Provision of Accurate Information to
Outside Requestors by HIM

            Health Information Management (HIM) is
the practice of acquiring, analyzing, and protecting digital and traditional
medical information vital to providing quality patient care. Health information is the data
related to a person’s medical history. This including symptoms, diagnoses,
procedures, and outcomes. It is important that HIM departments provide accurate
information to outside requestors as this could lead to patient safety, saving
of financial resources and the expedience of the healthcare process.

            Information can be requested or
shared with other healthcare providers, insurance companies and governmental
agencies. Throughout the healthcare process, there are transfer of patients
from General Practitioners to specialists. Proper, well updated medical records
are important for the effective communication between healthcare professionals
and their patients.

            A child with abnormal electrocardiogram
would be referred by the general practitioner to a pediatrician. This would
call for the exchange of information between two agencies. The practicing
pediatrician would need access to the medical history as well as previous
medical images. Thus, both the primary health record and the patient health
record would be made available to the pediatrician. The pediatrician would use
his or her expertise and the data provided by the HIM department of the general
practitioner to further evaluate and treat the child. Secondary patient records
can then be sent out for payment purposes to the insurance company covering the
cost of treatment. Any inaccuracy in information can be fatal to the child.

            Poor record keeping as well as
inaccuracies may have devastating consequences to a patient and all concerned
in the care of a patient. Thus, the paramount importance of providing accurate
information to outside requesters.

How the Integration of EHR Systems Can
Improve Patient Safety and Care

            An Electronic Health Record (EHR) is
a computerized versions of a patient’s paper charts. It is a digital version of
a patient’s medical history. The integration of EHR systems has numerous
benefits to a clinical setting. EHR Systems offer many institutions and physicians
opportunities to improve the quality of patient care delivery as well as
patient safety.

EHR can be created, managed, and
consulted by authorized providers and staff across more than one health care facility.
A single EHR compiles information about a patient’s history. This information
composes of current and past doctors, emergency facilities, school and
workplace clinics, pharmacies, laboratories, and medical imaging facilities.
The aggregation of information reduces the adverse effects of information

            EHRs are beneficial. First of all,
with EHRs, providers can easily make diagnosis. EHRs provide reliable access to
a patient’s complete health information. This aids in the reduction of errors
and the repetition of tests. Thus, they improve patient safety. An EHR automatically
checks for problems associated with medication and allergies whenever a new
medication is prescribed. The clinician is alerted to any potential conflicts
if there is any before the information is transferred to a pharmacy.

Information recorded in
an EHR tells a clinician in the emergency department about a
patient’s life-threatening allergy and other pre-existing conditions. Even
though a patient might be unconscious, the emergency staff can adjust care
appropriately. Additionally, EHRs aid clinicians to quickly and systematically
identify and correct operational complications. Compared to a paper-based
setting, identifying such complications is more difficult and may take years to
make corrections.

            Moreover, EHRs improve public health
outcomes. They can be used to benefit groups of patients with similar conditions.
Data can be pooled and groups of patients with similar conditions can
identified. Healthcare providers with health information about a population of
patients they cater for can look to improve and serve the needs of patients who
suffer from a specific condition, are eligible for specific preventive measures
and are currently taking specific medications.

Systematized Nomenclature of Medicine (SNOMED)
is a coding language that allows providers and electronic medical records to
communicate in a common language. This increases the patient care quality
across many different provider specialties as it improves patient data analysis
accuracy. The use of a coding language that standardizes medical terminology from
one healthcare provider to another, simplifies the query and resulting
report. It allows users to be confident in their definition of a diagnosis
without fear of missing anything life threatening.