Introduction
Information management (IM) is a critical aspect of healthcare organizations, as it involves collecting, storing, and disseminating sensitive patient information. In order to guarantee the confidentiality, integrity, and availability of this information, healthcare organizations must comply with various IM standards set forth by regulatory bodies such as the Joint Commission. In this paper, three IM standards from the Joint Commission will be discussed, and a process for ensuring compliance with these standards will be outlined.
IM.02.01.01
IM.02.01.01: The organization protects the privacy of health information. One of the essential IM standards set forth by the Joint Commission is IM.02.01.01, which protects the privacy of health information. To ensure compliance with this standard, a process should be established that involves several key stakeholders, including the HIM department, information technology (IT) department, and legal department.
The first step in this process would be to develop a written policy addressing health information privacy. This policy should clearly outline the organization’s stance on protecting patient information, including the types of information considered private and the measures that will be taken to protect this information. The HIM department should be involved in developing this policy, as they thoroughly understand the information collected and stored within the organization. According to Culot, Nassimbeni, Podrecca, and Sartor (2021), “The ISO/IEC 27001 information security management standard is the international standard that organizations use to assess and manage risks to the security of their information” (p.78). Once the policy has been developed, the IT department should apply it by implementing technical safeguards such as encryption and access controls to protect patient information. The legal department should ensure that the organization complies with relevant laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA).
To secure ongoing compliance with this standard, regular audits should be conducted to identify any vulnerabilities or policy violations. The HIM department should be involved in these audits to make sure that patient information is being used and accessed according to the organization’s policy. According to Orcos and Palomas (2019), “Regular audits are an important part of the ongoing process with environmental management standards” (p. 557). Compliance with IM.02.01.01 is crucial in protecting the privacy of health information within the organization. It involves the development of a written policy that addresses the protection of patient information, the appliance of technical safeguards, and ongoing audits. The HIM, IT, and legal departments should be involved in this process to verify that all policy aspects are covered and that the organization complies with relevant laws and regulations.
IM.02.01.03
To establish compliance with the IM.02.01.03 standard, the HIM department should play a vital role by developing and accomplishing security policies and monitoring these policies. One way the HIM department can contribute to compliance with IM standards is by helping to create a written policy that outlines the organization’s approach to securing health information, including guidelines for access, use, and sharing (Culot et al., 2021). This policy should align with relevant laws and regulations, such as HIPAA, privacy, and security rules (Clark, 2000). In addition to the security policy, the organization should develop a written policy addressing the integrity of health information. This policy should outline procedures for maintaining the integrity of health information, such as regular backups and disaster recovery plans (Orcos & Palomas, 2019). Additionally, the organization should have a policy for intentionally destroying health information with state and federal regulations.
To meet the requirements of the IM.02.01.03 standard, the organization needs to safeguard the confidentiality and consistency of health-related information. To provide the security of health information, the organization should put in place protocols such as user authentication, encryption, and firewalls to prevent unauthorized access to sensitive data (Culot et al., 2021). Regular security audits should be conducted to identify vulnerabilities and monitor compliance with the policy (Clark, 2000). The HIM department should be involved in these audits to confirm that patient information is being used and accessed by the organization’s policy. Overall, the HIM department plays a crucial role in the IM.02.01.03 standard by developing, implementing, and monitoring these policies.
IM.02.02.01
IM.02.02.01: The organization effectively manages the collection of health information. To ensure compliance with the IM.02.02.01 standard, the organization should have processes for standardizing data collection using uniform data sets and standardized terminology, definitions, abbreviations, and symbols. As Culot, Nassimbeni, Podrecca, and Sartor (2021) point out in their literature review of the ISO/IEC 27001 information security management standard, “data integrity is a crucial aspect of information security” (p. 83). By enacting these standardized data collection processes and prohibiting certain abbreviations, symbols, and dose designations, the organization can ensure the integrity and accuracy of the collected health information. This, in turn, will improve the reliability and usefulness of the data for patient-related purposes, including reimbursement, risk management, performance improvement, and infection surveillance. Additionally, as Clark (2000) notes in his article on mastering the information management standards, involving the HIM department in the process can help ensure that these standards align with the organization’s overall health information management goals and strategies.
Conclusion
In conclusion, ensuring compliance with the Joint Commission’s IM standards is crucial for maintaining the integrity and security of health information and effectively managing data collection. By involving the HIM department in the process, organizations can benefit from the expertise of HIM professionals in developing and carrying through policies and procedures, providing training and education, and monitoring. However, it is essential to remember that ensuring these standards may require resources such as IT support, staff training, and education. Therefore, organizations should take a holistic approach when implementing these standards, considering the requirements and resources needed to ensure them.
References
Clark J. S. (2000). Mastering the information management standards. Journal of AHIMA, 71(2), 45–47.
Culot, G., Nassimbeni, G., Podrecca, M., & Sartor, M. (2021). The ISO/IEC 27001 information security management standard: Literature review and theory-based research agenda. The TQM Journal, 33(7), 76–105. Web.
Orcos, R., & Palomas, S. (2019). The impact of national culture on the adoption of environmental management standards. Cross Cultural & Strategic Management, 26(4), 546–566. Web.