HIM in Non-Acute Settings: Examining HIM Issues Impacting Home Health, Long-Term/Post-Acute Care, Skilled Nursing Facilities, and Other Healthcare Areas
Take 5 minutes to reflect on what was read and answer the following questions:
1. What is the most important point(s) in this article?
2. How does this article relate to this week’s topic? (Health records in a non acute health care settings
3. What questions do you still have about the what you read?
HIM in Non-Acute Settings: Examining HIM Issues Impacting Home Health, Long-Term/Post-Acute Care, Skilled Nursing Facilities, and Other Healthcare Areas
By Mary Butler
Among healthcare providers, there is nothing new about the desire to keep people out of the hospital. For years, procedures that used to require an inpatient stay have been moved to outpatient surgical centers and ambulatory clinics. Not only does this save payers money, but it also helps reduce exposure to hospital-acquired infections. Health information management (HIM) professionals have also been moving with the patients to outpatient settings, but their migration has been a slower one since government resources for their tasks have been disproportionately allocated to hospitals. The infusion of “meaningful use” Electronic Health Record (EHR) Incentive Program payments meant that hospitals could more easily adopt EHR systems, which gave HIM lots to do. Much to their disappointment, non-acute care proivders were not offered such incentive payments. Nevertheless, HIM has been plugging away in post-acute settings, such as nursing homes and home health, which are more reliant on Medicaid and its lower reimbursement levels.
“The world, to me, doesn’t revolve around acute care, our goal is keeping people out of hospitals. It’s not just a trend. It’s where things are going. Care is happening in the community,” says Michelle Dougherty, MA, RHIA, CHP, senior health informatics research scientist, digital health policy and standards, at RTI International.
Dougherty says there’s tremendous opportunity for HIM professionals in long-term and post-acute care (LTPAC) settings, especially as telemedicine and telemonitoring tools grow in use and as the population ages. “We are well positioned, in our expertise, to really advance current LTPAC practices, and support the direction we’re going in with interoperable data,” Dougherty says.
This article examines how HIM is handled in several non-acute care settings, and the challenges and successes HIM professionals have seen in these areas when it comes to documentation, reimbursement, technology changes, privacy, security, and interoperability.
HIM in Long-Term Care Hospitals
HIM professionals working in long-term acute care hospitals (LTACs) have their work cut out for them. The typical length of stay in an LTAC combined with the acuity of the patients means that a patient’s chart can run hundreds of pages in a very short amount of time. Patients being treated in this setting can be on ventilators, have spinal cord injuries, traumatic brain injuries, and other complex conditions.
Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager of HIM consulting at UASI, is an HIM consultant who works in a variety of post-acute settings. In her experience, coding in LTACs is usually done by coders who might be “home grown” or credentialed. Due to the acuity of the patients and the documentation needed to reflect their care, however, it’s increasingly important that such facilities hire credentialed coders.
“I think the risk is significant in not using designated coders to do the work because of the understanding of ICD-10 and understanding the anatomy and physiology and pathophysiology of what’s going on with the patient,” DeVault says. “Being able to distinguish between a symptom and a condition [is important for coding].”
For example, a clinician might mention “weakness” multiple times while documenting in a chart. A coder needs to understand that they should not use a code for weakness because it’s associated with paraplegia.
“And there’s a coding guideline that tells us that. But in some cases the coding of the weakness is necessary to tell the whole story about what’s happened to that patient,” DeVault says.
Like just about every care setting, interoperability is a struggle in LTACs. Patients are admitted to these facilities from hospitals and intensive care units, and are sometimes discharged to home health or skilled nursing facilities. Keeping a longitudinal record is challenging.
“What’s really key with these kind of patients is the longitudinal ability and record collection. Can we look at ‘Kathy DeVault’ and her illness in the spectrum from when she had the accident to her long-term care? It’s not a challenge for these settings, but it’s a challenge for interoperability overall,” DeVault says.
In long-term care hospitals, skilled nursing facilities, and other outpatient settings, medical records are often a hybrid of electronic and paper, which can increase the level of risk, especially with written prescriptions. This is partly due to post-acute facilities being left out of the meaningful use program when it was launched, which offered financial incentives to those who implemented and properly used EHRs. This has caused disruption in home health and post-acute settings when trying to transfer patient’s medical records. Often, there are completely separate medical records between hospitals and long-term care facilities—even when they are owned by the same parent company.
HIM in Hospice
By its nature, hospice has a lot in common with home health and skilled nursing settings; hospice care can be provided in an individual’s home or in designated wings of hospitals or skilled nursing facilities. As a result, hospice providers inherit health IT applications originally designed for home health or skilled nursing facilities, which are then adapted to meet hospice needs. But right-sizing this software for hospice doesn’t always work, according to Shawna Zastoupil, RHIT, hospice coding manager for the consulting group Corridor.
For example, in one EHR system that’s been adapted to hospice, if a coder is in the process of reviewing a chart after a patient’s been admitted, then the record can’t process physician orders. This can be a substantial hardship for the patient getting palliative care.
“So we have a sick person who’s in hospice and a coder doing their due diligence trying to get through referral documentation, and that can take up to 24 hours. The orders for pain meds cannot be processed [until] that coder is done with the EMR [electronic medical record],” Zastoupil says.
In recent years, the Centers for Medicare and Medicaid Services (CMS) has changed coding guidelines for hospice, presenting challenges for hospice coders, Zastoupil says. Until a new regulation that came out in 2013, coders only had to use one ICD-10 code per claim.
Under new CMS guidelines, in terms of a principal diagnosis, “when the provider has established, or confirmed, a related definitive diagnosis, codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses. Hospice providers may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-9-CM/ICD-10-CM Coding Guidelines and that require further compliance with various ICD-9-CM/ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing or etiology/manifestation guidelines.”1
This change increased the profile of certified coding professionals in hospice. Nurses used to do the majority of the coding, but with the new guidelines and quality measure reporting now required of hospices, there’s a growing demand for HIM professionals.
HIM in Skilled Nursing Facilities
At a minimum, the healthcare professionals working in skilled nursing facilities or nursing homes wear six or seven hats, says Mary Ann P. Leonard, MSL, RHIA, RAC-CT, principal, supervising consultant with Health Information Professionals. As a result, the HIM department is frequently a department of one, with a single individual holding the title HIM director or medical records manager. This person might carry out release of information, perform the duties of a privacy and/or security officer, and be in charge of minimum data set (MDS) assessments and coding. For the most part, though, Leonard says registered nurses do ICD-10 coding, and the codes are built into the MDS software.
One of the challenges for HIM at skilled nursing facilities is that the hierarchy of leadership is flat compared to hospitals. Whereas a hospital HIM department could have a vice president, a HIM director, an assistant director, a medical records manager, and five or six people under that manager, a skilled nursing facility has far fewer levels. HIM might report solely to an administrator or executive director or director of nursing, and have tasks as varied as scheduling transportation, doing payroll, and coding—as well as developing nursing staff schedules. As a result, HIM professionals are spread thin and are asked to do more with less staff.
Like acute care, new regulations have also impacted HIM in skilled nursing facilities. Passed in 2014, the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) is just starting to be implemented in skilled nursing facilities and other long-term and post-acute care settings, including inpatient rehab facilities, home health agencies, and long-term care hospitals. It requires these settings to report standardized assessment data based on the assessment tools used by each setting, such as the OASIS tool in home health or the MDS in skilled nursing facilities. It also requires CMS to make all that data interoperable so that it can be shared among other post-acute care facilities and other providers.
RTI’s Dougherty says programs like the IMPACT Act give HIM professionals an opportunity to show off their expertise in post-acute settings. “There’s a tremendous role for visibility [of HIM] in long-term care. Our understanding of data quality, information governance, and the intersection of care delivery, those things are critically important,” Dougherty says.
She notes that as a result of the IMPACT Act HIM professionals have been really focused on the quality of the data, as well as monitoring or overseeing the quality assurance programs. They have been key in understanding, in intimate detail, all of the different measures and investigating the factors that result in lower quality scores.
A relatively new HIPAA concern for skilled nursing facilities is a recent wave of cases in which skilled nursing employees have taken photos of residents and uploaded them to social media platforms such as Snapchat and Facebook. This has been happening so often that US lawmakers have asked regulators to take action.2 Leonard attributes this trend to the fact that skilled nursing facility employees do their best to createa home-like environment for residents—after all, 80 percent of skilled nursing facility residents are there for a year or longer. And it’s the homey atmosphere that can seem to lower the privacy threshold—though not in the eyes of the law.
“Information that would be identified as private in a hospital is not necessarily seen as private [in a skilled nursing facility],” Leonard says. “…For the most part it’s just employees sharing photos on Facebook saying, ‘Look at my lovely lady,’ not realizing that’s nobody else’s business, and they’re breaking the rules.”
HIM in Home Health
The nature of home health means that the healthcare professionals providing care in this setting walk into an environment over which they have little control. They can’t control the cleanliness of the homes they visit, nor can they control the technological circumstances that are the norm in other outpatient or inpatient settings.
“This may come as a surprise, but there are large parts of this country where people live and need care in their home, that do not have reliable broadband access. So the ability to even access a medical record—never mind charting or communicating in real time—is significantly impaired in those environments,” says Danielle Pierotti, PhD, RN, CENP, vice president, quality and performance improvement, at Elevating Home, formerly known as the Visiting Nurse Association of America.
If a home doesn’t have an Internet connection to help a nurse complete their OASIS assessment, he or she might go to a nearby Starbucks with WiFi access—which comes with concerns about the WiFi network’s security.
“In an ideal world, real time charting is still the gold standard. As a profession, nursing tries to do documentation as close to the point of care as possible because it reduces the risk of memory problems, which we are all subject to,” Pierotti says.
According to Tricia Twombly, RN, BSN, HCS-D, HCS-O, COS-C, CHCE, HCS-C, CEO of the Board of Medical Specialty Coding and Compliance, the CEO for the Association of Home Care Coding and Compliance, and senior director with Decision Health, in recent years home health has started to centralize its coding. While nurses used to do coding during a patient assessment, most home health agencies now have certified coding professionals who review charts after the completion of a clinical assessment.
Home-based care also opens clinicians to a number of additional HIPAA-related concerns. It’s becoming common for nurses to take photos of pressure wounds and surgical wounds using mobile devices. While that’s a legitimate part of the medical record, nurses can be uncertain about how to permanently remove those images from their phones to prevent any risk of a privacy breach.
Because of these issues—as well as perennial HIM challenges such as interoperability and coding—Pierotti is hoping to welcome more HIM professionals into the home health fold. Of particular interest to Pierotti is spreading the information governance (IG) message to home health.
“I think that technology in general is moving into home-based care at a very, very fast rate. We are adopting a lot of telehealth opportunities in a myriad of ways. As an industry we are moving very quickly into EHRs. We’re trying to develop ways for our records to talk to offices and hospitals and payer systems without the benefit of the meaningful use payments that other settings have benefited from… Having that broader sense of IG as a whole would be beneficial for helping people to frame the work that they’re doing and see the strategic long-term plan,” Pierotti says.
HIM in Public Health
State and county health departments offer a range of health services, such as mental health treatment centers, domestic crisis housing, physician clinics, inpatient substance abuse treatment facilities, nursing homes, and group homes for the disabled. Such is the case for Lake County, IL, the third most populous county in the state and home to many of Chicago’s sprawling suburbs. Lake County’s health department is expanding its population health efforts—which include monitoring immunization rates, studying trends in income disparities and access to care, and monitoring mortality rates in different parts of the county.
The sheer diversity of the services provided has obvious opportunities for HIM professionals. On any given day, Shalina Richie, RHIA, the health information manager at the Lake County Health Department, is immersed in multiple HIM tasks. She offers training and assistance to coders, and guidance to providers who have questions about coding mental health records—clearing up confusion about coding with DSM-5 codes and ICD-10 diagnosis codes. Richie also helps process release of information (ROI) requests with an outside vendor, assists providers with patient portals, and scans paper records from patients who see providers outside the county system. She offers feedback on the department’s discussions around joining health information exchanges (HIEs) and keeps fellow staff members aware of regulatory changes that affect their work, including quality measure reporting required under the Medicare Access and CHIP Reauthorization Act (MACRA) and new regulations issued by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Given the nature of working in public health, Richie notes that patient education has a heightened importance—especially as it relates to release of patient information processes and rights.
“If a patient walks in and requests their record, it’s not just, ‘Here’s your record.’ It’s, ‘Do you want your substance abuse records, mental health records? Do you want your immunization records?’ It takes a lot more probing to find out what they need and where they need to go,” Richie says.
The department also has to carefully educate patients about authorizing the release of behavioral health and substance abuse records under new SAMHSA regulations, which are designed to make it easier for researchers studying these issues to have access to patient identifying information.
For example, a patient may come in and ask for their full psychiatric history in order to prove that they qualify for disability housing. HIM has to advise them why a brief diagnosis note is more prudent than the full record. While SAMHSA changes might make it easier for researchers studying this, it can complicate matters when deciding how to protect information when participating in an HIE.
HIM in University Health Clinics
Students on the campuses of larger universities often have access to healthcare facilities that rival the size of major medical centers’ ambulatory clinics. Yet, student health isn’t a setting one normally associates with HIM professionals. Lisa Teel, RHIA, manager of HIM services at Northwestern University in Evanston, IL, performs all of the activities you’d expect from an HIM manager. Northwestern’s Health Service has a pharmacy, a laboratory, a radiology department, a women’s health clinic, a sports medicine department, an insurance department, and—until several years ago—had overnight observation beds in a setup similar to that of a hospital.
The biggest difference between student health at Northwestern and a more traditional ambulatory clinic comes down to reimbursement and privacy policy. Northwestern has opted to comply with the Family Education Rights and Privacy Act (FERPA), which predates HIPAA and is frequently employed by educational institutions. FERPA is more conservative in the sense that written authorizations are required in more release of information scenarios than under HIPAA. All Northwestern students are required to have health insurance, either through their parents’ plans or through plans offered by the university, which is contracted with a payer offering university plans. In essence, the student health service deals with one payer—the contracted insurance company. Students with other plans pay in cash up front and submit claims to their insurer afterwards. As a result, while it’s still important that ICD-10 and CPT coding is accurate, the concern about losing revenue from the switch of ICD-9 to ICD-10 was less stressful in this setting as it was with other providers.
“I took the physician training for ICD-10 so I could see suggestions they were making for physicians and modeled my training after that, and did training to give physicians a heads up,” Teel says.
While the university itself complies with FERPA, it does have to be HIPAA-compliant as well when it comes to release of information forms sent to other providers the students may see, such as allergists and other specialists. Additionally, like any other healthcare entity, student health centers have business associates and the university develops the FERPA equivalent of a HIPAA-compliant business associate agreement.
College health centers can decide at their own discretion whether to comply with HIPAA or FERPA. If the health center limits their treatment to just students, as Northwestern’s center does, they only have to comply with FERPA. According to Department of Health and Human Services guidance, if a student health center treats only students, then they can comply with just FERPA—which again is more strict than HIPAA since it, for example, covers all non-medical information as well. But if they also treat staff or other non-students, they have to comply with HIPAA and FERPA. To simplify things, Northwestern restricts its care to students only—hence FERPA compliance.
But student health has some unique HIM considerations. Teel says it’s common for students to start their freshman year when they’re 17, and occasionally 16. She notes that college is frequently the first time a student has seen a doctor without a parent present; subsequently, students may call their parents from the treatment room.
Students under 18 must have their parents sign a “consent to treatment” form authorizing university providers to treat students who are ill. That form is kept on file until the student turns 18. Additionally, the parents of students under 18 can call university health professionals to discuss their child’s health unless their questions fall into protected categories such as sexual or mental health and treatment related to substance abuse.
Non-Acute Care Presents Opportunities for HIM
As shown above, acute care and non-acute care HIM professionals face similar challenges. This presents an opportunity for current acute care-based HIM; their skills will directly translate to these other healthcare settings. And with the high number of acquisitions in healthcare—especially larger hospitals buying out physicians, clinics, and other non-acute care facilities—HIM professionals could soon find themselves in charge of newly acquired business lines. The healthcare industry in general is moving away from acute care, and moving care outside the hospital—and experts say HIM should both embrace and leverage this future.
Notes
[1] Centers for Medicare and Medicaid Services. “Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election.” MLN Matters. August 22, 2014.
[2] Butler, Mary. “Senator Demands Action on Nursing Home Social Media Abuses.” Journal of AHIMA website. March, 31, 2016.
Mary Butler ([email protected]) is associate editor at the Journal of AHIMA.
Article citation:
Butler, Mary. “HIM in Non-Acute Settings: Examining HIM Issues Impacting Home Health, Long-Term/Post-Acute Care, Skilled Nursing Facilities, and Other Healthcare Areas” Journal of AHIMA 88, no.8 (August 2017): 14-19.
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