To say that health information management (HIM) has changed is an understatement. From a paper-based system of recording medical encounters to today’s industry that has been transformed through the widespread use of technology, analytics, and artificial intelligence, the role of an HIM professional continues to evolve. And at the core of HIM is the data collected in medical records, making the accuracy and integrity of that data paramount to ensuring healthcare quality.
Paper-Based Medical Records: A Thing of the Past
In the past, medical records were all paper-based and patient information was traditionally housed and maintained by the provider. Documentation of the care that a patient received has always been important, especially for HIM professionals who were ultimately responsible for record retrieval, collection, aggregation, and utilization of information for payment and statistics. The adage “if it wasn’t documented, it didn’t happen” was important then and is even more critical today.
If an error was discovered in the patient record, it was corrected in one place and anyone using that record going forward was assured of accuracy. The patient record, even in paper format, was considered the single “source of truth” and a legal document that provided information regarding the care that the patient received.
EMRs and Aggregators Bring Challenges
With the utilization of electronic medical records and the introduction of multiple systems that cross organizations and providers, managing health information has become more complex. While there are many advantages to electronic records, these advantages also come with some risks. One risk that we as HIM professionals can mitigate is the risk of passing erroneous data that does not present the patient’s “True Clinical Picture” to multiple end users.
Since data from medical records are aggregated, omissions, errors and incomplete documentation can be magnified by the various creators, systems, and aggregators. That can affect the patients, providers, facilities and other users of that data. Since the patient record ultimately determines the perception of the care provided, it is more important than ever to provide proper documentation that reflects the true clinical picture. That is why it is so critical for us as HIM professionals to ensure that every record presents the True Clinical Picture across the full continuum of patient care.
TRUE CLINICAL PICTURE: A complete and comprehensive record that serves as the source of truth by accurately reflecting the care provided. The True Clinical Picture allows healthcare organizations to make meaningful use of health information and achieve positive outcomes for both patients and the organization.
Healthcare today is value-based and consumer-driven, and there is much more information available to all the stakeholders in our healthcare system. As HIM professionals, we play a critical role in ensuring that the data we govern is accurate and optimizes outcomes for both the clinical and financial pathways of healthcare.
- Documentation drives patient care so it should provide current and future providers with the level of detail needed to ensure continuity and quality of care.
- Given the importance of quality scores, physicians have a stake in improving documentation now more than ever.
- Patients now have access to more information about providers, and that information is aggregated in part from outcomes reported in clinical data.
- Let’s not forget that documentation drives coding and ultimately drives patient care and reimbursement.
- Finally, high-quality documentation will minimize denials and the cost of researching and resubmitting claims.
The Key to Capturing the True Clinical Picture
As HIM professionals, we have always been in the business of data governance, and today’s technology-driven healthcare environment requires us to ensure the information we share presents the True Clinical Picture. The key to achieving that objective is taking a holistic approach with an integrated team of clinicians, coders, and clinical documentation specialists working together to effectively manage the data — from collection to aggregation to reporting.
While the format of patient records may have changed due to disparate systems, integrated data, robust analytics and the increased use of artificial intelligence, the foundation for HIM professionals remains, “if it wasn’t documented, it didn’t happen.” However, in some cases, care may have been provided but the documentation was missed. HIM professionals must continue to ensure a complete and comprehensive patient record that serves as the “source of truth” and represents the True Clinical Picture. Every record represents a real person, and the data in that record must reflect care provided in the past so it can be effectively utilized for future care, diagnoses, treatment, and payment.
By taking a holistic approach to managing health information, healthcare organizations can improve data quality, ensure compliant coding, increase revenue, decrease operational expense, lower the risk of quality-related penalties and improve care. When you focus on the true clinical picture, your organization can make meaningful use of health information and achieve positive outcomes for both your patients and your business.
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