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.

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.

Author: AHIMA

Source: AHIMA Advantage

Publication Date: March 2008

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....

Author: AHIMA

Source: AHIMA

Publication Date: 2017

Author: AHIMA

Source: AHIMA

Publication Date: 2017

Author: AHIMA

Source: AHIMA

Publication Date: 2017

Author: AHIMA

Source: AHIMA

Publication Date: 2017

Author: AHIMA

Source: AHIMA

Publication Date: 2017

Author: AHIMA

Source: AHIMA

Publication Date: 2017

Author: AHIMA

Source: AHIMA

Publication Date: 2017

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....

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....

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.

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.

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....

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....

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.

Author: AHIMA HIE Practice Council

Source: AHIMA report

Publication Date: December 09, 2012

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.

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....

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.

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.

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.

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: American National Standards Institute. Healthcare Informatics Standards Board

Source: External web site

Publication Date: September 24, 2003

Author: American Nurses Association. Committee for Nursing Practice Information Infrastructure (CNPII)

Source: External web site

Publication Date: April 11, 2003

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....

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....

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....

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....

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....

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....

Author: BRG HIM and Healthcare Technology Staff

Source: Journal of AHIMA - website

Publication Date: November 11, 2016

This article is published in sponsorship with Berkeley Research Group (BRG).



A physician approaches a health information management (HIM) staff member, upset because the location of a document in their office is not in the same location in the hospital record.....

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....

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.

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....

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

Publication Date: November 2016

The new National Coordinator for Health IT, Dr. Vindell Washington, MD, plans to focus on some old issues for the healthcare industry—a lack of universal standards, limited interoperability, and the difficulty present for both providers and consumers trying to exchange and access hea....

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....

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....

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....

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: CEN/TC 251

Source: External web site

Publication Date: January 02, 2004

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....

Author: Davoudi, Sion; Flanigan, Jill; Houser, Shannon H.; Kadlec, Lesley; Kirby, Annessa; VanSlyke, Daniel; Wendicke, Annemarie

Source: AHIMA practice brief

Publication Date: December 2016

This update supplants the 2012 practice brief “Managing a Data Dictionary.”


As healthcare organizations move to the electronic environment, the large volume and complexity of data collected is growing at unprecedented rates. While access to data has the potential to en....

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....

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....

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....

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....

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....

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....

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....

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....

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: November 2016

AHIMA and other key stakeholders continue to drive national and global progress to achieve information systems interoperability in healthcare.


Like a complex puzzle, health information data and system interoperability takes time, effort, and collaboration to solve. And solvin....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Author: Gordon, Lynne Thomas

Source: AHIMA testimony and comments

Publication Date: September 26, 2012

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....

Author: HITSP Security and Privacy Technical Committee

Source: External - used with permission

Publication Date: October 15, 2007

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....

Author: Houser, Shannon H.; Meadows, Jean M

Source: Journal of AHIMA

Publication Date: February 2017

There are a number of recent factors driving changes to how healthcare quality is being measured. First, there’s the rapid adoption of healthcare information technology (HIT) due to the Centers for Medicare and Medicaid Services (CMS) “meaningful use” Electronic Health Re....

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

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....

Author: International Standards Organization (ISO)

Source: External web site

Publication Date: January 01, 2003

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....

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.

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....

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....

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....

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....

Author: Lusk, Katherine; Manahan, Jennifer

Source: Journal of AHIMA

Publication Date: March 2017

THERE ARE SEVEN billion people in the world, with more than three billion using the Internet. And of the North American population of 565 million, 320 million are using the Internet. There are also 6.8 billion cellphone subscriptions across the world, with two-thirds of Americans owning a....

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....

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....

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....

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....

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,....

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....

Author: National Committee on Vital and Health Statistics (NCVHS)

Source: External web site

Publication Date: August 02, 1996

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.

Author: National Council for Prescription Drug Programs

Source: External web site

Publication Date: August 02, 2003

Author: Neiman, Liz

Source: Journal of AHIMA

Publication Date: November 2016

The US Department of Commerce’s International Trade Administration just released a staggering statistic. According to their latest research, up to 93 percent of global trade is impacted by standards and technical regulations.1


Feel free to trot that number out the next time....

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....

Author: Orlova, Anna

Source: Journal of AHIMA

Publication Date: October 2016

Data quality management has always been an area of focus for AHIMA. But the need for quality and integrity of data and information is greater than ever in all healthcare settings—especially with the growing adoption of health information technology (HIT), including electronic health....

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....

Author: Orlova, Anna; Rhodes, Harry B.; Warner, Diana

Source: Journal of AHIMA | AHIMA practice brief

Publication Date: November 2016

Despite the many advancements in health information technology (HIT) that the industry has seen in recent years, the interoperability of HIT applications continues to present a challenge. Implementing standards—a definition, set of rules or guidelines, example format, or other document th....

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: 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....

Author: Orlova, Anna; Warner, Diana; Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: November 2016

The health information management (HIM) professional has a large role to play in ensuring health IT standardization and the health IT interoperability that comes from those standardization efforts.


The Practice Brief “Standardizing Data and HIM Practices for Interopera....

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....

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....