American Health Information Management Association (AHIMA)

Health Information Management (HIM) is the process of protecting, analyzing, inspecting and acquiring medical information such as health records, each time a patient is seen by a healthcare provider. The HIM professional is an important connection between doctors, nurses, patients, insurance companies and everyone in the medical field. Every time a healthcare professional sees and treats a patient, they record what they observed, how the patient was treated medically, and future steps in the treatment plan discussed between the patient and the healthcare worker. The medical record includes the patient’s symptoms, medical history that includes past, present, and family history, results of studies, such as x-ray reports, or lab results, diagnosis,

Confidentiality and data breaches are a few of the main concerns, as many providers become neglectful when sharing patient electronic health information. Current use of Electronic Health Records (EHR) has proven to be helpful for hospitals and independent medical practice to provide efficient care for patients. Balestra reports that using computers to maintain patient health records and care reduces errors, and advances in health information technology are saving lives and reducing cost (Balestra, 2017). As technology advances EHR are going to continue to be the main method of record keeping among medical providers. Therefore, staff and medical providers need to be trained on how to properly share patients EHR safely and in a secure form in order to maintain patient confidentiality.

Its determination is to associate patients to their data to improve the capability to generate a simplicity in sharing this data amongst the multiple health facilities patients visit. UPIs engendered by Electron Health Records (EHR) data can be manipulated by other healthcare systems including hospitals, pharmacies, insurance companies, patients, clinical research firms or diagnostic medical devices. These entities allocate data to be encapsulated, assembled, managed and then interconnected together universally. According to the article, Registries for Evaluating Patient Outcomes: A User 's Guide, “PIM has become crucial in order to (1) enable health record document consumers to obtain trusted views of their patient subjects, (2) facilitate data linkage projects, (3) abide by the current regulations concerning patient information–related transparency, privacy, disclosure, handling, and documentation,2 and (4) make the most efficient use of limited health care resources by reducing redundant data collection.” (Gliklich, R. E., & Dreyer, N. A., 2010).

Healthcare providers and organizations are obligated and bound to protect patient confidentiality by laws and regulations. Patient information may only be disclosed to those directly involved in the patient’s care or those the patient identifies as able to receive the information. The HIPAA Act of 1996 is the federal law mandating healthcare organizations and clinicians to safeguard patient’s medical information. This law corresponds with the Health Information Technology for Economic and Clinical Health Act to include security standards for protecting electronic health information. The healthcare organization is legally responsible for establishing procedures to prevent data

EHR has its advantages and disadvantages of implementing new technology in the health care system, EHR can help improve collaboration, communication, performance, and decrease added work. The author believes that the incentives that the government is providing for physicians and hospitals to adopt electronic health records system will help improve accessibility to patient data, improve preventative health, and provide a collaboration from both patients and health professionals to increase patient ’s outcomes of their overall

Other than HIPAA, Health Information Technology for Economic and Clinical Health (HITECH) Act is a major federal policy initiative that affects the healthcare information technology (HIT) in the past years. However, its policy is used to protect the EHR system from a security breach that can cause multi-million dollar fines to the company (Campus Safety Magazine, 2010). In 2009, President Obama signed HITECH Act as part of the American Recovery and Reinvestment Act to support the Department of Health and Human Services (HHS) with authority, so it can establish programs that will improve healthcare quality, safety, and efficiency using HIT (Hebda & Czar, 2013).

The Health Insurance and Portability and Accountability Act ( HIPAA) of 1996 provides security provisions and data privacy for protecting a patient’s medical information. HIPAA has guidelines to ensure that a patient’s confidentiality is maintained while allowing the communication of a patient’s medical records between certain bodies or people or officials. Officials that a patient’s medical records can be shared with are other health care providers, health plans, business associates, and health care clearinghouses. HIPAA protects all “ individually identifiable health information”. There is a specific protocol to follow when sharing a patient’s medical information. Theses steps are imperative to maintaining the patient’s privacy.

“Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care” (HealthIT, 2014). Health Information exchange is becoming important in the communication between providers to provide the best care possible to patients. Every state along with their hospitals has their own way of exchanging information between each other.

Quality care and protecting patient information is the major task of healthcare organization. Like in hospital, Ambulatory care

Health Information Exchange Providers across the U.S. are turning to the Health Information Exchange also known as HIE. HIE provides secure online access to patients charts among a network of providers, hospitals, clinics, doctor’s offices, and pharmacies who join in the exchange, so they can have timely electronic access to records their patients will allow them to share. For patients this means having their medical records available no matter where they go and for providers it means having instant access to life saving information when seconds count

The policies and procedures should address the following areas that include, effective communication among various entities in the organization, education and training program for the every department, and most especially the HIM department, implementation of communication channel within the HIM department and other department in the organization, procedures for appropriate disciplinary action/corrective measures, and auditing/monitoring system. Furthermore, the policies and procedures should outline specific action plans that should be followed in the HIM department; the policies and procedures will be fashioned to adhere the guidelines and recommendations of major accrediting and professional organizations such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and National Center for Health Statistics. The issue of medical record availability should be addressed to specify the document requirements necessary for effective coding practice, and also the establishment of the role of physician advisor should be considered in order provide guidance on coding issue and to act as liaison between medical staff and the HIM department. Additionally, as part of the effort to address the coding issues, the HIM coordinator should set goals that will guarantee 100% coding accuracy report and less

Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, services, assessment, or procedure with respect to the physical or mental condition, or functional status of an individual. Health Care Clearinghouse, Businesses that process or facilitate the processing of health information received form other businesses. It includes groups such as physician and hospital billing services. Health Plans, Individuals or group plans that provide or pay the cost of medical care and includes both Medicare and Medicaid programs. HIPAA protects an individual’s health information and their demographic information.

The Health Insurance Portability and Accountability Act (HIPAA) sets security standards for safeguarding important patient health information that is being stored and maintained in analog and digital forms. As new technologies continue to facilitate the healthcare industry’s transition to paperless processes, health care providers, insurance companies, and other institutions are also growing increasingly dependent on electronic information systems to manage their HIPAA compliance programs. As a result, the safety and security of sensitive health data has become a major concern across the board. Security Risks and Challenges Today, health care professionals are using technology extensively in almost every aspect of the practice.

The purpose of the HIPAA transactions and code set standards is to simplify the processes and decrease the costs associated with payment for health care services. The transactions and code set standards apply to patient-identifiable health information transmitted electronically. Physician practices will continue to be able to submit paper claims. When the regulations take effect in October 2002, standard formats and code sets will take the place of any payer-specific or location-specific formats or requirements.

There are two Associations for Medical Coders, one is the American Health Information Management Association (AHIMA) and the other is the American Academy of Professional Coders (AAPC). AHIMA is the leading association of health information management for professionals all over the world (www.ahima.org 2015). In 1928, AHIMA was known for refining the quality of health records. “AHIMA is working to advance the implementation of electronic health records by leading key industry initiatives and advocating high and consistent standards” (www.ahima.org 2015). AHIMA 's credentials includes Certified Coding Associate (CCA)