By Diana Warner, MS, RHIA, CHPS, FAHIMA
The use of health information technology (HIT) in the clinical setting brings both opportunities and challenges for health information management (HIM) professionals regarding data capture and exchange; data storage, use and reuse; record ownership and access; e-discovery and e-forensics; and other issues. It is critical that HIM practices in healthcare organizations are supported by capabilities of HIT products in order to carry out our practices in electronic health record (EHR) systems, electronic document management systems (EDMS) and other HIT applications.
What could be done to enable interoperable, standards-based capabilities in HIT systems to support HIM practices? In fact, HIM professionals must guide the development of HIT capabilities to support HIM practices in electronic environment by participating in the development of HIT interoperability standards at the standards development organizations including Integrating the Healthcare Enterprise (IHE) and International Organization for Standardization (ISO), Technical Committee 215 Health Informatics (ISO/TC215).
Leading the global information governance (IG) initiative in healthcare, AHIMA formed a Standards Task Force of HIM subject matter experts and HIT professionals (vendors and standards developers). For the first time we have been working together on developing IG and HIT standards to ensure that system interoperability will be addressed from an HIM perspective. Together, HIM and HIT professionals are promoting the development and adoption of standards to achieve functional interoperability (“rules of the road”), semantic interoperability (“shared content”) and technical interoperability (“information transport infrastructure”) for effective use and re-use of health information.
A jointly published AHIMA and IHE white paper “Health IT Standards for Health Information Management Practices,” (http://qrs.ly/lb4vec0) is a first-of-its-kind white paper that serves as a guide for HIM and HIT professionals to develop interoperability standards. A methodology has been introduced in this white paper to inform standards developers about HIM practices. The white paper also specified a roadmap for developing standards to support information governance in healthcare.
What’s next? The AHIMA Standards Task Force has been focusing on developing standards for IG business requirements and functional requirements including specifications of HIM practice checklists and use cases on:
- Patient registration
- Patient matching
- Copy and paste
- Transition of care
- Data quality
To participate in the development of Information Governance Standards, please contact Diana Warner at diana.warner@ahima.org.
Diana Warner, MS, RHIA, CHPS, FAHIMA is a director of HIM Practice Excellence at AHIMA.