| Health Information Management (HIM) plays a critical role in any health care setting. Its core duty is the maintenance and protection of medical records and the data that resides within them to meet relevant organizational, legal, regulatory and ethical standards. . The rise of information technology has created benefits and challenges for the health care industry and the HIM profession. The capture of vast amounts of information in electronic form and the ability to access it easily is a great benefit that can improve the quality of health care and the efficiency of health care operations. However, with these benefits comes a new set of challenges. The responsibility for maintaining and protecting medical records and the discrete data elements within them in an electronic environment is changing the roles and practices of HIM professionals in significant ways. Because the discrete data elements being collected in electronic medical record systems are increasingly being used to support automated clinical decision support systems and, in the aggregate, being used to support quality management efforts, administrative decision-making and clinical research, one of the most important new responsibilities in HIM practice is that of ensuring the highest quality of the data captured in these systems.;The project focused on a 200 bed community hospital and the development of a Data Governance section within its HIM department. This project involves preliminary specification of an organizational structure for a Data Governance section whose mission is to promote excellence in health care services by ensuring health care data of the highest integrity. The product of this project includes a statement of the Data Governance section's core functions, policies and procedures and job descriptions.;It is important to note, that considering the United States health care system, as a well as the 200-bed community hospital which served as the studied organization for this project, are in a period of continuous change, the work presented here should be considered preliminary and open to revisions. In that sense, this particular model for a Data Governance section within an HIM Department is a work in progress. |
