Health information management (HIM) was founded in 1928 by the American Health Information Management Association (AHIMA). Times have changed with the emergence of advanced technologies in healthcare in the collection, analysis, and protection of medical information pertinent to quality care. Health information includes medical history, records, imaging, lab results, and the providers clinical notes. This combined information provides a comprehensive ‘roadmap’ to guide the appropriate treatment recommendations. This information is valuable for scientific studies because HIM combines business, science, and IT to improve healthcare and it may be used to support public health measures and to protect patient privacy.
Some examples of IT in healthcare are health information systems (HIS) which use technologies to capture, manage, store, and exchange health data. The next is electronic health records (EHRs) include patient health history, diagnoses, medications, allergies, lab results, and treatment plans. Electronic medical records (EMRs) are like EHRs but consist of a more limited scope to only include a patient’s medical history and treatment details. Picture archiving and communicating systems (PACS) use digital imaging technology to gather important health details. Other systems which have been implemented to increase the use of HIT are laboratory information systems (LIS), radiology information systems (RIS), pharmacy information systems (PHS), Clinical decision support systems (CDSS), and health information exchange systems (HIE).
The responsibilities of the health information management department (HIMD) are responsible for improving healthcare using EHRs and other emerging healthcare technologies. The HIMD maintains records utilizing the principles and practices consistent with efficient and elective record management, review records for accuracy and completeness, and safeguards the confidentiality of health records. Efficiency with HIT is evident due to the automation of tasks, an improvement in communication, and the guidance of better clinical decision making for providers. Clinical decision support systems (CDSS) provide evidence-based guidance for providers when creating treatment plans and a safe prescription medication protocol. Additionally, data analytics and predictive modeling can identify trends and patterns to predict future demands to prepare more methodically.
Challenges in implementing IT in healthcare are due to the lack of standardization and integration issues with interoperability. Data and cybersecurity threats pose an issue and require robust encryption and overall increased cybersecurity protection. The cost of implementing technology and maintaining it is intense and sometimes unattainable for some organizations. The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 as part of the American Recovery and Reinvestment Act (ARRA) played a pivotal role in the interoperability measures in healthcare by incentivizing the use of EHRs through ‘meaningful use’ programs and funding for health information exchanges (HIE). In summary, the HITECH Act provided a regulatory framework for how EHRs would be used and the criteria for interoperability and suitable safeguards.
I think the thing which comes to mind is the topic of ‘meaningful use’ when using EHRs. You would assume people know what it means to use data for an appropriate use. However, it is wise we continue to train and remind why meaningful use is essential to provide legally just and ethical care. In times of question, we must rely on our ethical judgment when making key decisions. I recently heard of a story where a dental patient left her journal with very personal health data in the journal at her dental appointment. While there was no mention of the patient’s name, a mockery of her journal was made on social media and soon it circled back to her. This is a prime example of a healthcare provider who claims she did not disclose the name of the patient so she was not in HIPAA violation, but what would ethics say?