Question

Make note of the definition of HIM (Health Information Management) and review AHIMA's history, mission and future predictions, the discuss documentation guidelines developed by AHIMA.

Describe how the recent and future technological changes in health records management has/will impact your career path as a health care professional.

Answer 1

Health Information Management is an information management system related to health care sector which includes the practice of collecting, analyzing and storing information that serves an important role in the quality of care provided to patients.

History: The American Health Information Management Association represents professionals working in the field of health care information management. It is a global non profit organization.It originated in 1928 as Association of Record Librarians of North America,  It was renamed as American Association of Medical Record Librarians in 1938 and in 1970 as American Medical Record Association. Finally in 1991 to present it's named as AHIMA.Their Mission is to empower people to impact health. AIHMA has a vision for a health care sector transformation with trusted information and by connecting peoples, organizations and their views.Their prediction in the field of health management includes safe and secure patient data with introduction of more competent security protection programs,integration of client care data through Electronic Health Records(EHR) and Virtualization of care experience, which provides easy access to information from any locations and can provide quality care though the care provider is outside the health care setting.In addition to this web portals and applications can enable maximum patient participation through accessing their data and communicating with the provider online.

Documentation guidelines by AIHMA:

• Documentation of all patient care related data, needs to be documented by the care provider.
• Health record can also be used for evidence purpose
• The organisations must develop policies for obtaining and retention of documents from external sources either in physical or electronic forms. If such records are not acceptable, the policy must also address measures to store or destroy such data.
• Organizations must consider introduction of locking the documents in case their system allow editing with no access to track the changes or if their system does not automatically record the date and time of new entries. Locking the documents at a predetermined time, after completion of a client care service prevents manipulation of data.
• Institutions should also set clear cut procedures for correcting the data entered in an EHR. Corrections should show the date and time of edit, it should be done in chronological order and must be accessible to all related staffs.
• Authentication of individual entries with the staff details is mandatory. In case ,if the documents are prepared outside(eg: scanned images), it must be electronically signed along with date and time. Such documents must be clearly visible and comprehensible for all those who have access to it.

Influence of technological advances in future health care profession:

• Changes in the information management system has remarkably brought changes to the traditional practices in health care profession.
• EHR started a revolutionary change in the health care sector.
• Along with EHR,other technologies like voice recognition software,patient portals, computer assisted coding process also brings about changes in the Health Information Management System.
• As the technology advances, the roles and educational qualification as well as the competency and skills required for health care professionals may also change in order to perform the modified job.
• All the health care professionals may need to acquire skills and knowledge in fundamental HIM tasks like management of data, safety and security and exchange of information.
• Advanced technology offers job to only the competent, up to date and skilled professionals and this may initiate including the basics of IT in the health care curriculum itself.