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Metadata and Meaningful Use

Author: Viola, Allison F.; Mookencherry, Shefali

Source: Journal of AHIMA

Publication Date: February 2012




The healthcare industry will find out soon if ONC intends to include metadata requirements in stage 2 of the meaningful use program. Many feel it is too soon. But given metadata's potential to support health information exchange, the expanded and standardized use of metadata tagging....

Needed: Data Content Standards. Data Content Standards Streamline Data Reporting for Performance Measurement Initiatives

Author: Kallem, Crystal; Fenton, Susan H.

Source: Journal of AHIMA

Publication Date: January 2007


Many performance measurement data collection and reporting initiatives are under way both nationally and locally through public and private partnerships. Healthcare providers are asked, and often required, to collect and report data for quality, public health, performance, and financial measure....

New World of Information Governance

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: February 2016



This month, AHIMA celebrates our fourth annual Information Governance (IG) Month. AHIMA created this event to increase awareness and understanding of IG and to help members understand IG’s importance to HIM practice. You’ll be seeing more details about IG Month in our publicati....

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.

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....

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....

Prepare Now for Meaningful Use Attestation and Compliance Audits

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: March 2014

A warning issued in 2013 by the Centers for Medicare and Medicaid Services (CMS) has come to pass. “Meaningful use” Electronic Health Record (EHR) Incentive Program audits have begun. The College of Healthcare Information Management Executives (CHIME) reported that out of their 1,400 member organizations, almost 100 received audit notices in October 2013, totaling six percent of membership. In order to protect incentive payments earned through the meaningful use program, organizations need to be prepared for every audit contingency and know exactly what to expect. Organizations also need to avoid common mistakes that could lead to an audit and follow best practices for staying compliant to meaningful use standards.

Privacy Officer Evolution

Author: Downing, Kathy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 25, 2015



Within my 20 years in the realm of privacy officer, we called work in privacy first “appropriate access,” then “information protection,” and now, thanks to the Health Insurance Portability and Accountability Act (HIPAA), have finally settled on the term “priva....

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....

Projects Help Students Prepare for e-HIM

Author: Eramo, Lisa A

Source: Journal of AHIMA - website

Publication Date: February 2015



The technical, legal, and collaborative aspects of information governance had always appealed to Kristi Lundgren, MS, RHIA. Although Lundgren, a former graduate student at the College of St. Scholastica, had studied about the importance of governing data in an electronic environment, she c....

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....

Retention and Destruction of Health Information

Author: AHIMA

Source: AHIMA practice brief

Publication Date: October 2013


Editor's note: This update supersedes the August 2011 practice brief "Retention and Destruction of Health Information."



Health information management professionals traditionally have performed retention and destruction functions using all media, including paper, images, optic....

Risk-Based MPI Management

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: June 2008


Meticulous management of the master patient index (MPI) has always been a mission-critical data integrity function for HIM professionals. One advantage of having credentialed health information staff manage the index is their dual knowledge of the multiple legal dimensions of the MPI and their....

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....

Sample Job Description: Chief Data Officer

Author:

Source: AHIMA sample job description

Publication Date: 2015

Chief Data Officer (CDO)


A CDO provides vision and strategy for all data management activities. He or she is a champion for global data management, governance, quality, and vendor relationships across the enterprise. The CDO oversees the enterprise information management (EIM) program,....

Sample Job Description: Data Architect

Author:

Source: AHIMA sample job description

Publication Date: 2015

Data Architect


Job Overview


Enterprise architecture serves a critical role in the understanding, documentation, maintenance, control, and planning. The data architect's role is to serve as a subject matter expert and perform tasks that contribute to the organization's mis....

Sample Job Description: Information Analyst

Author:

Source: AHIMA sample job description

Publication Date: 2015

Information Analyst





Job Description


Put your reporting and analysis skill set to work by cooperating with data services staff, key business stakeholders, and IT staff to support enterprise data management and service efforts.


As the informati....

Sample Job Description: Master Data Analyst

Author:

Source: AHIMA sample job description

Publication Date: 2015

Master Data Analyst





Description


This position will support operations by monitoring and analyzing master data, key data, and master relationship data within the organization.


Ensures master data integrity in key systems as well as maintaini....

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....

Setting the Right Expectations for the EHR Standard

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: March 2004


The electronic health record (EHR) standard has been receiving widespread attention since the spring of 2003, when the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services asked the Institute of Medicine for guidance on care delivery functions and H....

Setting the Standard: EHR Quality Reporting Rises in Prominence Due to Meaningful Use

Author: Dolin, Robert H; Goodrich, Kate; Kallem, Crystal; Alschuler, Liora; Holtz, Patrice

Source: Journal of AHIMA

Publication Date: January 2014



Federal quality reporting initiatives are expected to improve our ability to measure the quality of care provided to patients. As Scottish mathematician and physicist Lord Kelvin said more than 100 years ago, “If you cannot measure it, you cannot improve it.” Measurement, in tu....

Setting the Standards

Author: Jeffries, Jane

Source: Journal of AHIMA

Publication Date: April 2000


After years of learning and teaching HIM, Mary Alice Hanken, PhD, RHIA, now develops the standards that shape it. Hanken leads an American Society for Testing and Materials (ASTM) subcommittee that authors the standards that are changing the meaning of security.

Hanken has....

Slow to the Information Governance Starting Line: First-of-its-kind Survey Tracks Healthcare’s IG efforts, Shows Most Organizations are Behind

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2014



Majority of Healthcare Organizations Lack Vital Information Governance Strategy


AHIMA has fired the starting pistol heralding in the urgent race to implement information governance (IG) practices within the healthcare industry. While some organizations were quick off the bloc....

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,....

Spoliation of Medical Evidence

Author: Tomes, Jonathan P.

Source: Journal of AHIMA

Publication Date: October 2005


To avoid the improper destruction or alteration of records, HIM departments must follow a retention schedule, train personnel, and ensure that corrections leave original entries intact.
Although the legal concept known as spoliation of evidence has been a part of the American legal syste....

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....

Standardized Data: the Difference for EHR Solutions

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: February 2005


This month, Dallas will be the center of the health IT world as HIMSS hosts its 2005 trade show, of which AHIMA again will be a sponsor. We look forward to learning how electronic health record (EHR) solutions are maturing and how provider organizations are succeeding in improving patient care....

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