HIM’s Value with EHR Implementations
LTC facilities and senior living communities are at various stages of EHR adoption. HIM professionals can offer leadership and
support in the planning, implementation, and ongoing maintenance of EHRs and other health information technologies.
While the EHR brings new variables to heath record management, the foundation of information management remains the
same: health records and information must comply with regulations, accreditation, professional practice, and legal standards,
and they must be complete, timely, accurate, readily accessible,
and protected.
As with other healthcare sectors, LTC has been burdened with
the false perception that an EHR eliminates the need for HIM
services and functions. While the elimination of the paper record changes the HIM department and its functions, deploying and maintaining an EHR requires professionals with higher
technical skills.
Healthcare organizations that have implemented EHRs have
found that clerical roles and staff are eliminated and more educated, technically advanced staff are required to perform HIM
functions. Early EHR adopters in LTC are also finding this to be
the case.
Due to the complexities in maintaining and managing EHRs,
HIM positions in LTC can no longer be staffed with untrained
clerical staff or nursing assistants. In order to maintain quality
health information systems, properly trained staff and allocation of resources for education and ongoing training are necessary.
Appendix A, available in the online version of this practice
brief, provides a comprehensive description of the HIM roles
and functions in LTC (see the AHIMA Body of Knowledge at
www.ahima.org).
New Roles for HIM with the EHR
HIM responsibilities are increasing as more LTC facilities adopt
EHRs. Due to limited funds and resources, as well as the corporate structure, LTC facilities often lack on-site IT support
services. Lack of on-site support increases user frustration and
disrupts workflow processes, hampering the effectiveness of the
EHR.
HIM professionals are taking on the following new tasks in
LTC to provide user support and health IT management:
x Performing workflow analysis and redesign
x Coordinating system updates and downtime procedures
x Supporting users and providing on-site IT troubleshooting
x Managing system access and security
x Monitoring and continuously improving data quality and
data integrity
x Planning, evaluating, and selecting new technology with a
leadership team
x Leading and managing EHR implementations
x Optimizing, streamlining, and coordinating multisystem
integration and interface for continuity of data across mul-
tiple systems within an organization
x Training staff on how to use the EHR
x Leading EHR governance processes, policies, procedures,
HIM services can support implementation and maintenance
of the EHR by serving as the internal go-to person to support all
users with issues related to timeliness, accuracy, retention, se-
curity, access, and data integrity. The HIM professional’s skill set
and the organization’s complexity will dictate the exact nature
of the new roles and functions. At a minimum HIM profession-
als must be part of the EHR implementation team and establish
EHR governance and management processes.
Changes in Traditional LTC HIM Functions with the
EHR
Many of the qualities needed to manage the paper medical record are the same qualities required to manage the EHR. Attention to detail; ability to organize data and ensure data accuracy;
data reporting; evaluating, understanding, and interpreting regulatory standards; and the many other skills that HIM professionals possess will be critical to maintaining an accurate and
functional EHR. 6
Some of the basic HIM functions may remain the same with
the implementation of EHR; however, the process to complete
the functions will change. As described below, traditional HIM
functions will be redefined, leveraging the HIM skill set to facilitate the transition from a paper-based process to EHRs: 7
Master resident index. HIM staff members can assist in researching how to positively identify patients at the time of registration and import photographs to reduce duplicate registrations. They can monitor assigned medical record numbers and
amend source documents with the accurate number when applicable.
HIM professionals also can address index integrity issues such
as duplicates, aliases, and proper identity processes for HIE activities.
Record assembly. In lieu of assembling the hard-copy chart,
HIM staff will be redeployed to review EHR documentation, facilitate completion of outstanding data, monitor completion of
data and records on admission (concurrently and discharge),
and scan and index paper documents received from outside
providers.
Auditing. While some auditing processes will be automated
by internal flags such as unsigned reports, unreviewed lab, or
special reports or missing reports, HIM staff will still assume
responsibility for ensuring the information is tracked and com-
