Health Information Management Profession

Although the EHR is still in a transitional state, this major shift that electronic medical records are taking is bringing many concerns to the table. Two concerns at the top of the list are privacy and standardization issues. In 1996, U.S. Congress enacted a non-for-profit organization called Health Insurance Portability and Accountability Act (HIPAA). This law establishes national standards for privacy and security of health information. HIPAA deals with information standards, data integrity, confidentiality, accessing and handling your medical information. They also were designed to guarantee transferred information be protected from one facility to the next (Meridan, 2007). But even with the HIPAA privacy rules, they too have their shortcomings. HIPAA can’t fully safeguard the limitations of who’s accessible to your information. A short stay at your local

The purpose of this paper is to discuss the electronic health record mandate. Who started it and when? I will discuss the goals of the mandate. I will discussion will how the Affordable Care Act ties into the mandate of Electronic Health Record. It will describe my own facility’s EHR and what steps are been taken to implement it. I will describe the term “meaningful use,” and it will discuss possible threats to patient confidentiality and the what’s being done by my facility to prevent Health Information and Portability Accountability Act or HIPAA violations.

The American Health Information Management Association (AHIMA) is a recognized, respected association of health information management (HIM) professionals worldwide. Founded in 1928, AHIMA has become a respected authority for professional education and training in the effective management of health data and medical records needed to deliver quality healthcare to the public. Throughout AHIMA’s history back to 1928, the American College of Surgeons established the Association of Record Librarians of North America (ARNLA) to “elevate the standards of clinical records in hospitals and other medical institutions” (www.ahima.org, 2015). Since its formation, the Association has undergone several name changes in its evolution of the profession. In 1938 the Association changed its name to the American Association of Medical Record Librarians (AAMRL) for a more concise representation. When the Association became the American Medical Record Association in 1970, health information professionals had increased their involvement in hospitals, community health centers, and other health service facilities. As the health industry continues to evolve, the Association changed its name in 1991 to American Health Information Management Association to capture the expanded scope of clinical data beyond medical records to health information comprising the entire continuum of care.

There are many challenges associated with HHR. For example, there must be additional instructions to find the storage locations of patients’ health information. The instructions must show whether the documents are in electronic, paper, or scanned format. An additional process to link all of documentation formats needs to be deployed so that patients’ data can be collected and saved accurately. Not all the time those extra helps are available. Therefore, composing and organizing a completed HHR take a significant amount of time for health information management (HIM) professionals to gather all paper records and retrieve digital documents. The functions of HIM professionals encounter many challenges when working with HHR. The privacy and security policies for different types of records must be fully reinforced. Moreover, the updated data for each HHR have to be kept in detail for accuracy of information and easy accessing. In case of disclosing information requests, HIM professionals face a big burden of locating and verifying the information that is needed to fulfill the reasonable demand while limiting the release of information to the minimum. HIM professionals sometimes have to search through multiple systems to find the requested documents. According to Dimick, another disadvantage of the HHR system is when healthcare organizations participate in quality

Several years ago, a mandate was ordered requiring all healthcare facilities to progress from paper charting and record keeping to electronic health record (EHR). This transition to electronic formatting has pros and cons associated with it. I will be describing the EHR mandate, including who initiated it, when it was initiated, the goals of the EHR, and how the Affordable Care Act and the Obama administration are tied into it. Then I will show evidence of research and discuss the six steps of this process as well as my facilities progress with EHR. Then I will describe meaningful use and how my facility attained it. Finally, I will define HIPAA law, the possible threats to patient confidentiality relating to EHR, and how what my facility

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

As the national health care system transitions to the electronic health record (EHR), it is important to recall the impetus to this reform. Prior to the implementation of the electronic health record, the national health care system encountered many problems that impeded quality patient care. There was not a standardized formal structure with the process. Consequently, it lacked communication across disciplines and among providers and

But as noted previously, more is needed than standardizing these processes. Health care providers (physicians and hospitals) should embrace electronic health records (EHRs) and should integrate appropriate information from billing systems with clinical information (the recording and analysis of clinical services) from EHRs (Wikler et al., 2012; Cutler et al., 2012). To address concerns that occur due to accessing medical records, the secretary of health and human services could expand criteria under the Health information Technology for Economic and Clinical

AHIMA recognizes that superior quality health care and clinical data are critical resources needed for effective healthcare, and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. This group is concerned about the effective management of health information from all sources and its application in all forms of healthcare and wellness preservation. Health issues, disease, and care quality also transcend across national borders. AHIMA’s professional interest is in the application of best health information management practices when and wherever they are needed. (The American Health Information Management Association, 2010).

It has only been within the last five years that health information management (HIM) has experienced exponential changes, due to the healthcare reform. The electronic health record (EHR) is connected to health information exchanges and other systems of interoperability. The timely completion of charts, coding and release of information (ROI) has become much more efficient with the electronic record. Traditional HIM functions will just be transformed and will always be an integral part of successful patient care. Professionals must be flexible and willing to adapt and even generate change. As Health Information Technology continues to evolve, so will the roles

As more jobs are being created, Health Information Management (HIM) professionals, especially those that are studying in the field of research and analytics should be aware and care about any and all the changes and updates related to IRBs and research. HIM professionals should care greatly about IRB’s and the research because as these jobs are evolving, patient privacy, patient rights, patient welfare and patient confidentiality are often being put at risk (Layman & Watzlaf, 2009). That said, because HIM professionals have a large amount of knowledge regarding HIPAA’s privacy and security standards, quality improvement, data management and proper use of electronic health records (EHRs), HIM professionals play a vital role in safeguarding the human subject’s rights and well-being (Layman & Watzlaf, 2009). This typically happens at the beginning of the protocol with proper documentation and ensure that reasonable recruiting standards are being met and privacy safeguards are being followed (Layman & Watzlaf, 2009). With that said, it is important for HIM professionals to care about IRBs and research, especially if they are part of a research study team and have a role of a research analyst, because their knowledge, skills and expertise play an enormous role of protecting the human subject’s health

I would like to thank you and your staff for a great experience. The lessons I learned have taught me so much about this field and I now know that I should not limit myself just to coding and that there are many opportunities in other areas.

Health information technique is biggest term in today’s era, technology used for various administrative, operations management, and direct clinical functions in health care organization. An electronic health record (EHR) is define by the Health Information Management System Society (HIMSS) as a longitudinal electronic record of patient health information generated by one or more encounter in any health care setting including patient demographics, progress

“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an

Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).