2929 results.
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How to Help Physicians Accept CDI Programs
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....
Information Governance— Are You On Board?
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....
Data Analytics: It’s Hip to be Square
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....
As Medical Apps Increase, Litigation Issues Continue
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....
Yin and Yang: Data Governance and Information Governance
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....
Information Governance Road Map: Mile Marker 3—Travel to America’s Most Prized Treasures
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....
Copy and Paste Run Amok—EHRs and Malpractice
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....
Release of Information: When to Call a Healthcare Compliance Attorney
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....
Understanding Information in EHR Systems: Paving the Road for Semantic Interoperability through Standards
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....
Pain at the Printer: How To Stop HIM's Addiction To Printing Records From The EHR
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....
Seat at the Table: Testimony to NCVHS
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....
Study Analyzes Causes and Consequences of Patient Overlay Errors
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....
OCR Continues to Define Patient Access Guidelines
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....
On the Yellow Brick Road to IG: part 3
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.....
Solving the Documentation Puzzle with Data Analytics
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....
Primer on Avoiding Sanctions for the Loss of Electronically Stored Information
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....
AHIMA's Comments on CMS' Proposed Patient Relationship Categories and Codes
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
On the Yellow Brick Road to IG: Part 2
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....
Stopping Thieves in Their Tracks: What HIM Professionals can do to Mitigate Medical Identity Theft
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....
Taking Up the Interoperability Mantle
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....
When Doctors and Patients Troll Each Other, PHI Protection Suffers
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....
Health Records All Access Pass
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....
Making the Call for Patient Experience: Using Health IT to Address Gaps in Patient Data-Sharing, Communication, and Interoperability
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....
Solving the Health IT Interoperability Quagmire
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,....
Making HIPAA Work for You: Discussing Record Access (and More) for Consumers
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....
Create a Learning Environment for Information Governance
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....
How Do CDI Programs Impact the Patient
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....
Seventh Character Application for Injuries in the Principal Diagnosis and the Impact to Data Quality
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....
What It Means to Be Deposed
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....
Pokémon Go Poses Privacy and Security Concern for Healthcare Providers
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....
Developing Productivity Standards through Analytics [sponsored article]
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....
HIM Can Propel IG to Where It Needs to Be
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....
Clinical Documentation Improvement Toolkit (2016 version)
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.
SNOMED CT to ICD-10-CM Map
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.
Clinical Terminology and Clinical Classification Systems: A Critique Using AHIMA’s Data Quality Management Model
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....
Mapping Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): Lessons Learned from Applying the National Library of Medicine’s Mappings
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....
Utilizing Open-Source Government Data Sets in Health Information Management Teaching: An Application in Statistics and Data Analytics
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....
CDI: A Cog in the Wheel of Information Governance
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&....
Querying Through the Chaos: How to Get Docs' Attention Amidst the Digital Healthcare Haze
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....
Impact of Clinical Documentation Improvement on the International Stage
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....
Transitioning from Coding to CDI Offers New Career Opportunities
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....
Considerations for Contracting with Cybersecurity Firms
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....
Clinical Documentation for Value-based Reimbursement: Why It Takes a Village to Ensure Success
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....
Cross-walking Health Content Standards Using the ISO/IEC 11179 Metadata Registries Standard
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....
Clinical Validation: The Next Level of CDI
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.
Information Governance Road Map: Mile Marker 2—Updates from the Journey
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....
Reinventing HIM as Enterprise Content Management
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....
Information Release to Patient Families and Caregivers: What Does HITECH/HIPAA Actually Say?
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....
CDI is Expanding as Need for Quality Documentation Grows
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....
IG is Critical for Our World of Growing Health-Related Data
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....
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