Identifying Health Information Management HIM to Consumers and other Healthcare Professionals

1. Identifying Health Information Management (HIM) to Consumers and other Healthcare Professionals Julie A. Dooling, RHIT Note to presenter: This presentation is meant to assist in educating consumers, health information management (HIM) professionals, and other healthcare professionals regarding the importance of ensuring accurate health information in today�s complex healthcare environment. This presentation is created to raise awareness of who the HIM professional is, what role he or she plays in the current healthcare landscape, and the importance of accurate health information for the consumer. Welcome to the session �Identifying Health Information Management (HIM) to Consumers and other Healthcare Professionals� My name is ______________and I am _________________ (position, title). This presentation will focus on the importance of ensuring accurate health information in today�s healthcare landscape. Many ongoing industry efforts affect the management of health information today. It is important to understand these changes and how they will impact the ability to ensure accuracy, availability, and protection of health information data in the future.Note to presenter: This presentation is meant to assist in educating consumers, health information management (HIM) professionals, and other healthcare professionals regarding the importance of ensuring accurate health information in today�s complex healthcare environment. This presentation is created to raise awareness of who the HIM professional is, what role he or she plays in the current healthcare landscape, and the importance of accurate health information for the consumer. Welcome to the session �Identifying Health Information Management (HIM) to Consumers and other Healthcare Professionals� My name is ______________and I am _________________ (position, title). This presentation will focus on the importance of ensuring accurate health information in today�s healthcare landscape. Many ongoing industry efforts affect the management of health information today. It is important to understand these changes and how they will impact the ability to ensure accuracy, availability, and protection of health information data in the future.

2. The Professional Definition of HIM �HIM improves the quality of healthcare by ensuring that the best information is available to make any healthcare decision. HIM professionals manage healthcare data and information resources. The profession encompasses services in planning, collecting, aggregating, analyzing, and disseminating individual � and aggregate clinical data�� 2 What is HIM? Here is the professional definition developed by the AHIMA Committee on Professional Development (Health Information Management Concepts, Principles and Practice, Third Edition, Figure 4.1, page 87). HIM professionals are acutely aware of the importance of the consumer�s needs for healthcare accuracy and integrity. Their responsibilities include a wide variety of tasks to help guarantee complete, accurate, and accessible data for the care you, the consumer, trust.What is HIM? Here is the professional definition developed by the AHIMA Committee on Professional Development (Health Information Management Concepts, Principles and Practice, Third Edition, Figure 4.1, page 87). HIM professionals are acutely aware of the importance of the consumer�s needs for healthcare accuracy and integrity. Their responsibilities include a wide variety of tasks to help guarantee complete, accurate, and accessible data for the care you, the consumer, trust.

3. New National Coordinator for Health Information Technology �We need to ensure and maintain the public�s trust in health information systems and the exchange of their health information.� �A key to the success of widespread implementation of electronic health records, as well as health information exchanges, is to build public confidence that the information is secure and their privacy rights are protected.� Dr. Farzad Mostashari, ScM National Coordinator for Health Information Technology 3 Farzad Mostashari, the new National Coordinator for Health Information Technology at the Office of the National Coordinator (ONC) was quoted saying the above in April 2011. He emphasized trust in health information systems, and securing and protecting privacy rights among his list of priorities in his new position.Farzad Mostashari, the new National Coordinator for Health Information Technology at the Office of the National Coordinator (ONC) was quoted saying the above in April 2011. He emphasized trust in health information systems, and securing and protecting privacy rights among his list of priorities in his new position.

4. HIM Principles Availability�HIM professionals ensure consumer health information is readily available only to those who need it, when they need it. They ensure the appropriate and rightful access to health information only to those legally authorized to do so. Accuracy�HIM professionals manage all information collected about an individual�s health to ensure it is correct and done so with timeliness, authenticity, and precision to meet all state and federal regulations and ensure optimal continuity of care outcomes. Protection�HIM professionals pledge to keep personal health information confidential from anyone except those who have a legal right to see or review it. They employ privacy and security measures to optimally safeguard health information in all forms�paper, electronic, in transit, and at rest. And Dr. Mostashari�s priorities are in line with HIM professional principles. Consumers need to trust their health information is accurate, available, and protected. Today, more than ever before, consumers realize the value of having electronic access to their health information. Consumers take more of an active role in their healthcare and are becoming increasingly informed and educated. On a daily basis, HIM professionals are confronted with new challenges on how to manage health information with existing and new regulations and guidelines to maintain a sound and legally compliant health record. The principles mentioned on this slide are a sampling of what HIM professionals strive to achieve. These principles are evident through many of the tasks and functions HIM professionals conduct, from managing and releasing health information, to documentation of best practices, to proper coding and billing of care rendered, all within a paper, electronic, or hybrid environment. And Dr. Mostashari�s priorities are in line with HIM professional principles. Consumers need to trust their health information is accurate, available, and protected. Today, more than ever before, consumers realize the value of having electronic access to their health information. Consumers take more of an active role in their healthcare and are becoming increasingly informed and educated. On a daily basis, HIM professionals are confronted with new challenges on how to manage health information with existing and new regulations and guidelines to maintain a sound and legally compliant health record. The principles mentioned on this slide are a sampling of what HIM professionals strive to achieve. These principles are evident through many of the tasks and functions HIM professionals conduct, from managing and releasing health information, to documentation of best practices, to proper coding and billing of care rendered, all within a paper, electronic, or hybrid environment.

5. History of AHIMA The HIM profession began with the founding of the Association of Record Librarians of North America (ARLNA) in 1928. Their original goal was to improve clinical recordkeeping in healthcare facilities. Today, the American Health Information Management Association (AHIMA) is more than 61,000 members strong. The American College of Surgeons established the ARLNA to �elevate standards of clinical records in hospitals and other medical institutions.� Even then, medical record quality for patient care was something they strove for. Today, the HIM profession continues to place quality first through actively managing quality information for patient care and addressing many emerging national issues, including adopting and implementing electronic health records (EHRs), the ICD-10 transition, and health information exchange (HIE) to name a few. The American College of Surgeons established the ARLNA to �elevate standards of clinical records in hospitals and other medical institutions.� Even then, medical record quality for patient care was something they strove for. Today, the HIM profession continues to place quality first through actively managing quality information for patient care and addressing many emerging national issues, including adopting and implementing electronic health records (EHRs), the ICD-10 transition, and health information exchange (HIE) to name a few.

6. HIM Professionals Now that you�ve seen AHIMA and the HIM profession from an historical perspective, let�s discuss how they work in the healthcare arena. Do you know someone with the following credentials after their name? CCA CCS CCS-P RHIT RHIA CHDA CHPS If you do, you know an AHIMA-certified HIM professional! AHIMA�s certification paths include HIM, coding, healthcare privacy and security, and health data analysis as a guide to career advancement. Credentials are earned through a challenging program of examinations, education, and experience, and maintained through continuous review and education. HIM professionals serve in a variety of healthcare settings and roles and responsibilities. HIM professionals are expertly trained in management of health information. Now that you�ve seen AHIMA and the HIM profession from an historical perspective, let�s discuss how they work in the healthcare arena. Do you know someone with the following credentials after their name? CCA CCS CCS-P RHIT RHIA CHDA CHPS If you do, you know an AHIMA-certified HIM professional! AHIMA�s certification paths include HIM, coding, healthcare privacy and security, and health data analysis as a guide to career advancement. Credentials are earned through a challenging program of examinations, education, and experience, and maintained through continuous review and education. HIM professionals serve in a variety of healthcare settings and roles and responsibilities. HIM professionals are expertly trained in management of health information.

7. Managing Information There are an estimated 1.2 billion ambulatory care visits in the United States per year. Physician Offices Hospital Outpatient Emergency Department 7 The volume of information and data managed by an HIM professional is staggering. According to the CDC, there are an estimated 1.2 billion ambulatory care visits in the US per year�and this only takes ambulatory care into account. What if we included hospitals, long-term care facilities, and all other types of healthcare organizations providing care? How much information would that total up to? Unsurprising, it�s a lot! With volume increase comes demand for staffing. According to the Bureau of Labor Statistics, 10 of the 20 fastest-growing occupations are healthcare-related. They project that healthcare will generate 3.2 million new wage and salary jobs between 2008 and 2018; more than any other industry, largely in response to growth in the elderly population. The volume of information and data managed by an HIM professional is staggering. According to the CDC, there are an estimated 1.2 billion ambulatory care visits in the US per year�and this only takes ambulatory care into account. What if we included hospitals, long-term care facilities, and all other types of healthcare organizations providing care? How much information would that total up to? Unsurprising, it�s a lot! With volume increase comes demand for staffing. According to the Bureau of Labor Statistics, 10 of the 20 fastest-growing occupations are healthcare-related. They project that healthcare will generate 3.2 million new wage and salary jobs between 2008 and 2018; more than any other industry, largely in response to growth in the elderly population.

8. HIM Professionals Healthcare settings include: Acute Care Hospitals Clinics or Physician Practices Integrated Healthcare Delivery Systems Government/Public Health Agency Long-Term Care Behavioral/Mental Care Ambulatory Surgery Centers Home Health or Hospice 8 HIM professionals serve in a variety of healthcare settings. Some include: Acute care hospitals, which include larger facilities, to small critical care access hospitals (CAHs), clinics or physician practices, integrated healthcare delivery systems, government or public health agencies, long-term care facilities, and behavioral and mental care facilities; ambulatory surgical centers; and home health or hospices. HIM professionals can also be found in other settings, such as consulting services, educational institutions, vendors� health information technology products and services, HIEs, regional extension centers (RECs), corporate compliance, insurers or managed care organizations, third-party billing services, associations or agencies, staffing services, and pharmaceutical companies. HIM professionals serve in a variety of healthcare settings. Some include: Acute care hospitals, which include larger facilities, to small critical care access hospitals (CAHs), clinics or physician practices, integrated healthcare delivery systems, government or public health agencies, long-term care facilities, and behavioral and mental care facilities; ambulatory surgical centers; and home health or hospices. HIM professionals can also be found in other settings, such as consulting services, educational institutions, vendors� health information technology products and services, HIEs, regional extension centers (RECs), corporate compliance, insurers or managed care organizations, third-party billing services, associations or agencies, staffing services, and pharmaceutical companies.

9. HIM Professional Roles Today HIM professionals serve in various roles, including: Coding Professional Technology (data/systems analysts) Director/Manager/Supervisor Compliance or Security Officer Consultant Executive/President/Vice President 9 HIM professionals hold a variety of roles in healthcare. The titles and responsibilities are diverse and continually transforming, alongside the ever-changing national healthcare landscape. Due to healthcare�s increasing need for workers�coupled with federal and state initiatives fueling enhanced use of information technology�HIM titles, roles, and responsibilities will continue to change for the foreseeable future with new emerging positions being created. HIM professionals hold a variety of roles in healthcare. The titles and responsibilities are diverse and continually transforming, alongside the ever-changing national healthcare landscape. Due to healthcare�s increasing need for workers�coupled with federal and state initiatives fueling enhanced use of information technology�HIM titles, roles, and responsibilities will continue to change for the foreseeable future with new emerging positions being created.

10. HIM Professional Emerging Roles Health Data Analyst Speech Recognition Editor Data Systems Analyst Medical Scribe Data Integrity Specialist EHR Trainer/Educator Patient Portal Manager Medical Abstracting Analyst 10 HIM professionals are going beyond today�s roles and are now working in roles such as clinical vocabulary manager, data analyst, and other new and emerging positions. As you can see, these new roles involve working with data and information technology that correlates to the increased adoption of electronic health records (EHR) and organizations preparing to share data in HIE environments. HIM professionals are going beyond today�s roles and are now working in roles such as clinical vocabulary manager, data analyst, and other new and emerging positions. As you can see, these new roles involve working with data and information technology that correlates to the increased adoption of electronic health records (EHR) and organizations preparing to share data in HIE environments.

11. Why HIM Professionals? We: Ensure health information is available throughout the healthcare delivery system by managing information and data in various forms and media. Manage the health record from paper to EHR and final storage, and retrieval in legal archive. Coordinate health information throughout the individual�s entire life; from birth to death. 11 The scope of health information is a collection from multiple sources with a wide variety of uses. Within the professional definition of HIM shown earlier, health information includes the following types of data: Clinical Data Epidemiological Data Demographic Data Financial Data Research Data Reference Data Coded Data The HIM professional may engage in one or multiple types of data and services with the goal of providing high quality data for healthcare. The scope of health information is a collection from multiple sources with a wide variety of uses. Within the professional definition of HIM shown earlier, health information includes the following types of data: Clinical Data Epidemiological Data Demographic Data Financial Data Research Data Reference Data Coded Data The HIM professional may engage in one or multiple types of data and services with the goal of providing high quality data for healthcare.

12. Why HIM Professionals? We: Protect confidentiality by following all state and federal guidelines. Release information only to those who are authorized. Consolidate the consumer�s healthcare data and information resources. 12 The HIM professional ensures patient privacy and confidential information are protected and that data security measures are used to prevent unauthorized access to information. Our professional code of ethics includes the protection of patient privacy and confidential information outlining what information should be collected; how the information should be handled; who has access to the information; and under what conditions the information should be disclosed. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established national standards for privacy and security of health information. HIM professionals ensure compliance with HIPAA�s enforcement program. One of the driving forces behind HIPAA was securing patient information as more healthcare providers move from paper-based records to EHRs. HIM Professionals play an extremely important role in managing and protecting health information as organizations move toward an integrated EHR. Not only within the four walls of their facility, but also through actively participating in the development and operation of state and national initiatives such as HIEs and regional health information exchanges (RHIEs). The HIM professional ensures patient privacy and confidential information are protected and that data security measures are used to prevent unauthorized access to information. Our professional code of ethics includes the protection of patient privacy and confidential information outlining what information should be collected; how the information should be handled; who has access to the information; and under what conditions the information should be disclosed. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established national standards for privacy and security of health information. HIM professionals ensure compliance with HIPAA�s enforcement program. One of the driving forces behind HIPAA was securing patient information as more healthcare providers move from paper-based records to EHRs. HIM Professionals play an extremely important role in managing and protecting health information as organizations move toward an integrated EHR. Not only within the four walls of their facility, but also through actively participating in the development and operation of state and national initiatives such as HIEs and regional health information exchanges (RHIEs).

13. A Day in the Life� 13 This graphic provides a glance into the world of HIM, with only a sampling of some responsibilities in the day-to-day life of an HIM Professional. This graphic provides a glance into the world of HIM, with only a sampling of some responsibilities in the day-to-day life of an HIM Professional.

14. What Is the Health Record? It�s the anchor that helps guide the continuity of a consumer�s care. It serves as part of the record of business as defined by a healthcare organization. It exists in a paper, hybrid, or electronic environment. 14 Every action during a consumer�s stay in a healthcare facility is documented in the health record for diagnosis and treatment. From registration to discharge, the health record serves to document not only the quality of care but is also there to fulfill legal requirements and evidentiary purposes. The information in the health record must outline and justify the individual�s treatment, support diagnosis of the individual�s condition, describe the individual�s progress and response to medications and services, and explain the outcomes of the care provided. As documentation of all activities in the individual�s care, the health record promotes continuity among the providers who treat the individual. The health record itself is the property of the healthcare facility. However, the consumer has the right to be informed about the use of his or her protected health information (PHI). HIPAA regulations require the consumer be notified of the uses of PHI through the notice of privacy practices. Every action during a consumer�s stay in a healthcare facility is documented in the health record for diagnosis and treatment. From registration to discharge, the health record serves to document not only the quality of care but is also there to fulfill legal requirements and evidentiary purposes. The information in the health record must outline and justify the individual�s treatment, support diagnosis of the individual�s condition, describe the individual�s progress and response to medications and services, and explain the outcomes of the care provided. As documentation of all activities in the individual�s care, the health record promotes continuity among the providers who treat the individual. The health record itself is the property of the healthcare facility. However, the consumer has the right to be informed about the use of his or her protected health information (PHI). HIPAA regulations require the consumer be notified of the uses of PHI through the notice of privacy practices.

15. Consumers Rely on HIM Professionals To ensure: Their health information is accurate and available when they need it. High levels of privacy and security for confidentiality. Released or accessed information is timely, accurate. and appropriate. 15 HIM professionals traditionally served as information rights resources to consumers. Now they serve as privacy officials and release of information specialists. But they did all this and more long before HIPAA was introduced. As the consumer-driven healthcare market increases and changes, HIM professionals will continue to assist the public with managing their health information and answering their questions. HIM professionals traditionally served as information rights resources to consumers. Now they serve as privacy officials and release of information specialists. But they did all this and more long before HIPAA was introduced. As the consumer-driven healthcare market increases and changes, HIM professionals will continue to assist the public with managing their health information and answering their questions.

16. Consumer Rights Consumers should understand and exercise their rights to: View and access your health information Request and receive a copy of your health information Request confidential communications of protected health information (PHI) Request a correction/update to your health information Request a restriction to your health information Keep certain information from ever being released Request an accounting of disclosures Log of where certain information was released as defined by law 16 As HIM professionals, we encourage consumers to know and understand their rights with regard to their health information as enforced by HIPAA�s privacy and security rules. As a consumer, your healthcare provider is required to give you a �notice of privacy practices� on your first visit and at least once every three years the notice is available upon request. This notice describes ways the HIPAA privacy rule allows them to use and disclose your protected health information (PHI), their duties to protect your information, your privacy rights including the right to complain to Health and Human Services (HHS), and how to contact the provider or organization for more information or to file a complaint. As HIM professionals, we encourage consumers to know and understand their rights with regard to their health information as enforced by HIPAA�s privacy and security rules. As a consumer, your healthcare provider is required to give you a �notice of privacy practices� on your first visit and at least once every three years the notice is available upon request. This notice describes ways the HIPAA privacy rule allows them to use and disclose your protected health information (PHI), their duties to protect your information, your privacy rights including the right to complain to Health and Human Services (HHS), and how to contact the provider or organization for more information or to file a complaint.

17. Time of Change 17 As shown in the American Hospital Association�s (AHA) graphic on this slide, many of the initiatives HIM professionals are involved with on a daily basis have tight deadlines and overlap. For example, the transition to ICD-10, administrative simplification, meaningful use of EHRs, health reform initiatives, and HIPAA privacy changes. In this time of change, the role of the HIM professional is instrumental. They are driving many of the changes currently facing healthcare. In addition, they continue to serve in the core role of improving the quality of healthcare by ensuring information is complete, accurate, and accessible. Do you know who your HIM professional is now? As shown in the American Hospital Association�s (AHA) graphic on this slide, many of the initiatives HIM professionals are involved with on a daily basis have tight deadlines and overlap. For example, the transition to ICD-10, administrative simplification, meaningful use of EHRs, health reform initiatives, and HIPAA privacy changes. In this time of change, the role of the HIM professional is instrumental. They are driving many of the changes currently facing healthcare. In addition, they continue to serve in the core role of improving the quality of healthcare by ensuring information is complete, accurate, and accessible. Do you know who your HIM professional is now?

18. Questions 18

19. References AHIMA Advocacy and Public Policy ahima.org/advocacy/default.aspx Centers for Medicare and Medicaid Services EHR Incentive Programs cms.gov/EHRIncentivePrograms/ Health IT Buzz Blog healthit.hhs.gov/blog/onc Office of the National Coordinator healthit.hhs.gov/portal/server.pt 19

20. References Health Information Career Pathfinder hicareers.com/Toolbox/pathways.aspx Health Information Management Concepts, Principles, and Practice, Third Edition Bureau of Labor Statistics bls.gov/oco/cg/cgs035.htm 20