copies of their records than patients visiting their physician.
14 In
addition, only 27 percent of patients treated with acupuncture
have a copy of their medical record while almost half of patients
treated by physicians have a copy of their medical record.
Most acupuncture patients feel “somewhat” confident about
asking their acupuncturist for a copy of their health records,
while patients feel “very” confident asking their physician for
their records. All patients appeared to be equally interested in
the information kept in their health records. However, acupuncture patients were more interested in finding out how to obtain
copies of their health records than patients of physicians. These
findings support the need to educate both integrative medicine
practitioners and patients about their rights and responsibilities
with regard to their health information.
The Roles for HIM Professionals
HIM professionals can play several key roles in the standardization of clinical documentation in healthcare systems that impact patient care, research, coding, EHR implementation, and
healthcare planning. HIM professionals can begin by learning
which integrative medicine therapies are provided in the organizations where they work, as well as where the services are
provided. The HIM professional can determine how IM providers are documenting in health records as well as how other
healthcare practitioners who care for the same patients are using the IM documentation. Once HIM professionals have gathered this basic information about the healthcare systems where
they work, they can take some or all of the five following recommended actions:
Educate. HIM professionals can educate physicians, clinicians, and administrators about the importance of standardizing all clinical documentation, including documentation provided by integrative medicine practitioners. There is a need to
develop formats for integrative medicine documentation that
are understandable to all healthcare practitioners as well as
useful to the IM practitioner. These standards should be incorporated into all electronic health record templates.
Rethink practices. Documentation from an integrative practitioner may change some coding practices. For example, is it
legitimate to query a physician based upon clinical documentation provided by a chiropractor, acupuncturist, or naturopathic
doctor? Currently, these opportunities are likely to be more
prevalent in the outpatient setting. However, current research
has shown that IM practices are continuing to be integrated into
inpatient care as well.
Consider capturing codes. HIM professionals may also want
to consider whether it may be a good practice to capture codes
for certain integrative medicine services. Currently CPT provides codes for acupuncture and massage therapy, shown in the
table on page 33. But as research in the area of CAM continues
to be funded by the National Institutes of Health, the need for
more reliable coded data will grow. In addition, ICD- 10 will provide additional opportunities to capture relevant data in both
inpatient and outpatient settings that may involve integrative
medicine therapies. Given the amount of revenue generated by
integrative medicine services, these data are important for both
patient care and healthcare system strategic and budget plans.
Educate patients. One of the HITECH Act’s meaningful use
criteria requires healthcare providers to make electronic copies of patient health information available to patients upon request. Should these records include documentation from integrative medicine professionals, the healthcare system will need
to ensure that both physicians and patients will understand the
documentation. Under HIPAA, patients have the right to ask
for clarification of their health information. That responsibility
often falls to the HIM professional. This is another reason why
standardizing the documentation of these practices is so important.
Look for new roles. In addition to opportunities within current healthcare systems, HIM professionals may find possibilities for employment with independent IM practitioners. There
are about half as many IM practitioners as there are physicians
in the US, but these IM practitioners have not been trained in
the clinical documentation practices common to most healthcare systems. Most have their own methodology for documentation that may not be understood by other practitioners. It is
clear that integrative medicine professionals are in need of HIM
resources. In addition, patients of IM practitioners are in need
of education about their health information rights. There are
54 acupuncture and oriental medicine schools and 97 massage
therapy schools in the US. All of these schools have one or more
clinics where students, under the supervision of licensed practitioners, treat hundreds to thousands of patients weekly. These
schools are a great opportunity for health information professionals to educate and inform the growing cadre of IM practitioners. The school clinics may also be an opportunity for HIM
professionals to provide consultative services.
HIM professionals may want to research integrative medicine treatments for themselves. With up to 92 percent of the US
population receiving some form of IM therapy, it appears to be
worthwhile. Many IM therapies are backed by evidence-based
support, as illustrated in the tables. In general, patients feel that
IM gives them a sense of empowerment, and it appeals to their
holistic approach to health where mind, body, and spirit are interconnected. ¢
Notes
1. SIMUS Survey, State of Integrative Medicine in the U.S. CIMEx Health, 2009. See also the National Center for Complementary and Alternative Medicine housed within the
National Institutes of Health at www.nccam.nih.gov.
2. “What is Integrative Medicine?” University of Arizona
Medical Center. http://integrativemedicine.arizona.edu/
about/ definition.html.
3. Neiberg, R.H., et al. “Occurrence and Co-Occurrence of
Types of Complementary and Alternative Medicine Use
by Age, Gender, Ethnicity, and Education Among Adults in
the United States.” The Journal of Alternative and Comple-
