Physician Practices and Health Information Management Report

Report Objectives

The primary objective of the report ‘Physician Practices and Information Management: HIM Professionals Offer Value in Changing Practice,’ authored by Kevin Heubusch, is to demonstrate the amount of value and expertise that health information management (HIM) professionals can extend to physician practices in terms of making patient health data and medical records more manageable and useful to the medical practice. Another objective of this report is to reveal the reasons why HIM professionals are not only needed in large healthcare institutions, but also in small practices which are struggling with finding a proper balance regarding health records management and the integration of computer information systems in medical records management (Heusbusch para. 12).

The third objective of this report is to demonstrate how HIM professionals’ serves to link the health practice’s clerical members of staff and the clinical practitioner through efficient management of medical records (Heubusch para. 2). The underlying principle that necessitates the formulation of this objective is that people can generate different perceptions or viewpoints of the same medical record. According to Heubusch, “…physicians and HRM professionals may approach the health record from different directions…Understanding their shared goals requires good communication” (para. 31). The report further aims to demonstrate why efficient management of patient health data and medical records is of fundamental importance in other areas outside the medical field. Such data, according to the author, can be used by the government or insurance companies to access health situations.

Order of the Report

Apart from the brief introduction highlighting some of the positive impacts that HIM professionals have on physician practices, the report is subdivided into three major sections. The first section, under the topic ‘Where are the HIM Professionals,’ discuss some of the factors that hinder the absorption of HIM professionals into the mainstream health practice, including lack of awareness, financial constraints, and perceptions issues. The second section, under the topic ‘From Practice Managers to EHR Consultants,’ discusses a variety of issues concerning HIM professionals, including why they are needed in both large hospitals and small practices, various roles performed by the professionals, how they could be of assistance to physician practices in setting up an effective electronic health register (EHR), and what the future holds for the profession. The last section, under the topic ‘Expertise in Two Areas,’ basically discusses the various kinds of assistance that the HIM professional can offer physician practices in terms of effective management of electronic health records and documentation management.

Evaluation Section

The report under analysis is clear that time has come for health practitioners to completely embrace HIM professionals as partners in effective health information management. According to Green & Bowie, “each time patients receive healthcare, a record is generated to document the patients current symptoms, medical history, results of examination, treatments rendered along with outcomes, ancillary results (e.g. laboratory), diagnosis, and plans for treatment” (38). It becomes difficult for physicians and untrained clerical staff to organize, analyze, and maintain such amounts of data and information on each patient, thus the need for institutions, large and small, to engage the services of HIM professionals to not only guarantee the delivery of quality healthcare, but also ensure that health information is properly maintained.

Using the useful insights of distinguished medical practitioners and HIM administrators, this report has broadly outlined the various roles that HIM professionals can play to facilitate physicians’ transition to EHR’s, enhance documentation processes, and offer professional expertise in quality reporting. Although EHR is an evolving concept described as a systematic and coordinated gathering of electronic health information or data about an individual patient, the computerized record of patient experiences not only necessitates the automation and documentation of workflow processes in health practices, but also reinforces safety of the patient through evidence-based decision support, transition in advance of implementation, quality management, and results reporting (Heubusch para. 23; Walker et al 16). The above has tangible benefits for physician practices in that it curtails challenges that are occasioned by lack of adequate preparation and information loss, not mentioning the fact that transitioning physicians to ETR’s “…fill a common gap between in the practice’s knowledge between the clerical staff and clinical staff” (Heubusch para. 24).

HIM professionals can greatly assist to improve documentation of health records in a number of ways, not mentioning the fact that they have the capability to offer more cost-effective strategies and techniques for documentation (Berg 18).A major challenge affecting health professionals and support staff today is the miscommunication arising from the different interpretations that can be offered on the same record. According to Heubusch, medical experts and HIM professionals may approach a particular health issue from dissimilar directions (para. 27). Walker & Bieber, however, are of the opinion that properly documented electronic health records may not necessarily bring the kind of variances of perceptions witnessed in manual registers or computerized entries done by inexperienced staff (43).

It is true that most health practitioners under code or inadequately capture the actual charges due to lack of proper documentation. As such, the physicians do not receive the proper reimbursement for services rendered (Heusbusch 28), thus the need to involve HIM professionals since they have exceptional qualifications in coding and health information management, not mentioning the fact that the assistance offered by the professionals in terms of health IT, generation of compliant medical records, and creating proper reimbursement frameworks serves to improve the productivity of the health institution through quality healthcare medical records management (Berg 26). According to Heusbusch, adequate documentation not only helps to curtail malpractice premiums, but also reduces denied medical claims (para. 11).

HIM professionals can also greatly assist in quality reporting. As noted in the report, insurers, government agencies, and other stakeholders are increasingly requesting coded data from health facilities for reasons other than reimbursement. As such, quality reporting is essential, and many health institutions are increasingly engaging the services of HIM professionals to generate objective, quality, and accurate patient data when called to do so (Walker & Bieber 67). No health institution, large or small, will be exempted from reporting requirements to the institutions that need such information. But while many large health institutions engage the services of HIM professionals in quality reporting, it is the small practices that must pull up their socks to ensure they don’t lose out (Heusbusch para. 32). The only alternative to them, it seems, is to embrace the services of HIM professionals. Quality reporting is also needed to maintain efficient legal health records.

Suggested Issues

Heusbusch suggest that the HIM professionals’ star is increasingly shining as there exists many openings “for physician practices to call on HIM professionals to help them navigate personal healthcare records, health information exchange, and all the issues around privacy, stewardship, ownership, and sharing of records” (para. 18). It has also been suggested that HIM professionals can assist physician practices in many other roles apart from those discussed above, including acting as an integrator, practice administrator, or project administrator.

Works Cited

Berg, M. Health Information Management: Integrating Information Technology in Healthcare Work. New York, NY: Routledge. 2004.

Green, M.A., & Bowie, M.J. Essentials of Health Information Management: Principles and Practices. Clifton Park, NY: Thomson Delmar Learning. 2005.

Heubusch, K. Physician Practices and Information Management: HIM Professionals Offer Value in Changing Practices. Journal of AHIMA 79.1 (2008): 18-22. Web.

Walker, J.M., Bieber, E.J., & Richards, F.M. Implementing an Electronic Health Record System. London: Springer. 2005.