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Footprints Newsletter - February 2016

Inside This Issue:

President’s Message

As we enter 2016, I am reminded of my own personal journey throughout my HIM career. We all have a story. Our story may be filled with happiness and excitement while for others it is filled with sadness, grief and sorrow. In time, we all move past the happiness to our time of sorrow, grief or sadness and the tide may turn that back into happiness and excitement about life. The past two years have been tangled with each of these emotions for me for many reasons. I am reminded of the movie “The Pursuit of Happiness” where Chris Gardner’s line in the movie says there is no “y” in happyness, it is spelled happiness with an “I” when speaking with his son’s childcare worker. How do you define happiness, with a “y” or with an “I”?

This year has been full of excitement and opportunity for NCHIMA. As our Governance team made strides last year to hire an Executive director for our association and to assist our volunteers in their duties, to hopefully lighten the load, to which we are already seeing results and we will share those at our Annual business meeting in May. As I have stated in my previous messages this year, our focus is on Leadership; Innovation; Education in the areas of Informatics, Information Governance and Payment Model changes; Advocacy and Public Good. I believe you will see that each of these are evidenced in our annual meeting agenda. Our NCHIMA annual meeting will be held May 3 – 6, 2016 at the Omni Grove Park Inn located in Asheville, NC. Registration and hotel information can be found on the NCHIMA website. This is always a fun time to gain some new knowledge, refresh some forgotten skills, connect with college roommates, friends, colleagues and mentors that we have each encountered in our journey in this amazing profession and I hope each of you can join us! As NCHIMA’s 2016 Theme of “Enjoying Opportunities, Keeping things in perspective” suggests, for me, this means, as I stated, we all have a story and there are no perfect people. Instead of criticizing and comparing one another to our expectation of “perfect”, let’s keep it in perspective and ask one another to realize there is good in everyone and we all have the potential to succeed in life, but you have to want to succeed and develop disciplined habits to become productive citizens in this country. It is our stewardship to hold one another accountable and be good stewards in each area of our lives. Yes, we all fail, but we must get back up and keep trying to be better tomorrow than we were today and make a difference in our lives and the lives of others. Our VP/Annual program chair, Melissa Ward has jumped in with both feet and worked with the program committee, myself, our executive director and president-elect to pull together and exciting agenda that is jam-packed with AHIMA approved CE’s for our members, non-members and vendors. We are very fortunate to have a variety of topics included in our annual meeting this year, including breakout sessions for HIM professionals, coders, educators, and students. Rather than having the Coding Roundtable Meeting on Friday only, we have integrated coding sessions throughout our meeting as well as special sessions with our sister associations, NCHICA, NCHIMSS, NCHA, as well as a speaker from the new NC Department of Information Technology to speak on the Health Information Exchange Authority. We have also included session for all of our coding sector attendees. Our keynote speaker, Laura Hamilton, will deliver a special session on “Why are you looking for the Wiz” and we know this will be a fantastic session in which we will all take something back with us to our organizations.

In closing, I hope to see you all at the NCHIMA annual meeting and am looking forward to hosting in Asheville. Take some time between now and our annual meeting in May and write down some thoughts about how you can begin to reassess your personal and professional life and how you can begin to “keep things in perspective” this year.
Until next time,

Valerie Dobson, MHS, RHIA
NCHIMA President 2015-2016​

Save the Date!
2016 NCHIMA Annual Meeting

May 3-6, 2016
The Omni Grove Park Inn
Asheville, NC

Learn More!

Delegate Updates

AHIMA House of Delegate Forum – Patient-Generated Data

By: Kozie V. Phibbs, MS, RHIA
NCHIMA 2nd Year Delegate – Strategic Planning

As your Strategic Planning Delegate, I continue to attend the AHIMA House of Delegate’s (HoD) Envisioning Collaborative Committee and the AHIMA HoD Forums. 

The Forum on December 11, 2015 was on “Patient-Generated Data”. The Consumer Engagement Task Force identified this growing trend in patient-generated health data (PGHD) and developed a practice brief on the topic which was published in February 2015. It defines what patient-generated health data is, how consumer interest in PGHD is growing at an accelerating rate, how to prepare for incorporation in the EHR, role in the EHR and Information Governance (IG), and recommendations for working with PGHD among other information.

Three of the trends that were brought to House:
  • Patient advocacy/Consumerism – new patient navigator role
  • Risk of security breaches will increase, leading to technology for improved authentication and management of personal devices
  • Expanded use of mobile devices will lead to technology to track use of these devices and improved authentication mechanisms
For discussion, the forum discussed the primary issues occurring in the marketplace:
  • Issue:  Patients sending information to providers
    • What do we do with the information?
    • Integrity of data/validity?
    • Provider reviews information and decides what is relevant?
    • Provider not always willing to receive information, or have it added to record without review first?
  • Issue: Security technology - need to keep up with latest mobile technology
    • 5-10 years -> Facilities lagging behind because of lack of resources to keep up with technology expectations of patients and providers.
  • Issue: Legal record
    • 5-10 years -> Information overload = record out of control
    • Worried about lack of inter-operability
    • How do we standardize terms, etc. for patients?
    • Also practitioner standards for documentation?
  • Issue: Need to update definition of legal record to include telehealth - patient mobile information.
  • Future need for patient navigator to educate and help patients understand
  • Issue: State credentialing
  • 5-10 years -> National credentialing with monitoring, which will allow crossing of boundaries
  • Issue: Patient participation with education
    • 5-10 years -> Patients more involved in health record
    • Need better technology for authentication of data
    • Patient and Information Technology Advocacy
  • Issue: So much data – how will we get through it?
  • 5-10 years: Standardization
    • Vendor/Technology tools to help
    • Regulatory standard in place for documentation
    • EMR
    • Telemedicine
    • Home care
Following the discussion, the following were considered the most urgent trends:
  • Legal Record
  • Update definition, improve standardization, interoperability to control what is going on. If not – trend = chaos and confusion of ownership.
  • Credentialing
    • Trend in future = national credentialing at federal level
  • Patient Advocacy/Patient Navigator
    • 5-10 years HIM helping patient with thier own record with navigation
  • Security
    • Improved authentication
    • Vendor products
    • BYOD – how do we manage?
    • Risk of breaches
    • ID mobile info with meta data
    • Mobile device management
      • Tech to track devices and authentication
      • Need control​

Documentation and The “CMS Quality Strategy 2016”

Submitted By: Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA
NCHIMA President-Elect
CEO Recovery Analytics, LLC

December 3, 2015

“CMS Quality Strategy 2016” was released by CMS (Centers for Medicare and Medicaid Services) in November 2015. As evidenced by recent changes in the OPPS Final Rule 2016 and other quality and value-based trends, movement has been aggressive and persistent towards value versus volume.

Long-term goals for value-based payments for Medicare Fee-For-
Service include:
  • Goal 1: 30% of Medicare payments are tied to quality or value through alternative payment models by the end of 2016, and 50% by the end of 2018.
  • Goal 2: 85% of all Medicare FFS payments are tied to quality or value by the end of 2016, and 90% by the end of 2018.
At the center of these goals is the aim of “Better Care, Smarter Spending, and Healthier People, Healthier Communities”.

In looking at the above without knowing anything about changes in PQRS, fee schedules, readmissions, or other value-based/quality initiatives, it is evident that providers have to begin implementing and working toward changing how it operates, provides and delivers services, utilizes innovation, and focuses on the patient to survive the future.

CMS has gone on to develop 6 (Six) CMS Quality Strategy Goals as part of this National Quality Strategy.
  • Goal 1: Make care safer by reducing harm caused in the delivery of care.
  • Goal 2: Strengthen person and family engagement as partners in their care.
  • Goal 3: Promote effective communication and coordination of care.
  • Goal 4: Promote effective prevention and treatment of chronic disease.
  • Goal 5: Work with communities to promote best practices of healthy living.
  • Goal 6: Make care affordable.
There are a few areas within this strategy that warrant an increased focus on documentation however “Goal 4” related to chronic disease is very important to pay attention to. Providers must ensure they are identifying these conditions within the documentation and coding early on and treating appropriately. This is important for targeted treatment, patient management, forecasting, and possible payment implications. Ensuring you are implementing documentation integrity processes in the clinic and other ambulatory settings as well as the acute setting is something we must do now. As mentioned by CMS, chronic conditions can include MCCs (Major Complications and Comorbidities) but also include HCCs (Hierarchical Condition Categories) for risk adjustment.

Potential Ambulatory Documentation Challenges:
  1. Mental and cognitive disorders: Is this a depression that is major, situational, post-schizophrenic or other?
  2. Cancer: Is this a primary or secondary cancer? Has the cancer been removed, not under treatment, and no longer active?
  3. Arthritis: Is this juvenile, gouty, or other cause?
Focusing on documentation, holistically” within not only the inpatient world but also within outpatient/ambulatory is important to achieve positive impact on population health but also revenue as incentives will be tied to provider success. Begin to take a closer look at your ambulatory documentation to be ready for the changes already in progress.

New Member Spotlight

Jessica Kelly
Data Integrity Supervisor
Mission Health System

What initially drew you to this particular profession?
I knew I wanted to work in healthcare and realized that patient care was not in the cards for me, so I decided that Health Information Management would be more ideal. Originally, medical transcription was something I had heard about and felt I would enjoy. I started out working as a Medical Records Clerk while I was taking the transcription classes. I moved on to work in transcription for many years.  When I realized there would be a reduction of workforce for transcriptionists, I decided to complete the HIT program to move forward in my career in HIM. Currently, I am an HIM Supervisor for the Data Integrity team whose main focus is management of the EMPI.  

What are your future plans?  
I plan to enroll in the Bachelor’s program for Healthcare Informatics and will sit for RHIA certification when I have completed the program. Career advancement is my goal as I would like to be promoted to HIM Manager. I really enjoy being involved with more than one sector within HIM and I feel that in a management position I would have that opportunity to utilize my knowledge, experience and leadership skills effectively.  

How did you decide this was a good fit for you? 
Working in an office environment was something I enjoyed, but I wanted to know that I was helping people. Working in HIM provides this rewarding opportunity for me. We play a vital role in ensuring patient safety. I can say each day that I make a positive and proactive difference in improving patient care.

What advice would you present to those considering the HIM profession?
The HIM profession is a great choice if you would like to have many positions to choose from within one department. This is a field that requires great attention to detail, good problem solving skills, willingness to learn and adapt to change. HIM is an ever evolving department that balances system changes and patient care. There is always something new to learn. Don’t be afraid of change.  Embrace it. It is through the positives and negatives of change coupled with the teamwork and efforts of the staff that the department grows and improves. It is exciting to see where HIM once was and where it is now, from paper charts to electronic records, from delayed access to records to immediate access, etc. It has been amazing to watch the evolution and improvements in healthcare as a result. I am excited for the changes that will happen in the future.​

Newly Credentialed Professionals

Tammy Clay – 12/18/2015

Consovelia Harris – 12/5/2015
Edward Williams – 12/17/2015

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