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Meaningful Use and Clinical Documentation

Author: Benson, Sean

Source: Journal of AHIMA

Publication Date: February 2011


Little direct attention has been paid to clinical documentation in the context of meaningful use. Discussion and debate instead focused on electronic health records (EHRs), computerized physician order entry, and other health IT systems.

However, the electronic capture and exchange....

Optimizing Data Representation Through the Use of SNOMED CT

Author: Bronnert, June; Daube, Julie L; Jopp, Gretchen; Peterson, Kathleen; Rihanek, Theresa; Scichilone, Rita A; Tucker, Vanna

Source: Journal of AHIMA

Publication Date: March 2014

Electronic health records (EHR) have changed the landscape for data representation. For many years health information management (HIM) professionals have relied on classifications for data representation and the support of clinical documentation. SNOMED CT is a data standard frequently used in electronic systems and has been included in the requirements for the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR Incentive Program. SNOMED CT is maintained and distributed by the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED CT is recognized throughout the world, and the terminology is available at no cost. The National Library of Medicine (NLM) serves as the US release center and the IHTSDO member country representative.

Meaningful Use Opens Up Its Deep End: With Some Providers Still Dipping Toes, CMS has Opened up its Health IT Program's More Challenging Deep End with Stage 2

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: October 2013



Sink or swim. These are the two choices participants of the "meaningful use" EHR Incentive Program will soon face now that the federal government has opened up the program's deeper, more complex second stage.


Though physician and hospital involvement in the program has incre....

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