager when necessary as well.

Leslie: Thanks Pam. I am also interested in learning how many employees on the HIM staff are dedicated to public reporting, how many abstracts they do and your budget.

Barbara: We dedicate 9.5 full-time equivalents (FTEs) to public reporting. The abstractors have either an inpatient coding or nursing background. Their role is to abstract data from medical records to fulfill public reporting requirements not satisfied by coded data. They complete about 525 abstracts per month. The abstractors report to the inpatient clinical data manager. Our budget for medical record abstraction alone is around $740,000.

Patty: Do the abstractors focus on inpatient and outpatient abstraction?

Barbara: The outpatient departments do their own abstraction and reporting. The HIM department focuses on inpatient data collection and reporting.

Patty: Who does the data mining in your organization?

Barbara: For non-complicated coded data requests we may mine the data, but in general HUMC's knowledge manager handles the lion's share of requests for data. The knowledge manager reports to the chief operating officer and has a thorough understanding of where data resides in HUMC and which sources provide answers to questions either related to research or public reporting. We have worked closely with our knowledge manager through the years as well as our colleagues involved in quality management activities.

Leslie: It sounds like a very collaborative effort with individuals from various disciplines. If your part of the budget is close to a million dollars, this effort is clearly a significant expense to organizations.

Patty: Barbara, what tips would you give our readers on how to best get involved in these activities?

Barbara: New HIM roles are emerging quickly that require a significant budget allocation to support public reporting activities. Get to the table now and stake your claim to the data steward role, ensuring the quality of clinical documentation and coded data. In our case we participate in the Champion meetings and various other meetings related to clinical documentation. We work closely with physicians to educate them on coding rules and regulations and to ensure that our data sources are of the best quality possible. Also this is a huge initiative and impossible for one department to handle completely. It's a collaborative activity.

Leslie: Thank you Barbara for giving us a glimpse at public reporting in your organization. You have increased my awareness of secondary data usage and the importance of carving out the HIM role in one's organization. I will definitely keep this topic on my radar screen!

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 .