Monday, February 29, 2016

Why is Health Information Management so Important?

The Health Information Management (HIM) professional is an expert in managing all aspects of patient health information. The comprehensive knowledge that the HIM associate possesses assists in all aspects of this position, including managing that health information through health records, administering computer information systems, and collecting and analyzing patient data. Also very important is the ability to comfortably and accurately use classification systems and medical terminologies.

The HIM associate must have the ability to document clearly and support an accurate diagnosis that confirms the patient’s clinical findings, progress, and finally, discharge planning. A clear understanding of the medical foundations of patient care includes basic pathophysiology, abnormal clinical findings, and anatomy and physiology. Understanding this information is paramount to the successful HIM associate’s assurance that coding is precise, and diagnoses and outcomes are exact.

Two courses in an HIM program of study include Pathophysiology and Anatomy and Physiology. An understanding of anatomy (what’s in the body) and physiology (how it works) is the basis of all medicine. If we know how the body works, how it is put together, and what can go wrong, we can then understand the treatments and interventions that are the basis of medical treatment. The study of Anatomy and Physiology bridges the knowledge of the intricacies of the human body to the complexities of managing the data and information to medically manage a patient.

The study of Pathophysiology examines the alterations in the normal functions of the body that affects individuals across the lifespan. Understanding the mechanisms of disease processes essentially give a HIM associate the ability to recognize abnormalities and alterations in function and enable him or her to identify code-able diagnoses and/or procedures. This must be supported by a strong working knowledge of anatomy, physiology, clinical disease processes, medical terminology and even pharmacology. 

It becomes very clear with the study of anatomy and physiology that the body works in a collaborative manner to maintain balance and equilibrium. Understanding the basic knowledge of the components of the body then allows us to recognize in more detail the processes that interrupt that balance and equilibrium. A strong understanding of pathophysiology means having that ability to recognize those interruptions of the normal physiologic processes.

Consider the role of a documentation specialist in an acute care hospital. This professional is considered an HIM associate, and reviews all physician documentation in the medical record on a daily basis while the patient is in the hospital. This review ensures that treatment regimens, diagnosis and plan of care are clearly and consistently present in the record. Upon discharge, this record is then reviewed by another HIM specialist to code, or assign very specific alphanumeric numbers that are tied to how much reimbursement is realized. Everything that happens to that patient must be present and detailed clearly in the medical record. A history and physical, the first time a medical diagnosis is identified in the record, every lab value, x-ray result and treatment plan and regimen must be coded. The HIM associate has skills to not only recognize abnormal lab values and the intricacies of medical intervention, they also begin to anticipate and investigate nuances of care that may lead to even more accurate management of the medical record that results in quality data administration.

Understanding the body in as many ways as possible gives the HIM associate the skills and competencies to become an essential part of a health care team. Never has the management of patient information and data been more crucial. Not only does the HIM professional offer skills that manage the medical record, but is instrumental in ensuring that information is complete, documentation is timely, and the information that is tied to reimbursement for services rendered is accurate. Having an understanding of how the body works, and then recognizing the intricacies of disease processes assists the HIM associate in assuring quality patient care.

 Submitted by Katie Cross, MSN, RNC-OB, Adjunct  Faculty BS HIM Program

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