Data governance: it’s not what you may think it is

In today’s healthcare environment, the subject of data governance is at the top of the list for hospital executives. Within the framework of strategic planning, quality, big data and regulation, your data reflects everything you do: patient care, cost practices and outcomes. In fact, the very sustainability of your organization relies on quality data. Dr. Elliot King, Department of Communication Chair, Loyola University, MD, makes the powerful point that “Data is an organization’s most valuable asset.

Data governance is a proactive process that provides the necessary framework to ensure data can be trusted and that there is clear accountability in place should an adverse event occur as an outcome of poor data quality. This structure is vital in managing the use, monitoring, maintenance and protection of an organization’s data. Without it, you may be missing crucial information needed to align clinical and business goals while reducing risk.

Data governance is not the routine maintenance of your data with oversight by the Information Services/Technology department. Data governance is a commitment organizationally to a process that manages the integrity of data. In turn, there is increased consistency and confidence in clinical and business decision making. There is better organizational planning, data transparency and optimized staff effectiveness through less re-work and decreased risk of regulatory fines.

In 2001, Congress passed The Data Quality Act (also referred to as the Information Quality Act). Embedded within a two-sentence rider was the requirement that the information you provide to any Federal agency must be consistent, of high quality and have data integrity. In other words, you are required by law to provide quality data.

Consider these notable comments:   

  • When asked about the biggest challenges and opportunities associated with the significant influx of data in healthcare, Anil Jain, MD, Vice President with (IBM) Watson Health responded: “The biggest challenges relate to the interoperability of data and then standardizing and cleansing the data.” “Just because you can get the data, that does not mean you can make sense of it.”
  • “Accurately measuring costs and outcomes is the single most powerful lever we have today for transforming the economics of health care” Dr. Robert Kaplan, Emeritus Professor of Leadership Development, Harvard Business School

The American Health Information Management Association (AHIMA) has been a leading authority on health information management since 1928 and was one of four parties responsible for ICD-10 Coding Guidelines as well as a contributor to the AMA’s CPT terminology. Some important AHIMA tenets are that Information Governance (IG) should ensure information is trustworthy, actionable, and aligned with organizational strategy. It is needed for all information, whether it is in electronic or paper form. EHRs are assets. Like other critical assets—people, capital, inventory, etc.—information is a strategic asset that requires high-level oversight in order to effectively use it for organizational decision-making, performance improvement, cost management, and risk mitigation. Information Governance requires a system-wide, multidisciplinary team (clinical, finance, decision support, materials management, risk management, pharmacy & IT) with executive-level sponsorship.  

How “Bad Data” Can Increase Risk

The Controlled Risk Insurance Company (CRICO) is the patient safety and medical malpractice insurer for the Harvard medical community. The Massachusetts-based company has expanded its proprietary coding system to capture EHR-related problems that have contributed to patient harm, and to guide the hospitals, physicians, and other providers it serves toward addressing vulnerabilities in their systems.

Results from a 2013 analysis of 147 medical malpractice cases were found to have an EHR-related contributing factor:

Top Issues in Claims w/EHR factors % Cases
Incorrect Information in the EHR 20%
Hybrid health records/EHR Conversion issues 16%
System failure – electronic routing of data 12%
System failure – unable to access data 10%
Pre-populating/copy & paste 10%
Failure of system design to meet the need 9%
EHR user training/education 7%
Lack of integration/incompatible systems 7%
EHR user error (other than data entry) 7%

These errors can range from faulty data entry (inches vs. centimeters can distort BMI calculation), unexpected automatic data conversions (2.5 becomes 25 impacting medication error), accessing wrong patient file or field, and repeated errors (mistakes that persist in patient records for years). Which EHR vulnerabilities are most troubling? CRICO’s early analysis reveals that incorrect information in the EHR was a factor in 20% of the 147 medical error cases reviewed. Half of the cases resulted in severe injury with $61 million in direct payments and legal expenses. This risk can and should be eliminated.

How Good Data Goes Bad

EHR system conversions are one of the most prevalent sources of data issues. Whenever data from different sources (multiple hospitals, physician office, and outpatient clinics) is merged, the result can be inconsistency, duplication and questionable validity. Data may not be compatible when different systems are linked/interfaced together. Additionally, formal data standards can be old or not consistently applied over time.  Without standards, you may end up with data that can’t be used for accurate comparisons or other analytics.

Deferring ownership of clinical data to IT is all too common; everybody uses data but nobody really knows who “owns” it. Your IT department needs to know how to resolve technical issues with data; don’t assume they know what the content should be. Data content issues fall into the overview of clinical and informatics staff, working hand in hand.

What is Good Data?

Your data must be available and easily accessible. This requires integration to enable all caregivers to see patient data in the right location at the right time while supporting patient care decisions and optimum utilization of resources.

You must have standardization as a bedrock of your data tables/files.

  • Any information that is recorded using free text is not reportable.  
  • Non-standardized procedures, for example, can result in duplicates or incorrect selection while documenting a patient’s surgical procedure. Procedures that cannot be tied to industry standards may introduce insufficient specificity.
  • A recent study published in the Journal of the American Medical Informatics Association found that a lack of standardization of observable markers of diabetes being collected in the EHR resulted in a significant variation from the standards created by the American Diabetes Association to diagnose the disease. The findings point to the need for standardization to avoid confusion among symptoms related to other conditions the patient may have.

Data must be complete. You must be able to show improved outcomes, regardless of the acuity mix of your patients. Data must be consistent. Necessary information is collected for all patients, all the time and data must be accurate.  A single source of truth ensures that each time a data element is used, it means the same thing everywhere it appears.

Introducing Data Governance

The most important point of data governance is to recognize that senior leadership and stakeholders must be engaged to ensure that your data meets the requirements of “good data;” not only within your EHR but also with every other system with which it interacts. Governance means putting a strategy and process in place for the proper proactive management of good data practices.

Some example considerations in the development of a successful strategy for the management of data are:

  • Put audit and validity checkpoints in place to keep your data accurate. Any interaction with humans will generate data errors – your aim is to identify and remediate as part of everyday activities across your hospital/health system.
  • Institute a schedule of routine audits of information that crosses from one system to another to find items that impact accuracy of cost and charge for supplies used during patient care.  Missing supply, implant or pharmacy charge coding and inaccurate mapping to codes can have a significant impact on revenue and case costing analytics.
  • Challenge the content of your reports. “Apples-to-apples” comparisons aren’t always what they seem to be. Do you collect data that does not result in action? If so, why are you collecting it? Can you see your data in real time to allow proactive action to mitigate unplanned barriers to efficiency?
  • Find any free text that can be converted to a standardized list of selections.
  • Review all of the lists of options selected by staff during the documentation process to search for duplicates, missing options and “home grown” areas that need to be updated to today’s clinical and regulatory standards.
  • Ensure that you are meeting all regulatory requirements by examining the data used to report to outside entities.

Introducing and establishing data governance is a challenging endeavor that takes discipline and time. Check out The American Health Management Association for more information.

A Standardized Master Surgical Procedure File – Patient-Centric Care & Revenue Management

The healthcare environment is frenetic with activity around the use of information systems and the ability to generate “big data” for purposes of discrete analysis of performance and cost. More and more health systems are converting to integrated EHR’s that cover the care continuum from the physician’s office to ambulatory or inpatient care facilities to include a portal for patient access to their own health records. Along the continuum is the need to effectively manage the surgical revenue cycle, analyze evidence-based care outcomes, and to publish the cost of delivering that care in an effort to compare results within or across health systems. At the perioperative level is the need to analyze cost and margin at the service line, surgeon and procedure level while contributing to the financial bottom line. In a June 2016 OR Manager article “Make It Your Business to Grow a Healthy Bottom Line”, Keith Siddel, PhDc, JD, MBA, CHC states, “OR leaders can improve the bottom line by managing the revenue cycle, minimizing denials, improving billing and reimbursement, and understanding business models.”

How does a standardized master surgical procedure file relate to patient-centric care and management of the perioperative revenue cycle? One critical piece of reportable information from the perioperative continuum is the surgical procedure description. Over many years of working with clients, we have seen the Master Surgical Procedure File (MPF) pendulum swing in varying degrees of quality from no standardization to rigid standardization. In the earlier days of perioperative clinical information systems, non-standardized procedure files with a high level of customization in descriptions and approach were the norm. The concept of Healthcare Exceptionalism as found in “Advanced Lean in Healthcare” is defined as “the belief that healthcare provision is so unique, complicated, challenging, and regulated that any lessons to be learned from other industries are largely irrelevant.” This resulted in “homegrown” procedure files because each Operating Room believed they were unique and best suited to develop their own list of surgical procedures. Standardized sources were hard to come by.

More recently, comprehensive and integrated clinical information software and the need for standardization has resulted in software vendors offering “starter content” and professional organizations (i.e. AORN) developing procedure lists that are linked, in part, to industry coded sources.

In Non-Standardized lists, we generally observe:

  • Variable “homegrown” sources and descriptions
  • 3rd party sources that are not always all-inclusive & subject to source/software release process
  • Negative impact on system maintenance leading to missing or duplicative procedures
  • Lack of common language to support financial clearance pre-surgery
  • Lack of common language between MD office & hospital schedulers
  • Lack of common language among clinical caregivers
  • Inadequate association of precise resources for each procedure
  • Negative impact on reporting and analysis (“apples-to-apples” comparisons difficult)

In today’s world, a better approach is:

  • To standardize all procedures & descriptions
  • To account for all procedures from the outset in one standardized version (w annual updates)
  • To use a Coded list as the initial source (such as CPT); it offers the basis for ensuring a complete list that shares common clinical language and support for accurate financial pre-clearance
  • To refine coded sources based on an agreed upon methodology to ensure end-user clinical accuracy
  • To ensure that procedure-specific resources of time, staff, room, equipment, supplies and instruments are associated to each procedure for accuracy of scheduling and resource management (i.e. supply chain)
  • To allow outcomes and cost reporting that are procedure/surgeon-specific and avoid skewing due to inadequate MPF maintenance or generic grouping of procedures resulting in outliers
  • To understand that using a coded source does NOT replace medical record coding or billing; it IS common clinical language that can be adapted for precise and standardized results

To establish parameters around some of the terms we are using, let’s review the following critical definitions:

  • Procedure Description – the name of a single discrete surgical procedure with sufficient wording to differentiate one version of a procedure from a similar variation of that same procedure
  • Non-Standardized – Common description but without cohesive methodology to support the usual search and sort capabilities of a database table (“what the surgeon’s office is used to calling it”)
  • Standardized – Description that contains a clinically accurate and surgically specific approach to word choice, sequence, length and abbreviations
  • Coded – Description of a procedure provided directly from an industry source (i.e. CPT procedure description)
  • Note: in all cases, you must ensure that the procedure description will work within the architecture and functionality of your information system.

Standardized and coded are not synonymous. Recognizing the difference is the first step in developing a complete and accurate MPF for all end-users. By starting with a coded source (i.e. CPT), all recognized surgical procedures are accounted for. No procedures are missing. Working from a complete list and refining it to support effective scheduling, documentation and reporting is a necessary step. Industry coded lists did not originate to support effective operational management but they should be a component of your MPF to more effectively support a patient-centric culture and improved revenue management.

The use of the MPF is central to the hands-on delivery of patient care. At the core of a patient-centric culture is the commitment to ensuring the dignity and safety of patients. Staff at all levels and of all types must “elevate their game”. It is not OK to be “close” when scheduling a patient for surgery or documenting their care – it must be clinically discrete and accurate. Creating an MPF that meets the need for standardization and accuracy is essential. Simply put, the use of the MPF in a patient-centric OR means:

Pre-Operatively (scheduled procedure)

  • Accurate scheduling (right patient, right procedure; right consent) starting with the surgeon’s office where the scheduling transaction begins
  • Timely financial pre-clearance/authorization for the correct procedure(s)
  • Accurate time allocation for the patient, patient’s family and the OR team
  • Appropriate pre-surgical education and readiness of the patient
  • Selection of the appropriate facility in which the specific surgical procedure should be performed for best results
  • Development of preference cards that are appropriate to the surgical procedure scheduled to ensure optimal resource management (right resources in the room at the right time in preparation for the patient)

Intra & Post-Operatively (actual procedure performed)

  • Accurate documentation of the actual procedure performed (especially if it varies from what was scheduled) as a required piece of the patient’s EMR.
  • Post-surgical discharge planning & instructions for the patient based on the surgical procedure performed
  • Accurate perioperative billing of the patient based on actual case level and specific resources used

The impact of a standardized master surgical procedure file on revenue cycle management isn’t to be overlooked either. Hospitals collect information needed to ensure payment which includes, among many things, the planned surgical procedure in order to obtain authorization. Among the reasons for denial of payment are lack of authorization, level of care, or “not medically necessary.” It is not unusual for a patient to have authorization for one procedure while a different or additional procedure is performed in the OR. There is a small window for getting an updated authorization. While OR’s routinely evaluate the impact on time resources of this change in procedure from scheduled to actual, it is equally important to understand the implications on payment. The level of care required (inpatient vs outpatient) should be established before admission and the case resource level, which is a driver of billing, is a data element typically associated with a specific procedure within the MPF. Denials based on “not medically necessary” are often a case where the procedure was not coded or billed correctly. OR staff & physicians can contribute to the accuracy of coding by using a master surgical procedure file that includes a link to industry codes and supports sufficiently discrete clinical documentation of the procedure performed.

Starting with a standardized or coded source is important, however, bringing cohesion to your surgical MPF requires a dedicated perioperative clinical informaticist with relevant clinical knowledge and critical thinking skills acting as the “communication bridge” between practitioners and IT. These skills permit them to understand & document the rationale for MPF standards to avoid an MPF that “morphs” over time to include duplicative or non-standardized procedures and lacks cohesion or understanding about the source or intent of the file. Ongoing collaboration is the key to successful system maintenance and effective change control.

While development of a standardized list is easier at the time of a new implementation, it is still possible to standardize your MPF in your current production system. It is a worthy exercise to evaluate your existing master surgical procedure file either to improve your existing system & processes or in preparation for conversion to a new EHR.

The big decision is to just “get started.”

Complete Traceability Documentation of Flexible Endoscopes

In the past few years, there have been a significant number of patients affected with infections as a result of having gastrointestinal endoscopy procedures using unclean flexible endoscopes.  In particular, duodenoscopes used in endoscopic retrograde cholangiopancreatography have set off a rash of sometimes deadly infections.

These tragic patient safety occurrences have resulted in a critical focus by regulatory agencies on the processes used to clean and sterilize flexible endoscopes at hospitals and outpatient clinics.  It is now recommended that hospitals and health systems completely trace the use of each individual scope to each procedure, patient, provider and the related processes which were used to clean and sterilize each endoscope.

Complete traceability means scanning and documenting the instrument path from patient use through the phases of sterilization to the shelf. Additional documentation within the EHR during intra-procedure point-of-care should include minimum data required to verify the sterilization of the scope and associate with the patient and procedure in the event of recall or alerts.

In order to document the entire path of the instrument, we start with listing the scope as instrumentation within an Instrument Tracking System. From there, tracking should include where the scope was sterilized prior to the procedure, who participated in the sterilization process and what sterilization method was used. During the procedure, nursing documentation is critical as well as utilizing any endoscopy software documentation (i.e. pictures taken during procedure, physician notes, etc).

To track scope usage on each procedure, nursing procedural documentation must now accommodate all information on each scope. Since that can be an overwhelming amount of information, the minimum documentation requirements, as published by SGNA (The Society of Gastroenterology Nurses and Associates, Inc.) 2013, is shown below:

  • Scope utilized (drop down box with all available scopes)
    • Not applicable
    • Scope ID number

The above example is the minimum data requirements. However, in J2’s experience, to achieve complete traceability of endoscopes, it is crucial to establish a standard naming methodology across clinical Information systems, Instrument tracking systems and Materials Management systems. Naming standardization means that each individual scope’s name within your database follows the same pattern. For example, the name starts with the same noun, then should include the type, model/catalog number, serial number and descriptive details which make each scope distinctive.  This information should be captured in a data type that is reportable since free text fields do not provide information that is easily analyzed and is open to inconsistent formatting from the end user.

Documentation errors may also arise when information systems do not support the workflows of clinicians and vice versa. For example, a clinician may not be able to find needed information in a poorly configured EHR. On the flip side, workflows may not accommodate the capabilities of current information system technology. Workflows and technology should be reviewed and aligned.

Additional benefits from a standard naming methodology:

  • Provides staff from all departments (OR, Endoscopy Units, Sterile Processing, Materials Management) with a consistent method to easily find the scope item within the database to support efficient documentation workflow
  • Supports scanning technology
  • Facilitates vendor endoscope recalls and alerts which are typically based on the “Model” level
  • Facilitates regulatory documentation compliance standards to support usage tracking and sterilization tracking information flow and workflow

For more information on how to clean, disinfect and sterilize instruments beyond manufacturer’s instructions, The US Food and Drug Administration has issued additional guidance. AORN has also published 2016 Guidelines for Processing Flexible Endoscopes with Competency Statements/Performance Criteria.

Are you facing these challenges? Comment below or contact us with any questions.