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Preparing for Discovery

Author: Baldwin-Stried, Kimberly A.

Source: Journal of AHIMA - website

Publication Date: October 21, 2010



She also presents a scenario that led to discovery and recommends that organizations prepare for the changing world of discovery by developing similar use cases. Scenarios such as this, she writes, help organizations identify the types of data and systems that may require legal holds in re....

Strategies for Remote Coding Success: Remote Coding Program Helps Norman Regional Retain Quality Coders

Author: Miller, Amy; Ridpath, Debra

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2010


Remote coding is helping organizations attract and retain experienced coding professionals at a time when highly skilled coding professionals are in short supply. Successfully implementing a remote coding program requires that facilities have their entire clinical documentation online and qual....

Integrating Medical and Dental Records: A New Frontier in Health Information Management

Author: Rudman, William J.; Hart-Hester, Susan; Jones, Warren A.; Caputo, Nadine; Madison, Mary

Source: Journal of AHIMA

Publication Date: October 2010


Integrating records of systemic and oral health would improve patient care. It would also open up a new frontier in health information management.

A fully integrated patient record and care model for both systemic health (medical) and oral health (dental) is needed for health informa....

CPOE Lessons Learned

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2010


Hospitals and healthcare providers acknowledge that computerized physician order entry (CPOE) systems effectively address patient safety issues such as medication errors and document legibility. Built-in clinical decision support alerts can help identify drug-to-drug interactions or dosage err....

Payout: Reviewing Meaningful Use Payments

Author: Viola, Allison F.; Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2010


CMS will pay meaningful use bonuses through three programs: Medicare Fee for Service (FFS), Medicare Advantage (MA), and Medicaid programs.
FFS Payments to Providers

For eligible professionals (EPs), understanding the payment system is especially important, because they must ch....

Wake-up Call on the Security Rule

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: October 2010





Recent changes to the enforcement of the HIPAA security rule have left many and HIM professionals wondering what, if anything, they need to change in order to stay compliant.


Federal regulation last year introduced the potential for additional random....

EHRs Prove a Difficult Witness in Court

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: September 2010


Sep 24, 2010

The EHR is a valuable clinical tool for streamlining and improving patient care. But it is complicating and confusing the courts.

As the first cases involving electronic health records make their way into legal proceedings, everyone involved is discovering th....

Summer Reading: Skimming the New ARRA-HITECH Regulations

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: September 2010


In July the Department of Health and Human Services (HHS) ended the waiting game for the HITECH privacy and security regulations, the meaningful use final rule, and the final rule on standards and certification.

HIM professionals and their organizations, anxious to familiarize thems....

Deleting Errors in the EHR

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: September 2010



Many types of documentation errors can occur in electronic health records (EHRs), such as incorrectly recording the sex of a patient, documenting in the wrong patient record, and incorrectly identifying the ordering physician on a laboratory report.


It is important to addres....

The ICD-10 2011 To-Do List

Author: Dowling, Alan F.; Wisdom, Theresa A

Source: Journal of AHIMA

Publication Date: September 2010



As the ICD-10 conversion deadline approaches, its implementation is likely to become a healthcare facility's most significant objective. It presents HIM professionals with an opportunity to demonstrate their expertise and assume a leadership role within their institutions as they lead this....

United RECs of America

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2010


Most of the 60 regional extension centers have officially launched operations and begun helping providers implement health IT.


The RECs were created under the federal American Recovery and Reinvestment Act of 2009, which provided $642 million in grants for the centers' first two....

Certified Meaningful

Author: Costa, Kerry F

Source: Journal of AHIMA

Publication Date: August 2010


This month providers will begin seeing the first EHR products approved for use in the "meaningful use" incentive program. Another piece of the ARRA puzzle is falling into place.

In March 2010 the Office of the National Coordinator (ONC) proposed two programs to test and approve EHR p....

ARRA Timeline

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2010


ARRA arrived with a bang in February 2009, but the regulations enabling the law's healthcare provisions have inched forward since then. Much of the responsibility for drafting regulation fell to the Department of Health and Human Services, which had a tall order to fill within deadlines mandate....

$58 Billion to Go

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2010


The Department of Health and Human Services received approximately $146 billion in funds through the American Recovery and Reinvestment Act. It was tasked with disbursing that money through programs or objectives specified within the act's healthcare-related provisions.

Over the year....

A First Peek at the Privacy Regulations

Author: AHIMA

Source: Journal of AHIMA

Publication Date: August 2010


The office for Civil Rights got a late start on the HITECH privacy regulations (due last February), and it's clear from the draft rule it released in July that the office still has almost as many questions as answers on how to enact the HITECH provisions. However, the release does offer a good....

Aligning HIE: Model to Organize Networks on Core Principles, Collaborative Activities

Author: Finn, Zach; McNeill, Marjorie H; Cooper, Lontejuana S; Kaelin, Lawrence Dan; Byington, Allen

Source: Journal of AHIMA

Publication Date: August 2010



An HIE model developed in Florida leverages local and regional networks and offers a flexible, scalable framework that aligns them with national health IT and exchange priorities.



By Zach Finn; Marjorie H. McNeill, PhD, RHIA, CCS; Lontejuana S. Cooper, MSHA, RHIA, CPM; L....

DOQ-IT Déjà vu

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: August 2010

Chris Dimick


Aug 01, 2010 07:15 am


The regional extension center program might have some people experiencing déjà vu.

Granted, the REC program is an unprecedented attempt by the federal government to transition American healthcare to electronic health record sy....

Establishing a CDI Program: How One Organization Leveraged Nursing and Coding Skills to Improve Clinical Data

Author: Lopez, Barbara A

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2010


Establishing a clinical documentation improvement (CDI) program is an organization-wide, transformational process that affects a hospital’s culture, reaching across all disciplines and touching every colleague and the way they perform their jobs. Many factors can lead healthcare organizations....

Achieving Coding Consistency

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: July 2010


Even small departments may never experience complete harmony in their assignment of codes, but they have good motivation for achieving as much consistency as they can. Training, communication, monitoring, and coding reviews help reach that goal, HIM experts say.

Coding manager Julie....

Smart Training on Privacy and Security

Author: Bacik, Sandy

Source: Journal of AHIMA

Publication Date: July 2010


ARRA's modifications to the HIPAA privacy and security rules are setting off a new round of training in facilities large and small. Trainers must fit the new training into existing schedules that already include organizational policies and procedures, HIPAA, and other regulations such as the R....

Ready, Set, Automate: Preparing for Automation in Coding Workflows

Author: Peterson, Kathleen; Smith, Gail I.; Phibbs, Kozie V.; Eminger, Heather; Giustina, Elizabeth

Source: Journal of AHIMA

Publication Date: July 2010



Coding departments are in training for a triathlon. They are swimming in regulations, cycling through changes in source documents, and running at breakneck speed to ICD-10-CM/PCS implementation. Luckily, new workflow “gear” is emerging that can help them improve endurance and e....

E-Discovery from the Judicial Perspective

Author: DeLoss, Gerald E.

Source: Journal of AHIMA

Publication Date: July 2010


In a typical legal action, judges have a different perspective on the production of electronically stored information (ESI) than do HIM professionals. The Federal Rules of Civil Procedure, case law, and past experiences with discovery disputes play an important role in how judges view e-discov....

Managing Patient-provided Information in EHRs

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: July 2010


Ensuring correct and complete patient health information is an ongoing challenge for healthcare organizations. Patient-provided health information can help organizations gain a more complete view of a patient's health, and electronic health records (EHRs) provide multiple tools that allow pati....

Many Roads to Data Exchange

Author: Fernandes, Lorraine M.; O'Connor, Michele

Source: Journal of AHIMA

Publication Date: June 2010


Federal dollars are spurring efforts for health information exchange, but to say there is more than one approach is an understatement. Providers and payers are taking local, state, regional, and federal routes in search of connected healthcare.

The last year has seen tremendous excit....

Virtual Record

Author: Frankel, Harris; Bass, Deb

Source: Journal of AHIMA

Publication Date: June 2010




Nebraska HIE offers light solution for robust data exchange

Depending upon your perspective, NeHII, the Nebraska Health Information Initiative, may have a name that evokes a soft drink popular in the early 20th century, or it may induce images of cornstalks waving in the v....

Enhancing Patient Care through Data Analysis

Author: Spencer, Gregory

Source: Journal of AHIMA

Publication Date: June 2010


Healthcare organizations, just like individuals, can suffer from information overload. Increasingly tasked with linking quality data to reimbursement parameters, providers now attempt to capture every piece of possible data.

The problem is that data collection has a price tag. Someti....

Obstetric Coding in ICD-10-CM/PCS

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2010


ICD-10-CM/PCS will capture a greater level of specificity for obstetric coding. This article highlights some of the new features in coding obstetric cases with ICD-10-CM/PCS.
OB Diagnoses Coding with ICD-10-CM

Obstetric cases require diagnosis codes from chapter 15 of ICD-10-CM,....

Correcting Dates of Service in the EHR

Author: Dinh, Angela K.

Source: Journal of AHIMA

Publication Date: June 2010


Data errors are inevitable, and they happen every day. Various types of errors can occur in electronic health records (EHRs), including errors in dates of service (DOS). DOS errors happen for a number of reasons, such as a user choosing the wrong encounter or entering the wrong date.

Coding Hip Fractures

Author: Endicott, Melanie

Source: Journal of AHIMA - Coding Notes

Publication Date: June 2010


Hip fractures are most commonly seen in elderly patients. They are a serious concern for this population because they can lead to a decreased quality of life, extended hospitalizations, or admission to nursing facilities.

Two of the most common causes for fractures are falls and ost....

Accrediting HIEs

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: June 01, 2010




Health information exchange (HIE) networks have always understood the importance of gaining patient and provider trust. However, beyond describing the privacy and security policies and procedures they establish to protect the information they exchange, they have largely had to ask pat....

New Patient Rights Scenarios

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: June 2010





HIPAA gave consumers the right to request that covered entities restrict certain disclosures of their protected health information, but it did not require covered entities to comply. ARRA does—in certain situations. ARRA also expands patients’ rights to an accounti....

Harnessing the Power of PHRs

Author: Bowen, Rita K.

Source: Journal of AHIMA

Publication Date: May 2010


If you have ever had to coordinate care for yourself or a loved one, you know that the personal health record (PHR) is a powerful tool.

Five years ago when my dad was receiving treatment for bone cancer, it became painfully obvious that the healthcare system within our community was....

Correcting Lab Results in an EHR

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: May 2010


The laboratory system within an EHR automates the historical process in which technicians documented results on lab shingles and pasted them on pages in the health record. In the paper environment, shingles were numerous and often taped one on top of the other to condense the record.

ICD-10-PCS Root Operation Groups, Part 2

Author: Barta, Ann

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2010


Root Operations that Take Out Solids, Fluids, Gases from a Body Part, Involve Cutting or Separation Only, and Put In OR put Back or Move Some OR All of a Body Part

The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically coded and repor....

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....

Using Clinical Photos in EHRs

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: April 2010



For most organizations, patient-identifiable source data include data from interpretations, summaries, or notes. These data are usually maintained within the originating department, separate from the HIM department and the health record, and sometimes in a different database. Examples incl....

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