unit 1

Hospital and Healthcare Information Management Unit 1

Sikkim Manipal University Page No.: 1

Unit 1 Introduction to Health Information

Management

Structure

1.1 Introduction

Learning Objectives

1.2 Basic terms and functions of HIM

Definition of a Hospital

Information Management

Health Information Management

1.3 Transition from Medical Records to Health Information Management

Common Functions of Health Information Professionals

Job Responsibilities of various groups of staff

1.4 Evolving Role of Health Information

Evolving Role of Health Information

Health Information Consultant Services

1.5 Managing the Transition

1.6 Summary

1.7 Terminal Questions

1.8 Answers

1.1 Introduction

This unit is going to introduce you to health information management. The

purpose of this book is to equip you with the necessary knowledge on health

information management and how important is its role for the success and

efficacy of the health care system. In this unit you will be reading about the

basic terms that will be used throughout the book.

Objectives

After reading the chapter you should be able to:

Define Health Information and Health Information Management

Tell the functions of health information management

Explain the transition of Medical Records to Health Information

Management



List the functions and job responsibilities of Health Information

Management Professionals

Describe the evolving role of health information

1.2 Basic terms and functions of Health Information Management

The scope and functions of a hospital have undergone tremendous changes

in the last century. In the early days the functions of a hospital were mainly

curative; in other words hospitals existed mainly to treat and cure the sick.

Over the years, the preventive and rehabilitative aspects also began to be

recognized as important functions of a hospital. Preventive functions

included immunization, health education, early detection of diseases,

antenatal care etc. Rehabilitation meant not only physical but also social

and psychological restoration. Many hospitals started to reach out to

communities and help people in their environment, rather than wait for

patients to come to the hospital. In addition to the curative, preventive and

rehabilitative functions, which are known as “service functions”, certain other

functions such as teaching, training, research also started to gain importance.

With the enormous number of services being added into the healthcare

spectrum, managing the healthcare information became important.

Before we go into the management of Health Information System, it will be

useful to have an understanding of the basic terminologies.

Definition of a hospital: Considering the scope, functions and philosophy

of hospitals in the present scenario, the WHO defined a hospital as:

“Hospital is an integral part of the social and medical organization of the

community, the functions of which are complete health care, and whose

outpatient services reach out to the family in its home environment; it is also

a centre for training of hospital/health workers and provides facilities for

biosocial research”.

American Hospital Association defines a hospital as a health care institution

with an organized medical and professional staff, and with patient beds

available round-the-clock, whose primary functions are to provide inpatient

medical, nursing and other health-related services to patients for both

surgical and non surgical conditions, and that usually provides some

outpatient services, particularly emergency care.



Information Management: The process of planning, organizing, directing

and evaluating systems for collecting, maintaining, analyzing and

disseminating the data and information resources of an organization.

Health Information Management: It is the profession that focuses on

healthcare data and the management of healthcare information resources.

This stream addresses the nature, structure, and translation of data into

usable forms of information for the advancement of health and healthcare of

individuals and populations.

Health information professionals collect, integrate, and analyze primary

and secondary health care data; disseminate information; and manage

information resources related to research, planning, provision, and

evaluation of health care services.

Self Assessment Questions

1. In earlier times, hospitals existed only for to offer ___________ services.

2. What is the difference between information management and health

information management?

3. Over the years ________________ and _____________ aspects were

also considered as functions of the hospital.

4. Give the WHO definition of a hospital.

5. _________________ is the process of planning, organizing, directing

and evaluating systems for collecting, maintaining, analyzing and

disseminating the data and information resources of an organization.

6. _______________ is the profession that focuses on healthcare data and

the management of healthcare information resources.

1.3 Transition from Medical Records to Health Information

Management (HIM)

The terms health information and health information management are used

throughout this unit to represent the medical record and medical record

department. In the early 1990’s the American Medical Record Association

(AMRA) changed its name to the American Health Information Management

Association (AHIMA) to better reflect the role of the medical record

professional. The new terminology recognized the maintenance of clinical

information in a variety of formats, and the evolution of the role of a medical



record director to one whose role is to manage health information beyond

the medical record.

Common functions performed by Health Information Professionals

A professional in health information should be able to perform and train on

all of the functions of a Health Information Coordinator, as well as many of

the functions of the Health Unit Coordinator. The following functions are

unique to the role of health information professional.

Ability to provide assistance and function as a key resource for the

development, transition, and maintenance of an electronic medical

record.

Assist with implementation and function as a key resource on the Health

Insurance Portability and Accountability Act (HIPAA) including

information system security issues and privacy.

Provide expertise on compliance issues and the integration of clinical

documentation and coding with the billing process.

Develop, implement and monitor health information department policy

and procedures and job descriptions. Make recommendations or assist

with implementation of corporate policies.

Provide training and orientation to health information personnel on

functions of the department and staff on documentation.

Develop and maintain health information systems and processes that

meet regulatory requirements (both state and federal), professional

practice standards, legal standards, and management/corporate policy.

Establish a process for systematically reviewing documentation on an

ongoing basis for both quality and quantity of documentation.

Ability to complete documentation/medical record audits and monitoring

with an ability to assess the quality of documentation.

Ability to recommend corrective actions for findings on medical record

audits/monitoring.

Initiate clinical record systems and indexes.

Assist with forms development and forms analysis/flow.

Support compliance process of facility/organization.

Support quality assurance/quality improvement process of the

facility/organization.



Train staff on quality assurance/quality improvement process related to

health information management and appropriate methods for the

collection of data.

Provide resources to the facility on health information, documentation,

regulations, standards of practice, etc.

Develop consultation reports in a timely manner. Communicate findings

and recommendations effectively to hospital administration and

interdisciplinary team members.

Maintain good communication with MRD (Medical Records Department)

staff and interdisciplinary team members. Empower MRD staff to work

independently.

Job responsibilities of a qualified HIM professional

The following functions are recommended for a credentialed health

information practitioner, and represent the core functions for health

information. MRD size, admission and discharge rates, department staffing

and other non-HIM responsibilities assigned to the position should all be

considered when developing the final job description for an MRD staff. In a

department that also employs health unit coordinators; some of the

functions outlined may be managed by this position but performed by the

health unit coordinator.

1. Supervisory/Management Functions

Maintain current policy and procedures and job descriptions for the

health information department.

Manage human resource functions for the department including

interviewing, hiring, staff scheduling, performance evaluation,

disciplinary actions, and termination.

Supervise health information staff to assure staff competency and

performance.

Provide guidance, motivation and support to health information staff.

Monitor department budget as directed.

Serve as the Privacy Officer under HIPAA (Health Information Portability

and Accountability Act of 1996 United States) and may serve as the

Security Officer depending on expertise and facility need.



2. Quality Monitoring and Quality Assurance Functions

Participate in the quality assurance committee and process. Optional:

Coordinate the quality assurance program.

Maintain a qualitative and quantitative audit/quality monitoring process.

Collect and report data from audit findings to QA committee. Report,

monitor and follow-up on problems/concerns. Maintain routine audit and

monitoring systems (admission, MDS, concurrent, acute problem,

discharge) and focus audits on problem areas, QA concerns, and

Quality Indicator and survey issues.

3. Health Information Policy Management Functions

Maintain security of health information systems and medical records.

Assure physical protection is in place to prevent loss, destruction and

unauthorized use of both manual and electronic records. For example,

assure safeguards are in place such as record sign-out systems,

assignment of computer passwords/log-ons, and systems for securing

file cabinets and file rooms where overflow and discharge records are

stored. Assure systems are in place to maintain confidentiality of both

manual and electronic health information.

Manage the release of information functions for the hospital including

review and processing of all requests for information.

Maintain hospital policies and standards of practice to assure release of

information requests are appropriate and meet legal standards.

Maintain a forms management system for development, review, and

reproduction of forms. Maintain a master forms manual.

Maintain systems for filing, retention and destruction of overflow/thinned

records and discharge records.

Develop systems for retention and destruction of medical records stored

in an electronic format.

Complete hospital statistical reports such as monthly statistics, daily

census, and licensure reports as applicable.

Participate in meetings and committees such as daily stand-up,

administrative/department head, quality assurance/quality improvement,

and Medicare documentation review.

Provide in-service education as applicable on health information issues.



Provide orientation to new employees on topics such as the medical

record organization and content, record completion, confidentiality,

documentation standards and error correction procedures.

Support and assist in carrying out corporate compliance initiatives as

assigned by administrator.

Manage the credentialing process for physicians and other professional

staff when applicable.

4. Computerization/Automation

Understand all aspects of clinical computer system.

Participate in decisions related to the computer system, including

systems selection, planning, and future expansion.

Provide resources for training on computer system and use of clinical

applications.


7. List the common functions performed by health information

professional.

8. What are the job responsibilities of a qualified HIM professional?

9. The expansion of MRD is _____________.

10. The expansion of HIPAA is ___________.

1.4 Evolving Role of Health Information

As computerization continues to evolve, the role of the HIM practitioner will

also change. Although some traditional functions in maintenance of a

manual record may be eliminated, new issues will take their place. The HIM

role will continue to be responsible for oversight of confidentiality,

compliance, privacy and security management programs, ongoing auditing

of the electronic medical record, and audit trails. HIM practitioners should be

responsible for orientation and ongoing training of clinical staff on the

information system, and overall administration of the information system.

Even with a computerized record system, many of the routine HIM functions

will still need to be carried out.

With the implementation of HIPAA (United States), the HIM practitioner will

see new roles as a privacy officer and possibly a security officer. Expertise

on code sets will also be necessary for proper coding and reporting under



the federal regulation. The HIM role in corporate compliance and billing

should also evolve to assure that documentation supports services billed by

the provider.

Health Information Department Staffing

Staffing the health information department is based on five critical

issues:

The time requirements for functions under the responsibility of the health

information department

Patient acuity and complexity.

Census based on number of inpatients

Number of patient exchanges (admission, discharge, hospital transfer

and hospital return).

Availability of information technology.

Health Information Consultant Services

A health information consultant provides a healthcare provider or corporate

office with professional expertise on health information, medical records,

and documentation based on their education, skills and experience. At a

time in the industry when quality of documentation for survey and litigation,

coding, confidentiality and security are emerging as critical issues; the

consultant is an invaluable resource for a provider. Consultants provide

assistance with monitoring potential fraud and abuse issues, assistance with

corporate compliance plans, and evaluation of documentation that supports

the billing process.


11. Which are the criteria to be considered for health information

department staffing?

1.5 Managing the transition: Challenge to Health Information

Professionals

The 20 years spanning 1990 to 2010 will mark the active development and

deployment of computer-based and electronic patient records as a unifying

principle within organizational clinical information systems. The tasks before

health information professionals focus on multiple parallel efforts. Staging

the technology development and deployment is only one facet of this long



range goal. A number of coordinated milestones must be acknowledged and

appropriate management direction adopted. Let us consider a set of

essential activities that must occur. We need to lead and facilitate these

activities, so that moving ahead to technology improvements becomes

feasible, particularly in the direction of the EHR (Electronic Health Records).

Here are some ideas for moving ahead now:

a) Educate health care organizations, practitioners, and consumers to

prepare them for the changes. The technology today invites those in

health care organizations to communicate with their peers, their

practitioners, and their patients in new and innovative ways. Educating

users to rely on computers to supply their data needs is a continuing

agenda for professional organizations and institutions. This educational

initiative requires that we track the progress of EHR developments. We

need to understand clearly how EHR advances affect documentation, as

well as patient data availability for the care process. We know, for

instance, that record availability issues decrease when information can

be retrieved through a local workstation. The consumer will also need

education as we become more efficient in delivering and coordinating

consumers. As providers can rely on up-to-the-minute data and research

to communicate with patients, we will foster a different kind of patient –

one who can function as a stronger member of the health care team.

b) Recognize that the technology itself must be in place. Electronic data

system and the networks required to link them within organizations

continue to be dependent on fundamental and affordable technology.

Foundation systems are needed to provide daily transaction processing

for all health services, and enough workstations, must be deployed to

afford clinicians ready and rear-to-care access. Until there are sufficient

numbers, the shift to replacing the dependence on paper and increasing

direct dependence on paper and increasing direct use of computer

systems by providers will not occur. For many organizations, this will

take up the better part of the next decade. On the business operations

side, managers are already expected to use computers in their own daily

activities, including budgeting, data analysis, and writing and

communication. Active participation in planning and implementation of

technology within organizations will strengthen manager’s skills and

better prepare them to understand technological needs.



c) Address the crucial acceptance factors: This includes working to secure

sponsor endorsement, engaging clinical “champions” to assist in

marketing to their peers, and selecting and marketing demonstration

pilots to move ahead in incremental steps. Ease of use is a crucial

acceptance factor for workstations. Another acceptance issue is the

necessary preparation to manage confidentiality adequately. Patients,

and those associated with the user communities, are concerned about

privacy and worry about who has access to their data. This is likely that

we will need participation in public forums on this topic.

d) Model demonstrated quality and cost incentives to encourage individual

organizations to adapt aggressive programs: To do this, a sound

business cost-benefit rationale is required. Closer scrutiny will be

directed to systems development projects to be sure that clear cost

containment targets are included in the planning, and the opportunity for

“nice-to-have computer system” will give way to “cost-justified computer

systems”. Managers will apply cost-benefit tools in their forecasting with

greater discipline than ever before. A realistic analysis is essential. For

example, consider bringing transcription reports or consultation referral

letters on line to build components of EHR in your organization. As an

HIM manager, be sure you fully understand the business process and

current costs of transcription. Gather facts about bringing transcription

on line experienced by peer organizations, including production

increases or decreases, to demonstrate full understanding of cost. Then

make the case.

e) Upgrade organizational policies and procedures to redefine the patient

record and move from a paper record to a combined record: This work

can be led at national and state association levels, as well as within

individual institutions. We need to find ways to combine multimedia

patient health information into a clinically designated “virtual” record.

This helps formalize the data system’s content as part of the patient

record.

f) Coordinate programs that stage EHR related development within

information systems master plans: This endorses the concept of a

unifying principle. Institutional strategies serve as the basis for

incremental steps to automate more and more clinical data. Some of

these go hand in hand to cover the most return on investment and at the



same time, extend value added to multiple customers. Systems must

become more affordable, dependable, and useful to more customers. A

new clinical laboratory system, added to a large organization’s

integrated clinical systems development plan, can drive the results

reporting for clinicians and send data to a clinical repository in which a

growing EHR is maintained. It may also offer a new service to generate

mailed test result reports to patients. Your organization may be in the

process of providing increasing patient data from laboratory and

pharmacy to radiology images, electrocardiograms, and more to a

clinical data repository or data warehouse. It is important to contribute to

and use a master information technology plan to map out and confirm a

step-wise process that builds toward EHR systems.

g) Endorse and support revised legal frame works so that federal and state

legislation allows the transition from paper to electronic media to occur:

State laws are in the progress of being realigned with federal

requirements in these areas. New definitions of the patient record

accepted changes in storage requirements, and automated

authentication techniques are all needed to advance the work.

h) Find ways to deliver better clinical information from the current

information systems now: Propose that EHR components be introduced,

evaluated, and rapidly deployed. The best illustration of this strategy is

the production of mini summaries that show the “patient at a glance,” for

example, problem list, medications, and laboratory test results or a

specific patient care plan, perhaps designed to manage a chronic

disease. This strategy focuses on the experience that bringing

technology to the eager customers first- particularly clinicians-

accelerates technology diffusion. Happy customers market the

technology most effectively. At this point in health information systems

development, there are many demonstrations that illustrate this

experience. If we provide new data or data in new and more effective

formats, clinical customers will be more willing to modify their data

collection behaviors to contribute the value added.

i) Monitor the work on clinical guidelines and protocols and find ways to

introduce them into the organization: Not only are they needed for

reasonable support to medical providers, but they are clearly a resource

for inclusion in EHR systems. In the simplest form, guidelines can be



stored electronically and lookup features can be provided. In the more

sophisticated approaches, organizations may tailor guidelines for

internal use and may incorporate advice and reminder protocols in

developing systems. Experiments that connect individual patient data to

guidelines to offer feedback before, during, and after the care delivery

process will best illustrate the requirements expected of EHR systems.

Today, the event monitoring capability places this process in the

decision support realm.

j) Study the known barriers already published to develop action plans to

overcome them – learn from others mistakes: We need to survey the

deployment tactics and identify the success benchmarks. Sharing

experiences with other organizations will help to develop a collective

wisdom as we move to such new environment. To illustrate a simple

case, many health professionals have not learned to type. This means

that introducing computer systems – even point-of-care systems – to

personnel who do not possess simple keyboarding skills, will require

expensive pertaining in the technology itself before a specific application

can be taught. Time is also needed to adjust from character-based

terminal screens to the newer graphical user interfaces. It must be clear

that newer user interface styles are going to be more effective. In some

cases, such as a high-volume prescription data entry function, icons and

a Windows user interface style may not be the most efficient for the

organization, but evidence indicates that the interface benefits have led

to easier and more intuitive learning for information system users.

k) Lead and participate in reengineering current user processes: We need

to prepare the operational environment for change. One of the driving

forces of this decade is reengineering. We have learned that simply

installing computer systems for existing business processes fails to

realize the benefits. Business processes, the way we move patients

through appointment, check-in, care, and follow-up, must be

reexamined. Along with other business processes, this work flow

requires careful review to see if there are more efficient ways to

accomplish it. This would apply to the way we organize and use the

patient record content and formats. The notion of continuously improving

our business processes to be sure that the best methods are in place fits

in with the total quality management philosophy and practices that have



been used with positive results since the late 1980s. We can expect to

reengineer the way patients are seen and treated for long-term services

and to update the processes used to move the information around and

use it more effectively. Reengineering means fundamental rethinking

and radical redesign of business processes to achieve dramatic

improvements in the performance such as cost, quality, service, and

speed. Considering that providers are expected to incorporate new

technology in direct are practices, examining how data capture and

retrieval can occur most efficiently can lead to better alternatives.

l) Once an EHR project is under way, incorporate a thorough knowledge of

the impact of change on the workforce into strong project leadership

from a top-down approach: We know that technology affects

organizational culture, including structure and design. It changes work

flows and brings in new job designs and responsibilities. Staff requires

new skills and knowledge to perform their work. Worker motivation and

incentives call for new communications and operations policies and

procedures to build the kind of strong teamwork required to absorb

change. Human resources personnel are strategic partners for all

managers in the long-term change agent tasks, and new skills are

required for managers as well as workers. Assembling and participating

in strong teams are essential. HIM professionals are already assuming

leadership roles with project management requirements.


12. What is the role of Health Information Professionals in reengineering

current user processes?

13. What is the role of Health Information Professionals in EHR Project?

Activity

Visit a Healthcare Centre near your location and ask them whether they

are using Information system. If yes, find about the advantages of Health

Information system.



1.6 Summary

The medical record professional plays a major role in the ever-expanding

health care field. To provide competent assistance to health professionals

involved in the complex process of quality patient care, he is called upon to

advance daily by continuing his own education and maintaining a thorough

knowledge of his specialty. The health information professional often

donates valuable time and assistance to health care administrative activities

and other health related organizations and agencies to advance the art and

science of medical record administration.

Glossary

Terms Description

Healthcare The efforts taken by professionals to restore and maintain health of people

Health Information Management

It is the profession that focuses on healthcare data and the management of healthcare information resources. This stream addresses the nature, structure, and translation of data into usable forms of information for the advancement of health and healthcare of individuals and populations

HIM professional Is one who work on the Health Information Systems

EHR Electronic Health Record. Systematic collection of electronic health information about patients.

1.7 Terminal Questions

1) Discuss the transition of Medical Records to Health Information

Management.

2) What are the challenges faced by the Health Information Professionals

as a result of transition? How should they manage?



1.8 Answers


1. Curative

2. Information management is a general term. For this you have to write

about basic management functions. And for health information

management you have to specify the management functions taken up

for handling the patient health information.

3. Preventive and rehabilitative

4. Refer 1.2

5. Information management

6. Health Information Management

7. For this you have to list the various management functions generally

taken up by the medical record officer. The function includes the

management and handling of patient information for analysis and also

for providing reports for various impersonal uses of medical records.

8. For this additional management functions which have been delegated

to the qualified HIM professional have to be performed. The functions

like supervisory functions, quality assurance, quality monitoring, and

management of various policies restricted to patient information

control and computerization of the information have to be discussed.

9. Medical Records Department

10. Health Information Portability and Accountability Act

11. Refer to section 1.4. Five criteria given in this section have to be listed

for this answer.

12. Refer to section 1.5 point k. You have to include how reengineering

and redesigning can change radical redesign of business processes

to achieve dramatic improvements in the performance such as cost,

quality, service, and speed. As the providers are expected to

incorporate new technology into their practices, examining how data

capture and retrieval can occur most efficiently, you can suggest

better alternatives.

13. Refer to section 1.5 point l. For this you have to know about EHR and

its advantages over the paper source and computerized medical

records. For this project you have to do data designing and format

designing for the system.



Terminal Questions

1) Refer to section 1.3. For answering this question you have to first

understand the trend of health care delivery systems. From the crude

early documentation methods the evolution of current trends should be

discussed (refer Management of medical records by Edna Huffman).

Various management functions taken up by health information

professionals must be listed.

2) Refer to section 1.5. This answer should cover all the points given in this

section from the challenges faced by the HIM professions due to

transition from paper source medical records to EMR. It should include

all the points from orientation programs to health care providers and

caregivers, teaching programs about the technology, policies and

procedures to be followed and various guidelines for reengineering

process and system designing.

unit 1

Health & Medicine

sikkim manipal universitypage

health information portability

health information department

health information system

electronic medical record

health information professionals

health information management

healthcare information resources