The AHIMA World Congress (AWC), the international arm of AHIMA, was formed in October 2016. AWC is dedicated to providing the gold-standard in membership services, best practices, professional training and development, and certification to AHIMA members and credential holders, AWC organizational members, and healthcare information professionals around the world. AHIMA represents more than 103,000 healthcare information professionals in 66 countries and through AWC provides easy access to AHIMA’s high-quality products and services. AHIMA launched its first certification in 1932 and has certified more than 85,000 healthcare professionals in 44 countries.
AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. As the health industry continues to evolve, AHIMA is working to advance the accuracy, reliability, and usefulness of health data by leading key industry initiatives and advocating for consistent standards. Needs are evolving from simply translating data to turning data into knowledge that powers better healthcare decision making.
AHIMA best practices
AHIMA is sharing its ninety years of HIM leadership experience with the global community at the upcoming AWC Healthcare Information Summit in Abu Dhabi, UAE, 25-27 October 2018. The Summit brings together both regional speakers and subject matter experts from AHIMA to share best practices on clinical documentation improvement (CDI), medical coding, and data analytics.
Clinical documentation improvement (CDI)
At the center of healthcare today is the clinical documentation in the health record. An AHIMA survey conducted in 2017 indicated that 95% of acute care facilities in the United States have a CDI program. The purpose of a CDI program is to initiate concurrent and, as appropriate, retrospective reviews of health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on patient care units or in outpatient clinics, or they can be conducted remotely via the electronic health record (EHR).
The diagnoses and procedures documented in the record need to be clearly supported by clinical indicators so that the codes assigned are accurate. The method of clarification used by the CDI professional is often written queries in the health record. Verbal and electronic communications are also methods used to contact providers. These efforts result in improved accuracy and completeness in documentation, coding, reimbursement, and severity of illness (SOI) and risk of mortality (ROM) classifications.
CDI programs are growing in popularity in the UAE due to the recent implementation of the ICD-10-CM diagnostic coding system and the increasing regulatory audits. Complete and accurate clinical documentation is also essential to dispute denials and recover appropriate reimbursement. Providing quality patient care is the most significant outcome of improved clinical documentation.
CDI professionals should obtain professional certification to validate their expertise. The gold-standard CDI certification is the AHIMA Clinical Documentation Improvement Practitioner (CDIP) credential.
The next step, after the health record is complete and the patient is discharged, is medical coding. Trained coding professionals review the clinical documentation and follow coding guidelines to translate the documentation into codes. These codes are then submitted to insurance companies and other external agencies for statistical and population health purposes. An example of clinical documentation transformed into coded data is as follows:
“Group B Streptococcus pneumonia” J15.3
The UAE recently adopted the U.S. version of the ICD-10 code set (ICD-10-CM) for diagnosis coding. For procedure coding, the UAE uses the CPT® coding system, which is published by the American Medical Association (AMA). Coding professionals in the UAE must be skilled in both ICD-10-CM and CPT® coding, which requires extensive training and professional certifications are recommended to demonstrate competency. The most recognized coding certifications are the AHIMA Certified Coding Specialist (CCS®) for hospital coders and the Certified Coding Specialist – Physician-based (CCS-P®) for physician office/clinic coders.
Coding guidelines and regulations change on a regular basis, so it is imperative that coding professionals receive ongoing continuing education. Accurately coded records will result in appropriate reimbursement and less denials.
Within the healthcare environment, data is limitless. Whether it is clinical, administrative, financial, patient-generated, or other data, the need to manage the data efficiently is more important than ever. With the advent of new electronic data capture methods such as mobile health apps, patient self-monitoring, wearable devices, patient portals, and health information exchange, there has been a dramatic increase in the ways healthcare organizations acquire patient data for use in the EHR.
The patient’s administrative and clinical data is captured at various sources inside and outside the healthcare organization. The process is typically initiated at registration of the patient. At the point of registration, data such as the patient’s demographic and insurance information are captured. As the patient moves throughout the visit, additional data is collected at each care site. Capturing electronic discrete data elements can include the following: pre-defined or custom-built templates, electronic forms with or without drop-down menus, use of bar-coding technology, direct entry into free text fields, front-end or back-end speech recognition with or without applied natural language processing, traditional dictation, and transcription. Unstructured data is also captured such as handwritten notes and scanned images.
External data is captured and brought into the health record as well. One trend on the rise is patient-generated data, generated when patients enter their data into the healthcare provider’s system via templates, drop-down menus, or free text fields.
Data workflows vary depending upon the care setting. The workflow in physician practice is more streamlined when compared to hospital outpatient or inpatient processes. In all care settings, charges are captured through a coding classification system such as ICD-10-CM or CPT®. The data is then transferred to a claim form for submission to the third-party payer.
Best practices for EHR data capture should incorporate the following:
• Consider what data needs to be captured and customize available tools to collect it.
• Evaluate the data and determine its placement in the record to determine what rules or procedures need to be put in place to upload the information most efficiently and without errors.
• Collect the data in a standardized format using templates or discrete fields to make retrieval for reporting easier.
• Routinely audit a sample of records collected using the data capture methods described above.
• Acquire primary and secondary data from existing internal or external data sources.
Validation of data can occur at many different points in the capturing, storing, managing, reporting, and analyzing process. The main steps in data validation are:
1. Data extraction and aggregation
2. Calculation and statistics
3. Presentation of data
Presentation of data should depend on your audience and what they are expected to derive from the data. There are many ways to present the data, such as graphs, tables, and charts.
The future of health information management
As healthcare models transition from the traditional fee-for-service to paying for quality with value-based-purchasing (VBP) programs, the HIM profession must adapt. At the core of this transition is the documentation in the health record. Quality documentation will result in accurate payment, no matter which payment methodology is being used. From quality documentation comes quality coding and quality data.