Fenton S H, Low S, Abrams K J, Butler-Henderson K
Yearb Med Inform. 2017 Aug;26(1):72-77. doi: 10.15265/IY-2017-021. Epub 2017 Sep 11.
With the evolution of patient medical records from paper to electronic media and the changes to the way data is sourced, used, and managed, there is an opportunity for health information management (HIM) to learn and facilitate the increasing expanse of available patient data. This paper discusses the emerging trends and lessons learnt in relation with the following four areas: 1) data and information governance, 2) terminology standards certification, 3) International Classification of Diseases, 11th edition (ICD-11), and 4) data analytics and HIM. The governance of patient data and information increasingly requires the HIM profession to incorporate the roles of data scientists and data stewards into its portfolio to ensure data analytics and digital transformation is appropriately managed. Not only are terminology standards required to facilitate the structure and primary use of this data, developments in Canada in relation with the standards, role descriptions, framework and curricula in the form of certification provide one prime example of ensuring the quality of the secondary use of patient data. The impending introduction of ICD-11 brings with it the need for the HIM profession to manage the transition between ICD versions and country modifications incorporating changes to standards and tools, and the availability and type of patient data available for secondary use. In summary, the health information management profession now requires abilities in leadership, data, and informatics in addition to health information science and coding skills to facilitate the expanding secondary use of patient data.
随着患者病历从纸质媒介向电子媒介的演变,以及数据获取、使用和管理方式的变化,健康信息管理(HIM)有机会学习并推动可用患者数据的不断扩展。本文讨论了在以下四个领域出现的趋势和经验教训:1)数据与信息治理;2)术语标准认证;3)《国际疾病分类》第11版(ICD-11);4)数据分析与HIM。患者数据与信息的治理越来越要求HIM专业将数据科学家和数据管理员的角色纳入其职责范围,以确保数据分析和数字转型得到妥善管理。术语标准不仅是促进这些数据的结构化和主要用途所必需的,加拿大在标准、角色描述、框架和课程认证形式方面的发展就是确保患者数据二次使用质量的一个主要例子。ICD-11的即将推出使得HIM专业有必要管理ICD版本之间的过渡以及国家层面的修改,包括标准和工具的变化,以及可用于二次使用的患者数据的可用性和类型。总之,健康信息管理专业现在除了需要健康信息科学和编码技能外,还需要具备领导力、数据和信息学方面的能力,以促进患者数据不断扩大的二次使用。