Introducing the Core Model - AHIMA Body of Knowledge - American

A New View of HIM: Introducing the Core ModelReview DraftREVIEW

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A New View of HIM: Introducing the Core Model | 2

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ContentsExecutive Summary______________________________________________3

Introduction ____________________________________________________5

A Call for a New Professional Core Model _______________________5

Background - Developing the New Core Model ___________________6

A New HIM Profession Core Model _____________________________6

Functional Components and Statements __________________________8

Data Capture, Validation & Maintenance ________________________8

Data / Information Analysis, Transformation & Decision Support _____8

Information Dissemination & Liaison ____________________________8

Health Information Resource Management & Innovation ___________9

Information Governmance and Stewardship ______________________9

Core Model Extensions __________________________________________9

Research ___________________________________________________9

Policy ______________________________________________________9

Education __________________________________________________9

Standards ________________________________________________ 10

Settings of Practice for Health Information Management ________ 10

Roles and Value ______________________________________________ 11

Data Capture, Validation and Maintenance ____________________ 11

Data/Information Analysis, Transformation and Decision Support __ 11

Function: Information Dissemination & Liaison __________________ 12

Health Information Resource Management and Innovation _______ 12

Function: Information Governance and Stewardship _____________ 13

Bibliography _______________________________________________ 16–24

Appendix A ________________________________________________ 25–35

Appendix B ________________________________________________ 36–40

Appendix C ________________________________________________ 41–42

Appendix D ________________________________________________ 43–44

The American Health Information Management Association is the worldwide professional

association of recognized leaders in health information management, informatics, heath data

technology, and innovation. To learn more about AHIMA visit www.ahima.org. ©2011

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Executive SummaryIn the last year the AHIMA Board of Directors undertook the challenge of developing a new view of Health Information Management (HIM)—one that addressed changing practice roles, settings, and functions emerging from increased automation, changing regulations, and dissemination of data.

The result, with input from AHIMA members, industry experts, and AHIMA staff is a draft HIM Core Model to describe a robust set of functions and opportunities open to current and future HIM professionals. This Core Model has been extended to include an inventory of inventory of HIM functions and a description of a desired future state of health information management’s roles across the healthcare industry over the next 10 years.

This white paper represents an AHIMA consensus of the future functions and roles of health information management. It:

• Extends the core model description of HIM to ensure inclusion of a complete and comprehensive set of future HIM functions

• Addresses major health settings in which health information must be managed, mapping future HIM functions to future HIM practice settings across the industry

• Transfers interim ideas to AHIMA programs to advance members, the HIM profession, and AHIMA

• Leads to and enables, but does not include, follow-on work to publish future-state HIM roles, functions, and value to external agencies, organizations, and communication channels

Throughout the process, AHIMA has continued to collect feedback from its members and industry experts to further refine the model. The publication of this draft version, intended for AHIMA members, represents the next step in this ongoing professional dialogue.

In the Core Model, the primary role of the HIM professional is focused on five main functional areas of health information:

• Data capture, validation, and maintenance

• Data/information analysis, transformation, and decision support

• Information dissemination and liaison

• Health information resource management and innovation

• Information governance and stewardship

Functional statements were then developed for each of the core elements of the model.

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In addition, the model identifies four areas of HIM practice that do not include direct interaction with patient level health information but require an understanding of HIM and additional unique knowledge, leadership, and innovation. These “extenders” serve two purposes. First, they describe additional roles for HIM professionals outside but related to the core functions. Second, they describe operations that enhance and extend the core functions. Education, policy, research, and standards are key enablers that support, advance, extend and contribute to the evolution of the functional components and of the Core Model as a whole. The second purpose of the model extenders is to describe the roles HIM professionals take in performing these functions. The functional statements and descriptions of extenders are attached as Appendix A.

The functional statements were also reviewed from the perspective of the multiple settings in which HIM professionals work today and are anticipated to work in the future. Specific settings were identified and then grouped into nine categories. A matrix of functional statements to settings is attached as Appendix B.

Finally, HIM roles were identified for each element of the Core Model. They were cross matched against healthcare settings to express what roles are or could be present in each healthcare setting. For a list of roles in alphabetic order, see Appendix C.

The Core Model described in this white paper identifies many current and future roles for HIM professionals across the healthcare continuum. It is designed to provoke thoughtful discussion, ideas, and challenges as AHIMA and the HIM profession continue to envision and move toward the future. To send us your feedback, write to us at “Core Model” via AHIMA, 233 N. Michigan Avenue, 21st floor, Chicago, IL 60601 or [email protected].

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IntroductionAHIMA’s Pocket Glossary of Health Information Management and Technology defines health information management (HIM) as “an allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions.”

As healthcare evolves and becomes more dependent on technology, a contemporary view of HIM and the role of the HIM professional must evolve. Health information management is the practice of collecting, assessing the completeness of, maintaining, and sharing (as authorized) patient information through paper-based and electronic means. It is practiced in provider, payer, research, and governmental settings, as well as in health information exchanges and other settings that provide healthcare or maintenance of health records. With the widespread adoption of electronic health records and other technology-based information sources and the use of the electronically available data for healthcare management measurement purposes, research functions, and governmental initiatives, health informatics and health information technology are being increasingly utilized in HIM practices in the healthcare industry.

A Call for a New Professional Core ModelAs a profession, HIM must become savvy in its use of technology and data analytic tools in order to better serve patients, inform policy leaders, and move into the 21st century and beyond. To meet the needs of various healthcare organizations in their use of emerging technologies, HIM professionals need to be involved at an executive level where decisions are made regarding the design, implementation, and use of technology from a systems approach.

From an operational perspective this would suggest involvement in the adoption and implementation of systemwide technology; the use of data to improve patient care and reduce cost; and a role as leaders who define future policies and procedures as they relate to the privacy and security of the organization.

In 2011 AHIMA brought together HIM experts to identify the roles, settings, and impact of the profession through the next decade. The group extended and advanced a draft core model of HIM functions into a description of the desired future state of HIM roles as they will be performed across the healthcare industry. The group’s aim was to articulate desired HIM professional roles across industry settings in order to:

• Identify and specify the future scope of HIM practice functions and roles

• Identify and specify the value of such roles to society, the health industry, current and future employers of HIM professionals, and current and future HIM professionals

• Differentiate HIM from other related disciplines

• Provide a professional scope of practice that clarifies the role of AHIMA in serving the industry

• Enable follow-on work (phases)

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Background - Developing the New Core Model To address the evolving definition of the HIM professional and their role, the AHIMA Board of Directors engaged in a comprehensive environmental scan of the health information landscape. Through scenario planning and alternate future analysis, it became apparent that a new view of HIM was required to address changing practice roles, settings, and functions emerging from increased automation, changing regulations, and dissemination of data. The Board conducted initial work to redefine a model for HIM practice. A draft HIM Core Model was developed to describe a robust set of functions and opportunities open to current and future HIM professionals. The draft model was validated and refined with stakeholders including state association leaders, committee members, members attending CSA meetings and AHIMA professional staff. The input resulted in a broadening of the model components and functional statements to better reflect the HIM profession. To further vet the model, the AHIMA House of Delegates compared and contrasted the of HIM professionals functions in applied health informatics roles and other informatics disciplines.

To further refine the model and ensure it accurately captured emerging HIM functions, roles, and settings, a task force was charged to research and evaluate up-and-coming roles in healthcare in the next 10 years, health informatics functions within the HIM domain, and the broad array of settings where HIM professionals work today and in the future. Review of the HIM Core Model was coordinated with the Canadian Health Information Management Association staff and members to discuss future functions within HIM. This discussion resulted in further refinement of the model, particularly with regard to data display and interpretation. The final vetting of the HIM Core Model was conducted in March 2011 at the AHIMA Winter Team Talks in Washington, DC, and Las Vegas.

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A New HIM Profession Core ModelThe new HIM Core Model embodies current and emerging roles and functions for the profession (Diagram 1). As an October 2011 Journal of AHIMA article by Cassidy et al. states, at the center of the Core Model is the HIM professional’s direct interaction with patient level health information. The interactions are shaped by information governance and stewardship responsibilities. HIM’s skills in managing the resources, processes, and innovations within the health information environment continue to be a valued function and role into the future. A focus on quality and patient safety was also added and will be explored in later iterations.

Diagram 1:The HIM Profession Core Model

Functional Components and Statements A combination of extensive literature review, domain expert input, and collaboration with the Canadian Health Information Management Association, informed the development of the model’s functional components. Each functional component of the model is further defined by a set of functional statements. The functional statements were designed from with a broad perspective in mind to accommodate the multiple settings in which HIM professionals work. A comprehensive list of functional statements is contained in Appendix A.

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Data Capture, Validation, and MaintenanceData capture, validation and maintenance requires the development and implementation of standard practices, policies and procedures that support effective and efficient capture of data that are valid and reliable. This involves clear understanding and direction with regard to the design and implementation of data quality and integrity strategies, management of data structures and terminology assets, and support for optimum information flow.

Diagram 2: Functional Components of HIM Profession Core Model

Data / Information Analysis, Transformation and Decision SupportThis component requires the development and implementation of standard practices, policies and procedures that enable reliable and effective analysis, transformation and reporting of data and information. Transforming data and information into knowledge is critical for patient care, improving healthcare quality, advancing research, and supporting operations.

Information Dissemination and LiaisonData functions related to establishing dissemination and reporting practices related to data, information and knowledge are foundational to this component. HIM functions include the formatting and provision of information, reports, and other knowledge-driven assets.

Health Information Resource Management and InnovationManaging the health information environment is an essential HIM component to ensure that health personnel are educated on HIM, HIM management processes, responsibilities and compliance. Resource management extends to managing health data through its life cycle. Innovation and adopting advanced health information management processes is a critical attribute of this Core Model component.

Data/Information, Analysis,

Transformation & Decission Support

HIM Core Model

Data Capture, Validation, & Maintenance

Information Dissemination &

Liaison

HI Resource Management and

Innovation

Information Goverance & Stewardship

Quality and Patient Safety

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Information Governance and StewardshipInformation governance provide a foundation the other data-driven functions in the Core Model by providing parameters based on organizational and compliance policies, processes, decision-rights and responsibilities. Governance functions and stewardship ensure the use and management of health information is compliant with jurisdictional law, regulation, standards, and organizational policies. As stewards of health information, HIM roles and functions strive to protect and assure the ethical use of health information.

Core Model ExtensionsFour areas of HIM practice were identified that do not include direct interaction with patient level health information, but require an understanding of HIM and additional unique knowledge, leadership, and innovation. These “extenders” serve two purposes. First, to describe additional roles for HIM professionals outside but related to the core functions. Second, to describe operations that enhance and extend the core functions. Education, policy, research, and standards are key enablers that support, advance, extend and contribute to the evolution of the functional components and of the core model as a whole.

ResearchHIM research advances and validates best practice. Research also increases and enhances HIM’s contribution to patient safety and the quality of care. It identifies areas of risk and where improvements in practice are required. The research extension serves to understand and advance the practice. HIM researchers need to be proficient in research methodology and statistics.

PolicyThe healthcare industry is highly regulated in order to protect patients and the public interest. HIM policy is expressed in laws and regulations that protect patients and their privacy. Regulations control the appropriate flow of public funds and regulate the insurance industry. Policy is also important in establishing public health standards and to codify best practice. The policy extension of the Core Model addresses the advancement of HIM principles and professional standards by influencing government policy and shaping and leading HIM policy at all levels of healthcare organizations. Along with standards, this extension interfaces with a variety of other industry stakeholders to a high degree.

EducationHIM education defines and builds competence for those entering and working in the field. It promulgates best practice and creates professionals for the future. The education extension of the model addresses the formal academic education that is provided in colleges and universities as well as the delivery of continuing professional education. Where there are HIM professionals whose primary function is to develop and deliver training to end users or to consumers, these functions are included in this extension. The functions in this extension also apply to all HIM professionals who have an obligation to maintain their professional competence through a commitment to lifelong learning.

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StandardsStandards advance HIM practice by creating uniform approaches to interoperability at the technical and semantic level. Standards reduce costs and support the transfer of information to support care. Standards also streamline development and adoption of technology and data methods. The Standards extension requires an understanding of the unique stakeholder and healthcare setting perspectives and domains to advance HIM standardization. These domains have been defined by the Office of the National Coordinator for Health Information Technology as provider perspective; consumer perspective; public health perspective; care management and delivery domain; health information domain; confidentiality, privacy and security domain; infrastructure, interoperability and exchange domain; administrative and financial domain; and quality measurement and assessment domain.

Settings of Practice for Health Information ManagementAs the delivery of healthcare has diversified over the last 30 years from acute care hospitals to a wide spectrum of ambulatory and specialty centers, health information management professionals’ work settings have followed a similar diversification pattern. These changes continue as new models for healthcare delivery, payment, and monitoring are formed. Added to that is the increased production of and reliance on healthcare data generated by electronic health records and ancillary data capture systems. This expansion of the availability of personal health information now extends to the patient themselves. As health information is shared and used more widely, HIM work settings expand accordingly.

HIM functions are performed where personal health information exists, where there is a need for health data and/or information, and where products and services for managing health data and/or information are designed. Where there is health information, there is HIM. To identify the near-future state work settings where HIM professionals will add value, the team examined three sources of data in addition to knowledge of the changes occurring in healthcare delivery. The literature review suggested some settings, a search of job postings specifically to identify new work settings and a search of the AHIMA profile database to identify those “other” job settings identified by current members that suggest future potential. Specific settings were identified and then grouped into nine categories:

• Healthcare Provider Organizations

• Healthcare Data Organizations

• Healthcare Payer Organizations

• Healthcare Supplier Organizations

• Planning Organizations, Regulators, and Industry Support

• Educational Institutions

• Research Institutions

• Third-Party Compliance Organizations

• Consumer Organizations

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Roles and Value HIM roles were identified for each element of the core model. They were cross matched against healthcare settings to express what roles are or could be present in each healthcare setting. The value of each function and role were discussed and are expressed in the table below.

Data Capture, Validation, and Maintenance

Roles

Chart correction analyst

Classification editor and exchange expert

Clinical coding validator

Clinical content manager

Clinical documentation improvement specialist/supervisor

Coder

Coding compliance coordinator/supervisor/manager

Computer assisted coding validation practice leader

Data architect

Data capture design specialist

Data dictionary manager

Data integrity and transitions specialist/auditor

Data mapper/translator

Data quality manager/analyst

Documentation/EHR trainer

EHR content manager

Enterprise patient master index data integrity analyst

ICD-10 implementation specialist

Information workflow designer

Patient identity manager

Registrar (Birth, Cancer, Device, Bone marrow, tissue)

Research coordinator/associate

Research data abstractor

Terminology asset manager

Voice capture specialist

Value

• Increased revenue potential by assuring accurate coding supported by documentation

• Improved cash flow caused by first time claims processing with few denials and appeals required

• Improved efficiency of data capture through section and implementation of technology

• Decreased operational costs by efficiencies gained in workflow

• Increased patient safety and satisfaction by reduction of duplicate records

• Increase in patient safety and satisfaction through standardized data collection across systems and sites

• Improved research outcomes through optimized data capture and abstraction.

• Increased value and accuracy of information through planning for the capture of discrete data

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Data/Information Analysis, Transformation, and Decision Support

Roles

Business analyst

Claims data analyst

Clinical data analyst

Clinical content manager

Data abstractor/coordinator

Data architect

Data integration manager/analyst

Data integrity and transitions specialist/auditor

Data quality manager/analyst

Data repository architect/manager/analyst

Decision support analyst

Decision support officer

Health data analyst/manager/director

Health data statistician

Health outcomes analyst

Healthcare data quality engineer

Information warehouse/repository director

Interface reconciliation specialist

Patient centered outcomes researcher

Quality outcomes and cost analyst/director

Physician practice liaison

Record analyst

Referral specialist

Regional health information management specialist/manager/administrator

Registrar (Birth, Cancer, Device, Bone

marrow, tissue)

Report writer

Research coordinator/associate

Values

• Increased strategic value of data through informed presentation of payor mix and case mix index

• Compliance with mandated reporting requirements

• Information available to assess and improve patient care delivery and outcomes

• Information provided for marketing to the public

• Minimize the risk of exposure to the practice by improving the quality outcomes

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Function: Information Dissemination and Liaison

Roles

Clinical documentation analyst

Data exchange manager/analyst

Data report design specialist

Data transfer analyst

Health information exchange coordinator/ facility representative

Information assessment specialist

Personal health information exchange manager/director/administrator

Quality information exchange director

Value

• Improved decision making through the appropriate availability of decision support tools

• Improved data for reporting and quality i.e., care measures, outcomes, and research.

Health Information Resource Management and Innovation

Roles

Accounts receivables manager

Accreditation readiness manager

Ancillary services systems manager/administrator/officer

Application support specialist/coordinator/manager

Chief health information officer

Chief knowledge officer

Chief information officer

Clinical information manager

Corporate records manager

Data administrator

Data standards director/administrator

Denial appeals coordinator

Director of strategic information management

eHealth transition specialist/manager/director

EHR implementation specialist/leader/manager/officer

EHR model/workflow project manager/director/officer

Health information implementation specialist

Values

• Improved patient care across the continuum through appropriate and timely information access and exchange.

• Optimized design of EHRs matched to clinical and operational workflow that returns higher value on the investment

• Optimized resource planning through the availability of aggregate clinical information

• Decreased cost created by improved coordination of services and technology

• Increased revenue and decreased transaction cost from revenue integrity management programs

• Enhanced project management through application of broad knowledge of the healthcare delivery system within an organization and with other external organizations

• Improved patient care outcomes by effective design of information capture and communication systems

• Empower patients in their own healthcare by advocating for their rights and providing understandable information to them

• Increased revenue through assistance with achieving meaningful use requirements

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Health Information Resource Management and Innovation (continued)

Roles

Health information interoperability and standards specialist/administrator

Health information project officer

Health information trainer

HIM application support specialist/manager

HIM integrity specialist/manager

HIM manager

Implementations redesign specialist/tester

Informatics specialist

Information operations manager/administrator/officer

Information resource manager

Local/ regional policy analyst/officer

National health data coordinator

Nationwide health information management specialist/manager/ director/officer performance improvement specialist

Project manager

Quality improvement coordinator/advisor

Quality improvement director

Quality outcomes project manager/analyst/director

Physician health information liaisons

Regional health information management specialist/manager/administrator

Registrar (Birth, Cancer, Device, Bone marrow, tissue)

Reimbursement specialist

Revenue integrity analyst

Systems analyst

Vice president of data integrity services

Vice president of strategic information development

Workflow design analyst

Values

• Reduced healthcare costs by ensuring reliable data that eliminates duplicate tests and record keeping practices

• Improved adoption of EHRs through effective training

• Enhanced relationship between hospitals and physicians through coordinated HIM resources

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Function: Information Governance and Stewardship

Roles

Access manager/auditor

Accounting of disclosures coordinator

Compliance officer/auditor

Electronic discovery auditor

Health information exchange privacy gatekeeper

Health record advocate

Healthcare consumer access manager

Healthcare fraud investigator/analyst

Health information security analyst

HIM government relations specialist/consultant

Information analyst for business continuity

Patient advocate

Personal health record advisor

Privacy and security officer/auditor

Public relations liaison

Recovery audit coordinator

Vice president of health information governance

Value

• Decreased risk of litigation based on appropriate retention of data

• Increased compliance with current laws and regulations

• Decreased liability and enhanced reputation through reduction of breaches

• Decreased liability through maintenance of an accurate and complete clinical record

• Optimized access to information through processes and technology that maintain confidentiality and security

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Introducing the Core Model - AHIMA Body of Knowledge - American

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