Health information Management refers to storing, maintaining and retrieving patient healthcare data in accordance with applicable Federal, State and accrediting agencies’ requirements. With the advent and popularity of digitization, the healthcare industry is converting all paper-based medical records into Electronic Health Records for better storage, maintenance and retrieval of patient data. In this digital transition, healthcare organizations are assisted by providers of document conversion service. Digitization of all records into e-format ensures quick access and better coordination among healthcare professionals themselves, as well as with patients, which is most important to ensure efficient care and facilitate health information management. Health Information Management (HIM) is not an easy task; within its framework are some major responsibilities to meet. Let us examine what these responsibilities are:
- Medical transcription: Physician’s notes and recordings need to be transcribed into accurate medical notes. Timely transcription of patient health information is vital to make accurate data accessible to healthcare professionals. All important information such as medical history, physical reports, consultation reports, discharge summaries radiology reports, operative reports etc should be transcribed promptly.
- Medical Coding: Medical coding refers to correct assignment of medical codes for timely reimbursement from insurers. It ensures that all health records include proper diagnoses according to the ordered procedures. It is the process of transforming healthcare diagnosis, procedures, medical services and equipment into universal medical alpha numeric codes including ICD-9 codes, CPT codes, HCPCS codes, DRG ( Drug Related Group) codes, and Modifiers.
- Staff support: Staff support is very important in a healthcare setup. With healthcare information management and medical support, patients can be given optimum care. It also includes proper reviewing of records for compliance with state, federal and private insurance guidelines. If any weakness is noticed after review, then it must be communicated to the respective physician or clinician to ensure better medical documentation.
- Basic medical necessity: It refers to basic, reasonable and necessary treatment provided for an illness. It is important to establish basic medical necessity for any medical service provided. Most insurers including Medicare and Medicaid will not pay for a treatment that is not considered medically necessary based on standards of care.
- Arrangement of medical records: Proper arrangement of medical records is important to provide better healthcare service. The medical chart should be an accurate legal record and include transcribed copies of medical reports, and claim submission details for reimbursement. It should provide accessibility to authorized entities requesting information.
- Maintenance of medical records: Efficient maintenance of medical records is vital to ensure accuracy and accessibility of medical data to ensure continuity of care to patients throughout their lifetime.
- Medical records filing: This involves designing and developing a healthcare information management system that is easily accessible, organized, protects patient confidentiality, and is compliant with the laws and guidelines of HIPAA.
- Release of patient data: Patient information may be important for many reasons – for ongoing care, insurance purposes, legal cases etc. The medical office is responsible for providing patient information in a timely manner, but only upon authorization from the patient or authorized representative. The release of information steps include the following:
- Obtaining legal authorization for the release of PHI or Protected Health Information
- Completion of the medical record
- Transmitting the EHR
- Tracking the requests and monitoring the aptness of response
- Security and privacy of information: With rising use of information technology in healthcare, your medical office must take necessary steps to ensure privacy and security of patient information. The following measures can assure safety of patient data:
- Storage of protected health information in a manner that protects the confidentiality of patients.
- Use encryption controls to ensure safe and protected transmission of data over a network.
- Deploy features that promise that the medical staff has proper training and authorization to access PHI
- Confidentiality: Confidentiality of medical records can be achieved through proper disposal, storage, access and disclosure of data.
A complete and accurate medical record helps physicians provide quality and effective patient care. HIM professionals can ensure that the medical records of patients are complete and accurate in all regards by performing detailed analysis of the information contained in the health records. Document conversion companies providing service to health systems understand the important role the HIM department plays in ensuring the confidentiality of health information in the medical record. By keeping the above mentioned responsibilities in view, HIM professionals can ensure error-free medical records, excellent documentation, communication and healthcare implementation.