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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.

Opting for Opt Out: How One HIE Manages Patient Consent

Author: Bass, Deb

Source: Journal of AHIMA

Publication Date: May 2011



Every health information exchange must determine how it will gain consent from patients to share their information. The Nebraska Health Information Initiative chose opt out and with good communication and management has maintained a high rate of patient participation.

Even afte....

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....

Overview of Trauma Registries in the United States

Author: Garthe, Elizabeth

Source: Journal of AHIMA

Publication Date: July 1997

Overview of Trauma Registries

How many trauma registries are there in the US? This is a tough question to answer. According to a survey conducted by members of the Emergency Nurses' Association (ENA), the number of clients reported by trauma registry software companies exceed 1850 organi....

Owning the EHR and Information Governance at Your Facility

Author: Head, Erin

Source: Journal of AHIMA

Publication Date: August 2015



For many decades, health information management (HIM) departments have been the hub for information collected within healthcare organizations. HIM has frequently been referred to as the “medical records department” due to the perceived idea that the department’s main tasks are receiving a....

Personal Genomic Information Management and Personalized Medicine: Challenges, Current Solutions, and Roles of HIM Professionals

Author: Alzu'bi, Amal; Zhou, Leming; Watzlaf, Valerie J.M.

Source: Perspectives in Health Information Management

Publication Date: April 2014


Abstract


In recent years, the term personalized medicine has received more and more attention in the field of healthcare. The increasing use of this term is closely related to the astonishing advancement in DNA sequencing technologies and other high-throughput biotechnologies. A l....

Planning Forms Automation

Author: Hyde, Cynthia S

Source: Journal of AHIMA

Publication Date: November 2008


A carefully crafted project plan is the first step in achieving expectations and lasting value from electronic forms management.

The intent of transitioning from paper-based processes to electronic, automated systems and solutions is to benefit the operations of healthcare facilities....

Policies and Procedures for a Legal EHR

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: April 2007


As organizations move from paper to electronic health records (EHRs), one of the most critical steps is ensuring that there are policies that support the EHR as the legal health record.

Most managers know the importance of having up-to-date policies and procedures. Good pol....

Post-acute PPS: Changing the Way We Code

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: June 1999


HIM professionals in post-acute care are reinventing their roles to accommodate the new coding demands of a prospective payment system. Here are some of the developments that are creating new interest in coding issues for post-acute settings.
Three major forces -- the prospective payment....

Power of Data Analytics is Within Reach

Author: Birnbaum, Cassi L

Source: Journal of AHIMA

Publication Date: October 2015



Data are the lifeblood of our healthcare ecosystem, with the potential of enabling organizations to improve care, manage chronically ill patients, lower costs, achieve compliance, support research, increase patient safety, and meet operational and strategic initiatives. Although health inf....

Prescribing a Clean Bill of Health for Data

Author: Fletcher, Donna M.

Source: Journal of AHIMA

Publication Date: January 1999


Ensuring data quality is not really glamorous, but it is critical," Jane Griffin, vice president of business solutions for Prism Solutions in Atlanta, GA, maintains. "And nowhere is it more critical than in the healthcare environment."

A data warehouse can b....

Primer on Encryption

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: June 2004


Encryption is an addressable implementation specification under HIPAA’s access control and transmission security standards. Many providers are grappling with just how to address these specifications:
Is there a difference between the two specifications, and if so, what is the diff....

Privacy and Security Solutions for Interoperable Health Information Exchange: North Carolina HISPC Final Implementation Plan Report

Author: Anderson, Holt; North Carolina Information and Communications Alliance; RTI International

Source: U.S. Agency for Healthcare Research & Quality

Publication Date: April 15, 2007

The report includes an analysis of policy, technological, and legal barriers to exchanging health information within North Carolina and describes in greater detail the proposed solutions intended to reduce or eliminate those barriers.

Privacy in the Spotlight

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: November 2007


Varying privacy practices that pose barriers to health information exchange are putting HIM concerns in the national spotlight.
The 35-year-old Minnesota woman’s winter vacation in the neighboring state of Wisconsin was going great, until her ski snapped and the accident happened. B....

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....

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....

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....

Projected Impact of the ICD-10-CM/PCS Conversion on Longitudinal Data and the Joint Commission Core Measures

Author: Fenton, Susan H.; Benigni, Mary Sue

Source: Perspectives in Health Information Management

Publication Date: July 2014


Abstract


The transition from ICD-9-CM to ICD-10-CM/PCS is expected to result in longitudinal data discontinuities, as occurred with cause-of-death in 1999. The General Equivalence Maps (GEMs), while useful for suggesting potential maps do not provide guidance regarding the frequen....

Protection of Personal Data -- The European View

Author: Mathews, Steve

Source: Journal of AHIMA

Publication Date: March 1998


A new series of laws are being passed to control the processing of personal information -- including medical information -- inside the European Commonwealth. The author gives an overview of the European view of personal information and examines the implications for healthcare professionals bo....

Public Health: a Special Case for Data Standards

Author: Rollins, Gina

Source: Journal of AHIMA

Publication Date: January 2007


The need for thorough, rapid, and reliable public health data reporting was brought home starkly in the fall of 2006 when nearly 200 people were sickened and at least three died after eating packaged spinach that had been contaminated with E. coli bacteria. Yet despite its importance, pub....

Putting the EHR to the Test

Author: Hawkins, Fanny

Source: Journal of AHIMA

Publication Date: September 2002


Is clinical documentation significantly different before and after implementing the electronic health record (EHR)?
Believing that the development and implementation of an EHR strategy is required for success, Baylor College of Medicine sought to answer this question. This article present....

Putting the ICD-10-CM/PCS GEMs into Practice (2016 update) - Retired

Author: Archer, Anita; Campbell, Angela; D'Amato, Cheryl; McLeod, Melissa; Rugg, Donna

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2016


Editor's Note: This Practice Brief supersedes the May 2013 and March 2010 Practice Briefs titled "Putting the ICD-10-CM/PCS GEMs into Practice."


Mappings between ICD-9-CM and ICD-10-CM/PCS will play a critical role in the successful utilization of ICD-10-CM/PCS. The Centers for Me....

Quick Take on Clearinghouses

Author: McLaughlin, Mark

Source: Journal of AHIMA

Publication Date: January 2001




HIPAA's provisions have brought healthcare clearinghouses into the spotlight. What is a clearinghouse, and how is its role affected by the new regulations? This article answers these questions.

A clearinghouse is typically used to collect, validate, and distribute insurance c....

Rare and Unlikely ICD-10 Codes are Needed

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: October 2015


This summer, if you listened very closely, you could almost hear a vast chorus of coders saying “I told you so,” after a freak accident alarmed local boaters in Southern California. On June 21, an over-excited dolphin accidentally jumped into a California family’s speed boat and broke both ankl....

Registries and Networks in Healthcare

Author: Frazeur, Mary; Brown, Patricia J.

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

Most states have used electronic record systems to report birth registry information for at least 10 years. However, the improved quality of the data from using such systems has not been realized. The Division of Vital Statistics National Center for Health Statistics (NCHS)....

Registries and Networks in Healthcare

Author: Wiedemann, Lou Ann

Source: AHIMA Convention

Publication Date: October 15, 2004

Introduction

Trauma registry is a relatively new development in the US when compared to other countries such as New Zealand. Many states, such as Oklahoma, has had a trauma registry reporting system for less than five years. During that time, Oklahoma has made this a mandatory reporting....

Reinventing CDI: Organizations Relaunching And Reworking Data Integrity Efforts, And Coding Roles, With Clinical Documentation Improvement Programs

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2014



It’s a particularly busy night in the local hospital’s emergency department, which is running—as usual—slightly short-staffed. The on-call attending physician goes from room to room treating and diagnosing patients with typical emergency department maladies: influenza, fractured ankle, in....

Renewing Our Commitment to Confidentiality

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: November 2006


With renewed interest in privacy and security, a renewed role for HIM.

Confidentiality has been an HIM domain ever since the profession recognized and accepted Hippocratic responsibilities to keep health information secure. Pre-HIPAA, HIM professionals were responsible for....

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