Health information managers / professionals have a variety of different roles that they are responsible for with regard to record keeping. Which role do you feel is the most important and why? Which one do you think will be the most challenging for you to implement and why? What steps could you take to address this challenge?
and respond to these 2 discussion responses as well with 4 sentences min. :
Hicks (2016) presents a general categorization of the array of responsibilities of health information managers that relate to record keeping into the assembly, organization and maintenance, dissemination and storage of medical records. In my opinion, the most important health information management role that relates to record keeping is the organization and maintenance of medical records. This opinion is premised on the fact that the primary objective of health information management is the improvement of healthcare quality by ensuring that healthcare decisions are facilitated by making the best information available through efficient management relevant data and information assets (Zeng, Reynolds, & Sharp, 2009). Therefore, to make the best information available, the records have to be accurate, legally complaint, organized and easily accessible, factors that can only be achieved through their efficient organization and maintenance. The most challenging role to implement relates to the dissemination of medical records because of the stringent authorization, privacy and confidentiality requirements demanded by the law whose failure to observe may expose both patients and healthcare providers to risk and associated legal liability for the service provider. This challenge can be addressed by being proactive and confirm that all authorization is credible and authentic before disseminating the information.”
Health Information Management professionals are an often unrecognized part of the team because most of what they do is behind the scenes. That doesn’t make their job any less important, and actually the work performed by HIM professionals has significant implications to the health care organization they work in. They are responsible for data quality, which includes timeliness and completeness. There are many processing controls that are utilized by the HIM department. Processing controls are preventive, meaning they are in place to prevent any errors from occurring. Also there are detective controls, which aid in the discovery of errors. This leads to corrective controls, which is correcting any errors that are discovered. HIM professionals are also responsible for post discharge processing. This includes storage, security and access as well as record retention. Part of the discharge processing is identification of records that need to be processed, assembly of the record, quantitative analysis, deficiency determination, coding and abstracting. Once the post discharge processing is complete, and the record is permanently filed, the HIM staff is responsible for release of patient information.
To me the post discharge processing is the most important because dealing with deficiencies and coding have significant implications for the organization. The coded data is used in many avenues such as public reporting and billing. If a record is coded incorrectly the organization can loose large sums of money. They can also appear to have negative outcomes, which will impact their reputation, status and finances.
I feel coding is also the most challenging because of the brief education the staff has in order to be certified as a coder. Also the transition from ICD-9 to ICD-10 codes that occurred in October 2015. ICD is International Statistical Classification of Diseases and Related Health problems 10th Revision. These codes are classified by the World Health Organization and when the United States transitioned to ICD-10, we went from 13,000 codes to over 68,000 codes. The US delayed implementation of the transition from ICD-9 to ICD-10 as long as we could. There were others in the world using ICD-10 codes since 1994. There is now ICD-11 coding under development with a projected release in 2017.
To address the challenges of ICD-10 we could improve career opportunities, increase staffing levels, and increase interactions with medical staff that may provide additional education or understanding of procedures allowing more accurate coding.