Driving Success with an Electronic Health Record:

The Value of the Partnership Between Physicians and Health Information Management Professionals

October 2014

Valuable Collaborations Series

Issue No. 1

2   DRIVING  SUCCESS  IN  AN  ELECTRONIC  HEALTH  RECORD  ENVIRONMENT    

As professionals trained in the regulatory

and technology infrastructures of electronic

health records, health information

management professionals are ideally

matched to serve as the principal

supporters of physicians working in EHRs.

Health Information Management—Partners in Navigating Health System Pressures

As modern delivery systems are making the

transition to electronic health records

(EHRs), physicians are under pressure to

rapidly adopt and use systems that are not

fully optimized or integrated into their

clinical workflows. The information

technology (IT) professionals typically

assigned to support healthcare systems

with these technology implementations

frequently lack the regulatory and workflow

knowledge to guide the physicians to

becoming highly efficient users. As a

counterpoint, health information

management (HIM) professionals have been

key to guiding physicians through

regulatory changes and documentation

requirements as a core competency of their

profession. Today’s increased emphasis on

informatics and electronic health record

design in HIM are aligning HIM

professionals as the best equipped for

handling physician support in an EHR

environment.

Physicians need to know more than just

how the software works and where to click;

they need to know how those clicks affect

clinical care, revenue generation, and how

their data input is used in a variety of

incentive—and penalty—programs. Many

organizations have a focus on clinical

informatics programs to address the gap

between technology and clinical care, but

few have any focus on revenue cycle

informatics. As CMS and other payers

expand their incentive programs using

ratings based on administrative data,

revenue cycle informatics will become

increasingly important. The complexity of

these programs means it will be difficult for

IT Analyst to remain up-to-date on them,

especially since it is not their specialty.

Technology Implementations Primed for HIM Involvement

There are at least three technology

implementations where HIM professionals

should take the lead in supporting

physicians: electronic health record

implementation/optimizations, voice to

text/physician assisted documentation (such

as M*Modal’s Fluency Direct), and

Health Information Management Professional Skills Relevant to EHRs

• State and federal laws governing health records  

• Regulatory standards for physician documentation  

• Coding guidelines for accurate and complete billing  

• Payer guidelines for billing practitioner requirements  

• Understanding of information governance requirements  

DRIVING  SUCCESS  IN  AN  ELECTRONIC  HEALTH  RECORD  ENVIRONMENT   3    

Computer Assisted Coding (such as 3M’s

360 Encompass). The common thread

through these implementations is that the

words the physicians document and the

speed at which they document will greatly

impact the success of the implementation.

An HIM professional’s understanding of

documentation requirements—from the

language required to accurately code the

service or procedure through the regulatory

standards governing the timing and

location of the documentation within the

EHR—are needed to aid physicians with

establishing functional, productive

documentation habits.

If new technologies adversely impact the

timeliness, completeness, or accuracy of

clinical documentation, revenue generation

and incentive program performance will be

hindered, so these side effects are actively

combated. Rarely does the inverse of

improving these metrics get attention when

working on optimization of these systems. If

leveraging technology can improve the

timeliness, completeness, or accuracy of

the record, revenue generation and

incentive program performance will

improve over baseline—adding value to the

organization and a solid return on

investment for these initiatives. HIM

professionals are the right group to guide

the physician’s efforts so that he or she can

address the issues of how, when, and what

to document in the record to achieve

accurate, complete, and timely

documentation.

A Valuable Partnership

HIM professionals may have apprehension

and fear around directly supporting,

advising and interacting with physicians on

technology initiatives. An invisible barrier to

gaining the teamwork needed to move

health systems ahead exists when HIM

professionals are not recognized in the

technology sphere. This barrier can be

overcome. Electronic records mean HIM

departments can move to virtual support

models where they can help physicians who

are located in any area around the world,

rather than requiring providers to walk

down to medical records. HIM specialists

can provide real-time education via screen

sharing at the very moment a physician is

struggling. Advances in analytics allow for

HIM professionals to meet with physicians

and discuss the exact problem the provider

is having, recommend changes to the

template, or suggest the use of a new

technology. An IT professional would not

have provided support or guidance on

clinical documentation in a paper record

and they are not best equipped to handle

documentation questions in an EHR.

Technology Innovations

EHRs  

CDI  Support  

CAC  

4   DRIVING  SUCCESS  IN  AN  ELECTRONIC  HEALTH  RECORD  ENVIRONMENT    

The HIM Opportunity

HIM has a window of opportunity to forge a

lasting partnership with physicians, but they

must act quickly before the moment is lost.

If HIM does not rise to the occasion,

physicians will inevitably turn to someone

else for support, even if that support is of

lower quality. Investing in the HIM skills of

informatics, information governance,

medical records management, and

understanding of regulatory rules including

coding and billing guidelines will lead HIM

professionals into the role of effective,

valuable partnership with physicians.

Educational Opportunities

Join Propel Health IT on November 3 in

Atlanta, GA to learn our Data Driven

Documentation Excellence Maturity Model

that is the roadmap to a lasting partnership

between HIM professionals and physicians.

Visit propelhealthit.com to register or to

learn about our community.  

About the Authors

John Showalter, MD, MSIS

Dr. John Showalter is an

influential thought leader

on the innovative use of

health information

technology, devices, and

data to drive improvements in healthcare

delivery. Dr. Showalter serves as the Chief

Health Information Officer at the University

of Mississippi Medical Center. He received

his B.S. in biomedical engineering from

Columbia University and his medical

degree and a master of information systems

in health care delivery and management

from Penn State University. In addition to

his board certification in internal medicine,

Dr. Showalter became one of our nation’s

first physicians to become board certified in

clinical informatics in 2013.

Leigh Williams, MHIIM, RHIA, CPC, CPHIMS AHIMA Approved ICD-10-CM/PCS Ambassador Leigh Williams is an

innovative revenue cycle

leader specializing in transforming health

information management to improve care

communications, gain accuracy in health

data capture, and in successfully

operationalizing a response to

governmental mandates for improved

quality in healthcare systems. As director of

revenue cycle & HIM at the University of

Mississippi Medical Center (UMMC), Leigh

heads the hospital and professional fee

coding, electronic health records, and

clinical documentation improvement

departments. She has served as the

institute’s executive director for ICD-10

implementation since 2013 and currently

oversees the clinical documentation

excellence program for 6 hospitals and

more than 100 clinics. Leigh holds a

bachelor’s degree from Wellesley College

and a master of health informatics and

information management from the

University of Mississippi Medical Center.