Summary Of Abstracting In Health Information Management

Healthcare has evolved over past decades and continues to remain an issue of concern for individuals everywhere. Effectively managing data is important to improving the performance in the health care system. Accumulating, evaluating, deciphering and acting on data for particular performance measures allow health professionals to identify shortcomings and make the necessary adjustment, and track the outcome.

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

Although handwritten records are still the mainstay of clinical record keeping, many medical professionals believe that the increased use of information technologies has the potential to effect healthcare for the better. For example, Dr. Daniel R. Masys said, “Against a background of an explosively growing body of knowledge in the health sciences, current models of clinical decision making by autonomous practitioners, relying upon their memory and personal experience, will be inadequate for effective twenty-first-century health care delivery.” While keeping in mind how far manual records have gotten us, we need to realize that information technologies result in better data correlation and management.

Healthcare systems are highly complex, fragmented, and use multiple information technology systems and vendors who incorporate different standards resulting in inefficiency, waste, and medical errors (Healthinformatics, 2016). A patient 's medical information often gets trapped in silos, which prevents information from being shared with members of the healthcare community (Healthinformatics, 2016). With increasing healthcare costs, a system needed to be created that would lead to the development and nationwide implementation of an interoperable health information technology system to improve the quality and efficiency of healthcare. Introducing the National Health Information Network (NHIN), this organization can be defined as a set of

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.

Patients are taking an aggressive role in their healthcare needs. Patients desire to in touch with their medical records. Medical professionals are utilizing the Electronic Health Records to implement current data into information necessary to provide quality care for the patient. Thereby, managing patients’ current, and past histories. To understand what is occurring today, one must recognize why patients are taking an active approach to their healthcare.

How data is captured varies from institution to institution. In order for data to be well understood, data should have a definition that is consistent and comprehensively understood by all users of the data. Standardization of how data is captured is critical to allow the production and export of data needed to support quality assessment, decision support, exchange of data for patients with multiple health care providers and public health surveillance. Patient safety and quality improvement are dependent upon embedded clinical guidelines that promote standardized, evidence-based practices. Unless we can achieve standardization with terminology, technologies, apps and devices, the goals of EHR implementation will not become a

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

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

When I first enrolled in BMI 5300: Introduction to Biomedical Informatics class, I was very eager and excited to learn the role of biomedical informatics in healthcare organizations and the importance of data capture and analysis in improving public health. One of the major misconceptions I had was that this course would not cover wide range of factors influencing the biomedical informatics field. Much to my surprise, the course provided a comprehensive analysis of factors related to biomedical informatics, including but not limited to EHR systems, interfaces, Health Information Exchanges, Meaningful Use (MU) requirements, and controlled medical vocabularies such as Logical Observation Identifiers Names and

While many people believe that health information exchange is a relatively new thing, it has been around for over four decades. However, in the beginning phases it was nowhere near as complex as it is now. Sometime in the middle of the 60’s, an early form of a data processing system was formed and it focuses on clinical data management. This system began to catch on even though they were nowhere near as sophisticated and or functional as the health records in today’s time.

The American Health Information Management Association is a body of health information professionals that majorly concerns itself with the improvement of the quality of medical records (Harman 104). These

In health care, patients’ lives are in the hands of the health care practitioners, health care organizations, insurance companies, and to some degree, even health care technology. The growth and future implications of evidence-based medicine (EBM) through improvement of technology in health care are important today, because health care practitioners and organizations want to ultimately decrease cost, improve quality of care, and increase access to health care (Glandon, Smaltz, & Slovensky, 2014, p. 28). One way to achieve these goals is through the implementation and improvement of EBM and interoperability which will enhance the efficiency of work production resulting in these positive outcomes. According to Glandon, Smaltz, and Slovensky (2014), EBM is an “information management and learning strategy that seeks to integrate clinical expertise with the best evidence available to make effective clinical decisions that will ultimately improve patient care,” (p. 6). “Interoperability is the ability of different information and communications technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use information that has been exchanged,” (Iroju, Soriyan, Gambo, & Olaleke, 2013, para. 1). Without interoperability and EBM, fundamental data and information such as patient records cannot be easily shared across and within enterprises having a direct impact on the quality of care. It