Health information management: how does it work?

Health information management (HIM) refers to the collection, storage, and management of patient data. HIM plays a significant role in decision-making within the healthcare sector, ensuring that patient records are accurate, up to date, and secure.

Earlier this week, it was announced that full medical records will be made available to patients via the NHS app, as part of a 10-year plan for NHS England. It’s part of the health service’s much needed, large-scale move from “analogue to digital”.

But with this news in mind, how do medical records actually work- and how do doctors access your medical info so quickly during appointments? The answer is health information management (HIM).

HIM is crucial to the healthcare sector, and that’s what we’ll be covering in today’s blog, as well as how HIM relates to medical dictation.

How does health information management actually work?

Health information management ensures patient data is easily accessible for medical professionals. That data is captured through electronic health records (EHRs), and typically includes a patient’s medical history, test results, and treatment plans.

While more and more of HIM is becoming automated, there are HIM professionals (as in not just robots!) in place to ensure that everything is organised, accurate, safeguarded, and compliant with UK privacy laws. It’s their work behind the scenes that makes decision making in healthcare- and healthcare in general- possible.

How does health information management relate to medical dictation?

Medical dictation is speech recognition software aimed at medical professionals. Nuance Dragon Medical One (DMO), for example, allows those working in healthcare to automatically transcribe notes, appointments with their patients, and data input, all by simply speaking into a compatible microphone. We’ve written quite a bit about the benefits of medical dictation, but in short: access to automated transcriptions can save medical professionals hours every day in repetitive admin.

Where does Health Information Management come in? HIM ensures that all data transcribed via medical dictation is accurate, legally compliant, and stored securely in patients' health records. Ultimately, HIM and medical dictation exist to achieve the same goal: ensuring the timely, accurate, and secure documentation of medical info. Together, they streamline healthcare workflows, freeing up medical professionals to focus more on patient care than on administrative tasks.

The potential challenges of health information management and medical dictation

One of the reasons some people are still wary of implementing speech recognition software, particularly in such high-pressure environments as the healthcare sector, is the worry that transcriptions won’t be accurate enough. And given all that we’ve discussed so far (namely the importance of meticulous documentation), it’s a reasonable concern. A doctor wouldn’t want to rely on speech recognition software if the platform was going to make dozens of mistakes in its transcriptions, because if those mistakes went unnoticed, it would lead to inaccurate medical records.

Fortunately, mistakes are few and far between when it comes to medical dictation, particularly in the case of Dragon Medical One; DMO boasts a 99% accuracy guarantee. Yes, it’ll make the odd mistake in transcriptions, but as long as the user is proofreading all of their documentation (which most medical professionals would be doing regardless), there’s no reason for those mistakes to be permanent, nor for them to impact the integrity of the system’s health information management. With the additional oversight provided by HIM professionals, the risk of transcription errors negatively impacting patient care is further minimised.

Health information management: how does it work? (conclusion)

For medical professionals, health information management is essentially a safety net for all the sensitive patient data that’s required for patient care. Tech like medical dictation streamlines the documentation process, and in today’s overloaded healthcare landscape, the collaboration between DMO and HIM is critical to maintaining the public’s trust in that very landscape.