Hospital Healthcare Unit 1 Introduction

Hospital and Healthcare Information Management Unit 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

Sikkim Manipal University Page No.: 1


 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 It is the profession that focuses on healthcare data and
Management 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.


Hospital Healthcare Unit 1 Introduction

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