Medical Information: getting it where it is needed …safely, accurately…on time and secure

It’s just a glimpse through an open door; shelves full of manila folders. One of those folders has my medical records. And I trust the information in that folder is complete and accurate.

But is it complete? Has it been kept private? Has it been billed accurately?

And will it be available immediately if needed?

Step through that door and you have entered the world of health information systems. But there is far more to that world than simply filing paper and organizing data. Health Information Systems (or HIS) includes such diverse activities as codifying all the individual actions of a hospital service or surgical procedure, analyzing data to ensure complete, accurate and timely information, and making sure patient records are secure. Sometimes the job can be as exciting as a detective novel, and staffers have contact with most other professionals in the hospital, including the physicians.

“People are just amazed when they job shadow you,” said Denise Steinberg, former Director of HIS at Bigfork Valley.

Electronic Medical Record

Today the field is changing rapidly. With the emerging use of electronic medical records, the whole relationship of a patient, his health care provider and his medical information is set to change dramatically.

The technical part of the change will be easy, believes Steinberg, compared to the adjustments health care professionals and patients themselves will need to make. When records become electronic, they are available quickly and can be accessed by more than one provider at the same time.

A new patient may need services from several places in the hospital – such as laboratory, dietary, radiology. Today the patient’s chart is passed sequentially from place to place, but in the future, more than one location can access the chart at once. Documentation can be entered immediately and tracked through the system. A remote specialist can advise in real time if necessary. The patient record can include material scanned into digital form such as advance directives, consents or outside reports.

When the record is complete and timely, Steinberg pointed out, better decisions can be made by both the patient and the provider.

Privacy

Still, with all this movement on the cyberfreeways, isn’t it hard to keep information confidential?

Health Information Systems is also in charge of keeping records private, a responsibility all health care providers take very seriously. Bigfork Valley has a Privacy Officer and Security Officer who makes sure other employees know what information is protected. Confidentiality is also a federal mandate in legislation called HIPAA, the Health Insurance Portability and Accountability Act.

How is it maintained? Protected electronic health information requires a multi-character passcode to access. Access to records is only by legitimate need, and in the digital age, that access can be kept off limits to those without the proper access codes and tracked for those who do. Even today’s paper records are stored by code, so that the untrained observer cannot easily locate a patient’s file.

But codes also have other big roles to play in the HIS profession, and in a completely different way: they are used by insurance companies to pay medical claims, for multiple methods of data collection and for research purposes.

Medical bills are reimbursed by what is actually done. For instance, each part of a procedure in the operating room might be billed separately, and these are all coded. Matching the code with the procedure - and making sure that all the clinical diagnoses and procedures are included and documented - is a specialized, skilled job, said Steinberg. A coder can be like a detective, one who also has the medical knowledge to understand how a disease process or a surgical procedure works. If something appears to be missing, the coder may contact the physician to see if a medical action was actually done and not documented.