By Alan Kelsky

When I began my career in hospital administration, most hospitals, regardless of size had their medical records department hidden away in the basement. The job of the people who staffed medical records at that time was limited to organizing and storing medical records, and occasionally sending them to another health care provider at the patient’s request.

Today, I had to pick up some medical images for a consultation with an orthopedic doctor. My hospital actually medical-recordshas a complete department devoted to releasing of medical images, that is not part of the health information management department (HIM).

The Evolving Role of HIM

Today, in additional to many hospitals segregating medical information and medical imaging, the role of HIM specialists has evolved to more than organizing and storing. Specialists in HIM have careers in several pathways such as;

  • Information Release;
  • Privacy; and
  • Coding.

Most Institutions Run Hybrid Systems

For example, the specialty of information release sounds a bit silly. Look up the patient’s medical record number and hit copy. Not so fast! To properly search for a patient record, the specialist has several things to do. First, search the medical records electronic database on the current system. However, many providers never scanned the paper records that an electronic system replaces due to prohibitive costs. As a result, he or she must also search the paper records as well. It is possible that there is more than one electronic system, so it might take two or three searches on electronics systems to find the patient data. Many departments have their own individual databases for things such as clinical trials, cancer registries, and other registries. Departmental databases must also be searched to insure that the transferred records from the provider are complete.

Despite the obstacles of old systems and paper records and departmental databases, an efficient HIM information release specialist gets the job done.

From Paper to EHR and EHR Again

Without evolving from hardcopy to electronic record keeping on perhaps more than one system, a medical records specialist is required to do a little more than make copies. However, by embracing the expanding role of HIM a person can build a great career.

Important Tasks of HIM Staff

The HIM staff has several roles throughout the workplace that are important. They are the first to spot areas where quality of documentation is poor and reach out to other departments to help them improve.

Two Areas of Risk Management for HIM

Within the health information department are two areas where their contribution to managing provider risk is important.


Ever since the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was passed in 1996, fines for not protecting the privacy of people receiving medical care became a concern. Today, with most medical record systems being electronic, the potential for a single or multiple breach is far greater than when the bill first became law. HIM staff routinely checks to make sure that their systems are safe, difficult or impossible to hack, and promptly report a suspected or confirmed breach immediately to the facilities top management.

Financial Risk

Incomplete documentation to support procedures or improper coding can lead to huge civil fines and or criminal prosecution. Savvy HIM coders are the antidote for this and can save a provider a great sum of money and potential grief.

The Future of HIM

Some, like Charlie Saparano, President and CEO of Medical Record Associates, believe that the current trend of remote HIM staff will grow. Reasons being;

  • A larger candidate pool;
  • A happier workforce; and
  • Ability to allocate work better.

Nevertheless, he warns that without the cultural/social aspect of the workplace, managing remote workers is harder.

Without a doubt, HIM is a field that has evolved largely due to the electronic health record. It is a vital component of more than hospitals and is integral to private practice, ambulatory surgery centers, outpatient laboratories and more.


About the Author

Alan Kelsky is a freelance writer with a master’s degree in business administration from Xavier University with a specialty in healthcare management. Alan was formerly a hospital CEO with an active emergency room and was the CEO of an urgent care center in Pompano, Florida.





abeo Management Corporation (abeo) serves as a leading source of revenue cycle management and practice management with a specialization in anesthesia. The company leverages its people, processes, and software to serve independent practices, surgery centers, hospitals and healthcare systems with a scope of services that include billing, coding, transcription, practice management, and business consulting.

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