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Journal Q&A (11/04)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2004


Q: As a covered entity, do I need to have satisfactory assurance (as required by HIPAA) that an individual has been notified when I am served with a search warrant for a patient's protected health information (PHI)?
A: No. A search warrant is issued by a judge and is considered the same a....

Journal Q&A (11/04)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2004


Q: From a Washington State Community of Practice discussion thread: What should our facility do when we receive medical information burned to a CD in place of hard copies? Should we print copies? Should we send the CD back? If copies are printed, should the CD be maintained or destroyed?
....

Better Patient Care Through Data Quality

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 2004



"Paper kills” has become a catch phrase in certain political circles to dramatize the need for a digitized healthcare system. Former House Speaker Newt Gingrich, now head of the Center for Health Transformation, stated, “A paper-based system is an ignorant system” and the....

Redesign of Diagnostic Coding in Pediatrics: From Form-based to Discharge Letter Linked

Author: Prins, Hilco; Büller, Hans; Zwetsloot-Schonk, Betty

Source: Perspectives in Health Information Management

Publication Date: December 2004


Abstract

Diagnostic coding after hospital discharge is mainly based on abstracting of paper medical records by medical record coders. Studies show that the quality of these data is often moderate, possibly because discharge registries play no role in daily patient care. Timely writi....

Implementing Patient Access to Electronic Health Records under HIPAA: Lessons Learned

Author: Wang, Tiffany; Pizziferri, Lisa; Volk, Lynn A; Mikels, Debra A; Grant, Karen G.; Wald, Jonathan S; Bates, David W

Source: Perspectives in Health Information Management

Publication Date: December 2004

Abstract


In 2001, the Institute of Medicine (IOM) and the Health Insurance Portability and Accountability Act (HIPAA) emphasized the need for patients to have greater control over their health information. We describe a Boston healthcare system’s approach to providing patients....

Brailer: "We're Here to be Catalysts"

Author:

Source: Journal of AHIMA

Publication Date: January 2005


Nation's First Health Information Technology Coordinator Delivers Monday Keynote
AHIMA members are “people who have stepped to the front lines, who live and breathe the question of how we make changes” in the healthcare system, David Brailer, MD, PhD, told a general session au....

EHR in India

Author: Hanson, Susan P.; Hanson, Raymond J. Jr.

Source: Journal of AHIMA

Publication Date: January 2005


On opposite sides of the globe, India and the US spell the future of health information management the same: EHR.
The numbers are staggering and hard to absorb by US standards—the Indian healthcare system delivers care to a population of more than 1 billion people. With acceleratin....

Journal Q&A (1/05)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: January 02, 2005

Q: What is medical informatics, and is there a connection between it and health information management?
A: Medical informatics is “the collection, classification, storage, retrieval and dissemination of recorded knowledge.”1 It features an “emphasis on technology as an integr....

Access Controls: Striking the Right Balance

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: January 2005


As healthcare organizations put the finishing touches on their HIPAA security compliance plans, many are finding that updating access controls is not easy. Clinicians often scoff at the word “control” in general and at “access control” in particular. Not all products ar....

Journal Q&A (1/05)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: January 02, 2005

Q: Is there a standard addressing who should document in medical records?
A: The answer to this question is left up to individual organizations. Most facilities create a policy that covers who can document in a patient’s medical record. This may also be covered in the medical staff bylaw....

EHR Development Steps in Long-term Care

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: January 2005


In the past year there has been a whirlwind of activity around the electronic health record (EHR). Hospitals and physician offices are in the forefront of planning for EHR development at the national level. However, long-term care (LTC) is often mentioned as the third area of priority. This ar....

Letters accompanying Collaborative Response to the Office of the National Coordinator for Health Information Technology (ONCHIT) Request for Information (RFI) on National Health Information Network (NHIN)

Author: AHIMA; Kloss, Linda L

Source: AHIMA testimony and comments

Publication Date: January 18, 2005


January 18, 2005

David J. Brailer, MD, PhD
Office of the National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW, Room 517-D
Washington, DC 20201
Dear Dr.....

Collaborative Response to the Office of the National Coordinator for Health Information Technology (ONCHIT) Request for Information (RFI) on National Health Information Network (NHIN)

Author: AHIMA; et al.

Source: AHIMA testimony and comments

Publication Date: January 18, 2005


This Collaborative Response is submitted by: American Health Information Management Association (AHIMA), American Medical Informatics Association (AMIA), American National Standards Institute-Healthcare Informatics Standards Board (ANSI HISB), Center for Information Technology Leadership (CITL)....

Practice Toolkit: Hospice

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: February 2005

Hospice Challenges

When asked about challenges in HIM in the hospice care setting, Myers notes that the challenges in ensuring hospice records are complete and reflect the care given are very similar to those in other healthcare facilities. In fact, another member of the CoP, Susan Torzew....

Standardized Data: the Difference for EHR Solutions

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2005


This month, Dallas will be the center of the health IT world as HIMSS hosts its 2005 trade show, of which AHIMA again will be a sponsor. We look forward to learning how electronic health record (EHR) solutions are maturing and how provider organizations are succeeding in improving patient care....

Data Linkage: Ready or Not, It's Here [part 1]

Author: Fernandes, Lorraine M.

Source: Journal of AHIMA

Publication Date: February 2005


In early 2004 Connecting for Health, a public-private collaborative funded by the Markle and Robert Wood Johnson Foundations, engaged a cross-section of experts in security, technology, privacy, consulting, and medical informatics to define how healthcare information could be shared more effec....

Making Amendments Meaningful

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: February 2005


Now that we’re well entrenched in compliance with the privacy rule and headed toward the electronic health record (EHR), the personal health record (PHR), and regional health information organizations (RHIOs), amendments may seem like a mundane topic. But, as this article explains, it is....

Practice Toolkit: Substance Abuse Treatment Programs

Author: Haines, Pamela T.

Source: Journal of AHIMA

Publication Date: March 2005


HIPAA’s privacy rule has heightened awareness about confidentiality of healthcare information among the general public. However, pockets of confusion still exist. Misunderstandings between healthcare providers and law enforcement officials (LEOs) abound about the laws governing protected....

HIPAA Marches On--Or Does It?

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2005


HIPAA has taught us that standardization is hard. When the act was signed into law in 1996, the optimists among us believed that within four years the healthcare industry would be using a variety of uniform national administrative transactions, most associated with what we now call the revenue....

Data Linkage: Ready of Not, It's Here [part 2]

Author: Fernandes, Lorraine M.

Source: Journal of AHIMA

Publication Date: March 2005


As stewards of the data housed within our organizations, HIM professionals must be cognizant of ongoing work to facilitate sharing of data across networks. Such activities will gather momentum in the coming years as electronic health records become common practice. HIM professionals must endea....

CCR--Not an EHR

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: March 2005



In 2003 the American Society for Testing and Materials (ASTM) kicked off the development of the Continuity of Care Record (CCR) standard, which was finalized in that year and passed by ASTM in April 2004. Sponsorship of the CCR brought together ASTM International, the Massachusetts Medical....

Transforming Healthcare: the Time for Change is Now

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2005


In recent remarks to Connecting for Health’s steering group, David Brailer, MD, PhD, the national health information technology coordinator, noted that if this is the decade of health IT adoption, 2005 could well turn out to be the year of “maximum flexion.” Brailer urged the....

State of Document Management: an HIM Roundtable

Author: Friedman, Beth

Source: Journal of AHIMA

Publication Date: April 2005


In this panel discussion, four experts discuss the big picture and the fine grain of document management now and in the years ahead.
Document imaging, document management, electronic document management systems (EDMS)... these terms have all been part of the HIM vernacular for more than....

Reaffirming Your HIPAA Compliance Efforts

Author: Woloszyn, William

Source: Journal of AHIMA

Publication Date: April 2005


Two years after the HIPAA privacy compliance date, is it time for your organization to reassess your efforts and recommit to enforcing HIPAA?
Revisiting HIPAA’s Roots

The HIPAA privacy regulation was created in response to public healthcare concerns about the privacy of pa....

HIM Role in Bringing e-HIM to Small Practices

Author: Hanson, Susan P.

Source: Journal of AHIMA

Publication Date: April 2005


In order for the nation’s health IT strategy to succeed, small physician practices must adopt electronic health records (EHRs). The transition of the paper-based small physician practice to the digital world will require a fundamental understanding of the practice and the deployment and....

Outsourcing ROI: Does it Make Sense for You?

Author: Bellenghi, G. Michael

Source: Journal of AHIMA

Publication Date: April 2005


Governed by state and federal regulations, release of information (ROI) is a time-consuming and sensitive process. Failure to fulfill requests accurately and on time can have painful ramifications, affecting quality of patient care and prompting irate phone calls and legal action or fines. Not....

Physicians, Patients, and EHRs: When it Comes to a Consultation, Is Three a Crowd?

Author: Wager, Karen A.; Ward, David M; Lee, Frances Wickham; White, Andrea Weatherby; Davis, Kimberly S; Clancy, Dawn E

Source: Journal of AHIMA

Publication Date: April 2005


Research in an ambulatory care practice finds that, despite physician concerns, patients don’t perceive EHRs as intruders in the exam room.
Although great strides have been made in the use and acceptance of EHR systems in ambulatory care practice, there are still barriers that kee....

EHRs, the Doctor Will See You Now

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: April 2005


EHR systems are costly to purchase, complex to evaluate, and require expertise to implement. So why are small physician practices buying more of them than ever before?
There are plenty of good reasons why EHRs have been scarce in small and medium-sized physician practices. Enormous cost....

Leading from the Middle

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: May 2005


With one eye on strategy and one on operations, HIM managers not only have the opportunity to facilitate change, they also have the responsibility.
Awareness of senior-level strategy combined with detailed organizational knowledge can give HIM managers keen eyesight. For Mary Staub, RHIA....

Making the Clerical Transition to e-HIM

Author: Lambton, Karanne

Source: Journal of AHIMA

Publication Date: May 2005


As we move forward with the developing electronic health record (EHR), the emphasis on changing work processes, increasing productivity, and eliminating many paper-driven tasks may leave clerical staff fearful of an uncertain future. Helping clerical staff understand how their current skills a....

How to Safely Recycle PCs

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: June 2005


Securing the privacy of both protected health information and personal information should be a primary concern when personal computers have outlived their usefulness. Recycling or disposing of a computer safely can be a challenge.

It’s not enough to simply give an old computer....

Problem List Coding in e-HIM

Author: Fraser, Greg

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2005


In 1968 Larry Weed, MD, introduced the idea that a complete and accurate problem list is an essential component of the medical record.1 The problem-oriented medical record (POMR), in which all data contained in the medical record can be linked to a list of problems, has been almost universally....

Data Abstraction Unplugged: Taking Trauma Registry to the Point of Care with Wireless Technology

Author: Eisenhower, Cynthia; McElwee, Karen; Wargo, Christina; Woodruff, Tracy

Source: Journal of AHIMA

Publication Date: July 2005


Central to Geisinger Medical Center’s success with concurrent abstraction is wireless technology that enables registrars to work at the point of care.
Registry abstraction can have trouble keeping up with technology. Often located away from IT-intensive clinical departments and oper....

When the Doctor Calls: Opportunities in Ambulatory Care

Author: AHIMA

Source: AHIMA Advantage

Publication Date: August 2005


It wasn't too long ago that physicians could hire a file clerk to handle simple filing tasks and doctors themselves decided how patients could view their records. But today doctors' information needs are much more complex.
Just look at how many credentialed HIM professionals are bringing....

Radical Technology: Your Grandfather's Telephone

Author: Smith, Douglas L.

Source: Journal of AHIMA

Publication Date: September 2005


More than 100 years ago, a cutting-edge technology offered the potential to improve and better manage care. But like each innovation that was to follow, the telephone wasn’t implemented in a day.
Editor’s note: The most common technologies surrounding us were once revolutiona....

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