New! – The Use of New Technologies (IM/Texting) in Supporting Provider-Patient Communications

This professional practice brief outlines the benefits and uses of IM and texting and provides guidelines for best practice, emphasizing security, in introducing their use in health care.

New! – Clinical Documentation Improvement (CDI)

This professional practice brief (PBB) focuses on the concept of clinical documentation improvement (CDI) and how it can be used to benefit the health care system. It will also explore the role that HIM professionals play in the implementation and maintenance of a CDI program. This PPB will not cover the development of CDI programs and query policies.

Revised Health Level 7 (HL7)

As the Electronic Health Record (EHR) in Canada continues to be developed, adopted, and sustained, Health Information Management (HIM) professionals will play a much larger role and will work closely with technical professionals. It is imperative that HIM professionals are familiar with different standards including Health Level 7 (HL7) messaging standards, other types of HL7 standards, health informatics-related standards (e.g. ISO (International Organization for Standardization) and IHE (Integrating the Healthcare Enterprise), and the purpose of them. They need to monitor, implement, and contribute to the advancement of health information standards as they continue to evolve in Canada and internationally.


It is now generally recognized that it is not a case of ‘if’ a security breach will occur, but ‘when’ it will occur. This comprehensive professional practice brief (PPB) describes the most common cyber threats, outlines system vulnerabilities and provides legal and regulatory requirements for Cybersecurity. It also provides recommendations for a Cybersecurity plan.

Redesigning Clinical Workflow

Workflow analysis and design plays an important role in the implementation of EHR systems as it supports streamlining and organizing the process. Because of their understanding of the flow and uses of information in their facility and how individuals and organizations work together, HIM professionals are well positioned to perform workflow analysis to support the smooth implementation of EHR systems.

Cloud Computing

In this brief, we define the essential characteristics of cloud computing and the applications in a Canadian healthcare context. The security and privacy challenges, of particular importance to health information management professionals, and the end benefits of adopting a cloud computing model are also highlighted.

Privacy Impact Assessment (PIA)

This Professional Practice Brief (PPB) outlines the importance of and reasons for conducting a Privacy Impact Assessment (PIA). It discusses what should be included, highlights some complications that might arise and delves into the role an HIM plays in the process.


This PPB will discuss the topic of mentoring, specifically its application to the HIM profession as a platform for skill and knowledge sharing. The target audience is members of the HIM profession; however, it must be emphasized at the outset that mentoring relationships are often established outside the HIM domains.

Utilization management

The reality of health care is rising costs. Utilization management (UM) is increasingly important to address the paramount importance of balancing costs and quality health care.  This professional practice brief (PPB) will concentrate on UM as it pertains to acute care. Key areas of concern for an effective UM program will be examined, including: Appropriateness of admission, Length of stay, Conservable bed days, Readmission rates, Discharge planning, Alternate level of Care, and Wait times. The valuable contribution of the HIM professional will be highlighted throughout.

Naming Clinical Forms

It is no secret that technological advances have dramatically changed the business of health care delivery and administration. This PPB on Naming Clinical Forms discusses one facility’s experience in this area and highlights the value of the HIM skill set in supporting the process.

The Role of the HIM Professional in Primary Care

An exciting and expanding opportunity for the Health Information Management (HIM) professional lies within the primary care setting. As technology advances with the move to the electronic health record (EHR), it is evident that HIM expertise is needed at the primary source of health information. This practice brief delivers an overview of HIM in the primary care setting and within Family Health Teams including areas for HIM involvement and reasons why HIM professionals should be a part of the Family Health Team model.

Research: A Brief Overview

What is research? This PPB is intended to highlight what research is and how HIM professionals can be involved. The document discusses the types of research, associated paradigms, and tools as well as the basic steps to the research process

HIM Role in Patient Safety

The focus on patient safety and quality care has resulted in many initiatives in agencies, the regulatory environment, the information and communication domains, education, research and professional ethics. All of these are influenced by changing evaluation methodologies, new technology and system innovation issues. The role of the HIM professional within patient safety spans the scope and breadth of eHealth transformation, standards setting, system functions, information and screen design, MPI, documentation practices, technology, performance management, patient advocacy, ethics, workflow, data quality, and data reporting. This PPB provides an overview of the many agencies and influences that have increased the profile of Patient Safety and Quality Care in Canada and the important role of the HIM professional.

The HIM Profession in Telemedicine

Telemedicine is a method of enabling the delivery of health care to patients/clients at a distance, using different telecommunication and information technologies eliminating barriers such as distance, patient mobility, and challenges related to health professional or specialist access and availability. As Health Information Management (HIM) professional opportunities expand beyond traditional hospital and clinical care settings, the area of Telemedicine is worth exploring. This PPB provides an overview of opportunities for the HIM in telemedicine.

Principles of the Electronic Health Record (EHR)

Within the healthcare industry there is a growing need and increasing urgency for the establishment of sound guiding principles to support evolving electronic health records (EHR). This paper explores many of these principles within the health care industry.

Checklist for HIM Readiness

This PPB identifies 28 components to be considered in the transition of the paper-based to EHR HIM Department from getting started to forms, interfaces and comprehensive departmental plans. In addition, it provides references to additional reference material.

Delving Into Computer Assisted Coding

This PPB discusses computerized coding tools, identifying the influence of the technologies, and provides guidance on how coding professionals of today can position themselves for the coming coding revolution.

Health Data Access, Use, and Control for Secondary Uses

There is a perception that it is permissible to access and uses data for secondary purposes if an individual/organization ‘owns’ the media. Linking, sharing, and retrieving information has been made easier by technology in that it can be transmitted, shared, and leveraged for a myriad of purposes to multiple users more quickly. This PPB discusses secondary use of health data considering key factors including: the status of the data in the context of a legal record; the de-identification of data; contracts and business arrangements, provincial/federal laws; and the right of the individual about whom the data is collected.

Visioning eHIM: A Process for Imagining &Anticipating HIM's Future

The transformation from paper-based to EHR will impact every aspect of health information management. Every fundamental will need to be rethought and affirmed or discarded. To face this future, HIM professionals must envision the future and develop a mapping strategy; this PPB provides key steps and resources for this process.

Data Standards, Quality and Interoperability

The PPB identifies a list of standards to reference in data dictionary development, evaluation of health data software applications, EHR tools, and general management processes to ensure information integrity and reliability.

EHR Career Opportunities (Updated Jan 2014)

The migration of health care organizations to the EHR will affect the entire HIM profession. Many new and altered job titles and roles are emerging. This brief highlights a number of the new opportunities within the evolving HIM profession.

Speech Recognition

This PPB is intended to increase the HIM professional’s understanding of how the technology works, the driving forces for this technology, and the benefits and risks. It provides a glossary of terms and illustrates the work flow, tasks and best practices for this new technology and process.

Electronic Document Management as a Component of the EHR

With the evolution of the EHR, organizations are becoming cognizant of EDMS to manage both paper and electronic computer generated documents. This PPB is a compilation of best practices detailing the keys steps and issues in implementing an EDMS.

Essential People Skills for EHR Implementation Success

Successful EHR implementations require people skills – everything from leadership, communication and training to change management. This PPB outlines some of success factors for EHR adoption and the people skills for HIM professionals. Tools that can assist in assessing readiness of change are identified.

Facsimile Transmission of Health Information

This PPB discusses the technology and legal requirements associated with FAX transmission. It identifies 10 recommendations for safely using this communication technology, and a few steps in dealing with a breach.

The RHIO Landscape

Health care organizations have many approaches to the sharing of health care data. This PPB describes several types of linkages and the three levels of complexity in the practical application of EHR technologies.

Identity Theft- The Impact on HIM Operations

Identity theft is the ‘crime of the 21st century’, and health care organizations are particularly vulnerable due to the wealth of information collected, stored, maintained, and transmitted. This PPB identifies practical preventive guidance; how to resolve ID theft in an MPI; and discusses how to respond to an ID theft within your organization.

Wireless Communication: Safeguarding Privacy and Security

This PPB discusses select new communication technologies (such as Bluetooth) and the challenges associated with these. Specific advice is given in how to deal with these technologies as they become mainstream in health care delivery.

Guidelines Developing a Data Dictionary

Information systems are only as good as their data. Without agreed clearly defined terms and definitions, validity and reliability of data are suspect. The data dictionary is a building block of effective health information systems supporting health care delivery. This PPB defines a data dictionary, explains their purpose, and provides specific guidelines to create and maintain this pivotal EHR component.

Data for Electronic Patient Record (EPR) Documentation

Structured data enhance the flow of information into an EPR and ultimately into the pan-Canadian EHR. HIM professionals must understand the data standards and how these standards support effective information management. This PPB discusses data dictionaries, data standards, and data content to support an EPR.

Privacy and Security in a Health Information Exchange (HIE)

With the development of local, regional, and provincial networks for the exchange of health data, it is important that HIM professionals are aware of the many related privacy and security issues. This PPB provides a brief description of the types of HIE environments, and discusses some of the considerations within legal and operational issues. These include: variations is laws; data sharing agreements; accountability for privacy; consent; ensuring safeguards; and identity management.

Disaster Planning for Health Information Services

Most HIM departments never experience a disaster, however a well-designed action plan will protect health information (regardless of format) from damage and minimize disruption. This PPB provides guidance in creating a disaster plan specific to health information.

Assessing and Improving EHR Data Quality

Quality health care depends on the availability of quality data. Without accurate and appropriate content in a usable and accessible form, the incredible value of the EHR will not be realized. This PPB identifies 5 best practices, and the potential technical challenges for data quality.

Guidelines for EHR Documentation to Prevent Fraud

This brief offers guidelines to prevent potential EHR documentation fraud including guidelines for electronic documentation, a check-list and three case studies.

Writing a Business Case

At some point in their career, it is likely that an HIM professional will need to provide a compelling solid rationale to a Senior Manager. This PPB will outline the key steps in creating an effective Business Case and provides a checklist for reference.

Building an EMPI

Clinical care relies on the basic premise that an organization can accurately identify clients. An enterprise master patient/person index (EMPI) is a software application that identifies persons in an integrated delivery network across disparate registration, scheduling, financial, and clinical systems.

Limiting Disclosure - the "Lock Box"

A fundamental principle of CSA Model Code for the Protection of Personal Information is that of Informed Consent. The corollary of this is that the person has the right to withhold or withdraw consent to disclosure. This PPB discusses the challenges, limitation and legislation of limiting disclosure, and articulates suggestions for addressing a person’s request to ‘lock’ their data.

Email as a Provider - Patient Communication

Email can be effective in facilitating communication between health care providers and patients. It offers many benefits, but requires safeguards different than other communication such as paper and phones. This PPB outlines some of the challenges and benefits of email, as well as identifies recommendations for the HIM professional in dealing with this communication medium.

Health Information Management (HIM) & Health Information Technology (IT)

This PPB discusses the connection and working relationship between Health Information Management and Health Information Technology in the developing EHR. These two different but related disciplines are essential to the successful development and deployment of the EHR in Canada. An understanding of the three domains that require collaboration will assist an HIM professional to become a valuable member of an EHR team and bring needed skill-sets to an organization.

Personal Health Record in the EHR

A new component of the Electronic Health Record is the Personal Health Record (PHR). Created, owned, maintained and shared by the individual, the PHR will impact the existing health care records regardless of setting, and therefore will impact the HIM professional. The advent of the PHR will require the HIM professional to rethink organizational approaches to health information collection, dissemination and access and to adapt to ever-changing new technologies.

An IT Primer for Interoperable Health Information

With a demonstrated understanding of basic internet and IT terminology related to data exchange, HIM professionals can improve communication between technical and clinical professionals. Serving as a bridge between the professions, HIM professionals can facilitate the successful adoption and use of exchanged clinical information

Health Level 7

Standards are the most effective and efficient way to facilitate interoperable systems. If Canada’s health service delivery organizations implemented the same standards in their information management systems, data and information exchange would be facilitated. With the transition to the Electronic Health Record, HL7 is one standard with which HIM professionals should be familiar. This PPB describes HL7 at a high level and identifies references and resources available to all HIMs.

Standards Councils

A pan-Canadian Electronic Health Record requires standards – technical, data, process, information, etc. These standards must be developed, implemented, monitored, and changed as appropriate and these activities must be coordinated. One key piece of the implementation of standards is the Health Standards Council. This Professional Practice Brief is a primer on what a Standards Council is, how it operates, and identifies common activities and goal of Councils across Canada.

Incident Management

It is an inevitable reality that in healthcare, incidents or adverse events occur. As HIM professionals know, the management of personal health information brings potential risk. This PPB highlights and emphasizes that patient safety concerns and associated improvement initiatives are directly transferrable to the Health Information Management (HIM) profession. Some HIM functions, involving very sensitive information or significant privacy concerns, may be even more heavily impacted.

Value of the HIM Practicum Experience

It is a well-known fact that the practicum experience is an invaluable component of a Health Information Management (HIM) professional’s education. By applying theoretical knowledge learned in the classroom with the experiential learning the practicum offers, students gain a broader knowledge and gain a greater understanding of the HIM field. This PPB also discusses the value of taking a student to the practicum site.

Big Data and Data Analytics

This PPB outlines definitions of Big Data and provides highlights on the potential uses and users of Big Data and Data Analytics. It includes examples of applications and the skills required for those working with Big Data and Data Analytics. It highlights the skill set a HIM professional has and those they could build upon to support roles in these two areas.

Balanced Scorecard

This PPB describes what a Balanced Scorecard (BSC) is and how it is utilized and evaluated. A step by step model on how to develop a BSC is included as well as samples for the user of the PPB to review. The role of the HIM professional in Balanced Scorecard use is also included.



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"I allowed my HIM certification to lapse in 2015, and this year I decided it was time to get back into this rewarding profession. I had quite a few CPEs to accumulate to become recertified and having these Professional Practice Briefs (PPBs) available all at once, it allowed me to complete my recertification quickly. Not only was the information concise and informative, but they were available to non-members at a very affordable price. The PPB’s allowed me to re-familiarize myself with many areas of HIM and complete the requirements of recertification!"

Ashley M,, Nova Scotia Chapter