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6 emerging responsibilities for HIM professionals in a digital era
Clinical documentation is still one of the key responsibilities for health information professionals. But digital documentation and new patient payment models are rapidly changing the landscape for HIM. To be meaningful, documentation must be accurate, timely and reflect the scope of services provided. But new payment approaches—such as value-based care and risk-based contracts—place new pressure on HIM pros to change to help their organizations achieve new incentives. The American Health Information Management Association, representing HIM professionals in the industry, list these challenges facing their members today.
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Accurately tracking patient status
Successful clinical documentation programs facilitate the accurate representation of a patient's clinical status--that information then must be translated into coded data. The data then is translated into coded processes such as quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. Nowadays, it's crucial to better track patients as they move among various care sites in ever-expanding integrated delivery systems.
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Improving clinical documentation
The convergence of clinical, documentation and coding processes is vital to a healthy revenue cycle and more important, to a healthy patient. Clinical documentation improvement, or CDI, has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later time. CDI efforts frequently rely on clinician involvement and support, and gaining that backing has been more challenging in the digital era.
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Understanding changing rules and regulations
HIM professionals also are familiar with documentation rules and regulations, and with accreditation standards affecting documentation. These frequently change, requiring ongoing attention to regulatory requirements.
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Protecting patient confidentiality
Other HIM skills areas such as privacy, security and confidentiality also impacts the sharing of clinical information. This continues to shift, as more patient information is maintained in digital records. To ensure patient records aren’t breached, HIM professionals now work more closely with information security executives and personnel.
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Identifying gaps in documentation
HIM professionals and nurses typically have strong clinical backgrounds that help them identify gaps in the clinical evidence and documentation. Electronic documentation adds new challenges and nuances to the role, and even though coding software can provide support, human intervention is still crucial for HIM staff to do their jobs effectively.
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Committing to ongoing professional growth
A program to improve clinical documentation includes people, processes and technology that work together. Providers need a well-rounded individual who can effectively articulate all of the pieces, including documentation requirements, code assignment, coding guidelines and quality reporting. CDI professionals come from a variety of backgrounds, most often from a HIM or nursing position. These pros need ongoing education that helps keep them familiar with documentation rules and regulations, as well as accreditation standards that affect timely documentation.