Evolution of Health Information Management

Health information technology (HIM) plays a vital role in how care is delivered to patients. When health information technology is used and governed appropriately, the general healthcare experience - to include quality of care and health outcomes - is improved. Therefore, it’s frustrating to know that, in the era of increased health information technology, some healthcare professionals consider health information management (HIM) departments and/or paper medical records as irrelevant to the work they do. 

Prior to healthcare migrating to electronic medical records, clinical documentation was and is the footprint of how providers record and dictate services that have been delivered. Clinical documentation provides an amazing story of patients' experiences; however, that amazing story is contingent on HIM departments' policies and infrastructures, regulatory requirements, clinical documentation accessibility to other providers in the continuum of care, and the validity of documentation to meet medical necessity for proper payments. If HIM professionals do not effectively meet these core principles in HIM departments, healthcare organizations will not be very effective with improving health outcomes.

One way to validate the necessity of health information technology is to imagine there being no more HIM departments. If that were to occur, several barriers would immediately arise. For example, medical professionals would have to find ways to monitor documentation to meet regulatory guidelines and adhere to medical staff rules and regulations and devise a plan to provide patients' access to medical records. Further, because paper documents are still produced in an electronic environment, medical professionals would need to determine who in the healthcare organization would ultimately be responsible for scanning paper documents to the EMR and who would determine the clinical documentation infrastructure for interoperability of what is released to external reviewers, auditors, and payers. Additional concerns would be related to the integrity of clinical documentation. Specifically, medical professionals would need to specify who would address concerns if there were issues with the clinical documentation integrity and who would support and enhance patients' experiences when they have access to clinical documentation. 

Appropriate clinical documentation also determines the accuracy and timeliness of payments received by healthcare organizations. Failure to manage this process creates havoc within the healthcare organizations regarding cash on hand for operations and potentially increases negative patient experiences connected to unexpectant costs. Furthermore, HIM professionals are the patient advocates when it comes to privacy of the clinical documentation. Therefore, if HIM departments are eliminated, who would ensure the required practices and procedures are followed?

It is true that the advancement of health information technology has enhanced the automation of certain functions in HIM departments. However, the expertise of HIM professionals is required to ensure such automations are beneficial to healthcare organizations and patients. Time and time again, HIM professionals are subjected to perceptions that our roles are irrelevant, but automation efforts often fail, and substantial gaps are noted, along with additional healthcare costs. If HIM professionals' expertise were valued at the initial stages, potential automation gaps could be discussed and prevented. Health information technology and HIM professionals' expertise are needed collaboratively to prevent awful “Project Creep.” Thus, I highly recommend that any clinical documentation project, revision, or change to health information technology system include an HIM Subject Matter Expert (SME) to ensure all HIM core principles are identified and managed. In using the analogy of the wheel, HIM departments are the hub of the health care organization. We are the clinical documentation SMEs with the use of health technology to manage patients care. It is our core principles which make us relevant in patients' continuum of care. Healthcare organizations who invest in both health information technology and HIM professionals and principals will see the most consistent improvements in overall patient outcomes and experiences.