Health information professionals are involved in the collection, record, review and in the management of all health information. This requires them to safeguard the privacy, integrity and confidentiality of health information.
Personal data contains a wide range of medical information. The basic medical data is inclusive of patients’ diseases and medical interventions, history of all conditions diagnosed, medications that were prescribed and all laboratory test results.
Additionally, such data may also contain sensitive data regarding an individual’s mental health, behavioral patterns, relevant family history, sexual life and socioeconomic factors. Together with personal data is also the healthcare administrative data that includes hospital admissions and discharge data, routine data detailing the operations, insurance data and other financial transactions.
These information are recorded and electronically processed and remain private and confidential; even upon the death of an individual. They also gather and interpret individual health data. This interpretation serves as a basis on which a medical decision is made.
To fully understand the this career path it is better to analyze its progressive growth from the early 1940s to the present. These professionals had always been involved in health care quality management.
Earlier on in the 1940s they were routinely involved in the review of hospital records and documentation of morbidity and mortality, analyzing all reports for completeness. However at this time the advent of ethical issue had not been incorporated into the professionals system.
This was until 1946 when Eleamer F. Full, a medical record librarian at the Fullerton Hospital, reiterated that for the duties of a medical librarian to be inline with the doctors they work with, they constantly had to acquire information to help them move with changing times, such a person must be kind, cultured, honest, sympathetic, courteous and honorable.
These were the cornerstones that would mark the beginning of definition and regulation of health information and management professionals (Laurinda Beebe Harman, 2001).
These regulations commenced with the passage of Medicare legislation, key changes in health care reimbursement and configurations and the use of ‘report cards’.
This led to the creation of an environment of ethical dilemmas where ethical concerns became multifaceted and complex. These rules regulated professional standards, stipulated the conduct upon which an organization could operate and personal values concerning the promotion of ethical behavior in health information management.
It is this growth that saw the introduction of Utility Review (UR) programs in all health organizations hence increased litigation in malpractice cases. Today, these organizations have legal, regulatory, ethical and social responsibilities that ensure the provision of efficient high quality health services.
To carry out these activities therefore, health information management professionals have been continually involved in ensuring not only the quality of services but that ethical standards are upheld and compliance standards met.
Specific duties of a health information professional involve keeping records that contain patient information on medical history; physician’s notes or other input from assisting clinicians and the course of treatment; medical prescriptions or laboratory test results. Across the cadres duties may vary but basically, they translate all information contained in form of paper documents to electronic forms.
Patient diagnostic and intervention information are converted to a standardized format that is in line with internationally accepted classification system. Health information professionals ensure that information recorded in every patient’s record is complete, accurate, secure and readily accessible by relevant and appropriate medical personnel.
These are provisions and regulations safeguard the release of any information regarding the patient. In the United States the Health Insurance and Accountability Act enacted by Congress under the Administrative Simplification (AS) provision ensures that national standards for electronic data interchange addresses the privacy and security of personal patient data.
Title I of the act has specific articles that offer a regulation of health care accessibility, portability and renew ability. Title II ensures the prevention of health care fraud. Other chapters ensure that the privacy of security of personal data is upheld and that transactions are carried in accordance with the transactions and code rule.
Health information management professionals also collect additional patient information with regard to the duration of their hospital stays.
This data is necessary in the estimation of patient populations. Health information professionals use their proficiency in information technology to apply computer applications in the compilation, sorting, grouping, retrieving, analyzing and in the presentation of such data in ways that are coherent and useful.
Their presentations are necessary in the research, education and overall playing of the health care system, it is for this reason that the data must be accurate and secure from any alterations.
Generally, health information professionals have skills and knowledge related to biomedical sciences, information and technology, clinical data systems and management, standardized classification systems, information analysis and presentation and the prerequisite legislations and regulations governing the activities of a health information professional.