Informatics in managed care: HIM adds value to data.

Abstract

The third installment of the Journal of AHIMA's special series on managed care focuses on informatics--methods that add value to data, turning it into useful information. How do informatics and managed care fit together and what is HIM's role in this picture? The HIM professional's knowledge is critical to the health team responsible for the interpretation and use of statically valid information. For example, HIM professionals are well positioned in their understanding of the construct and application of coding classification systems (ICD-9-CM, CPT, etc.), and groupers (DRGs, APCs, ETGs, etc.). Their unique training positions them to understand the associated rules, principles, guidelines, and nuances associated with correct coding and grouping. And when codes or groupers change, HIM professionals work closely with the health team to ensure parity, validity and reliability of the appropriate data or data sets. Managed care organizations use value-added data, as you will see in this article, to evaluate contract pricing, develop contracts, evaluate existing services or detail benefit plans, process and in some instances pay claims, and report results to a number of interested parties. The previous article in this series ("Can You Manage Managed Care?" July/August 2001) focused on effective management of data, including data acquisition. This article takes us to the next level, where informatics creates value-added information, and discusses some important uses of this information within managed care. These articles build on two of the functional areas that form the HIM process within managed care organizations. Author Scott Stratton studied under the creators of DRGs and was involved in the development of their nursing home counterpart, RUGs. He also has worked with the creators of ETGs. As a result, he can present the perspective and context within which these systems were created and intended. and how they form the foundation for informatics as a functional area within managed care.