Health Information Management: Changing with Time

Abstract

SummaryObjective: With the evolution of patient medical records from paper to electronic media and the changes to the way data is sourced, used, and managed, there is an opportunity for health information management (HIM) to learn and facilitate the increasing expanse of available patient data. Methods: This paper discusses the emerging trends and lessons learnt in relation with the following four areas: 1) data and information governance, 2) terminology standards certification, 3) International Classification of Diseases, 11th edition (ICD-11), and 4) data analytics and HIM. Results: The governance of patient data and information increasingly requires the HIM profession to incorporate the roles of data scientists and data stewards into its portfolio to ensure data analytics and digital transformation is appropriately managed. Not only are terminology standards required to facilitate the structure and primary use of this data, developments in Canada in relation with the standards, role descriptions, framework and curricula in the form of certification provide one prime example of ensuring the quality of the secondary use of patient data. The impending introduction of ICD-11 brings with it the need for the HIM profession to manage the transition between ICD versions and country modifications incorporating changes to standards and tools, and the availability and type of patient data available for secondary use. Conclusions: In summary, the health information management profession now requires abilities in leadership, data, and informatics in addition to health information science and coding skills to facilitate the expanding secondary use of patient data.

Findings from the 2017 Yearbook Section on Health Information Management

“…The survey paper of the 2017 HIM section [11] focuses on a different perspective and describes the impact on the practice and profession of HIM of the issues related to data governance, new terminology standards, and data analytics. Noting the evolution of patient medical records from paper to electronic media and the accessibility of new data sources and uses, the paper focuses on four areas: 1) the increasing need for effective data and information governance; 2) the development of a terminology standards certification; 3) the upcoming release and implementation of the International Classification of Diseases, 11th edition (ICD-11); and 4) the growing role of data analytics within HIM.…”

“…The lead author of the survey paper of the 2017 HIM section [11], Susan Fenton, PhD, RHIA, FAHIMA, was selected for her expertise in both HIM and Informatics and her co-authors bring an international perspective as well. Together, the survey paper of the 2017 HIM section and the 15 candidate best papers published in 2016 provide a picture of the current state of the intersection of the disciplines of health information management and informatics.…”

“…A key barrier to the exchange of information is arriving at agreement on standards, both on terminology standards, traditionally within the domain of HIM and addressed by Fenton et al [11], and on messaging standards. Three of the 15 candidate papers address this issue, one of which was selected as a best paper.…”

Consequences of ineffective information and knowledge management (IKM) in hospitals: junior doctors’ perspectives

“…Important aspects of IKM include the capability to instil and promote positive information behaviours and values in people to ensure effective use and sharing of information (Evans & Price, 2012). IKM is forecast to become the biggest growth area in health due to digital transformation of the healthcare sector (Fenton et al, 2017).…”

“…The healthcare sector in Australia comprises multiple agencies, including public and private hospitals, outpatient services, general practice and allied health, with limited information exchange across the sectors (Pearce & Brainbridge, 2014), partly due to the complexity of information security and privacy (Fenton et al, 2017). Information and knowledge in medicine is ever-changing and IKM practices and systems must keep up with change (Ganzinger & Knaup, 2017).…”