Lesson

Today's HIM professionals operate in increasingly complex environments, both technically and ethically. With the many complex uses and demands for health information, how can we be sure that we are doing our jobs not only correctly but ethically as well? The article "Confronting Ethical Dilemmas on the Job as an HIM Professional's Guide" examines some basic principles of ethics as they relate to HIM and shows how one can apply them to day-to-day dilemmas in the workplace.

Alphabetic Filing

• Filed by last names A–Z
• Works in facilities with fewer than 5,000 records and little computerization
• Does not work in areas in which last names are frequently repeated
• Uses file guides to aid in the filing process

Numeric Filing (Three Types)

1. Straight Numeric Filing
   • Basic system begins with lowest number value to highest (e.g., 0–100)
   • Works in facilities with more than 5,000 records with computerization
   • Works well with frequently repeated last names
   • New records filed at the end
   • Hard to account for accuracy
   • Uses file guides to help determine change in digits
   • Must consider inactive records when implementing
2. Terminal-Digit Filing
   
   • Based on patient identification number
   • Divided into three parts, using six digits (e.g., 00 – 11 – 22)
   • Read from left to right for ID purposes
   • Read from right to left for filing purposes
   • File guides used to mark primary digit sections
   • In larger facilities, every 10th section guided
   • Easiest method for space planning
3. Middle-Digit Filing
   • Similar to terminal-digit filing
   • The primary unit is the middle unit (e.g., 44 / 33 / 98)
   • The secondary unit is the first unit to the left (e.g., 44 / 33 / 98)
   • Followed by the last digits (e.g., 44 / 33 / 98)
     

 Alphanumeric Filing Systems

• Based on a combination of letters and numbers
  
• First two letters are the patient's name followed by a unique numeric number

Probably one of the most fundamental functions of any HIM department is health record storage and maintenance. Paper systems require storage space, equipment, and a system of record identification. Most record systems use a numerical filing system. Small organizations, such as physician offices, however, may use an alphabetic filing system. Although filing systems have been used traditionally for storing paper records, newer technologies are making it possible to digitally scan records and store them electronically. To keep track of health records and be able to locate and retrieve them any time, the HIM department must have good tracking systems in place and continuously audit its filing and retrieval practices.

There are questions to consider when deciding on an HIM storage and retrieval system:

• What health record numbering system is used?
• What type of MPI is used: automated or manual?
• What type of health record system is used: paper based, electronic, or hybrid?

In a paper-based storage system, some types of record storage or filing equipment used are vertical or lateral filing cabinets, open shelving units, and mobile or compressible units.

Storage of paper-based health records, over time, can take up a great deal of space. There are other options for record storage that significantly reduce space needs. Traditionally (over the past 3 or more decades), micrographics or microfilm have been used. Microfilm is a good storage alternative for inactive or infrequently used health records. Microfilm comes in a variety of formats, including roll microfilm, jacket microfilm, and microfiche.

The HIM department usually has been the custodian of the master patient index (MPI), the key to identifying and locating any health record. Although the MPI was traditionally a paper-based manual function, this is changing dramatically as hospital systems and other MPI systems are transitioned to an electronic format. Regardless of the storage system used, the HIM department is responsible for the integrity of this important index.

Tracking the location of health records removed from the HIM storage is vital to ensuring record accessibility to authorized persons. Record tracking systems can be manual or automated. In a manual record tracking system, out guides, out cards, or requisition slips may be used to keep track of the health record locations.

Automated record-tracking systems store current and past locations of the record in a database. This type of automated record-tracking system can be thought of as an inventory control system. One of the major advantages of automated systems is that they have the capability to link to other healthcare facility systems in order to avoid duplications of data. These systems are usually developed to address the disadvantages of manual tracking systems. Some automated systems use bar codes to capture the health record data. HIM departments that have automated systems rarely use out guides and requisition slips.

The record completion function involves making sure that information in the health record is accurate and complete. This requires that the procedures involved in maintaining the health record be performed in an organized way and that the record be monitored for quality (Johns, 350). Record processing refers to the procedures performed that support the maintenance of each patient record in an organized and standard manner. These procedures can be performed manually or by automation. This function facilitates efficiency, accuracy, and completeness of the health record. The quality of patient care is adversely affected when complete and correct information is not readily available for delivery of patient care (Johns, 351). Examples of processing the health record for quality are quantitative analysis, concurrent review, and retrospective review. If the review discloses that reports are missing, the HIM professional usually completes a deficiency slip that indicates what reports are missing or require authentication, and he or she then enters this information into a computer system that logs and tracks health record deficiencies.

Clinical coding is the use of a classification or nomenclature system, such as ICD-9-CM, ICD-10-CM/PCS, or CPT, to categorize diagnoses and procedures. As with quantitative analysis, clinical coding can be a concurrent or a retrospective process. The clinical coding function includes the processes of abstracting and assigning ICD-9-CM, ICD-10-CM/PCS, or CPT codes to an encounter or hospital stay. The coding professional reviews the health record and enters specific data from it into a computer database. The process of extracting data from a health record and entering them into a computer database is called abstracting (Sayles, 394).

Release of information is the process of disclosing patient-identifiable information from the health record to another party. Medical transcription is the conversion of verbal medical reports dictated by healthcare providers into written form for inclusion in patients’ health records. 

The use of simulation software is also a way of evaluating, planning, and designing healthcare information systems. Simulation is rather new to the industry and is becoming a trend of significance and curiosity. Simulation is a way of representing a process in a computer-aided model without disturbing the actual process itself. It provides a what-if analysis, permitting computer representation for the system while testing various scenarios without actually doing them. It yields prospective information about the outcome; however, it is based on the scenario. The methodology of simulation works by building the model to imitate or to mimic the process or design of the product, as well as factors that affect that process. This type of analysis also allows manipulation of information and construction of the system for accurate modeling to include workflow and variability of installations. The tool introduces enhanced realization and simulation of system design through possible concepts. Although a concept was initially introduced in the business and manufacturing industry, it is becoming more common to use it to improve healthcare processes.

Making ethical decisions is one of the health information technician’s most challenging and rewarding responsibilities. It requires courage because there will always be people who do not choose to do the right thing. HITs have a professional obligation to themselves, their peers, employers, and patients, as well as to the public and professional associations, to discuss these issues with their peers and other health information management professionals and seek the advice of the professional association when necessary.

The HIT's job responsibilities inherently require an understanding of ethical principles, professional values and obligations, and the importance of using an ethical decision-making matrix when confronting difficult challenges at work. The knowledgeable HIT can move from understanding problems based only on a moral perspective to understanding the significance of the problems by applying an ethical decision-making process. Ethical decision making takes practice, and discussions with peers will help HITs to build competency in this important area.

When making ethical decisions, the HIT must use the entire ethical decision-making matrix to acknowledge all the stakeholders, their obligations, and the important HIM professional values. More than one response can be given for any ethical dilemma as long as the entire matrix is applied. Just as there can be more than one right answer to a problem, there can be wrong answers too, especially when an answer is based only on the moral value or perspective of one individual.

When faced with ethical decision making, these are some of the questions HIT professionals should consider:

• What is the ethical question?
• What facts do you know, and what do you have to find out?
• Who are the different stakeholders?
• What values are at stake?
• What are the different obligations and interests of each stakeholder?
• What options for action do you have?
• What decision should you make, and what core HIM values are at stake?
• What justifies your choice?
• What prevention options can be put into place?

Bioethical decisions involving the use of health information require action, and such actions always require courage. The healthcare team, the patients, and the others who are served need to know that the HIT has expertise and the courage to make the appropriate ethical decisions.

The ability to protect patient privacy is challenged by the amount of information collected, the increasing number of requesters, and the information released. The HIM professional must balance patients' privacy rights and confidentiality with third parties' increased access to health information.

Harman, L. B. (2000). Confronting ethical dilemmas on the job. Journal of AHIMA, 71(5), 45–50