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Journal Q&A (11/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2003

Q: How does AHIMA plan to be involved in the development of a functional model for the EHR?

A: AHIMA has been a voting member of HL7 for approximately 10 years and attends the group’s regularly scheduled plenary meetings three times a year. This year AHIMA increased staff attendance....

Journal Q&A (11/03)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: November 02, 2003

Q: I heard about meetings held around the country to discuss a functional model for the EHR. What are these about and who sponsored them?

A: The Centers for Medicare & Medicaid Services (CMS) asked Health Level 7 (HL7) to develop a model—specifically concerning functionality....

How Law, Investigation, Ethics Connect to HIPAA

Author: Ruano, Michael

Source: In Confidence (newsletter)

Publication Date: November 02, 2003


Part nine in a 10-part series.
This article is the ninth of a 10-part series that introduces the domains of information security and relates them to federal HIPAA regulations. The information security domain of law, investigation, and ethics covers these topics in depth and provides a p....

Data Quality: Part of the e-HIM Agenda

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 2003


This has been another remarkable year for advancing HIM issues and the HIM profession. Programs to improve patient safety through information solutions have gone from the drawing board to demonstration projects. On April 14, the HIPAA privacy rule went into effect across the US. In July, the se....

Data Warehousing: Myths, Pitfalls, and the Secret Weapon

Author: Moyer, Rich

Source: Journal of AHIMA

Publication Date: November 2003


Is your organization using its data warehouse to its fullest potential? The author provides some pitfalls to avoid and some tips that may help improve care and use resources more efficiently.
Most healthcare organizations have invested in building a data warehouse. But once the warehouse....

Handling Release of Information Over the Phone

Author: Hjort, Beth M.

Source: In Confidence (newsletter)

Publication Date: November 02, 2003


Q: Hospitals must have sensitive yet confidential policies for handling concerned family and friends with questions about loved ones within their facilities. How can a covered entity (CE) be confident about appropriate telephone release of information when it’s so difficult to validate a call....

Keen Eye on Core Measures: Joint Commission Data Quality Study Offers Insights into Data Collection, Abstracting Processes

Author: Watt, Ann; Williams, Scott; Lee, Kwan; Robertson, James; Koss, Richard D; Loeb, Jerod M

Source: Journal of AHIMA

Publication Date: November 2003


The Joint Commission has been collecting core measures data for more than a year. But how reliable are the data being collected? Strategies from successful organizations show how improving your documentation processes can improve the reporting of core measures.
In July 2002, the Joint Co....

Standard Terminology Helps Advance EHR

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: November 2003


On July 1, 2003, Secretary of the Department of Health and Human Services Tommy Thompson announced a new agreement between the National Library of Medicine (NLM) and the College of American Pathologists (CAP) to license SNOMED-CT. This five-year agreement is seen as a significant advancement f....

Physician Record Completion Policy

Author: Lutz, Laurie J.

Source: AHIMA Foundation

Publication Date: December 16, 2003


The HIM Department has a commitment to provide accurate, timely and friendly customer service.
Our goal is to strive for excellence in our day-to-day activities. With this in mind the following is how we achieved our success in decreasing the numbers of delinquent medical records.
D....

SEER's Training Web Site

Author:

Source: External web site

Publication Date: January 01, 2004

Web-based training modules for cancer registration and surveillance. When complete, will comprise 12 training modules, each covering a particular cancer registration training subject. The site is under continual development.

HIPAA and the EHR: Making Technical Safeguard Changes

Author: Fodor, Joseph

Source: Journal of AHIMA

Publication Date: January 2004


As electronic health records (EHRs) become more commonplace in healthcare, changes, adjustments, and improvements will be inevitable. When designing, implementing, upgrading, or remediating an EHR system, your organization’s implementation team should consider the impact of complying wit....

E-HIM: a "Glocal" Challenge

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: January 2004


The US is embarked on a public works agenda as major as highways, water works, and electrical grids. This same agenda is being pursued around the world in many developed and developing countries. It is a worldwide project to design and implement electronic health information systems. As HIM pr....

Panel Hears 'Drumbeat' for Future in EHR Efforts

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: January 2004


In 2010 will HIM professionals be working in a paperless environment in the context of a robust national health information infrastructure? According to a panel of experts, public and private entities are taking steps to move closer to this goal. Leading decision makers and public policy exper....

Standards for the Content of the Electronic Health Record

Author: Watzlaf, Valerie J.M.; Zeng, Xiaoming; Jarymowycz, Christine; Firouzan, Patricia Anania

Source: Perspectives in Health Information Management

Publication Date: January 2004




This research study was funded in part by the AHIMA Foundation for Research and Education. The authors would also like to acknowledge the University of Pittsburgh HIM students that participated in this research project: LaTonya Thompson, Brandi Long, Manisha Ghate, Leanne Borelli, Jul....

EHR Train Has Arrived at the Station -- All Aboard!

Author: AHIMA

Source: AHIMA Advantage

Publication Date: February 2004


Many veteran HIM professionals remember first hearing about the electronic health record (EHR) in the late 1970s. "They were saying it was just around the corner," remembers Linda Frank, MBA, RHIA, chief operating officer at Servnet, Inc., an Evansville, IN-based healthcare IT consulting compan....

Debate Surrounding Unique Health Identifier Continues

Author: Wheatley, Victoria

Source: Journal of AHIMA

Publication Date: February 2004


Whatever happened to the unique health identifier for individuals (UHI)? The UHI was one of four identifiers included in HIPAA. In July 1998 the Department of Health and Human Services (HHS) and the former Health Care Financing Administration (now the Centers for Medicare and Medicaid Services....

Further Defining e-HIM

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: February 2004


As articulated in “A Vision of the e-HIM Future,” health information in 2010 will be “electronic, patient-centered, comprehensive, longitudinal, accessible, and credible.”1 As we transform from a paper to an electronic health information infrastructure over the next few....

Safe at Home: Remote Coding Meets HIPAA

Author: Keough, Tim

Source: Journal of AHIMA

Publication Date: February 2004


Remote coding offers big benefits and unique security challenges. Here’s how one organization moves patient data securely across the Internet.

"Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought....

Journal Q&A (2/04)

Author: AHIMA Professional Practice Team

Source: AHIMA Q and A

Publication Date: February 02, 2004

Q: Our organization is building an electronic health record. What do we need to consider as we develop a printing policy?
A: As the evolution to the electronic health record will likely include points at which a hybrid, or part-electronic, part-paper, record exists, the printing of all or part....

Health Information Security: Revisiting the 80/20 Rule

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2004


One of the most useful lessons I learned while working in healthcare quality improvement was the Pareto Principle, often referred to as the 80/20 rule. The concept is that in any endeavor, 20 percent of something is always responsible for 80 percent of the results.

This phenomenon i....

Electronic Record, Electronic Security

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: February 2004


New technologies are enhancing the ability to protect patient information. But there’s more to successful implementation than just what’s inside the box.

Melanie Schattauer, RHIA, Jack Obert, and their colleagues at Mercy St. John’s Health System in Springfield, M....

Proof Is in the Policy

Author: Walsh, Tom

Source: Journal of AHIMA

Publication Date: February 2004


Proving security compliance later requires establishing documentation now. HIM professionals have a valuable role to play.

HIM professionals played central roles in their organization’s privacy efforts, ensuring that appropriate policies, procedures, and documents were in plac....

Assessing Privacy Risk in Outsourcing

Author: Davino, Margaret

Source: Journal of AHIMA

Publication Date: March 2004


Healthcare providers can outsource transcription, but they can’t outsource their obligation to safeguard privacy. Here’s how to minimize risk.
Healthcare providers are faced with multiple pressures, many of them financial. The need for management to meet financial constraints....

Validating MDS and OASIS Data with DAVE

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: March 2004


In January 2004 the Center for Medicare and Medicaid Services (CMS) launched a new initiative to improve the accuracy and reliability of Minimum Data Set (MDS) data in long-term care. The Data Assessment and Verification program (DAVE) is a collaborative effort between multiple CMS program ar....

Setting the Right Expectations for the EHR Standard

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: March 2004


The electronic health record (EHR) standard has been receiving widespread attention since the spring of 2003, when the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services asked the Institute of Medicine for guidance on care delivery functions and H....

Study Weights Industry Knowledge of Standards for EHR

Author:

Source: Journal of AHIMA

Publication Date: March 2004


Respondents to a study measuring industry awareness and use of the minimum content recommended in the American Society for Testing and Materials (ASTM) standards for electronic health records (EHR) believe that the minimum data elements outlined in the standards should be included in all system....

EHR: Life after the Draft Standard Is Approved

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: April 2004


In the March 2004 issue of the Journal of AHIMA, this column described how the second version of the EHR functional outline and draft standard currently being developed by the Health Level 7 (HL7) EHR Special Interest Group appeared to be dramatically improved over the first version, which was....

Dictating for Dollars: Is It for You?

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: April 2004


Even with increasingly automated systems, the dictation of discharge summaries in a timely manner is still an issue. Some managers report that physicians are requesting hospitals provide them relief by allowing them to hire nurses, physician assistants, or HIM professionals to dictate the disc....

Getting Information "to the Fingertips"

Author: AHIMA

Source: AHIMA Advantage

Publication Date: April 2004


Stacey Bradley's daughter was playing basketball in Libby, MT, when a teammate injured her hand. The teammate was rushed to the local hospital, where x-rays determined that surgery was required. The closest facility was back in Kalispell, the team's hometown, 90 miles away. When the injured bal....

Data Synch: Aligning US Data Exchange Initiatives

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: May 2004


A number of health information infrastructure, electronic health record (EHR), personal health record (PHR), and health-care data exchange initiatives are happening all around the world. As is common in healthcare, these initiatives are being implemented independently of each other and are in....

On the Line (May 2004)

Author: Dougherty, Michelle

Source: AHIMA Q and A | Journal of AHIMA

Publication Date: May 2004


Q: The October 2003 Journal of AHIMA published an article on cutting and pasting entries into the EHR. Our EHR does not allow entries to be cut and pasted. Is this functionality missing from our EHR?
A: No. The question you raise is not an issue of missing functionality but one of using....

On the Line (June 2004)

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: June 2004


Q: Why shouldn’t we document incidents or incident reports in the patient’s health record? Isn’t it a part of the documentation of the patient’s care? Don’t incident reports become evidence if there is legal action?

A: First, we should define “i....

Primer on Encryption

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: June 2004


Encryption is an addressable implementation specification under HIPAA’s access control and transmission security standards. Many providers are grappling with just how to address these specifications:
Is there a difference between the two specifications, and if so, what is the diff....

Analysis of the Implementation and Impact of Speech-Recognition Technology in the Healthcare Sector

Author: Parente, Ronaldo; Kock, Ned; Sonsini, John

Source: Perspectives in Health Information Management

Publication Date: June 2004



This research was sponsored by a grant from the American Health Information Management Association (AHIMA) Foundation of Research and Education (FORE).
Abstract

This paper develops a conceptual framework and offers research propositions for understanding the adoption of....

HIM Director on Cutting Edge of Electronic Records

Author: Hicks, Jewelle E

Source: Journal of AHIMA

Publication Date: July 2004


As the director of medical records at RML Specialty Hospital in Hinsdale, IL, Donna Hofer, RHIA, is essentially responsible for all the functions of an HIM department. Coding, transcription, release of information, and compliance auditing all fall under Hofer’s jurisdiction. But her org....

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