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A look at: Health Information Management

At times, Lisa Lickey feels like a detective.

A patient will call Yale New Haven’s Health Information Management (HIM) department seeking details on a procedure performed at one of YNHHS’ hospitals, or the name of a medication they were prescribed during an outpatient visit. 

“Sometimes, trying to find what the patient needs is like solving a mystery,” said Lickey, a release of information technician with HIM. “Most patients don’t know medical terminology, so we’re not always speaking the same language.”

This kind of investigative work is part of what makes working in HIM so interesting, said Lickey, who is a certified medical assistant. 

Every day, she and more than 120 other HIM employees scrutinize, analyze and organize countless pieces of information – much of it critical to providing safe, high-quality patient care. 

“We are behind the scenes, but front and center,” said Sabrena Gregrich, HIM director. “Everything we do affects patient care at some level.”

HIM works closely with clinical areas throughout the health system, along with Corporate Compliance, Information Technology Services, Accreditation and Regulatory Affairs, Legal and Risk Services, Patient Relations and other departments. 

HIM staff perform a wide variety of functions, but the department’s main areas are Patient Identity, Release of Information Services, Documentation Integrity and Document Imaging. These areas frequently collaborate to ensure information is complete and accurate, and that services supporting clinical care and patients are coordinated. 

“There’s a lot of teamwork among all of us in HIM,” said Sylvia Stoudmire, a Document Imaging quality specialist.

Here’s an overview of HIM’s areas and some of their major functions:

Document Imaging: Most of YNHHS’ health information is now digital, but there is still “quite a bit” on paper, Gregrich said. HIM staff work with patient care areas to ensure clinically relevant documents are transmitted to HIM and uploaded to Epic to support patient care. Document Imaging staff also round on departments throughout the health system to collect other, non-clinically relevant documents for upload after patient discharge. This team supports the Smilow Cancer Care Centers, urology practices and other outpatient service lines, and is involved in a pilot program to centralize document imaging for Northeast Medical Group. A key component of their work to support physician practice groups is uploading external results and routing them to providers. In addition, Document Imaging plays an important role in Yale New Haven Hospital earning Health Level Seven (HL7) certification, which requires that all clinically relevant documentation be available in Epic within 24 hours. HL7 designates healthcare organizations that meet international standards for transferring and sharing data between various providers. This is a significant effort across YNHHS; the health system is pursuing HL7 certification in the fall.

Documentation Integrity staff help ensure patients’ health records include complete, accurate and timely information. They focus on medical staff requirements, which must comply with The Joint Commission, Centers for Medicare and Medicaid Services and medical staff bylaws. In reviewing documentation, Documentation Integrity staff look for medical history and physical exams, procedure notes, consultations, emergency provider notes, discharge summaries and timely signing of physician orders. More recently, this team began supporting Rehabilitation Services and YNHHS’ Home Health enterprise. Team members also support patients’ requests for amendments of their medical records, which must comply with HIPAA regulations. When a request is submitted, Documentation Integrity staff search all medical records entries that are subject to the requested amendment. These searches can span more than 100 visits and involve multiple providers. In addition, Documentation Integrity staff set up and assist providers with YNHHS’ dictation systems, and produce case lists for physicians for their boards and/or credentialing outside of YNHHS.

HIM facilitates the multidisciplinary System Medical Record Forms Committee, which standardizes forms across YNHHS. This committee meets monthly to review and approve new and revised forms – such as consent for procedures – to be included in the patient’s legal health record. Many of these forms must meet government, regulatory and legal requirements, which change frequently. The team also works closely with Translation Services to ensure patient-facing medical record forms are translated into multiple languages. COVID-19 brought additional forms challenges. 

“The health system needed to expedite approval and translation of COVID-related forms, including vaccination consents, with delivery to support test centers across the region, sometimes overnight,” said Donna Russo, payer audit coordinator, who leads the committee. 

Release of Information (ROI) provides centralized services for the health system’s five hospitals, Northeast Medical Group and Yale Medicine. ROI is the area most members of the public interact with when they request their medical records; and the team prioritizes these requests to ensure patients have what they need when they need it. The team must adhere to a variety of state and federal laws when releasing medical records for continuity of care, disability, insurance, travel, regulatory, legal proceedings, research and other reasons. ROI also works closely with YNHHS’ Accreditation and Regulatory Affairs to provide on-site survey and audit support for entities such as the Department of Public Health and Joint Commission. Additionally, ROI provides components of the legal health record to support specialized clinical services’ certification or re-certification. ROI staffs’ challenges include extracting data from the many systems containing medical information, including numerous legacy systems. Change is a constant in this field.

“I’ve had to be very adaptable,” said Annette Apuzzo, an ROI technician for nearly 30 years, including 10 at YNHHS. “I learn something new every day.” 

The Patient Identity team’s duties include ensuring each patient has one record in Epic containing the correct name, date of birth and other information. The team fixes issues such as duplicate medical records, erroneous charting entries and unidentified and alias patients. Staff members proactively investigate and update patients’ expired status and help prevent and spot patient identity theft. This team also plays a key role in helping patients access and use MyChart. 

“We handled thousands of calls during COVID-19, getting people enrolled in MyChart so they could participate in telehealth visits with their providers,” said Maria Michelangelo, Patient Identity manager.  

Despite the amount of information and level of detail they deal with every day, HIM staff members said their work is rarely dull. 

“We need to be flexible and adapt to different situations,” Gregrich said. “There’s nothing status quo about health information management.”