HIM: It’s myth-buster time
by Darice M. Grzybowski, MA, RHIA, FAHIMA
Quite a few years ago, I wrote an article on various HIM myths versus facts. The reason for that article was the unpleasant rumors circulating at the time that predicted the demise of the coder once Computer Assisted Coding (CAC)?then dubbed auto-coding?was implemented everywhere due to the demands of ICD-10-CM.
As we now know, CAC solutions are not yet fully mature and have yet to be successfully implemented consistently across hospital inpatient, outpatient, and physician practice environments. This is due to a variety of reasons including limitations in EHR system documentation integrity and ability to handle full encounter based coding, as well as the unique and ever changing regulatory, compliance, and financial factors influencing coding in the United States.
HIM reimagined?
Unfortunately, these rumors are once again circulating, this time even in published documents such as AHIMA’s HIM Reimagined initiative. This multimedia campaign infers the eventual elimination of RHIT programs or even a fast track transition to an RHIA status without a bachelor’s degree, and downplays the value of clinical and coding knowledge by predicting the "demise" or importance of the RHIT. The concept behind HIM Reimagined appears to be based on little factual research studies with questionable and dated sources (some outside the U.S.). The document makes erroneous assumptions, such as coding jobs decreasing, which are directly contradicted by activity in the industry and data from the U.S. Bureau of Labor Statistics showing that demand for coders is higher than ever before.
The critical need for qualified coders and coding auditors is readily demonstrated by the number of educational programs teaching medical coding, the extraordinary growth of professional coding associations, and increasing numbers of certifications being offered in specialty areas. There is a high demand for domestic as well as international outsourced coding, and recruitment activities and compensation trends have grown due to the large number of open coder positions.
Based on my own experiences across the country and talking to thousands of HIM professionals who are in the trenches, it is clear that coding jobs are still on the increase. Clinical documentation jobs are expanding in numbers to the point that other professions are entering the field (e.g., clinicians, specifically nurses and physicians). Daily interaction with recruiters searching for qualified clinical coding professionals is the norm for anyone holding an AHIMA or AAPC certification in coding. The U.S. Bureau of Labor Statistics anticipates that medical record coding and health information occupations will have a 16% growth rate through 2024, almost double all other U.S. job growth rates. This certainly does not indicate a decrease in the focus of coding jobs as indicated by the flawed HIM Reimagined campaign, and in fact quite the opposite, leading one to question why AHIMA proposes a decrease in the support of enhanced coding and clinical knowledge as a key pillar of HIM skills that is needed in today’s competitive job market.
Familiar?and faulty?predictions
Previous rumors about the demise of coding were preceded by predictions in the 1980s and 1990s that transcriptionists were disappearing due to speech recognition technology. Yeah, right?another myth busted. The dictated and transcribed documents are in demand more than ever due to problems in document and data integrity present in most current EHR systems. Transcription vendors appear to be growing rapidly, and physicians depend on these critical documents for basic care and communications in the provider setting. Even CMS instructed facilities that medical transcription is a key part of the record and should not be completely eliminated. Coders and outside review organizations now rely heavily upon transcribed documents. Some payer organizations are reportedly issuing payment denials until a transcribed discharge summary is present in the record?no exceptions.
Other predictions making the rounds include an erroneous assumption where the HIM department is made obsolete by EHRs. While EHRs have improved some aspects of data collection and storage, they’ve also ushered in a new set of problems only the HIM department can handle. Even the largest EHR systems are still experiencing growing pains and will likely continue to evolve, battling challenges such as copy and paste and auto-template population. Technology advances continuously, but documentation and clinical knowledge remain vital to the professional health information manager, bolstering rather than undercutting the value of the HIM department. One of my clients just added more than 12 positions to assist with data integrity cleanup of EHRs.
Staffing needs weren’t the only thing to increase after the adoption of EHRs; printing has also increased. Anecdotal evidence from both vendors and providers such as paper and toner expenses clearly point to an increase in the volume of printed material, particularly related to release of information (ROI) requests. As the size of the medical record grows, it’s likely that more paper will continue to be generated as part of ROI requests and other needs.
Other common EHR issues, such as the use of copy and paste, auto-template population, inadequate integration and interoperability, and the lack of sufficient forms and purging controls in the dynamic record demand a return to HIM basics?not a move away from them. Therefore, HIM professionals must focus on producing quality documentation that can accurately tell the story of the patient in a stable system environment with a Level 3 Electronic Document Management system. Without a stable (versus dynamic) documentation environment from which to host the permanent legal health record, the true legal record can never be achieved, as it will be in a constant state of flux (great for data, bad for archive and retrieval).
Like a bad joke, rumors like these continue to circulate amongst HIM professionals. Too often, uneducated and inexperienced people (including those who have not worked or even visited a real HIM department for many years yet lead key AHIMA teams and initiatives and hold board member positions) and individuals who have no U.S. healthcare/HIM experience at all are predicting trends that minimize the importance of coding, clinical knowledge, and data analytics, and echo the weakening of the coding and CDI certification process.
Missing the education mark
Unfortunately, if some HIM professionals blindly follow the rhetoric and adopt these faulty assumptions as a go-forward strategy, our future will not be bright. And these strategies have led to changes in HIM degree programs. The very jobs that are cornerstones of the revenue cycle?primarily coding, revenue cycle, and CDI?are being virtually ignored as HIM degree programs focus less on clinical and coding skills and more on information technology training. This author believes these changes will leave newly graduated HIM professionals with serious skill gaps as they enter the job market.
Jobs evolve and move forward with technology as influencers. HIM analysts must now learn to work with software solutions that are very different than the flag and nag processes of years gone by. Release of information (ROI) has become a sophisticated process involving portals, electronic transfer of information, and remote access for reviews. While we must teach these new core HIM skills using new tools, we should not forget or ignore the basic goals and skills HIM professionals have that allow compliant record management, and patient and provider advocacy as an ombudsman. To do so is to provide pathways to other organizations and professions to displace and disrupt our mission in information integrity.
When I received my four-year degree in HIM in the early 1980s, I was privileged to take eight full quarters of clinical/medical domain education. Among my classmates in these classes were RN and pre-med students. An HIM student was expected to partake in clinical discussions and be able to evaluate nursing and physician documentation; and then validate the documentation from the care team, and offer educational suggestions for improvement. That need still exists, but today’s HIM degrees barely offer adequate clinical training to perform the sophisticated coding and CDI functions needed to compete for jobs such as CDI specialists, utilization review coordinators, and quality analysts. All of these positions were previously dominated by professionals with HIM credentials, but hiring trends have been steadily shifting toward other professionals as HIM degree programs have de-emphasized the importance of clinical training.
Instead, we now see HIM programs filled with classes on how to use tools such as Excel and how to create basic databases. Many students learn these skills in high school now, rendering a college-level class irrelevant. What they do not learn in high school is enough anatomy, physiology, disease process and theory, and terminology to support coding and CDI skills and the ability to communicate and evaluate needs in documentation quality. Without rapid repair to the educational focus in schools, jobs in these areas will continue to be lost to other clinical professions, such as nursing and physicians, and data integrity in the EHR will eventually erode?and has already begun to.
Students graduating with RHIT and RHIA degrees often miss other basic skills such as understanding terminal digit filing (hospitals often keep records more than 30 years and older records will remain on paper for many years to come), basic forms design (necessary to understand and implement EHR workflow, templates, integration, archive, and purging), and many other skills.
HIM professionals alone are to blame for allowing the abandonment of our essential skills in many of our educational institutions. We have been in too much of a rush to meet the future and abandoned core roles that are at the heart of good information governance and being the legal guardian of the health record regardless of which format of storage is used. It is the role of AHIMA members to stand up and reclaim this domain and ensure students are prepared to meet the demands of the workforce, and existing member skills are refortified so as to have the ability to compete for the many open jobs in coding and CDI.
The future is now, and if we continue to ignore the needs of today we will be jeopardizing our own future by focusing on a vision that does not reflect reality, does not alleviate the shortage of skilled staff needed for coding and CDI (and thus analytics), and is not comprehensively supportive of current AHIMA dues paying members and their needs.
While the AHIMA elections will be completed by the time this column runs, we must continue to focus on building a board, leadership, and HIM membership that is aware of the importance of professional practice and clinical knowledge, understands that research and validation starts with checking facts, and listens to industry trends and the voice of HIM professionals. We must bust myths about the future of HIM and defend HIM’s unique skill set by developing educational requirements that provide more, not less, clinical, coding, and CDI knowledge to ensure a robust career path for new HIM graduates.
Less than 10% of AHIMA members voted in the annual board elections last year. Will you add to the apathy, or will you become an involved member and ensure the strategy of a profession is not lost to those who have been out of the trenches for too many years? Are you aware of how your membership dues are spent? Do you support these expenditures? Are AHIMA board member salaries in line with the salaries of the average AHIMA member? Are you aware of strategic initiatives that are happening offshore? Are you aware of competitive for-profit businesses competing with AHIMA professional members? Do you see AHIMA-certified individuals participating and leading in roles that are defining an organization and a whole profession’s future or obsolescence? The choice is yours whether to believe in myths and rumors or to believe in the data and a core educational foundation for our students.
We must also be assertive enough to take our rightful seat at the health information governance table and lead by example, focusing on the content and structure of the medical record?the basic role of the HIM professional. With the Affordable Care Act, Accountable Care Organizations, and all of the regulations changing around Part B billing (i.e., MACRA, MIPS, and other value-based reporting), our expertise supporting document and data integrity across the full continuum of care is needed more than ever. Without clinical training, and without the skills to support coding and CDI within the patient flow and revenue cycle, we are selling future HIM professionals short.
We must demand HIM professionals take the lead in interpreting and setting coding policies and standards and developing EHR meaningful use standards to maintain the quality of our records. We must ensure that our leadership, speakers at our convention, and team practice members within AHIMA are fully educated and experienced in efficient and effective HIM practices. Most importantly, we must demand elected and employed staff at our professional organizations support the members and build sound degree paths based on appropriate clinical and professional practices.
Paying it forward means educating a whole new generation of HIM professionals that have the ability and skills to manage the electronic and paper health record, protect patient confidentiality, push for documentation and data integrity, advocate for quality care, and provide statistical translation from narrative to coded numbers?the basics upon which our profession was founded. May we all have the clarity and insight to support each other as we grow into new challenges. May we keep the vision our professional forbearers left to us. May data integrity, coding compliance, and record and information management continue to guide us as a profession. Go HIM!
Editor’s note
Grzybowski is an AHIMA-approved ICD-10-CM/PCS Trainer/Ambassador. She is the president of HIMentors, LLC, which specializes in HIM operations, education, best practices, EHR/EDMS implementation, CAC, and CDI coding consultation, legal health record management, data analytics, and the provision of strategic marketing services for physician-owned practices, hospitals, and healthcare technology vendors. She is a nationally recognized speaker, multiple Triumph award winner, and has recently authored the new AHIMA resource, "Strategies for Electronic Document and Health Record Management." For more information, go to www.HIMentors.com or email [email protected].
