Health Information Management

Chapter 3 of 11



The advent of Health Information Management has improved the collection and storing of medical information from patients. Healthcare experts collect certain information from patients, ranging from medical history, medical examination results, treatment plans, and for others various purposes.

The information is collected and entered into the healthcare information systems electronically, where it is stored and maintained. There is an entire workforce that is dedicated to the practice of acquiring, studying, and protecting traditional and digital medical information. These processes are referred to as Health Information Management (HIM).

HIM professionals play a critical role in planning information systems, developing health policies, and identifying current and future needs of a health care organization. They apply the science of informatics in retrieving, gathering, storing, analyzing, using, and transmitting information to meet professional, legal, administrative, and ethical record-keeping requirements needed for proper health care delivery. The World Health Organization (WHO) states that the HIM professionals’ role is so critical that their proper collection, management, and use of health care information within the health organizations will determine the effectiveness of the system in defining priorities, detecting healthcare problems, allocating resources, identifying innovative solutions, and improving overall health outcomes.


The application of HIM in a healthcare facility is expected to:

  • Improve healthcare quality, reduce health disparities, reduce the occurrence of medical errors, and advance the delivery of patient-centered medical care
  • Secure and protect patient information
  • Reduce healthcare costs by minimizing inefficiencies, inappropriate care, incomplete information, duplicative care, and other medical errors
  • Help guide medical decisions by providing appropriate information
  • Ensure meaningful public input in the development of healthcare infrastructures
  • Improve the coordination of care and information between hospitals, physician offices, laboratories by facilitating secure and authorized exchange of information
  • Improve the response rate to public health threats by facilitating early detection of health problems in the community
  • Facilitate healthcare and clinical research
  • Promote early detection, management, and prevention of chronic diseases
  • Promote better consumer choice, outcomes in health services, and marketplace effectiveness


The American Health Information Management Association was founded in 1928 when the American College of Surgeons decided to build the Association of Record Librarians of North America to improve the standards of patient record procedures in hospitals and other healthcare institutions. In 1938, the members of AHIMA became the medical records experts, their main goal was to raise the standards of patient record-keeping in health care facilities such as hospitals and clinics. They became promoters and managers of clinical records to ensure precision and accuracy in health information and serve to bridge roles, administrative functions, and clinical operations by handling quality patient information in the healthcare delivery cycle.

Health Information and Management Systems Society (HIMSS), a group in the independent, nonprofit, voluntary association of individuals, was established in 1961 as a response to the increasing amounts of management engineering demands in healthcare during the 1950s.

In the modern era, electronic health record management became the primary role of professionals handling HIM. They became safe keepers of patient security and privacy and assumed the role of sole trainers of their employees in managing confidential patient information. These HIM experts became responsible for preserving the competency with the use of healthcare information databases to generate crucial reports for clinical and administrative purposes.


In most cases, a patient’s health information data may include anything from symptoms or diagnoses to procedures and final results. Upon examining a patient’s health information records, a healthcare professional is expected to come across clinical notes, X-rays, lab results, etc. from previous visits.

According to AHIMA, a professional organization that promotes the clinical and business uses of both paper-based and electronic medical information such medical records; HIM can be helpful on an individual basis. It can help to evaluate the health status of a patient over time. It can also serve an essential purpose as part of more extensive data, which helps to understand how the health of a population has changed over time as well as how specific medical interventions can have a significant impact on healthcare outcomes.

Professionals in the HIM sector accomplish the overarching goal of ensuring the health records of a patient are accurate, complete, and continually improved. HIM specialists are absolutely necessary for the day-to-day management of health information. They serve as a bridge that connects administrative, clinical, and operational functions in a wide range of settings and under a number of diverse job titles, all aimed at taking care of patients by caring for the patients’ medical data i.e., at all touchpoints in the healthcare delivery cycle. They also work on the classification of both diseases and treatments, thereby seeing to it that they are standardized for financial, clinical, and legal uses in healthcare.


These are the structural and physical prerequisites of a proper health information system. Resources may also include the needs of the system, such as office supplies or computer systems.


Indicators are used to monitor the system’s effectiveness and they reflect the change in the measurable needs of the organization’s system over time.


Data sources are a combination of sources to provide the best information for better efficiency. The health information system mixes a range of sources and integrates them into meaningful information products for ready access and use.


Data management is essential to secure the best collection, processing, storage, analysis, compilation as well as quality assurance, and ensure that no mistakes, inaccuracies, or duplications occur.


Information products are data transformed into basic information for decision-makers to use in order to improve health care services. These may be in the form of reports, alerts, queries, user dashboards, and other types of information that result from the analysis of healthcare data.


Dissemination and use of information are the value of enhanced information accessible to decision-makers to provide incentives for information use.


The collection, storage, as well as analysis of medical data, is presently playing an increasingly significant role in the healthcare field. The 2017 HIMSS Leadership and Workforce Survey reported that about 53 percent of hospitals and 61 percent of consultants/vendors had boosted the size of their IT workforce within a year.

As the field of health information continues to grow, it is progressively used to develop new apps that will help to enhance the experience of the patient as well as increase efficacy and efficiency of healthcare organizations.

HIM graduates are expected to become familiar with the current, future, and most important trends in the field of HIM.

The following tools and techniques are as follows:

3.5.1. ICD-10

ICD 10 is the 10th revision World Health Organization-released medical classification of patient complaints, signs and symptoms, abnormal findings, external causes of diseases and injuries, and codes of diseases.

ICD enables efficient storage and retrieval of healthcare information for clinical and epidemiological purposes. It also facilitates better reimbursement and resource allocation of decision-makers, not just in the United States.


The Office of the National Coordinator for Health Information Technology released the Guide to Privacy and Security of Health Information to serve as a comprehensive instruction handbook for healthcare providers and information technology workers who want to know more about the crucial aspects of privacy and security in health information technology.


Electronic Health Records are the digital version of a patient’s real-time record that makes patient information available securely and instantly to authorized users. EHRs contain essential patient information, including the patient’s medical history, diagnoses, treatment plans, immunization dates and schedules, past and current medications, laboratory tests, radiology images, and history of previous allergies.

Each HIM expert aims to meet the goals of optimal healthcare information interoperability in all the various systems, standards, specifications, and applications involved in the collection, storage, retrieval, and maintenance of patient health information across all healthcare organizations.


Clinical documentation improvement tools focus on improvement in the quality of clinical documentation. They aim to facilitate an accurate representation of healthcare services through the complete reporting of procedures and diagnosis. This can greatly influence Medicare and Medicaid quality measures, pay-per-performance, admission data collection, value-based purchasing, and decision-making of healthcare providers leading to healthcare reforms and better national healthcare initiatives.


Information governance is one of the considerable challenges in HIM. It the implementation of policies, controls, structures as well as other procedures which ensures that an organization’s information assets are suitably handled.

In an interview with Becker’s Health IT & CIO Review, the executive vice president of AHIMA, Deborah Green, stated that the advancement in technology is enabling the creation, capture as well as the retention of more information and data from multiple sources every minute of each day.

The healthcare’s needs for controlling, managing, and ensuring the integrity of healthcare information is the main reason why HIM needs information governance tools. Through information governance, healthcare can meet the aim of quality care for patients, population health, while lowering healthcare costs.

Information governance, according to AHIMA, is an essential addition to the traditional approaches that are utilized by HIM professionals. It optimizes health data extraction abilities, mitigates risk, and also ensures that compliance guidelines are adhered to.

  • HIM professionals hold several job titles, with common Health information manager being the most common
  • Healthcare data analyst
  • Medical research analyst
  • Medical coder
  • Privacy officer
  • Medical records abstractor
  • Clinical documentation improvement specialist
  • Release of information specialist
  • Data quality specialist
  • Medical coding compliance auditor
  • Business analyst
  • Meaningful use specialist
  • Information security manager

HIM departments continue to be progressively virtual as some HIM department staff can work remotely from a satellite location, which is not part of the organization’s headquarters or from home. Health information managers must be able and willing to monitor and manage remote staff members.

The healthcare industry is booming, and there is no sign that it will slow down any time soon. Technology professionals can engage in any of the thirteen careers outlined above, which are true-to-market samplings of the numerous opportunities in the healthcare industry.


Advances in healthcare technology have led to an increase in the amount of information is stored online. Although this offers several benefits when it comes to patient care, it also makes the data incredibly susceptible to attack from hackers whose goals are to steal and sell personal information that is found in EHRs. TrapX Security, a renowned security organization, has stated that cyber-attacks waged against healthcare institutions significantly increased by up to 63 percent in 2016 as compared to 2015. The security organization expects this upward trend to continue.

Lack of innovative technology, as well as the absence of best practices, also makes it extremely difficult for hospitals or healthcare institutions to detect and rectify ransomware attacks quickly and efficiently. To combat this growing threat, technologies and strategies designed to guarantee privacy, as well as the security of health data, continues to be the ever-increasing focus of HIM professionals in the field.

Healthcare organizations need to be able to foster trust with their patients. Most patients will be reluctant when they learn their health information will be stored online, especially if they feel that their healthcare provider is not capable of keeping their personal data secure and safe from cyber threats.

HIM professionals are the stewards of health care information. They help establish the guidelines and principles to ensure safe, consistent, and uniform collection and exchange of useful patient health data for purposes such as quality management. HIM experts should continually develop and implement standards for data mapping data content, and documentation across the healthcare sector. The roles of these professionals are continually changing and expanding. Traditional HIM experts were simply record custodians. But now, they are expected not only to ensure the safekeeping of health care information within an organization but also to facilitate global focus on the security and privacy of healthcare information while providing access to information.

HIPAA (the United States Health Insurance Portability and Accountability Act of 1996) acts as the first-line federal regulation that shapes and aims to preserve health information security and privacy. It mandates the guidelines and policies to safeguard integrity and confidentiality while ensuring accessibility of health information to both consumers and providers. However, as health information technology expands from EHRs to Personal Health Records (PHRs), the gaps in privacy and confidentiality started to appear. Many consumers are now concerned about privacy and security, with these two as the primary reason why they do not intend to use a PHR platform for their personal HIM.

Additionally, telemedicine technologies and home health monitoring further expand the landscape for security and privacy concerns. These new aging services technologies help the aging and the disabled population, and they also increase the demand for HIM professionals to bridge the widening gap of privacy and security protection of health care information.

The following three HIM strategies can overcome the challenges with the privacy and security of healthcare information:

  • HIM experts should ensure that the practice of HIM complies with the guidelines and the federal laws
  • Privacy and security should always be their top priority when participating in the design, development, and implementation of an information platform for sharing and management of patient health information.
  • HIM professionals should educate consumers by demonstrating the proper way of accessing their health information while ensuring the confidentiality of their records.


Interoperability of information facilitates the movement of electronic healthcare information to support healthcare needs and population-directed uses, such as bioterrorism surveillance, disaster management, and community healthcare tracking. Standards for data nomenclature, content, terminology, messaging, and structure of health information are the keys to achieving interoperability.

Interoperability, according to HIMSS, is the ability for computer systems or software to exchange and communicate information in such a way that the data is clear to the user. This enables medical histories, test results, images as well as other vital data to be transmitted from one provider to another, whether or not the patient is changing doctors, seeing a specialist or being treated by several professionals at a given time.

HIM professionals serve as the stewards of health data; they play the role of a broker between stakeholders.

HIM experts should facilitate the adaptation of health information standards for health information interoperability. The most demanding tasks of HIM professionals and other healthcare professionals is the transition of health transaction codes from ICD-9 to ICD-10. ICD-10 has tremendous benefits in the healthcare system. It requires extreme caution during its implementation process. HIM professionals need to work closely with other health organizations during this critical transition period and voice their concerns and their priorities to ensure that the process is conducted smoothly without mistakes.

The Office of the National Coordinator for Health Information Technology (ONC) outlined three principal stages for achieving nationwide operability by 2024:

  • Send, receive, find, and make use of priority data elements to enhance health and healthcare quality (2015-2017)
  • Expand interoperable health information technology and users to lower cost and improve health (2018-2020)
  • Accomplish nationwide interoperability to enable a learning health system (2021-2024)

These stages are in line with the ONC’s goal of creating an unassailable foundation in healthcare IT to furnish patients with a digital depiction of personal health over their lifespan.


Due to advances in technology, the rate at which data is generated or developed, collected, and analyzed is much higher today. According to IBM, the entire world creates more than 2.5 quintillion bytes of data each day. But raw data, on its own, has little use or impact on patient care. The numbers need to be analyzed to verify that the information is leveraged in good order. In and of itself, data analytics continues to play a significant role in HIM.

According to HIMSS, HIM specialists are playing an active role in regulating the type of data that must be focused on in order to resolve the demands in healthcare en route to rendering high-quality care to patients.

HIM professionals are getting more and more involved wherever healthcare data is being garnered, stored, or retrieved. This wealth of information requires in-depth analysis for decision-making purposes, and HIM professionals are equipped with the critical thinking skills that are needed to effectively analyze information and health data of all types.

Data analytics, in its basic form, refers to the techniques and processes that are employed when examining a wealth of data to find trends that will be of immense benefit to a business in one way or the other. These strategies can be quantitative or qualitative, and specific approaches vary from one organization to another.

George Zachariah, a consultant at Dynamics Research Corporation, wrote an article that was published in Healthcare IT News. The report highlighted the five significant ways that hospitals or healthcare institutions can benefit from the use of data analytics. According to George Zachariah, analytics can help to:

  1. Improve care coordination
  2. Reduce administrative costs
  3. Boost patient wellness
  4. Support non-subjective decision-making
  5. Minimize fraud and abuse

Since healthcare organizations can enjoy these benefits, especially when their accumulated information is appropriately leveraged, the use of data analytics in the field is likely to increase and even continue beyond 2019.


HIM professionals who have training in both information management and information technology are responsible for the task of promoting the adoption of patient health records and EHRs. Healthcare organizations and small clinics in underserved areas are struggling to adopt EHRs because of their limited resources and experience. On the other hand, consumers in these underserved areas are also in a disadvantaged position because of an existing gap in health literacy and accessibility to health information. HIM experts should reach out to these underserved areas to guide them in the adoption of EHRs. Without the willingness of the majority of healthcare organizations to adopt to EHRs for their transactions, it will be impossible to build a centralized health information infrastructure. The American Health Information Management Association, with its approximately 51,000 members, can help redefine the United States’ health information system.


The United States Department of Health and Human services (HHS) is pushing to establish the development of HIT infrastructure. It aims to build a coordinated organizational process at the tribal, local, state, and federal levels – to support information used for public health. One strategy is to build a public-private governance entity that will help advance interoperability and support the exchange of health information across all states, even at the tribal and local levels. It is understandable that with the administration change and priorities realignment in health information technology, many collaborative governance bodies will form at all levels. HIM professionals must take advantage of these changes and assume a more active role in the decision-making regarding health information technology. AHIMA now advises the master’s degree as the terminal degree in HIM. It gives HIM professionals more power to take leading roles in health information technology governance.


WHO estimates that the investment in HIM systems could lead to multiple benefits, including:

  1. Detection and better control of emerging and endemic health problems
  2. Empowerment of individuals and communities to timely and understandable health-related information and improvement of quality healthcare services in all levels
  3. Establishment of evidence-based effective healthcare policies, thereby permitting innovation through research and evaluation of scale-up efforts
  4. Improvement of governance by ensuring accountability in the way health resources are used and mobilizing new resources for healthcare benefits


  1. Stansfield, S. (2005). Structuring information and incentives to improve health. Bulletin of the World Health Organization. Geneva: WHO.
  2. Zeng, X., Reynolds R., & Sharp, M. (2009, September). Perspective in Health Information Management; Redefining the Roles of Health Information Management Professionals in Health Information Technology
  3. AHIMA (2019). Who we are. Retrieved from
  4. Ibid.
  5. Ibid.
  6. World Health Organization (2010). Components of a strong health information system. Geneva: WHO
  7. Ibid.
  8. Ibid.
  9. Ibid.
  10. Ibid.
  11. Ibid.
  12. World Health Organization (2019): Classifications. Geneva: WHO. Retrieved from
  13. The Office of the National Coordinator for Health Information Technology (2015). Guide to Privacy and Security of Health Information. Washington, DC: ONC. Retrieved from
  14. AHIMA: Electronic Health Records
  15. AHIMA: Guidance for Clinical Documentation Improvement Programs
  16. AHIMA: AHIMA – Leading Information Governance in Healthcare
  17. Op. Cit. Zeng, Reynolds, & Sharp
  18. Ibid.
  19. Ibid.
  20. Ibid.
  21. Kimollo, P., Lenoir, M., & Niemi, M. (2010). Health Management Information System for Hospitals. Learning Brief. The Hague: International Institute for Communication and Development. Retrieved from