Health

Domain Description

Unique Impact

• Clinical data captured during the process of diagnosis and treatment.
• Epidemiological databases that aggregate data about a population.
• Demographic data used to identify and communicate with and about an individual.
• Financial data derived from the care process or aggregated for an organization or population.
• Research data gathered as a part of care and used for research or gathered for specific research purposes in clinical trials.
• Reference data that interacts with the care of the individual or with the healthcare deliver systems, like a formulary, protocol, care plan, clinical alerts or reminders, etc.
• Coded data that is translated into a standard nomenclature or classification so that it may be aggregated, analyzed, and compared.

• Clinical Data Organization of information supports direct patient care and serves a variety of industry needs like reimbursement, planning, and research.
• Epidemiological databases Aggregate statistics reveal disease trends.
• Demographic Data Attention to data quality provides unique identification of patients in a healthcare enterprise and accurate information available to run the business of healthcare.
• Financial Data Understanding the clinical context of costs and the rules for reimbursement improves organizational decision making.
• Research Data Planning for future use of data improves the quality and reduces the cost of data capture and analysis.
• Reference Data Providing current literature and research outcomes enhance clinical knowledge at the point of care and in operational decision making.
• Coded Data Aggregate statistics enhance analysis for epidemiological patterning.Combining knowledge of the clinical content, documentation principles, coding systems, and data use provide accurate information for the industry.

Information

Domain Description

Unique Impact

• Data individual and aggregate
• Reports
• Medical records an aggregation of reports and data that describe an individual patient usually within one delivery site or system.
• Data dictionaries
• Vocabularies

Information may be stored using a variety of media:

• Paper
• Databases
• Microfilm/microfiche
• Computer stored

Data

• Healthcare generates enormous amounts of data that are only useful if well managed.

Reports

• Summarization of data into relevant reports quickly communicates vital information.

Medical Records

• Developing uniform definitions of the most critical information gathered about a patient to create a legal document.

Data Dictionary

• Creating standards to define critical content.

Vocabularies

• Defining the language of healthcare.

MEDIA

Paper

• Managing the historic and pervasive method of healthcare communication.

Databases

• Constructing relevant collections of data.
• Microfilm/microfiche
• Reduction of storage space required for maintaining legal documents.

Computer Stored

• Assuring preservation of a legal standard when applying new technologies.

Management

Domain Description

Unique Impact

Management of health information uniquely stems
from a knowledge of clinical, management, and informatics principles and is performed by individuals focused at the strategic, management,
and technical levels.

Extended Roles

As with any robust profession, individuals evolve into divergent roles to develop, support, and nurture aspects of the profession. Although related to the profession, additional skills are developed to contribute to health information management without directly managing health information. For example, they support the core definition by:

• Teaching others to manage health information
• Developing and marketing products and services that help to manage health information
• Developing software that manages health information
• Consulting with others in the management of health information

PLANNING

Administration

• Managing data collection and storage
• Managing information retrieval and release

Policy development

• Establishing security, confidentiality, retention, integrity, and access standards
• Developing training programs that empower others to carry out the information policies
• Advocating for privacy, confidentiality, and access

Strategic planning

• Identifying the organization or projects information needs to support current and future strategic operations and initiatives
• Planning capture, storage, and display of data to insure operational effectiveness, including use of technology.

INFORMATICS

• Data Modeling determining data needs and identifying the relationships among these data
• Process and Workflow Modeling identifying the flow of work and information required to perform a function including: decomposition diagrams, dependency diagrams, and data flow
• Data Capture and Display Design including system design, screen design, report design, and forms design
• Data Dictionary Maintenance dictionary design, standardization, update, and dissemination
• Access Control designing, implementing, and monitoring the map between information and user access
• Data Quality Management effecting the collection, application, warehouse, and analysis of data to improve information quality
• Nosology analyzing and interpreting disease and procedure classifications and terminologies for accuracy of translation of healthcare data

TECHNICAL

• Classification and Coding assigning the appropriate code or nomenclature term for categorization
• Abstracting compiling the pertinent information from the medical record based on predetermined data sets
• Registry development assembling a chronological set of data for an express purpose
• Storage implementation and oversight of electronic and paper-based filing systems
• Retrieval making accessible information stored in various media and sites
• Release appropriately responding to requests for information based on laws and policy
• Analysis qualitative and quantitative analysis of documentation against standards and policy

PLANNING

Administration

• Reduced cost of health information
• Successful implementation of enterprise-wide master person index

Policy development

• National policy discussion on health information privacy
• Organizational policies that conform with state and federal regulations

Strategic planning

• Market position strategies influenced by sound outcomes data
• Easy access to health information by care providers across an enterprise

INFORMATICS

Data Modeling

• Better access to healthcare data
• Improved quality of information

Process and Workflow Modeling

• Faster access to cash through improved revenue cycles
• Less time spent by clinicians in charting, more time for patient care

Data Capture and
Display Design

• Improved patient safety through reduced documentation error
• Reduced training time for clinicians in how to chart

Data Dictionary Maintenance

• Accurate and timely data available for clinical and business decisions
• Increased access to data

Access Control

• Patients’ right to privacy is protected
• Compliance with state and federal laws and regulations
• Improved access when appropriate

Data Quality Management

• Consistent and methodical improvement of the quality of data
• Improved decision making influenced by reliable information

Nosology

• Access to clinically relevant aggregate data

TECHNICAL

Classification and Coding

• Reduced threat of fraud and abuse litigation
• Improved data accuracy
• Accurate reimbursement
• Abstracting
• Access to key data at the patient and aggregate levels

Registry Development

• Information to support long term care of chronic disease
• Research information for the value of treatment of chronic disease

Storage

• Reduced costs of storing records
• Compliance with state and federal laws

Retrieval

• Information available for healthcare emergencies
• Most cost-effective access to information

Release

• Patient rights for privacy of health information are protected
• Reduced risk of litigation from inappropriate release
• Meaningful interpretation of statistical data
• Both business and clinical information are presented with appropriate content and context review