Light the candles! Happy 50th birthday HIMJ ! Underpinning an agile,future-facing health information management profession

Considering the future, informed by the past

The move from paper and manual processes to electronic medical records (EMRs), systems and databases is sometimes construed by those external to the profession as a new disruptor to health information management practice. In reality, Health Information Managers (HIMs) have always embraced technology. The incremental electronification of patient information since the 1960s has accelerated rapidly in the 21st century and HIMs’ long-standing involvement in informatics, system development and implementation is reflected in HIMJ’s publications and the profession’s early conference proceedings. In addition to providing evidence of HIMs’ informatics and health ICT-related work, the journal demonstrates the profession’s long-term, primary accountabilities in its other core knowledge domains (Robinson, 2017). These are health information science and governance (incorporating patient identity, data integrity, information risk management, informing quality of care and patient safety, statutory compliance, clinical documentation and privacy); health classification (including terminologies and applications of coded data, e.g. activity-based funding (ABF)); and health data analytics and research (including managerial epidemiology).

Gazing into the crystal ball is fraught with risk: prediction requires acknowledgement of evidence from the past melded with an understanding of current practices and trends. The evolution of the health information management profession continues to be propelled by complex societal influences identified by Robinson (2017), which include scientific medicine, standardisation, technologisation, the risk society and the health consumer movement. In this editorial, we present potential innovations and practices in the management of health information that provide challenges and opportunities for the profession that readers may see reflected in future volumes of HIMJ.

The need for a health information policy reset

The profession’s specialised translations and outputs of health data and information inform and support health policy, planning for infrastructure and care delivery, funding models, population health, quality of care and medical-health research. Recent trends, some accelerated by the COVID-19 pandemic, highlight the need for a health policy reset concerning primary care and early intervention; equitable access to excellent health services for the aged and socially disadvantaged groups; personalised, integrated data; intra-sectoral interoperability; information exchange; accessible health information, including for medical researchers; sophisticated health surveillance systems; and real-time health data interpretation, analysis and reporting. Additionally, as health systems face a mounting burden of cost, payors seek more efficient funding models for better health outcomes. While ABF remains foundational to the acute care sector, value-based healthcare will further expand the utility of health information management. These all infer the need for a complementary health information policy reset, informed by HIMAA and its expert members and supported by the profession’s research.

Beyond the digital revolution: Challenges and opportunities for the profession

The risk society, characterised by inherent, increasing pressures created by science and technological change, preludes and underpins the fast-paced information society (Beck, 2013; Lash, 2002). Consistent with these risks, Schwab’s (2016) conception of the fourth industrial revolution is superseding the digital revolution. This presents major problems, for example, vulnerability of data to cyberattack (World Economic Forum, 2020b) and concomitant risks for confidentiality and data loss. This new era is characterised by an ever-increasing force of profoundly complex and intrusive technologies. Inevitably, the plethora of yet-to-emerge technologies in ubiquitous and mobile computing, and artificial intelligence (AI), will impact in unpredictable ways upon the healthcare system and the management of health information. This presents opportunities for the profession with assured roles for HIMs as knowledge experts. For instance, Wiens et al. (2019) see them contributing in multidisciplinary teams developing machine learning-based interventions. Of critical importance will be the profession’s ability to wisely evaluate, adopt and implement, where suitable, new technologies for improved information management across health service delivery.

While the profession has made significant health data and information contributions in the digital health revolution, technologies will become more integral to health information management and clinical coding. For instance, integrated “intelligent” global networks or federated data systems moderated by scalable governance frameworks are being pursued (Johannessen, 2018; World Economic Forum, 2020a). It will be up to HIMs and other health information workers to identify and pave their roles amid these and other “big” data initiatives. The profession must navigate the implications of “learning health systems” (Institute of Medicine and National Academy of Engineering, 2011; National Academies of Sciences, Engineering, and Medicine, 2018; Price and Cohen, 2019: 37). These involve interconnectedness with EMRs, research and privacy; nexus with quality of care data; and continuous analysis of routinely collected EMR data to inform concurrent care.

Notwithstanding these developments, the fundamental premises of health information science will not change: good quality local data are prerequisite to high-quality health data and services across the health ecosystem. The fundamentals also include high-quality and accurately interpreted coded data, expert curation and well-managed systems. HIMs’ undisputed expertise in health data provenance, data integrity, confidentiality, privacy and access applies equally to all health data and their uses. HIMs’ initiative and ownership also reside in system-wide standardisation and yet-to-be-developed standards for health data auditing; health data, records and systems; and clinical coding auditing. The implementation and management of fit-for-purpose information systems including EMRs in the non-acute and community sectors will provide substantial employment and research scope for HIMs and others in the health information workforce.

Schwab (2018) observed that technology is a tool and not a predetermined force outside our control. This prompts us to remind those whose work situates them under the umbrella of HIMAA – HIMs, Clinical Coders, Clinical Coding Auditors, Health Data Analysts, Health Data Auditors, Clinical Documentation Improvement Specialists, future Digital Navigators and others involved in health informatics – that our engagement with technologisation lies in our hands and in how we choose to learn, adapt to and apply it. The myriad examples in our field range from the challenges presented by enhanced access to shared, enterprise EMRs and personal health records, to computer-assisted health classification, embedded clinical terminologies and AI-based predictive analytical techniques.

Health information governance and risk mediation, and leadership of related organisation-wide policy and practice, sit squarely in the HIMs’ domain. The greatest barriers will not be technical; rather, they will concern policy and deep understanding of the data (Institute of Medicine, 2013). HIMs have the requisite expertise and high-level digital and health literacy. We foresee an increasing, ill-founded perception of the EMR being “all things to all people” with pressure for it to be open to external parties, including researchers, insurers and owners of proprietary research databases. The use of genetics to inform personalised precision medicine will also present HIMs with challenges concerning confidentiality of individuals’ genetic data and their secondary uses. Indeed, Schwab (2018) foreshadowed that our society will be confronted by questions around “what data and information about our bodies and health can or should be shared with others” (p. 23).

As the pre-eminent custodians and curators of health data and information in all formats and media, HIMs should anticipate increasing consumer involvement in, and contribution to, information on their treatment and outcomes. Patient-reported outcome measures come to mind, along with the mooted inclusion in the EMR of these and other items hitherto considered peripheral to immediate clinical need (Williams and Thompson, 2018; Zhang et al., 2019). Similarly, large tracts of “copied-and-pasted” information and suggestions to include non-clinical data in EMRs support a widely held view that the EMR is morphing into an ever-expanding repository of irrelevant components that offer minimal value to clinicians and diminish the benefits of medical record technologies (Kuhn et al., 2015; Lowry et al., 2017; Martin and Sinsky, 2016).

HIMs are the expert informational and ethical gatekeepers. The healthcare system’s reliance on them for sound, ethical practices and informed organisational policies on access to EMR and other data will increase in an era of greater transparency and transferability of confidential health data.

Shaping a future-facing profession

The profession is at an inflexion point. The dire shortage of HIMs necessitates substantial expansion of this expert workforce’s capacity and size. We foreshadow escalating demand for the generalist HIM and a parallel trend to higher level, post-basic HIM specialisation within the profession’s sub-disciplines to meet the healthcare system’s complex information needs. We also predict greater demand for the other components of the health information workforce within HIMAA’s membership. How the industry seeks HIMs’ skills will depend upon the profession’s strength in grappling with insufficient graduates and consequent role substitution by other disciplines that wrongly perceive their understanding of health information management as adequate or equivalent. These challenges require strategic leadership and robust advocacy by HIMAA in partnership with universities and industry, including iterative adaptation for industry requirements of the HIM competency standards. More than ever, there is a need to appeal to prospective students faced with a raft of educational choices and for educators’ delivery – via HIMAA-accredited programmes – of reflexive curricula and pedagogy that comprehensively prepare HIMs and other health information workers for the future.

Conclusion

The profession’s practices and emerging issues will always demand investigation and research by HIMs and others. The scope of HIMJ encompasses the profession’s knowledge and practice domains; inevitably, it will flex over time to align with refreshed definitions of “health information” and developments in the field. The journal has a crucial role now and in the future in formal inquiry, questioning the status quo, and knowledge-building. It is an asset that HIMAA and the profession should further leverage in our advocacy efforts. HIMJ’s independent review and publication of research and practice are vital in augmenting and reinforcing the knowledge base that underpins health information management as an agile, technologically oriented, future-facing profession.