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Health Information Management ebook

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The Updated and Extensively Revised Guide to Developing Efficient Health Information Management Systems Health Information Management is the most comprehensive introduction to the study and development of Health Information Management (HIM). Students in all areas of health care gain an unmatched understanding of the entire HIM profession and how it currently relates to the complex and continuously evolving field of health care in the United States. This brand-new Sixth Edition represents the most thorough revision to date of this cornerstone resource. Inside, a group of hand-picked HIM educators and practitioners representing the vanguard of the field provide fundamental guidelines on content and structure, analysis, assessment, and enhanced information. Fully modernized to reflect recent changes in the theory and practice of HIM, this latest edition features all-new illustrative examples and in-depth case studies, along with: * Fresh and contemporary examinations of both electronic and print health records, data management, data privacy and security, health informatics and analytics, and coding and classification systems * An engaging and user-friendly pedagogy, complete with learning objectives, key terms, case studies, and problems with workable solutions in every chapter * Ready-to-use PowerPoint slides for lectures, full lesson plans, and a test bank for turnkey assessments A must-have resource for everyone in health care, Health Information Management, Sixth Edition, puts everything you need at your fingertips.

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Table of Contents


Title Page


About the Editor

About the Contributors



Chapter 1: Health Information Management and the Healthcare Institution

Responsibility of the Board of Directors

Responsibility of the President/Chief Executive Officer (CEO)

Responsibility of the Medical Staff

Functions of the HIM Department

The HIM Professional



Chapter 2: Health Record Content and Structure of the Health Record

Health Record Content

Master Patient Index

Disease and Operation Indexes or Databases

Registers Maintained by Healthcare Facilities



Chapter 3: The Health Record: Electronic and Paper

Record Identification Systems

Filing Systems for Paper‐Based Records

Logistical, Space, and Equipment Considerations

System and Equipment Selection

Impact of the Electronic Health Record

Health Information Management in Multisite Systems



Chapter 4: Healthcare Topics in Data Governance and Data Management


Data Governance

Data Management

Working Examples/Case Scenario


Chapter 5: Health Law, Data Privacy and Security, Fraud, and Abuse

The U.S. Legal System

Sources of Law

Theories of Liability

Legal Requirements Affecting Health Information Management

Fraud and Abuse Implications for HIM and Corporate Compliance



Chapter 6: Informatics, Analytics, Data Use, and System Support

The Field of Health Informatics

Data Analytics

Application of Basic Statistical Techniques and Presentation of Data



Chapter 7: Coding, Compliance, and Classification Systems

International Classification of Diseases

Coding Quality

Challenges and Technology Advancements in Coding



Chapter 8: Clinical Documentation Improvement

Managing Coding Audits

Computer‐Assisted Coding: A Review of Accuracy of CAC Coding Assignments

Communicating with Physicians

CDI External Coding Audits

CDI and the Case Mix Index



Chapter 9: Revenue Cycle and Reimbursement

Administrative Functions of the Revenue Cycle

Federal Regulation of Meaningful Use

Lack of Consensus Regarding Interoperability Standards

Information Governance

Identity Theft

Privacy and Security

Security Breaches

Healthcare Facilities Are Facing Collection Issues

Charge Description Master (CDM)

Revenue Codes and the Form CMS‐1450 (UB‐04)

Clinical Documentation Improvement (CDI)

Necessity of a CDM Team

Charge Capture

Fraud and Abuse

ICD‐10‐CM and ICD‐10‐PCS Required Restructuring of the Revenue Cycle

Determination of Which Codes Are Placed in the Charge Master

Clean Claim Submission

Remittance Processing

Denial Management

Revenue Cycle Key Performance Indicators



Chapter 10: Strategic, Financial, and Organizational Management

Utilize Health Information to Support Enterprise‐Wide Decision Support

Strategic Planning

Develop Information Management Plans That Support the Organization's Current and Future Strategy and Goals

General Principles of Management Utilized in the Administration of Health Information Services

Health Information Exchange

HIM Contribution to HIE

Budget Planning

Overview Human Resources Including Labor/Employment Laws



End User License Agreement

List of Tables

Chapter 6: Informatics, Analytics, Data Use, and System Support

Table 6.1. Healthcare Facility Rates Are Based on the Concept of

Actual versus Possible

Table 6.2. Healthcare Mortality Rates Indicate Quality of Care

Table 6.3. Gross Autopsy Rates Typically Exclude Fetal Death Autopsies but Include Newborn Deaths and Autopsies

Chapter 7: Coding, Compliance, and Classification Systems

Table 7.1. Classification and Coding Systems Development Timeline: History of the Statistical Classification of Disease and Causes of Death

Table 7.2. Mapping Example

Chapter 8: Clinical Documentation Improvement

Table 8.1. POA Indicators

Chapter 9: Revenue Cycle and Reimbursement

Table 9.1. Charge Master Acute Care Hospital

List of Illustrations

Chapter 1: Health Information Management and the Healthcare Institution

Figure 1.1. Sample Hospital Organization Chart.

Chapter 4: Healthcare Topics in Data Governance and Data Management

Figure 4.1. Sample Data Dictionary.

Figure 4.2. Sample Data Types.

Figure 4.3. Sample Structured Data.

Figure 4.4. Inpatient Prospective Payment System Summary FY 2011.

Figure 4.5. Sample Data Set Exported to a Spreadsheet.

Figure 4.6. Inpatient Prospective Payment Data Sorted by DRG.

Figure 4.7. Inpatient Prospective Payment Data Sorted by the Desired States.

Figure 4.8. Inpatient Prospective Payment Filtered by DRG Definition.

Figure 4.9. Sample Screenshot Depicting the Highest Average Medicare Payment for the State of PA.

Figure 4.10. Average Medicare Payments for Maryland, Pennsylvania, Virginia, and Ohio.

Chapter 5: Health Law, Data Privacy and Security, Fraud, and Abuse

Figure 5.1. Distinctions Between Public Law and Private Law.

Chapter 6: Informatics, Analytics, Data Use, and System Support

Figure 6.1. Volume of Services by Discharge.

Figure 6.2. Number of Discharges per Quarter for the Med/Surg Unit.

Figure 6.3. Control Chart for Analyzing Surgical Site Infection Rates.

Figure 6.4. Discharges by Medical Staff Units.

Figure 6.5. Distribution of CPT Codes.

Chapter 7: Coding, Compliance, and Classification Systems

Figure 7.1. ICD‐9 and ICD‐10 Diagnosis Code Comparison.

Figure 7.2. ICD‐9 and ICD‐10 Procedure Code Comparison.

Figure 7.3. The SNOMED Logical Model.

Chapter 10: Strategic, Financial, and Organizational Management

Figure 10.1. Processing and Transformation of Data.

Figure 10.2. Elements of Strategic Planning.



Table of Contents

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Health Information Management

Principles and Organization for Health Information Services












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Library of Congress Cataloging-in-Publication Data

Names: Skurka, Margaret Flettre, editor.Title: Health information management : principles and organization for health information services / edited by Margaret A. Skurka.Other titles: Health information management (Skurka)Description: 6th edition. | Hoboken, New Jersey : Jossey-Bass [2017] Includes bibliographical references and index.Identifiers: LCCN 2016053257 (print) | LCCN 2016054679 (ebook) | ISBN 9781119151203 (pbk. : alk. paper) | ISBN 9781119151234 (pdf) | ISBN 9781119151210 (epub)Subjects: | MESH: Health Information Systems—organization & administration | Medical Records | Hospital Information ManagementClassification: LCC RA976 (print) | LCC RA976 (ebook) | NLM WX 173 | DDC 651.5/04261—dc23LC record available at

Cover Design and Illustration: Wiley


Margaret A. Skurka, MS, RHIA, CCS, FAHIMA, is a Professor and Director of the Health Information Technology Program at Indiana University Northwest in Gary. She has served as Assistant Dean and Department Chair of HIM for the past 40‐plus years at the university. She received her BS in Health Information Management (HIM) from the University of Illinois and was awarded a Master of Science from Purdue University. She has been actively involved in the American Health Information Management Association for her entire career. She served a six‐year term on the national Board of Directors of AHIMA, and was the national president in 2000. She received the Association's highest honor of Distinguished Member in 2010. She was named the Alumnus of the Year in the Allied Health Professions at the University of Illinois at Chicago in 2002. Skurka was the president of the International HIM Association in 2013 and was on the board of that association for 12 years. She was named a Chancellor's Professor, one of the university's highest honors, at Indiana University Northwest in 2015. As a consultant, Skurka has provided consulting services to numerous physician practices and ambulatory surgery centers and conducted extensive nationwide training for AHIMA as an approved trainer for ICD‐10‐CM and PCS.


Dilhari R. DeAlmeida, PhD, RHIA, is an Assistant Professor in the Department of Health Information Management at the University of Pittsburgh. She received her Bachelor of Science degree in Cell and Molecular Biology from University of Toronto, Canada. Prior to joining the HIM department, she had over 12 years of experience working in government, academic, and the private sector in the field of Molecular Biology. She received her Master of Science (HIS/RHIA option) and Doctorate degrees from the University of Pittsburgh. Her dissertation research involved evaluating the ICD‐10‐CM coding system for documentation specificity and reimbursement. Documentation specificity in the ICD‐10 coding system and the Electronic Health Record have been a great area of interest and she is an AHIMA‐approved ICD‐10‐CM/PCS trainer. In addition to research, she teaches both the undergraduate and graduate courses in HIM.

Linda Galocy, MS, RHIA, is a Clinical Assistant Professor and Program Chair in the Health Information Management programs at Indiana University Northwest in Gary, Indiana. She received her baccalaureate degree in Health Information Management from Indiana University Purdue University in Indianapolis (IUPUI), and Master of Science in Adult Education from IUPUI School of Continuing Education. Prior to joining the full‐time faculty at Indiana University Northwest, she held a variety of roles in health information management in acute care. She has been active in her local professional association and the Indiana Health Information Management Association. She is currently active at the national level for the American Health Information Management Association as a workgroup member for various committees of the Council on Excellence in Education. She continues to consult with physician practices, performing documentation and coding reviews and education. She has presented nationally and teaches a variety of course at the BS and AS level in the HIM programs at Indiana University.

Katie Kerr, MA, RHIA, is an Assistant Professor and the Academic Coordinator of Professional Practice Experiences for the Department of Health Informatics and Information Management at The College of St. Scholastica in Duluth, MN. She teaches in both the undergraduate and graduate HIM programs. Prior to joining the CSS HIIM Department, she was a Health Information Manager for Essentia Health in Sandstone, MN for seven years and the IT Department Manager at FirstLight Health System in Mora, MN for three years. Katie is an active Minnesota Health Information Management Association (MHIMA) member and currently co‐chairs the Coding Key Focus Area. Mrs. Kerr has a Bachelor and Master's Degree in Health Information Management from The College of St. Scholastica and is currently pursuing her Ed.D. in Leadership in Higher Education at Bethel University in St. Paul, MN.

Suzanne Paone, MBA, DHA, RHIA, has a full‐time appointment at Ashford University in Health Information Management and dual adjunct appointments at the University of Pittsburgh in the Department of Medicine's HIM Program and the Graduate School of Public Health's MHA program. She also has an adjunct appointment in the MBA Program at Carlow University in Pittsburgh, PA. She holds several not‐for‐profit board positions and has published on technology adoption, eHealth services innovation, and health data analytics. She has received awards from organizations such as the American Hospital Association and Microsoft for innovation in healthcare operations and IT strategy development. She has more than 10 years of teaching and curriculum development experience in the academic community in the areas of analytics, informatics, health process transformation, business strategy, and HIM. She is an experienced speaker and a consultant to several academic and healthcare organizations.

Sandra K. Rains, MPA, MBA, RHIA, RHIT, is a Health Information Management Educator with more than 30 years of solid experience in university level Health Information Technology instruction, mentoring, and administration. She is presently employed as a Clinical Documentation Improvement Specialist (CDIS) and educator at a nationally known Children's Hospital. In addition, she possesses more than 30 years of experience in Health Information Management roles with skills in budgeting, staff training, coding, documentation improvement teams, revenue cycle and medical record review. Her education achievements include Master of Public Administration with an emphasis on Health Care and Master of Business Administration, RHIA, RHIT, and she is a certified ICD-10-CM/PCS trainer.

Dorinda M. Sattler, MJ, RHIA, CHPS, CPHRM, is a Clinical Assistant Professor in the Health Information Management programs at Indiana University Northwest in Gary, Indiana. She received both her associate degree in Health Information Technology and her baccalaureate degree in Health Services Management from Indiana University Northwest. She also earned her Master of Jurisprudence in Health Law degree from Loyola University Chicago School of Law. She is a Registered Health Information Administrator and is certified in Healthcare Privacy and Security from AHIMA. She is also a Certified Professional in Healthcare Risk Management from the American Hospital Association. Prior to joining the full‐time faculty at Indiana University Northwest, she held a variety of roles in health information management and practice management, and most recently served as a hospital risk manager. At various times throughout her career, she has been active in her local and state health information management associations. She is currently active at the national level for the American Health Information Management Association as a CHPS exam item writer, exam development committee member, and volunteer on the HIM Reimagined leadership initiative. Sattler has also been involved in the Indiana Society for Healthcare Risk Management, serving as co‐president. She also owns a consulting company that specializes in health information and risk management consulting.

Janelle Wapola, MA, RHIA, is an Assistant Professor in the Department of Healthcare Informatics and Information Management at the College of St. Scholastica in Duluth, MN. She has published, presented, and taught various HIM topics during her career. Her teaching responsibilities also include student advisement, SHIMA advisor, IRB board member, academic committees, and virtual lab coordinator, and she is also an advocate for global HIM. A highlight was when she was able to help lead two study abroad groups to India and Germany to see firsthand about their healthcare system and culture. Prior to teaching, Wapola enjoyed the health information management profession, serving as a consultant, operations manager, release of information specialist, and trainer. She has been volunteering in her community and HIM for over 20 years. She received both her bachelor and master's degrees in Health Information Management from the College of St. Scholastica.

Margaret J. (Margie) White, MS, RHIA, NHA, CPHQ, was the first author of Chapter 7. She was the Director of the Health Information Technology Program at Marion Technical College in Marion, OH. She was a member of AHIMA and had earned multiple credentials from AHIMA and other associations including RHIA, CCS, CCS‐P, NHA, and CPHQ. She passed away in Westerville, OH shortly after her first submission of the chapter. We thank her for her contribution to the content.

Felecia Williams, MPA, RHIA, is a Clinical Assistant Professor in the Health Information Management Program at the University of Illinois at Chicago (UIC). She received her baccalaureate in health information management from UIC and a master's degree in Public Administration with a concentration in Health Services Management from Roosevelt University. Williams has presented at AOE and served on the board of the local CAHIMA chapter. She previously held positions of provider profiling manager, manager of the national provider finder, and vendor management with Blue Cross Blue Shield affiliates. She currently teaches both campus and online students in the bachelors and post‐baccalaureate certificate programs.

Karen Wright, MHA, RHIA, was the Director of a large acute care Health Information Management department at a 365‐bed acute care hospital in Ohio. Prior to that, she served as a manager of two physician's medical practices and served as a medical transcription supervisor. She was a consultant to Long Term Care, Mental Health and Substance Abuse facilities. She also served as Coordinator and primary professor of the Health Information Technology Program at Hocking College in Ohio. Ms. Wright has a Bachelor's Degree in HIM from The Ohio State University and a Masters in Health Services Administration from Ohio University.


Health Information Management: Principles and Organization for Health Information Services, sixth edition, recognizes the continuing need for guidance in developing efficient health information management (HIM) systems for healthcare institutions. This important revision of the 2003 edition is designed to capture the significant changes in the HIM field and profession in recent years.

The first edition of this book was published in 1984, and it replaced Medical Record Departments in Hospitals: Guide to Organization, which had originally been published by the American Hospital Association in 1962 and revised in 1972. Second and third editions of the book were published in 1988 and 1994, respectively, under the title Organization of Medical Record Departments in Hospitals. The fifth edition was published by Jossey‐Bass in 2003.

This book serves as a comprehensive general reference to patient medical records and HIM. It is useful to a healthcare institution's chief executive, chief operating and financial officers, and information systems technology personnel. It is also essential reading for health professionals who need a general overview and understanding of HIM practices. The text also covers appropriate information for faculty and students in health information administration and technology educational programs. It serves as an introduction to HIM practices and issues for information systems. In addition, individuals in smaller healthcare institutions will find this book useful in applying the basic principles of HIM. As the appropriate application of these basic principles requires a careful analysis of the individual healthcare institution's needs, various operations in HIM are discussed herein. The healthcare industry continues to undergo constant change and the technology used in managing health information has experienced very rapid change.

Throughout this book, the term health information management practitioner will encompass both the registered health information administrator (RHIA) and the registered health information technician (RHIT). Both levels of the profession hold a variety of positions within the HIM discipline. These include management and supervisory positions, as well as clinical documentation specialists, coders, quality managers, and more.

The American Health Information Management Association (AHIMA) has over 100,000 members. Many additional credentials are available for HIM professionals besides the long‐standing RHIA and RHIT. Readers are encouraged to visit the website,, for a significant amount of information regarding the field and the profession.

—Margaret A. Skurka


A significant thank you goes out to my contributing authors for this sixth edition of Health Information Management: Principles and Organization for Health Information Services. Without their assistance, this work would not have been possible. They each contributed their long‐time experience in the specific areas of health information management in which they work and/or teach, which gives this text a hands‐on feeling. They were timely and on point, consistently.

Thank you:

Felecia Williams

Linda Galocy

Dilhari R. DeAlmeida

Suzanne Paone

Dorinda M. Sattler

Sandra K. Rains

Margie White (deceased)

Karen Wright

Janelle Wapola

Katie Kerr

A special thank you also goes to my two work colleagues at Indiana University Northwest, Linda Galocy and Dorinda Sattler, who shouldered the additional work in the department when I was on sabbatical. And, as always, a thank you to my husband Richard, who is accustomed to my long evenings in my home office at my computer. He has always understood and accepted my intensity and commitment with regard to the Health Information Management profession, and for that I am grateful.

This book is dedicated to my three now‐grown children—Erik Skurka, Kirstin Skurka Johnston, and Erin Skurka. They are all young professionals working in Chicago. I wish to them in their respective fields the same wonderful 40‐plus years I've enjoyed in my profession. It is a good thing to love what you do.

—Margaret A. Skurka

CHAPTER 1Health Information Management and the Healthcare Institution

Felecia Williams

The more things change, the more they stay the same.

—Jean‐Baptiste Alphonse Karr

To say that the field of health care has evolved over the past decade would be an understatement, but the quote from Mr. Karr is as true today as it was the day he made the statement. But with all that has changed, some things have remained the same. People still get sick and seek care at the hospital or clinic and physicians, nurses, therapists, and a host of other health professionals continue to provide care, in hopes of a healthier world. Additionally, the terms health and medical are still used interchangeably; this is even more pronounced when speaking of health/medical records in an electronic format.

In reality, medical and health are very different colors in the wide spectrum of the field of medicine. Health care, much like the health record, is not limited by the activities or documentation of activities that take place under the care of a physician and/or hospital. Health care not only includes services provided by a physician, but also includes a patient's lifestyle (i.e., food choices, physical activity, sleep patterns) and genetic predispositions. Where health incorporates outside forces, medical care and the medical record are driven by services provided under the care of health professionals.

Advancements in technology have changed the manner in which health information management (HIM) professionals perform their work, but it hasn't changed the work. Timely, accurate, and complete health records are still the foundations for high‐functioning HIM departments, which contribute to the overall success of a hospital.

In this chapter the discussion will focus on the roles and responsibilities of professionals that work within or for the hospital and their relationship to the HIM department. This will include the Board of Trustees, the CEO/President and the Medical Staff. This chapter will also discuss the functional areas of the HIM department, the HIM professional, and finally, the interactions between HIM and other departments and healthcare professionals within the facility.

Figure 1.1 shows a sample hospital organization chart. In this case, the HIM department's executive reporting structure falls under the medical staff. This is not always the case. To begin the discussion on the hospital hierarchy and roles of key players, it should be noted that the role of HIM is not restricted to a single reporting line.

Figure 1.1. Sample Hospital Organization Chart.

Note: The HIM executive reporting structure falls under the medical staff.


At the top of a hospital hierarchy resides the Board of Directors. The board of directors for a hospital, or any organization for that matter, has the ultimate responsibility for the success and/or failure of the organization. Members of the Board of Directors are generally leaders in their professional area of study, which is not restricted to health care, and are also considered to be upstanding citizens in the community. These members may be appointed to their position, but most are elected to serve for a specific time frame (term).

The hospital Board of Directors is responsible for the strategic vision casting activities such as planning for expansions, increased quality care through community outreach, as well as policy development for the hospitals' services. The board also has the responsibility of assigning the President or Chief Executive Officer (CEO) to take on the responsibility of the day‐to‐day activities within the hospital.

The board has regular communication with the President/CEO. These communications keep the board apprised of changes to local, state, and federal regulations that may impact the way the hospital is doing business. In addition to working with the CEO, the board may work directly with other departments' leadership when a strategic plan directly involves resources for that area. The board expects the CEO to work with the medical staff to ensure enforcement of policies and procedures and their bylaws. Reporting of activities of the medical staff and other departments are directed to the CEO, who then shares this information with the Board of Directors.

Information shared with the board is used for continuous improvement of policies and procedures, as well as future strategic activities. Strategic planning activities at the board level may be planned for as many as 10 years ahead. Using reports from the CEO allows the board to define visionary opportunities to improve the quality of care provided, and allows providers on staff to offer increased services and partner with the community to increase their presence and improve the overall health of the community.


The President/CEO of the hospital, generally an appointed position, is responsible for the day‐to‐day activities taking place within the hospital. This individual addresses the quality of care from all aspects, including the completion of medical records. Areas of patient satisfaction, patient safety, and employee satisfaction are not merely items on a checklist when it comes to their responsibilities; these items are just as important as the legal and ethical aspects of running a hospital, including health record compliance.

Given all the technology and patient accessibility to rating tools, ensuring patients are comfortable and satisfied is a priority. Unhappy patients and families use social media as well as the local news stations to report any incidence of discomfort. Contrary to the promotional statement claiming that “any publicity is good publicity,” in the hospital business bad publicity is just that, bad publicity, and can negatively impact patient counts and therefore the financial status of the facility. The CEO works with the marketing and public relations staff to increase awareness of any new programs being offered, the latest accreditation requirements, and any other accomplishments to help build a positive reputation for the hospital.

Because the CEO is ultimately responsible for the day‐to‐day workflow, this individual generally has hired some of the best and brightest in the areas of medicine, technology, finance, and law to handle the ground‐level activities. In the area of medicine, an appointed Medical Director takes on the responsibility of hiring decisions, including credentialing criteria, residency programs, quality improvement, continuing education, and committee assignments. This is not an exhaustive list of the medical director's responsibilities. The medical director may have constant communication with the HIM director, as the subject matter expert (SME) for health record development, maintenance, laws, rules, and regulations. The Chief Financial Officer (CFO) is responsible for ensuring the hospital is in good financial standing, and this includes keeping the lights on. Keeping the lights on may seem like a trivial phrase to attach to such a major responsibility. This is more than just the physical lights in the build, but encompasses determining all available funding sources, working with the actuarial area for predictive modeling, and meeting payroll according to the schedule developed by the facility. The CFO may also interact regularly with the HIM department, as the coding of health records generates revenue.

The Chief Information Officer (CIO) is responsible for all aspects of technology being used in the hospital. If the entire hospital used a single system, this would be a relatively easy task; however, given the nature of hospital work, it is quite possible that areas like registration, laboratory, and radiology are working on completely independent systems. They may be interfaced to communicate with one another, but maintenance schedules and unplanned system downtime can seriously complicate these responsibilities. Additionally, the HIM department may have a completely separate system.


The rules, regulations, and bylaws for a hospital command the ethical terms by which a provider is expected to perform, but also address the areas pertaining to the maintenance of health records. In the technology‐driven world in which we currently live, the expectation for a provider to maintain the HIM tenants of timely, accurate, and complete health records is significantly heightened. Although the terms electronic health record (EHR) and electronic medical record (EMR) are continuously exchanged, what most hospitals have is an EMR. The lack of interoperability keeps facilities from having a true EHR. The medical staff and the HIM department play a major role in the format and design of paper forms, as well as screen design and navigation in an electronic environment. As a member of the forms committee, the medical staff is able to provide feedback on the most efficient way for providers to use the record.

Credentialing and Privileges

Any provider seeking to offer care at a hospital must go through the credentialing process. The Joint Commission's Comprehensive Accreditation Manual for Hospitals (CAMH) contains a section that is very specific to medical staff. Per Standard MS.01.01.01, medical staff bylaws will dictate the privileges granted to the provider (The Joint Commission, 2015). Privileges granted through the credentialing process do not simply impact the care the provider can render to patients, but this also drives the expectations for their completion of the medical record. For example, an anesthesiologist is not expected to complete the operative report. Although he is a member of  the surgical team, this is not his responsibility and would be cause for concern in the HIM department if he were authenticating operative reports.

Though physicians have the ultimate responsibility for the patient, they are not the only persons who document activities and other data in the health record. Nurses, therapists (e.g., physical, speech, respiratory), social workers, dieticians, and others write in the health record. The record serves as a communication tool between providers and other healthcare professionals engaged in the care of a patient.


The very definition of the legal health record is under scrutiny in the electronic environment, and this is further complicated by authentication standards. How providers authenticate health records should be specifically addressed in the bylaws, but at a minimum, standards should include the full name and credentials of the author, along with a unique identifier, the date and time. A unique identifier may be the provider's national provider identifier (NPI) or an identifier assigned by the facility. Regardless of the identifier used, the provider is responsible for making sure that they are the only person using it.


The HIM department is still the nucleus of patient information. Whether the health record is paper or electronic, the ability to support the continuity of care through collection, analysis, verification, protection, and dissemination of information is essential. The emphasis on timely, accurate, and complete records allows the health record to serve as a communication tool between providers within the facility, and externally as well. Health Information Management professionals' knowledge of data collections supports research efforts as well as reporting requirements, such as vital statistics, cancer registry, and other diseases registries if established. HIM professionals also have responsibility for coding, transcription (where still in use), and release of information. Even though some services may be outsourced to vendors, the HIM department has the ultimate responsibility for meeting the needs of the patients and families for these service areas.


The roles and responsibilities of HIM professionals continue to grow as technology advances and patients take a more active role in their health. The American Health Information Management Association (AHIMA) is the professional association for HIM professionals. AHIMA (2013) defines Health Information Management as “an allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare‐related decisions.” Responsibilities for HIM professionals are growing both inside the hospital as well as externally. Some of the responsibilities can be easily placed into the categories that support the acronym of the profession:


Analyze and code clinical data

Collect data to support research and required reporting

Use clinical data to support financial decisions


Storage of patient data in a defined format

Reports of aggregate patient data

Maintenance of data dictionaries according to state and federal standards


Development of policies and procedures for use, maintenance, and destruction of health records

Management of HIM functional areas (i.e., coding, abstracting, release of information)

Chair/participation in hospital committees

This does not at all reflect an exhaustive list of HIM functions. HIM professionals hold over 200 job titles in 40 types of organizations (AHIMA, 2015a, 2015b). The increase in technology directly related to HIM, as well as the increase and variety of credentials now available, makes the HIM professional a sought‐after professional to fill a great variety of roles. It is not uncommon to find HIM professionals as Privacy and Security Officers, Chief Information Officers, or even in Risk Management. Traditional roles like HIM Director, HIM Manager, or Coding Supervisor are still relevant in HIM, but nontraditional roles are becoming more accessible to HIM professionals.

Even with the growth in the profession, some responsibilities of HIM remain very traditional. An example is the maintenance of the Master Patient Index (MPI). The MPI database is used to capture demographics of every patient that enters the hospital in any capacity. Sometimes duplicate records are created for a patient; the HIM department is responsible for the merging of duplicate records to ensure that all documentation for a patient exists in a single record. Another responsibility of HIM professionals that remains in the traditional role is the knowledge and understanding of Joint Commission standards. A review of medical records is always a portion of the Joint Commission survey process. HIM professionals can help a facility to successfully navigate the survey process.

Educational Requirements

The growing list of jobs, roles, and responsibilities for HIM professionals are not merely happenstance. HIM professionals receive education and training that prepare them to take on the growing roles at expert levels. Currently masters, baccalaureate, and associate‐level educational programs are accredited by the Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM). Programs must be accredited by CAHIIM in order for graduates to be eligible for AHIMA professional HIM certification exams (CAHIIM, 2015).

AHIMA's Vision 2016 focused on changes to HIM education (Gordon, Watzlaf, & Mancilla, 2013). These changes include transforming HIM to a graduate‐level profession, creating specialty tracks at the associate level, and developing a more qualified HIM faculty (Calhoun, Rudman, & Watzlaf, 2012).

Changes to the HIM curricula map for all education levels continue to propel HIM professionals into varying healthcare roles. Listed below are AHIMA's required course content areas for accredited programs:

Classification Systems

Health Record Content and Documentation

Data Governance

Data Management

Secondary Data Sources

Health Law and Ethics

Data Privacy, Confidentiality, and Security

Release of Information

Health Information Technologies

Information Management and Strategic Planning

Analytic and Decision Support

Healthcare Statistics and Research Methods

Consumer Informatics and Health Information Exchange

Information Integrity and Data Quality

Revenue Cycle and Reimbursement


Fraud and Surveillance

Clinical Documentation Improvement

Leadership Roles and Change Management

Work Design and Process Improvement

Human Resources Management

Training and Development

Strategic and Operation Management

Financial Management

Project, Vendor, and Contract Management

Enterprise Information Management

According to the U.S. Bureau of Labor Statistics, the job growth between 2012 and 2022 is expected to be more than 20% for HIM professionals (Bureau of Labor Statistics, 2015). The list of topics covered in HIM courses helps to develop the attributes that enhance the skills of HIM professionals and contribute to this growth. The topics are intended to be covered at every educational level.

AHIMA used Bloom's Taxonomy to indicate the level at which a student is expected to master a particular skill (Peterson, 2015). For instance, Data Governance, Subdomain I.C, found in Domain I (Data Content, Structure, & Standards‐Information Governance) has a taxonomy level of 3 (Apply) at the associate level, level 4 (Analyze) at the bachelors level, and level 5 (Evaluate) at the masters level. Another area of interest and growth for HIM professionals is found under Subdomain II.A, Health Law (Domain II—Information Protection: Access, Disclosure, Archival, Privacy, & Security). At the associate level, the taxonomy level is 3 (Apply), but at the master's level the taxonomy level is 6 (Create). Masters' level HIM professionals have the responsibility for creating and maintaining policies related to regulatory areas such as HIPAA, Meaningful Use, the Accountable Care Act, and HITECH, just to name a few.

As shifts in the field of HIM continue to occur, educational goals will continuously be adjusted to meet market and employer needs.

After successful completion of a CAHIIM accredited program, graduates are eligible to take AHIMA's national certification exams. There are two HIM certifications: At the associate level, graduates take the Registered Health Information Technician (RHIT®) exam, and at the bachelors' level, they take the Registered Health Information Administrator (RHIA®) exam.

Individuals who hold the RHIA credential are experts in the management of health information. They manage the maintenance of health records including abstracting, coding, and reimbursement. They may also have responsibility for legal and regulatory requirements as it relates to health records, data analysis, release of information, vendor management, information systems, and department budgets. They serve as the liaison between providers, insurers, and patients, with a goal of ensuring that each party has accurate, timely, and reliable health information. They interact across all levels of an organization, including serving as the chair of committees regarding information management standards (AHIMA, 2015d).

Individuals who hold the RHIT credential are described as technicians, having a more hands‐on role than that of the manager. Where RHIAs manage the duties in HIM departments, RHITs perform a great deal of the day‐to‐day activities. They abstract, analyze, and code data from health records, input data into computer systems, and some may serve as cancer registrars.

Passing the exam to receive the certification and use the HIM credentials is just the beginning. HIM professionals must complete continuing education in order to maintain continued use of the credentials. RHITs are required to obtain 20 hours of continuing education units (CEUs) every 2 years, whereas those with the RHIA credential are required to obtain 30 hours of continuing education every 2 years (AHIMA, 2015d).

Although the RHIA® and RHIT® credentials are probably the most widely recognized in the field of HIM, AHIMA currently has seven additional certifications available to HIM professionals. The first three certifications are in the area of coding; the last four certifications are considered specialty areas.

Certified Coding Associate (CCA



Certified Coding Specialist (CCS



Certified Coding Specialist—Physician‐based (CCS‐P



Certified Documentation Improvement Practitioner (CDIP



Certified Health Data Analyst (CDHA



Certified in Healthcare Privacy and Security (CHPS



Certified Healthcare Technology Specialist (CHTS)

More on Certification

Certified Coding Associates (CCAs) are medical coding experts who demonstrate coding expertise in all healthcare settings (AHIMA, 2015d). They are not limited to hospital‐only or physician‐only roles. This provides a great deal of flexibility as well as opportunities for increased learning. The U.S. Bureau of Labor Statistics had predicted a shortage of qualified CCAs by the year 2015, so the job outlook for HIM professionals in this area is extremely positive. The October 2015 implementation of ICD‐10‐CM was a potential primer for this predicted shortage of qualified workers in this area.

Unlike the CCA®, the Certified Coding Specialist (CCS®) has expertise in the area of hospital coding. This is not to say that they are unable to code physician records, but their focus and area of expertise lies within the hospital setting. HIM professionals with the CCS credentials serve as subject‐matter experts in both ICD and CPT coding nomenclature. This is necessary as hospitals provide services in both inpatient and outpatient settings (AHIMA, 2015d).

On the flip side of the CCS® credential is the CCS‐P®. These are coding professionals whose expert level lies within the physician office setting. This includes group practices, multispecialty clinics, and specialty centers. Heavily versed in CPT coding, these professionals are familiar with ICD coding as well (AHIMA, 2015d).

Certified Documentation Improvement Specialists (CDIP®) are HIM professionals who have the expertise to assist organizations to improve the quality of information documented within the health record. Improved documentation has the ability to improve patient outcomes, meet standards and regulations, improve reimbursement, and minimize legal issues. Keeping in mind that the health record serves as a communication tool across the organization, improved documentation aids everyone, and these professionals drive that improvement (AHIMA, 2015d).

Individuals who possess the Certified Health Data Analyst (CDHA®) credential are experts in data analysis and validation techniques. Although they may appear to be knee‐deep in the details and working with data at a molecular level, their role provides a more strategic view for an organization. The analysis these HIM professionals provide can assist organization executives with decisions that can impact the services provided within the organization for years to come (AHIMA, 2015d).

For many years, the issue of privacy in health care was the responsibility of the legal area and security was driven by the technology or operations management area. While this may still be true in some organizations, more and more, HIM professionals are being sought to take on these responsibilities. Hence the Certified in Healthcare Privacy and Security (CHPS®) credential was developed. Individuals who possess this credential have the responsibility for creating, implementing, and maintaining a privacy and security program that meets federal, state, and local regulations and laws, as well as any organization‐specific rules. They must continuously keep abreast of changes in legal mandates that will impact their organizations.

One more HIM credential is the Certified Healthcare Technology Specialist (CHTS). This credential is designed to meet the needs of the rapidly changing technology that directly impacts and is specific to health care. The electronic health records, patient portals, and other applications used specifically within healthcare organizations require technology experts to implement and maintain these systems (AHIMA, 2015d). Known as HIT Pro prior to 2013, the CHTS credential has six subspecialty exams (Pearson, 2015), with specific CHTS designation extensions. They are:

Certified Healthcare Technology Specialist—Clinician/Practitioner Consultant (CHTS‐CP)

Certified Healthcare Technology Specialist—Practice Workflow and Information Management Redesign Specialist (CHTS‐PW)

Certified Healthcare Technology Specialist—Implementation Manager (CHTS‐IM)

Certified Healthcare Technology Specialist—Implementation Support Specialist (CHTS‐IS)

Certified Healthcare Technology Specialist—Technical/Software Support Staff (CHTS‐TS)

Certified Healthcare Technology Specialist—Trainer (CHTS‐TR)

The continued growth as well as the challenges in the field of health care have been drivers for additional certifications in health information management. The challenges related to the collection, storage, retention, and security of health data in an electronic format, coupled with the growing amount of health data that is being collected from various sources, require a level of expertise that HIM professionals can offer to healthcare organizations. Specific details outlining some of the duties as well as the eligibility requirements and maintenance for all HIM credentials can be found on the AHIMA website at

As of the end of 2014, AHIMA's Commission on Certification reported that there were more than 80,000 certified HIM professionals. Of this population, 55% hold the RHIA® or RHIT® credentials (AHIMA, 2015d).

Career Opportunities

Healthcare organizations everywhere use health records to document plans of care for patients. The need to capture, secure, maintain, and distribute patient information is a justifiable reason to hire HIM professionals. AHIMA has developed a career map to assist current and future HIM professionals with choosing a career path (AHIMA, 2016). HIM professionals span across the healthcare continuum in employment opportunities. Below is a list of just a few of the work environments:

Hospitals (civilian and military)

Insurance companies

Behavioral health facilities

Nursing homes

Home health agencies

Long‐term care facilities

State and federal penal facilities

Veterinary services

Health data organizations

Information systems organizations

Compliance organizations

Educational institutions

Healthcare professional associations

The paradigm shift from “Medical Record” managers to “Health Information” managers continues to occur and HIM professionals are even stronger information stewards. Patients now are not merely seeking medical services, but are truly consumers of healthcare services. The roles of HIM professionals continue to grow. The professional who was once completely behind the scenes, deep in the basement, surrounded by paper files filled with dust, may now have an office in the “C” suite (i.e., Chief Information Officer, Chief Financial Officer, Chief Medical Officer, Chief Executive Officer).

HIM professionals have a strong commitment to the profession and are constantly striving to ensure a seat at the table. There is a unique body of knowledge in HIM that is unparalleled in the other health profession area. There is a strong Code of Ethics that drives the profession and all that have chosen to walk the HIM path.

HIM Jobs

With over 200 job titles to choose from, HIM professionals can write and rewrite the script on their career paths. Below is a sample list of traditional and emerging jobs that HIM professionals hold.