April 17, 2023 | Diana Ortiz
It’s Health Information Professionals Week and we want to take the time to thank all those who keep health information accurate, secure and accessible.
Health information management (HIM) professionals are the valuable connection between clinical care documentation and how that story is told in coded data outcomes. Health Information professionals started out as custodians of the patient health record and have expanded into true mid-revenue cycle experts, overseeing growing initiatives like data governance within electronic health records (EHRs) and clinical documentation integrity (CDI) programs, all while maintaining release of information, deficiency management and of course, coding of the medical record for reimbursement and quality reporting.
It is quite a challenge to connect the author of documentation (physicians) to the published data that describes patient outcomes and determines provider and hospital reimbursement. This translator/educator/editor role comes naturally to HIM professionals whose training includes courses to understand the clinical references and documentation scenarios, paired with a deep understanding of legal documentation standards and the implications and applications of compliantly applying coding rules and regulations.
Health information professional’s roles have evolved and expanded over the years, especially with the mass implementations of EHRs, a tool that HIM professionals have long been champions for within their organizations. Not only are EHRs crucial to see through quality initiatives, but also for the continuous optimization of workflows and efficiencies that benefit HIM teams and the entire organization. Additionally, the growth of CDI programs, an effort that HIM professionals have guided, bring an understanding to both clinical and coding teams as they work together to identify gaps and further propel consistency in how guidelines are applied in new and innovative medical and surgical advancements.
As coding automation continues to develop, and both CDI professionals and physicians realize the benefits of leveraging technology for both quality and efficiency, HIM roles continue to shift to a more consultative and innovative mid-revenue cycle contributor. The operationalization of technology in workflows requires the HIM skillset to transition to a future state to continue to drive both opportunities and outcomes.
Much like the EHR requires support and expertise long after implementation, revenue cycle technology leverages HIM skillsets to tweak current capabilities and content to help drive future needs. HIM professionals are expected to have expertise in a broad range of areas as compared to decades ago, however, that expansive knowledge, including public quality measures, CDI, social determinants of health, sets them up for success in consultative problem solving roles within the traditional revenue cycle. Seeing the big picture from capture to code is the key to HIM professionals’ success.
Diana Ortiz, senior manager of global content at 3M Health Information Systems.