By Lorraine Fernandes, RHIA, Kerryn Butler-Henderson, PhD, FAIDH, FHIMAA, Marci MacDonald, CHIM
On March 11, 2020 the World Health Organization (WHO) declared COVID-19 a pandemic. This inspired the International Federation of Health Information Management Associations (IFHIMA) to explore how this catastrophic event was impacting the work life of HIM professionals. Between March 19 and April 11, IFHIMA conducted a survey of its membership who are representative of the WHO regions, including Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific. The survey results represent the early days of the pandemic and IFHIMA anticipates conducting a similar survey when COVID-19 has lessened.
IFHIMA, a nongovernmental organization in official relations with the WHO, is committed to the global advancement of health information management (HIM) practices. IFHIMA’s vision is “a healthy world enabled by quality health information.” Its international reach provides an opportunity to gather information globally.
HIM professionals are the data custodians and stewards responsible for the management of health information within any setting where healthcare is delivered. When the WHO declared COVID-19 a pandemic a hidden consequence was the massive challenge for healthcare organization to capture and manage the large volume of data created during this challenging time.
This data became critical, not only to the management of individual patient care, but to inform the epidemiological efforts to monitor the outbreak nationally and globally. Reports from HIM professionals around the globe, which are explored in this article, indicated they were the hidden workforce working alongside the clinical counterparts at the care delivery sites to assist in efforts to manage the growing crisis.
The survey response was enthusiastic and indicates some quite dramatic changes to HIM work life even in the early days of the pandemic, with implications for the short and long term. Observations and data from this survey validates the importance of data and privacy for IFHIMA and the profession it supports. Further, the importance of managing information privacy, data integrity, rapid technology adoption, and the behavioral aspects of rapid change were made clear by the survey respondents. The result of our IFHIMA COVID-19 Survey are detailed in this article and a companion webcast.
Demographic Representation of Respondents
Responses were received from 180 individuals representing the six WHO regions:
- 7% Western Pacific
- 7% Americas
- 9% Europe and Eastern Mediterranean (aggregated)
- 9% South-East Asia
- 8% Africa
Breakdown of respondents by their work location:
- 3% Hospital
- 3% Government
- 3% Education
- 2% Vendor/Consultant
- 9% Primary Health Care
- 9% Non-profit organizations or none
HIM roles are ordinarily undertaken on site and involve health data and information management, maintaining privacy of personal information, stewardship, data reporting, system implementation, management and training, and clinical coding. Pre-COVID-19, 83.9 percent reported they worked in an office, whether that be in a hospital, government, or university setting.
COVID-19 presented several challenges for a workforce that is largely operational, hands-on, and working both front and back of house. As information needs changed, reporting requirements intensified.
In the US, 86 percent of physicians are using an electronic medical record and 96 percent of hospitals nationwide use an electronic record. However, a high percentage of organizations in countries around the world still capture information on paper, locking HIM to the physical workplace.
A recent study in the Journal of Applied Learning & Teaching suggests the differences in the education setting may be the result of the slower transition to online learning in countries not yet impacted by COVID-19.
The level of impact and change in the HIM roles was minimal in countries where COVID-19 was not yet prevalent, compared to countries where COVID-19 was widespread. Similarly, the way the roles changed varied by region, as shown in Table 1 below. Countries in South East-Asia and Europe reported functions were not primarily conducted virtually and functions included previously out-of-scope tasks. Countries in Africa reported they were now doing COVID-19 related operational tasks, such as registrations and screening. And at the time of the survey, countries in the regions of Americas, Eastern Mediterranean, and Western Pacific were in a transition period, with some countries reporting they were moving towards roles as seen in South East-Asia and Europe, whereas others were still business as usual. This reflects the progression of the disease across the globe.
|TABLE 1: Changes in HIM Practices Related to COVID-19|
|In the past week have your business operations changed?|
|Africa||Americas||Eastern Mediterranean||Europe||South-East Asia||Western Pacific|
|No, It’s business as usual||0%||23.08%||33.33%||0%||28.57%||36.84%|
|No, it’s business as usual, but at an accelerated rate with less staff||0%||3.85%||0%||0%||0%||14.91%|
|Yes, most or all functions are now conducted remotely/virtually||0.00%||57.69%||0%||0%||42.86%||39.47%|
|Yes, staff doing other functions such as registration, screening||100%||15.38%||33.33%||0%||14.29%||6.14%|
|Yes, staff helping with privacy management, data analysis, tracking, coding, and other areas not previously within our scope||0%||0%||33.33%||100%||14.29%||2.63%|
The data is best summarized by a comment from a South East-Asia respondent, “the COVID-19 pandemic is going to change the work culture and operational aspects to a great extent across all professions including HIM domain; considering a protective and preventive measure to address such situations in future. Working remotely/virtually becomes an integral part of our working system.”
Participants were given two opportunities to share personal impact, key concerns, and advice. Over 200 comments were received with people sharing very rich impact statements and advice. Five themes arose from their narrative input:
- Organizational development and management
The capture and integrity of health data is even more important during a pandemic. The challenges include managing the privacy of data while addressing a public health data focus. Managing privacy sometimes becomes contentious.
An HIM professional from the Western Pacific region shared that “the protection of data is really at the forefront in light of the pandemic. With requests by non-designated people, including researchers (internal and external), who want access to patient data.”
The other side of the data discussion was the need to ensure accuracy, consistency, and integrity of all the data associated with COVID-19. Early data collection decisions sometimes lacked robust governance considerations, thus auditing retrospectively was essential to ensuring that data could be integrated to create a longitudinal record for care, tracing, and research. This was highlighted by an Americas respondent. “There was additional focus on telehealth, with concerns about patient data integrity, especially with correct lab results being attached to the correct patients.”
According to an Eastern Mediterranean government professional, “COVID-19 certainly added tremendous amount of burden on HIM to ensure appropriate data capture, and timely and accurate reporting of facts to support decision making for operational and clinical initiatives and COVID monitoring.”
Technology, or lack of it, had a broad impact on operations and management. Having an electronic health record (EHR) was vital to smoothly and quickly moving staff from an office-based to a virtual work environment. Organizations that didn’t have an EHR either had to keep staff in the care setting or devise a hybrid environment that addressed social distancing, sanitation, and infection control. Several respondents shared that staff actually had to collect paper or scan paper records, which created stress and risk. One Western Pacific respondent noted that “the lack of advice on safe handling practice of paper was an issue, and the advice received was inconsistent.”
Several respondents indicated that they had increased responsibility for assisting in establishing telehealth with the scope varying from designing data capture for a telehealth visit, to auditing the integrity of the telehealth record to meet compliance, finance, and reporting requirements.
Added technology responsibilities ranged from establishing the appropriate data access profiles for staff who moved to a virtual environment or switching access profiles as staff move to new roles.
Survey respondents repeatedly cited the need for clear, consistent communication with staff as well as executive leadership. Rapidly changing direction and the volume of COVID-19 patients created stress and anxiety. “Because the environment is always changing…change management is an important part of the process of recovery. Keep everyone informed and prepare them for any potential changes. Support the team to learn from each other…” This became the mantra from an Americas respondent.
The behavioral impact of suddenly working from home or working in a care setting with disease transmission risk was stressful on a personal level, as well as professional level. Sage advice from a Western Pacific respondent included conducting safety huddles each morning with all staff not only to give updates, but to remind them of basic safety measures: frequent handwashing, self-distancing, wearing masks, and remembering to take precautions upon arriving home, such as, removing clothes and showering to deter virus spread to family, and to provide time to share concerns.
Organizational Development and Management
While management is interwoven to all themes, an Americas HIM director emphasized the importance of “working with other health authorities and organizations to streamline and standardized processes…Be engaged with your peers who are non-HIM and HIM professionals to initiate discussions; dissolve any silos.” Creative approaches to business continuity planning and execution included dividing the department(s) into two team to ensure redundancy and flexibility in staffing.
Challenges and Opportunities
The pandemic created challenges that cannot be immediately addressed with lessons learned for the future planning.
- Lack of an EHR impacts operations, staffing, and limits the flexibility of management
- Junior staff who lack a diverse skillset, who can’t readily be deployed to a new role, are at risk of being furloughed first
- Volume shifts when elective or nonurgent care is closed created risk for furloughs even in high skillset areas
New roles or functions were experienced in every region, including:
- COVID-19 registry design or data auditor
- Contact tracer
- Front-line staff including intake, registration
- Screeners in mobile testing or triage sites
- Design and deployment of telehealth
While this was a COVID-19 survey, the responses reflect the broader issues of future-proofing an organization and the HIM function for any health crisis. “Have a pandemic plan ready that includes what work is essential to service provision to the hospital. Include policy on working from home and letter of agreement that staff can sign that acknowledges that this is a temporary arrangement,” stated a Western Pacific respondent.
Call to Action
The themes, opportunities, and limitations indicate a strong call to action for HIM professionals in our day to day roles, as well as during a pandemic or natural disaster.
Don’t abandon core functions. Release of information, coding, and managing data quality may look a bit different in a pandemic, but they continue to be important and vital to the future use of data.
Ride the data wave. Capturing, managing, auditing, and validating data for all aspects of healthcare is the future. If this isn’t in your realm of comfort, it’s essential to upskill in this area.
Be a Leader. Challenges can create limitations, but they can also create exciting new opportunities. Be ready to step up and break down silos that will impede your career and serve the healthcare community.
An HIM leader from Europe summarized it best, “This crisis has enhanced the HIM role in the hospital as a nuclear department. We have had to rapidly adapt our focus and work out how we can best help the hospital from our position.”
IFHIMA and its members encourage HIM professionals to learn from this crisis and advance the profession by taking a leadership stance in advocating for and assisting in the adoption of an EHR, and by developing a work force that embraces the need for high-quality data. The future of the profession depends on this, as does a healthy world enabled by quality health information.
Lorraine Fernandes, RHIA, is the president of IFHIMA, and principal at Fernandes Healthcare Insights, Bigfork, MT. Kerryn Butler-Henderson, PhD, FAIDH, FHIMAA, is the president-elect of IFHIMA, associate professor of digital health, at the College of Health and Medicine, University of Tasmania, in Tasmania, Australia. Marci MacDonald, CHIM, is the immediate past president and membership chair of IFHIMA, Oakville, Ontario, Canada.
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