Health Information Management (HIM) is acquiring, analyzing, and protecting digital and traditional medical information for patient care. It involves planning, organizing, and managing health information to ensure its accessibility, accuracy, and security.
Components of health information management
Health information systems: HIM involves using technology to manage health information. This includes electronic health records (EHRs), health information exchange (HIE) systems, and other health information technologies.
Data governance: This refers to the overall management of the availability, usability, integrity, and security of the data employed in an enterprise. It involves establishing processes to ensure high data quality and compliance with regulations.
Coding and classification systems: HIM professionals use standardized coding systems, such as the International Classification of Diseases, 10th edition (ICD-10) and Current Procedural Terminology (CPT), to categorize diseases, diagnoses, and medical procedures for billing, research, and healthcare planning.
Privacy and security: HIM professionals are responsible for procedures to safeguard patient information, ensuring it is confidential and protected from unauthorized access.
Record management: HIM involves the organization and maintenance of patient health records, whether in paper or electronic form, to ensure that accurate and complete information is available when needed.
Compliance and regulations: HIM professionals must stay abreast of the ever-evolving healthcare regulations and standards, including those related to patient privacy, such as HIPAA.
Quality improvement: HIM is also concerned with improving the quality and efficiency of healthcare services. This involves analyzing health data to identify strategies to enhance patient care.
Related: What is a health information organization?
Functions of health information management
Privacy regulations
HIM policies and procedures: HIM professionals are responsible for developing, implementing, and enforcing policies and procedures that ensure the privacy of patients' health information. This includes defining who has access to protected health information (PHI), under what circumstances, and the protocols for disclosing this information.
Access controls: HIM specialists implement access controls within health information systems to restrict unauthorized access to PHI. This involves assigning unique user IDs and passwords and implementing other security measures to ensure that only authorized personnel can access sensitive patient data.
Security measures
Technology implementation: HIM professionals are involved in selecting, implementing, and maintaining health information systems. They ensure these systems have security measures to protect against unauthorized access, data breaches, and other security threats.
Encryption and data protection: HIM specialists may implement encryption technologies and other safeguards to protect electronic PHI during transmission and storage. This helps prevent unauthorized interception or access to sensitive information.
Patient rights and access
Release of information: HIM professionals manage the release of patient information, ensuring that PHI is disclosed only to authorized individuals or entities. This process involves verifying the identity of individuals requesting PHI and adhering to the specific requirements outlined in HIPAA.
Patient access to records: HIM plays a crucial role in facilitating patients' access to their own health records. This involves developing procedures to ensure individuals can easily request and obtain copies of their PHI, as HIPAA mandates.
Compliance monitoring and auditing
Regular audits: HIM professionals conduct audits of health information systems and processes to ensure ongoing compliance with HIPAA regulations. This includes assessing the effectiveness of security measures, evaluating access logs, and identifying and addressing potential vulnerabilities.
Training and education: HIM specialists educate healthcare staff about HIPAA requirements and the importance of safeguarding PHI. This includes training sessions on privacy practices, security measures, and consequences of non-compliance.
Incident response and reporting
Breach management: HIM professionals manage data breach responses, investigate impacts, and report incidents to authorities and affected parties as per HIPAA requirements.
Documentation: HIM ensures that proper documentation regarding breaches, responses, and corrective actions is maintained.
Related: HIPAA Compliant Email: The Definitive Guide
Tshedimoso Makhene
