Since working in the healthcare industry in the 1980s, I have witnessed a lot of change. One of the most notable changes was switching paper medical records to electronic health records.
My primary objective as a nurse was to ensure accurate and timely documentation of patient’s medical records. This same objective was important when I moved into the field of health information management. However, my responsibilities expanded to include data analytics and all aspects of health data. Imagine my joy when I was able to run a report without having to tally or analyze the data manually.
Since 1928, the management of health data has evolved continuously. This was even before the American Health Information Management Association was founded. Flash forward to 2022, and health information technology is growing daily. New technologies have created an abundance of health data that must be managed. Health informatics is here to help.
What are the characteristics of quality health data?
Virginia K. Saba, Kathleen McCormick and the ” Essentials in Nursing Informatics” define health care informatics. He focuses primarily on the retrieval and storage of health data. HI focuses more on how these data can improve patient outcomes.
AHIMA suggests HIM professionals look at 10 data quality characteristics when managing the quality and integrity of clinical documentation.
Health informatics should be integrated with information management to meet these characteristics. A doctor mustn’t order a medication that could cause adverse effects from drug interactions. Health informatics can alert the doctor of possible adverse effects before they submit the order to the pharmacy. This scenario meets data quality criteria of data accuracy, timeliness, and data quality.
How does Artificial Intelligence affect Health Records?
Artificial intelligence is another area in which we see HIM and IHI blending.
Clinical documentation improvement (CDI) ensures that patients’ medical records accurately and clearly reflect their diagnosis, treatment and procedures. In the mid-1980s, many insurance companies began to use Diagnostic Related groups (DRGs) to classify hospitalization costs. This kind of categorization required physicians to provide more detailed documentation. A simple addition of “due to bleeding loss” to a patient’s file could affect the reimbursement of patients with secondary anemia.
Just as clinicians were learning best practices in the documentation for DRG assignments, ICD-9-CM was replaced by ICD-10-CM. This changed the medical coding classification system, increasing the number of medical codes by 70,000+ and increasing the demand for CDI programs.
Enter computer-assisted physician documentation or CAPD. ICD10 Monitor explains that CAPD is an artificial intelligence type that searches a patient’s medical records for clinical indicators that may require clarification. A query is sent directly to the physician if additional information is required. This is similar to how medical coders contact physicians to clarify the documentation.
CAPD can quickly review large amounts of data and pose queries to physicians at the point where documentation is completed. This allows medical coders more time to work on complex medical coding assignments than sending queries to doctors. The time efficiency of physicians is improved, while the time savings for medical coders can be attributed to better quality metrics and accurate reimbursements for healthcare organizations.
Participate in the Management of Health Data
These are only two examples of how information management and informatics can work together to improve patient care, manage data and lessen the burden on healthcare professionals. This is a great time to work in health care. Health sciences students should be aware that there are many opportunities for creating and managing health data tools. Providing the best care for each patient involves collaborating with various health care disciplines.
Purdue Global offers a Bachelor of Science in Health Information Management and a Master of Health Information Management. A Master of Health Informatics degree may interest you if you are interested in the technology side of data management.