As physician practices move away from paper-based record keeping and into the era of electronic medical records, the caliber of staff needed to coordinate, manage, and protect patient information grows exponentially. Clerical staff, once well-qualified to manage paper charts, may not make the grade where new technology is concerned.
For example, practices that receive stimulus dollars under the Health Information Technology for Economic and Clinical Health (HITECH) Act will be under closer scrutiny for HIPAA security and privacy compliance. Providers that implement an EHR that then results in HIPAA violations can face fines as hefty as $50,000 per occurrence?quickly negating the $44,000 per physician incentive. Security and privacy of health information within the EHR is of paramount importance.
With all of these challenges, how can physician practices successfully make the transition to electronic records? The answer for many practices is to hire a credentialed Health Information Management (HIM) professional.
Who are HIM Professionals?
Formerly known as medical record technicians or administrators, these allied health professionals provide tremendous value to physician practices in such areas as HIPAA compliance, record management, coding, reimbursement, clinical documentation, and more. HIM professionals bring a wealth of knowledge, training, and expertise to the areas that are critical to the overall financial health of a physician's practice. And because they possess a unique combination of clinical knowledge and business acumen, they are highly effective in translating the clinician's process of diagnosis and treatment into dollars and cents.
Accredited by the American Health Information Management Association (AHIMA), HIM professionals are a vital layer of protection for all chart-management concerns. They are the keeper of the keys, so to speak, and provide a tremendous return on the investment in their services.
Managing and Protecting Charts
For over 70% of physician practices, loose documents, untimely filing, and misplaced records can be the downfall of their businesses. Some practices have records dating back to the 1950s, which can be a nightmare when cleaning out in preparation for EMR. The HIM professional knows state and federal guidelines for all aspects of record management?storing, archiving, retrieving and purging. If pulled into court, the practice must have well-organized, accurate, and accessible records (paper or electronic) that comply with state and federal regulations to back a case. HIM professionals can help.
Migrating to an HER
HIM professionals also provide valuable support for EHR initiatives in physician practices in three critical areas: demonstrating a return on investment, training and support, and migration of clinical documentation and legal records to an electronic environment.
HIM can help the entire practice become informed about the various aspects of EHR. "We can show providers how to save time, reduce operating costs, increase revenue, and sustain quality of care," says Catherine Stemple, RHIT, Office Manager of Barbour County Family Medicine, Philippi, WV. The benefits are contingent upon the internal efficiencies of the practice and the ability to make informed decisions that will ensure successful implementation. That's a key area where the HIM professional can add value to the practice.
Finally, HIM professionals are astute at creating policies and procedures to protect patient information. Though electronic records are more secure in many ways, there are new risks for privacy and security breaches. The American Recovery and Reinvestment Act (ARRA) includes guidance related to "breach notification," how providers must notify stakeholders in the event of a privacy breach, and security of personal health information (PHI). The Act includes specific definitions for a "breach" and lays out the various notifications that must be made to the individual and the media.<