POST-GRADUATE DIPLOMA IN PUBLIC
HEALTH
PPGD 520
HEALTH INFORMATION MANAGEMENT
SYSTEM
LECTURER: MRS ENWEREM G.O
Health Information Management (HIM)
Health Information Management (HIM) is the practice of acquiring,
analyzing, storing, and protecting healthcare information. It
ensures that medical data is complete, accurate, and available to
healthcare professionals whenever it is needed. HIM sits at the
intersection of healthcare, technology, and administration.
Introduction to HIM
HIM is a crucial component of modern healthcare systems. It
involves the management of health information using both paper
and digital records to support high-quality patient care, safety, and
compliance with healthcare regulations.
Professionals in HIM work to organize and manage health data to
ensure it meets legal, professional, and ethical standards. HIM
supports clinical decisions, billing processes, public health
initiatives, and research.
Objectives of Health Information Management
The primary goals of HIM include:
Maintaining accurate and complete records – Ensuring
data integrity and accessibility.
Protecting patient privacy – Managing who has access to
information.
Ensuring legal and regulatory compliance – Following
standards like HIPAA.
Supporting reimbursement processes – Enabling accurate
coding and billing.
Facilitating clinical and administrative decision-making
– Providing data insights.
Career Roles in HIM
The field of HIM offers various career opportunities:
Health Information Manager – Oversees the storage,
retrieval, and analysis of health data.
Medical Coder – Translates healthcare services into universal
codes for billing.
Clinical Documentation Improvement (CDI) Specialist –
Ensures documentation accurately reflects patient care.
EHR Specialist – Implements and maintains Electronic Health
Record systems.
Compliance Officer – Ensures adherence to data privacy and
health regulations.
Understanding Healthcare Systems
A healthcare system includes all the organizations, people, and
actions whose primary intent is to promote, restore, or maintain
health.
Main Functions:
Delivering quality healthcare
Promoting health
Preventing disease
Managing public health emergencies
Stakeholders in the Healthcare System
Healthcare systems are supported by several key players:
1. Providers – Doctors, nurses, clinics, hospitals.
2. Patients – The population receiving care.
3. Payers – Health insurance companies, government programs
(Medicare, Medicaid).
4. Regulators – WHO, CDC, FDA, national health ministries.
Types of Healthcare Systems
System Type Description Example Countries
Single-Payer Government-funded UK (NHS), Canada
healthcare
Multi-Payer Mix of private & public USA, Germany
insurance
Out-of-Pocket Patients pay directly for Many developing
services nations
HIM in Healthcare Systems
HIM plays a vital role in supporting:
Interoperability – Linking data across multiple providers.
Clinical decision-making – Ensuring reliable data.
Public health reporting – Tracking disease and health
outcomes.
Population health management – Using data for
prevention and planning.
Patient Records
A patient record is the official documentation of a person’s medical
history, diagnosis, treatment, and health outcomes.
Purposes:
Guides patient care and continuity
Provides evidence in legal issues
Supports billing and insurance
Assists in research and policy-making
Types of Patient Records
Paper-Based Records: Traditional but prone to errors,
damage, and misfiling.
Electronic Health Records (EHRs): Digitally stored,
searchable, and sharable records.
Key Components of a Patient Record
Patient Demographics: Name, date of birth, contact info.
Medical History: Allergies, chronic illnesses, past surgeries.
Progress Notes: Daily or visit-based updates from providers.
Lab & Imaging Results: Diagnostic information.
Medications: Prescriptions and administration records.
Electronic Health Records (EHRs)
An EHR is a digital version of a patient’s medical chart. It includes
all the patient’s health information in one place and can be shared
across healthcare providers.
Advantages of EHRs
✔ Enhanced communication and coordination between providers
✔ Reduces duplication and human error
✔ Supports population-level analytics
✔ Provides quick access during emergencies
✔ Environmentally friendly (paperless)
Challenges of EHR Implementation
Cost: Expensive to install and maintain.
Training: Staff need to learn new systems.
Privacy: Vulnerability to cyberattacks.
Compatibility: Systems may not share data easily
(interoperability issues).
EHR vs EMR
Feature EHR EMR
Across multiple Within one
Use Scope
organizations hospital/clinic
Sharing Highly shareable Limited sharing
Comprehensive patient Focused on single
Data Coverage
history encounter
Data Collection and Standardization
Standardized data ensures accurate analysis, consistency, and
sharing across systems.
Benefits of Standardization:
Easier billing and claims processing
Supports interoperability
Reduces errors in documentation
Enables comparative studies
Medical Coding Systems
Coding translates services into universal codes for billing and data
tracking.
Code System Use Example
ICD-10-CM Diagnosis coding E11.9 – Type 2
Diabetes
CPT Procedure coding 99213 – Office visit
SNOMED CT Clinical terminology Multilingual coding
system
Legal Aspects of HIM
HIM professionals must follow rules that protect patient data.
Key Laws:
HIPAA (1996):
Health Insurance Portability and Accountability Act – protects
patient privacy and sets standards for electronic data.
HITECH Act (2009):
Promotes EHR adoption and increases penalties for breaches.
Legal Risks in HIM
Data Breaches: Unauthorized access or leaks of patient data.
Improper Disclosure: Sharing information without consent.
Fraudulent Billing: Using incorrect codes to inflate claims.
Negligent Documentation: Failing to record care properly.
Medical Coding in HIM
Medical coding ensures that procedures and diagnoses are
recorded in a universally understandable way.
Purposes:
Insurance claims and billing
Health statistics and planning
Hospital reimbursement
Quality control and performance tracking
Healthcare Reimbursement
Healthcare providers are paid through various models. HIM
ensures accurate data is used for fair reimbursement.
Payment Models
Fee-for-Service (FFS):
Payment is made for every procedure or visit.
Value-Based Care:
Providers are rewarded for keeping patients healthy and
avoiding unnecessary procedures.
Capitation:
Providers receive a fixed amount per patient regardless of how
many services are used.
HIM's Role in Reimbursement
Ensures accurate coding for insurance claims
Prevents delays and denials due to documentation errors
Reduces fraudulent claims
Helps in audits and appeals
Future Trends in HIM
1. Artificial Intelligence (AI):
Used for predicting health trends, detecting fraud, and
personalizing care.
2. Blockchain Technology:
Ensures health records are secure, unchangeable, and traceable.
3. Cloud Storage:
Stores large amounts of data accessible anywhere with internet
connectivity.
4. Telemedicine Integration:
HIM supports digital record keeping for online consultations.
5. Mobile Health (mHealth):
Apps allow patients to monitor their health and communicate with
providers.
