Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 28, 2016

Have you ever gone to a staff meeting only to hear the news that a process you’ve been following for years is about to change? How does that make you feel? Maybe you love change and welcome any opportunity to improve a process. But maybe you are a creature of habit and the thought of a cha....

Author: Meehan, Ann M.

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 23, 2016

If you are reading this blog you are curious about information governance (IG), learning about IG, or on board with IG. Our goal is to get all members of AHIMA on board with IG.


Let’s start with a definition of IG. AHIMA defines information governance as an organization....

Author: Wiedemann, Lou Ann

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 21, 2016

Big data. Data explosion. Predictive analytics. Population health. Data management. Chronic disease monitoring. Natural language processing. As though healthcare was not struggling enough to keep up with acronyms, synonyms, abbreviations, and poorly defined buzzwords, we have entered the e....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 20, 2016

In my last post of 2015 I tried to predict what types of challenges health information management (HIM) professionals might have to deal with in 2016 and beyond. One prediction involved technological innovation, as I surmised that we could “expect to see more and more ‘apps’ being off....

Author: Washington, Lydia

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 08, 2016

As we talk with healthcare organizations around the country about information governance (IG), many tell us they have embarked on a data governance (DG) program. Most of these data governance programs seem to be emanating from the IT area and are driven by the need to improve data quality....

Author: Reeves, Mary G

Source: Journal of AHIMA

Publication Date: September 2016

Editor’s Note: This article is the sixth in a series that provides a road map for implementing an information governance (IG) program in any organization. Each month a set of concepts will be discussed that tie to the IG Road Map Infographic developed by AHIMA. Any organization can t....

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: September 2016

As if physicians needed another reason to be wary of electronic health records (EHRs), a new study finds that malpractice claims related to EHR use have risen in accordance with increased EHR adoption.


The study, which was conducted by The Doctors Company, a malpractice insurance....

Author: Herrin, Barry S.

Source: Journal of AHIMA

Publication Date: September 2016

The HIPAA-HITECH modifications to the Privacy and Security Rules have made the management of the release of information function even more complex for providers. Add in state law and other protections, and it can be difficult for health information management (HIM) professionals to know ju....

Author: Orlova, Anna; Salyards, Kenneth

Source: Journal of AHIMA

Publication Date: September 2016

Today, both clinicians and health information management (HIM) professionals have been experiencing overwhelming challenges with the usability of electronic health record (EHR) systems due to shortcomings in supporting user needs.1,2,3,4 A five-year study recently published by the US Nati....

Author: Carey, Susan; Beahan, Sally

Source: Journal of AHIMA

Publication Date: September 2016

Historically, health information management (HIM) staff has provided paper copies of medical records in response to authorized requests. No specialty patient education was needed because the paper record was essentially self-explanatory.


But with the ongoing industry trans....

Author: Martin, Melissa

Source: Journal of AHIMA

Publication Date: September 2016

Back in June I had the opportunity to represent both AHIMA members and the HIM profession while testifying at a National Committee on Vital and Health Statistics (NCVHS) hearing on the need for a better definition of the minimum necessary standards. I would like to share with you some hig....

Author: Landsbach, Grant

Source: Journal of AHIMA

Publication Date: September 2016

For years, many in the health information management (HIM) industry have been aware of the dangerous patient misidentification problem known as an “overlay.”


This situation occurs when the incorrect patient is registered/admitted/documented on another patient&rsq....

Author: Bowen, Rita K.; Hofman, Judi; Lucci, Susan; McLendon, Kelly

Source: Journal of AHIMA

Publication Date: September 2016

The Office for Civil Rights (OCR) has made it abundantly clear through numerous communications that providing individuals easy access to their own health information is one of OCR’s most important mandates. Giving patients and their personal representatives access to their own information....

Author: Goodell, Suzanne

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 24, 2016

In early 2016, Suzanne Goodell, co-chair of AHIMA’s Information Governance Practice Council and director of meaningful use in a large regional health system, invited our blog readers to accompany her on her IG Journey. This is the third blog post describing how the journey is going.....

Author: Monga, Kapila

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 17, 2016

“It’s a beautiful day to save lives. Let’s have some fun,” so says Dr. Derek Shepherd (of “Grey’s Anatomy” fame) and with a smile on his face, gets on with his day’s activities—to help patients heal. I haven’t seen many doctors work, except in “Grey’s Anatomy,” but I have interacted w....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 16, 2016

Several of my posts have addressed sanctions for the loss of electronically stored information (ESI) through AHIMA’s Information Governance Principles for Health CareTM (IGPHC). I have also referred on several occasions to the December 1, 2015 amendments to the Federal Rules of Civil....

Author: AHIMA Advocacy and Policy Team; Gordon, Lynne Thomas

Source: AHIMA testimony and comments

Publication Date: August 15, 2016

Comments to Andy Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services

Author: Goodell, Suzanne

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: August 11, 2016

In early 2016, Suzanne Goodell, co-chair of AHIMA’s Information Governance Practice Council and director of meaningful use in a large regional health system, invited our blog readers to accompany her on her IG journey. At that time, she stated, “I feel like I am Dorothy taking the f....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: August 2016

The clues are subtle but critical: Perhaps you get a bill for urgent care services you never received. Or upon reviewing your medical record through a patient portal, you see a diagnosis of back pain and multiple prescriptions for narcotic pain relievers.


Though not definiti....

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: August 2016

In May the Office of the National Coordinator for Health IT (ONC) released a Data Brief describing the state of interoperability among non-federal acute care hospitals in 2015.1 The report looks specifically at four “domains” of interoperability: the ability for health systems....

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: August 2016

A lot of good things are happening in healthcare in the name of transparency. Rating systems, usually in the form of a designated number of stars, are now being assigned by the public to hospitals, physicians, and nursing homes. And it’s become easier for consumers to comparison shop when they....

Author: Payne, Thomas H.; Beahan, Sally; Fellner, Jane; Martin, Dan; Elmore, Joann G

Source: Journal of AHIMA

Publication Date: August 2016

Patient Portals that allow viewing of clinical notes and hospital discharge summaries: the University of Washington OpenNotes implementation experience




Many healthcare organizations are striving to improve patient engagement by facilitating patient access to clin....

Author: Labow, Kim

Source: Journal of AHIMA

Publication Date: August 2016

Interoperability and integration within the health IT landscape remain high priorities for providers, patients, and technology firms. Interoperability in health IT holds the promise of more satisfied patients, providers, and health information management (HIM) professionals. But approachi....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: August 2016

As the sun begins to set on the Obama administration, Vice President Joe Biden has been leveraging the weight of his office to speak out on the health IT interoperability quagmire in which the nation currently finds itself. During a speech at the industry’s Health Datapalooza in May,....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: August 01, 2016

The US Department of Health and Human Services (HHS) has taken many steps to try and clear up consumer confusion regarding the more consumer-centric aspects of HIPAA’s Privacy Rule and Security Rule. The most recent efforts include the Office of the National Coordinator’s Patien....

Author: Reeves, Mary G

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 28, 2016

To get information governance (IG) off the ground, there must be a leader who is willing to step up and make the case for IG by clearly identifying its benefits—the IG Value Proposition. As a first step in building the value proposition, leaders can create an IG learning environment w....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 27, 2016

We talk a lot about the impact of clinical documentation improvement (CDI) on healthcare organizations and physicians. We look at ways to reflect appropriate reimbursement and accurate quality scores, both of which are very important. But do we take the time to look at the true extent of t....

Author: Wall, Kathleen E.

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 25, 2016

By now, we’ve all had practice assigning 7th characters for injuries. And, by now, we all know that in theory the guidance seems very clear—but the application of this new concept is not clear at all. Why is there so much confusion and why does it matter? What are the short- and long-term....

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 22, 2016

In this blog I talk about legal consequences. I usually provide current examples of what those consequences might be under a specific set of facts. Here, instead, I want to highlight a litigation-related event that readers might experience in the future—or perhaps already have: a depo....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 21, 2016

The mobile app game that has thousand of players roaming streets, parks, and even workplaces—healthcare providers included—has health privacy experts concerned.


Pokémon Go is a smartphone app that uses a phone’s GPS and camera to help players search for virtual chara....

Author: Pitsikoulis, John; Doty, Laura

Source: Journal of AHIMA - website

Publication Date: July 15, 2016

“Productivity” is defined as the effectiveness of productive effort, measured in terms of the rate of output per unit of input, easily defined and applicable in many manufacturing scenarios. For the line worker in a manufacturing plant, output is basically the number of widgets or com....

Author: Seargeant, Lori

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 14, 2016

The more I learn, the more I realize how much I do not know.

-Einstein



Information governance (IG) is a growing discipline in many industries, yet we are finding it just taking hold in healthcare with the robust momentum it merits. Recognizing the many comp....

Author: Arrowood, Danita; Bailey-Woods, Linda; Barnette, Erin; Combs, Tammy; Endicott, Melanie; Miller, Jennifer

Source: AHIMA toolkit

Publication Date: July 2016

This toolkit provides many of the necessary tools and documents needed for implementing and/or maintaining a robust CDI program.

Author: National Library of Medicine

Source: Government (U.S.)

Publication Date: July 2016

The purpose of the SNOMED CT to ICD-10-CM map is to support semi-automated generation of ICD-10-CM codes from clinical data encoded in SNOMED CT for reimbursement and statistical purposes.

Author: Alakrawi, Zahraa M

Source: Perspectives in Health Information Management

Publication Date: July 2016

Abstract


Clinical coding constitutes one of the fundamental functions in the field of health information management. Clinical classification systems and clinical terminologies represent two distinct sets of coding schemes that are used in healthcare. In this context, it is critica....

Author: Nandigam, Hari; Topaz, Maxim

Source: Perspectives in Health Information Management

Publication Date: July 2016

Abstract


The Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) are two commonly used standardized health terminologies in the United States. In fall 2015, healt....

Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Aborde, Jon; Johnson, Carey; Johnson, Timothy

Source: Educational Perspectives in Health Informatics and Information Management

Publication Date: July 2016

Abstract


The American Health Information Management Association (AHIMA) Council for Excellence in Education acknowledges the importance of improving the data analytics skills of health information management (HIM) students at the baccalaureate level. This importance is especially....

Author: Downing, Katherine

Source: Journal of AHIMA

Publication Date: July 2016

Information governance (IG) is an emerging discipline in healthcare that focuses on how an organization ensures information is complete, accurate, trustworthy, and usable. The goal of information governance is to enable organizations to utilize a valuable strategic asset—information&....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2016

It wasn’t that long ago that online dating—and resultant marriages—carried a stigma. There was a sharp divide between the people who believed in meeting their loves the old fashioned way, and those who felt that online dating was a natural extension of their already Internet-centric profe....

Author: Combs, Tammy

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2016

Illness doesn’t care what country or region a person lives in, and it doesn’t care the race or origin of a person. Since illness is found everywhere around the globe it only stands to reason that providers should also look beyond the boundaries of one country or patient population when re....

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2016

The clinical documentation improvement (CDI) profession is flourishing as more organizations see the wide range of benefits a robust CDI program has to offer. The benefits of a CDI program include complete and accurate clinical documentation that supports correct reimbursement, proper repo....

Author: Glondys, Barbara

Source: Journal of AHIMA

Publication Date: July 2016

On March 28, 2016, the information systems at 10 MedStar Health hospital locations were attacked by a virus that prevented certain users from logging in to the organization’s information systems. The organization immediately moved to back-up systems using paper transactions. All facilitie....

Author: Fee, James P; Clesi, Wendy

Source: Journal of AHIMA

Publication Date: July 2016

Like it or not, the transition to value-based healthcare is well underway. In January 2015, the Department of Health and Human Services (HHS) announced its Better, Smarter, Healthier campaign with clear goals and a timeline for shifting Medicare reimbursement from volume to value. Through....

Author: Warzel, Denise B; Reeves, Dianne M

Source: Journal of AHIMA

Publication Date: July 2016

Key challenges in clinical and translational biomedical research and personalized medicine include the need to integrate multidisciplinary, heterogeneous data sets. This requires both reusable data elements and content standards that unambiguously describe data within and across diverse da....

Author: Denton, Debra Beisel; Endicott, Melanie; Ericson, Cheryl E; Love, Tammy R.; McDonald, Lori; Willis, Daphne

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2016

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Meehan, Ann M.

Source: Journal of AHIMA

Publication Date: July 2016

Editor’s Note: This article is the fifth in a series that provides a road map for implementing an information governance (IG) program in any organization. Each month a set of concepts will be discussed that tie to the IG Road Map Infographic developed by AHIMA. Any organization can t....

Author: McCann, Linda F; Henciak, William A; Durand, Elizabeth

Source: Journal of AHIMA

Publication Date: July 2016

The University of Maryland Baltimore Washington Medical Center (UM BWMC) installed a new electronic health record (EHR) approximately three and a half years ago. As a result, significant challenges were experienced throughout the organization, but especially in the health information manag....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 01, 2016

One of the most important objectives of the HIPAA Privacy Rule—and the HITECH Act in particular—was to ensure that consumers have easy and affordable access to their own protected health information. The regulations also clarified how and when medical information about a patien....

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 23, 2016

Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as healthcare doesn’t stop when a patient is discharged, health problems begin....

Author: Meehan, Ann M.

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 23, 2016

In this world of growing health-related data, information governance is not only needed but is crucial to ensure that healthcare organizations can quickly and efficiently manage the data being produced, resulting in information being used effectively for patient care. The latest numbers on....