HCIS 318 Week 2 Health Care Roles Example

Who Has to Say Yes: Mapping the Health Care Roles an IT Team Must Work With to Replace Paper Surgical Consent Forms With Electronic Signatures

[Student Name]

University of Phoenix

HCIS/318: Health Care Industry Terms for IT Professionals

Week 2 Assignment

[Instructor Name]

[Date]

The hospital, the project and the people are composites written for a model paper; role descriptions come from the sources listed.

At a composite 300-bed hospital, the surgical services department still uses paper consent forms. Surgeons or their residents explain the procedure, the patient signs, a nurse witnesses and the form travels with the patient to the operating room. Last year, 22 surgeries started late because the form could not be found, and an audit found 31 forms missing a witness signature or date. Leadership asked the IT department to implement electronic consent signed on tablets. The analyst assigned to the project quickly learned that the hardest part was not the software but the number of people who had to agree. This paper maps those roles.

Clinical Roles: Who Obtains and Uses Consent

Surgeons are responsible for explaining the procedure, its risks, benefits and alternatives, and obtaining consent. They need a form that lists the procedure accurately and can be completed quickly in clinic or the preoperative area. Anesthesiologists obtain separate anesthesia consent and want it in the same system. Perioperative nurses verify consent before surgery as part of the safety checklist; they need to see at a glance that the form is complete. Residents often obtain consent under supervision, which raises questions about who may sign as the physician. Interpreters are needed when the patient prefers another language, and their participation must be documented.

Administrative Roles: Who Manages the Record

Registration staff create the encounter to which the consent attaches. Health information management professionals are responsible for the legal medical record; they decide how the signed document is stored, how long it is kept and how it is released when requested. The Bureau of Labor Statistics (2024) describes medical records specialists as organizing and managing health information data and ensuring its accuracy and security, work that makes them essential to any document project. Scheduling staff need to know when consent is missing so surgeries are not booked blind.

Oversight Roles: Who Defines Valid Consent

Risk management knows what makes consent legally defensible and has handled past claims involving consent disputes. Compliance ensures the process meets accreditation and state requirements. The privacy officer checks how signatures and images are stored and who can view them. The medical staff office confirms which practitioners have privileges to perform each procedure. Any one of these roles could halt the project late if consulted too late, which is why the analyst's first step was to put their requirements in writing before a single form was built.

Informatics Leadership: The Bridge

The chief medical information officer leads the project's clinical side. Sengstack et al. (2016), reporting for an informatics association task force, described the chief clinical informatics officer as an executive who bridges clinical care and information technology, needing knowledge of clinical practice, informatics, leadership and change management. In this project, the CMIO chairs the steering group, resolves disagreements between surgeons and nurses about workflow and speaks for the clinical staff to the IT department. A nurse informaticist handles day-to-day design with perioperative nurses.

IT Roles

The IT project manager coordinates the schedule. An application analyst configures forms in the EHR's document module. An integration analyst connects signature tablets and ensures documents file to the correct encounter. The security team reviews tablet management.

Education and Licensure Behind the Roles

Roles in health care rest on training and licensure that shape what each person may do. Surgeons and anesthesiologists are licensed physicians with residency training; residents practice under supervision; perioperative nurses are registered nurses, often with specialty certification; certified medical interpreters complete formal training; health information professionals often carry credentials from their professional association. For IT, these distinctions set the rules the system must enforce, such as which roles may sign as the person obtaining consent and which may only witness.

A Responsibility Chart

The analyst built a simple chart listing each decision and who approves, who must be consulted and who is informed. Form content: approved by risk management and the surgical department chair, with surgeons and anesthesia consulted. Signature and witness rules: approved by compliance and HIM. Storage and release: approved by HIM and the privacy officer. Workflow: approved by the CMIO with nursing and surgeons consulted. Go-live date: approved by the steering group, with scheduling and registration informed.

Lessons for IT Communication

Each role speaks a different language, and even the shared clinical vocabulary is dense with terms and abbreviations that IT staff must learn (Ehrlich et al., 2021). Surgeons want speed and accuracy about the procedure; nurses want a clear signal of completeness; HIM speaks of the legal record; risk management speaks of defensibility. The analyst learned to present the same design in each group's terms, to ask what each role could not live with and to confirm decisions in writing. Early involvement cost weeks at the start but avoided months of rework.

The Patient as a Role

The patient is the most important person in the process and the easiest to forget in an IT project. Patients need a form they can read on a tablet, with a larger font option, a translated version when needed and a copy afterward in the portal. Two members of the hospital's patient advisory council tested the tablet screens and asked for a button to request more time with the surgeon before signing, which the team added. Treating the patient as a role with requirements, not as an end user to be trained, changed the design.

Why Roles Matter for Technology

Health care is organized around licensed roles with defined responsibilities, and systems must fit them. A consent form that lets the wrong person sign, or that files where HIM cannot find it, fails regardless of how well the software works.

Conclusion

Replacing a paper form touched more than a dozen roles across clinical, administrative, oversight, informatics and IT groups. Knowing what each does, needs and can veto allowed the IT team to design a system that everyone could approve and use, and turned a technical project into a successful change in practice.

References

Bureau of Labor Statistics. (2024). Medical records specialists. In Occupational outlook handbook. U.S. Department of Labor. https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm

Ehrlich, A., Schroeder, C. L., Ehrlich, L., & Schroeder, K. A. (2021). Medical terminology for health professions (9th ed.). Cengage Learning.

Sengstack, P., Thyvalikakath, T. P., Poikonen, J., Middleton, B., Payne, T., Lehmann, C. U., & Kannry, J. (2016). The chief clinical informatics officer (CCIO): AMIA task force report on CCIO knowledge, education, and skillset requirements. Applied Clinical Informatics, 7(1), 143-176. https://doi.org/10.4338/ACI-2015-12-R-0174