123 results.
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Core Health Data Elements: Report of the National Committee on Vital and Health Statistics
Author: National Committee on Vital and Health Statistics (NCVHS)
Source: External web site
Publication Date: August 02, 1996
Data Elements for Emergency Department Systems (DEEDS)
Author: U.S. Centers for Disease Control and Prevention
Source: U.S. Department of Health & Human Services
Publication Date: January 02, 1997
Tools for Defining Data
Author: Shakir, Abdul-Malik
Source: Journal of AHIMA
Publication Date: September 1999
Similarly, data dictionaries, data sets, and data models have much in common, but many significant differences. Each can be used to define data, especially data that needs to get from point A to point B. This article describes each of these tools and the value they add to health information ma....
Update on Standardized Nursing Data Sets and Terminologies
Author: Warren, Judith J.; Bakken, Suzanne
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2002
HIM professionals can learn a lot from the nursing professions development of classification systems, terminology models, and quality indicators. Compared to other healthcare classification systems such as ICD-9-CM or CPT-IV, the nursing systems have not been widely used for reimbursemen....
ISO/TC 215 Medical Informatics
Author: International Standards Organization (ISO)
Source: External web site
Publication Date: January 01, 2003
ANA Recognized Standardizations
Author: American Nurses Association. Committee for Nursing Practice Information Infrastructure (CNPII)
Source: External web site
Publication Date: April 11, 2003
Basic Guide to Standards
Author: National Council for Prescription Drug Programs
Source: External web site
Publication Date: August 02, 2003
Inventory of Health Care Information Standards Pertaining to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-191)
Author: American National Standards Institute. Healthcare Informatics Standards Board
Source: External web site
Publication Date: September 24, 2003
Logical Observation Identifiers Names and Codes (LOINC®)
Author: Regenstrief Institute
Source: External web site
Publication Date: October 06, 2003
Core Data Sets for the Physician Practice Electronic Health Record
Author: AHIMA Task Force
Source: AHIMA Task Force
Publication Date: October 20, 2003
This practice brief has been retired. It is made available for historical purposes only.
Checking the Numbers: Public Reporting of Quality Measures Puts Nursing Homes, HIM Professionals in Spotlight
Author: Slomski, Anita J.
Source: Journal of AHIMA
Publication Date: November 2003
Nursing homes have long been aware of how they stack up to other facilities in terms of clinical quality. Now, with Nursing Home Compare, the public is aware, too. Heres how HIM professionals play a part in getting these data right.
Two years ago, if I had told our CQI team I wante....
DICOM: Digital Imaging and Communications in Medicine
Author:
Source: External web site
Publication Date: January 01, 2004
CEN/TC 251: European Standardization of Health Informatics
Author: CEN/TC 251
Source: External web site
Publication Date: January 02, 2004
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....
Comments to NCVHS on HIPAA Electronic Claims Attachments
Author: Rode, Dan
Source: AHIMA testimony and comments
Publication Date: January 26, 2004
January 26, 2004
Simon Cohn, MD, MPH, FACP
Chairman, NCVHS Subcommittee on Standards and Security, and
National Director for Health Information Policy
Kaiser Permanente Medical Care Program
One Kaiser Plaza
Oakland, California 94612
Re: HIPAA Att....
E-HIM Strategic Initiative: Core Data Sets
Author: AHIMA Work Group on Core Data Sets as Standards for the Electronic Health Record
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2004
This practice brief has been retired. It is made available for historical purposes only.
E-HIM Strategic Initiative: Core Data Sets. Appendix 1: Core Data Sets as Standards for the EHR, Part 2: Healthcare Standards Organizations
Author: AHIMA Work Group on Core Data Sets as Standards for the Electronic Health Record
Source: AHIMA web extra
Publication Date: September 02, 2004
This practice brief appendix has been retired. It is made available for historical purposes only.
CCR Mapped to HL7: an Initial Draft from Preliminary Elements
Author:
Source: AHIMA practice brief attachment
Publication Date: September 2004
This practice brief has been retired. It is made available for historical purposes only.
E-HIM Strategic Initiative: Core Data Sets. Appendix 1: Core Data Sets as Standards for the EHR (pt.1)
Author: AHIMA Work Group on Core Data Sets as Standards for the Electronic Health Record
Source: AHIMA web extra
Publication Date: September 02, 2004
This practice brief appendix has been retired. It is made available for historical purposes only.
Hospital Authority Clinical Vocabulary Table: the Past, the Present, and the Future
Author: Fung, V.; Cheung, N T; Szeto, K; Ngai, L; Lau, M; Kong, J HB
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Abstract
The use of standard clinical vocabulary to support the development of clinical information systems is well established. The ICD-9-CM was adopted locally to form the basis of the Hospital Authority Master Disease Code Table (HAMDCT) and incorporated for use into the Clinical Mana....
Assessment Across the Ages: Implications for the Electronic Health Record
Author: Garvin, Jennifer Hornung
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
Patients across the globe are using traditional and Western (allopathic) medicine to improve health. At the same time, the records of patients are being modified from paper-based documentation to an electronic format. This technical paper places some of the major medical tra....
Clinical Vocabularies: Essential to the Future of Health Information Management
Author: Fenton, Susan H.
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
The field of clinical vocabularies is incredibly dynamic. In this paper you will find topics and research from the past that support the principle of a clinical vocabulary as essential. The presentation at the conference will include the latest information regarding the avai....
Getting Better Data from the MDS: Improving Diagnostic Data Reporting in Long-term Care Facilities
Author: Dougherty, Michelle; Mitchell, Sue
Source: Journal of AHIMA
Publication Date: November 2004
Reporting diagnoses consistently can be a challenge in nursing homes. Analysis of the MDS by AHIMA suggests future improvements, but there are also ways to improve reporting today.
Consider the following scenario: a patient in a long-term care facility has many diagnoses, including one fo....
EHR Development Steps in Long-term Care
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: January 2005
In the past year there has been a whirlwind of activity around the electronic health record (EHR). Hospitals and physician offices are in the forefront of planning for EHR development at the national level. However, long-term care (LTC) is often mentioned as the third area of priority. This ar....
CCR--Not an EHR
Author: Quinsey, Carol Ann
Source: Journal of AHIMA
Publication Date: March 2005
In 2003 the American Society for Testing and Materials (ASTM) kicked off the development of the Continuity of Care Record (CCR) standard, which was finalized in that year and passed by ASTM in April 2004. Sponsorship of the CCR brought together ASTM International, the Massachusetts Medical....
SNOMED CT Helps Drive EHR Success
Author: Giannangelo, Kathy; Berkowitz, Lyle
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2005
With the advent of electronic health record (EHR) systems, IT solutions are needed to ease the recording of standard codes for clinical encounters. The basis for these products is a standard terminology, without which the full benefits of an EHR are unlikely to be realized. One expert notes th....
Introduction to the Unified Medical Language System
Author: Fenton, Susan H.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2005
Coded data is the basis for knowledge transfer in 21st-century healthcare. The Unified Medical Language System (UMLS) is often called the Rosetta stone of international terminologies used in healthcare worldwide.
The purpose of the UMLS is to “facilitate the development of com....
Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems
Author: Bowman, Sue E
Source: AHIMA report | Perspectives in Health Information Management
Publication Date: May 2005
Executive Summary
A standard electronic health record (EHR) and interoperable national health information infrastructure require the use of uniform health information standards, including a common medical language. Data must be collected and maintained in a standardized format, u....
Problem List Coding in e-HIM
Author: Fraser, Greg
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2005
In 1968 Larry Weed, MD, introduced the idea that a complete and accurate problem list is an essential component of the medical record.1 The problem-oriented medical record (POMR), in which all data contained in the medical record can be linked to a list of problems, has been almost universally....
When the Doctor Calls: Opportunities in Ambulatory Care
Author: AHIMA
Source: AHIMA Advantage
Publication Date: August 2005
It wasn't too long ago that physicians could hire a file clerk to handle simple filing tasks and doctors themselves decided how patients could view their records. But today doctors' information needs are much more complex.
Just look at how many credentialed HIM professionals are bringing....
Public Health and E-HIM: How EHRs Can Provide Data to Help Monitor the Population's Health
Author: Fenton, Susan H.
Source: Journal of AHIMA
Publication Date: September 2005
As HIM professionals, we are well aware of the need for public, or population, health data. However, as we now enter the era of electronic health records (EHRs), our e-HIMTM and EHR implementations have not placed much emphasis on public health data. The 2001 anthrax attacks and the SARS outbr....
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....
Structuring Objects, Restructuring Workflow
Author: Flite, Cathy; Foley, Margaret M.; Morton, Lisa; Shams, Kam
Source: AHIMA Convention
Publication Date: October 21, 2005
Introduction
The electronic health record (EHR) will produce change in an organization and specifically produce change to its workflow and staff. With the emergence of the EHR and the complexity of its functionality, the HIM professional will surely have a changing role. Emerging standard....
Long-term Care's IT Agenda: Industry Summit Produces 11 Action Items for Health IT Adoption
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: January 2006
The benefits of health IT are particularly important to long-term care (LTC), yet to date little planning has taken place within or without the LTC community. That is beginning to change. An LTC industry summit last August produced 11 actions items to help shape and coordinate health IT a....
Guidelines for Developing a Data Dictionary
Author: AHIMA e-HIM Work Group on EHR Data Content
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: February 2006
This practice brief has been retired. It is made available for historical purposes only.
Data Standard Time: Data Content Standardization and the HIM Role
Author: AHIMA e-HIM Work Group on EHR Data Content
Source: Journal of AHIMA
Publication Date: February 2006
To efficiently and accurately share clinical information, EHRs must be interoperable—the IT systems and software applications used by various facilities and made by different vendors must be able to communicate so that usable data can be exchanged accurately, effectively, and consistentl....
Look at LOINC: The Established Standard for Lab Data Gains Visibility as Data Exchange Increases
Author: Stark, Marilyn
Source: Journal of AHIMA
Publication Date: July 2006
Advanced health data exchange requires that organizations agree on how to transmit and label the data they share. Organizations need standards for transmitting messages, and then they need standards for identifying the data inside them.
One set of content standards is well ahead....
Key Points of the UB-04
Author: AHIMA Clinical Terminology and Classification Practice Council; Garrett, Gail S.; Johnson, Laurine; Johnson, Kathy M
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: October 2006
This practice brief has been retired. It is made available for historical purposes only.
Privacy and Confidentiality by Design: Fundamental Design Principles for Health IT
Author: Mon, Donald T.
Source: Journal of AHIMA
Publication Date: November 2006
Virtually every stakeholder group-consumers, providers, payers, vendors, and HIM and IT professionals alike-is well aware of the importance of protecting the privacy and confidentiality of health information. Not everyone, however, is well acquainted with the actual guidelines, principles,....
Baby Steps: Industry Helps Data Content Standards Find Their Footing
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: January 2007
An improved healthcare system depends not only on wiring it up but also ensuring that data are usable for evidence-based clinical practice, to empower consumers, and to improve the health of the population. Progress is being made on data transmission standards; however, similar progress is need....
Unwrapping Data Standards
Author: Rollins, Gina
Source: Journal of AHIMA
Publication Date: January 2007
Data content standards affect a wide range of day-to-day HIM work. Here’s what you need to know.
They may sound like they belong up in the IT stratosphere, but data content standards-or the lack of them-affect a wide range of day-to-day HIM work right here on....
Language Barrier: Getting Past the Classifications and Terminologies Roadblock
Author: Campbell, Keith E.; Giannangelo, Kathy
Source: Journal of AHIMA
Publication Date: February 2007
Health IT is bogged down in a quagmire of unaligned classification and terminology systems. New recommendations from AHIMA and AMIA help point to the way out.
The healthcare industry is looking to IT to reduce costs, assess quality of care, and deliver services more effici....
Unraveling the Data Set, an e-HIM Essential
Author: Giannangelo, Kathy
Source: Journal of AHIMA
Publication Date: February 2007
There is a great deal of talk about healthcare data and its potential uses once providers have implemented an EHR system. Without question, an EHR will collect more data in terms of volume. It will also, through standard clinical terminologies, capture a more granular level of detail. Th....
What Mapping and Modeling Mean to the HIM Professional
Author: Wilson, Patricia S
Source: Perspectives in Health Information Management
Publication Date: March 2007
It's Official: HL7's EHR Model Becomes Approved Standard
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: May 2007
For the past three years, we have been hearing about the development and progress of the Health Level Seven (HL7) electronic health record (EHR) system functional model. As it went through various drafts, HL7’s EHR technical committee gathered feedback from a broad group of stakeholders throug....
Taking the Measure of Inpatient EHRs: Hospitals Inch Closer to Certified Products
Author: Metzger, Jane; Welebob, Emily; Del Beccaro, Mark; Spurr, Cindy
Source: Journal of AHIMA
Publication Date: May 2007
Certification of inpatient EHR products begins this year with an initial focus on orders and medication management.
Increasing the adoption of health IT such as electronic health records (EHRs) has been a major focus of improving healthcare quality and efficiency ever since the Inst....
Portrait of a Legal EHR: Developing a Legal EHR Conformance Profile
Author: Dougherty, Michelle; Rhodes, Harry B.; O'Neill, Megan
Source: Journal of AHIMA
Publication Date: June 2007
Paper legal documents have certain characteristics. They are signed in ink and dated, and they often are a specific size and certain quality or weight of paper. Legal business records are even processed and handled in a certain, unique manner.
Now, since the spread of electronic heal....
Data Content for EHR Documentation
Author: Kallem, Crystal; Burrington-Brown, Jill; Dinh, Angela K.
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2007
This practice brief has been retired. It is made available for historical purposes only.
Revisions to HIPAA Transaction Standards Urgently Needed
Author: National Committee on Vital and Health Statistics (NCVHS)
Source: Government (U.S.)
Publication Date: September 26, 2007
This letter to the Secretary of HHS summarizes the July 2007 NCVHS hearings on the proposed new versions of the HIPAA transaction standards, and makes recommendations.
HITSP Security and Privacy Technical Note
Author: HITSP Security and Privacy Technical Committee
Source: External - used with permission
Publication Date: October 15, 2007
Data Content Standards: Part and Parcel of Data Integrity Management
Author: AHIMA
Source: AHIMA Advantage
Publication Date: March 2008
Getting to Know e-HIM Coding Systems: Settings and Disciplines Offer Myriad of Documentation Systems for EHR Use
Author: Scichilone, Rita A
Source: Journal of AHIMA
Publication Date: March 2008
Electronic health record (EHR) systems require encoded data to function, even if the “codes” captured are the words on this page or ASCII text on a computer screen. Today healthcare professionals of all disciplines work with electronic tools. Patient care systems have evolved just....
Developing Emergency Access Standards for EHR Systems: The HL7 Standards Development Process Helps (and Empowers) HIM Processes
Author: Gelzer, Reed D.
Source: Journal of AHIMA
Publication Date: May 2008
Many activities are under way to standardize electronic health records (EHR) systems. Among them are Health Level Seven’s technical committees and special interest groups.
HL7 is an international standards development organization accredited by the American National Standards I....
Standards Development and HIM: HL7’s IT Standards Work and Its Uses in Health Information Management
Author: Edwards, Wannetta
Source: Journal of AHIMA
Publication Date: July 2008
Health Level Seven (HL7) is an American National Standards Institute-accredited standards developing agency that specializes in developing healthcare standards. Its vision is to “create the best and most widely used standards in healthcare.”
For HIM professionals, underst....
OASIS for Access Management: Emerging Standards Offer Healthcare Help with Security
Author: Lockhart, Hal
Source: Journal of AHIMA
Publication Date: March 2009
Technology standards not only facilitate the exchange of electronic health information, they also provide for its security and confidentiality by promoting mechanisms that have been reviewed by experts. If electronic data exchange cannot ensure privacy and security, it will never realize its p....
Health IT Certification Developments: CCHIT’s Current Work and How to Get Involved
Author: Birnbaum, Cassi L; Hall, Terri; Sweet, Helayne; Wiedemann, Lou Ann
Source: Journal of AHIMA
Publication Date: March 2009
For the last five years the Certification Commission for Healthcare Information Technology (CCHIT) has been working to promote the adoption of health IT by certifying electronic health record (EHR) products against common, baseline criteria.
The private, nonprofit certification body....
Advancing Data Standards: A Prerequisite for the Full Value of Health IT
Author: Kloss, Linda L
Source: Journal of AHIMA
Publication Date: April 2009
The integrity of clinical and administrative data is a core concern in managing health information—data must be accurate, complete, useable, and available where and when needed. However, we are a long way from knowing how to achieve all of these dimensions in electronic health records, h....
Healthcare Standards Development: The Value of Nurturing Collaboration
Author: Hammond, William Edward; Jaffe, Charles; Kush, Rebecca Daniels
Source: Journal of AHIMA
Publication Date: July 2009
Two standards developing organizations—CDISC and HL7—demonstrate that collaboration, while challenging, delivers benefits to standards developers, end users, and ultimately patients.
Technical standards are essential to improving healthcare. For health IT to reduce medic....
The Standards Value Chain: Where Health IT Standards Come From
Author: Marshall, Glen F
Source: Journal of AHIMA
Publication Date: October 2009
The Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act contains clear requirements for actively using healthcare IT standards. But where do standards come from? And how can IT implementers and users contribute to the st....
Streamlining Quality Measures Reporting: NQF Health IT Division Aims to Simplify Quality Measures Reporting from EHRs
Author: Dimick, Chris
Source: Journal of AHIMA
Publication Date: February 2010
In 2008 The National Quality Forum (NQF) created a health IT division that, in part, hopes to simplify what it takes to abstract quality measurement data from electronic health records. HIM professionals are among those serving on the workgroups.
The division was developed in respons....
Model EHR: Status and Next Steps for an International Standard on EHR System Requirements
Author: Mon, Donald T.
Source: Journal of AHIMA
Publication Date: March 2010
Six years in the making, the HL7 EHR System Functional Model is now a worldwide standard.
Work on the next version’s wish list is already under way.
In November 2009 the International Organization for Standardization and Health Level Seven International (HL7....
SNOMED at the Point of Service: The Challenges and Opportunities of SNOMED-Encoded Data
Author: Dolin, Robert H
Source: Journal of AHIMA
Publication Date: March 2010
SNOMED CT is a comprehensive clinical healthcare terminology developed in part for use within electronic health records (EHRs) to enable a more complete record of care. According to the International Health Terminology Standards Development Organisation (IHTSDO), the organization responsible f....
Enabling EHR Use in Clinical Research
Author: Seidl, Patricia
Source: Journal of AHIMA
Publication Date: April 2010
Health information collected in electronic health records (EHRs) can support a variety of initiatives, including clinical research. However, technical standards are needed to enable EHRs to communicate with clinical research applications.
Work from the American National Standards In....
Key Points of the UB-04 (2010 update)
Author: AHIMA Clinical Terminology and Classification Practice Council; Garrett, Gail S.; Jorwic, Therese M; Novak, Natalie; Ruhnau-Gee, Becky; Safian, Shelly C; Zeisset, Ann M.
Source: AHIMA practice brief
Publication Date: April 2010
Editor’s note: This update replaces the October 2006 practice brief “Key Points of the UB-04.”
In 2005 the National Uniform Billing Committee (NUBC) approved the Uniform Bill (UB-04) paper claim and data set as the replacement to the UB-92 paper form.1 Currently, all paper claims must....
Primer on MDS 3.0: An Overview of MDS 3.0 for the October 1 Transition
Author: Anderson, Rhonda L.
Source: Journal of AHIMA
Publication Date: July 2010
Long-term care skilled nursing facilities must transition to the new Minimum Data Set (MDS) 3.0 by October 1, 2010. MDS 3.0 changes the assessment focus, using the resident’s voice to more thoroughly assess residents and link to the care plan that meets the resident’s needs. This change requir....
The Problem List beyond Meaningful Use: Part I: The Problems with Problem Lists
Author: Holmes, Casey
Source: Journal of AHIMA
Publication Date: February 2011
The meaningful use program requires that problem lists in the EHR use a common dictionary through coding. It is a good first step in boosting the usefulness of problem lists, but getting to the next level will be a harder challenge-agreeing on standardized content and use.
Last mont....
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....
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....
Managing a Data Dictionary - Retired
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: January 2012
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
Problem-Centered Care Delivery: How Interface Terminology Makes Standardized Health Information Possible
Author: Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank; Rose, Eric; Aldin, Greg
Source: Journal of AHIMA
Publication Date: July 2012
Terminologies ensure that the 'languages of medicine' can be understood by both humans and machines.
Electronic health records (EHRs) are the industry standard for documenting patient care. Industry initiatives and government legislation have facilitated EHR i....
AHIMA Letter to Secretary Sebelius and Attorney General Holder Concerning EM Coding in EHRs
Author: Gordon, Lynne Thomas
Source: AHIMA testimony and comments
Publication Date: September 26, 2012
SNOMED CT Integral Part of Quality EHR Documentation
Author: Kostick, Karen M.
Source: Journal of AHIMA - Coding Notes
Publication Date: October 2012
The use of many distinct standardized clinical vocabulary terminologies and classifications is integral to the development of a nationwide health IT infrastructure that allows for electronic use and exchange of health information. SNOMED CT is one of the key clinical terminologies designated f....
Problem Lists in Health Records: Ownership, Standardization, and Accountability
Author: AHIMA HIE Practice Council
Source: AHIMA report
Publication Date: December 09, 2012
Connect the Dots: Linking Together the Nation’s Disparate and Growing Health Information Exchanges has become a Formidable Challenge
Author: Romeo, Jim
Source: Journal of AHIMA
Publication Date: March 2013
Establishing a health information exchange (HIE) and building an infrastructure to support it internally and externally is a daunting task. Whether funded by federal and state grants or launched as a private sector initiative, launching a HIE often means blazing new territory and making de....
Reading Up on LOINC: What Coders Need to Know
Author: Sheide, Amy; Wilson, Patricia S
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2013
What do coders need to know about Logical Observation Identifiers Names and Codes (LOINC)? A health records coder is unlikely to come across a LOINC code when looking for the correct ICD-9-CM code to reflect the documentation provided. A compliance officer may not see a LOINC code when eva....
The Often Mismatched Shoes of Healthcare: SNOMED vs. ICD-10-CM/PCS
Author: Mills, Ronald E
Source: Journal of AHIMA
Publication Date: November 2013
The healthcare industry has spent millions of dollars implementing electronic health records (EHRs). Most EHR systems use concept dictionaries like SNOMED or a similar system for internally representing medical information. With the ICD-10-CM/PCS implementation making headlines, people hav....
New Name of the HIM Game
Author: Abrams, Kelly; Giannangelo, Kathy; Schneider, Sue; Scichilone, Rita A
Source: Journal of AHIMA
Publication Date: February 2014
Terminology asset management roles are emerging for HIM due to the EHR, but some key competencies are necessary to land the job.
Health IT Standards Committee Takes On Patient-Generated Health Data
Author: AHIMA Advocacy and Policy Team
Source: Journal of AHIMA
Publication Date: March 2014
Efforts from the Office of the National Coordinator for Health IT (ONC) in the area of patient-generated health data began in 2011. With mobile health on the rise and the “meaningful use” EHR Incentive Program progressing throughout the US healthcare system, these efforts continue to grow in importance to the future of healthcare and health information.
Optimizing Data Representation Through the Use of SNOMED CT
Author: Bronnert, June; Daube, Julie L; Jopp, Gretchen; Peterson, Kathleen; Rihanek, Theresa; Scichilone, Rita A; Tucker, Vanna
Source: Journal of AHIMA
Publication Date: March 2014
Electronic health records (EHR) have changed the landscape for data representation. For many years health information management (HIM) professionals have relied on classifications for data representation and the support of clinical documentation. SNOMED CT is a data standard frequently used in electronic systems and has been included in the requirements for the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR Incentive Program. SNOMED CT is maintained and distributed by the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED CT is recognized throughout the world, and the terminology is available at no cost. The National Library of Medicine (NLM) serves as the US release center and the IHTSDO member country representative.
Protecting High-Stakes PHI: DS4P Healthcare Standards Enhance the Privacy of Sensitive Data
Author: Coleman, Johnathan
Source: Journal of AHIMA
Publication Date: April 2014
Sensitive health information is not a rarity in the United States by any means, according to a recent Issue Brief published by the Office of the National Coordinator for Health IT (ONC).1 In the brief, ONC estimated 26 percent of Americans age 18 and older are living with a mental health d....
AHIMA Helping Set the Standards for Health IT
Author: AHIMA Advocacy and Policy Team
Source: Journal of AHIMA
Publication Date: June 2014
Standards development for health IT and healthcare has become an increasingly important part of AHIMA’s work over the last several years. Now, through the association’s recent work with both national and international standards groups, AHIMA staff and members are playing a deciding role i....
Using the C-CDA Standard to Meet Meaningful Use
Author: Campbell, Robert James
Source: Journal of AHIMA
Publication Date: July 2014
The Centers for Disease Control and Prevention reported that in 2010, 35 million patients were discharged from non-federal short-stay hospitals in America.1 Vitally important not only to those discharges—but to every discharge that takes place—is whether important information about the pa....
High Time for Information Governance, Standards, and Streamlined Certification
Author: AHIMA Advocacy and Policy Team
Source: Journal of AHIMA
Publication Date: July 2014
As healthcare organizations implement electronic health records (EHRs), and as new care delivery and financing mechanisms such as accountable care organizations proliferate, there are increasing demands for the accountability, reliability, and security of data and information. It has beco....
Accessing and Using Data from Wearable Fitness Devices
Author: Rhodes, Harry B.
Source: Journal of AHIMA
Publication Date: September 2014
A rapidly aging global population in many industrialized countries accompanied by an increase in chronic diseases and the high cost of managing such diseases has led many to turn to a technological solution to ease the burden on healthcare professionals and provide useful tools to the elde....
Driving Standards Toward Interoperability with PHR Functionality
Author: Osborne, Kim
Source: Journal of AHIMA
Publication Date: October 2014
Healthcare is poised to experience true interoperability when it can exchange personal health information via electronic health record (EHR) systems, insurance claims systems, and other health information exchanges with personal health records (PHRs). A comprehensive PHR will help individ....
What’s the Difference? SNOMED CT and ICD Systems are Suited for Different Purposes
Author: Stearns, Mike; Fuller, Jan C.
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: November 2014
The International Classification of Diseases (ICD) and SNOMED CT are similar in that both systems have alphanumeric codes associated with clinical concepts. But the systems differ in their purpose and structure, and are best used in different ways in healthcare. For starters, ICD is a cla....
ONC Takes Action: Health Information Systems Interoperablity to Support Learning Health System
Author: Orlova, Anna; Warner, Diana
Source: Journal of AHIMA - website
Publication Date: February 2015
In the effort to advance secure and interoperable health information exchanges, the US Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) has released Connecting Health and Care for the Nation: A Shared Nationwide Intero....
Overview of Health IT Standards
Author: Orlova, Anna
Source: Journal of AHIMA
Publication Date: March 2015
Health IT Standardization is the process of agreeing on standards that allow electronic exchange of data, information, and knowledge between disparate data systems. The goals of standardization are to achieve comparability, compatibility, and interoperability between independent systems; t....
Blue Button Project: Engaging Patients in Healthcare by a Click of a Button
Author: Mohsen, Mona Omar ; Aziz, Hassan A
Source: Perspectives in Health Information Management
Publication Date: April 2015
Abstract
The Blue Button project has become a way for many Americans to download their health records by just a click in any way that suits them, such as in print, on a thumb drive, or on their mobile devices and smartphones. Several organizations have developed and applied Blue B....
Standardization of Standards
Author: Orlova, Anna
Source: Journal of AHIMA
Publication Date: May 2015
In 1898 Yale University graduate Charles Dudley, PhD, looked for a solution to the seemingly intractable problem of building a consensus on standards for industrial materials used on the Pennsylvania Railroad. To sooth the antagonistic attitudes that marred relationships between the Penns....
Health IT Standards for Health Information Management Practices
Author: Integrating the Healthcare Enterprise (IHE)
Source: External healthcare industry report
Publication Date: September 18, 2015
Integrating the Healthcare Enterprise HIT Standards for HIM Practices revision 1.1
Four Applications of C-CDA to Consider: The Case for Why C-CDA is Needed to Advance Shared Savings and Interoperability
Author: Bonney, Steven
Source: Journal of AHIMA
Publication Date: November 2015
In an ideal world, the following scenario wouldn’t be uncommon: You’re attending a conference in another state and suddenly find yourself experiencing shortness of breath and chest pain. After having flown for several hours on a plane, you worry that it could be a blood clot. Y....
Reformatting Healthcare through Standards: AHIMA Building a Standards Strategy to Improve Interoperability and Healthcare
Author: Butler, Mary
Source: Journal of AHIMA
Publication Date: November 2015
Since the turn of the century, Hollywood has provided Americans with a reliable form of escapism that allows individuals to enter darkened theaters and feel as if they are being transported to a different world.
Over time, the movie-going experience has remained remarkably....
Building Interoperability Standards and Ensuring Patient Safety
Author: Glickman, Michael; Orlova, Anna
Source: Journal of AHIMA
Publication Date: November 2015
Anyone who has ever developed a standard knows well the many challenges that must be surmounted. Once a standard is published, however, it’s not the end but in many respects only the beginning. Moving standards from specification to practice requires an equivalent if not greater effo....
Standards Activities Respond to Consumer Mobile Health IT Trends
Author: Rhodes, Harry B.
Source: Journal of AHIMA
Publication Date: January 2016
All of the current excitement about the potential of mobile technologies and patient engagement opportunities comes at a time when many providers are frustrated about their electronic health record (EHR) systems. Struggling against poor EHR system usability, a lack of interoperability, and....
Peddling Out of the HIE Peloton: Some Mass HIway Providers Pulling Away from the Pack and Using HIE for True Care Coordination
Author: Belanger, Mark
Source: Journal of AHIMA
Publication Date: March 2016
The world of health information exchange remains busy in Massachusetts as the Mass HIway, the statewide health information exchange (HIE), enters its fourth year of rolling out Direct messaging statewide. Overall, Mass HIway officials feel things are going very well, with more than 580 or....
Managing PHI Content Standards
Author: Sawatsky, Elaine; Warner, Diana
Source: Journal of AHIMA
Publication Date: April 2016
Interoperability standards and their continuing adoption by e-health programs expand the capacity of information systems to capture, use, and exchange clinical data. For exchange to occur, the majority of data processing decisions need to take place both computationally and automatically.....
Three Keys to Simplifying Interoperability in Healthcare [sponsored article]
Author: INTERFACEWARE
Source: Journal of AHIMA - website
Publication Date: April 15, 2016
There’s no question that healthcare is in the middle of a data explosion. New sources of information like medical devices, wearables, and mobile apps are being introduced all the time.
While more information can do wonders for clinical decision making and improving operationa....
Role of Standards in IG
Author: Warner, Diana
Source: AHIMA blog post | Journal of AHIMA - website
Publication Date: May 13, 2016
The use of health information technology (HIT) in the clinical setting brings both opportunities and challenges for health information management (HIM) professionals regarding data capture and exchange; data storage, use and reuse; record ownership and access; e-discovery and e-forens....
Semantic Content in EHR Systems
Author: Bhattacharyya, S. B; Warner, Diana
Source: Journal of AHIMA
Publication Date: June 2016
An electronic health record (EHR) can greatly help the timely delivery of efficient healthcare if the information it contains is adequate, accurate, and accessible in a timely manner. An EHR is a longitudinal record of an individual’s health journey made up of electronic documents from va....
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