Whole-Person Healthcare€¦ · representatives for their support on various pieces of legislation...

Whole-PersonHealthcare

SOCIAL DETERMINANTSSUCCESS BEGINS WITH DATA

MARCH 2020

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/ Journal of AHIMA March

Contents

14 Whole-Person HealthcareSocial Determinants Success Begins with DataBy Matt Schlossberg

Cover

Medical data alone tells an incomplete story.

pg. 14

Features

18 Developing Leaders for the Future of HIM By Carolyn Guyton-Ringbloom, MBA, CAE

22 Quality Payment Program 2020: Changes and RequirementsPart III: MIPS Promoting Interoperability Per-formance Category in 2020By Michael Stearns, MD, CPC, CRC, CFPC

Profi le

30 HIM at the Cook County JailBy Mary Butler

Excerpt

32 HIM Evidence-based Operations Management: A Case StudyBy Susan H. Fenton, PhD, RHIA, CPHI, FAHIMA, and Diann H. Smith, MS, RHIA, CHP, FAHIMA

March 2020

Journal of AHIMA March /

Vol. 91, no. 2

Departments

36 Health DataCombatting the Opioid Crisis with Data By Wesley Combs and David Morin, MD, FACP, CPI, FACRP

38 CodingCurrent Procedural Terminology Update for 2020By Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC

40 Health DataHow Multi-payer Platforms Represent a Single Source of Truth for Provider Data ManagementBy Mark Martin

42 CodingPreventing Denials Through Clinical ValidationBy Amanda Suttles, BSN, RN, CCDS; Angela Brisson, BSN, RN, CCDS; and Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA

44 Practice BriefCDI Expanding Beyond the Hospital Walls through Standards

56 Free TextPrivacy Under the Microscope By Mary Butler Quizzes

From AHIMA

5 President’s MessageSupporting Our Mission and Vision

6 Speaker’s MessageMoving Ahead with 2020 Vision

8 Under the DomeAdvocacy Brings Progress for Patient Matching

11 CEO’s MessageHIM Professionals Change the World

12AHIMA News

AHIMA members may earn continuing education credits by successfully completing the following quizzes at https://my.ahima.org/store

17 “Whole-Person Healthcare”Domain: Clinical Data Management

29 “Quality Payment Program 2020: Changes and Requirements”Domain: External Forces

36 “Combatting the Opioid Crisis with Data”Domain: Clinical Data Management

39 “Current Procedural Terminology Update for 2020”Domain: Clinical Data Management


Journal of AHIMA (ISSN 1060-5487) is published six times a year by the American Health Information Management Association, 233 North Michigan Avenue, 21st Floor, Chicago, IL 60601-5800. Subscription Rates: Included in AHIMA membership dues is a subscription to the Journal. The annual member subscription rate is $22.00 for active and graduate members, and $10.00 for student members. Subscription for nonmembers is $100 (domestic), $110 (Canada), $120 (all other outside the U.S.). Postmaster: Send address changes to Journal of AHIMA, AHIMA, 233 North Michigan Avenue, 21st Floor, Chicago, IL 60601-5800. Notification of address change must be made six weeks in advance, including old and new address with zip code. Periodical’s postage is paid in Chicago, IL, and additional mailing offices.

Notice of PolicyEditorial—views expressed in articles contributed to the Journal of AHIMA are those of the author(s) and do not necessarily reflect the policies and opinions of the Association, editorial review board, or staff. Articles are not to be construed as endorsing any particular product or service. Advertising—products, services, and educational institutions advertised in the Journal do not imply endorsement by the Association.

Copyright © 2020 American Health Information Management Association ® Reg. US Pat. Off.

ADVERTISING REPRESENTATIVESMCI USA

Jeff RhodesPhone: (410) [email protected]

AHIMA OFFICE233 N. Michigan Ave., 21st FloorChicago, IL 60601-5800(312) 233-1100; Fax: (312) 233-1090

AHIMA ONLINE: www.ahima.orgJOURNAL OF AHIMA: [email protected]

JOURNAL OF AHIMA MISSIONThe Journal of AHIMA serves as a professional development tool for health information managers. It keeps its readers current on issues that affect the practice of health information management. Furthermore, the Journal contributes to the field by publishing work that disseminates best practices and presents new knowledge. Articles are grounded in experience or applied research, and they represent the diversity of health information management roles and healthcare settings. Finally, the Journal contains news on the work of the American Health Information Management Association.

EDUCATIONAL PROGRAMSThe Commission on Accreditation for Health Informatics and Information Management Education (www.cahiim.org) accredits degree-granting programs at the associate, baccalaureate, and master’s degree levels. For more information on HIM career pathways and CAHIIM accreditation, visit www.ahima.org/careers.

AHIMA CEO Wylecia Wiggs Harris, PhD, CAEVICE PRESIDENT, CONTENT AND PRODUCT DEVELOPMENT James Pinnick

EDITOR Matt SchlossbergASSISTANT EDITOR/WEB EDITOR Sarah Sheber

ASSOCIATE EDITOR Mary ButlerCONTRIBUTING EDITORS Sue Bowman, MJ, RHIA, CCS, FAHIMA

Patricia Buttner, MBA/HCM, RHIA, CDIP, CHDA,CHDA, CPHI, CCS, CICATammy Combs, RN, MSN, CCS, CCDS, CDIPJulie Pursley Dooling, MSHI, RHIA, CHDA, FAHIMAMelanie Endicott, MBA/HCM, RHIA, CHDA, CCS, CCS-P, CDIP, FAHIMALesley Kadlec, MA, RHIAMelissa Potts, RN, BSN, CCDS, CDIPDonna Rugg, RHIT, CCS, CCS-P, CDIP, CICAGina Sanvik, MS, RHIA, CCS, CCS-PRobyn Stambaugh, MS, RHIA Cheryl Martin, MA, RHIAMaria Ward, MEd, RHIA, CCS, CCS-P

ART DIRECTOR Graham Simpson EDITORIAL ADVISORY BOARD Linda Belli, RHIA

Gerry Berenholz, MPH, RHIA Carol A. Campbell, DBA, RHIA, FAHIMA Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FAHIMA Diane A. Kriewall, RHIA Glenda Lyle, RHIA Daniel J. Pothen, MS, RHIA Tricia Truscott, MBA, RHIA, CHP Carolyn R. Valo, MS, RHIT, FAHIMA


IT IS AN exciting time for AHIMA. Our stra-tegic plan is a huge opportunity for our or-ganization, our members, our partners, and future audiences to join together to move our profession forward, be the disruptor, demand a seat at the table, and lead others to transform health and healthcare. What you are willing to do as an AHIMA member to support our mission and vision?

The AHIMA Board of Directors kicked off 2020 with their Strategic Governance ses-sion in January. The session focused on the work of associations and nonprofit boards, governing as a high-performing board, partnering with professional staff, and max-imizing the contribution of committees and volunteers. The next day was our first board meeting of the year. These two days gave us the opportunity as a board to welcome our new members:

� President/Chair-Elect Katherine Lusk, MHSM, RHIA, FAHIMA

� Directors Brenda Beckham, RHIA; Terri Eichelmann, MBA, RHIA; and Jami Woebkenberg, MHIM, RHIA, CPHI, FAHIMA

� Speaker of the House Christine Wil-liams, RHIA

Stepping Up with AdvocacyAdvocacy allows each of us to have our voice heard on issues that are important to us, and is an important undertaking to support AHIMA and our profession. For many years, March has been an important advocacy month for our members. AHIMA’s Advocacy Summit, taking place from March 23–24 this year, brings AHIMA members from around the country to the steps of Capitol Hill in Washington, DC. The Advocacy Summit be-gins with the AHIMA Public Policy Institute. This event allows attendees to hear from federal officials and other stakeholders in Washington, DC, about ongoing public policy work impacting our profession. The Capitol Hill visits take place on the second day of the

summit, giving attendees the opportunity to meet with members of Congress and staff to advocate on behalf of the HIM profession. This is a great example of group advocacy, in which people with similar experiences and knowledge come together in groups to talk, listen, and learn, as well as speak with one voice about important issues. Hill visits of-ten result in attendees asking Congressional representatives for their support on various pieces of legislation that will help us move AHIMA and our profession forward.

You can visit the AHIMA Advocacy Action Center on AHIMA’s website to contact your Congressional representatives. It is a quick and easy process and takes a matter of min-utes to complete. In addition, you can arrange to visit your Senators and Representatives when they are on recess and back home in their local offices. Each and every one of our voices is important.

March is a busy month for AHIMA and our profession, but advocacy can take place throughout the year—and can reach beyond the scope of legislation. I hope each of you will give thought to what you can do to help advocate for AHIMA and our profession as we work to achieve our vision of “a world where trusted information transforms health and healthcare by connecting people, systems, and ideas.” x

Ginna Evans ([email protected])

is coding educator, internal medicine special-

ties division, Emory Clinic, Emory Healthcare.

Time to Step Up

By Ginna Evans, MBA, RHIA, CPC, CRC, FAHIMA

President’s Message

Advocacy allows each of us to have our voice heard.


PART OF OUR organization’s transfor-mational journey requires our own self-transformation and growth. While that may seem scary, I want to share how I am inspired by this fact. AHIMA’s new mis-sion is built on the foundation of what we as members have brought to AHIMA and our profession—it was created with our history in one hand and our future in the other.

I am grateful we aren’t just changing—we’re also evolving, just as AHIMA’s members evolved from medical librarians to health in-formation managers. Through this process,

we will build up the House of Health Informa-tion to be stronger and more recognizable than ever before. Just as we thank our asso-ciation’s earlier members, future HIM profes-sionals will thank us for the difficult decisions we are making today so that the future will be more sustainable and successful.

As we grow and strengthen, we are be-coming a more inclusive organization that’s exploring new areas where our members can flourish. It is time to view allied health-care industry professionals as partners rather than competitors. With partners we can transform industry relationships into sources of strength that complement the work that we do at AHIMA and in our every-day roles. I am excited for the new opportu-nities that this will bring.

It is important to trust in the experts who lead the business of our association, guided by research and market analysis. As mem-bers, we have a vital role to play in provid-ing guidance and caution as it pertains to representation of our membership—without

becoming our own barriers for growth and progress.

The association’s journey is very much like that of a butterfly. The shortest part of their lifespan is the actual butterfly phase. To me, the butterfly is a perfect metaphor for our current path: “success” is the but-terfly phase, and we must be constantly transforming to attain it. We can’t afford to get stuck in any single phase. We must continue to transform to stay agile in the industry. I am looking forward to working with AHIMA’s Board members this year as we continue that journey. I recently had

a conversation with AHIMA CEO Wylecia Wiggs Harris, PhD, CAE, that resonated with me. As we discussed the future of HIM, she emphasized that we need to be intentional to empower people to impact health and to be proud to be on team AHIMA. She couldn’t be more correct—the time is now, and I am ready. She has tasked me with keeping the House of Delegates at the forefront of the Board’s conversations, consistently looking for feedback and ensuring open bidirectional communication. I have accepted that task and am inspired by her passion for ensuring the House is heard.

Finally, I would like to thank my predeces-sor, mentor, and friend, Shawn Wells, RHIT, CHDA. His passion for HIM and AHIMA sets us up for 2020 and beyond. I am honored to be leading the House of Delegates for 2020 and am looking forward to continuing his work. x

Christine Williams (christine.williams@ahi-

ma.org) is the document integrity manager at

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Moving Ahead with 2020 VisionBy Christine Williams, RHIA

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Under the Dome

WHILE ACCURATELY MATCHING patients to their health data is widely recognized as critical to enhancing patient safety, achiev-ing better patient outcomes, and ensur-ing accurate health information exchange, widespread challenges persist.

The topic of patient identifi cation and matching in healthcare is far from new. In fact, it was in 1996 that the Health In-surance Portability and Accountability Act (HIPAA) fi rst established a set of na-tional privacy and security standards for the protection of health information with-in the healthcare industry. At that time, language was included in HIPAA that re-quired the US Department of Health and Human Services (HHS) to adopt a stan-dard unique patient identifier (UPI) for health plans, employers, providers, and patients. However, in 1998, due to privacy and security concerns, language was in-cluded in the annual appropriations bill prohibiting the use of federal funds to promulgate or adopt a UPI. This prohibi-tion has remained in law ever since.

Fast forward to 2019: In June, the US House of Representatives adopted an amendment to the Labor, Health, Human Services, Education, and Related Agencies Act of 2020, which struck the existing ban from the bill. Removal of the ban would have allowed HHS to move forward with developing a national patient identifi cation strategy

Unfortunately, when Congress passed its fi nal spending package in December 2019, the bill retained the UPI prohibition language. But the bill included language that, among other things, directs the Of-fi ce of the National Coordinator for Health IT (ONC) to issue a report within one year that evaluates the effectiveness of cur-rent patient matching methods and rec-ommends actions that increase the like-lihood of an accurate match of patients to their health data. We have made more

progress on this issue in the past year than we have since the ban was fi rst put in place two decades ago.

AHIMA recognizes that HIM profession-als have a voice and an opportunity to infl uence healthcare policy that extends beyond the walls of their organization. Policies impacting HIM, including patient identifi cation, exist at both the state and federal levels. This has made advocacy increasingly important as healthcare organizations strive to create safe, in-teroperable health information systems to manage their growing volume of health data. AHIMA will continue to advocate for legislation that repeals the existing ban on the use of federal funds to promulgate or adopt a UPI to enable HHS to identify a national solution to address patient mis-identifi cation.

We need your help to make this happen. Ways you can participate in AHIMA’s advo-cacy efforts include: � Subscribe to our advocacy email list

to keep up to date on our work on pa-tient identifi cation and matching and other HIM-related advocacy issues at http://cqrcengage.com/ahima/app/register?5&m=369187.

� Let your voice be heard on social me-dia. You can follow AHIMA on Facebook or follow us on Twitter at @AHIMARe-sources.

Regardless of your position or role in health information, you can make a real difference in the health and safety of all patients by promoting a solution for ac-curate patient identifi cation and match-ing. We look forward to working with you as we move AHIMA’s advocacy agenda ahead in 2020 and beyond. x

Lesley Kadlec ([email protected]) is di-

rector, policy and state advocacy engagement at

AHIMA.

Advocacy Brings Progressfor Patient Matching

By Lesley Kadlec, MA, RHIA, CHDA

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Certified and ready tomake a difference

38.20


THE AMERICAN SOCIETY of Association Ex-ecutives is celebrating “100 Years of Associa-tions” this year with an interactive timeline highlighting “the positive impact of associa-tions on world history over the last 100 years.” Inspired, we looked through our archives to see how AHIMA and HIM professionals have changed the world, and we found some things you may have forgotten about. For instance:

� In 1955, AHIMA (then known as the American Association of Medical Re-cord Librarians) collaborated with the Food and Drug Administration and the American Society of Hospital Pharma-cists to develop better methods of re-porting adverse drug reactions, with the goal of addressing the problem with a coordinated national response.

� In 1991, AHIMA (then known as the American Medical Record Association) helped fund research that resulted in the Institution of Medicine report “The Computer-Based Patient Record: Re-vised Edition: An Essential Technology for Health Care,” a seminal publication that mapped out the future of health-care and electronic health records.

� In 2003, AHIMA collaborated with the American Hospital Association on a pilot test of the ICD-10 coding system, still years from implementation. The field test results were used to create a final version of ICD-10-CM.

� For 13 years, AHIMA advocated for bet-ter legislative protection for genetic information, work that helped bring about the Genetic Information Nondis-crimination Act of 2008, a major break-through in consumer protection.

These are just a few of the times HIM profes-sionals and AHIMA have changed the world. And we have more opportunities to keep do-ing so, because we understand the power of the story health information tells. This year, you’ll be hearing more about social determi-

nants of health (SDOH), which are defined as the societal and environmental conditions and attributes that contribute to an individual’s health and to the way they receive healthcare. AHIMA believes the availability and exchange of this data will improve health—for both indi-viduals and for populations.

It’s a timely topic. In January, a report from the Robert Wood Johnson Foundation, NPR, and the Harvard T.H. Chan School of Public Health found that nearly half of lower- and middle-income adults struggle to pay their dental and healthcare bills. Such findings,

and the story they tell of a need for health-care policies that promote greater equity and access to care, are directly tied to the need to address the social determinants of health.

In this month’s cover story, “Whole-Per-son Healthcare,” Matt Schlossberg explores how the strategic incorporation of social determinants data can drive innovations in care, and how the HIM team is a key stake-holder in formulating an interdisciplinary strategy to do so.

As HIM professionals, we are helping to drive the transformation of health and healthcare by the work we do: advancing the importance of the integrity of healthcare information, access to information, and pri-vacy and security of information. And, per-haps just as importantly, we understand the human stories the information tells as well.

We’ll have more to say on this topic as 2020 unfolds, because as a profession, we’re not done changing the world. x

HIM Professionals Change the World

By Wylecia Wiggs Harris, PhD, CAE, chief executive officer

CEO’s Message

As a profession, we’re not done changing the world.


AHIMA Triumph Award Nominations Due June 1, 2020AHIMA Triumph Awards are designed to honor and recognize the excellence, dedication, and service of those professionals or groups whose steadfast efforts have enriched the HIM pro-fession. These awards honor leaders in the HIM field, reward contributions that build our knowledge base, recognize excel-lence in preparing future HIM professionals, and encourage fresh talent and new leadership. Component State Associa-tions (CSAs) are also encouraged to apply for a Triumph Award that best aligns with their state’s program and initiatives.

The 2020 AHIMA Triumph Awards will be presented at the AHIMA20: Health Data and Information Conference in Atlanta in October. To learn more about award categories, descriptions, and guidelines, as well as past recipients, and about the 2020 nomina-tion form, visit https://app.smarterselect.com/programs/59205-AhimaAhima-Foundation. Nominations are due June 1, 2020.

The AHIMA Triumph Awards are sponsored by .

Applications to Help Lead AHIMA’s Future Due March 31AHIMA members interested in being considered for a 2021 elect-ed volunteer position should review the descriptions of these vol-unteer positions under the Elected Positions tab on www.ahima.org/volunteers. The online application forms are now posted on the Engage Volunteer Center. Elected positions include the board of directors, commissioners, and Council for Excellence in Educa-tion members. Consider nominating yourself for the AHIMA Board of Directors, or as the next president/chair-elect. Before you ap-ply, assess your leadership skills and abilities with the AHIMA Volunteer Competencies Self-Assessment Tool available online at www.ahima.org/volunteers?tabid=assessment. All applicants submitting a nomination for the board should review the list of 2021 Board Attributes and determine their qualifications. Applica-tions for elected positions are due March 31, 2020.

AHIMA Fellowship Program Deadline is May 22The AHIMA Fellowship Program (FAHIMA) is a program of earned recognition for AHIMA members who have made significant and sustained contributions to the profes-sion. Review the eligibility criteria at www.ahima.org/about/recognition?tabid=fellowship and use the Fellowship Eligibil-ity Tracking Tool to see if you qualify. The next application deadline is Friday, May 22, 2020. E-mail [email protected] to request the online application link.

Celebrate National Volunteer Week 2020 this April 19-25AHIMA is pleased to participate in National Volunteer Week, being held April 19-25, which will celebrate volunteers all over the country who take action and solve problems in their com-munities. At AHIMA, we’re extending our thanks to all of our hard-working and dedicated volunteers for everything they do in the service of AHIMA. We recognize the irreplaceable value of volunteer leadership: your time, diverse talents, and dedica-tion to the association, profession, and membership. Follow and share the hashtag #NVW and visit www.ahima.org/volun-teerweek for more on National Volunteer Week.

Grace Award Application Opens March 9The annual Grace Award recognizes an outstanding organi-zation’s journey toward new and innovative HIM practices that deliver better patient outcomes. The 2020 recipient will be honored at the AHIMA20: Health Data and Information Conference in Atlanta. The Grace Award is an opportunity to celebrate your team’s success with AHIMA. This year’s ap-plication has been shortened and simplified, allowing appli-cants to easily document their hard work and achievements. Applications are due by May 22 at 11:59 p.m. CT.

AHIMANews

Journal of AHIMA readers are going to be seeing—and hearing and reading—a lot about “Integrity,” “Connection,” and “Access” this year. Cornerstones of health information management, all Journal feature content in the year ahead will highlight one or more of these areas.

Integrity: Advancing the knowledgeable, contextual, secure, and appropriate creation and use of health data, leading industry conversations on innovative ways to ensure integrity Connection: Facilitating optimal sharing of data between providers, consumers, health information networks, and health plans through technology-enabled, secure access to electronic health information Access: Guiding the industry toward the most effective policies and practices to balance the ever-evolving need for appropriate access to protected health information with ensuring the confidentiality, integrity, and security of protected health information

I

C

A

IMPACT AREAS: INTEGRITY, CONNECTION, AND ACCESS

Journal of AHIMA March / Journal of AHIMA March /

New Titles from AHIMA PressHealth Information Management: Concepts, Principles, and Practice, Sixth EditionVolume Editors:Pamela K. Oachs, MA, RHIA, CHDA, FAHIMAAmy L. Watters, EdD, RHIA, FAHIMAThis text helps students and profession-als already working in the healthcare

fi eld understand the value of quality information from the point of patient-specifi c data collection to the aggregation of that data to generate information that can then be utilized to increase knowledge and support decision-making. This book sets the path for excellence in four-year baccalaureate programs and identifi es the critical competencies in the HIM discipline today.

Health Information Management Technology: An Applied Approach, Sixth EditionVolume Editors:Nanette B. Sayles, EdD, RHIA, CCS, CHDA, CDIP, CPHI, CHPS, CPHIMS, FA-HIMALeslie L. Gordon, MS, RHIA, FAHIMAThis text transforms and enhances the

education and training for HIM professionals. The content in this book supports AHIMA’s current curricula competencies, and the chapters are mapped to AHIMA’s Registered Health Information Technician (RHIT) domains. The organization of the information provides students with a logical fl ow for skill development and knowledge building.

Medical Coding in the Real World, Second EditionBy Elizabeth Roberts, MA Ed, CPCThis text combines the intricacies of medical coding in ICD-10-CM, ICD-10-PCS, CPT®, and HCPCS code sets with accessible instruction on how to correctly identify, select, and ap-ply codes to the health record in a real-world

setting. Each chapter focuses on a specialty and builds in complex-ity from topic to topic, addressing each in a natural progression that allows students to learn the coding process intuitively and organi-cally. Chapters contain coding exercises ranging in diffi culty from simple to complex, case studies to code, and required billing forms to complete.

HealthInformation ManagementTechnologyAn Applied ApproachSixth Edition

DownloadableResources

Volume EditorsNanette B. Sayles, EdD, RHIA, CCS, CHDA, CDIP, CPHI, CHPS, CPHIMS, FAHIMA

Leslie L. Gordon, MS, RHIA, FAHIMA

HealthInformation ManagementConcepts, Principles, and PracticeSixth Edition


Volume EditorsPamela K. Oachs, MA, RHIA, CHDA, FAHIMA

Amy L. Watters, EdD, RHIA, FAHIMA


Elizabeth Roberts, MA Ed, CPC

Medical Coding in the Real World

Second Edition

The Journal of AHIMA Expands Digital FootprintThe Journal of AHIMA began publishing a bimonthly digital-only issue of its award-winning publication in February. This is part of the Journal’s broader strategic vision to transform the way we deliver critical information to our readers.

Expanding our digital footprint enables us to:� Include more perspectives from different HIM roles

to explore the opportunities and challenges facing the healthcare industry and the HIM profession.

� Make linking to Journal-associated quizzes and other educational content more intuitive and seamless for HIM professionals to maintain an upward trajectory of professional growth.

� Enables our editorial team to deliver innovative and multimedia storytelling that connects readers to the larger conversations happening in healthcare.

Check out last month’s issue at https://journal.ahima.org/february-2020 and visit https://journal.ahima.org for the latest Journal content.

Whole-PersonHealthcare

SOCIAL DETERMINANTSSUCCESS BEGINS WITH DATA

By Matt Schlossberg

Cover



Whole-Person Healthcare

ASTHMA IS ONE of the most signi�cant chronic diseases in pe-diatric medicine, a�ecting seven million children in the United States. According to one study, asthma exacerbation accounts for “an estimated 14 million missed school days and more than 1.8 million emergency department visits each year.”1

The most significant nonphysiological determinants of multiple emergency department (ED) visits and admissions for childhood asthma include race, ethnicity, and socioeco-nomic disparities. The links between childhood asthma and social and environmental disparities have been established for decades, but the ability to incorporate those factors into the healthcare journey of an individual or population have been sporadic.

However, key technology advancements and the industry-wide shift to value-based care have given providers the ability to leverage data to look beyond the patient medical record at the socioeconomic circumstances that in�uence health quality.

�ese nonmedical elements are grouped under the term social determinants of health (SDOH). “Understanding your patient’s history isn’t just identifying medical history, it’s identifying their vulnerability,” says Michael A. Simon, PhD, principal data sci-entist at Arcadia.io, a population health management company that specializes in data aggregation, analytics, and work�ow soft-ware for value-based care. “�ere’s an opportunity to use data to help infer not just the typical medical causality that we assign to chronic conditions, but also to look at the factors that may be in-�uencing them.”

In other words, medical data alone tells an incomplete story.“�e intention is to have a broad set of data to work o� of,” says

Rich Parker, MD, chief medical o�cer, of Arcadia.io. “[Child-hood asthma] is a speci�c example where information technol-ogy identi�es patients in need of speci�c care management or a social welfare intervention. �is is where we really can get down to the level of identifying the interplay between clinical data and social determinants. Put together a registry of asthmatic patients and cross that with social determinant data. Look at pa-tients who are bouncing into the ED several times a year. Maybe you see that they live in a poorer census block or they live in houses that have more dust and dust mites.”

�e addition of SDOH data tells a more complete story, Parker argues, and will in�uence how a provider approaches treat-ment, education, and care management. From the health infor-mation management (HIM) perspective, SDOH presents chal-lenges that extend far beyond coding. HIM professionals need to �nd creative and innovative ways to acquire, analyze, and ap-ply SDOH data to whole-person healthcare.

“Health information managers understand how to report on claims and how to work with very rigorous data standards,” says Claire Zimmerman, vice president of product Innovation at HealthBI, a technology company focused on care coordina-tion. “But the opportunity and challenge today is to think a little bit di�erently about the information resources that are available and piece it together with that structured information to tell that person’s story.”

A New Old IdeaWhy has SDOH, an idea that has been kicking around since Greek antiquity, suddenly captured the collective imagination of the US healthcare industry? Part of the reason is the decade-long shift toward value-based models of care, according to Zimmerman. “Providers are held increasingly accountable for both out-comes and costs,” Zimmerman says. “If I’ve taken on risk for the outcomes of a given population, and 60 percent or 80 percent of what drives those outcomes is not actually directly impactable by me, then I need to make sure that I have resources and tools available to help drive the appropriate outcomes.”

A survey from the Deloitte Center for Health Solutions found a high correlation between health systems that were screening for social determinants and those involved in at-risk payment models.2 However, despite pockets of innovation, the gulf be-tween the potential of SDOH and actual results is signi�cant. According to �ndings published in September 2019 by the Jour-nal of the American Medical Association, only 24 percent of hos-pitals and 16 percent of physician practices reported screening for SDOH factors.3

“You can �nd physicians that are doing it and in bits and pieces here and there based upon the type of program they may be in,” says Sita Kapoor, chief information o�cer of HealthEC, a population health technology company. “But holistically, no one is really gathering the SDOH data elements that we need to help drive health outcomes.”

Unlocking the Data PuzzleOne of the most signi�cant barriers to the mainstream utiliza-tion of SDOH is data—how to acquire it, how to analyze it, and how to make it actionable.

“�e daily practice of medicine requires compliance with contracts, and those contracts have very speci�c goals in terms of quality measures and utilization. And there are no speci�c goals in these contracts around SDOH,” says Parker. “Doctors may see patients who are poor or have been incarcerated or experience food insecurity, but there’s only so much that they can do about it.”

“In order to e�ectively deploy value-based care and sustain it, I believe that you have to focus on health in addition to healthcare. In order to be able to focus on health, I believe you need to move upstream to extend your reach in the community,” says Steve Mi�, PhD, president and CEO of the Parkland Center for Clinical Inno-vation (PCCI), a nonpro�t healthcare analytics research and devel-opment organization.

“To be able to do that, I believe we need to better understand our community, our patients, from multiple standpoints, not only healthcare, but their life, their environment,” says Mi�. “And to be able to do that, you need much more sophisticated data analytics and ways to digitally share it with entities across the community to coordinate those e�orts.”

�ere’s data available—it’s just not easy to get to. According to a 2019 eHealth Initiative survey, SDOH and behavioral health data are the most di�cult types of information to collect and share.4

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Whole-Person Healthcare

“�e challenge with [SDOH data] is that it resides in much more isolated, less sophisticated systems,” Mi� says. “It resides in systems in our local municipalities, in an Excel sheet, the food pantry, or the homeless shelter. We need to �gure out how to bring this information together. And to truly start to address so-cial determinants of health, we need to leverage advanced ana-lytics to make sense of this data.”

�is leads to the question of what to do with the data once ac-quired. “Do organizations just grab the data and drop it into a folder on a computer somewhere, and bring it up whenever it’s needed? Or do they have a thoughtful design session or an op-portunity to talk through how this information gets incorporated into their grander health IT plans?” Simon asks. “�e degree to which folks think ahead about how they want that information used could make a big di�erence in how well they can act on it, and how much they can get feedback from it and report on it.”

Ideas on AcquisitionA research report by Dell EMC and the research analyst �rm IDC predicts that the digital universe will contain 44 trillion gi-gabytes of data by the end of 2020, a third of which will be col-lected and stored by the healthcare industry.4

�e challenge is that about 80 percent of this healthcare data is unstructured.5 Because those “dark data” elements are di�-cult to identify and apply to business or clinical challenges, they have little inherent value. For this reason, Joe Nicholson, MD, a practicing family medicine physician and chief medical o�cer of CareAllies, a subsidiary of Cigna that partners with providers in the transition to value-based care, argues that provider or-ganizations just stepping into an SDOH initiative may start by peering into the ocean of data they already possess.

Complex organizations entering value-based payment mod-els need connective infrastructure to support network-wide performance. �is includes underlying technology to aggregate and analyze data from a range of sources, including electronic health records (EHRs), laboratory results, claims-based payer feeds, and real-time admission, discharge, and transfer (ADT) noti�cations. Advanced analytics capabilities create new possi-bilities for whole-person care.

“For HIM professionals, SDOH is a conversation about big data management,” Nicholson says. “I would be looking for all of the touchpoints—pharmaceutical data, EHR data, patient survey data—that can better inform an algorithm and will al-low organizations to step into something that feels more like a predictive modeling.”

For example, consider the determinant of housing security. At Acadia, one of Simon’s provider clients hypothesized adding homelessness to one of the organization’s contracts. What sort of story could be told from the organization’s own data?

“We dug through a lot of pseudo- and semi-structured infor-mation to try to assign concepts to them. We found direct ref-erences to homelessness, but also to living in shelters, tempo-rary housing, living with family—all these sorts of concepts that circle around the idea of housing insecurity,” Simon explained. “�ere wasn’t a strong work�ow or a commitment to coding as-sociated with the data. But, as that information made it into the

EHR, we were able to start codifying and formalizing this infor-mation to enable better reporting.”

Ultimately, the bulk of SDOH data is going to originate from sources outside the provider organization. A major component of data acquisition is understanding what types of information are critical to an SDOH program’s success. HIM professionals should be educated on social issues and health equity, as well as understand how providers could act on information.

“�e connected community component starts with assess-ment, to understand and create the governance structure,” Mi� says. “How do you actually prioritize and start to deploy some of these components? Who are the anchor organizations? �ey need to be initially part of the governance structure and then start to be able to deploy those work processes.”

Making Data Integrated and ActionableAcquiring SDOH information doesn’t mean much if it can’t be used to serve patient populations or collaborate with external service entities. Some organizations, such as the Gravity Proj-ect, are developing use-cases related to screening SDOH data to identify food insecurity, housing stability, and transportation access, as well as de�ning and standardizing de�nitions at the discrete data �eld level.

However, standardization of codable SDOH data remains na-scent. Some provider organizations are attempting standardiza-tion within the EHR.

“We need to be sure that SDOH data is always going to be in that exact same spot, it’s always going to be completed in this exact same way,” says Catrena Smith, CCS, CCS-P, CHTS-PW, CPC-I, CPC, president of Access Quality Coding & Consulting. “In the EHR, making sure that the information is housed in the same part of the chart, it’s indexed the same way. So that for one patient, it’s not in the nursing notes, and a di�erent patient it’s mixed in with the physician’s progress note, and a di�erent pa-tient it’s over in some case management note.”

For the HIM professional, the complexity of this interplay means that SDOH is very much a team sport. “When the HIM team tackles this data, it’s going to be a matter of pulling together a team, preferably a disparate team of pharmacists and social workers and doctors to create the sort of data-driven opportuni-ties to identify patients at the highest risk,” says Nicholson.

Connecting patients with the appropriate community resources, then assessing the outcomes of those referrals, requires both in-teroperability and analytics. Essential to the sustainability of an SDOH initiative is creating a data-driven feedback loop among pro-viders, patients, and community service organizations.

“At the center of this is a governance structure,” Mi� says. “To enable this data vision, we need to work with multiple enti-ties across the community, whether it’s other providers and payers, local philanthropic organizations, community-based organizations across the spectrum of food pantries, transpor-tation, daycare, and local municipalities.”

Another piece of the puzzle is integrating the patient into this data collection and analytics infrastructure.

“It’s not enough to just create these connected communities to address the social determinants of health, to address some of

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the underlying environmental factors that are associated with those conditions,” Mi� says. “Engaging individuals themselves is the next level that I strongly believe we need to move toward, whether it’s social determinants of health or whether it’s the broader component of value-based care.”

Putting It TogetherRecently, Mi�, unveiled the results of an SDOH pilot program launched in 2018 and focused on reducing preterm births.

“One of the key things to population health is being able to identify who’s the high-risk and prioritize your activities and your resources to be able to reach out to those where you can impact the most,” Mi� says. “In this case, we wanted to reduce preterm delivery rates and work upstream. One of the key el-ements was increasing prenatal visit attendance, and then through that, reduce and extend the pregnancy, reduce preterm rates, reduce per member per month costs, and ultimately over-all reduce maternal mortality post-delivery.”

�e PCCI Preterm Birth Prevention Program was fueled by predictive models combining accurate risk prediction, provid-er noti�cation, risk-driven and tailored patient education via digital technology, and work�ow redesign to improve birth out-comes and reduce the rate of preterm births.

�e prediction model incorporated multiple data sources, in-cluding claims, eligibility, EHR, and community data as well as demographic, clinical, and socioeconomic data, to predict the risk for preterm delivery at any point during pregnancy.

“We infused that information into the predictive model be-cause we’re risk stratifying 26,000 pregnancies a year,” Mi� ex-plains. “If you’re able to map social determinants at the block level, then geo-map individuals to speci�c blocks and use that as a very strong proxy for the needs that they’re likely experienc-ing in their day-to-day life, you can incorporate those models very e�ectively into these predictive algorithms.”

�e primary interventions were text messages, including ap-pointment reminders, nutrition tips, and other tailored mes-sages. In the �rst year of intervention, over 21,000 unique preg-nancies were prospectively risk-strati�ed, with about 7,000 pregnancies risk-strati�ed every month.

More than 800 at-risk patients received text message interven-tions, and more than 75 percent of patients reported satisfaction with the program. Compared with matched controls, patients re-ceiving the text messages saw a 24 percent increase in prenatal visit attendance and 27 percent drop in early preterm delivery, Mi� says.

�e back-end technology infrastructure fueling the initiative was a home-grown creation called Isthmus, a cloud-based plat-form for acquiring and harmonizing data from disparate sources to create a community data platform for inferring population- and patient-level insights for SDOH.

“Part of our journey was attempting to leverage existing tech-nology infrastructure or license existing platforms, but we ulti-mately decided to build our own back-end technology infrastruc-ture,” Mi� says.

In creating the technology for this initiative, PCCI concluded that it needed to be cloud-based, enable machine learning, and have API-based integration with work�ow tools.

“We were very thoughtful about using as much open-source modalities as possible because it facilitates that collaboration and translation of knowledge much more e�ectively,” Mi� says.

In addition to the Preterm Birth Prevention Program, Isthmus has been deployed for other SDOH frameworks. �ese include a pediatric asthma population health initiative that:

� Reduced emergency room visits by 30 percent � Reduced asthma-related inpatient admissions by 42 percent � Realized a 36 percent drop in the cost of asthma care for a

savings of $12 million

PCCI also developed a predictive model that in two years has helped prevent more than 2,000 adverse drug events (ADEs) for hospitalized patients, delivering a potential savings of over $17 million by reducing readmissions and ADEs.

During its two years of implementation at Parkland, the pro-gram has screened more than 87,000 patients, with 8,731 high-risk patients identi�ed. Of the high-risk patients, 16 percent received timely pharmacy intervention and more than 2,000 ADEs were prevented. For high-risk patients receiving a consult, the 30-day readmission rate was cut by 23.5 percent.

Closing the Loop on SDOHFor many providers, SDOH presents the best chance to build a more e�ective, e�cient, and holistic health system. Data—and how it is applied—will play a central role in the success of every SDOH initiative, which means that HIM professionals are es-sential stakeholders.

“We know that right now, at least from a coding standpoint, we can’t capture everything that links back to SDOH by way of an ICD-10-CM Z code. We can capture a lot but not everything,” Smith says. “What that means is that we’re not—unless some-thing changes—going to be able to rely on ICD-10 Z codes as a data point for all social factors. We’re going to have to �gure out other ways to be able to determine that the patient hit that mark for a particular social determinant of health.”

HIM professionals need to think far beyond coding issues when it comes to SDOH and where they need to be involved. �ere are many more questions than answers right now:

� How do we ensure the right information is being collected? � How will the data be analyzed/checked? � What SDOH data elements are being collected and why? � Are SDOH data elements being prioritized in terms of being

the ones most likely to be in�uenced for purposes of care delivery and care coordination?

Continued on page 48

Review Quiz Questions and Take the Quiz Based on this Article Online at https://my.ahima.org/store

Journal of AHIMA Continuing Education QuizQuiz ID: Q2019103 | EXPIRATION DATE: MARCH 1, 2021HIM Domain Area: Clinical Data Management Article—“Whole-Person Healthcare”

Whole-Person Healthcare C

DEVELOPING LEADERS FOR THE FUTURE OF HIM By Carolyn Guyton-Ringbloom, MBA, CAE

Feature



Developing Leaders for the Future of HIM

STRENGTHENING LEADERSHIP SKILLS is an important un-dertaking for health information management (HIM) profes-sionals that will help advance the profession in the healthcare industry. From learning about leadership roles to developing leadership skills, pursuing growth as leaders can help accel-erate opportunities for professional advancement as well as raise the pro�le of the HIM profession in healthcare.

Defining LeadershipLeadership is multifaceted; just as there is more than one way to be a leader, there are multiple de�nitions for it. Author and business consultant Ken Blanchard de�nes leadership as “the capacity to in�uence others by unleashing the potential and power of people and organizations for the greater good.”1 Key elements of this de�nition that embody leadership include:

� In�uencing others, not telling them what to do. Having in�uence allows one to have an e�ect on the character, behavior, or development of colleagues, which gives them the potential to guide others

� Others listen to and respect what a leader has to say � Leaders support others by helping them grow and reach

their own potential � Leaders help their colleagues and their organization to

grow and succeed; they are not focused solely on accom-plishing their own agenda, but instead focus their e�orts outwardly for the bene�t of others

Transformational leadership, a concept �rst introduced in 1973, “is the process whereby a person engages with others and creates a connection that raises the level of motivation and morality in both the leader and the follower.”2 �ere are four factors outlined in the book Leadership �eory and Prac-tice that describe transformational leadership:3

� Idealized in�uence—characterized by “walking the talk” as a leader

� Inspiration motivation—characterized by the ability to inspire others

� Individualized consideration—characterized by a genu-ine concern for the needs of others

� Intellectual stimulation—characterized by challenging others to be innovative and creative

Leaders inspire trust, create loyalty, have a vision, and sup-port others. In particular, trust—the �rm belief in the reliabil-ity, truth, and ability in someone—is a cornerstone of e�ective leadership.

According to Neysa Noreen, MS, RHIA, inpatient coding and CDI manager at Children’s Hospitals and Clinics in Min-neapolis, MN, and co-chair of the AHIMA House Envisioning Collaborative Team, “a leader is someone others can turn to for help with direction, does not always have the answers, but is able to listen and assist in �nding the answers, as well as sur-rounding him/herself with others who have the answers.”

Leaders also strive for lifelong learning and seek to continu-ously better themselves and those around them.

Developing Leadership SkillsPeople are not necessarily born as leaders. Rather, leaders are made by what they do every day—learning, gaining experi-ence, and developing skills. Motivational speaker Gordon Tredgold suggests nine questions for great leaders to ask of themselves daily:4

1. Am I engaged and excited about the work we do?2. Do I listen to my team enough?3. Am I open to feedback?4. How could I improve the quality of the feedback I provide?5. Am I giving my team the support they need?6. How could I better develop my team?7. Am I a good role model for my team?8. How could I be a better leader?9. Am I accountable?

Evolving as a leader takes time and e�ort. In his book Good to Great: Why Some Companies Make the Leap and Others Don’t,5

Jim Collins outlines di�erent levels of leadership: � Level 1: Highly Capable Individual—makes productive

contributions with their talent, knowledge, skills, and good work habits

� Level 2: Contributing Team Member—contributes to the achievement of group objectives and works e�ectively with others

� Level 3: Competent Leader—organizes people and per-formance to e�ectively pursue predetermined objectives

� Level 4: E�ective Leader—catalyzes commitment to the pursuit of a compelling vision and stimulates people to perform at a high level

� Level 5: Executive—builds enduring greatness with a combination of personal humility and professional will

HIM professionals need to learn to lead and transition to a higher level of leadership at their organizations. Jeannine Pugh Cain, MSHI, RHIA, CPHI, co-chair of the AHIMA House



of Delegates Leadership Team, says she shows her value in any situation by “exhibiting skills of awareness, �exibility, and adaptivity to ensure successful interaction and direction.” She also practices re�ection in order to learn from her experience, focusing on what she could have done di�erently, identifying opportunities to improve, and formulating a plan to make any necessary corrections. �is practice of self-assessment, al-though at times di�cult, is an important part of the process for growing as a leader.

�e August 2014 Journal of AHIMA article “Taking Your Seat (At the Head of the Table)” o�ers several tips for how HIM professionals can strengthen their leadership skills and demonstrate how their role and the health information they work with are integral to their organization. �e article recom-mends HIM leaders start setting small, incremental goals in order to achieve the level of leadership they desire.

Leading AHIMA and Industry in TransitionOne of the outcomes outlined in AHIMA’s 2020–2023 Stra-tegic Plan is to shape the health information profession by growing the influence and competitiveness of health infor-mation skillsets. One of the three multi-year strategies to achieve this outcome is to align professional development and educational programs with shifting market needs to advance hard and soft skill sets and support rebranding of the profession.6

�e concepts represented in transformational leadership are particularly relevant for AHIMA members as the association continues to transform along with the profession. It is impera-tive that today’s HIM professionals respond to today’s health-care ecosystem.

Christine Williams, RHIA, document integrity manager at UW Health and speaker of the House of Delegates at AHIMA, discussed leading the association and its members through this environment. “When I think about leading through trans-formation, I look at the new opportunities with an open mind to ensure I am not a barrier for growth and progress,” Williams says. “�at doesn’t mean it is easy or that I roll over to changes, but that my thought process has evolved to be more purpose-ful to ensure positive outcomes.”

Recognizing the need to help AHIMA’s members develop leadership skills, AHIMA will be o�ering the Blanchard Lead-ership modules in 2020 to support members in their profes-sional development. More information will be coming in the second quarter of 2020.

HIM professionals just starting to strengthen leadership skills can start by assessing their current competencies with AHIMA’s volunteer leadership competencies self-assessment, available at www.ahima.org/volunteers?tabid=assessment. �e assessment identi�es ideal skills for leaders in several key areas and tracks progress toward acquiring and strengthening those skills. �ough the tool was designed to help volunteers identify skills needed for volunteer roles, these same compe-tencies pertain to the HIM profession.

�e self-assessment includes �ve core competencies: 1. Adheres to and advocates for the AHIMA code of ethics 2. Demonstrates commitment to the association 3. Acts as a team player/collaborator 4. Respects diversity and fosters inclusion 5. Presents a positive professional image

Each competency is key for success in all professional roles. Beyond these five core competencies, there are nine additional competencies with sub-competencies for mem-bers to use to assess their skills and experience. HIM pro-fessionals can use the tool to determine their skill level and identify areas for improvement, as well as develop goals to help gain the skills needed to either become leaders or im-prove as leaders.

For HIM professionals not in leadership positions, stepping up as a volunteer for a component state association (CSA), AHIMA, or other volunteer organization can provide oppor-tunities to gain valuable experience that will help them grow as leaders.

“Being a leader means to expect failure and con�ict but to know that it just takes re-framing and a new perspective to learn from failed attempts and mistakes,” says Aurae Beidler, MHA, RHIA, CHPS, CHC, compliance and privacy o�cer at Linn County Health Services in Albany, OR, speaker-elect of the AHIMA House of Delegates, who has volunteered at her local CSA and now serves as a volunteer at the national level. She has learned these principles of leadership through her volunteer experience. “�ere is usually another way to do things, especially when we work collaboratively and listen to all ideas,” Beidler says.

From managing a budget to planning a meeting or taking a governance role, there are myriad opportunities to grow your skillset as a volunteer with AHIMA or your local CSA. Members who serve at AHIMA’s national level with the board of directors, the Commission on Certi�cation for Health In-formatics and Information Management (CCHIIM), and the Council for Excellence in Education (CEE) have achieved level 5 in Collins’s leadership level model. �ese leaders are visionary, strategic thinkers with the business acumen needed to manage a multi-million-dollar business, and they are comfortable making tough decisions. For members inter-ested in pursuing a board of directors role, the 2021 AHIMA Board of Directors Competencies self-assessment is avail-able online at www.ahima.org/volunteers.

�ese documents are vital for each potential candidate to review, says Ginna Evans, MBA, RHIA, CPC, CRC, FAHIMA, coding educa-tor, internal medicine specialties division at Emory Clinic, Emory Healthcare and president of the AHIMA Board of Directors.

Serving on AHIMA’s Board requires individuals to be com-mitted and understanding of the time, energy, and work need-ed to succeed in the position, Evans says. �e online applica-tion to serve includes the Volunteer Leadership Competencies Self Assessment as well as the 2021 AHIMA Board of Directors Competencies.

I



Evans cites her abilities to think strategically, participate in discussions as a change transformation leader, and focus on governance as just a few of the attributes that have proven es-sential as a member of the board.

Ethics in LeadershipAHIMA’s Code of Ethics (Code) provides a guideline for members, credential holders, and students to follow to en-sure they are leading by example when it comes to ethical behavior in the workplace. Each of the thirteen principles included in the document includes examples of ethical and unethical behavior, which assist with proper interpretation of the Code. All leaders must consistently demonstrate this high standard of behavior.

Beidler encourages leaders to ask themselves “Are you doing the right thing when no one is looking, and do you live the val-ues of a leader throughout all facets of your life?”

�e ethics self-assessment helps HIM professionals determine how well they adhere to the Code and to identify areas where improvement is needed. �ese materials are available online in the Ethics section of the AHIMA website. HIM professionals should also determine whether their organization has a Code of Ethics. It is essential to be familiar with these guidelines.

Leading Through Change�e only constant is change. As AHIMA moves forward with its mission, vision, and strategic plan to help its members and the HIM profession achieve success in the rapidly changing healthcare landscape, leadership skill development is key for HIM professionals to advance and become in�uencers—not followers—in the industry.

AHIMA members are an important part of a movement to transform healthcare. Realizing our potential as leaders is the �rst step. x

Notes1. �e Ken Blanchard Companies. www.kenblanchard.com. 2. Northouse, Peter G. Leadership �eory and Practice, Sev-

enth Edition. SAGE Publications, 2015.3. Ibid.4. Tredgold, Gordon. “9 Questions Great Leaders Ask of

�emselves.” �rive Global. January 12, 2020. https://thriveglobal.com/stories/9-questions-great-leaders-ask-of-themselves.

5. Collins, James. Good to Great: Why Some Companies Make the Leap and Others Don’t. HarperCollins Publish-ers, 2001.

6. AHIMA. 2020–2023 Enterprise Strategic Plan. 2019. http://bok.ahima.org/PdfView?oid=302888.

ReferencesAndersen, Erika. “What Leading with Vision Really Means.”

Fast Company. November 21, 2012. www.fastcompany.com/3003293/what-leading-vision-really-means.

Eramo, Lisa A. “Taking Your Seat (at the Head of the Table): How to Become a Leader and Decision-Maker in Healthcare.” Journal of AHIMA 85, no.8 (August 2014): 14-21.

Kruse, Kevin. “What Is Leadership?” Forbes. April 9, 2012. www.forbes.com/sites/kevinkruse/2013/04/09/what-is-leadership.

Mancilla, Desla, Carolyn Guyton-Ringbloom, and Michelle Dougherty. “Ten Skills �at Make a Great Leader.” Journal of AHIMA 86, no.6 (June 2015): 38-41.

Stoker, John R. “Do people trust you? Advice for building trust and inspiring con�dence.” SmartBrief. January 13, 2020. www.smartbrief.com/original/2020/01/do-people-trust-you-advice-building-trust-and-inspiring-con�dence.

Carolyn Guyton-Ringbloom ([email protected])

is senior director, governance and board operations at AHIMA.

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Part III

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Part IV

Part I

Part III

Part IIPart V

Part IV

Part I

Quality Payment Program 2020: Changes and RequirementsPART III: MIPS PROMOTING INTEROPERABILITY PERFORMANCE CATEGORY IN 2020By Michael Stearns, MD, CPC, CRC, CFPC

Feature



Quality Payment Program 2020: Changes and Requirements

THE CENTERS FOR Medicare and Medicaid Services (CMS) made relatively few changes to the Promoting Interoperability (PI) category of MIPS. However, the overhaul of this category in 2019 created challenges for some practices that will carry over into 2020.

Reporting Period: �e reporting period for PI remains a mini-mum of 90 consecutive days in 2020. Any 90-day period can be selected, so practices may wish to start collecting PI data well before the last possible performance period start date of Octo-ber 3, 2020. �is approach allows users to identify areas of de�-ciency prior to the actual reporting period.

Weighting and Reweighting Requirements: PI continues to be weighted at 25 percent of the MIPS total score. However, it is reweighted to 0 percent (and its points are reallocated to the quality category) if one or more of the following criteria are met:

� Reporting by a non-physician clinician. �is includes nurse practitioners, physician assistants, clinical nurse specialists, certi�ed registered nurse anesthetists, clini-cal psychologists, physical therapists, occupational ther-apists, quali�ed audiologists, quali�ed speech language pathologists, registered dieticians, or registered nutri-tional professionals.

� A group of nonphysician clinicians (with no physicians as per the CMS de�nition of physician). Individual clinicians or groups that claim a PI hardship exception if they meet certain challenges during the performance year, such as the use of decerti�ed electronic health record (EHR) tech-nology, insu�cient internet connectivity, or signi�cant �-nancial distress. Hardship exceptions must be submitted by December 31, 2020.

�e following circumstances quali�ed for exceptions in 2019 but may change when the PI hardship exception application process for 2020 opens in mid-year:

� A small group or individual clinician has experienced sig-ni�cant barriers to meeting the PI category requirements

� �e practice is using decerti�ed electronic health record technology

� �e practice is facing extreme and uncontrollable circum-stances, including but not limited to: disasters, natural and otherwise

� Practice closure � Severe �nancial distress � Vendor issues � Lack of availability of certi�ed EHR technology (CEHRT).

�is is de�ned as lack of control over the availability of CEHRT in one or more practice locations where more than 50 percent of the patient encounters occurred.

CMS will generally grant hardship exceptions without re-questing supporting information. Practices will be required to provide evidence as to why they quali�ed for an exception if the practice is selected for a data validation audit.

Non-patient-facing clinicians and groups are also eligible for reweighting of the PI category points to the quality category. �ese are de�ned as MIPS-eligible clinicians that bill for fewer than 100 patient-facing encounters during the MIPS determina-tion period. CMS modi�ed the requirement for groups for 2020. For a group to be eligible for reweighting, more than 75 percent of the national provider identi�ers (NPIs) in the group must be non-patient-facing.

Hospital-based clinicians, de�ned as MIPS-eligible clini-cians who furnish 75 percent or more of their covered profes-sional services in inpatient hospital (place of service [POS] 21), on campus outpatient hospital (POS 22), o� campus outpatient hospital (POS 19), or emergency room (POS 23) settings. CMS modi�ed the group reporting requirement in the 2020 Physician Fee Schedule (PFS) Final Rule. Starting in 2020, more than 75 percent of the clinicians in the group must meet the require-ment for being hospital-based as individuals for the group to qualify for reweighting.

Ambulatory surgery-based clinicians are de�ned as a clini-cian who furnishes 75 percent or more of his or her covered pro-fessional services in sites of service identi�ed by POS 24.

�e above listed clinicians and groups retain the option to sub-mit PI data. If they report PI data, they will be scored the same as other groups submitting PI data. If they elect not to report PI data, 25 percent weighting of the PI category will be redistributed to the quality performance category (in most cases).

PI Objectives and Measures�e 2020 �nalized PI objectives, measures, and point totals are shown in Table 1 on page 24. All the minimum requirements identi�ed in Table 1 must be met for the entire PI performance category to receive a score greater than zero, unless an exclusion for the measure is claimed.

ePrescribing Objective�e requirements for the e-prescribing measure in this objec-tive have not changed from 2019. Clinicians need to create at

Editor’s note: This article is the third part of a five-part series on the Centers for Medicare and Medicaid Services Quality Payment Program (QPP) in 2020. Parts I and II are available on the Journal of AHIMA website at https://journal.ahima.org.

� Part I provided an update to the current requirements for MIPS, emphasizing key components that changed in 2020. � Part II provided information on the current requirements for the Merit-based Payment Incentive Program (MIPS) quality per-

formance category. � Part III, below, focuses on the current requirements for the MIPS Promoting Interoperability performance category. � Part IV will detail the requirements for the cost and improvement activity performance categories of MIPS and MIPS audit

considerations � Part V will review the 2020 QPP Alternative Payment Models (APMs) and MIPS APMs.

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least one permissible prescription that includes querying of a drug formulary and transmission of the prescription electroni-cally using CEHRT. �e score for this measure is determined by the percentage of prescriptions created that meet these criteria. All prescriptions, including handwritten prescriptions, attrib-uted to the clinician’s NPI are included in the denominator.

Clinicians or groups who write fewer than 100 permissible prescriptions during the performance period can claim an exclusion for this measure. If this exclusion is claimed, the 10 points assigned to this measure will be redistributed to the Pro-vide Patients Electronic Access to �eir Health Information PI measure.

Clinicians and groups that work in multiple settings of care, often using disparate EHRs and e-prescribing applications, are required to aggregate the total number of prescriptions written by the practice. CMS requires practices to aggregate data on all prescriptions created by the individual or group regardless of method used (e.g., electronic, phone order, paper, etc.) to popu-late the denominator for this measure. �ey must also identify the prescriptions that meet the e-prescribing requirements, as these are used to populate the numerator for this measure.

Practices that see 50 percent or more of their patient encoun-

ters in settings of care where they have no control over the use of CEHRT may be eligible to claim a hardship exception for the PI category in 2020. However, the recommended best practice would be to work towards harmonizing the e-prescribing pro-cess by writing all prescriptions using a single e-prescribing tool.

Opioid MeasuresTwo optional measures were introduced under the e-Prescrib-ing Objective for 2019:

� Query of Prescription Drug Monitoring Program (PDMP) � Verify Opioid Treatment Agreement

CMS removed the Verify Opioid Treatment Agreement op-tional measure for the 2020 performance period.

�is Query of PDMP measure remains optional and if utilized will earn practices �ve bonus points in the PI category. �e re-porting requirement for the Query of PDMP measure has been changed from having to report performance data (i.e., numera-tor/denominator values) to a simple “Yes” or “No” attestation in 2020 (and retroactively to the 2019 performance year).

CMS stated in the 2020 PFS Final Rule: “A ‘yes’ response would indicate that for at least one Schedule II opioid electronically

TABLE 1: OVERVIEW OF PI OBJECTIVES AND MEASURES

Objectives Measure Minimum Reporting Requirement (If no exclusions claimed) Maximum Points

E-Prescrib-ing

E-Prescribing (required) One prescription submitting electronically 10 points

Bonus: Query of Prescription Drug Monitoring Program (PDMP)

None: Optional measure 5 bonus points

Health Information Exchange

Support Electronic Referral Loops by Sending Health Information (required)

Using CEHRT export and send one summary of care document electroni-cally in association with a referral or transition of care

20 points

Support Electronic Referral Loops by Receiving and Incorporating Health Information (required)

Using CEHRT receive and incorporate one summary of care document for patients in transition of care, inbound referrals, or a patient never previously encountered by the clinician

20 points

Provider to Patient Exchange

Provide Patients Electronic Access to Their Health Information (required)

For at least one unique patient seen during the performance period provide timely access to view online, download, and transmit to a third his or her health information, AND, health information is available to the patient via the application of their choice

40 points

Public Health and Clinical Data Exchange(Maximum of 10 points under this objective)

Immunization Registry Reporting Active engagement with a public health agency to receive and submit immunization data

5 points

Electronic Case Reporting Active engagement with a public health agency to electronically submit case reporting of reportable conditions

5 points

Public Health Registry Reporting Active engagement with a public health agency to submit data to public health registries

5 points

Clinical Data Registry Reporting Active engagement with a clinical data registry to submit data 5 points

Syndromic Surveillance Reporting Active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting

5 points

C



prescribed using CEHRT during the performance period, the MIPS-eligible clinician then used data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law.”

Health Information Exchange Objective�ere are two measures under this objective. �ey created chal-lenges for a signi�cant number of practices in 2019 and one of these measures has become more challenging in 2020.

Support Electronic Referral Loops by Sending Health In-formation Measure: �is measure requires clinicians to create and then export at least one Summary of Care Record using 2015 Ed. CEHRT (in the consolidated clinical document architecture [CCDA] format) when patients are transferred to another care setting or when they are referred to another clinician. Clinicians must have “reasonable certainty” that the receiving clinician is able to receive the CCDA document using an EHR that is capa-ble of importing the CCDA document (although the receiving EHR does not have to be 2015 Ed. CEHRT). CMS clari�ed that

referrals include when a patient is instructed to follow up with a provider they have previously encountered.

Each referral or transition of care that occurs during the per-formance period is used to populate the denominator. �e numerator is populated when the CCDA is created, exported, and exchanged electronically. �ere is no requirement for the receiving clinician to import or otherwise address the inbound CCDA document. However, the exchange must be compliant with security protocols for ePHI under HIPAA. Examples of ac-ceptable transmission methods include secure email, Health Information Service Provider (HISP), query-based exchange, or use of third-party HIE.

�e CCDA must contain the �elds listed in Table 2, above, if the MIPS-eligible clinician knows it. �e current problem list, medication list, and allergy list �elds cannot be blank. For ex-ample, if the patient is not taking medication, the �eld should contain text such as “patient on no current medications.” Other �elds may be left blank if the information is not available.

�is measure has an exclusion for clinicians and groups that

TABLE 2. CCDA CONTENTS

*cannot be left blank

Information Type

Patient name

Demographic information (preferred language, sex, race, ethnicity, date of birth)

Smoking status

Current problem list (eligible clinicians may also include historical problems at their discretion)*

Current medication list*

Current medication allergy list*

Laboratory test(s)

Laboratory value(s)/result(s)

Vital signs (height, weight, blood pressure, BMI)

Procedures

Care team member(s) (including the primary care provider of record and any additional known care team members beyond the referring or transitioning clinician and the receiving clinician)

Immunizations

Unique device identifier(s) for a patient’s implantable device(s)

Care plan, including goals, health concerns, and assessment and plan of treatment

Referring or transitioning clinician’s name and office contact information

Encounter diagnosis

Functional status, including activities of daily living, cognitive and disability status

Reason for referral

C


transfer patients to another setting or refers a patient fewer than 100 times during the performance period. Referrals are de�ned in the speci�cation document for this measure as: “Cases where one provider refers a patient to another, but the referring pro-vider maintains his or her care of the patient as well.”

If the exclusion is claimed the 20 points from this measure are redistributed to the Provide Patients Electronic Access to �eir Health Information measure, giving it a weighting of 60 points.

Some practices have experienced challenges with identifying settings of care and clinicians that have the capability (and will-ingness) to receive inbound electronic summary of care records. CMS stated in the 2020 PFS Final Rule that if the practice cannot identify at least one clinician or facility capable of receiving and incorporating the summary of care document, the practice will receive a total PI score of zero points.

Performance on this measure will continue to be challenging in many settings. Each referral, based on the de�nition and in-formation provided above, and each transition of care must be tracked and used to populate the numerator and denominator for this measure.

CMS provides the option of including or excluding all referrals and transitions of care for providers sharing the same EHR. CMS

clari�ed that this includes internal referrals and transitions of care under the same tax identi�cation number (TIN). Howev-er, the referring provider must create the CCDA using CEHRT and send it electronically to the receiving clinician/facility. �is may be an option for practices that are facing challenges with meeting the minimum requirement for this measure. In settings where there are no providers or facilities capable of receiving the CCDA document, practices may elect to include internal re-ferrals when applicable. �is would allow practices to avoid a score of zero points for the PI performance category.

Support Electronic Referral Loops by Receiving and Incor-porating Health Information Measure: �is measure requires clinicians to import and reconcile at least one CCDA document under the following circumstances:

� �e practice is using 2015-edition CEHRT � A CCDA has been received by the practice � One of the following criteria are also met:

» �e clinician was the receiving party of a transition of care or referral

» �e clinician has never before encountered the patient.

Only encounters that meet these requirements are counted in

TABLE 3. INFORMATION THAT MUST BE AVAILABLE TO PATIENTS TO VIEW, DOWNLOAD, AND TRANSMIT

Information Type

Patient name

Provider’s name and office contact information

Current and past problem list

Encounter diagnosis

Procedures

Laboratory test results

Current medication list and medication history

Current medication allergy list and medication allergy history

Vital signs (height, weight, blood pressure, BMI, growth charts)

Smoking status

Immunizations

Functional status, including activities of daily living, cognitive and disability status

Unique device identifier(s) for a patient’s implantable device(s)

Demographic information (preferred language, sex, race, ethnicity, date of birth)

Care plan field(s), including goals, health concerns, assessment, plan of treatment and instructions

Any known care team members including the primary care provider (PCP) of record

Quality Payment Program 2020: Changes and RequirementsC


the denominator. If the receiving clinician/facility does not “re-ceive” a CCDA, the encounter is excluded from the denomina-tor. CMS did not further specify the meaning of “received,” but in general this implies that a clinician or facility sent the CCDA to the receiving provider.

Practices are required to import the CCDA and then reconcile at a minimum the following CCDA �elds: current problem list, current medications, and current allergies. Nonmedical sta� may perform the reconciliation process under the supervision of a clinician if the clinician or other credentialed medical sta� are responsible and accountable for review of the information.

CMS clari�ed that the term “never before encountered the patient” is not the same as the new patient de�nition for ambu-latory evaluation and management coding, which de�nes new patients as those not seen by the practice within the past three years. For this PI measure, a patient being seen by a clinician that they have never previously encountered, even if they were seen recently by another clinician in the same group, would be counted in the denominator.

�is measure has an exclusion for clinicians and groups that receive transitions of care, referrals, or have patient encounters in which the MIPS-eligible clinician has never before encoun-tered the patient fewer than 100 times during the performance period. �ese requirements summate; for example, if the prac-tice has 40 inbound referrals, receives 20 patients in transition of care, and 50 encounters where the clinician has never previous-ly encountered the patient, they will not qualify for the exclu-sion. If the exclusion is claimed, the 20 points for this measure is reweighted to the Support Electronic Referral Loops by Sending Health Information measure.

Some practices may not receive any inbound CCDAs during the performance period. CMS granted an exclusion for the 2019 reporting year for when practices were unable to implement this measure. It required no speci�c documentation and addresses

this speci�c scenario. For the 2020 reporting year this exclusion has been removed. Practices that do not receive, import, and reconcile at least one CCDA during a transition of care, inbound referral, or newly encountered patient will receive a zero in the numerator for this measure and receive a total PI score of zero out of 25 points.

CMS allows clinicians the option of counting referrals/transi-tion of care when the same EHR is being used by the sending and receiving parties, including internal (same TIN) referrals as the denominator. However, the receiving clinician must go through the steps of receiving, importing, and reconciling the CCDA for the encounter to count in the numerator. �e practice must also include all internal (and external) inbound referrals, transitions of care, and new patient encounters in the denomi-nator.

Practices that have no inbound CCDAs from external sources may wish to exercise the internal referral option. In that setting the practice would have greater control over performance on this measure, and higher scores could readily be achieved.

PI measures do not have case minimums or benchmarks. For example, if a practice only received one CCDA from an external referral source that was imported and reconciled, they would receive a numerator/denominator score of 1/1 (e.g., 100 percent performance). �is would earn the 20-point maximum score for this measure.

Provider to Patient Exchange Objective�e Provide Patients Electronic Access to �eir Health Informa-tion Measure has a maximum value of 40 points. It requires that at a minimum of one patient that has an encounter during the reporting period is o�ered “timely access” to a patient portal or other application they can use to view, download, or transmit their health information electronically. Patients that decline ac-cess are still counted in the numerator and denominator for this

Measure Name Exclusion Criteria for Clinician or Practice

Clinical Data Registry (CDR) Reporting The practice does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the performance period.

Syndromic Surveillance Reporting The practice is not in a category of healthcare providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system.

Immunization Registry Reporting The practice does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the performance period.

Public Health Registry Reporting The practice does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician’s jurisdiction during the performance period.

Electronic Case Reporting The practice does not treat or diagnose any reportable diseases for which data is collected by their jurisdic-tion’s reportable disease system during the performance period.

TABLE 4. EXCLUSION CRITERIA UNIQUE TO EACH PUBLIC HEALTH AND CLINICAL DATA EXCHANGE MEASURE

Quality Payment Program 2020: Changes and Requirements C


measure. �e denominator for this measure includes all unique patients

seen by the MIPS-eligible clinician during the performance pe-riod. �e numerator consists of the number of patients seen during the reporting period who were provided or o�ered time-ly access to their health information. Timely access is de�ned as within four business days. �is must be ongoing during the reporting period and not limited to information shared in as-sociation with encounters.

�e measure also requires that clinicians provide the patient with access to their health information via an application of their choosing, as long as the application is compatible with the application programming interface (API) available within the clinician’s EHR. Clinicians may not prohibit patients from using any application, including third-party applications, which meet the technical speci�cations of the EHR’s API. CMS expects clinicians to provide patients with detailed instruc-tions on how to authenticate their access through the API. Practices covered by civil rights laws are required to provide individuals with disabilities equal access to information and appropriate auxiliary aids and services as provided in the ap-plicable statutes and regulations.

�ere are no exclusions for this measure. At a minimum the patient will need to be able to view, download, and transmit the following electronic information outlined in Table 3 on page 26.

Public Health and Clinical Data Exchange Objective�is objective has �ve measures with similar requirements:

� Clinical Data Registry Reporting � Immunization Registry Reporting � Electronic Case Reporting � Public Health Registry Reporting � Syndromic Surveillance Reporting

Reporting for these measures requires a simple “yes” or “no” attestation as to whether the practice was in (or tracking to-wards) “active engagement” with a registry/public health agen-cy. If the practice can attest “yes” to two measures or “yes” to one measure and claims an exclusion for any one of the remain-ing four measures, they will earn the full ten points associated with this objective. If the practice can claim exclusions for two of the measures in this objective, the points in this objective will be reassigned to the Provide Patients Electronic Access to �eir Health Information measure.

�e active engagement requirements have the same de�nitions and requirements for all �ve measures under this objective: �e clinician “…is in the process of moving towards sending ‘pro-duction data’ to a public health agency or clinical data registry, or is sending production data to a public health agency (PHA) or clinical data registry (CDR).” Practices do not need to re-register each year with a PHA or CDR once they achieve active engagement.

CMS states that active engagement may be demonstrated in one of the following three ways:

� Option 1—Completed Registration to Submit Data: �e practice has completed registration to submit data with

the public health agency or clinical data registry to which they intend to submit data. Registration must be complet-ed within 60 days after the start of the MIPS performance period chosen by the practice. �e practice must also be “awaiting an invitation” from the PHA or CDR to begin testing and validation. �is option is applicable to when the PHA/CDR does not have adequate resources to initi-ate the testing and validation process.

� Option 2—Testing and Validation: �e practice is in the process of testing and validation of the electronic submis-sion of data. �e clinician or group representative must respond to requests from the PHA or CDR within 30 days. Failure to respond twice within the MIPS performance period would result in that MIPS-eligible clinician not meeting the measure.

� Option 3—Production: The practice, having completed the testing and validation of the electronic submission, is electronically submitting production data to the PHA/CDR.

Each of the �ve public health/clinical data exchange measures have certain exclusion criteria in common, including:

� �e PHA/CDR operates in a “jurisdiction” where there are no PHAs or CDRs (depending on the measure) capable of accepting electronic PHA/CDR electronic transactions at the start of the performance period.

� �e PHA/CDR operates in a “jurisdiction” where no eligi-ble PHA or CDR (depending on the measure) has declared readiness to receive electronic PHA/CDR transactions as of 6 months prior to the start of the performance period.

Each of the �ve measures also has a unique exclusion crite-rion (as shown in Table 4 on page 27).

Per CMS, “The definition of jurisdiction is general, and the scope may be local, state, regional or at the national level. The definition will be dependent on the type of registry to which the provider is reporting. A registry that is ‘‘border-less’’ would be considered a registry at the national level and would be included for purposes of this measure.” Practices that claim an exclusion for one or more of the above PHA/CDRs will need to carefully review the exclusion criteria and provide supporting documentation if they are selected for a MIPS Data Validation Audit.

MIPS PI Performance Category: Clinical Documentation Integrity and AuditsPractices should consider creating an audit checklist for the PI performance category supported by documentation. If a data validation audit �nds that the practice failed to meet the mini-mum reporting requirements for any of the required measures, the practice may have their PI score reduced to zero points and could face additional consequences. CMS will in general accept the data and attestations submitted by practices without addi-tional validation during the reporting process. Compliance re-views are limited, at least initially, to the MIPS Data Validation Audit process.

Quality Payment Program 2020: Changes and RequirementsC



Journal of AHIMA Continuing Education QuizQuiz ID: Q2029103 | EXPIRATION DATE: MARCH 1, 2021HIM Domain Area: External Forces Article—“Quality Payment Program 2020: Changes and Requirements (Part III)”

Supporting documentation, including screenshots of actions taken, website information (e.g., for PHA/CDRs), attempts to har-monize data, etc. are strongly encouraged and should be gener-ated during the performance period. CMS requires that practices retain documentation to support all measure submissions for the PI category.

Auditors may request documentation for each performance year, with a look-back period of six years. Screenshots should in-clude information such as date accessed, website addresses, etc. as applicable. �is has created an additional information man-agement requirement for the MIPS program.

Caution is advised for the following aspects of PI in particular: � Data aggregation across disparate settings of care (if ap-

plicable) for all PI measures � Meeting the detailed requirements of the HIE Objective

measures � Ensuring that new information is updated in the patient-

facing application within four business days � Meeting the speci�c requirements for claiming exclu-

sions for PI measures � Meeting the speci�c requirements for claiming a hard-

ship exception � How documentation supporting actions related to PI is

generated, stored, and maintained for a minimum of six years x

References�e Centers for Medicare and Medicaid Services (CMS).

“2020 Physician Fee Schedule Final Rule.” Federal Register, November 15, 2019. https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other.

CMS. Quality Payment Program Resource Library. https://qpp.cms.gov/about/resource-library.

CMS. Quality Payment Program 2019 Promoting Interoperability Hardship Exception application. https://qpp.cms.gov.

Michael Stearns ([email protected]), is the founder and CEO of

Apollo HIT, LLC.

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Quality Payment Program 2020: Changes and Requirements C

HIM at the Cook County JailBy Mary Butler

Profile

FULLBODY PAT downs and metal detector screenings don’t phase Linda Kampe, MPH, RHIA. As the director of correctional health information at Cermak Health Services, the healthcare clinic for detainees at Cook County Jail in Chicago, IL, they’re a mandatory part of her daily routine. Asked if the grim setting can take a psy-chological toll, Kampe explains, “If I stop and think about it, yes, but I try to just focus on my tasks at hand and not think about the circumstances under which many of our patients are here.”

Kampe acted as the tour guide for a small group of AHIMA members during the AHIMA19: Health Data and Information Conference held last September, giving attendees a rare glimpse into her workplace—a healthcare setting seldom seen by the public. �e group walked through unoccupied sections of the jail’s living quarters, reminiscent of the housing featured in the television series Oz, and explored the underground tunnels that connect the buildings of the sprawling 99-acre jail complex. As the tour continued, it was easy to appreciate the tenacity Kampe’s position requires. “You can almost feel the despair,”

Kampe noted as the group walked through the abandoned cell block, punctuated with dead roaches and concrete bunks.

Affinity for Nontraditional HIM JobsKampe received her bachelor’s degree in health information management (HIM) in 1987 from the University of Illinois at Chicago (UIC), where she discovered an early interest in public health and research.

“When I graduated from the UIC program, I didn’t really know what direction I was going to go. I just knew that I didn’t really want to work in a hospital setting. One of my professors told me, ‘Hey, there’s someone over at the school of public health doing some research. He needs somebody to abstract some [emer-gency room] charts. Do you think you could help him?’” Kampe recalls. And she thought, “Why not? I’ll call him.”

“�at project led to another, to another, to another, and that’s how my career took o�,” Kampe says.

When a colleague approached her about applying to UIC’s



HIM at the Cook County Jail

� rst online master of public health (MPH) program, Kampe hesitated, arguing that having three small children and a full-time HIM job left her with little time for a new degree. Yet, her colleague persisted.

“You’re doing all the work of a person with an MPH, but you don’t have the credentials,” he told Kampe.

“So I did the online program and, yes, it took me a little bit longer because of my personal situation with raising my fam-ily, and all the mom duties and household duties,” says Kampe. “But I did it. I got the MPH 20 years after I graduated from my bachelor’s program.”

In 2008, Kampe was working at John H. Stroger, Jr. Hospital, formerly known as Cook County Hospital, when a coworker told her about the HIM director role at Cermak Health Services, which is part of the Cook County system. � e facility needed someone who could help convert the jail’s paper records to an electronic health record (EHR) system. She didn’t think twice about applying and was undaunted by the prospect of working in what many might consider to be an unsettling environment.

HIM Behind BarsWhen Kampe started her EHR conversion project at Cermak, there was an adjustment period; Cermak employees aren’t al-lowed cell phones without special permission and she had to invest in a see-through bag for personal belongings that she brings into the building. She acknowledges that periodic lock-downs made her nervous when she started there. Not much phases her now, although the question she gets most often from other HIM professionals is: “Is working at the jail scary?”

It’s not hard to understand this line of questioning. When the jail is in the news, it’s usually reports on riots and prisoner escapes. � e facility was put under a consent decree, or federal oversight, in 2007 when a Department of Justice investigation looked into “allegations of abuse and unconstitutional con� nement, issuing a report a year later that found glaring de� ciencies across the board, including in medical care, detainee safety and excessive force,” the Chicago Tri-bune reported. � e jail was released from the federal oversight in 2017. Signi� cant reforms were enacted by the consent decree and the facility is now touted as a federal model for addressing mental health and addiction issues. In the last � ve years, the population of the jail has dropped from 10,000 detainees to about half that. How-ever, the acuity of the health of that population has gotten worse.

� e � rst day a new patient arrives for processing—healthcare sta� only refer to inmates/detainees as “patients”—they receive physical and psychiatric screenings, including a chest X-ray as a tuberculosis screening. � ey can also request dental services and a visit with an optometrist if eyeglasses need to be made. � e clinics include an obstetrics department, a women’s con-traception program, dialysis care, radiology, a laboratory, and an urgent care clinic.

Because detainees often enter the jail with substance abuse issues, Cermak has detox housing and works with patients on methadone taper plans. � e facility is also certi� ed as a Medica-tion Assisted Treatment (MAT) program. � e onsite pharmacy dispenses up to 500,000 doses of medications per month.

As AHIMA members noted during the site visit, the Cermak

clinic looks like any other healthcare facility, aside from the ra-zor wire that runs the perimeter of the facility and the bars that cover every window. Now that the massive EHR conversion proj-ect is complete, Kampe’s HIM responsibilities are comparable with those of an HIM director in any hospital—albeit with a twist. Patient matching is a challenge for any kind of provider, but for Kampe it can mean untangling the records for patients for whom revealing their legal name is not advantageous. She’s seen cases where siblings have been processed through the jail but use each other’s names to avoid lengthening their criminal record. She’s also been sent on labyrinthine quests to track down the medical records of patients whose records are in long-term storage, but are suddenly relevant due to post-conviction appeals.

Care coordination and release of information, critical tasks for any HIM department, carry additional weight in correctional health and attempts to address recidivism.

“I think it makes a big di� erence if we provide the information to the other organizations, such as halfway houses, which are helping the people on the outside indirectly. What we do, keep-ing accurate records, keeping them safe, making sure every-thing’s released and where it’s supposed to be, I think it makes a big di� erence,” Kampe says. x

Mary Butler ([email protected]) is associate editor at the Journal

of AHIMA.

LINDA KAMPE, MPH, RHIA


Abstract This is a case study of the evidence-based management practic-es of a centralized health information management (HIM) depart-ment in a large integrated healthcare delivery system. The case study used interviews and focus groups, as well as de-identified dashboards, to explore the impact of reporting on the organi-zation. The dashboards and key performance indicators (KPIs) were initially developed in 2012 and have continued to evolve since that time. The themes that resulted include:

1. Evidence-based management is integral to the culture of the organization;

2. Communicating regularly via dashboards and KPIs is key to transmitting the value of HIM to the entire organization; and

3. Staff not only report the required measures for the dash-board, they take pride in it and often develop methods for tracking their individual performance.

The most evidence supporting HIM operations management is related to coding and clinical documentation improvement, though even in those areas, national benchmarks are missing. It is important for HIM to develop national and regional bench-marks to assist professionals in managing operations effectively and communicating their value to the healthcare industry.

IntroductionAs a profession, HIM has been actively engaged in data man-agement since at least 1998.1 The last two decades have seen continued growth and use of data in healthcare. However, even today, the use of data to manage health information operations still deserves investigation. This case study was undertaken to explore how the centralized health information management de-partment of a large integrated healthcare delivery system uses data to manage its operations.

This integrated healthcare delivery system is a faith-based, nonprofit system that cares for more patients in North Texas

than any other provider. The system’s primary service area con-sists of 16 counties, home to more than 7 million people.

The healthcare delivery system was formed in 1997 with the assets of two large existing hospital systems. Later that year, another hospital in the area joined the system.

Currently, the system has 27 hospital locations including 18 acute-care hospital locations, five short-stay hospitals, three rehabilitation hospitals and one transitional care hospital, all owned, operated, joint-ventured or affiliated with the system. It has more than 4,000 licensed beds, employs more than 25,000 people, and counts more than 6,200 physicians with active staff privileges at its hospitals.

To our knowledge, this is the first case study exploring the use of dashboards and key performance indicators (KPIs), or the ev-idence-based management, of an HIM department. The authors believed this study was needed in order to demonstrate how data can be used effectively and, hopefully, to suggest additional areas for HIM operations data analytics.

This case study is important because it begins to build the foundation for evidence-based HIM operations management. Hopefully, this case study will also be utilized by HIM educational programs.

Literature ReviewThe HIM profession has approached data management from many different perspectives, yet, publications related to evi-dence-based HIM operations management are difficult to find. Both PubMed and the American Health Information Manage-ment Association (AHIMA) HIM Library were searched. There are some, most often related to patient record coding and clini-cal documentation improvement.2,3 Unfortunately, this foci does not encompass the entire range of HIM operations, leaving out scanning and release of information, at a minimum. Other ar-ticles are focused on more broad-based analytics, applicable to the delivery of healthcare, rather than the management of HIM

HIM Evidence-based Operations Management: A Case StudyBy Susan H. Fenton, PhD, RHIA, CPHI, FAHIMA, and Diann H. Smith, MS, RHIA, CHP, FAHIMA

Editor’s Note: This article was first published as part of the Fall 2019 issue of Perspectives in Health Information Management.

Excerpt


operations.4, 5 While valuable, this does not assist HIM profes-sionals in managing their day-to-day operations.

Since approximately 2014, HIM’s professional association, AHI-MA, focused on information governance, performing studies and creating many resources for healthcare organizations to imple-ment information governance. In 2017, Houser and colleagues discussed the need for information governance related to sup-port for analytics.6 This article reviewed several models that can be used when managing the information needed for man-agement, but never addressed the actual use of the data and information for operations management. Likewise, the practice brief for data analytics reporting provides guidance regarding the reporting lifecycle, reporting methods, and tools for report-ing; however, no actual example is provided.7

The lack of a comprehensive review of evidence-based op-erations management in case study or other form reveals a gap in the HIM literature. It is expected that the following case study is only a starting point for evidence-based HIM opera-tions management.

MethodsThis case study is a joint project between a graduate program in health informatics and the large integrated healthcare deliv-ery system. It was approved by the university Committee for the Protection of Human Sub-jects, approval number HSC-SBMI-18-0567.

The meth-ods chosen for conducting the analysis of the health deliv-ery system’s evidence-based HIM operations were inter-views and focus groups over a two-day period. All interviewees and focus group participants signed informed consents related to their participation in the case study. The questions included a de-scription of the Key Performance Indicators (KPIs) used, how they are selected and calculated, as well as how the data is collected for each KPI. They were also asked about the evo-lution of the KPI reporting, and what they liked best or least about using and reporting KPIs. The IRB-approved focus group and interview questions can be found in Appendix A, available in the full version of this article published on per-spectives.ahima.org.

The interviews were held with the Vice President of Health In-formation Management Services (HIMS) and Clinical Documen-tation improvement (CDI), the direct supervisor, and the direct reports to this position. Focus groups were held with coding,

clinical documentation improvement, data integrity, release of information, operations and regulatory compliance. Transcripts were made of all sessions and grounded theory used as the anal-ysis method. A total of 50 persons took part in the focus groups, with six persons interviewed individually.

DiscussionThis case study explores the evidence-based HIM manage-ment of a centralized HIM department. For clarity, this case study will focus on the reporting from each department to the VP of HIMS and CDI, as well as to senior level executives at the system level and executives at the entity level across the healthcare organization. As with all case studies, one of the limitations is the examination of a single organization. Other HIM departments in other healthcare delivery organizations are expected to have different needs for their reports and/or dashboards so these results cannot be generalized. Addition-ally, the subjective nature of the case study method may influ-ence the case study, it can be difficult to replicate, and case studies are time consuming.

The HIM organization is centralized and complex, as might be expected when managing HIM operations for 19 hospitals and related organizations. The organizational structure is found in Figure 1, available in the full version of this article published

on perspectives.ahima.org.

The initial organi-zational structure was established in 2012 after a two-day rapid design ses-sion that involved all HIM directors and managers; rep-resentatives from Human Resources and Information Technology (IT). Over time the orga-

nizational structure evolved as responsibilities under the VP’s leadership were added. Key objectives of the rapid design ses-sion were to design and build the future state of the enterprise HIM, identify best practices, create performance specifications, and develop methods of communication. It was crucial to the or-ganization to design a unified system approach to streamline op-erations and achieve excellence with the long-term expectation of benchmarking operations. Consistent quality and timeliness of data reporting across the enterprise with a focus on develop-ment of leading-edge use of tools and enablers to consistently support a leveraged enterprise HIM model was a key initiative. From the beginning the organization developed standardized key performance indicators “KPI” to be included in a reporting ma-trix for each functional area. Performance baselines were estab-lished for post-implementation comparisons.

“AHIMA is the logical organization to lead the effort to collect HIM operations management data that their members can use for analytics and evidence to support operations. AHIMA could become a source of benchmarks and a resource for the healthcare industry.”


The use of dashboards and KPIs for the HIM operations have been in development over a period of five years. Staff who worked in other healthcare organizations or those who worked at the health delivery system prior to the central-ization of HIM services experienced a period of adjustment related to the extensive reporting, as well as the sharing of the data. They reported initially feeling that the dashboard reporting was going to be used as a “gotcha.” However, they discovered that reporting the data allowed them to identify opportunities for improvement, as well as providing evidence to celebrate achievements. It is important to note that not all goals are achieved. This is consistent with the practice of set-ting “stretch” goals. It must also be noted that the processes and dashboard reviewed for this case study is not static. It has evolved and continues to evolve.

Data is gathered in a variety of ways from each staff member. Examples include turnaround times for different types of re-quests for patient records; physician documentation compliance by documentation type; data integrity as demonstrated by dupli-cate accounts; scanning records management; coding productiv-ity and denials; and a financial analysis of HIM operations. The

summary HIM dashboard is seen in Figure 2, while Figure 3 is the CDI dashboard. Figure 2 and Figure 3 are available in the full version of this article published on perspectives.ahima.org. In order to preserve confidentiality for the organization, all data in the dashboards is synthetic. The structure of the dashboards is accurate.

In addition to providing an overall view of the measures for the integrated healthcare delivery system, each hospital or separate organizational unit receives a dashboard detailing their performance for all of the measures. For example, the integrated health delivery system may be compliant with the standard of 95 percent Completion of History & Physical Up-date within 24 hours for a given measurement period, while one or more of the hospitals or organizational units may not be in compliance with the standard.

Themes emerging from the interviews and focus groups are:1. The focus on evidence-based management is pervasive

across and throughout the organization. Most, if not all, or-ganizational units have dashboards they utilize to help them manage their areas using KPIs.

2. Communicating regularly via dashboards and KPIs not only enables more effective management, it ensures senior man-agement understands the impact of HIM operations on the

overall health of the organization.3. Setting and achieving goals instills pride in doing a job well

across the HIM and CDI personnel. The staff not only report the required measures for the dashboard. More than one person reported that they have created their own individual dashboards to track their individual performance.

As reported by the healthcare organization employees, an es-sential component of a useful dashboard is benchmarks. Howev-er, as seen in Figure 2, approximately 62 percent of the HIM oper-ational measures used by this data-driven organization have no comparable industry-wide benchmarks. This lack of comparable benchmarks was the topic of a recent JAHIMA article focused on coding accuracy.8 It is reasonable to suggest that this lack of comparable industry-wide benchmarks applies to a majority of HIM operations.

Careful attention to Figure 2 reveals multiple measures where the organization standard is much stricter than the industry standard or there is an organization standard without an in-dustry standard. For example, the release of information stan-dards for continued care request turnaround time (TAT) organi-

zation standard is 7 days, against the Texas requirement of 15 days. The organizational goal for stat requests turnaround time is 30 minutes with no industry standard, with a Year-To-Date measure of 29 minutes. Similarly, the organization’s standard for medical record delinquency rate is 25% as opposed to the Joint Commission standard of 50%, with a reported Year-To-date rate of 2.1%. Both management and staff report use of the dashboard and KPIs has resulted in an overall lowering of the targets over time demonstrating performance improvement.

Using a dashboard over a long period of time does not guar-antee problem-free management. During the interviews and focus groups it was noted that the reporting for Release of Information had recently encountered issues. Over a period of several months, the staff reported that they believed the dashboard numbers for a specific type of release request were incorrect. They contended that the numbers on the re-port were not consistent with what they were witnessing in their day-to-day operations. These reports prompted further investigation into the dashboard data that was automatical-ly extracted from the electronic health record (EHR). It was eventually determined that a recent upgrade to the EHR had altered the reporting related to the release requests. The no-table takeaway from this anecdote is that the front-line staff

The last two decades have seen continued growth and use of data in healthcare. However, even today, the use of data to manage health information operations still deserves investigation.


receive and pay attention to the dashboard. Further, they feel empowered to report inconsistencies and discrepancies they discover in the data reported on the dashboard.

Utilization of the dashboard over time can also assist the HIM department with compliance and external audits. In this organi-zation, the dashboard data reported for the transcription section was required to undergo an external audit. For those not familiar with an external audit, this is a standard practice at many large organizations. External auditors examine different practices and processes in the organization to ensure accuracy and compli-ance with regulations. All of the transcription data was reviewed for accuracy. The data collection sources were examined, as were the numbers reported. Due to the documentation support-ing the processes and the data collected, there were no recom-mendations for improvement.

It is also useful to note, while the current dashboard used by this healthcare delivery system is remarkable, it has evolved over the course of several years to meet the business needs of the organization and to align with enterprise strategic goals. The dashboard not only contains data from a system perspective, it also contains data at the hospital level, allow-ing transparency and benchmarking. It was important to the organization to create a culture of transparency which dem-onstrates the value of a centralized HIM model. Dashboard data are used by leaders across the enterprise to identify patterns/trends and as an internal comparison with similar size hospitals. This level of transparency has created a true partnership for improvement on specific measures between HIM and other departments within the organization. The dashboard has allowed improvement in HIM operations and in quality outcomes through collaborative efforts across the en-terprise. It has been reported on more than one occasion that stakeholders look for the monthly dashboard and appreciate the level of transparency.

HIM professionals wishing to initiate a dashboard should choose a starting point. This starting point could be with a single measure or a single organizational unit. For example, coding might be reasonable since HIM departments commonly track their coding productivity. Once this reporting is standardized and everyone is comfortable with the reporting, additional units such as release of information or documentation compliance can be added until all operations under HIM supervision have KPIs included on the dashboard.

ConclusionThis case study is the first thorough examination of evidence-based HIM operations management. As such, it exposes both challenges and benefits of using data to manage operations. Ini-tial challenges include securing employee cooperation for a new management process, efficiently collecting the data, and produc-ing the dashboard in a timely fashion. Benefits include substan-tiation of HIM operations effectiveness, HIM employee pride in their jobs, and validation of HIM reporting when under internal or external review.

What was especially noted was a lack of industry-wide bench-marks that would be useful for HIM operations management. This deficiency should be concerning for the HIM profession as data becomes ever more ubiquitous and important in all aspects of healthcare delivery.

AHIMA is the logical organization to lead the effort to collect HIM operations management data that their members can use for analytics and evidence to support operations. AHIMA could become a source of benchmarks and a resource for the health-care industry. x

Notes 1. AHIMA Data Quality Management Task Force. 1998. “Data

Quality Management Model (1998) - Retired.” Data Quality Management Model (1998) - Retired / AHIMA, American Health Information Management Association, June. http://bok.ahima.org/doc?oid=105639.

2. Wang, Tiankai, and Jackie Moczygemba. 2018. “Analyzing ICD-10 Diagnosis Codes with Stata.” Analyzing ICD-10 Diag-nosis Codes with Stata / AHIMA, American Health Informa-tion Management Association, May. http://bok.ahima.org/doc?oid=302491.

3. Czahor, Amy. 2017. “How Analytics Can Direct and Improve Clinical Documentation.” Journal of AHIMA 88 (9): 36–39.

4. Butler, Mary. 2018. “Niche Analytics.” Niche Analytics / AHI-MA, American Health Information Management Association, October. http://bok.ahima.org/doc?oid=302586.

5. Thomas, Felicia A., and Wahiyda A. Harding. 2018. “Data Analytics: The Power of Coded Data.” Data Analytics: The Power of Coded Data / AHIMA, American Health Informa-tion Management Association, October. http://bok.ahima.org/doc?oid=302591.

6. Houser, Shannon H., Donna J. Slovensky, and Luona Wang. 2017. “Information Governance for Analytics Support: Re-member the Life Cycle Component.” Journal of AHIMA 88 (6): 38–40.

7. Clack, Lesley, Shannon H. Houser, Lesley Kadlec, Ray-mound Mikaelian, Annemarie Wendicke, Jeannine MSHI Cain, and Amanda MA Spears. 2018. “Best Practices for Data Analytics Reporting Lifecycles: Quality in Report Building and Data Validation.” Best Practices for Data Analytics Reporting Lifecycles: Quality in Report Building and Data Validation / AHIMA, American Health Informa-tion Management Association, October. http://bok.ahima.org/doc?oid=302585.

8. Stanfill, Mary. 2019. “In Pursuit of Comparable Coding Audit Benchmarks.” Journal of the American Health Information Management Association 90 (1): 30–31, 47.

Susan H. Fenton is associate professor and associate dean for academ-

ic a�airs, at the University of Texas Health Science Center at Houston

School of Biomedical Informatics, in Houston, TX. Diann H. Smith is vice

president, health information management services and clinical docu-

mentation improvement, at Texas Health Resources, in Arlington, TX.


E ven as states across the economically challenged Appala-chian region of the US gain a foothold in combatting the opioid crisis, rates of opioid deaths in Tennessee are rising,

reaching the state’s deadliest year on record in 2018.1

Tennessee is among the hardest-hit states facing the nation’s opioid epidemic, with more than six million opioid prescrip-tions issued statewide and 1,818 opioid deaths in 2018, the highest since 2014. �e rate of death involving opioids reached 19.3 per 100,000 residents in 2017.

While opioid deaths decreased by four percent nationally and decreased even more in Appalachian states like Ohio (22.1 per-cent), Pennsylvania (18.8 percent), West Virginia (11.4 percent), and Kentucky (14.7 percent), Tennessee struggles to drive better health outcomes for those su�ering with opioid-use disorder.2

What’s holding Tennessee back from helping residents over-come this epidemic? One answer is lack of ready access to ac-tionable information at the point of care related to warning signs of opioid-use disorder.

In neighboring states like Virginia, access to a controlled sub-stance monitoring database is easily available through the elec-tronic health record (EHR). With a single sign-on, a prescriber or pharmacist can view a patient’s prescription history directly within their work�ows.3 �rough Virginia’s system—which is connected to a prescription drug monitoring program (PDPM) connecting 22 states, including Tennessee—clinicians and pharmacists are empowered to make safer prescribing and dis-pensing decisions within existing work�ows.

In Tennessee, however, the controlled substance monitoring da-tabase is not linked to the EHR with a single sign-on. �at means physicians must obtain this data through a separate system.

In addition, even as community health information exchanges (HIEs) in some areas of Tennessee give providers insight into pa-

tients’ comprehensive medical history—including recent emer-gency department (ED) visits or consultations with specialists—not all providers in Tennessee are linked to a community HIE. �ose that don’t possess a community HIE may miss signs that could point to a potential substance use disorder, such as:

� An extraordinarily high number of ED visits � Visits to numerous physicians in one year � Frequent inpatient hospital stays � An opioid prescription—currently or in the past year

Without unencumbered access to both a patient’s compre-hensive medical record and the state’s controlled substance monitoring database at the point of care, physicians are hard-pressed to make critical connections that point to opioid-use disorder. �is limits their ability to provide the right interven-tion for the right patient at the right time.

Case Study: One Provider’s ExperienceHow could widespread adoption of a community HIE—com-bined with state data monitoring prescriptions for opioids—strengthen Tennessee’s front-line defense against opioid-use disorder? One provider, Holston Medical Group (HMG), a re-gional medical group serving more than 200,000 patients in northeast Tennessee, southwest Virginia, and North Carolina found three distinct advantages.

Enhanced Collaboration Among ProvidersIn 2012, HMG invested in the only bidirectional common medi-cal record system in the state of Tennessee, inviting providers throughout eastern Tennessee, southwest Virginia, and the Charlotte, NC, region to participate. Today, more than 1,200 physicians are connected through the community HIE, which:

Combatting the Opioid Crisis with Data By Wesley Combs and David Morin, MD, FACP, CPI, FACRP

Departments


� Pushes automatic noti�cations to physicians regarding patients’ recent care interactions

� Helps providers more easily identify patients who show signs of complex health issues

� More tightly manages care for their sickest patients—the �ve to 10 percent of patients who typically account for 50 percent of healthcare costs

One example of the way in which a community HIE supports better care for patients with complex needs is the ability to bet-ter coordinate care for oncology patients. For example, patients who have cancer see specialists outside of HMG’s multispecial-ty practice. �e ability to review these specialists’ notes when these patients arrive with ailments seemingly unrelated to their disease empowers physicians to look for connections between their oncology treatment and the new health issues they face.

Among those su�ering with opioid-use disorder, 18.7 per-cent are estimated to be taking prescription opioids, and they receive 51.4 percent of the nation’s opioid prescriptions, ac-cording to a Journal of the American Board of Family Medicine study.4 Adequate treatment for one in �ve patients will require not only specialized addiction resources—such as medication-assisted treatment, counseling, and behavioral therapies—but also treatment of any underlying mental health conditions. �is requires tightly integrated care, which is most e�ectively sup-ported by shared data across providers and care settings.

Mining Data for Predictive AnalysisPairing HIE data with predictive analytic capabilities provides more complete data for risk strati�cation, real-time assessment of the most impactful areas in which to focus care interventions, and more e�ec-tive care management. It empowers providers to determine which patients need to be seen immediately, enabling a sophisticated form of care triage and more e�cient use of limited care resources. It can even predict which patients are likely to end up in the ED or are headed for an inpatient stay, as well as the types of interventions that could help keep them out of the hospital. In Tennessee, the impact in �ghting the opioid epidemic could be substantial, giving providers:

� �e ability to classify patients according to their risk of de-veloping opioid-use disorder or other forms of substance dependence5

� Increased understanding of the link between opioid use and suicide risk6

� Algorithms that predict which patients are most likely to experience opioid overdose7

At HMG, adoption of a community HIE enabled physicians to stratify patient populations into risk levels based on their number of chronic conditions and recent ED visits or hospital admissions. �is allows for the most appropriate allocation of care resources and deployment of outreach e�orts that help ensure adherence to care plans. Physicians also gain the ability to pinpoint trends in critical data (e.g., A1C levels, blood pressure) from various sourc-es and eliminate duplicative care and service.

�e impact has been signi�cant: HMG experienced improved performance around risk identi�cation under a commercial

health plan contract; a nearly 10 percent improvement in hos-pital admissions, with admissions-per-1,000 patients that are 20 percent below market rates; ED utilization that is 25 percent lower than the market average; and a 4.2 percent increase in evaluation and management services, which re�ects use of the right care in the right setting.

Data for Development of Specialized Programs Combatting Opioid AddictionAcross the country, healthcare leaders are seeking ways to use data to develop innovative ways to tackle the opioid epidemic. For ex-ample, in June 2019, the US Food and Drug Administration issued an innovation challenge to spur development of digital health tech-nologies for preventing and treating opioid-use disorder. More than 250 applications were received, and eight medical devices designed to detect opioid overdose, dispense medication, and provide pain treatment alternatives to opioids will receive FDA support in accel-erating the timeline for development (see the side bar above).

At HMG, data from the community HIE supported development

DATAFUELED INNOVATIONS FOR OPIOID TREATMENT

Source: Food and Drug Administration. “FDA Innovation Challenge: Devices to Prevent and Treat Opioid Use Disorder.” July 9, 2019. https://www.fda.gov/about-fda/cdrh-innovation/fda-innovation-challenge-devices-prevent-and-treat-opioid-use-disorder.

Company Product Name Category

Algomet Rx, Inc. Rapid Drug Screen Monitoring

Avanos Withheld per company request

Other

Brainsway, Ltd Brainsway Deep Transcra-nial Magnetic Stimulation Device (DTMS)

Opioid Use Disorder Therapy

CognifiSense, Inc.

Virtual Reality Neuropsy-chological Therapy (VRNT)

Pain Therapy

iPill Dispenser iPill Dispenser Medication Dispensing

Masimo Corporation

Withheld per company request

Overdose Therapy

Milliman Opioid Prediction Services Diagnostic

ThermoTek, Inc.

NanoThermTM and Vascu-ThermTM Systems

Pain Therapy

Health Data



Journal of AHIMA Continuing Education QuizQuiz ID: Q2039103 | EXPIRATION DATE: MARCH 1, 2021HIM Domain Area: Clinical Data Management Article—“Combatting the Opioid Crisis with Data”


Current Procedural Terminology Update for 2020By Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC

T he American Medical Association (AMA) released changes for the CPT code set in 2020 that include 248 new codes, 75 revised codes, and 71 deleted codes. �e numbers do not

tell the whole story, however, as guideline changes for exist-ing codes represent some of the most signi�cant and pervasive changes.

Modi�er 50 is not to be used on add-on codes per new CPT guidance; instead, the number of units will be assigned. For example, if a physician performs bilateral paravertebral fac-et joint injections at two levels, the correct coding would be 64493-50 for the �rst level and add-on code 64494 times two units for the second level.

Evaluation and Management updates include changes to the codes for Online Digital Evaluation and Management Ser-vices. �e AMA speci�ed that these services must be patient-initiated and that they require a clinical decision that would otherwise be made during an o�ce visit. �ree codes repre-sent di�ering amounts of time:

� Code 99421 for 5–10 minutes � Code 99422 for 11–20 minutes � Code 99423 for 21 or more minutes

Less than �ve minutes is not reportable. Time is calculated based on the total time spent evaluating and responding to the patient’s issue over a seven-day period. �e service is not billable if the patient is seen either through telehealth or in a face-to-face visit during the seven-day period. Only the time spent by a physician or other quali�ed healthcare professional (QHP)—a professional who is quali�ed through education, state licensure, and facility privileging to perform a service and who is allowed to independently report that service—may be counted.1 Similar codes were established in the Medicine

Section for these services provided by nonphysician health-care professionals such as physical therapists, social workers, and dieticians. �e same guidelines and time speci�cations apply to the nonphysician codes 98970, 98971, and 98972 and to the physician codes 99421, 99422, and 99423.

Remote physiologic monitoring code 99457 is revised to specify the �rst 20 minutes in the calendar month, with the new code 99458 as an add-on code for each additional 20 minutes.

When a patient’s blood pressure is elevated at an o�ce visit, it is common for the physician to ask the patient to measure their blood pressure at home over a period of time before a diagnosis and treatment plan is established. �is has always been considered part of whatever face-to-face services are performed; however, the 2020 update to CPT provides codes to report these services. Code 99473 will be reported when clini-cal sta� educate the patient on proper use of the blood pres-sure monitor. Code 99473 accounts for the physician work of reviewing the patient log, establishing the treatment plan, and communicating that plan to the patient. �e intent is for the patient to self-measure their blood pressure with two readings one minute apart twice daily; however, the physician may re-port this code with a review of at least 12 readings.

Changes in the Integumentary System include revisions to the Repair guidelines. �e 2020 update clari�es what criteria must be met to support complex repair versus intermediate re-pair. Complex repair requires documentation of at least one of the following:

� Exposure of bone, cartilage, tendon, or named neurovas-cular structure

� Debridement of wound edges (e.g., traumatic lacerations or avulsions)

Departments


� Extensive undermining � Involvement of free margins of helical rim, vermilion bor-

der, or nostril rim � Placement of retention sutures

Extensive undermining is de�ned as a distance greater than or equal to the maximum width of the defect, measured per-pendicular to the closure line along at least one entire edge of the defect. Physicians will be required to document measure-ments of the undermining along with the measurement of the defect and repair.

New codes have been established for grafting of autologous soft tissue, both when harvested by direct excision or by lipo-suction. Liposuction codes 15771–15774 are based on the re-cipient site and the amount of injectate.

Revisions to the breast procedure codes include a clari�ca-tion that mastectomy codes, other than the code for mastec-tomy for gynecomastia, may only be reported when performed to treat or prevent breast cancer. CPT code 19304 for subcuta-neous mastectomy was deleted as that is a surgical technique that is no longer used very often. Codes for excision of chest wall tumor were moved to the Musculoskeletal System, with no change in the code de�nitions.

Similar to trigger point injections, “dry needling” involves in-sertion of a needle into a point in a muscle but without injection of a medication. Prior to the 2020 update, these services were billed with unlisted codes. CPT code 20560 is used to report needle insertion into one or two muscles; code 20561 is to report when insertion is performed into three or more muscles.

New add-on codes were established to report manual prepa-ration and insertion of a drug delivery device during an ortho-pedic procedure, such as incision and drainage of a muscle or revision arthroplasty. �ese codes are not to be reported when the surgeon uses an “o�-the-shelf” device; rather, they require the preparation and insertion of the device, such as antibi-otic beads. Insertion without preparation will not be reported separately from whatever primary procedure is performed. If removal of the device is performed as the sole procedure at that operative session, existing code 20680 for removal of deep implant is assigned.

Due to changes in clinical practice in performing pericar-diocentesis, existing codes 33011 and 33015 have been deleted and new codes 33016-33019 were created. Code selection will be dependent on whether the catheter is left in place at the con-clusion of the procedure. A di�erent code, 33018, is available for patients under the age of �ve or for any patient with con-genital cardiac anomaly, regardless of the patient’s age. New codes were created for aortic arch graft to re�ect the reason for the graft—aortic dissection versus aneurysm—because a dissection would require an emergent procedure with signi�-cantly di�erent work than an aneurysm. Existing CPT code 33870 for transverse aortic arch graft was replaced by the new code 33871 to more speci�cally describe the work involved, in-cluding the required reimplantation of the arch vessels.

�ere are two new codes for a branched iliac artery endograft when a patient requires treatment of the iliac artery in addition to an aorto-iliac endograft. CPT code 34717 is an add-on code when the graft is placed at the same operative session as the aor-toiliac endograft. CPT code 34718 is a standalone code when the procedure is performed at a separate operative session. �ese codes represent unilateral procedures. If both iliac arteries are treated, code 34718 would be reported with modi�er 50, while code 34717 would be reported with two units of service.

Changes have been made to the codes for exploration of an artery, collapsing the existing codes into only three. Codes are no longer indicative of a speci�c artery (e.g., carotid, femoral, popliteal), but rather a general body area such as neck for code 35701, upper extremity for code 35702, and lower extremity for code 35703.

A new anoscopic treatment procedure for hemorrhoids re-quired a new CPT code to represent the unique work involved. Code 46948 for transanal hemorrhoidal dearterialization rep-resents ligation of the superior rectal artery rather than the traditional excision of the hemorrhoidal bundle. �is code re-quires treatment of two or more hemorrhoid columns, as one column is not treated in this manner. New code for preperito-neal packing for pelvic trauma represents the initial explora-tion and packing (code 49013) and re-exploration (code 49014).

Two new lumbar puncture codes were added to report proce-dures when they are performed under �uoroscopic or CT guid-ance. According to the Relative Value Update Relativity Assess-ment Workgroup, these services have been reported more often by Radiology and are reported with guidance more than 50 per-cent of the time. CPT code 62328 is reported when the procedure is diagnostic in nature, while code 62329 is reported when the procedure is performed to drain cerebrospinal �uid. Existing codes remain for use when the procedure is performed without guidance or under the less common ultrasound or MR guidance.

�e descriptions associated with the somatic nerve injec-tions, 64400–64450, were revised to specify that these codes are to be reported once per nerve regardless of the number of injections and that imaging guidance may be reported sepa-rately. �ese codes were also restructured to re�ect the par-ent/child coding concept common in CPT; code 64400 is the “parent code,” where the code descriptor establishes the lan-guage common to the child codes indented underneath. New codes include:

Coding



Journal of AHIMA Continuing Education QuizQuiz ID: Q2049103 | EXPIRATION DATE: MARCH 1, 2021HIM Domain Area: Clinical Data Management Article—“Current Procedural Terminology Update for 2020”


How Multi-payer Platforms Represent a Single Source of Truth for Provider Data ManagementBy Mark Martin

R ealizing the promise of value-based healthcare will re-quire a level of payer and provider collaboration virtually unheard-of in the recent past—and health information

management (HIM) professionals play an essential role in achieving this reality.

To achieve success in the new value-based world, both payers and providers must work together to develop the most efficient means of sharing data, managing risk, vali-dating provider credentials, processing claims, controlling costs, and optimizing the consumer experience. However, in the realm of provider data management (PDM), efforts directed towards payer-provider collaboration are expen-sive and time-consuming.

For example, each year it costs physician practices $2.76 billion to maintain provider directories—an average of about $1,000 per month per practice—according to a recent survey1 conducted by the Council for Affordable Quality Healthcare. Despite all the spending and allocation of re-sources toward ensuring accurate provider data, the indus-try often falls short, as shown by a recent report2 from the US Centers for Medicare and Medicaid Services (CMS). A CMS audit of Medicare Advantage provider directories re-vealed that nearly 50 percent of provider directory locations showed at least one mistake, with the most common errors including the wrong location, the wrong phone number, or an error in a directory stating that providers were accepting new patients when they weren’t.

Inaccurate provider directory information increases barri-ers to care for consumers, resulting in higher-than-expected medical costs when patients unwittingly visit an out-of-net-work provider. �at’s why CMS issued rules in 2016 requiring all Medicare Advantage organizations and quali�ed health

plans to verify the information in their provider directories di-rectly with each provider at least every 90 days.

Updating directory information can require signi�cant time and e�ort for providers, as most contract with a dozen or more health plans, and each plan may have its unique form and pro-cesses to follow.

To overcome this problem, HIM leaders are increasingly turning to multi-payer platforms to serve as a single source of truth for provider data. Multi-payer platforms are central-ized portals that enable providers and plans to exchange and reconcile provider data. By using a single platform for pro-viders to update and manage data for all of their contracted health plans, payers and providers can save time and money with streamlined processes and achieve better data quality and accuracy.

The Challenges of Accurate Provider DataFor both health plans and providers, maintaining accurate and up-to-date provider directories is an expensive and time-consuming process. Health plans and their networks are con-stantly changing, and providers frequently move, change jobs, or consolidate practices.

For providers, much of the challenge around updating in-formation stems from each payer’s di�erent questions and unique ways of requesting and accepting data. Many health plans, for example, update their provider data each year dur-ing their contracting and credentialing process, then feed that information into their provider directories.

�e fragmented processes can result in a signi�cant time and resource drain for providers. Each detailed provider re-cord may track up to 380 distinct line items, such as service locations, billing locations, payment locations, specialties,

Departments


certi�cations, a�liations, o�ce hours, and languages spoken, according to one vendor analysis.3 After receiving updated in-formation from a provider, the health plan generally sends an email to verify that information—which can divert sta� from more important patient-facing activities.

As a result, some payers have launched their own portals, which hardly solves providers’ problem of having to sub-mit the same data multiple times to multiple places. Using multiple portals is nearly as tedious and complicated for providers and staff members as the old days of submitting paper forms.

Multi-payer platforms represent a more convenient, intui-tive option for providers. By delivering a substantial boost to providers’ e�ciency, multi-payer platforms e�ectively incen-tivize providers to maintain current directory data.

Why Multi-payer Platforms Can HelpMulti-payer platforms provide a signi�cant amount of value through their ability to leverage the strength and market par-ticipation of many health plans as well as access data across all health plans. Provider sta� members who submit information do not have to worry about using di�erent interfaces, menus, work�ows, and commands because they’re the same across all participating health plans and, done well, the data analyt-ics can help them reduce time by focusing on just the ques-tionable data items.

Among HIM professionals’ most important contributions to multi-payer platforms is the development of machine learn-ing tools that eliminate many of the frustrating manual pro-cesses associated with directory updates. �ese platforms are most e�ective when they’re also conduits for healthcare data beyond provider information, such as eligibility inquiries, claims, and payment data. Modern tools enable platforms to quickly capture essential provider detail changes, in part be-cause multi-payer platforms aggregate and analyze provider activity across health plans, which helps them spot potentially inaccurate and anomalous data that would be missed by a single-plan system.

For example, imagine a scenario in which a doctor practices at locations A and B; the doctor started years ago at location A, but over time begins to perform the majority of their o�ce visits at location B. In this scenario without a multi-payer plat-form, the physician’s sta� would need to manually enter the location change in every single-plan system with which the practice contracts. In contrast, the machine learning tools of a multi-payer system would analyze the changing patterns of the location of the physician’s �led claims over time, �ag the physician’s record as one that may need to be updated, and prompt system administrators to review and make any corre-sponding changes. �is example illustrates multi-payer plat-forms’ ability to streamline work�ows and enhance e�cien-cies for providers.

For health plans, the bene�ts of multi-payer platforms are

similar. Each plan receives accurate up-to-date information in formats that their systems can consume and use. Further, plans don’t need to analyze submissions to verify that similar but unique specialty names, addresses, or certi�cations are consistently used.

Beyond Provider DirectoriesMulti-payer platforms are about more than just improving the quality of provider directories, though that certainly is one of their primary advantages. In the bigger picture, they’re about fostering better collaboration between payers and providers by enabling them to more e�ectively share quality and risk data—cooperation that will be increasingly necessary under current and future value-based arrange-ments. �rough better information sharing, this increased payer-provider cooperation has the potential to lead to better patient care and outcomes. x

Notes1. McGrail, Samantha. “Providers Spend $2.76B Annually

on Provider Directory Maintenance.” Revenue Cycle Intel-ligence, November 19, 2019. https://revcycleintelligence.com/news/providers-spend-2.76b-annually-on-provid-er-directory-maintenance.

2. Luthi, Susannah. “Medicare Advantage directories still riddled with errors.” Modern Healthcare, December 4, 2018. www.modernhealthcare.com/article/20181204/NEWS/181209985/medicare-advantage-provider-di-rectories-still-riddled-with-errors.

3. Availity. “67% of U.S. Provider Organizations Update their Provider Data through Availity.” PR Newswire. www.prnewswire.com/news-releases/67-of-us-provid-er-organizations-update-their-provider-data-through-availity-pdm-300924795.html.

Mark Martin ([email protected]) is director of payer solu-

tions, provider data management, for Availity.

Health Data

Through better information sharing, this increased payer-provider cooperation has the potential to lead to better patient care and outcomes.


Preventing Denials Through Clinical ValidationBy Amanda Suttles, BSN, RN, CCDS; Angela Brisson, BSN, RN, CCDS; and Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA

C linical validation is the process of reviewing documented diagnoses to determine if clinical criteria generally accept-ed by the medical community are present to support each

diagnosis. It ensures there is su�cient documented clinical evi-dence to support coding and reporting diagnoses. In most situ-ations, clinical documentation integrity (CDI) professionals are charged with the task of making these determinations and que-rying physicians for clari�cation when necessary.1

Clinical validation may result in an increase, a decrease, or no change in revenue for a particular case. Regardless, it is impor-tant to review for clinical validity to ensure complete and accu-rate representation of a patient’s clinical condition in the health record. It is appropriate to query a physician for clari�cation, regardless of the �nancial outcome. AHA Coding Clinic for ICD-10-CM/PCS o�ers the following advice on clinical validation: “It is not appropriate to develop internal policies to omit codes au-tomatically when the documentation does not meet a particular clinical de�nition or diagnostic criteria . . . Facilities should also work with their medical sta� to ensure conditions are appropri-ately diagnosed and documented.”2

Using Second-Level Clinical Review�ough CDI specialists and physicians have varying experience and comfort levels with the clinical validation process, clinical validation is important. �ere is signi�cant �nancial and com-pliance risk in charting diagnoses that cannot be independently validated. High-risk inpatient cases include, for example, cases with a single comorbid condition (CC) or major comorbid con-dition (MCC) and cases with short lengths of stay and highly weighted diagnosis-related groups (DRGs).

An example of the latter is a patient with a one-day length of stay and a diagnosis of sepsis due to urinary tract infection who

was discharged to their home. It is becoming increasingly com-mon for these cases to be targeted and denied by third-party payers. Such costly and time-consuming denials can be avoided by incorporating robust clinical validation in the inpatient CDI process.

Clinical validation can be incorporated in the regular inpatient concurrent review process. �is is achieved by issuing concur-rent clinical validation queries, when warranted, at any point during the inpatient stay. However, to ensure that all reported diagnoses are supported by documented clinical evidence, a second-level clinical review process is recommended.

Second-level clinical review is performed after �nal coding, before an inpatient claim is submitted. Clinical review at this point is performed on targeted inpatient cases to ensure there is su�cient clinical evidence for the diagnoses that impact DRG assignment. Second-level clinical review should be performed on inpatient cases that meet de�ned criteria indicative of high risk. An example of inpatient cases that should be targeted for second-level clinical review are cases with a single CC/MCC and high-reimbursement principal diagnosis (e.g., sepsis, non-ST-elevation myocardial infarction, congestive heart failure ex-acerbation, and respiratory failure) but with a short length of stay. Based on this review, action may need to be taken before submitting the claim. Actions might include an additional phy-sician query and/or revising the �nal code assignment.

Case Scenario #1One of the outcomes of clinical validation is reduced clinical denials. Case Scenario #1 is an example where a clinical vali-dation query may have prevented a denial. In this case, acute postoperative respiratory failure was a single MCC driving the DRG, but clinical evidence for this diagnosis was not explicit

Departments


and documentation of a normal postoperative course seemed to contradict the diagnosis of a postoperative condition. Clinical validation was not performed on this case, however, and the di-agnosis of acute postoperative respiratory failure was coded and submitted on the claim without obtaining any further clari�ca-tion. �e third-party payer denied payment on the claim based on insu�cient clinical criteria to support the diagnosis of acute postoperative respiratory failure. �e hospital determined they did not have su�cient clinical documentation to appeal the de-nial after discussing the case with the attending physician.

Case DocumentationConsider the following documentation excerpt for Case Sce-nario #1:

“Ms. Sue Smith, a 72-year-old morbidly obese patient who has a

medical history of COPD, obstructive sleep apnea on home bipap,

HTN, hyperlipidemia, and diabetes type II, was admitted on 5/18

for a planned aortic valve replacement. She underwent the pro-

cedure and was admitted to the critical care unit in stable condi-

tion. She was extubated 18 hours after surgery. Her postoperative

course went as expected and she was discharged on 5/23 being

transferred to an inpatient rehab facility.”

�e physician documented “acute postoperative respiratory failure” as a secondary diagnosis in the discharge summary.

If a second-level clinical review had been performed for this case before submitting the claim, the attending physician could have responded to a query and either acknowledged that acute postoperative respiratory failure was not a valid diagnosis for this encounter or con�rmed it was appropriate and added the documentation to support that. Assuming the physician ac-knowledged the diagnosis was not appropriate, the diagnosis would not have been submitted, avoiding the denial and the re-work that ensued.

Sample Clinical Validation Query �e following is a sample clinical validation query for this case:

Dear Dr. Jones,

Ms. Sue Smith underwent an aortic valve replacement and was

admitted to the critical care unit in stable condition. She was subse-

quently extubated 18 hours after surgery. Additional documentation

notes her postoperative course went as expected. �e discharge sum-

mary notes acute postoperative respiratory failure. Is acute postop-

erative respiratory failure an accurate diagnosis for this encounter?

☐ No, acute postoperative respiratory failure is not a valid di-

agnosis during this admission.

☐ Yes, acute postoperative respiratory failure is present/ac-

tive during this admission (please include additional clini-

cal indicators): ______________________________________

☐ Other, please specify: ________________________________

☐ Unable to determine

Case Scenario #2Another outcome of clinical validation is to ensure that un-avoidable clinical denials can be defended and overturned.

Case Scenario #2 illustrates how a clinical validation query can help strengthen clinical documentation to ensure there is suf-�cient clinical evidence for a reported diagnosis.

Case DocumentationConsider the following documentation excerpt for Case Sce-nario #2:

“Ms. Betty Brown, 75 years old, was admitted with Systolic CHF

Exacerbation. Patient noted with history of hypertension and

breast cancer. On admit patient had a creatinine of 1.3 with an in-

crease to 1.5 on hospital day 2.”

�e physician documented “acute kidney injury” as a second-ary diagnosis in the discharge summary.

Sample Clinical Validation Query �e following is a sample clinical validation query for this case:

Dear Dr. Jones,

Ms. Betty Brown, a 75-year-old, was admitted with Systolic CHF

Exacerbation. Patient noted with history of hypertension and

breast cancer. On admit patient had a creatinine of 1.3 with an

increase to 1.5 on hospital day 2. On the discharge summary, the

diagnosis of Acute Kidney Injury was documented.

For the diagnosis of Acute Kidney Injury, KDIGO notes the pa-

tient has to have an increase greater than or equal to 0.3mg/dl

from a measured baseline within 48 hours or less.

Is Acute Kidney Injury an accurate diagnosis for this encounter?

☐ No, Acute Kidney Injury is not a valid diagnosis during this

admission

☐ Yes, Acute Kidney Injury is present/active during this ad-

mission (please include additional indicators): __________

_____________________________________________________

☐ Other (please specify): ________________________________

☐ Unable to determine

�e physician response was:“Yes, Acute Kidney Injury is present/active during this admis-

sion due to the patient being seen in my o�ce the day before ad-

mission with a creatinine of 1.1. Additionally, patient has a known

baseline creatinine of 0.9. �e use of Lasix on this admission con-

tributed to the diagnosis of AKI.”

In Case Scenario #2, assigning the code for acute kidney injury (AKI) provided a lone CC that determined the DRG. �erefore, a second-level clinical review was performed and the case was held to obtain the physician’s response on the clinical validation query. �e physician’s response provided additional informa-tion that supported coding and reporting AKI. �ough this case was subsequently denied by the payer, the hospital used the validation query in the appeal letter and the denial was over-turned.

Notably, the physician query for Case Scenario #2 references clinical guidelines for AKI. �e Kidney Disease Improving Glob-al Outcomes (KDIGO), de�ned by the National Kidney Founda-

CDI



T he proverbial “apples and oranges” comparison is a well-known and often useful metaphor. While they are both fruit, there are still many differences between the

two. When talking about expanding clinical documenta-tion integrity (CDI) programs in light of today’s electronic health record (EHR) environment and efforts to improve information governance, the scope of CDI extends beyond the walls of the hospital to other areas, such as physician practices. As this expansion continues, the apples and or-anges metaphor is an apt one for the two types of docu-mentation—inpatient and outpatient—that we encounter. Just as clinical documentation is clinical documentation regardless of the setting, differences remain between the types. But are they really all that different? Herein lies the challenge: bringing the two together requires that the in-patient CDI program be placed in the same “fruit bowl” as the outpatient CDI program.

Why might a healthcare organization want to develop an outpatient CDI program in the �rst place? If an organization already has an inpatient program, it may be bene�cial to tie in outpatient reviews. As providers discover and acknowledge bene�ts of inpatient CDI programs, they may begin to look toward de�ning an outpatient CDI program’s bene�ts. One of these bene�ts includes better coding accuracy, which in turn results in more accurate diagnoses populating the patient problem list and then pulling the information into subsequent notes, so it can be coded and available for continuity of care. �e result is higher quality documentation and improved pa-tient care.

The Centers for Medicare and Medicaid Services (CMS) value-based reimbursement programs bring the apples and oranges together. As accountable care organizations grow,

consideration for bringing information from inpatient and outpatient encounters together makes for a sensible endeav-or. EHR systems and patient portals may lend a wider view of patient encounters. One portal for both the outpatient office and the hospital may be available. Once a patient is assigned their patient portal, the problem list f lows into the portal from interoperable inpatient, outpatient, and ancil-lary information systems and the patient can then see the complete, accurate, real-time documentation of their con-ditions. There are numerous ways CDI can impact the clini-cal specificity of these shared records, and the problem list is just one example. CDI programs bring those apples and oranges together and adapt the clinical documentation and diagnosis-related group (DRG) assignments based upon the documentation and diagnoses from the outpatient office notes and the hospital notes.

As healthcare shifts toward a system tied to quality of care and greater interoperability, it becomes increasing-ly necessary to ensure organizations’ health information technology (health IT) infrastructure and CDI programs are up to the undertaking. An essential element to this is expanding the role of a CDI program and ensuring that key standards are met.

Standards and Standards-based Services for CDIStandards enable health IT infrastructure, which in turn allows various information systems to interoperate, com-municating information broadly and overcoming distance, di�ering levels of expertise, location of delivery, and other barriers. Healthcare service delivery can cross physical walls of organizations and can occur safely with accurate reim-bursement and appropriately applied support of both health

CDI Expanding Beyond the Hospital Walls through Standards

Departments

Editor’s Note: �is Practice Brief supersedes the November-December 2017 Practice Brief titled “CDI Expanding Beyond the Hospital Walls through Standards.”


IT and health information management (HIM) practice standards. �ese standards provide consistent, reliable, and trusted communication between patients and those involved in their care. �e standards apply to all facets of healthcare delivery, delineating content and creating basic de�nitions for the required content. Data standards and information content standards are important in this regard.1,2

Data StandardsVocabulary, terminology, and classification system stan-dards allow uniformity with clinical content communica-tion. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modi-fication (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) and the Current Procedural Terminology (CPT) are the key standards for translation of human language in clin-ical documentation into machine-processable payload for health management, epidemiologic efforts, and reimburse-ment. Diagno-ses, procedures, diagnostic test-ing, and other services deliv-ered can be uni-formly commu-nicated due to the use of these standards. For example, ICD-1 0 - C M / P C S classifies dis-eases and health problems, while CPT translates delivered services in a uniform manner na-tionally and internationally.

�e Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) is a comprehensive multilingual clini-cal healthcare terminology with scienti�cally validated clinical content that enables consistent, processable repre-sentation of clinical content in EHRs including diseases and pharmaceutical, laboratory, and social factors data. SNOMED CT provides a standardized way to represent clinical phrases captured by the clinician and enables automatic interpreta-tion of them. Mapped to other international vocabulary and terminology standards, such as ICD-10-CM/PCS, SNOMED CT is used in more than 50 countries.

In the United States, SNOMED CT is one of the designated standards for use in US federal government systems for the electronic exchange of clinical health information. It is also a required standard in interoperability speci�cations of the US Healthcare Information Technology Standards Panel (HITSP). As the United States National Release Center for SNOMED CT, the National Library of Medicine (NLM) provides SNOMED

CT data and resources to licensees of the NLM UMLS Metath-esaurus.3

Information Content Standards�e Continuity of Care Document (CCD) speci�cation is an eXtensible Markup Language (XML)-based standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange.4 CCD was devel-oped by Health Level Seven (HL7) International, a standards development organization (SDO), in coordination with the ASTM International Technical Committee E31 responsible for development and maintenance of the Continuity of Care Re-cord (CCR) standard.

CCD is a constraint on the HL7 Clinical Document Archi-tecture (CDA) standard.5 CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing).

The structured part is based on the HL7 Refer-ence Information Model (RIM) and provides a frame-work for referring to concepts from coding systems, such as SNOMED, Logical Observa-tion Identifiers Names and Codes (LOINC), ICD-10-CM/PCS, and

CPT. CDA can contain any type of clinical content, includ-ing a patient summary (administrative, demographic, and clinical information about a patient’s healthcare, covering one or more encounters), discharge summary, imaging re-port, admission data, physical data, and laboratory report.

�e HL7 Fast Healthcare Interoperability Resources (FHIR) is a draft standard describing data formats and elements (known as “resources”) and an application programming in-terface (API) for exchanging electronic health records. FHIR is built on earlier HL7 data format standards, such as HL7 versions 2.x and HL7 version 3. One of its goals is to facilitate interoperation between legacy healthcare systems, to make it easy to provide information to providers and patients on a wide variety of devices—from computers to tablets to cell phones—and to allow third party developers to provide medi-cal applications that can be easily integrated into existing systems. FHIR provides an alternative to a document-centric approach by directly exposing/specifying discrete data ele-ments as resources for patient demographics, admissions, di-agnostic reports, medications, etc.

Practice Brief

“As healthcare shifts toward a system tied to quality of care and greater interoperability, it becomes increasingly lecessary to ensure organizations’ health information technology infrastructure and CDI programs are up to the undertaking.”


Content Standardization ProductsComputer-assisted coding (CAC) uses technology and lin-guistics within an EHR system to translate clinical language to ICD-10-CM/PCS, CPT, SNOMED CT, and other codes using mapping across these data standards.

Assignment of diagnosis and procedural codes may be automated using CAC. Templated EHR documentation can auto-assign standard codes based on data entered, ensuring compliance with coding guidelines and enabling consisten-cy in clinical documentation across clinicians.

Mapping services are critical to widespread acceptance and use of EHR systems by clinicians, data collection for re-search, governmental reporting, and reimbursement. The International Organization for Standardization, Technical Committee 215 Health Informatics (ISO/TC215) has been working on a new standard: Terminology Resource Map Quality Measures (MapQual). It defines the quality require-ments for a terminology resource map set. Based upon the existing ISO standard—ISO Technical Report (TR) 12300 – Principles of Mapping Between Terminological Systems—the new standard will establish measures (determinants) to assess the quality and utility of a map between terminologi-cal resources resulting from the mapping processes used (including manual and tool-based mapping). In addition, the standard determines the levels of measure required for common use cases in healthcare, which can be used for conformity assessment.

Natural language processing (NLP) is a tool that processes the words in free text using statistical inference algorithms to produce models that are robust to unfamiliar input (con-taining words or structures that have not been seen before) and to erroneous input (with misspelled words or words ac-cidentally omitted). The increased use of the EHR has led to widespread adoption of NLP in health information systems, creating a more efficient user interface because the systems with NLP are based on automatically learning the rules—and can be made more accurate by recognizing/supplying more input data that enables machine learning.

Various SDOs, professional organizations, and governmen-tal agencies have been developing content standardization tools to create standardized, semantically exchangeable clini-cal concepts templates and document templates, facilitating interpretation of information exchanged between sending and receiving systems.

Expanding Role of CDI Professionals in Supporting Outpatient ServicesIn 2004, CMS implemented the Hierarchical Condition Cat-egories (HCC) model. Some institutions focusing on HCC scores may afford this supplementary revenue and severity capture. The overarching strategy provides for a stratified care reimbursement of Medicare Advantage plans based on a direct correlation of how ill their enrollees are reported

to be. Medicare Advantage plans are encouraged to regis-ter members who are considered more ill or are considered more at risk due to their past medical history. Covering this “risk adjusted” patient population may garner more reim-bursement. Approximately one-fourth of Medicare enroll-ees receive benefits via a Medicare Advantage plan. Ev-ery fiscal year, CMS adjusts the risk-associated weight for each HCC category; within each category are a multitude of codes. Accurate specification of as many of an enrollee’s HCC-related diagnoses as possible benefits a hospital and/or its system when reporting HCC diagnoses of individual enrollees and its entire Medicare Advantage population. As part of the protocol for reporting, for each member, HCC scores are submitted at least once every 12 months, regard-less of whether the encounter occurred in an inpatient or outpatient setting.

Considering that many CDI programs occur only in an inpa-tient setting, increasing the potential severity capture in the outpatient setting would be a likely next step. �e role an out-patient CDI specialist would perform may parallel that of an inpatient CDI specialist. Careful evaluation should be under-taken regarding the appropriate diagnosis capture, as vary-ing coding conventions and guidelines apply depending on the setting. In addition, assessing overlaying factors and the planned focus of the program is a necessary and compliant approach.

Depending on the type of medical facility, two areas often are considered for initial CDI program implementation: physi-cian practices and the emergency department. Both settings may provide untapped areas of severity capture. Per CMS, while inpatient admissions have been steadily declining, out-patient visits have been increasing over the same period. A hospital may likely lose Medicare Advantage consumers if its CDI program focuses solely on the inpatient admission.

Another aspect to consider when implementing an expand-ed program is the type of record review: concurrent review, retrospective review, or a combination of the two. Areas of concern should include:

� Which services to target (general medical, medical sub-specialties, pediatrics, etc.)

� Location of review (in o�ce or remote) � Method of review (focused concurrent EHR review based

on previously reported, third party vendor-assisted re-view, or a combined method of focused patient review and vendor-assisted review)

Lastly, a balance should be created to permit the CDI spe-cialist to perform his or her role without impeding physicians’ day-to-day functioning.

As healthcare delivery is changing, and reimbursement is actively transitioning to the electronic environment, the need for CDI efforts are on the rise in both inpatient and out-patient settings: as inpatient CDI programs mature, natural

Practice Brief


expansion often leads to exploration of outpatient services for additional opportunity. The data and information con-tent standards (SNOMED CT, ICD-10-CM/PCS, CPT, HL7/ASTM CCD/CCR, HL7 CDA, and FHIR), data mapping ser-vices, NLP, CAC, and content standardization tools provide foundation and building blocks for CDI programs to enable automation of health information capture, processing, and use across inpatient and outpatient healthcare organiza-tions. The role of a CDI professional who understands doc-umentation and reimbursement as well as standards and standard-based technology applications for interoperable CDI programs will increasingly be in demand as the health-care industry continues to evolve.

Bringing the Apples and Oranges TogetherA CDI program that encompasses inpatient and outpatient services enhances an organization’s ability to accurately classify patients for registries, assign risk scoring to a pa-tient or population, and participate in Medicare Advantage plans. Managing a population requires expanding beyond hospital walls. Current data standards, information content standards, and content standardization services normal-ize data across the continuum of healthcare for individual patient and population management. Bringing together the “apples” and “oranges” of the inpatient and outpatient en-vironment requires CDI and HIM professionals at large to engage in standards development as the world changes. As author and humorist Mark Twain said, “Why not go out on a limb? That’s where the fruit is.” If HIM professionals em-power themselves with standards, they can definitely bring the apples and oranges together. x

Notes1. AHIMA. “AHIMA Standards Fact Sheet: Standards

Category: Data Standards.” https://bok.ahima.org/PdfView?oid=302329.

2. AHIMA. “AHIMA Standards Fact Sheet: Standards Cat-egory: Information Content Standards.” https://bok.ahi-ma.org/PdfView?oid=302332.

3. US National Library of Medicine. “SNOMED CT.” https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/SNOMEDCT_US/index.html.

4. Health Level Seven International. “HL7/ASTM Imple-mentation Guide for CDA® R2 – Continuity of Care Docu-ment (CCD®) Release 1.” https://www.hl7.org/implement/standards/product_brief.cfm?product_id=6.

5. Health Level Seven International. “CDA® Release 2.” https://w w w.hl7.org/implement/standards/product_brief.cfm?product_id=7.

ReferencesAbdelhak, Mervat et al. Health Information Management:

Management of a Strategic Resource, 2nd Edition. Chicago,

IL: AHIMA Press, 2001.Association of Clinical Documentation Improvement

Specialists. “Outpatient Clinical Documentation Improvement (CDI): An Introduction.” White Paper. 2016.

Health Level Seven. HL7 Fast Healthcare Interoperability Resources (FHIR). https://www.hl7.org/participate/index.cfm?ref=nav.

Johns, Merida L. Health Information Management: An Applied Approach, 3rd Edition. Chicago, IL: AHIMA Press, 2011.

Pope, Gregory C. et al. “Evaluation of the CMS-HCC Risk Adjustment Model, Final Report.” March 2011.

Prepared ByTammy Combs, RN, CDIP, CCS, CCDSOkemena Ewoterai, BSN, MA, CCS, CCDS, CDIP Katherine Lusk, MHSM, RHIAAnna Orlova, PhDMelissa Potts, RN, CDIP, CCDSAzia Powell, MSHIA, RHIA, CCSNirmala Sivakumar, CDIP, CCSGlenda Tower, MAPP, CIPP/C, CHIMDonna Young, RHIA, CDIP, CCS

AcknowledgementsMarjorie Greenberg, MA Sharon Slivochka, RHIA

Practice Brief


� Are stakeholders (e.g., healthcare institutions, government agencies, clinicians, payers, multi-stakeholder organizations) standardizing the most important SDOH codes to collect?

� Is there consensus about which data elements should be collected?

� Privacy—what is the patient’s role in all of this? Should mi-mum necessary standards apply? Is patient consent required?

�is is certainly not an exhaustive list of questions organiza-tions and the industry must address. It’s very clear that HIM professionals can enhance and inform stakeholder discussions about SDOH.

From their expertise in data integrity and their insights into the person behind the data, HIM can help ensure the best decisions are being made and that the right questions are being asked. Look for ongoing content addressing questions like those listed above—and more—as the Journal delves deeper into SDOH. x

Notes1. Johnson, Laurie H., Patricia Chambers, and Judith W.

Dexheimer. “Asthma-related emergency department use: current perspectives,” Open Access Emergency Medicine 8:2016, pp. 47–55.

2. Deloitte. “Addressing social determinants of health in hospitals.” www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/addressing-social-determinants-of-health-hospitals-survey.html.

3. Fraze, Taressa K. et al. “Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals.” JAMA Network Open 2, no. 9: 2019. https://jamanetwork.com/jour-nals/jamanetworkopen/fullarticle/2751390.

4. eHealth Initiative. “2019 Survey on HIE Technology Pri-orities.” May 15, 2019. www.ehidc.org/resources/2019-survey-hie-technology-priorities.

5. IDC. “The Digital Universe of Opportunities: Rich Data and the Increasing Value of the Internet of Things.” April 2014. www.emc.com/leadership/digital-universe/2014iview/executive-summary.htm.

6. Tolson, Bill. “Where Should Healthcare Data Be Stored In 2018 — And Beyond?” Health IT Outcomes. Feb-ruary 20, 2018. www.healthitoutcomes.com/doc/where-should-healthcare-data-be-stored-in-and-be-yond-0001.

Matt Schlossberg ([email protected]) is editor at the Jour-

nal of AHIMA.

of programs to address the needs of complex patient populations. Such programs include an extensivist clinic, sta�ed by hospital-ists and nurses, that helps patients su�ering from renal disease, heart disease, lung disease, and other issues receive the care they need while avoiding an inpatient hospital stay. �e extensivist clinic is a big contributor to HMG’s success under value-based payment models, which are tied to 30 percent of reimbursement for the practice. Pay-for-value payments have increased 44 per-cent since implementing the clinic in 2013.

Changing Opioid Outcomes with DataAs providers across Tennessee seek ways to strengthen the state’s response to the opioid epidemic, data exchanged be-tween healthcare providers will be vital to determining the right interventions for the right patients at the right time. Widespread adoption of a community health information exchange could be a critical tool in reversing the rates of opioid disorder and opioid overdose deaths and driving better health outcomes. x

Notes1. Kelman, Brett. “Tennessee has deadliest year yet for drug

overdoses, as nearby states improve.” Nashville Tennesse-an, October 18, 2019. www.tennessean.com/story/news/health/2019/07/19/opioid-crisis-tennessee-overdose-deaths-climbing-heroin-fentanyl-meth/1550137001.

2. Ibid3. Virginia Department of Health Professions. “Prescription

Monitoring Program PMP Toolkit.” www.dhp.virginia.gov/PractitionerResources/PrescriptionMonitoringProgram/PublicResources/EducationToolkit.

4. Davis, Matthew A. et al. “Prescription Opioid Use among Adults with Mental Health Disorders in the United States.” Journal of the American Board of Family Medicine. July 2017. www.jabfm.org/content/30/4/407.

5. Ellis, Randall J. et al. “Predicting opioid dependence from electronic health records with machine learning.” Bio Data Mining. January 29, 2019. https://biodatamining.biomed-central.com/articles/10.1186/s13040-019-0193-0.

6. Kaiser Permanente. “Study to examine the role of opioid use in suicide risk.” August 16, 2018. https://about.kaiserper-manente.org/our-story/health-research/news/new-kaiser-permanente-study-will-examine-the-role-of-opioid-use-.

7. Lo-Ciganic, Wei-Hsuan et al. “Evaluation of Machine-Learning Algorithms for Predicting Opioid Overdose Risk Among Medicare Bene�ciaries With Opioid Prescriptions.” JAMA Open Network. March 22, 2019. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2728625.

Wesley Combs ([email protected]) is chief information o�cer,

Holston Medical Group, and CEO, OnePartner. David Morin (david.mo-

[email protected]) is director of clinical research and practicing physi-

cian, Holston Medical Group.

Health DataContinued from page 37

Continued from page 17


� Code 64451 for injection of the nerves innervating the sac-roiliac joint

� Code 64454 for the genicular nerve branches

Code 64451 requires the use of imaging guidance, while 64454 includes imaging guidance when performed. Codes were also established for destruction of the genicular nerve branches (64624) and radiofrequency ablation of the nerves innervating the sacroiliac joint (64625).

It has become common for cyclophotocoagulation—laser treat-ment to reduce intraocular pressure—to be performed at the same session as cataract removal. New codes 66987 and 66988 were cre-ated to report those instances, and 66711 was revised to be used when cataract surgery is not performed at the same session.

Changes in Radiology coding for 2020 include new codes for double-contrast upper gastrointestinal (GI) studies and re-vised descriptions for other upper and lower GI codes to spec-ify that scout images and delayed images are included in the existing codes. CPT codes for myocardial positron emission tomography (PET) studies were revised and new codes estab-lished to report when PET and CT are performed concurrently. Revisions were made in the SPECT-CT section (single-photon emission computerized tomography) to employ a generic cod-ing approach. Codes for speci�c organs were deleted as the work involved was the same, regardless of the speci�c organ. Codes now re�ect planar, or two-dimensional imaging, versus SPECT, which is three-dimensional imaging.

Changes in Pathology and Laboratory coding for 2020 include six new codes for therapeutic drug assays, three new codes for Multianalyte Assays with Algorithmic Analyses (MAAA), and one new microbiology code for mycoplasma genitalium. In Mo-lecular Pathology, several codes were moved from Tier 2 to Tier 1 and vice versa. �e Proprietary Laboratory Analyses (PLA) codes continue to expand with 75 new codes for 2020. �e PLA codes were established by the Protecting Access to Medicare Act of 2014. �ese codes are not required to ful�ll the Category I criteria, but the test each represents must be commercially available in the United States for use on human specimens. �e manufacturer or clinical laboratory must request the code.

One of the most signi�cant changes, in terms of the number of codes and extent of coding guidelines, is for Long-term EEG Monitoring. �ese services represent electroencephalography monitoring of two hours or longer. �e codes have been separat-ed into those for reporting professional versus technical servic-es. Professional codes 95717–95726 are based on whether video recording is performed, the duration of the monitoring, and at what point the report is completed. Technical component codes are determined by the use of video recording and the duration and intensity of the monitoring services. CPT also speci�es that monitoring must be performed by an EEG technologist who is quali�ed by education, training, and licensure/certi�cation/regulation (when applicable) in seizure recognition. Services

may be continuously monitored, intermittently monitored, or unmonitored. Continuous monitoring may be remote or onsite and is considered the monitoring of no more than four patients with no break in monitoring. Likewise, intermittent monitoring may be remote or onsite but involves the monitoring of no more than 12 patients. A study in which the monitoring does not meet either of these criteria is considered unmonitored. Page 715 of the CPT 2020 Professional Edition includes a table delineating these requirements.

Other changes in the Medicine section include two new vac-cine codes:

� Code 90694 for In�uenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5-mL dosage, for intramuscular use

� Code 90619 for Meningococcal conjugate vaccine, se-rogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use

As of press time, both of these vaccines are awaiting FDA ap-proval and therefore carry the lightning bolt symbol. Codes for biofeedback training for perineal muscles were updated to re-�ect the time intensity of this service. CPT codes 92201–92202 are new for ophthalmoscopy for retinal drawing or drawing of the optic nerve. �is is commonly performed in addition to retinal photography, but only one service may be reported.

A new add-on code, 93356, was created to be used in con-junction with echocardiography when myocardial strain im-aging is performed. Myocardial strain refers to the change in the myocardium through the cardiac cycle and may indicate sub-clinical impairment of the heart before the development of symptoms and irreversible damage.

�ere are 51 new Category III codes for new technology. �ese codes are tracked to determine e�cacy of the treatment de-scribed and whether the use of such technology is widespread enough to warrant issuance of a Category I code. Services repre-sented in this category include transapical mitral valve repair, islet cell transplantation, and continence device procedures as well as two new procedures that may potentially replace DEXA scans in more accurately measuring bone density.

You can see that the changes in CPT for 2020 highlight the necessity of reviewing and understanding the guidelines as-sociated with each code, not just understanding the speci�c new, revised, and deleted codes themselves. x

Note1. American Medical Association. AMA CPT Professional

2020. Chicago: 2019, page xiii.

References American Medical Association. CPT Changes 2020: An Insider’s

View. Chicago: 2020.

Kim Huey ([email protected]) is consultant at KGG Coding and

Reimbursement Consulting, LLC.

Coding



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tion, are the diagnostic criteria currently used for AKI.3 Working with medical sta� representatives to establish or adopt ap-proved clinical guidelines for high-risk diagnoses (such as acute respiratory failure, sepsis, acute tubular necrosis, and encepha-lopathy) provides tools to aid the clinical validation process and to defend reported diagnoses.

Clinical Validation Can Help Avoid DenialsThe mere act of reviewing a denial is time-consuming and costly, and many times it does not result in a favorable out-come. A robust clinical validation process can help avoid denials. In addition, it can help anticipate and more ef-fectively overturn unavoidable denials. Effective clinical validation requires strong reciprocal working relationships with physicians as well as between the inpatient coding and CDI teams. Clinically validating high-risk diagnoses prior to submitting claims can significantly improve a hospital’s denial rate. x

Notes1. Denton, Debra Beisel et al. “Clinical Validation: � e

Next Level of CDI.” Journal of AHIMA 87, no. 7 (July 2016): extended web version. https://bok.ahima.org/doc?oid=301756.

2. American Hospital Association. “Omitting ICD-10 Codes.” AHA Coding Clinic for ICD-10-CM/PCS (Fourth Quarter 2017).

3. Kidney Disease: Improving Global Outcomes. “Acute Kid-ney Injury.” https://kdigo.org/guidelines/acute-kidney-injury.

Amanda Suttles ([email protected]) is supervisor

of CDI and UR services, Angela Brisson (angela.brisson@uasisolu-

tions.com) is supervisor of CDI and UR services, and Mary H. Stan� ll

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A DEPARTMENT OF DEFENSE (DOD) advisory released on December 24, 2019, warning military service members against using direct-to-consumer (DTC) DNA testing products, must have put a damper on the excitement of those who received these very popular (and deeply discounted for the holidays) stocking stuffers.

The DoD cautioned, “Exposing sensitive genetic information to outside parties poses personal and operational risks to service members. These [direct-to-consumer] genetic tests are largely unregulated and could expose personal and genetic information, and potentially create unintended security consequences and increased risk to the joint force and mission.” For example, the New York Times reported, DNA testing that reveals carrier status for sickle cell disease could limit advancement in aviation specialties.

In the Journal of AHIMA and elsewhere, privacy experts have been warning against DTC genetic tests such as AncestryDNA and 23andMe for some time, citing weak privacy policies in the user agreements that leave individuals’ data vulnerable to hacking, theft, or being de-anonymized. Genetic testing ordered by a physician, in contrast, is protected by HIPAA and has strict controls over how it can be shared. While the Genetic Information Nondiscrimination Act (GINA) prevents insurance companies and employers from using genetic information in decisions about a person’s health insurance eligibility or coverage, GINA does not apply when an employer has fewer than 15 employees. Nor does GINA apply to other forms of insurance, such as disability insurance, long-term care insurance, or life insurance, which has prompted at least one lawmaker in Florida to propose legislation blocking companies from requiring or soliciting genetic information from applicants.

Florida’s incoming House Speaker Chris Sprowls told The News-Journal that he learned about the GINA loophole when applying for life insurance and wondered when and if DTC genetic tests could be used against consumers in this way. Even the National Institutes of Health says it’s “unclear whether genetic information, including the results of direct-to-consumer genetic testing, will become a standard part of the risk assessment that insurance companies undertake when making coverage decisions,” and advises consum-ers to “weigh the possible benefits and risks of direct-to-consumer genetic testing, including potential impacts on insurance eligibility and coverage, before you start the testing process.” x

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