Health Information Management: What It Is, Careers, Skills and Digital Health

Every time someone receives healthcare, information is created.

It may include:

• symptoms,
• diagnoses,
• laboratory results,
• medical images,
• medicines,
• allergies,
• operations,
• clinical notes,
• appointments,
• billing information,
• and other information about the person's care.

This information has to be accurate, appropriately organized, accessible to authorized people when needed and protected from inappropriate access.

Managing this enormous and increasingly digital collection of health information is the field of Health Information Management (HIM).

What Is Health Information Management?

Health Information Management is the professional practice of acquiring, organizing, analysing, maintaining, protecting and appropriately using health information.

The American Health Information Management Association (AHIMA) describes HIM as the practice of acquiring, analysing and protecting digital and traditional medical information that is important for providing quality patient care.

The profession combines aspects of:

• healthcare,
• information management,
• data,
• technology,
• business,
• law,
• privacy,
• security,
• and administration.

Health information professionals help make sure health information is:

• accurate,
• complete,
• available when appropriately needed,
• properly classified,
• securely maintained,
• and used responsibly.

Why Is Health Information Important?

Good healthcare depends on good information.

Imagine a doctor treating a patient without knowing:

• which medicines the patient takes,
• whether the patient has allergies,
• previous diagnoses,
• recent laboratory results,
• previous operations,
• or other important medical history.

Incomplete or inaccurate information can affect clinical decisions.

Health information also supports activities beyond an individual consultation.

Health data can help with:

• planning healthcare services,
• monitoring disease,
• quality improvement,
• research,
• public health,
• financing,
• healthcare administration,
• and health policy.

WHO describes robust health information systems as an important foundation for understanding health trends, identifying disparities and making evidence-informed healthcare decisions.

What Does a Health Information Professional Do?

Responsibilities vary considerably according to the person's role and country.

A health information professional may work with:

• patient health records,
• electronic health records,
• clinical coding,
• data quality,
• information governance,
• privacy,
• health-data standards,
• health information systems,
• analytics,
• records retention,
• regulatory compliance,
• and information access.

Some professionals specialize heavily in one area.

Others have broad responsibility for health-information services within an organization.

Electronic Health Records

One of the biggest changes in healthcare has been the transition from predominantly paper medical records to electronic health records (EHRs) and other digital systems.

An EHR can contain information such as:

• diagnoses,
• medical history,
• medicines,
• allergies,
• laboratory results,
• clinical observations,
• imaging information,
• treatment plans,
• and clinical documentation.

Electronic records can make information easier to access and share appropriately.

But digital records also introduce important challenges involving:

• privacy,
• cybersecurity,
• interoperability,
• data quality,
• system reliability,
• and access control.

Health information management therefore becomes more—not less—important as healthcare becomes increasingly digital.

Are Paper Medical Records Obsolete?

Not everywhere.

Many healthcare systems have moved extensively toward electronic records, but paper records continue to exist in some healthcare organizations and countries.

Health information management therefore covers both digital and traditional health information.

The balance depends on the healthcare system and its level of digital development.

What Is Data Quality?

Healthcare information must be trustworthy if it is going to be used for patient care or decision-making.

Important characteristics of health-data quality include:

• accuracy,
• completeness,
• consistency,
• timeliness,
• accessibility where appropriate,
• and reliability.

For example, an incorrect allergy recorded in a patient's medical record could affect treatment decisions.

A missing diagnosis could influence future care.

Duplicated patient records can also create confusion.

Maintaining data quality is therefore an important part of HIM.

What Is Data Integrity?

Data integrity refers to maintaining the accuracy, completeness and consistency of information throughout its lifecycle.

Healthcare information may be:

• created,
• updated,
• transferred,
• accessed,
• analysed,
• archived,
• and eventually disposed of according to applicable requirements.

Organizations need appropriate controls throughout this process.

Health Information Privacy

Health information can be highly sensitive.

Patients reasonably expect information about their:

• diagnoses,
• medicines,
• mental health,
• sexual health,
• reproductive health,
• genetic information,
• and other medical matters

to be handled appropriately.

Health information professionals can play an important role in maintaining confidentiality and complying with privacy requirements.

WHO's data principles emphasize the importance of protecting personal health data and respecting privacy.

Privacy Laws Differ Between Countries

There is no single global health-data privacy law.

Different countries have different:

• privacy legislation,
• data-protection rules,
• patient rights,
• record-retention requirements,
• and information-sharing regulations.

Healthcare organizations must follow the requirements applying in their jurisdiction.

For this reason, articles about health information should not assume that U.S. HIPAA rules, European data-protection laws or the laws of any other single country apply everywhere.

Health Information Security

Privacy and security are related but not identical.

Privacy concerns appropriate use and access to personal information.

Security involves protecting information and systems against threats such as:

• unauthorized access,
• theft,
• alteration,
• loss,
• malware,
• ransomware,
• and other cyberattacks.

Healthcare organizations can hold extremely sensitive information, making cybersecurity an important health-management issue.

How Is Health Information Protected?

Organizations may use measures such as:

• user authentication,
• passwords,
• multi-factor authentication,
• access controls,
• encryption,
• audit logs,
• staff training,
• backups,
• security monitoring,
• and incident-response procedures.

No single measure provides complete protection.

Health-data security requires a combination of:

• technology,
• organizational policies,
• appropriately trained people,
• and effective governance.

What Is Information Governance?

Information governance establishes how an organization manages information responsibly.

It may address:

• who can access information,
• how information is created,
• data quality,
• retention,
• privacy,
• security,
• sharing,
• legal requirements,
• and eventual disposal.

Good governance helps ensure health information remains useful while protecting patients and organizations.

What Is Clinical Coding?

Clinical coding converts information about diagnoses, procedures and other healthcare activities into standardized classification codes.

These codes may be used for purposes such as:

• health statistics,
• reimbursement,
• healthcare planning,
• research,
• quality monitoring,
• and disease surveillance.

One important international classification is the International Classification of Diseases (ICD) developed and maintained by the World Health Organization.

Clinical coding requires specialized training because inaccurate coding can affect both healthcare information and administrative processes.

What Is ICD-11?

ICD-11 is the current revision of WHO's International Classification of Diseases.

It provides standardized ways of recording and reporting diseases, disorders, injuries and other health conditions.

Standardized classification helps health information from different organizations and countries become more comparable.

However, countries can implement new classification systems at different times and in different ways.

What Is Interoperability?

A major challenge in digital healthcare is making different computer systems work together.

Interoperability refers broadly to the ability of different information systems to exchange and appropriately use information.

For example, a patient may receive care from:

• a primary-care provider,
• hospital,
• laboratory,
• pharmacy,
• specialist,
• and rehabilitation service.

If their systems cannot exchange relevant information effectively, important clinical information may remain fragmented.

Interoperability aims to reduce this fragmentation while maintaining appropriate privacy and security safeguards.

Why Interoperability Matters

Effective interoperability may help:

• improve continuity of care,
• reduce unnecessary duplication,
• make relevant information available to healthcare professionals,
• support safer clinical decisions,
• and improve health-system efficiency.

However, sharing information must still comply with applicable:

• privacy laws,
• consent requirements,
• security standards,
• and governance arrangements.

What Are Health Information Systems?

Health Information Management should not be confused with a health information system (HIS).

WHO describes health information systems broadly as infrastructures that support monitoring of:

• health activities,
• population health,
• health outcomes,
• and policies affecting health.

Such systems include more than computer software.

They involve:

• people,
• organizations,
• technologies,
• laws,
• standards,
• processes,
• relationships,
• and data.

The information produced by these systems supports decision-making throughout health systems.

HIM vs Health Informatics

Health Information Management and health informatics overlap considerably, but they are not exactly the same field.

HIM traditionally focuses strongly on:

• health records,
• information governance,
• data quality,
• coding,
• privacy,
• compliance,
• and responsible management of health information.

Health informatics often focuses more heavily on the application of:

• information science,
• computing,
• technology,
• data,
• and digital systems

to healthcare and clinical decision-making.

In modern healthcare, the boundaries increasingly overlap.

Professionals from the two fields often work together.

HIM vs Health Information Technology

Health Information Technology, often called health IT, generally refers more specifically to technologies used to:

• collect,
• store,
• retrieve,
• exchange,
• and use health information.

Examples include:

• electronic health-record systems,
• clinical information systems,
• patient portals,
• health information exchanges,
• and other digital healthcare platforms.

HIM professionals may work closely with health IT teams, but their role is not simply to repair or install computer systems.

What Is HIMSS?

The old version of this article devoted considerable space to HIMSS while making it sound like part of the definition of HIM.

They are different things.

HIMSS is the Healthcare Information and Management Systems Society, a professional organization concerned with health information and technology.

HIMSS should therefore not be confused with the profession of Health Information Management itself.

What Is AHIMA?

AHIMA is the American Health Information Management Association.

It is a professional organization in the United States focused on health information.

AHIMA provides:

• education,
• professional resources,
• certifications,
• standards-related information,
• and career resources.

It is an important organization within the profession, but health information management is an international field, not solely an American profession.

Health Information Management Around the World

Health information management exists in different forms internationally.

For example, professional organizations include the Health Information Management Association of Australia (HIMAA).

Countries differ in:

• professional titles,
• qualifications,
• certification,
• registration,
• coding systems,
• healthcare structures,
• and privacy requirements.

Someone interested in an HIM career should therefore investigate the requirements in the country where they intend to work.

Where Do HIM Professionals Work?

Health information professionals may work in:

• hospitals,
• clinics,
• primary-care organizations,
• government health departments,
• public-health organizations,
• insurance organizations,
• research institutions,
• pharmaceutical organizations,
• health-technology companies,
• consulting organizations,
• universities,
• registries,
• and other organizations that manage health information.

Increasing digitalization has also created opportunities beyond traditional hospital medical-record departments.

Common Health Information Careers

Job titles vary by country and organization.

Examples can include:

• health information manager,
• health records manager,
• clinical coder,
• coding manager,
• health data analyst,
• clinical documentation specialist,
• information governance specialist,
• privacy officer,
• health information systems manager,
• data-quality specialist,
• health informatics professional,
• and health-data governance professional.

Some roles require specialized qualifications or professional certification.

What Skills Are Useful in HIM?

Health information professionals may need skills in:

• healthcare terminology,
• information management,
• data quality,
• privacy,
• digital systems,
• clinical coding,
• communication,
• analytics,
• problem-solving,
• organization,
• and regulatory compliance.

Increasing digitalization means knowledge of:

• cybersecurity,
• interoperability,
• data governance,
• analytics,
• and emerging technologies

is becoming increasingly useful.

Do HIM Professionals Need to Know Medicine?

They are not necessarily doctors or nurses.

However, many HIM roles require an understanding of:

• medical terminology,
• anatomy,
• physiology,
• disease processes,
• clinical documentation,
• and healthcare systems.

The depth of clinical knowledge required depends on the position.

For example, clinical coding may require detailed knowledge of medical terminology and classification systems.

What Qualifications Are Needed?

There is no universal qualification for HIM professionals worldwide.

Depending on the country and position, relevant education may include:

• Health Information Management,
• Health Informatics,
• Health Information Technology,
• Health Data Science,
• healthcare administration,
• information management,
• or related subjects.

Some countries have professional accreditation or certification pathways.

Employers may also require particular coding qualifications or experience.

Can Someone Move Into HIM From Another Career?

Yes, depending on the position and local requirements.

People may move into health information from backgrounds such as:

• healthcare,
• administration,
• information technology,
• data analysis,
• coding,
• public health,
• business,
• or records management.

Additional training may be necessary.

Someone considering the profession should examine actual job advertisements and professional requirements in their location before choosing a course.

Health Data and Public Health

Health information is important beyond individual patient care.

Aggregated health information can help authorities understand:

• disease patterns,
• mortality,
• healthcare utilization,
• health inequalities,
• vaccination coverage,
• health-service demand,
• and population trends.

WHO emphasizes that strong health information systems support evidence-informed health policy and planning.

Poor-quality data can therefore affect decisions far beyond one patient's record.

Health Information and Research

Health data can also contribute to research.

Appropriately governed information can help researchers investigate:

• disease trends,
• treatment outcomes,
• healthcare quality,
• medicine safety,
• and population health.

However, using health information for research requires appropriate:

• ethical oversight,
• privacy protections,
• governance,
• security,
• and compliance with applicable law.

Health Information and Artificial Intelligence

Artificial intelligence is increasingly being explored and used in healthcare.

AI systems may work with information including:

• medical images,
• clinical documentation,
• laboratory information,
• patient histories,
• and other health data.

The quality of AI output depends partly on the quality and suitability of the data used.

This makes principles such as:

• data quality,
• governance,
• privacy,
• transparency,
• security,
• and appropriate human oversight

particularly important.

AI does not remove the need for health information professionals.

It can actually increase the importance of managing healthcare data responsibly.

Patients and Their Health Information

Health information management ultimately concerns information about real people.

Patients may have rights regarding their health information under applicable laws.

Depending on the country, these can include rights to:

• access certain records,
• request corrections,
• understand how information is used,
• or receive information about privacy practices.

Exact rights vary internationally.

Patients should consult the relevant healthcare provider or data-protection authority for local requirements.

Can Patients Correct Errors in Their Medical Records?

Procedures vary by country.

If you notice information in your medical record that appears incorrect—for example:

• the wrong medicine,
• an incorrect allergy,
• inaccurate personal information,
• or another significant error—

contact the healthcare organization responsible for the record.

There may be a formal process for requesting correction or adding information to the record.

Do not ignore potentially important inaccuracies.

Challenges Facing Health Information Management

Modern HIM faces several major challenges.

These include:

• rapidly growing quantities of health data,
• cybersecurity threats,
• fragmented information systems,
• inconsistent data standards,
• privacy concerns,
• interoperability problems,
• digital inequality,
• workforce shortages,
• artificial intelligence,
• and changing laws and regulations.

WHO has identified lack of data standardization, delays in receiving information, poor system integration and shortages of trained personnel among challenges that can limit effective use of health information.

The Future of Health Information Management

Health information is becoming increasingly important as healthcare becomes more digital and data-driven.

Future HIM professionals are likely to work increasingly with:

• digital health,
• interoperability,
• advanced analytics,
• cybersecurity,
• information governance,
• artificial intelligence,
• population-health data,
• and large-scale electronic health systems.

The underlying responsibility, however, remains similar:

ensuring that health information is accurate, useful, appropriately accessible and properly protected.

The Bottom Line

Health Information Management is the professional practice of managing health information throughout its lifecycle.

It combines elements of:

• healthcare,
• information management,
• data,
• technology,
• privacy,
• security,
• law,
• coding,
• analytics,
• and administration.

HIM professionals help make sure health information is:

• accurate,
• complete,
• secure,
• appropriately accessible,
• and useful for healthcare.

Their work supports:

• patient care,
• healthcare administration,
• public health,
• research,
• quality improvement,
• and health-system planning.

As healthcare becomes increasingly digital, effective management and governance of health information will remain essential to building healthcare systems that patients and professionals can trust.

Information Disclaimer

This article provides general educational and career information for an international audience. Health-information laws, privacy requirements, professional qualifications, coding standards, certification requirements and patient rights vary between countries and jurisdictions. Consult relevant professional organizations, healthcare authorities, educational institutions and regulators for requirements applicable to your location.

Sources and Further Reading

World Health Organization — WHO Data Principles

https://www.who.int/data/principles

World Health Organization — Support Tool to Strengthen Health Information Systems

https://www.who.int/europe/publications/i/item/9789289061148

World Health Organization — International Classification of Diseases (ICD-11)

https://www.who.int/standards/classifications/classification-of-diseases

American Health Information Management Association (AHIMA) — Health Information 101

https://www.ahima.org/certification-careers/certifications-overview/career-tools/career-pages/health-information-101/

Health Information Management Association of Australia (HIMAA)

https://www.himaa.org.au/