Health Information Management and Informatics
What to know
Health information management (HIM) and informatics covers the capture, storage, protection, and use of health data. Candidates must know the electronic health record (EHR) components, meaningful use/ promoting interoperability, and the role of standards such as HL7, FHIR, ICD-10, CPT, and SNOMED. Understand data governance, data quality dimensions (accuracy, completeness, timeliness, consistency), and the difference between structured and unstructured data.
Know privacy and security requirements under HIPAA: the Privacy Rule, Security Rule (administrative, physical, technical safeguards), breach notification, and minimum necessary standard. Understand release of information, the legal health record, and retention requirements.
Informatics concepts include clinical decision support, computerized provider order entry (CPOE), health information exchange (HIE), and interoperability. Also know the role of the chief information officer and the chief medical information officer.
Traps
Questions often confuse the legal health record with the designated record set - the designated record set is broader and includes billing and other records used to make decisions. Another trap is treating the Security Rule as applying only to electronic data - it does, while the Privacy Rule applies to all protected health information. Watch for minimum necessary exceptions (treatment, disclosures to the individual).
Worked example / rule of thumb
Rule of thumb: Privacy Rule = all PHI; Security Rule = ePHI safeguards. If a question asks which safeguards apply to paper records, the Security Rule does not; the Privacy Rule does. For interoperability, FHIR is the modern standard for exchanging data via APIs.