How Teamwork Fuels Award Winning Health Information Management

At the core of any meaningful healthcare intervention is medical data. A patient’s health history, prescription information, and demographic data are the building blocks of quality care delivery, leading to better patient outcomes and improved population health. 

However, turning these many sources of data into actionable clinical information requires strong data governance and health information management practices. While the industry’s digital shift has aimed to improve these processes, the transition from paper to electronic records has also brought several well-documented challenges for providers and health systems. 

From incompatible EHR systems and complicated, unintuitive interfaces, to time and money constraints, the introduction of technology to the medical field has made health information management (HIM) a daunting task.

At Hospital Sisters Health System (HSHS), a Wisconsin-based healthcare organization, leaders understand that communication can play a critical role in overcoming these challenges and can improve HIM practices. 

HSHS recently received the AHIMA Grace Award for excellence in HIM, an honor that Jodi Kaftan, HIM and clinical documentation integrity director for HSHS’s Eastern Wisconsin Division, credits to inter-departmental collaboration. 

“I think that a lot of Eastern Wisconsin Division's success can be attributed to the fact that we work so well together. We're willing to listen to each other,” said Kaftan. 

“We're willing to evaluate how a certain technology will impact providers’ daily tasks. We ask ourselves, what does this technology mean for the physician, for the nurse, for the other clinical support teams? And then on the back end, what does it mean for HIM and making sure that patients’ records are as accurate and thorough as possible?”

AHIMA recognized HSHS for its efforts to use data to meet patient needs. The organization leveraged patients’ demographic data to increase the number of ICU rooms, increase X-ray capacity, open an intermediate care unit, and expand their specialty services.

“Demographic data has been instrumental in helping us identify what is needed and where,” said Kaftan. “We implemented wound center services in our northern-most hospital, because the demographics showed that we could better serve our patients by having those services there.”

In addition to identifying trends in demographic data, HSHS was able to create an inpatient clinical dashboard, helping providers track patients’ status in real time, as well as develop an electronic query process that allows providers to answer patients’ questions. 

HIM professionals at HSHS helped facilitate these improvements by educating providers and other administrative staff on HIM best practices, initiating conversations around best practices, and by serving as resources for their colleagues.

“Our IT team, as well as all the departments within our hospitals, are really willing to come to the table and have the conversation,” Kaftan stated. “Our saying is if it wasn't documented, it didn't happen. We help providers find the tools to appropriately document everything that’s critical for patient care.”

“We have leaders who will support implementation and communicate with physicians to help them understand how these tools will impact their day-to-day. We also have a group that comes together every month, where we look at the data and we walk through it to figure out what it’s telling us. How can we use this data to help us make better decisions?”

To ensure that all technology is intuitive and easy to use, Kaftan noted that her team collaborates with providers and chooses the systems that optimize clinician workflows. 

“We really take the time to vet tools and look at them together. We try to find the technology that is going to help the provider deliver the highest quality and safest care. When there are decisions to be made, we come together and say, ‘what is the ultimate goal here?’ We make sure that everybody who has a stake in it shares their input,” she said.

Major players across the industry have found that this is the best way for organizations to make sure that their tools are safe and intuitive. A July 2018 study from MedStar Health and the American Medical Association (AMA) noted that health IT developers and providers should work together to define workflow and implementation strategies to enhance EHR usability and safety. 

Other research has shown that consistently collecting feedback from end-users can improve software usability, especially when developers integrate new specialty functions into an EHR. 

While communication is a big part of HSHS’s HIM strategy, Kaftan noted that the team doesn’t just stop there. 

“We're constantly looking at what we need to do next to improve patient care and patient safety. We have a lot of discussions and we do a lot of problem-solving, but beyond that we implement software and we move things forward,” she said. 

One of the ways the organization has actively advanced HIM is by giving patients access to their health information through Epic MyChart. The patient portal allows users to review their medical data and talk to their providers about any concerns they may have. 

“Using MyChart, patients have their information in a timely manner. They can communicate with their providers more quickly. We’ve started implementing health history, physicals, consult notes, and discharge summaries after the visits into my chart so the patient can go home and see the information again,” Kaftan said.

“Sometimes, when you're with your physician, you're not listening as clearly as you would like to, because you're worried about what you're hearing. Now, patients can either communicate back to their providers to say, ‘I have some additional questions.’ Or they can read it and say, ‘Okay, I understand that.’ They can be more actively involved in their personal care.”

Kaftan noted that HSHS’s achievements in HIM wouldn’t be possible without the efforts of the whole organization. 

“This is an award for the entire division, because were it not for those other departments, we couldn’t do all of it. We facilitate the conversation and the problem solving, but it had to be a team effort,” she concluded.

“For me, this award tells patients that we're conscientious about their medical record information, and that we’re working to make care better and safer.”