Health Information Management

Health Information Management (HIM) is the field of study that deals with overseeing and maintaining health care information for patient populations. This arena is changing at a rapid pace through technological advancements and changes to the functions and roles within the traditional HIM department. Health information continues to move to an electronic format and health care facilities are embracing the need for interoperability of the Electronic Health Record (EHR), traditional HIM roles are evolving to meet the demands associated with both analyzing and managing the integrity and flow of health information. For example, Computer Assisted Coding (CAC), while it will not make medical coders obsolete, it is changing the coder’s role within the facility. Moving to an Artificial Intelligence (AI) environment decreases the need for entry level production type coders and increases the need for higher level coding skills such as clinical documentation improvement specialist, auditing, and education. As coders transition to auditors of computer-assisted and voice-translated data, they may also be responsible for testing and maintaining data integrity within these systems. Likewise, medical record technician roles could also transition to data integrity analysts, and release of information clerks could transition to patient advocates who, rather than copying hard copy records for the patient, they assist the patient in both navigating and understanding the data contained within their personal EHR. In fact, data integrity and data analytics will be driving future HIM jobs. In this ever-changing environment, the adaptability of the HIM professional is vitally important to the future of HIM.

STI has been in the HIM industry for 35 years which has provided a solid foundation in understanding the ever-changing needs of the HIM customer. Looking forward, STI has already begun to prepare for the future of HIM roles within the healthcare facility through the ongoing training and development of staffing resources using a multi-disciplined approach.

STI offers an Individual Development Plan (IDP) that provides staff with the opportunity to participate in cross-training to learn new disciplines. Each person is also assisted in obtaining and maintaining credentials in areas they are not yet credentialed in. For example, many of our coders are trained, experienced and now multi-credentialed in IP and OP facility coding, OP professional services coding, and EM leveling through the American Academy of Professional Coders (AAPC), the American Health Information Management Association (AHIMA) and/or the National Alliance of Medical Auditing Specialists (NAMAS). STI also have staff who are credentialed coders as well as credentialed auditors, educators, and documentation improvement specialists. In addition, STI staff are trained and educated in the EHR and other data repository systems used at the facility level allowing them to assist with the testing and education needed to maintain data integrity within these systems. STI’s CDIS staff are required to carry credentials from the Association of Clinical Documentation Improvement Specialists (ACDIS) and most of our CDI specialists are either a Doctor of Medicine (MD) or Registered Nurse (RN) that possess professional certifications. This multi-disciplined approach allows STI to quickly adapt to meet the ever-changing needs of the customer.

STI delivers solutions that are scalable and tailored to the specific requirements of each customer. We have supported more than 100 different facilities from a partial single coder supporting a branch health clinic to a Level-1 trauma center with more than 15 coders, Auditor/Trainers and Clinical Documentation Improvement Specialists. Our HIM program creates a bridge between each layer of the coding process from medical records management to coders, from coders to auditors and trainers, and from each of those areas to our Clinical Documentation Improvement Specialists. This comprehensive approach promotes a facility-wide effort to properly capture a patient’s care, apply the correct codes for continuity of care and to ensure the most accurate revenue cycle and workload credit.

STI supports medical coding with a team of certified coders who have extensive experience coding all service types found in Department of Defense (DoD) Military Treatment Facilities (MTFs) and Veterans Affairs (VA) facilities.

IP Facility Services
IP Professional Services
External Resource Sharing Agreement (ERSA)
Observation Services
Emergency Department
Ambulatory Procedure Visits (Facility and Professional)
Outpatient Clinic Visits (all clinical and surgical specialties as well as ancillary services)

Our team of seasoned coders delivers services based on customer requirements and is the foundation for determining workload, patient history, and third-party reimbursement. STI’s team utilizes a standardized process that is based customer on MHS, VA and CMS guidelines. We also develop steps to implement a productive and repeatable process that allows our outpatient coders to maintain established production requirements at a minimum of a 97% accuracy.

On-site and remote coders – scalable to your workflow, 24x7
Expertise in your domain – military, government, private healthcare
Low turnover – staff continuity gives you simplicity, efficiency
Proprietary Remote Coding Data Base (Global Code)

STI’s DoD and VA contracts support coding for over 100,000 professional service encounters and 2,000 inpatient facility records per month.

STI’s team of certified medical auditors works directly with each facility to establish a comprehensive and efficient audit schedule covering all inpatient and outpatient clinics and providers. This includes internal and external reviews of clinical documents, hospital charts, physician and facility billing records, administrative data, and coding records. The results of each audit are discussed with the provider in face-to-face or web-based trainings and compiled for facility leadership to prevent future coding or documentation deficiencies.

Documentation quality, compliance, and completeness
Provider coding
Quality Assurance audits for coders (Peer Review)
Chart audits (signatures, unapproved abbreviations, EHR generated discrepancies, completeness, etc.)
Quality Measures

Lessons learned from these audits are incorporated into the coding process as part of our continual process improvement. Historical documentation error trends are compared to current data to identify any trends impacting workload and reimbursements. These reviews are conducted to ensure compliance with industry regulations and maintain quality assurance in coding and documentation accuracy and completeness, effective policies and processes throughout the facility, and adherence to quality measure standards.

STI’s DoD and VA contracts support more than 3,000 inpatient and outpatient record audits per month.

Certified medical auditors and educators provided education and training to coders, physicians, support staff, and administrators based on industry changes and updates and information gleaned from documentation and coding related audits. Ongoing training is performed for continuing education.

Provider documentation training
Provider Coding training
Coder training and ongoing education
Coding training for the enlisted
Support Staff Documentation and Coding Training

STI’s DoD and VA contracts support more than 400 hours of provider training per month.

STI’s CDI Team is comprised of physicians, nurse practitioners, licensed nurses and certified healthcare professionals. These dedicated personnel assure that the medical record documentation reflects an accurate picture of the patient’s diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care. Our successful outcomes lead to appropriate MS-DRGs, Major Complications or Comorbidities (MCCs), and Complication or Comorbidities (CCs) by providers documenting on every condition that exists.

Inpatient and Outpatient CDI Support
Initial, Concurrent, and Retrospective Reviews
Proprietary STI CDI database

The success of each CDI program we’ve implemented is measured by quality care measures, overall improvement of documentation, and facility reimbursements. STI develops and maintains reports focused on data quality, workload capture, case-by-case reimbursement, and the focused performance of each CDI Specialist. Our collaborative and cooperative relationships amongst all stakeholders ensure all levels of leadership are involved. Actively involving every level of the facility guarantees successful outcomes for the individual provider, Provider Champions, department leadership and executive leadership.

STI established an Enterprise-wide Clinical Documentation Improvement Program for the Bureau of Medicine and Surgery (BUMED) and all of Navy Medicine. This included provided CDI at all 13 Navy Medical Centers and Inpatient Hospitals.

Data quality in healthcare consists of several characteristics, including accuracy, consistency, and relevancy of data. Data quality professionals analyze multiple points of data to identify the potential for process improvement throughout the healthcare facility. This data analysis identifies areas of inefficiency such as policies and procedures, coding and documentation practices, system issues, limitations, and write-back errors.

Ensure Efficient Communication Between Facility Staff as well as Healthcare Providers and Patients
Increase the Overall Quality of Patient Care
Ensure Accurate, Consistent, and Complete Documentation
Decrease in Coding Errors
Decrease in System Errors
Enhanced Health Outcomes
Improved Revenue Cycle Integrity
Enhance Education and Training

STI is a Leader in Providing Innovative Solutions to HIM challenges across the MHS and the VA.

Technical Capabilities

Medical Coding

Medical Auditing

Education & Training

Clinical Documentation Improvement (CDI)

Data Quality

Are you and STI a match?