Health Information Management Program Benefits from Informatics Insight, Clinical Expertise

Patients expect their private healthcare information to be accurately maintained with restricted access. These expectations are shared by the Health Information Management (HIM) team which protects and monitors patient data.

“HIM is vital to every healthcare facility across the country,” says Nicholas Judd, MBA, RHIA, Cleveland Clinic Senior Director, Revenue Cycle Management and Health Information Management. “It’s essential for effective hospital operations and allows providers to concentrate on delivering the highest standards of care.”

At Cleveland Clinic, HIM experts work behind the scenes to securely protect, manage and monitor the accuracy and accessibility of patient data.

“This area of healthcare ensures patients’ privacy and confidentiality by aligning processes and systems with HIPAA regulations,” says Sharon Slivochka, RHIA, Cleveland Clinic’s Director of Health Information Management. “This includes patient access to their own records, third-party disclosure of information and electronic health record (EHR) integrity.”

Linking technology to HIM workflows

Technological advances have helped streamline EHR documentation and reporting, making it easier for providers to meet regulatory requirements.

However, these advancements heighten the importance of evolving the HIM Physician Advisory role to include informatics expertise.

“Oftentimes, the advisory role is administrative.” Slivochka adds, “But to optimize digital functionality, we needed to shift the role toward a clinical leader with an informatics background.”

The group turned to Allison Weathers, MD, FAAN, a Cleveland Clinic neurologist and Associate Chief Medical Information Officer, to help fill this void.

“I served in a similar capacity before joining Cleveland Clinic,” says Dr. Weathers. “Using that experience, I’ve worked with HIM to fine-tune our oversight, increase HIM awareness among clinicians and tighten workflows leading to quicker resolution.”

Building efficiencies reduces administrative burden

With Dr. Weathers’ support, the HIM team constantly seeks enhancement opportunities to improve efficiencies.

“Our work spans from improving EHR usability to creating clear, easy-to-follow policies and procedures,” explains Dr. Weathers. “We work closely with our providers to understand their needs and challenges so we can support them. There’s ongoing training and education to ensure they can use the available tools and resources effectively.”

Additionally, HIM works closely with Cleveland Clinic’s Compliance and Legal departments to stay current with the rapidly changing and evolving regulations and standards.

“Our overall goal is to create an environment where our providers can focus on what they do best — providing high-quality patient care — while we handle the administrative and regulatory complexities,” says Slivochka.

Structure boosts HIM priorities

Organizationally, there’s a delicate balance between meeting regulatory requirements and supporting providers to deliver the best patient care.

Dr. Weathers explains, “There’s a continuous need to update and adjust our processes and systems. We carefully balance the benefits of personalized care with the need to maintain certain standards for quality, safety and compliance purposes.”

The HIM team relies on input from multidisciplinary workgroups to make informed decisions, and this iterative process requires collaboration from all stakeholders.

“Success is about alignment and focus - making sure we're all working towards the same goal of providing the best possible care for our patients, while also meeting the necessary regulatory and compliance requirements,” says Dr. Weathers.

Judd continues, “Having this broad organizational oversight is essential in connecting the dots between clinical practice, digital capabilities and compliance adherence while preventing excess demands on our providers.”

HIM continuity delivers consistent care, resolutions

The expanded HIM Physician Advisory role has yielded vast improvements in standardizing HIM activities.

“Dr. Weathers has been instrumental as our clinical liaison,” says Slivochka. “With her leadership, we’ve standardized our processes, documentation governance and related policies to provide continuity throughout our health system. That means consistent quality care regardless of location.”

As part of these standardizing processes, the team developed the HIM checklist to help identify the required steps when reviewing and correcting patient records. Since its implementation, the checklist has decreased the time and resources needed to resolve these patient record discrepancies.

“By addressing these discrepancies quickly and effectively, HIM safeguards the accuracy and completeness of patient records, which reinforces Cleveland Clinic’s commitment to providing compassionate, effective, and patient-centered care,” says Judd.

HIM Toolbox

• Work the checklist: a well-defined list of necessary actions to assess and correct patient information
• Flagging system: digital functionality to identify medical records under review
• Release request pop-up: electronic tool that requires provider documentation to block the release of information
• EHR upgrades: anticipate and educate about changes that will impact clinical workflows
• Organizational alignment: standardize processes, policies and procedures across facilities
• Structured governance: liaison to bridge clinical, operational and regulatory priorities

In the end, Dr. Weathers is mindful that technology is not a standalone solution.

To that point, she says, “A robust HIM program is more than technology. It needs to be complemented with effective strategies, policies and training to ensure that providers are well-equipped to handle the ever-evolving regulatory landscape.”