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Low-Tech Threats in a High-Tech World

Author: Rollins, Genna

Source: Journal of AHIMA - website

Publication Date: April 2011



Despite the rise of health IT, healthcare providers still face daily privacy and security risks of the mundane variety—paper records are misplaced, improperly disclosed, or released without confidential information redacted. No matter the opportunities and risks that technology bring....

Advancing Secondary Data Uses through Data Standards: HL7 Project Advances the “Collect Once, Use Many Times” Paradigm

Author: Kallem, Crystal; Richesson, Rachel; DuLong, Donna; Sison, Luigi; Van Dyke, Patricia; Mon, Donald T.

Source: Journal of AHIMA

Publication Date: April 2011


Organizations must consider a multitude of data standards and reporting requirements when capturing and aggregating healthcare data. These standards and requirements are vast in scope and complex to implement.

To help address these challenges, healthcare desperately needs clearly de....

Data Governance—HIM’s Sweet Spot

Author: Cassidy, Bonnie S.

Source: Journal of AHIMA

Publication Date: April 2011


HIM's primary ethical obligation is to protect patient privacy and confidential information, which includes oversight of information disclosure; health information systems and health records; and the quality of information. Both paper and electronic health records contain personal and private....

Cloud Computing 101

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: April 2011


In the past several years cloud computing has gained substantial recognition. However, it is still a relatively new concept for those in the healthcare industry.

Before adopting cloud-based services or applications, organizations need to understand how cloud computing works, the typ....

Patient’s Role in Ensuring Legal EHR Data Integrity

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2011


For nearly 40 years I have served as an HIM and health IT professional, but for my entire life I have been a healthcare patient. My understanding of the processes that create medical records has helped me identify system and human mistakes in my own records. Consequently, I know well that the....

Opting for Opt Out: How One HIE Manages Patient Consent

Author: Bass, Deb

Source: Journal of AHIMA

Publication Date: May 2011



Every health information exchange must determine how it will gain consent from patients to share their information. The Nebraska Health Information Initiative chose opt out and with good communication and management has maintained a high rate of patient participation.

Even afte....

Privacy Rights Never Die: And Sometimes Complications Linger On

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2011


The laws surrounding release of a deceased patient's records can lead to complex and frustrating situations in the HIM department. Just who has access rights depends on federal law, state law, and individual circumstances, illustrated by the two scenarios below.

Last summer the Office....

HIE Patient Consent Model Options

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: May 2011


Health information exchanges (HIEs) continue to expand across the nation as organizations prepare to meet the stage 1 meaningful use criteria. A 2010 eHealth Initiative survey found that there are currently 73 operational HIE initiatives, up from 57 in 2009.

During this rapid advanc....

Encryption Basics

Author: Stine, Kevin; Dang, Quynh

Source: Journal of AHIMA

Publication Date: May 2011


Healthcare and health IT professionals are entrusted with protecting the privacy and confidentiality of patient data. To provide this protection, these professionals frequently look to commonly accepted technologies and methodologies to safeguard the data while at rest and in transit. One tech....

Transcription and Data Capture in the EHR

Author: Dooling, Julie A

Source: Journal of AHIMA

Publication Date: June 2011


Transcription has always played an important role in HIM, but today it is taking on a new role in supporting the meaningful use program. Organizations are looking to leverage their transcription technology to capture structured data within their electronic health records (EHRs), a requirement....

A Possible Delay for Stage 2

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: June 2011


This spring, as the first providers began attesting to their performance in stage 1 of the meaningful use program, the rest of the industry seemed too absorbed with the program's next phase to take much notice.

Through the spring a subgroup of the Health IT Policy Committee was prepa....

Changes Ahead in Data Standards

Author: Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: June 2011


HIM professionals are most familiar with the data standards mandated through HIPAA. However, the data standard adoption process is also now part of the requirements for EHR technology in the meaningful use program.

Understanding the data standards adoption process under HIPAA and th....

Preparing for the CAC Transition

Author: Bronnert, June

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2011


One of the biggest technology advancements to influence coding since encoding systems is computer-assisted coding. CAC is the "use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare p....

Managing Physician Queries in the EHR

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2011


Federal incentives provided for the meaningful use program under the American Recovery and Reinvestment Act are encouraging hospitals to adopt electronic health records (EHRs). Eighty percent of hospitals are planning to become meaningful users of EHR technologies in 2011, and the healthcare i....

EHRs in the Cloud: Contract Protection for a Rainy Day

Author: Lamar, Marilyn

Source: Journal of AHIMA

Publication Date: July 2011


Cloud computing has been suggested as a cost-effective way to use electronic health records (EHRs), particularly for small providers that may not have an IT staff. Cloud-based EHRs store patient health records and the EHR software on computers operated by the EHR vendor.

The healthc....

10 Security Domains (2011 update)

Author: AHIMA

Source: AHIMA practice brief

Publication Date: July 2011

This is the original web version of the practice brief, published in the May 2012 Journal of AHIMA. This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

HIM Functions in Healthcare Quality and Patient Safety. Appendix C: HIM’s Role in Data Capture, Validation, and Maintenance

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011


A critical component of AHIMA's draft HIM Core Model, a robust description of the functions and opportunities open to current and future HIM professionals, is capture and maintenance of health data.1 HIM professionals are encouraged to assume a leadership role in outlining how data are captured....

Protecting Patient Information after a Facility Closure. Appendix D: Health Information Management Checklist for Acquisitions and Closures (2011 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: August 2011


This document is intended to be used as a guide and is not intended to be all-inclusive. It should be adapted to the setting or organization type.

Purpose: To ensure appropriate health information management tasks are processed during the acquisition, closure, or dissolution of an org....

Problem List Guidance in the EHR

Author: AHIMA Work Group

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2011


Problem lists facilitate continuity of patient care by providing a comprehensive and accessible list of patient problems in one place. Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifyi....

The EHR’s Impact on Staffing Models

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: September 2011


As facilities transition from paper to electronic records, HIM departments must review job functions and staffing models. EHRs enable automation and ease of access and affect how the HIM department operates.
From Clerical to Qualitative

In an electronic environment paper HIM fu....

Future of a Nationwide Health Information Network: An Explanation of the Minnesota NwHIN Direct Pilot and Implications For Improved Healthcare Delivery

Author: Briggs, Mark

Source: AHIMA Convention

Publication Date: October 02, 2011


Background


An initiative developed by the Office of the National Coordinator for Health Information Technology of the Department of Health and Human Services, the Direct Project was designed to help healthcare providers, departments of health, and payers nationwide communicate sec....

Is Your Outpatient Documentation Ready for I10?

Author: Clark, Andrea

Source: AHIMA Convention

Publication Date: October 02, 2011

BACKGROUND:

Hospital inpatient medical documentation has its distinctive challenges as the movement of I-10-CM requirements march closer. With that said, outpatient encounters has its unique characteristics and supplementary challenges for ICD-10-CM assignments. The variety of outpatient....

Building a Statewide Health Information Exchange in Maine

Author: Culver, Devore

Source: AHIMA Convention

Publication Date: October 02, 2011

Background

The federal HITECH Act sought to improve health care delivery and patient care through an investment of over $40 billion in health information technology. Combined, the various HITECH programs are intended to build the foundation for every American to benefit from an electronic....

Natural Language Processing – Is it the Silver Bullet for Health Information Management?

Author: Fritsch, Jürgen; Fallati, Donald T.; Kosegi, Lynn

Source: AHIMA Convention

Publication Date: October 02, 2011

M*Modal

The overarching goals driving the healthcare industry and the Health Information Profession and function have been clear for some time. Broad agreement exists that having clinical data readily available in an electronic environment, rather than paper-based, will improve patient ca....

Privacy and the EHR

Author: Nelson, Debra S

Source: AHIMA Convention

Publication Date: October 02, 2011


Determining how to implement privacy regulations and policies in an electronic record environment can not only be daunting but also thought of quite late in the EHR implementation process. Daily processes and tasks such as reviewing the medical record with patients to processing requests for a....

Issues with Automating a SNOMED CT® to ICD-9-CM Map

Author: Wilson, Patricia S

Source: AHIMA Convention

Publication Date: October 02, 2011

Introduction

An integral part of the interoperability of codified information within an electronic medical record is mapping of one terminology to another. Mapping is defined as the process of creating one-way links between concept and terms for specific purposes. Mapping is performed for....

HIM, Medical Staff and IT Collaboration: Driving from Meaningful to Exceptional Use of the EHR

Author: Mullen, Lee; Kauth, Peg; Pinzon, Gabrielle; Dunyak, Denise

Source: AHIMA Convention

Publication Date: October 02, 2011

Background and History:

As ARRA HITech is driving healthcare organizations to accelerate Electronic Health Record adoption, CentraState Health System finds themselves in the driver’s seat having spent the past 4+ years implementing various components of the EHR. CSHS finds themselve....

Utah’s All Payer Claims Database

Author: Cofrin, Kelly

Source: AHIMA Convention

Publication Date: October 02, 2011

Introduction

As part of its decades-long effort to collect, analyze, and report on healthcare quality and cost, Utah has funded and created one of the country’s leading All Payer Claims databases. This data resource brings an unprecedented ability to examine costs for episodes of ca....

Health Information Exchange – Our Successes and Challenges with the Virtual Lifetime Electronic Record

Author: Foley, Teresa; Gillen, Zachary; Teal, Jennifer

Source: AHIMA Convention

Publication Date: October 02, 2011

Background

In the spring of 2009, President Obama announced plans to create a joint Virtual Lifetime Electronic Record (VLER) to improve care and services between the Department of Veterans Affairs (VA), Department of Defense (DoD), and the private sector. President Obama directed the Dep....

Legal Considerations in Joining an HIE

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2011


The legal issues healthcare organizations must consider when joining a health information exchange (HIE) go far beyond the standard HIPAA-related concerns.

HIEs are rapidly gaining prominence in healthcare, bolstered by federal initiatives like the meaningful use program, which requ....

EHR Alternative Certification for Hospitals or EACH™, A Federally-authorized Certification for Installed Hospital EHR Technology

Author: Knighton, Michelle; Ray, Alisa

Source: AHIMA Convention

Publication Date: October 02, 2011

Introduction

As hospitals anticipate the benefits of federal incentive payments for meaningful use of certified EHR technology, some face an unexpected hurdle. Many hospitals will be able to meet the EHR certification requirement through use of certified EHR technology purchased from vend....

Understanding Patient Access and Amendments

Author: Wiedemann, Lou Ann

Source: AHIMA Convention

Publication Date: October 02, 2011


The Health Information Portability and Accountability Act (HIPAA, 45 CFR, section 164.524 and 164.526) and subsequent privacy rule revisions under the Health Information Technology for Economic and Clinical Health (HITECH) Act changed how covered entities approach a patient’s right to ac....

Amendment, Corrections and Deletions Technical Paper

Author: Wiedemann, Lou Ann

Source: AHIMA Convention

Publication Date: October 02, 2011


The health record is the legal and business record of the healthcare organization. As such, ensuring accurate and timely doucmenation is paramount for information management. The Centers for Medicare and Mediciad services (CMS) has patient safety goals. A key component to this process is to ma....

The cHIE, the Key to a Better Health Care World

Author: Rivera, Teresa

Source: AHIMA Convention

Publication Date: October 02, 2011

Background

The Utah Health Information Network, UHIN, has been exchanging data electronically since 1993. Formed and governed by the community, UHIN, is a solution to the high cost of sending claims and receiving payments electronically. UHIN has been operating as a nonprofit organization....

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