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‘I can’t find the Advanced Directive’ & Other Major Problems Your HIM Department Can Prevent

A few weeks back I wrote an article about the importance of not overlooking paper in today's electronic healthcare world, while pointing out some critical considerations to take into account during a Document Management System (DMS) or Electronic Health Record (EHR) implementation.  Every healthcare organization that I've worked with still manages some paper, resulting in a hybrid patient record (a mix of electronic clinical data & paper documentation).

Then, this week I read an article outlining the difficulty that providers have locating documentation within a patient's chart and the subsequent, negative patient care impact it can have. That got me thinking: healthcare organizations are probably struggling to manage this hybrid record, especially with changes to system functionality, sun-setting old systems, and requests to alter system workflows. On top of that IT nightmare, organizations are likely overlooking the opportunity to leverage change management to properly notify, educate, and reinforce the change to end users. And then you can top it all off with the lack of project management & governance that are required to successfully maintain all of these IT, operational, and change management facets...That's when you can really start to see the potential issues that face your organization in today's electronic world.

In my experience, Health Information Management (HIM) is historically the department responsible for "maintaining" the patient record. Back in the day, this department was full to the brim with paper charts (hopefully this volume has been decreasing at your organization). But, with the EHR boom and developments in the DMS sector, HIM started to realize that their "maintenance" responsibility just got a whole lot bigger. Gone are the days of solely managing the paper chart. HIM is now expected to manage old paper, converted legacy charts, documents within a DMS, and of course, the EHR.

It is quite likely that HIM managers, subject matter experts, and the director were involved with your organization's transition to its new EHR. You probably weighed in with how things have historically been handled and how you'd like to see them implemented in the new system to meet the many demands (federal, state and accrediting requirements) of the EHR. You even likely helped with some of the testing and training required as part of the implementation. But now that you're up and running on this new electronic system, the real work has just begun!

You're probably starting to realize just how dynamic this new system is. Information you found in a particular portion of the EHR a few months ago may be documented somewhere completely differently now. Perhaps you've integrated your EHR with some new ancillary systems for your provider specialties and are now seeing that clinical data flow into the EHR. Or you might find that IS (Information Services) has made some configuration changes, resulting in different clinical documentation workflows and variations in where information displays within the record. Sometimes you just wonder – who is steering this ship?

We believe that HIM plays an integral part in a healthcare organization's success as it straddles both the clinical and financial worlds. Without HIM staff ensuring that provider documentation is complete and compliant, your hospital coders would be unable to thoroughly and compliantly code the chart, which could either hold up billing or lead to the ever-dreaded denial. Furthermore, without this staff keeping an eye on clinician workflows and IS changes to the system, you could be releasing inconsistent or incomplete records.

Because HIM is in such a unique position (typically responsible for scanning, transcription, and ensuring the completion of the chart), it is critical that this department continues to maintain the record like it did in the past. Obviously, the scope and required practices to maintain the record have changed with the EHR, but centralized ownership by HIM remains the same.

At Wilshire, we know the struggles that HIM departments go through trying to adapt to the electronic world while maintaining a hybrid record. We know the processes that this department should own, the workgroups it should be plugged into, and the conversations that it should be having to ensure that the EHR is complete, discoverable, and consistent across patients and encounters. With our help, your HIM department can be the shepherd of the EMR; the department that has the knowledge to answer the ever-present question "where the heck did that disappear to in the chart?" and the peace of mind for executive leadership that someone is ensuring the quality, completion, and consistency of the record.

We’re here to help.