Health Information Management
Expert-defined terms from the Certified Professional in Electronic Health Records Documentation and Coding course at London School of Business and Administration. Free to read, free to share, paired with a globally recognised certification pathway.
Health Information Management (HIM) #
Health Information Management (HIM)
Health Information Management (HIM) is a practice that involves acquiring, analy… #
HIM professionals are responsible for managing health information systems consistent with medical, administrative, ethical, legal, and accreditation requirements of the healthcare system. The main goal of HIM is to ensure the accuracy, accessibility, and security of patient health records. HIM professionals play a crucial role in maintaining the integrity of healthcare data and supporting the efficient operation of healthcare facilities.
Electronic Health Records (EHR) #
Electronic Health Records (EHR)
Electronic Health Records (EHR) are digital versions of patients' paper charts #
EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs contain a wide range of data, including medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results. EHRs allow healthcare providers to access patient information quickly and securely, improving the quality and efficiency of patient care.
Protected Health Information (PHI) #
Protected Health Information (PHI)
Protected Health Information (PHI) is any information in a medical record that c… #
PHI includes patient names, addresses, birth dates, social security numbers, and medical record numbers. Under the Health Insurance Portability and Accountability Act (HIPAA), healthcare providers are required to protect the privacy and security of PHI to prevent unauthorized access and disclosure.
Health Information Exchange (HIE) #
Health Information Exchange (HIE)
Health Information Exchange (HIE) is the electronic sharing of healthcare inform… #
HIE allows healthcare professionals to access and share patient information securely, enabling better coordination of care and improving patient outcomes. HIE promotes interoperability between different healthcare systems and providers, enhancing the quality and efficiency of healthcare delivery.
Clinical Documentation Improvement (CDI) #
Clinical Documentation Improvement (CDI)
Clinical Documentation Improvement (CDI) is the process of enhancing the quality… #
CDI programs focus on ensuring that medical documentation accurately reflects the severity of illness and complexity of care provided to patients. By improving the specificity and completeness of clinical documentation, CDI programs help healthcare providers capture the true clinical picture of patients, leading to better coding accuracy, appropriate reimbursement, and improved patient outcomes.
Health Information Technology (HIT) #
Health Information Technology (HIT)
Health Information Technology (HIT) refers to the use of technology to store, re… #
HIT encompasses a broad range of tools and systems, including electronic health records (EHRs), health information exchanges (HIEs), clinical decision support systems, telemedicine platforms, and health analytics software. HIT plays a critical role in modern healthcare delivery by improving efficiency, accuracy, and quality of patient care.
ICD #
10-CM
International Classification of Diseases, Tenth Revision, Clinical Modification… #
ICD-10-CM codes are alphanumeric and are used to describe a patient's condition or disease accurately. Healthcare providers use ICD-10-CM codes to communicate diagnoses to insurance companies for billing purposes, track disease patterns, and improve public health reporting. Proper use of ICD-10-CM codes is essential for accurate reimbursement and data analysis in healthcare.
CPT #
CPT
Current Procedural Terminology (CPT) is a medical code set maintained by the Ame… #
CPT codes are used to report procedures and services performed by physicians and other healthcare professionals. CPT codes are essential for billing purposes and are used to communicate services rendered to insurance companies for reimbursement. Understanding and correctly assigning CPT codes is crucial for accurate billing and coding in healthcare.
Revenue Cycle Management (RCM) #
Revenue Cycle Management (RCM)
Revenue Cycle Management (RCM) is the process of managing the financial aspects… #
RCM includes everything from scheduling an appointment to receiving payment for services rendered. Key components of RCM include patient registration, insurance verification, coding and billing, claims processing, and collections. Effective RCM practices help healthcare organizations optimize revenue, reduce denials, and improve cash flow.
Health Insurance Portability and Accountability Act (HIPAA) #
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law… #
HIPAA sets standards for the electronic exchange of healthcare data, safeguards patient confidentiality, and gives patients control over their health information. Healthcare providers, health plans, and other covered entities must comply with HIPAA regulations to ensure the confidentiality and integrity of patients' protected health information (PHI).
Clinical Coding #
Clinical Coding
Clinical coding is the process of assigning alphanumeric codes to diagnoses, pro… #
Clinical codes are used for billing, reimbursement, research, and quality reporting purposes. Accurate clinical coding is essential for ensuring proper reimbursement, supporting clinical decision-making, and maintaining compliance with regulatory requirements. Certified Professional in Electronic Health Records Documentation and Coding (CPEHRDC) professionals play a vital role in accurately assigning clinical codes to medical records.
Audit Trail #
Audit Trail
An audit trail is a chronological record that shows who has accessed an electron… #
Audit trails help monitor and track EHR activity to ensure the security and integrity of patient health information. By reviewing audit trails, healthcare organizations can identify unauthorized access, prevent data breaches, and maintain compliance with privacy regulations. Audit trails are a critical component of EHR security and auditability.
Data Integrity #
Data Integrity
Data integrity refers to the accuracy, consistency, and reliability of data stor… #
Maintaining data integrity is essential for ensuring that patient health information is complete, accurate, and up-to-date. Data integrity controls, such as encryption, access controls, and audit trails, help protect EHR data from unauthorized access, alteration, or loss. HIM professionals play a key role in maintaining data integrity and ensuring the quality of healthcare data.
Interoperability #
Interoperability
Interoperability is the ability of different healthcare information systems and… #
Interoperability enables seamless data sharing between healthcare providers, systems, and organizations, improving care coordination and patient outcomes. Standards such as HL7 (Health Level Seven) and FHIR (Fast Healthcare Interoperability Resources) help facilitate interoperability by defining common data formats and communication protocols.
Meaningful Use #
Meaningful Use
Meaningful Use is a set of standards and criteria established by the Centers for… #
Meaningful Use requirements focus on using EHRs to improve patient care, enhance care coordination, and engage patients in their healthcare. Healthcare providers who meet Meaningful Use criteria are eligible for financial incentives through the Medicare and Medicaid EHR Incentive Programs.
Health Information Privacy #
Health Information Privacy
Health Information Privacy refers to the right of individuals to control the use… #
Healthcare providers are required to protect the privacy of patient health information under federal laws such as the Health Insurance Portability and Accountability Act (HIPAA). Health Information Privacy regulations govern how healthcare organizations collect, use, and disclose patient health information to ensure confidentiality and prevent unauthorized access. Protecting health information privacy is essential for maintaining patient trust and compliance with regulations.
Clinical Decision Support (CDS) #
Clinical Decision Support (CDS)
Clinical Decision Support (CDS) is a technology #
based tool that provides healthcare professionals with clinical knowledge and patient-specific information to enhance decision-making. CDS systems analyze patient data, guidelines, and best practices to offer evidence-based recommendations for diagnosis, treatment, and care management. CDS tools help improve clinical outcomes, reduce medical errors, and enhance the quality of patient care by assisting healthcare providers in making informed decisions at the point of care.
Health Information System #
Health Information System
A Health Information System is a comprehensive system that manages electronic he… #
Health Information Systems include electronic health record (EHR) systems, practice management systems, health information exchanges (HIEs), and other software applications used in healthcare settings. Health Information Systems support the collection, storage, retrieval, and sharing of patient information to facilitate clinical decision-making, care coordination, and administrative processes in healthcare organizations.
Data Governance #
Data Governance
Data Governance is the framework of policies, processes, and controls that ensur… #
Data Governance practices define how data is collected, stored, accessed, and used within an organization. Data Governance promotes data integrity, confidentiality, and availability, enabling healthcare organizations to make informed decisions, comply with regulations, and improve patient care. HIM professionals play a critical role in implementing and maintaining data governance practices in healthcare.
Health Information Management System (HIMS) #
Health Information Management System (HIMS)
A Health Information Management System (HIMS) is a software application or platf… #
HIMS solutions support the storage, retrieval, sharing, and analysis of health information within healthcare organizations. HIMS includes features such as patient registration, appointment scheduling, clinical documentation, coding, billing, and reporting. HIMS systems help healthcare providers streamline operations, improve data accuracy, and enhance patient care delivery.
Release of Information (ROI) #
Release of Information (ROI)
Release of Information (ROI) is the process of providing authorized individuals… #
ROI requests may come from patients, healthcare providers, insurers, legal entities, or other parties with a legitimate need for patient records. Healthcare organizations must follow HIPAA regulations and other privacy laws when disclosing patient information through the ROI process. HIM professionals are responsible for managing ROI requests, ensuring compliance with privacy regulations, and safeguarding patient confidentiality.
Master Patient Index (MPI) #
Master Patient Index (MPI)
A Master Patient Index (MPI) is a centralized database that stores and manages p… #
The MPI serves as a master registry of patient records, linking each patient to a unique identifier that allows for accurate identification and retrieval of health information. The MPI is essential for maintaining data integrity, reducing duplicate records, and ensuring that patients are correctly matched with their health records across different care settings.
Data Analytics #
Data Analytics
Data Analytics is the process of examining large datasets to uncover patterns, t… #
In healthcare, data analytics involves analyzing clinical, financial, and operational data to identify opportunities for quality improvement, cost reduction, and population health management. Data analytics tools and techniques help healthcare organizations extract valuable information from electronic health records (EHRs), claims data, and other sources to drive performance improvement and innovation.
Health Information Technician (HIT) #
Health Information Technician (HIT)
A Health Information Technician (HIT) is a healthcare professional responsible f… #
HITs play a key role in coding, billing, data entry, record maintenance, and information retrieval in healthcare settings. HITs ensure the accuracy, completeness, and security of health records, supporting clinical care, reimbursement, and compliance with regulatory requirements. HITs work closely with HIM professionals to maintain the integrity of healthcare data.
Data Security #
Data Security
Data Security refers to the measures and controls implemented to protect the con… #
Data security practices include encryption, access controls, authentication, audit trails, and data backup to prevent unauthorized access, data breaches, and loss of information. Healthcare organizations must comply with data security regulations such as HIPAA to safeguard patient health information and maintain trust with patients. Data security is a critical component of health information management to ensure the privacy and security of electronic health records.
Health Information Technician (HIT) #
Health Information Technician (HIT)
A Health Information Technician (HIT) is a healthcare professional responsible f… #
HITs play a key role in coding, billing, data entry, record maintenance, and information retrieval in healthcare settings. HITs ensure the accuracy, completeness, and security of health records, supporting clinical care, reimbursement, and compliance with regulatory requirements. HITs work closely with HIM professionals to maintain the integrity of healthcare data.
Data Security #
Data Security
Data Security refers to the measures and controls implemented to protect the con… #
Data security practices include encryption, access controls, authentication, audit trails, and data backup to prevent unauthorized access, data breaches, and loss of information. Healthcare organizations must comply with data security regulations such as HIPAA to safeguard patient health information and maintain trust with patients. Data security is a critical component of health information management to ensure the privacy and security of electronic health records.
Clinical Documentation #
Clinical Documentation
Clinical Documentation is the recording of patient information and healthcare en… #
Clinical documentation includes patient history, symptoms, diagnoses, treatments, medications, and other relevant information that supports clinical decision-making and care delivery. Accurate and complete clinical documentation is essential for communicating patient care, supporting coding and billing processes, and ensuring quality patient care. HIM professionals play a vital role in reviewing and maintaining clinical documentation standards in healthcare settings.
Health Information Privacy #
Health Information Privacy
Health Information Privacy refers to the right of individuals to control the use… #
Healthcare providers are required to protect the privacy of patient health information under federal laws such as the Health Insurance Portability and Accountability Act (HIPAA). Health Information Privacy regulations govern how healthcare organizations collect, use, and disclose patient health information to ensure confidentiality and prevent unauthorized access. Protecting health information privacy is essential for maintaining patient trust and compliance with regulations.
Health Information System #
Health Information System
A Health Information System is a comprehensive system that manages electronic he… #
Health Information Systems include electronic health record (EHR) systems, practice management systems, health information exchanges (HIEs), and other software applications used in healthcare settings. Health Information Systems support the collection, storage, retrieval, and sharing of patient information to facilitate clinical decision-making, care coordination, and administrative processes in healthcare organizations.