Health information management professionals (HIM™) provide services in all aspects of records management – including data collection and data quality management, integrity, standards, disclosure, coding, disposition, and privacy of health information. They perform detailed analysis of the information in the health record to facilitate health care delivery, patient safety and decision support. They play a role in ensuring the confidentiality of health information within the patient record and are advocates of the patient’s right to private, secure and confidential information. HIM professionals are essential in quality programs, and provide guidance on documentation, communication, eHealth implementation, EHR infrastructure, and policy issues.
Health data is coded and used for analysis by organizations such as the Canadian Institute for Health Information (CIHI), the Canadian Patient Safety Institute and the provincial ministries of health to look at adverse events. Hospital decision support departments use the adverse events, Hospital Standardized Mortality Rates (HSMR), complication rates, in-house infections etc. – to improve how they treat patients.
“Over the years I have been most fortunate to serve in different capacities that contribute to patient safety. As a decision support analyst, I provide indicators and analyses from our incident and infection control databases to our clinical teams to assess safety and risk. Leading the hospital accreditation process in the past included working with all teams to ensure that standards around patient safety were addressed. This included workflow analyses, staff education, communications and policy revision,” explains Jeanette Martin, Decision Support Analyst at Winchester District Memorial Hospital. “I truly feel that HIMs in all capacities greatly contribute to patient safety. From the core coding staff that collect data that provides much of the foundation for decision-making to the actual strategic level decision-makers. We all have our roles to play and I am proud to play mine every day.”
HIM coders – who bring strong biomedical science education, coding classification and abstracting knowledge – collect data from hospital visits (acute, ambulatory care, rehab, etc.) and codify the data using the International Classification of Diseases, Canadian adaptation or modification (ICD-10-CA) and the Canadian Classification of Interventions. The ICD codes were developed by the World Health Organization and are used internationally and adapted for use by country if needed.
As active participants in patient safety in a transforming Electronic Health Record (EHR) environment, HIMs champion patient safety and quality care by advocating for and managing complete, timely, accurate, and meaningful data. The Canadian Health Information Management Association (CHIMA) requires all certified HIM professionals to participate in Continuing Professional Education, ensuring HIM professionals maintain their knowledge, awareness of evolving data, new EHR developments, infrastructure innovations, and standards related to eHealth transformations, supporting their role as data and information stewards.
HIM professionals play an important role in patient safety as hospitals and ministries use the data they collect and analyze to:
• Ensure that patient information is secure and protected
• Improve healthcare quality by reducing medical errors, health disparities, and by advancing the delivery of patient-centered medical care
• Reduce healthcare costs resulting from inefficiency, medical errors, inappropriate care, duplicative care, and incomplete information
• Provide appropriate information to help guide medical decisions at the time and place of care
• Improve the coordination of care and information among hospitals, laboratories, physician offices, and other entities for the secure and authorized exchange of healthcare information
• Improve public health activities and facilitating the early identification and rapid response to public health threats
• Facilitate health and clinical research and healthcare quality
• Promote early detection, prevention, and management of chronic diseases.
In 2009, the Health Informatics (HI) and Health Information Management (HIM) Human Resources Report was released, which highlighted a serious risk of labour and skill shortages over the next five years. An additional 6,320 to 12,330 HI and HIM professionals are needed by 2014. HI and HIM™ professionals who require broader skills will increase from 8,880 in 2009 to between 13,690 and 32,170 by 2014.
“As the ehealth record gets rolled out across Canada, the role of the certified health information management professional will become increasingly important in ensuring our health information is protected, and properly managed,” says Gail Crook, CEO and registrar of CHIMA and CCHIM. “Without certified professionals doing the work, more errors occur, data is compromised and patient safety is at risk. As our health records go paperless, the privacy, confidentiality and safety of those records need to be managed by a certified HIM professional in order to ensure the best patient care.”