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Privacy and Security Advantages of EHRs

Author: Miller, Dale W.

Source: Journal of AHIMA

Publication Date: September 2005


During the late 1980s and early 1990s, the healthcare industry first began to consider implementing what was then referred to as computer-based health records. Concerns were raised about whether these electronic records could be made as secure as the paper records then being used at most organ....

E-HIM: Our Commitment to Lead

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2005



For the past two years, AHIMA’s report “Vision of the e-HIM® Future” has served as a touchstone in our rapidly adapting field. When published in 2003, the report painted a picture of evolving HIM roles and practice in a healthcare industry moving from paper to an elec....

Spoliation of Medical Evidence

Author: Tomes, Jonathan P.

Source: Journal of AHIMA

Publication Date: October 2005


To avoid the improper destruction or alteration of records, HIM departments must follow a retention schedule, train personnel, and ensure that corrections leave original entries intact.
Although the legal concept known as spoliation of evidence has been a part of the American legal syste....

Privacy Compliance: Maintaining the Gains

Author: Vogt, Nancy

Source: Journal of AHIMA

Publication Date: October 2005


Most HIM professionals would probably agree that the state of information privacy has dramatically improved as a result of all the HIPAA efforts over the past few years. Executive leadership has tuned in, and even boards of directors have addressed information privacy. Awareness is at an all-t....

e-HIM: From Vision to Reality

Author: Bloomrosen, Meryl

Source: Journal of AHIMA

Publication Date: October 2005


Health IT has been a hot topic in the two years since AHIMA published "A Vision of the e-HIM Future." Members of the original task force take a look back.
This fall marks the second anniversary of the AHIMA report "A Vision of the e-HIM Future." The report, published in September 2003,....

Towards Data Interoperability: Practical Issues in Terminology Implementation and Mapping

Author: Lau, Lee Min

Source: AHIMA Convention | AHIMA Clinical Vocabulary Mapping Meeting

Publication Date: October 15, 2005

Conclusion

The lack of data interoperability is a key obstacle in the implementation and use of EHR to achieve its full benefits. Standard vocabularies provide the means for organizations to exchange, compare and aggregate data externally. The problems surrounding the use of standard voc....

HIPAA Electronic Data Interchange Transactions: The Impact on Healthcare Billing Processes with Special Emphasis on 837 Electronic Claims Transactions and 835 Electronic Remittance Transactions

Author: Kubas, Debbie; Buck, Shawna

Source: AHIMA Convention

Publication Date: October 21, 2005


Rules for HIPAA-compliant electronic transactions were finalized on October 16, 2000. The finalized HIPAA transaction standards required that claims filed electronically after October 16, 2002 (or after October 16, 2003, if you filed for an extension) had to be in the HIPAA-compliant electroni....

Communication in Clinical Care: the Role of HL7

Author: Jones, Tom

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction: Interoperability and Communication

By the authority vested in me as President by the Constitution and the laws of the United States of America, and to provide leadership for the development and nationwide implementation of an interoperable health information technology infra....

Behavioral Health Organization's Journey to the EHR

Author: LePar, Kathleen

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction

Making the transition to an electronic health record (EHR) or, for the purpose of behavioral health organizations, an electronic client record (ECR) is a major undertaking for any organization. The ECR affects both quality and administrative aspects of the organization. It al....

Healthcare Quality: the Vital Role of Coders

Author: Vallejo, Beryl Craig

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction

Vast quantities of data are generated through the healthcare process and stored in large databases. Evaluation of this data may reveal trends and patterns that can significantly enhance our understanding of disease progression and management. Special techniques are needed to....

Documentation Improvement Initiative at Maimonides Medical Center, Brooklyn, NY

Author: Rivera, Madeline; Zusman, Irina; Kogan, Susanna; Sichalov, Nadia; Spector, Michelle

Source: AHIMA Convention

Publication Date: October 21, 2005


Summary


Maimonides Medical Center (MMC) in Brooklyn, NY, implemented a successful documentation improvement program in 2001. Under the auspices of the Case Management Department, documentation specialists, who are credentialed HIM professionals (RHIA, CCS), perform concurrent and....

Clinical Documentation Improvement Program Strategies

Author: Mills, Mary

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction
What Is CDIP?

Aclinical documentation improvement program (CDIP) is a program focused on improving clinical documentation on a concurrent basis where a coder or documentation specialist, such as a nurse, reviews the medical record and consults with physicians regarding....

Dirty Data Leads to Dirty EHR: Managing and Leveraging Health Information through Community-Based Master Patient Index (EMPI) and Medical Record Cleanup

Author: Shams, Kam

Source: AHIMA Convention

Publication Date: October 21, 2005

A Scenario—the Need For Unity

I once knew a fellow by the name of John Doe. He was a popular character who, aside from his remarkable ability to come up in fictional scenarios such as this one, had a genuine knack for finding himself in need of medical attention. In fact, just last....

Memphis Moves...Toward a Community Health Record

Author: McGill, Meg; Andrews, Donna

Source: AHIMA Convention

Publication Date: October 21, 2005


In February of 2002 a group of healthcare organizations in the Memphis medical center area came together for the common goal of improving patient care, inspired by the Leapfrog Group for Patient Safety. This group was originally called the University Medical Center Coordinating Council and inc....

Natural Language Processing Technology and Terminologies: Mining Free Text

Author: Jagannathan, V.; Heinze, Daniel T.; Naeymi-Rad, Frank; Flanagan, James R.; Bowie, Jack; Kivatinetz, Raul

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction
The dictation and transcription process is one of the most widely used ways of documenting clinical content. This session brings leading vendors with NLP and terminology solutions to discuss their approach and technologies in support of data mining of free text. The applications t....

Nurses' Attitudes About Computers: a Study

Author: Bifolco, Gigi

Source: AHIMA Convention

Publication Date: October 21, 2005


Abstract


The growth of information technology in healthcare makes it necessary to understand nurses’ attitudes toward computers. The purpose of this study was to assess nurses’ attitudes towards computers and to determine what factors influenced nurses’ computer-....

Most Wired Hospital Going Digital

Author: Stallings, Crystal

Source: AHIMA Convention

Publication Date: October 21, 2005

Introduction

The president of the US stated that within 10 years, all health records will be electronic. This will evolve patient care in health institutions across America and will reduce the complexity of obtaining information when it is needed. This momentum has already been experience....

ASTM Standards in the Medical Transcription Industry

Author: Hurley, Brenda J.

Source: AHIMA Convention

Publication Date: October 21, 2005


Standardization is important in our professional and personal lives. When we make purchasing decisions for standardized items, we can do so with confidence that they will fit and meet our needs. Imagine how complicated it would be if faxes could only be sent and received specific to the same m....

HIM Service with a Smile

Author: Goethals, Colleen

Source: Journal of AHIMA

Publication Date: November 2005


As HIM professionals we encourage consumers to maintain personal health records. Are we ready to help them do it? Here’s a quick refresher on good customer service in the HIM department.
AHIMA’s Consumer Education Campaign encourages consumers to create and maintain their own....

Practice Toolkit: EHR Implementation

Author: Hall, Terri

Source: Journal of AHIMA

Publication Date: November 2005


The Billings Area Indian Health Service (IHS) began implementing an electronic health record (EHR) about three years ago, beginning with the Crow Acute Care Hospital and its Wind River outpatient clinics. This article outlines the steps the organization took to reach “go live.”

Using MedPAR Data as a Measure of Urinary Tract Infection Rates: Implications for the Medicare Inpatient DRG Payment System

Author: Stringham, Jerry; Young, Nancy

Source: Perspectives in Health Information Management

Publication Date: December 2005


Abstract


A valuable metric of hospital performance is the rate of nosocomial infections, particularly urinary tract infections (UTIs). Current measurement techniques are expensive to administer and are not widely available. Determining a measurement index of nosocomial UTI incide....

Consumers Moving to the Center of NHIN Planning

Author:

Source: Journal of AHIMA

Publication Date: January 2006


Quality of Care Must Be the Reason behind HIE, Panelists Say

Experts offered their insights and predictions on health information exchange (HIE) and privacy, consumer involvement, and the HIM role during the October 18 general session, “Building Blocks Issues in the National He....

Connecting Interoperability to HIM

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: January 2006


This year the vision of connected health information will come into sharper focus. Federally funded initiatives for sharing health information are taking place in a dozen communities across the country. Four consortiums are under contract with the Department of Health and Human Services to de....

Experts: Clinical Terminology Mapping Will Be Essential Tool

Author:

Source: Journal of AHIMA

Publication Date: January 2006


Clinical terminology mapping is essential for creating an effective nationwide health information infrastructure, Simon Cohn, MD, MPH, told attendees at the first-ever institute on clinical vocabulary mapping methods, held October 15. Cohn, chair of the National Committee for Vital and Health....

Interoperability: What it Means, Why it Matters

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: January 2006


Healthcare’s hottest topic finally has two things it has badly needed: plain language and a sense of urgency.
Every health information story in 2006 will circle back to one word. In one way or another, every HIM story this year will relate to interoperability.

Healthcare....

Practice Toolkit: Medical Record Completion

Author: Hirsch, Ronald

Source: Journal of AHIMA

Publication Date: January 2006


Medical record completion compliance has always been a problem at Sherman Hospital, a medium-sized community hospital in Elgin, IL. The number of incomplete charts often exceeded the standard set by the Joint Commission on Accreditation of Healthcare Organizations, risking a type I violation.....

Data Content Standards: the Nexus of HIM Practice

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2006


One of AHIMA’s key goals for 2006 is to promote quality and safety through standards for data content and documentation. Quality and safety require that the right information is available at the right time to support patient care and health system management decisions. Gaining consensus....

Streamlining the System through e-HIM

Author: AHIMA

Source: AHIMA Advantage

Publication Date: February 2006


As director of medical information services, Mary Reeves, RHIA, is driving Vanderbilt University Hospital toward a paperless future. How has your organization progressed toward an e-HIM® environment?

Being in an academic center, we've been very aggressive in developing the electronic....

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