© 2014 White Paper: HIT Standards for HIM Practices Anna Orlova, Lisa Spellman Diana Warner, Harry Rhodes

Problem Currently, it is unclear how information management (HIM) practices in healthcare organizations are supported by capabilities of health information systems (HIS) to carry out these practices. It is also unclear if current IHE profiles support necessary HIS capabilities for HIM practices.

IHE Universe 1.People – Profile Specifiers (vendors, professional associations, HIS implementers) 2.IHE Committees where the Profiles are specified 3.IHE efforts are aimed to data/systems interoperability in the healthcare domains(examples) – ITI – Radiology – Cardiology – Other 4.Health Information Systems (HIS) that implement IHE profiles

HIM Practices Universe 1.People – HIM Professionals (coders, record managers, HIS implementers, HIS users (MDs and other clinicians), data analysts) 2.Healthcare Organizations where HIM activities are performed 3.HIM Practices are aimed to the Clinical Documentation Improvement (CDI)(examples) – Data coding – Clinical documentation (records) management (Data Capture, Data/Record Quality Validation, Record Management (Matching, Maintenance, Compliance, Archiving, Retention, Disposition)) – Data use to inform/support clinical practice – Data analysis – eDiscovery 4.Health Information Systems - HIS - that support HIM practices

HIM and IHE Universes Amalgamation Health Information Systems should support HIM practices HIM practices should inform IHE Profile Specifiers Health Information Systems built based on the IHE Profiles should support HIM practices

HIM and IHE Universes Amalgamation Examples of Current IHE Profiles That Support HIM Practices

IHE Universe – ITI XDS Profiles Family Cross-Enterprise Document Sharing (XDS) Profiles Family enables a number of healthcare delivery organizations belonging to an XDS Affinity Domain (e.g., a community of care) to cooperate in the care of a patient by sharing clinical records in the form of documents as they proceed with their patients’ care delivery activities. This profile is based upon ebXML Registry standards and SOAP. It describes the configuration of an ebXML Registry in sufficient detail to support Cross Enterprise Document Sharing. Integrating the Healthcare Enterprise (IHE). Information Technology Infrastructure (ITI) Technical Framework (TF). Cross-Enterprise Document Sharing (XDS) Integration Profile.URL:

IHE Universe – Information Technology Infrastructure (ITI) Technical Framework Integrating the Healthcare Enterprise (IHE). Information Technology Infrastructure (ITI) Technical Framework (TF). URL:

IHE Universe – Information Technology Infrastructure (ITI) Technical Framework Integrating the Healthcare Enterprise (IHE). Information Technology Infrastructure (ITI) Technical Framework (TF). URL: HIM

IHE Universe – ITI XDW Profile The Cross-Enterprise Document Workflow (XDW) Integration Profile enables participants in a multi-organizational environment to manage and track the tasks related to patient-centric workflows as the systems hosting workflow management applications coordinate their activities for the health professionals and patients they support. XDW builds upon the sharing of health documents provided by other IHE profiles such as XDS, adding the means to associate documents conveying clinical facts to a patient-specific workflow. XDW provides a common interoperability infrastructure upon which a wide range of specific workflow definitions may be supported. It is designed to support the complexity of health services delivery with flexibility to adapt as workflows evolve. Integrating the Healthcare Enterprise (IHE). Information Technology Infrastructure (ITI) Technical Framework (TF). Cross-Enterprise Document Workflow (XDW). T rial Implementation URL:

IHE Universe – ITI XDW Profile Integrating the Healthcare Enterprise (IHE). Information Technology Infrastructure (ITI) Technical Framework (TF). Cross- Enterprise Document Workflow (XDW). T rial Implementation URL:

IHE Universe – ITI XDW Profile Integrating the Healthcare Enterprise (IHE). Information Technology Infrastructure (ITI) Technical Framework (TF). Cross- Enterprise Document Workflow (XDW). T rial Implementation URL: HIM

IHE Universe – Radiology Domain The Scheduled Workflow (SWF) Integration Profile establishes the continuity and integrity of basic departmental imaging data acquired in an environment where examinations are generally being ordered. It specifies a number of transactions that maintain the consistency of patient and ordering information as well as defining the scheduling and imaging acquisition procedure steps. This profile also makes it possible to determine whether images and other evidence objects associated with a particular performed procedure step have been stored (archived) and are available to enable subsequent workflow steps, such as reporting. It may also provide central coordination of the completion of processing and reporting steps as well as notification of appointments to the Order Placer. Integrating the Healthcare Enterprise (IHE). Radiology Technical Framework (TF). Scheduled Workflow (SWF) Integration Profile. URL:

IHE Universe – Radiology Domain Integrating the Healthcare Enterprise (IHE). Radiology Technical Framework (TF). Scheduled Workflow (SWF) Integration Profile. URL: IHE Scheduled Workflow (SWF) Profile

IHE Universe – Radiology Domain Integrating the Healthcare Enterprise (IHE). Radiology Technical Framework (TF). Scheduled Workflow (SWF) Integration Profile. URL: IHE Scheduled Workflow (SWF) Profile HIM

IHE Universe – Cardiology Domain The Evidence Documents Profile defines ways for data recorded in the course of carrying out a procedure step, such as observations, measurements, and results (i.e., evidence documents), to be output by devices, such as acquisition systems and other workstations; to be stored and managed by archival systems; and to be retrieved and presented or used by display and reporting systems. This allows detailed non-image information, such as measurements, CAD results, procedure logs, etc. to be made available as input to the process of generating a clinical Report, either as additional evidence for the reporting physician, or in some cases for selected items in the Evidence Document to be included in the report. Integrating the Healthcare Enterprise (IHE). Radiology Technical Framework (TF). Scheduled Workflow (SWF) Integration Profile. URL: hhttp://ihe.net/uploadedFiles/Documents/Cardiology/IHE_CARD_TF_Vol1.pdf

IHE Universe – Cardiology Domain Integrating the Healthcare Enterprise (IHE). Radiology Technical Framework (TF). Scheduled Workflow (SWF) Integration Profile. URL:

IHE Universe – Cardiology Domain Integrating the Healthcare Enterprise (IHE). Radiology Technical Framework (TF). Scheduled Workflow (SWF) Integration Profile. URL: HIM

HIM Universe HIM Universe is Ruled by Information Governance

Information Governance (IG) in Healthcare Technology advances – devices, telemedicine, mobile, patient generated data Data and information growth Systems* implemented without Governance and without needed “rules of the road”** for functioning in digital environment * EHRs, ERPs, other clinical and non-clinical systems **principles, standards, definitions, protocols, guidelines Source: D. Green. Presentation at Health Data Palooza, June 2014

“Recognized as a healthcare imperative, information governance (IG) establishes the policy- level rules, investment priorities and accountabilities for managing the lifecycle of information.” Cohasset Associates | AHIMA 2014 “Information Governance in Healthcare – A Call to Adopt Information Governance Practices”. For healthcare, like other industries, adopting IG underscores the value of information as an asset essential for advancing the goals and priorities of the organization. In healthcare - information is necessary… for safe, quality and effective care of individuals, for reducing per capita costs of healthcare which requires operational excellence, and for improving the health of population(s) Information management and control is an undeniable healthcare imperative. For healthcare, like other industries, adopting IG underscores the value of information as an asset essential for advancing the goals and priorities of the organization. In healthcare - information is necessary… for safe, quality and effective care of individuals, for reducing per capita costs of healthcare which requires operational excellence, and for improving the health of population(s) Information management and control is an undeniable healthcare imperative. Information Governance Source: D. Green. Presentation at Health Data Palooza, June 2014

Information Governance in Healthcare: First Benchmarking Survey – White Paper White paper available now: IGwhitepaper White paper available now: IGwhitepaper Cohasset Associates | AHIMA 2014 “Information Governance in Healthcare – A Call to Adopt Information Governance Practices”. Source: D. Green. Presentation at Health Data Palooza, June 2014

Information Governance in the US: Examples beyond HIPAA K. Baldwin-Stried Reich. E-Discovery in Healthcare – A Crucial Role for HIM Professionals in the Information Governance Era. Presentation at ILHIMA Annual Meeting. Tinley Park IL, March 28, 2014

Information Governance in the US: Examples beyond HIPAA K. Baldwin-Stried Reich. E-Discovery in Healthcare – A Crucial Role for HIM Professionals in the Information Governance Era. Presentation at ILHIMA Annual Meeting. Tinley Park IL, March 28, 2014

Information Governance: Examples K. Baldwin-Stried Reich. E-Discovery in Healthcare – A Crucial Role for HIM Professionals in the Information Governance Era. Presentation at ILHIMA Annual Meeting. Tinley Park IL, March 28, 2014

The White Paper Objectives 1.Explain/model the relationship between HIM practices (clinical-HIM workflow, HIM activities checklist) and capabilities of HIS products to support these practices 2.Conduct a gap analysis between HIM practices and existing IHE and other HIT standards for HIS aimed to support HIM practices 3.Create the roadmap for the development of new IHE profiles to support HIM practices 4.Inform IHE development process by defining Profile Specifier checklist alligned with the HIM practices checklist

Efforts To Date #=8#=? 2014 AHIMA IG White Paper, 2014 AHIMA HIM Principles Taskforce Report (to be developed) IG Principle HIM Principles Information Governance Principles*: 1.Accountability 2.Transparency 3.Integrity 4.Protection 5.Compliance 6.Availability 7.Retention 8.Disposition * American Record Management Association (ARMA). Generally Accepted Record Management Principles. Information Governance Maturity Model. 2013

Needed Efforts

Needed Efforts- White Paper Scope

Use Cases #=8#=? 2014 AHIMA IG White Paper, 2014 AHIMA HIM Principles Taskforce Report (to be developed) IG Principle HIM Principles Information Governance Principles*: 1.Accountability 2.Transparency 3.Integrity 4.Protection 5.Compliance 6.Availability 7.Retention 8.Disposition * American Record Management Association (ARMA). Generally Accepted Record Management Principles. Information Governance Maturity Model. 2013

Use Cases #=8#=? 2014 AHIMA IG White Paper, 2014 AHIMA HIM Principles Taskforce Report (to be developed) IG Principle HIM Principles Information Governance Principles*: 1.Accountability 2.Transparency 3.Integrity 4.Protection 5.Compliance 6.Availability 7.Retention 8.Disposition * American Record Management Association (ARMA). Generally Accepted Record Management Principles. Information Governance Maturity Model Use Case 1

Use Cases #=8#=? 2014 AHIMA IG White Paper, 2014 AHIMA HIM Principles Taskforce Report (to be developed) IG Principle HIM Principles Information Governance Principles*: 1.Accountability 2.Transparency 3.Integrity 4.Protection 5.Compliance 6.Availability 7.Retention 8.Disposition * American Record Management Association (ARMA). Generally Accepted Record Management Principles. Information Governance Maturity Model Use Case 2 Use Case 1

Use Case 1: Standards for Record’s State(s) Medical records states from ARMA Model: (6) Availability (7) Retention (8) Disposition Activities 1.Select one of these record states based on priorities (e.g., record lifecycle model, other) 2.Develop HIM action checklist(s) by state(s) 3.Conduct IHE and other HIT standards gap analysis for the selected record state 4.Develop a roadmap for IHE standards development by record state

Use Case 2: Standards for State Attribute(s) Medical records states and states’ attributes from ARMA Model: (6) Availability (7) Retention (8) Disposition Activities 1.Select an attribute(s) for a record’s state (e.g., protection, integrity) based on priorities (e.g., lifecycle model, stakeholder value, other) 2.Model the attribute in the record lifecycle and information exchanges between systems 3.Conduct IHE and other HIT standards gap analysis for the selected attribute(s) 4.Develop a roadmap for IHE standards development by attribute (s) (1) Accountability (2) Transparency (3) Integrity (4) Protection (5) Compliance

Systems The White Paper will apply to a variety of HIS: Electronic Health Record Systems (EHRs) Laboratory Information Management Systems (LIMS) Pharmacy Public Health Research Personal Electronic Health Record Systems (PEHRs) Note: Originally we will focus on EHRs

Systems: Record Lifecycle * HL7 EHR Lifecycle Model Release 1, Draft Standard for Trial Use. 27 January 2008 Record Lifecycle Model*

Systems: Document Sharing/Exchange HIE System 2System 1

Record Building/Sharing Environment* Clinical Encounter Records/Documents Flow Patient Registration Chief Complaint Orders Test Results Diagnosis & Care Plan IHE XDW, SWF, Cardiology Profiles IHE XDW, SWF, Cardiology Profiles CCD Prescriptions HIM P R A C T I C E S* HIM P R A C T I C E S* HIM CCD *HL7 EHR Lifecycle Model Release 1, Draft Standard for Trial Use. 27 January 2008

Standards 1.AHIMA Information Governance Principles for Healthcare, September AHIMA First Information Governance Benchmarking White Paper, May Cohasset Associates | AHIMA 2014 Information Governance in Healthcare: Benchmarking White Paper. URL: 2.AHIMA Information Governance Principles for Healthcare (IGPHC). URL: HIM Business Standards

Standards * HL7 EHR Lifecycle Model Release 1, Draft Standard for Trial Use. 27 January 2008 Record Lifecycle Model*

Standards ISO Technical Committee (TC) 215 Health Informatics

Standards IHE ITI URL:

Standards IHE ITI Development Cycle URL:

Discussed with Experts (by country) 1.Trish Williams (Australia, IHE) 2.Vincent McCauley (Australia, IHE) 3.Grant Gillis (Canada, COACH) 4.Mike Nusbaum (Canada, IHE) 5.Don Newsham (Canada, JIC) 6.Charles Parisot (France, GE, IHE) 7.Jeremy Thorp (UK, NHS) 8.Harry Solomon (USA, DICOM)

Commitment 1.Two AHIMA Staff persons (Harry Rhodes and Diana Warner) 2.SMEs: a.AHIMA Practice Councils, HIM Advisory Panel, HIM Standards Task Force b.Healthcare Organizations (AHIMA alliance groups) 3.We need ITI Expert(s) to assist with modeling and ITI standards gap analysis such as Karen Witting, John Moehrke, Charles Parisot, Mike Nusbaum