Recently I had the privilege of attending the National Association of Healthcare Quality’s Annual Educational Conference in Nashville, Tenn. Not surprisingly, I found myself sitting in on the presentation titled “Making Sense of your Data After ACA and ICD-10.” As a health information management (HIM) professional working in multiple settings, including clinical documentation and ICD-10, I understand and am quite passionate about the overlap between data integrity and quality outcome reporting. I was very interested in what would be presented from “the other side of the fence,” which we refer to in the HIM world as “the quality world.” The session was presented well and was extremely informational; however, I walked away with a gnawing feeling of unrest that there still exists too much separation of these two worlds.
The actions of a quality-minded professional are clinically focused and revolve around direct care to patients and patient outcomes. The HIM professional considers the most appropriate code to assign based on the clinical documentation in the record and the financial implications as they relate to timeliness of coding the record and billing. The two worlds collide when patient quality outcomes are reported utilizing the coded data assigned by HIM coding professionals. This collision is the driving force for both sides to work together to ensure that clinical data integrity exists. The integrity of the clinical data being reported is essential to supporting and improving quality of care for patients as well as the fiscal health of organizations providing that care.