NULM 844
HEALTH INFORMATION
MANAGEMENT
LECTURER
DR JOSEPHAT KIONGO
PHD-HR&IM
PURPOSE
Purpose
To enable the learner appreciate the role of
Health Records Management and Health
Informatics in the healthcare industry.
OBJECTIVES/EXPECTED OUTCOME
By the end of the course unit, the learner will be able to:
1. Discuss importance, uses and value of health Information.
2. Describe the function and components of Health
Information/Data management
3. Describe the role of nursing professional in health
information management
4. Demonstrate understanding of legal and ethical issues in
health information management.
5. Compare and contrast a manual health information system
and an electronic health information system
6. Appreciate the role of health information in epidemiological
studies
COURSE CONTENT
Definitions and concepts. Foundations of Health Information Management (HIM):
overview of health care systems. Health information management profession: its
development, structure, goals and roles. Health care data: data collection standards;
users of data systems and the role of HIM professionals in data collection. Data
quality and technology. Data access and retention: indexing, coding, classification,
storage and retrieval. Data management and use: data-to-information
transformation; use of quality information for decision-making. Statistics: its use;
organizing and displaying results. Research and epidemiology: application of
epidemiology to health information management. Quality management and clinical
outcomes: methods for assessing and improving the quality of care and services in
health care systems; the critical role of HIM professionals. Legal issues pertinent to
the practice of HIM. Information systems: technology, applications, privacy,
confidentiality and security. Health informatics. Electronic health records: challenges
and opportunities. Information systems life cycle. Design and implement health
information system. Information system evaluation. Evaluation criteria in health
informatics
COURSE OUTLINE
WEEK TOPIC
1. Introduction: Definitions and concepts: Data, Information, Knowledge; Health records: uses, value and importance of
HR
2 Overview of health care systems; Data management and use: data-to-information transformation.
3 Data quality and technology. Characteristics of quality data
4 Legal issues pertinent to the practice of HIM. Information systems: technology, applications, privacy, confidentiality
and security.
5 CAT 1
6 Research and epidemiology: application of epidemiology to health information management
7 System: Characteristics of a system; Manual Vs Electronic systems
8 Electronic health records: challenges and opportunities
9 CAT 2
10 Information systems life cycle.
11 Design and implement health information system
12 Telemedicine
13 End of semester examination
DEFINATIONS
Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.
Information is Data that is:-
• Accurate and timely
• Specific and organized for a purpose
• Presented within a context that gives it meaning and relevance
• Can lead to an increase in understanding and decrease in uncertainty.
Information is valuable because it can affect behavior, a decision, or an
outcome. For example, if a manager is told his/her company's net profit
decreased in the past month, he/she may use this information as a reason
to cut financial spending for the next month. A piece of information is
considered valueless if, after receiving it, things remain unchanged.
DEFINATIONS CONt’
Health Information
Health information is an opinion about:-
• the health or a disability (at any time) of an individual; or
• an individual’s expressed wishes about the future provision of
health services to him or her; or
• a health service provided, or to be provided, to an individual;
• that is also personal information; or
• other personal information collected to provide, or in providing,
a health service; or
• other personal information about an individual collected in
connection with the donation, or intended donation, by the
individual of his or her body parts, organs or body substances; or
DEFINATIONS CONt’
• Health information management (HIM) is the practice of
acquiring, analyzing, and protecting digital and traditional
medical information vital to providing quality patient care.
• A system is a set of interacting or interdependent component
parts forming a complex/intricate whole. (Backlund, 2000)
• Every system is delineated by its spatial and temporal
boundaries, surrounded and influenced by its environment,
described by its structure and purpose and expressed in its
functioning.
• Health information systems refer to any system that captures,
stores, manages or transmits information related to the health of
individuals or the activities of organizations that work within the
health sector
DATA AND INFORMATION
• Usually, the terms “data” and “information” are
used interchangeably. However, there is a subtle
difference between the two.
• Data can be a number, symbol, character, word,
codes, graphs, etc.
• Information is data put into context.
Information is utilised in some significant way
(such as to make decisions, forecasts).
HRIM 253 Healthcare and Patient Data 9
System Joe
DATA AND INFORMATION Cont’
HRIM 253 Healthcare and Patient Data 10
System Joe
DATA AND INFORMATION Cont’
Data Information
Data is unorganised and unrefined facts Information comprises processed, organised data presented in a
meaningful context
Data is an individual unit that contains raw materials which do Information is a group of data that collectively carries a logical
not carry any specific meaning. meaning.
Data doesn’t depend on information. Information depends on data.
It is measured in bits and bytes. Information is measured in meaningful units like time, quantity, etc.
Raw data alone is insufficient for decision making Information is sufficient for decision making
An example of data is a student’s test score The average score of a class is the information derived from the
given data.
HRIM 253 Healthcare and Patient Data 11
System Joe
RECORD
• A document constituting a piece of evidence about the past,
especially an account kept in writing or some other
permanent form.
• the sum of the past achievements or performance of a
person, organization, or thing.
"the safety record at the airport is first class"
• A health records is any written documents about a patient in
a professional relationship with a doctor.
• Public records are all writings and recordings prepared or
owned by, or in the possession of a public body or its officers,
employees or agents in the transaction of public business.
VALUES AND USES OF HEALTH RECORDS
Treatment
Planning
Research
Teaching
Administration
TREATMENT
• The health record is the first and foremost of value in
the present and future treatment of the patient.
• The individual record is a reminder to the health care
workers of what they personally observed during the
patient’s illness.
• It provides the whole previous hospital record of the
patient, so that every fact that may be important is
permanently available for reference at any time.
• A complete records record prevents duplication of work
and facilitates futures care of the patients (patients
follow up).
PLANNING
• Health statistics and information gathered
from the health records will definitely be very
useful in the planning of health care services.
• It is very necessary that these statistics should
be very accurate and disseminated promptly
to users
• inadequate records mean incomplete
statistics leading to improper planning of
various activities in the health service.
RESEARCH
• Accurate recording of observation in the
health records will lead to accurate
information required for research. They
should contain that basic information that is
required of them to meet the purposes for
which they are intended, one being research.
The methods of filing and retrieving should be
systematic and simple.
TEACHING
• Health records can be used as an educational
tool or instrument. When the quality of the
records is high, the task of the student is
simplified conversely when the quality is poor
the student’s task is made more difficult and
his progress is impeded.
ADMINISTRATION
• Complete health records mean increased and efficient
services to the public, avoiding vexations, litigations and fair
settlement of claims and capacity to answer queries about
how hospitals work.
• For the record to meet and useful for the above it should
designed for the purposes for which it is to used.
• It is important for the record to meet requirements of both
the clinician and the records personnel.
• The records also should be complete. To be complete the
records should be analyzed quantitatively by the health
records officer and qualitatively by the clinician.
SOURCES OF HEALTH INFORMATION
1. Census 8. Epidemiological Surveillance
2. Registration of Vital 9. Other Health Service
Events Records
3. Sample Registration 10. Environmental Health Data
System (SRS) 11. Health Manpower Statistics
4. Notification of 12. Population Surveys
Diseases 13. Other routine statistics
5. Hospital Records related to health
6. Disease Registers 14. Non-quantifiable
information
7. Record Linkage
DATA QUALITY
Problems of Poor Quality Data
Diminished quality of Patient care data can
lead to problems:-
1. With Patient care
2. Communication among providers & patients
3. Documentation
4. Reimbursement
5. Outcomes assessment
6.Research
PROBLEMS OF POOR QUALITY DATA
cont’
Medical Record Institute cites
problems with (MRI, 2004)
– Patient Safety
– Public Safety
– Continuity of Patient Care
– Health Care Economics
– Clinical Research and Outcomes
ENSURING DATA/INFORMATION QUALITY
Medical Record Institute Principles of Health Care
Documentation (MRI, 2004)
• Unique Patient Identification within and across
systems
• Health care documentation must be
– Accurate and consistent
– Complete
– Timely
– Interoperable across systems
– Accessible
– Auditable
• Confidential and secure authentication and
accountability must be provided
CHARACTERISTICS OF QUALITY
DATA/INFORMATION
1. Accessibility 6. Accuracy
2. Consistency 7. Comprehensiveness
3. Currency 8. Definition
4. Granularity 9. Relevancy
5. Precision 10.Timeliness
SYSTEM
A system is a set of interacting or interdependent
component parts forming a complex/intricate
whole. (Backlund, 2000)
Every system is delineated by its spatial and
temporal boundaries, surrounded and influenced
by its environment, described by its structure and
purpose and expressed in its functioning.
HRIM 253 Healthcare and Patient Data System Joe Kiongo 24
CHARACTERISTICS OF A SYSTEM
1. A system has structure, it contains parts (or components)
that are directly or indirectly related to each other;
2. A system has behavior, it exhibits processes that fulfill its
function or purpose;
3. A system has interconnectivity: the parts and processes
are connected by structural and/or behavioral
relationships;
4. A system's structure and behavior may be decomposed
via subsystems and sub-processes to elementary parts
and process steps;
5. A system has behavior that, in relativity to its
surroundings, may be categorized as both fast
HRIM 253 Healthcare and Patient Data System
and strong.
Joe Kiongo 25
HEALTH SYSTEMS
• Health System - is defined as the system of all actors,
institutions, and resources that undertake “health
actions” – i.e. actions whose primary purpose is to
promote, restore, or maintain health (WHO 2000).
• Information System - System that provide specific
information support to the decision-making process at
each level of an organization
• Health Information System - any system that captures,
stores, manages or transmits information related to
the health of individuals or the activities of
organizations that work within the healthJoesector.
HRIM 253 Healthcare and Patient Data System Kiongo 26
DEFINATION Cont’
Health Information System definition incorporates
things such as:-
• Disease surveillance systems,
• Laboratory information systems,
• Hospital patient administration systems (PAS)
• Human resource management information
systems (HRMIS).
HRIM 253 Healthcare and Patient Data System Joe Kiongo 27
IMPORTANCE OF A HIS
• Good management is a prerequisite for
increasing the efficiency of health services
• Improved health information system is clearly
linked to good management
• Information is crucial at all management levels of
the health services from periphery to the centre.
It is required by policymakers, managers, health
care providers, community health workers
HRIM 253 Healthcare and Patient Data System Joe Kiongo 28
FUNCTIONS OF A HIS
The health information system provides the
underpinnings for decision-making and has four
key functions: data generation, compilation,
analysis and synthesis, and communication and
use.
HIS collects data from the health sector and other
relevant sectors, analyses the data and ensures
their overall quality, relevance and timeliness,
and converts data into information for health-
related decision-making
HRIM 253 Healthcare and Patient Data System Joe Kiongo 29
WHY HEALTH INFORMATION SYSTEM?
• Good management is a prerequisite for increasing
the efficiency of health services
• Improved health information system is clearly
linked to good management
• Information is crucial at all management levels of
the health services from periphery to the centre. It
is required by policymakers, managers, health care
providers, community health workers
HRIM 253 Healthcare and Patient Data System Joe Kiongo 30
ROUTINE HEALTH
INFORMATION SYSTEM (RHIS)
Definition:
• Ongoing data collection of health status, health
interventions, and health resources
• Examples: facility-based service statistics, health
administration statistics and community-based
information systems
HRIM 253 Healthcare and Patient Data System Joe Kiongo 31
ORGANIZATION OF HEALTHCARE IN KENYA
Role of the Ministry of Health
1. Planning
2. Coordination: service delivery, programmes
3. Organizing
4. Implementing
5. Health Information System
6. Monitoring & evaluation - supportive
supervision
ORGANIZATION OF HEALTHCARE IN KENYA
cont’
National Health Sector Strategic Kenya Health Sector Strategic Plan
Plan II (2005–2010) III (2012–2017)
Level 1 – Community
Tier 1: Community
Level 2 – Dispensaries
Level 3 – Health centers
Level 4 – District referral hospitals (47) Tier 2: Primary Care level
Level 5 – Provincial referral hospitals – Previous KEPH levels 2 and 3
(10) Tier 3: County level – Previous
Level 6 – National referral hospitals (2) KEPH level
Tier 4: National level – Previous
KEPH levels 5 and 6
TYPES OF HEALTH RECORDS
There are different types of health records:-
1. Case records
2. Outpatient records
3. Diagnostic records
CASE RECORDS
• These are records initiated for patients who
get admitted into the wards or who
continuously attend the various consultant
clinics.
• The range of documents to be included in the
case records also depends on the local
requirements although documents are
common in all hospitals
OUT-PATIENT RECORDS
• This includes all the cards that are used in the
Out-Patient Department, for example the
Casualty Ward, Ante-Natal Ward, and
Immunization cards any other card that may
be used in the out-patient departments.
DIAGNOSTIC RECORDS
• These include notes on Radiography,
Pathology, Electrocardiography and other
investigations that are usually initiated by
report forms.
• These forms are usually 6”x 4” in the size and
are available in all consultation rooms both in
the out-patient and in-patient departments in
a health care facility. They could be different
colours for quick identification.
LEGAL & ETHICAL ISSUES IN HEALTH
RECORDS MANAGEMENT
• Confidentiality
• Disclosure
• Ownership
• Retention
• Security
• Consent of Operations
• Medical Records Ethics
ETHICS
• Ethics are moral principles that govern a person's behaviour
or the conducting of an activity
• Etiquette is the customary code of polite behaviour in society
or among members of a particular profession or group.
• “Ethic” has more to do with moral principles and “etiquette”
with manners, although both govern the way people behave.
The term is “work ethic”. “Etiquette” is the accepted code of
behaviour among people in a group or society
• Professional ethics are principles that govern the behaviour of
a person or group in a business environment. Like
values, professional ethics provide rules on how a person
should act towards other people and institutions in such an
environment.
ETHICS CONt’
• One function of professional ethics is to assure clients
that professional services will be rendered in accordance with
reasonably high standards and acceptable moral conduct.
This confidence enables professionals to exercise relatively
independent judgments in decisions affecting clients.
The five main principles of ethics are usually considered to be:
• Truthfulness and confidentiality.
• Autonomy and informed consent.
• Beneficence.
• Nonmaleficence.
• Justice.
CONFIDENTIALITY
• Information concerning a patient is confidential and should not be release
to any unauthorized persons.
• If a member of the hospital staff improperly discloses any information
concerning a patient whereby that patient suffers material loss, the
patient can easily sue the hospital and the officer who is in breach of his
duty had made any improper disclosure.
• If a hospital authority is to minimize its risk in the matter, it is suggested
that it should have a rule for strict secrecy about all information regarding
patients, their disease, their affairs, and the affairs of their families
obtained by any officer in the course of his duties. Further it is
recommended that:-
• No unauthorized information should be given concerning patient or
former patients.
• Apart from normal replies, and enquiries concerning the progress of a
patient’s illness is to be given except from instruction of the consultant.
• Case notes are not produced to unauthorized members of staff.
DISCLOSURE OF INFORMATION
There are five main categories under which contents of
patients records can be disclosed;-
• Consent by the patient which could be expressed or implied.
• If there is a court order.
• If the interest of the doctor or hospital cannot be otherwise
safeguarded.
• If transference between hospitals, clinics or doctors in the
interest of the patient.
• If there exists a higher duty than the private duty e.g.
notification of infectious disease, notification of births and
deaths registration, and notification of poisons.
DISCLOSURE OF INFORMATION CONt’
Consent by the patient
• A patient can give his consent for disclosure either
expressly or implicitly.
• In general the consent form should always indicate the
reasons for that disclosure.
• In cases where requests for clinical information are
received from solicitors claiming to be acting on behalf of
the patient care should be taken to make sure that the
solicitors really are acting on behalf of the patient.
• Request from insurance companies and similar bodies
should only be acceded to with the patient’s written
consent but should be referred to the hospital authorities.
DISCLOSURE OF INFORMATION CONt’
Disclosure by an order of court
• A court in the pursuit of justice may make an “Order for
Discovery” or a Subpoena to produce case records.
• There is no question but that such an order must be
obeyed.
• Generally the appropriate person to attend court and
produce the appropriate record would be the Records
officer.
• It is the original document that should be produced in
court but if the original document cannot be traced then
the court may accept the photocopies must be certified
to be the true copy of the original document.
DISCLOSURE OF INFORMATION CONt’
Disclosure to safeguard the interest of a doctor or hospital
• If an action is brought against a hospital or doctor, then the
disclosure of a patient’s record may be done.
• Of equal important is the fact that disclosure is permissible if
the hospital is to work effectively.
• Disclosure of the contents of contents of a medical record is
necessary between departments or between members of
medical staff in staff in the hospital and this is justifiable of
course, as being in the patient’s interests.
• Such disclosure if made publicly by any member of the
hospital staff, resulting in the patient’s interest affected could
adversely affected could result in action for damages.
DISCLOSURE OF INFORMATION CONt’
Disclosure in transfer of information between
authorized medical agencies
• A doctor dealing with a patient has full rights
of access to any clinical data at the time.
• When a patient is seen subsequently by
another, strictly speaking that doctor has no
legal right of access to the notes made by the
previous doctor.
DISCLOSURE OF INFORMATION CONt’
Disclosure as a ‘higher’ duty
• The existence of the higher duty may be said
to apply when the interest of needs of the
public are better served if there is some
relaxation of the private duty and in some
cases there is a clear legal duty to give
information which supersedes the doctrine of
confidentiality. More common instances are in
the following circumstances:-
DISCLOSURE OF INFORMATION CONt’
• Notification of infectious disease by medical doctors to
local medical officers of health under the Public Health
Act (1936).
• Notification of the cause of death under the Births and
Deaths registration Acts 1836-1962.
• Notification of the industrial poisonings under the
Factory and Workshop Act 1901. (i) to (ii) above
represent statutory obligations, whereas (iv)below are
good causes. A statutory obligation must be complied
with, whereas although a good cause should be there,
there is no breach of law if it is not.
DISCLOSURE OF INFORMATION CONt’
• Claims for sickness benefits under the National
Insurance Acts.
• Exchange of records between doctors for
research purposes.
• Discloses to a central body for collective
statistics purposes e.g. hospital activity
analysis.
• In the foregoing instances, it is plain that
disclosure is in the public’s interest.
OWNERSHIP
• There records do not belong to the patient
even if fees have been paid. The records
belong to the various health institutions which
created them. In the case of government
institutions they belong to the government.
Case records of private belong to the
institutions because they have contributed to
the creation of the records.
RETENTION
• The Public Records Act stipulates that authorities responsible
for public records have a duty to make proper arrangements
for selecting those records which should be permanently be
preserved and for disposal of the rest. There are some records
that spelled out by that Act and they should not be destroyed.
Post Mortem books
Summary of clinical notes
Discharge registers containing diagnosis
• The rest of health records in the folder may be destroyed. This
should be done six years after the patient’s last attendance.
Each hospital should be able to decide on which records to be
destroyed depending on the institution’s demands.
SECURITY
• It is the responsibility of each and every health institution
to ensure that there is security in storage and handling of
health records. This security could be maintained by:-
• Provide adequate security in the departmental procedures
and use of equipment.
• Instructing lay staff on the confidentiality of health
records.
• Require all lay staff to sign a declaration of secrecy.
• Health records staff accepting responsibility for disclosure
of contents of health records in the possession.
CONSENT
• For operations
• Medical procedures
• Disclosure
HEALTH RECORDS ETHICS
• In Greece, Hippocrates, known as the “father of
medicine” was born about 460BC.
• He was the first to cast out superstition and to
practice medicine on scientific principles.
• He was the author of the Hippocratic Oath, which is
pledge by physicians and other health workers
including health records personnel.
• It states in part: “whatsoever in my practice or not in
my practice I shall or hear amid the lives of lives which
ought not to be noised abroad- as to this I will keep
silence, holding such things unfitting to be spoken”.
That is how confidentiality of health records originated
FUNCTIONS OF A HEALTH RECORDS
DEPARTMENT
Objectives
• Define a health records department
• Enumerate the functions of a health records
and information department
• Explain the various functions of a health
records and information department.
FUCTIONS cont’
• Reception • Coding and indexing
• Registration • Collection, tabulation, analysis
and dissemination (statistics)
• Admission
• Maintenance of health records
• Discharge equipment
• Appointments • Maintenance of the
• Filing confidentiality of health records
• • Manage special health records
Tracing
• Design medical forms
• Follow-up of patients
• Ensure quality assurance of
• Clinical preparation health records
FUCTIONS cont’
• Reception
This is the reception of patients when they arrive
in a health care facility. In this area the patient/
client is greeted and welcomed to the hospital.
• Registration
Registration is recording of identification details
mostly social on documents needed for any
attendance.
FUCTIONS cont’
• Admission
The same identification details recorded during
registration is used and the ward number added on the
form.
Discharge
• This is a procedure carried out when a patient is
supposed to leave the hospital after treatment.
Appointments
• Patients are asked to report to the various clinics on
certain time and dates ready to be seen.
FUCTIONS cont’
• Filing
Is a way of arranging the documents in a prescribed
order or in systematic manner.
Tracing
• This is tracing the movements of all the
documents and their whereabouts.
Clinic preparation
• This is getting ready all the documents-48 hours in
advance before a patient attends a clinic.
FUCTIONS cont’
• Follow –up of patients
There are some patients who need follow after they have
discharge from the hospital such as cancer cases.
Coding and indexing
• Disease and operations and other procedures in medicines
need to be coded and indexed using the international
classification of disease, icd and the international classification
of procedures in medicine icp (who).
Collection, tabulation, analysis, interpretation and dissemination
of data
• Raw data collected form health records are put in tables,
analyzed interpreted and forwarded to the users.
FUCTIONS cont’
• Maintenance of health records equipment
All the equipment used in a health records
department must be maintained by the health
records and information technician.
Maintain confidentiality
• All the information in a health records
document is confidential and should not be
handled by unauthorized persons.
FUCTIONS cont’
Manage special health records
There are special health records that are initiated
and handled differently from other records,
namely:-
• Psychiatric records
• Tuberculosis records
• Maternity records
• Sexually transmitted diseases records
• Hiv/aids
FUCTIONS cont’
• Design medical forms
All medical forms are supposed to be designed
by the health records and information
technician in consultation with the users.
• Ensure quality assurance of health records
The quality of the records will reflect the type of
health care being rendered to the patient/
client.
