SMU MBA ASSIGNMENTS

Health information management (HIM) is the practice of maintenance and care of health records by traditional (paper-based) and electronic means in hospitals, physician’s office clinics, health departments, health insurance companies, and other facilities that provide health care or maintenance of health records. With the widespread computerization of health records and other information sources, including hospital administration functions and health human resources information, health informatics and health information technology are being increasingly utilized in information management practices in the health care sector.

Health information management professionals plan information systems, develop health policy, and identify current and future information needs. In addition, they may apply the science of informatics to the collection, storage, use, and transmission of information to meet the legal, professional, ethical and administrative records-keeping requirements of health care delivery. They work with clinical, epidemiological, demographic, financial, reference, and coded healthcare data.

It has been suggested the proper collection, management and use of information within healthcare systems “will determine the system’s effectiveness in detecting health problems, defining priorities, identifying innovative solutions and allocating resources to improve health outcomes.” For example, health information administrators have been described to “play a critical role in the delivery of healthcare in the United States through their focus on the collection, maintenance and use of quality data to support the information-intensive and information-reliant healthcare system”. As the field grows and information technology becomes a more crucial part of the medical world, health information management is experiencing a transition from traditional managing practices with paper to more efficient electronic management, such as with Electronic Health Records (EHRs). But the main goal is still to analyze, manage, and utilize the information that is essential to patient care and making sure the providers can access the information when necessary

The hospital administrator must clearly define the duties and responsibilities of Health Information Administrator (HIA) and the policies under which his department will operate. He should keep the HIA informed of goals, policies, and current programs of the hospital. He must delegate sufficient authority to enable the HIA to carry out his responsibilities. In addition, the administrator must provide sufficient personnel to enable the HIA to carry out the duties of the department effectively. The administrator must also provide adequate facilities and equipment to meet departmental objectives. He must support the efforts of the HIA to maintain the standards set for his department, and he must encourage him to keep abreast of the latest developments in the medical record field by attending educational and professional meetings.

Medical Staff

Work in hospital is highly specialized and requires a great deal of interaction among health professionals. Much of the work of the hospital is performed by highly trained professionals, the physicians, who require the collaboration, assistance and services of many associated health professional and non-professional personnel. The medical staff is made up of physicians who are permitted to send their patients to the hospital for admission. Members of the attending staff agree to assume certain responsibilities, such as committee assignments and attending medical staff meetings. In return they have a vote and a voice in establishing policies relating to medical care in the hospital.

The medical staff is organized as self-governing group with bylaws, clinical departments and committees. The health information administrator plays an important role in promoting the continuing smooth functioning of medical staff activities. He provides medical statistical information and stimulates research from the medical records. He frequently assists the medical staff in planning the selection of data for studies, and suggests unusual cases for presentation at staff meetings.

The health information committee serves as the liaison between the health information department and the medical staff. It is the responsibility of the health information committee to see that accurate and complete medical records are secured for every patient treated. The HI administrator attends the meetings of the health information committee and gives professional advice if called upon to do so by the committee members. Committees of the medical staff that closely interact with the health information department include: health information committee, utilization review committee, committees involved in medical evaluation, infection committee and tissue committee. It is the responsibility of the HI administrator to keep abreast of the activities of these committees, provide input and expertise as required, and provide the necessary services for various review reasons.

Medical Education

Health Information is an important tool in the assessment of medical education programs by accrediting agencies. The health information administrator works closely with the educators in establishing orientation lectures for new residents. By participating in orientation, the health information administrator has an opportunity to explain the reasons for accurate and adequate Health Information when residents first arrive. The health information administrator also assists in research projects, group studies, and with other requests for medical data.

Anesthesiology

The primary function of the anesthesiology department is to recommend and administer anesthesia for use in obstetric and surgical procedure. The record of anesthesia administered during the operation must show the pulse, respiration, and patient reaction at regular intervals, together with an estimate of the condition of the patient at the close of the operation. The anesthesiologist should also visit patients postoperatively and make appropriate entries in the health information.

Other functions of the anesthesiology department include monitoring the quality of anesthesia care provided; recommendations regarding equipment selection; development of anesthesia safety policies and procedures; and provision of continuing education programs.

Nursing Service

The nursing service is the largest hospital department. It is organized into patient care areas by services which include medicine, surgery, obstetrics and gynecology, pediatrics, psychiatry, operating room and emergency outpatient. The fact that patient Health Information is in the hands of nursing service throughout a patient’s hospitalization brings about the need for a close relationship between medical records and nursing personnel. Prompt preparation and delivery of the Health Information by nursing service upon discharge of the patient assists the Health Information Department in carrying out its many functions.

Clinical and Pathological Laboratory

Laboratory tests are done only on the orders of a physician. Reports on all laboratory work done emanate from the laboratory and become a part of the patient’s Health Information. The laboratory should send the reports to the nursing units promptly, since these reports specifically aid the physician in the diagnosis and treatment of the patient.

The autopsy report is another responsibility of the laboratory and should become a part of the patient’s record. Prompt delivery of the provisional autopsy report assists in early completion of the Health Information by the attending physician.

The Health Information Administrator should be knowledgeable about the various types of laboratory and pathology reports. There are certain reports that are delayed because of the time elements involved in the completion of the tests, and the laboratory must understand that problems are incurred by the Health Information Department when such reports are late. One way to improve interdepartmental relationships is to appoint a pathologist as a member of the Health Information committee.

Radiology

The radiology department provides both diagnostic and treatment services. As does the clinical laboratory, the radiology department serves patients only upon the order of the attending physician. The radiologist, like the pathologist, counsels the attending physician on the interpretation of diagnostic films and on radiation therapy. The department serves both bed and ambulatory patients. All diagnostic and therapeutic procedures should be reported by the radiologist and become a part of the patient’s Health Information. It is then available for reference by the attending physician and consultants. Reports of therapeutic procedures are usually provided at the end the course or series of treatments.

The Health Information administrator may need to contact the radiology department in instances where reports have not reached the Health Information at the time of the patient’s discharge.

Physical Medicine and Rehabilitation

Another diagnostic and treatment facility is the physical medicine department which is directly concerned with the diagnosis and treatment of neuromuscular diseases and certain musculoskeletal defects. It also offers services to many other types of patients, such as those receiving psychiatric treatment, those undergoing chest surgery, the blind, and the mentally retarded. It has diagnostic capabilities but is concerned primarily with therapy. It provides services that will shorten convalescence and improve functional capacity. The department is directed by a psychiatrist, a physician specially trained in the field, who assists the attending physician in working out the most beneficial routine for the patient. The department serves both inpatients and outpatients.

A record should be made by the physical medicine department showing details of tests performed, treatments used and the results produced for each patient provided with such services in the current inpatient medical record. This is important so that nursing patient care plans will correlate with the goals of the physical medicine department.

Pharmacy

Another important service in the physician’s care of the patient is the pharmacy. Here drugs, prescribed by the physician, are compounded and dispensed. The Health Information Administrator co-operates with the pharmacist and the pharmacy and the therapeutics committee by providing Health Information which has been properly coded and indexed as to adverse drug reactions. Health Information personnel may find it difficult of compile facts on the effects, side effects, and contraindications of a particular drug because of various trade names used for the same drug. The pharmacist plays an important role in supplying the generic name for a drug where the trade name is used.

Medical Social Service

Medical social service departments vary widely among hospitals. Many hospitals have an active service; others have little or none. The trained social worker collects information from the patient and investigates the home situation. The medical social service department in the hospital is primarily concerned with providing casework services to patients, whose social and emotional problems are contributing to illness or are interfering with their ability to benefit from medical care and treatment. Social service also includes planning for discharge with the patient or his family in the use of outpatient, extended care, or home health services in the community.

To contribute effectively to patient care and treatment, social service information must be available to all persons concerned with the care of the patient. The Health Information administrator and the social worker should develop the appropriate method of incorporating social service information in the patient health information. Significant social service summaries should be entered promptly in the patient’s health information for the benefit of all involved with the care of the patient.

Respiratory Therapy

Another therapeutic aid to the physician is the inhalation therapy department. Inhalation therapy is an important facet in the care of patients, particularly those suffering from cardiac and pulmonary diseases. The inhalation therapy service is frequently under the professional supervision of either the anesthesiology department or an internist who is particularly interested in pulmonary disease. The Health Information administrator can be helpful in assisting in the development of patient health information forms for recording inhalation therapy treatments. Secondly, he can provide statistics which may be used in medical care evaluation of respiratory therapeutic services.

Dietary

The dietary department is responsible for preparing nutritionally adequate, attractive meals for patients and employees, and providing counseling to patients who have special problems or diet needs. Clinical dietitians like other members of the health care team, often work under the direction of the attending physician. Pertinent information should be recorded concerning the patient’s nutrition history, reaction to special diet, and response to diet instruction. These comments or notations should be signed by the dietitian, including name and title.

Admissions

The primary objective of the admitting department is the effective and efficient processing of the patient into the hospital. The admitting department originates the identification portion of the health information including such information as patient’s name, hospital number, address, phone number, birth place, date of birth, age, sex, marital status, religion and other identification data.

The Health Information Administrator concerned with bringing together all information regarding the hospitalization of the patient, is vitally interested in the admission department. Immediately upon admission of the patient, the Health Information Department must be informed so that any previous patient health information can be sent to the patient unit. The admitting department must work closely with the Health Information department in assigning the hospital number. The health information administrator and the admitting officer work together closely to obtain accurate and complete information for each patient admission, as well as to avoid error in assignment of numbers.

Housekeeping

The housekeeping department is responsible for cleaning and maintenance in all areas of the hospital. Hospital housekeeping requires exceptionally high standards of cleanliness to prevent infection. Special techniques must be used in specialty areas such as the operating room. The executive housekeeper consults the health information administrator in setting up definite procedures to be followed in the Department of Health Information. Timing of the housekeeping activities must not interfere with normal Health Information activities.

Purchasing

The purchasing agent is usually responsible for the procurement of supplies and equipment. In small hospitals the hospital administrator may do his own purchasing. The storage and distribution of materials and supplies is controlled by central stores, which is under the direction of either the purchasing agent or the business office. When new equipment is being purchased for the Health Information department, conferences with purchasing agent are necessary, since purchase supply requisition must be made out for all routinely used Health Information forms, pencils, erasers, printer ribbons, paper clips and other supplies so that the storekeeper can keep the perpetual inventory up to date. If change in size or quality of some item in current use is contemplated, this calls for a conference between the Health Information administrator and the purchasing agent.

Maintenance and Engineering

The maintenance and engineering department is responsible for the maintenance of the building and for the operation of equipment. In this department are the engineers, painters, carpenters and electricians with whom the Health Information administrator will have contact. Painters and carpenters will take care of needed departmental repair. The engineers will be helpful in maintaining a comfortable environment for the Health Information department employees.

Personnel

The personnel department is one of the administrative departments of the hospital. The function of the personnel department is to screen employee applications and make the necessary reference checks as to previous employment and past work records. It is this department’s responsibility to give the new employee a general orientation to the hospital including the benefits, rules, and working hours. The personnel department maintains the employee records including application, tax data, sick benefits, vacation time, as well as employee evaluation or performance records. The personnel director assists the Health Information administrator in recruitment and initial screening of applicants and by giving advice, counsel and guidance in personnel problems.

Accounting

In general the accounting department is concerned with the financial management of the hospital. It is responsible for the installation and maintenance of the accounting records and the analysis and interpretation of the financial data received from these records. The Health Information Administrator will have contact with several sections of the accounting department. He will prepare the departmental budget with assistance of the controller. He also has frequent contact with payroll section. He must verify employee’s time sheets or time cards. In addition, the payroll section controls employee benefits such as sick time, vacation time and pension plans.

The insurance section depends on the health information for validation of medical data in order to process patient insurance claims. Specific hospital policies will control the release of information. Completion of patient health record is essential for maintaining a financial balance for the hospital through rapid processing of claims. Final diagnosis and verification of treatments and services performed are required in order for financial statements to be presented to insurance companies and other third party payers. Therefore close co-operation between the Health Information department and accounting department is essential to the financial
well-being of the hospital.

Data Processing

Computers and electronic data processing have had a strong impact upon hospitals in recent years. Data banks are being developed for automating retrieval of hospital financial and medical record information. Also on-line systems are being developed that store and tie together current hospital information such as the patient’s medical data.

The Health Information administrator should become involved in planning for the electronic data processing of medical data for use in patient care, planning and controlling medical services, and medical and administrative research studies.

Emergency Service

Demands on the services of the emergency department have been steadily increasing. The public considers the hospital to be the medical center of the community and expects it to be ready to serve in time of need. Another factor is the increased use of emergency service facilities by the community physician. In order to take advantage of the highly trained personnel and up-to-date equipment that is available, the physician now treats many patients in the emergency department that he previously would have treated in his office.

Hospital policy will determine the organizational setup of the emergency department. In many hospitals there is a director of emergency services with whom the Health Information administrator would work closely. Interdepartmental relations between the Health Information administrator and this director are important in maintaining acceptable standards of patient health record. The emergency room record should become a part of the unit record of the patient.

Out patient

The primary function of the outpatient department is to provide diagnostic or treatment service, or both, for patients who primarily are ambulatory and do not currently require inpatient care. A current and complete patient health record is maintained for each patient. These clinical records are as important medically and legally as any record made while the patient is a bed patient. The clinic visit is comparable to the physician’s office visit. The Health Information administrator is in a position to advise as to patient health record forms. He works closely with the Health Information committee to maintain standards of medical recording. A unit record system combining both the impatient and outpatient record is helpful for review by the physician and ensures continuing patient care. Cooperation between the Health Information and clinic personnel and an effective and efficient messenger service avoid confusion and delay.