Health Information Management

Chapter 3 of 11



Health information management (HIM) is the practice of collecting, analyzing, and protecting paper-based and digital patient medical information essential to giving quality health care. With this rising trend of computerization of patient information, health informatics and health information technology tools, paper-based patient records are rapidly being replaced with electronic health records. The health care sector now uses informatics and information technology tools to make information management practices more efficient.  

Experts who play a critical role in planning information systems, developing health policies, and identifying current and future needs of a health care organization are called health information management professionals. 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. They focus on epidemiologic, financial, demographic, clinical reference, and health care data. The World Health Organization (WHO) states that the health information management 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 [1].


The application of health information management in a healthcare information is expected to [2]:

  • 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 who specialize in the studies of medical record science. 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 healthcare delivery cycle [3].

Health Information and Management Systems Society, a group in independent, nonprofit, voluntary association of individuals also known as HIMSS, was established in 1961 as a response to the increasing amounts of management engineering demands in healthcare during the 1950s [3].

In the modern era, electronic health record management became the primary role of professionals handling health information management. They became safe-keepers of patient security and privacy and assumed the role of sole trainers of their employees in handling and using confidential patient information entrusted to them. With the uncontrollable rising trend of technology in healthcare, these health information management experts became responsible in preserving the competency with the use of healthcare information databases to generate crucial reports for clinical and administrative purposes [3].  


Health Information System Resources

These are the structural and physical prerequisites of a proper health information system. The existence of necessary policies and laws, financial resources, skillful professionals to do the work, ability of those responsible to coordinate the process, and infrastructures are the examples of these prerequisites. Resources may also include the needs of the system, such as office supplies, 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

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

Data management

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

Information products

These 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 forms of information that result from the analysis of healthcare data.

Dissemination and use of information

This is the value of enhanced information accessible to decision makers to provide incentives for information use.

(Information lifted from World Health Organization: Components of a strong health information system [4])

Tools and Techniques


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

Physicians, nurses, researchers, health information technology experts, coders, policy makers, patient organizations, and insurance companies use ICD to classify diseases in a standardized manner. 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, but also other countries [5].

Privacy and Security Guidelines

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 important aspects of privacy and security in health information technology. Through this guide, concerned individuals will have a better grasp about the importance of privacy and security in the implementation of Meaningful Use and learn the essential requirements needed to preserve privacy and security in computer systems [6].

Electronic Health Records

The electronic health records (EHR) are the digital version of patient’s real-time record that make patient information available securely and instantly to authorized users. Electronic health records contain important 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. Healthcare providers use the information contained in EHRs to make decision for patient care.

Each health information management 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 and establishments [7].

Clinical documentation improvement tools

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. The successful usage of clinical documentation improvement tools 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 [8].

Information governance tools

The healthcare’s needs for controlling, managing, and ensuring the integrity of healthcare information is the main reason why health information management needs information governance tools. Through information governance, healthcare can meet the aim for quality care for patients, population health, while making the cost of healthcare affordable [9].

Best practices

Privacy and Security

The role of health information management professionals in facilitating electronic exchange for use and access of health information while protecting the security and privacy of patient health information can never be overemphasized. They 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 role of these professionals are constantly changing and expanding. Traditional HIM experts were just simple record custodians. However, nowadays, 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 or healthcare information while ensuring easy access to such information [2].  

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 heath information technology expands from EHRs to PHRs, the gaps of privacy and confidentiality started to appear. In fact, many consumers are now concerned about privacy and security, with these two as the primary reason why they do not intend to use PHR platform for their personal health information management.

In addition to this dilemma, telemedicine technologies and home health monitoring further expands the landscape for security and privacy concerns. These new aging services technologies help the aging and the disabled population; and they further increase the demand on HIM professionals to bridge the widening gap of privacy and security protection of health care information.

Three HIM strategies can overcome the challenges with privacy and security of healthcare information.

  1. HIM experts should ensure that the practice of health information management complies with the guidelines and the federal laws
  2. 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.
  3. HIM professionals should help educate consumers by demonstrating to them 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 [2].

HIM professionals serve as the stewards of health data; and since they often stand on the neutral ground when different involved individuals and organizations negotiate the framework of health information exchange (HIE), they can play the role of a broker between stakeholders.

HIM experts should also lead in the adaptation of health information standards for health information interoperability. Currently, the heaviest tasks of HIIM 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. However, it also 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 goes smoothly without missteps, mistakes, and other loopholes.

Adoption of health information technology (HIT)

HIM professional who have training in both information management and information technology are responsible for the task of promoting the adoption of patient health records and electronic health records. “Digital divide” exists in the adoption of EHRs, according to many surveys. 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. Health information management experts should reach out to these underserved areas to guide them in adopting EHRs. They could help provide consulting, student interns, and training. They could also be involved in negotiating with vendors or work as motivators. 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 [2].

Collaborative governance

The United States’ 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 use for public health. HHS proposed different strategies to promote collaborative governance in all levels and one of these strategies is to build a public-private governance entity that will help advance interoperability and support the exchange of health information across all states, even in the tribal and local levels, of America. It is but predictable that with the administration change and priorities realignment in health information technology, many collaborative governance bodies will form in all levels. Health information management professionals must take advantage of these changes and assume a more active role in the decision making regarding health information technology. In fact, AHIMA now pushes master’s degree as the terminal degree in health information management. This move gives HIM professionals more power to take the leading roles in health information technology governance [2].


The World Health Organization (WHO) projects that the investment in health information management systems could lead to multiple benefits [10], including:

  1. Detection and better control of emerging and endemic health problems globally by monitoring progress towards health goals and equity
  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. Bulletin of the World Health Organization; Structuring information and incentives to improve health; Stansfield S.; 2005
  2. Perspective in Health Information Management; Redefining the Roles of Health Information Management Professionals in Health Information Technology; Xiaoming Zeng; September 2009
  3. AHIMA: Get to Know AHIMA
  4. World Health Organization: Components of a strong health information system
  5. World Health Organization: International Classification of Diseases (ICD)
  6. Guide to Privacy and Security of Health Information
  7. AHIMA: Electronic Health Records
  8. AHIMA: Guidance for Clinical Documentation Improvement Programs
  9. AHIMA: AHIMA – Leading Information Governance in Healthcare
  10. International Institute for communication and development: Health Management Information System for Hospitals