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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....

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....

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....

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....

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....

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.....

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....

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....

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....

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....

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....

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....

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....

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....

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....

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....

Standardizing Interoperability is a Team Effort

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....

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....

Managing a Data Dictionary (2016 update) - Retired

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....

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....

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,....

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....

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.

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....

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....

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....

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....

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