We recently sat down with HIM employee Cindy Ness to discuss the history and value of medical records management.
Photo: Her coworkers affectionately refer to Cindy as "mother hen," texting her when they they're late or not coming in to work. She's also the only HIM staffer who can keep plants alive, as evidenced by the row of (everyone else's) plants on her desk.
Okay, let's talk shop. What is health information management?
First we were Medical Records (MR, or "mister"). Now we're Health Information Management (HIM).
We're responsible for coding charts, which are turned over to the insurance companies, then returned to us as revenue. Our coders play a huge role in financial wellness of the organization. And I don't know if enough people really understand that part of it.
Three techs on our team analyze charts to make sure they're complete before they get to the coders. If there's something lacking, like the provider forgets a progress note or didn't sign something, we apply a deficiency to ensure the provider completes what they need to.
Then we're able to pass things onto the coders. They can do their job and just code. Back in the day when we had paper charts, the coders would flag all the deficient places and hand wrote the codes. We didn't have computers. Everything was done on ledgers, on paper. When the hospital got its first fax machine, it was in our department. They wanted a secure location for it, to protect privacy.
And that's another part of what we do. Privacy. Cynthia Kelly, our department director, is the KVH privacy officer. She investigates potential health information breaches. Plus, she keeps us ducks going down the stream in the right direction.
Release of information. That's another big thing we do. A patient asks for copies of their record, they fill out a release of information and we provide the copies.
I also do birth certificates. That's really changed over the years. Before you had this big long form, you put it on a typewriter and typed it out. If you made a mistake, you start over. Now there's a website where you securely submit the information.
Health information management is multi-layered. There's a lot to us. We're small, but we're mighty.
So things come to you from various areas, departments, clinics, including external clinics?
Yes. If they have privileges here, we often process their paperwork, because they don't have an electronic connection with us, so to speak. External providers can chart here in the hospital electronically, but if they have office notes that come over, we scan those in. Also, any external provider who wants lab or imaging work done and their patient chooses to have it done here, those are paper orders also, so they need to be scanned in. Anything that comes from the nursing home or even from providers from Seattle or Yakima or Spokane, if the patient lives here and their specialist wants specific tests done, we can do them here. Saves the patient from having to go out of town.
Where is HIM in the flow of patient information? You're the last stop?
Pretty much. We really are.
And you're housing the information, so it needs to be complete because you are retaining the record?
Right. And, if something happened incorrectly upstream from us, we catch it and then we have to figure out what happened and how to fix it, and hopefully get everybody on board in the same direction.
Now, am I misremembering that you used to do transcription?
You are correct. I used to do transcription. That was what I was hired for originally.
And was that within medical records?
I've been in the same department my entire career here. Which is 31 years and two months.
But who's counting?
Transcription was done with a typewriter and a transcriber and a micro cassette. The providers could use the telephone. There was a series of tapes. One would kick over for recording, it would get four dictations on it and then it booted over to the ready to transcribe side. And so they were able to call from pretty much anywhere, into the dictation system.
Then it progressed to a display typewriter, and then to our first computer. Then we ended up with speech recognition. We'd read along to make sure we caught everything, cleaned it up, made sure it was accurate and everything was spelled correctly, and then that was the final product. So basically we were the gatekeeper, making sure everything was pretty and nice and correct. Then we went to physician documentation, and my role was to create the templates that the doctors used and set them up to gather all the information that was needed to make the record complete for coding and other purposes.
I miss doing transcription. It was always a challenge. I learned something new every day and I enjoyed it very much. And I know the doctors really appreciated the quality of work that we put out. That's really rewarding, providing a product that's correct and accurate and readable, and even though we weren't providing direct patient care, we were that checkpoint to make sure it was accurate.
From your perspective, what are the challenges of health information management?
Accurate and adequate documentation. For the coders to do their job, they need to have specific items within a document in order to assess the appropriate level of care that the provider provides. And so if they miss one of those pieces, it lowers the level of care value.
What would you consider the rewards of working in health information management?
I work with an absolutely fabulous team. Everybody is so positive and upbeat. We have a real cohesiveness and it's fun to go to work. It's neat to watch my younger teammates grow in their careers. To see people grow and learn new things. Health information management is not static. That's for sure. It's ever changing. And it keeps changing.
What qualities does it take to do well in HIM? Is humor important?
Oh, yeah. When we're reviewing charts, some of these things are pretty sad. And if you don't have a sense of humor to balance that sadness, you're going to be in trouble.
I would think attention to detail is important.
Yes! You have to really be on it, and don't be afraid to ask questions to find out what's going on.
Working in HIM, seeing all this patient information you have, you have to be a trustworthy group. You have to keep things confidential.
Let's put it this way. My husband quit asking me, "How was your day at work?" Because I couldn't tell him.
You were here when HIPAA laws went into effect. Was that a big change in how you did things?
No, because we already worked hard to protect our patients' privacy. Prior to HIPAA, if you had a friend who was admitted to the hospital, they'd say "Come by and see me." So, I've explained to people, "I'm trying to respect your privacy." You have to be very careful. I'm not on Facebook anymore, but when I was, I never said anything about anybody that I saw in the hospital. You just can't. It's a fine line of working in a healthcare facility and being a member of a community; it can be difficult at times.