Notes

Health informatics is at the intersection of information technology and healthcare. Health informatics is an evolving specialization working to improve the quality and safety of patient care. As technology has advanced, healthcare has drastically transformed the way in which medical data and information is collected, stored and communicated. Individuals who work in the health informatics pathway are involved with the documentation of patient records and health information.

There are a variety of career choices with varying education levels in this pathway. Some examples of careers include health information administrators, medical secretaries, medical records and health information technicians, health educators, medical transcriptionists, and epidemiologists.
The primary goal of health information management is to maintain accurate and complete health records. Every patient, whether they are going in for a routine checkup, or staying overnight in a hospital for a major surgery fills out health-related forms. These forms not only record basic contact information like the patient’s name and address but also ask for specific information regarding the patient's medical history.
When filling out a medical form, a patient will also need to provide the following information:
Pre-existing conditions: Any medical condition that would affect the patient’s treatment. Examples include diabetes or any heart condition.
Allergies: A list of medications the patient is allergic to. Some medications used in an emergency could be very dangerous for a person allergic to the medication.
Primary Care Physician: The contact information for the patient’s primary care physician in case additional information is needed or to consult with the physician.
Emergency Contact: The contact information of the patient’s emergency contact to obtain important medical or support information.
Medications: A complete list of any medications taken routinely by the patient, including any over-the-counter medications and herbal supplements. This is to ensure any medications administered during treatment won’t have an adverse effect on the medications already in the patient’s system.
Once a medical form has been filled out by a patient, that data is entered into an electronic database called a health information management system. This system is used to store the medical records of patients and is an easy and effective way to communicate medical information between doctors, medical organizations, the patient, and even insurance companies. Providers use this information to gain a better understanding of a patient’s profile, to document any diagnoses and treatments and to keep track of services provided.
Electronic Health Records (EHR) are a digital version of a patient’s medical record. EHRs are real-time, patient-specific records that make information available instantly and securely to authorized users across more than one healthcare organization. EHRs are built to share information with all other healthcare providers involved in a patient’s care. For example, when a physician orders a blood test be done on a patient, he/she can access the lab results through the EHR.

Benefits of using electronic health records include:
Minimizes errors due to misspellings, illegible handwriting and varying terminology used by providers
Provides consistency and a standardized way of recording information
Maximizes cost-efficiency by reducing paper-based records and speeding up patient care and ultimately saving time and money for healthcare professionals.
Better communication and information exchange between providers, improving quality of patient care
All providers, regardless of healthcare organization, have access to patient history
Medical coding is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. The diagnoses and procedures can come from a variety of sources within the healthcare system, including notes written by a physician, laboratory results, diagnostic results and other sources.
Diagnosis Codes referred to as ICD Codes (International Classification of Diseases) - used to describe the diagnosis of diseases and other health conditions.
Procedures Codes referred to as HCPCS Codes (Healthcare Common Procedure Coding System) - used to identify medical services and procedures ordered by physicians or other licensed professionals.