Author: Asmonga, Donald D.

Source: Journal of AHIMA

Publication Date: February 2005

Although healthcare headed the 108th Congress’s agenda in the first session, its second session included little in the way of HIM issues, focusing instead on election-year topics. However, the healthcare-lite agenda didn’t stop AHIMA from advancing its work in 2004.
A New Voi....

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....

Author: Humphrey, Heather L.

Source: Journal of AHIMA

Publication Date: February 2005

A few years ago, the Y2K crisis refocused the data world. Suddenly medical device manufacturers saw the inherent risks data brought to the business industry. What began with answering a simple question about date functionality quickly moved to conversations about personal information, its appr....

Author: Hall, Debra; Siegel, Barbara

Source: Journal of AHIMA

Publication Date: February 2005

Tracking case outcomes helps improve care and create efficiency. But without universal reporting standards, the workload for hospitals is heavy and the data lacks uniformity.
There are only so many hours in a day. Take the case of New Jersey hospitals.

The Leapfrog Group rates....

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: February 2005

As part of the Markle and Robert Wood Johnson Foundations Connecting for Health collaborative, a working group on policies for electronic information sharing between doctors and patients was formed. The working group comprised 25 industry leaders, including AHIMA former past president Barb....

Author: Herr, Victoria A.; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2005

In fiscal year 2005, new ICD-9-CM codes were created for reporting cervical dysplasias and abnormal Pap smears. From a clinical perspective, the new codes and instructional notes align ICD-9-CM with current terminology used in diagnosing and reporting cellular abnormalities of the cervix. From....

Author: Doll, Barbara A.

Source: Journal of AHIMA

Publication Date: February 2005

In last month’s column we defined and described projects, portfolios, and project management. We identified the project manager’s role and the concept of a project life cycle. This month we will begin to discuss the nine project management knowledge areas. First we will look at how....

Author: Dougherty, Michelle

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2005

This practice brief has been retired. It is made available for historical purposes only.

Author: Blobel, Bernd; Pharow, Peter

Source: Journal of AHIMA

Publication Date: February 2005

Smart cards help keep consumers and their health data in the same place. In Germany, a national project enters the test phase.
It’s a major challenge getting patients and their data in the same room. As consumers increasingly receive their care from a variety of providers, their hea....

Author: Hicks, Jewelle E

Source: Journal of AHIMA

Publication Date: February 2005

As vice president of quality and improvement for Child Health Corporation of America (CHCA) in Shawnee Mission, KS, Cheri Throop, RN, RHIT, MHSA, CPHQ, is part of a business alliance of the leading children’s hospitals in the country. Her role at CHCA allows Throop to work locally and na....

Author: Abdelhak, Mervat N.

Source: Journal of AHIMA

Publication Date: February 2005

From Team Talks to component state associations (CSAs), the input of AHIMA members has culminated in a set of interrelated strategic goals and priorities for 2005.

In late 2004 the Board of Directors approved these initiatives as well as a budget to support the implementation of pla....

Author: Fernandes, Lorraine M.

Source: Journal of AHIMA

Publication Date: February 2005

In early 2004 Connecting for Health, a public-private collaborative funded by the Markle and Robert Wood Johnson Foundations, engaged a cross-section of experts in security, technology, privacy, consulting, and medical informatics to define how healthcare information could be shared more effec....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: February 2005

Now that we’re well entrenched in compliance with the privacy rule and headed toward the electronic health record (EHR), the personal health record (PHR), and regional health information organizations (RHIOs), amendments may seem like a mundane topic. But, as this article explains, it is....

Author: Abdelhak, Mervat N.

Source: Journal of AHIMA

Publication Date: January 2005

It is an honor and a privilege to have been given this opportunity to serve as your president this coming year and to lead AHIMA at such an important and exciting time. While many other professions are facing uncertain growth and limited rewards, we are fortunate that our profession continues....

Author: Hjort, Beth M.

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2005

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author:

Source: Journal of AHIMA

Publication Date: January 2005

Nation's First Health Information Technology Coordinator Delivers Monday Keynote
AHIMA members are “people who have stepped to the front lines, who live and breathe the question of how we make changes” in the healthcare system, David Brailer, MD, PhD, told a general session au....

Author: Hanson, Susan P.; Hanson, Raymond J. Jr.

Source: Journal of AHIMA

Publication Date: January 2005

On opposite sides of the globe, India and the US spell the future of health information management the same: EHR.
The numbers are staggering and hard to absorb by US standards—the Indian healthcare system delivers care to a population of more than 1 billion people. With acceleratin....

Author: Friedman, Beth

Source: Journal of AHIMA

Publication Date: January 2005

From banking to travel, consumers manage a variety of personal records online. Now providers are experimenting with several ways to give consumers more control over their health records.
Every day consumers log on to the Internet to access bank accounts, stock portfolios, and travel itin....

Author: Pierson, Ed; Martin, Dan

Source: Journal of AHIMA

Publication Date: January 2005

It is terrible when we begin to turn into our parents. Suddenly, all those catch phrases we swore we would never use begin to creep into our conversations with our kids.

This is happening to security professionals. As many healthcare managers and executives spend huge amounts of tim....

Author:

Source: Journal of AHIMA

Publication Date: January 2005

As US healthcare professionals begin preparations for ICD-10, they can draw on the experiences of their counterparts in Canada. In “Implementation of ICD-10: Experiences and Lessons Learned from a Canadian Hospital,” two Canadian HIM professionals discussed Canada’s ICD-10 imp....

Author: Hagland, Mark

Source: Journal of AHIMA

Publication Date: January 2005

HIM leaders share how they welcome change, pursue new skills, and take some risks,
always seeking to help their colleagues and their organizations advance.
Mary Beth McCoy, RHIA, knows what it means to bring leadership to a changing HIM environment. As director of HIM and informati....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: January 2005

As healthcare organizations put the finishing touches on their HIPAA security compliance plans, many are finding that updating access controls is not easy. Clinicians often scoff at the word “control” in general and at “access control” in particular. Not all products ar....

Author:

Source: Journal of AHIMA | AHIMA HoD Resolution

Publication Date: January 2005

Whereas, the healthcare and technology environment will continually change the HIM professionals’ role;

Whereas, data shows that individuals who continually advance their educational standing are rewarded with the highest compensation;

Whereas, the most sought-after pr....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: January 2005

The question is often asked whether HIM will be able to make the transition from paper to electronic records. My answer is an unequivocal “yes, we already are.”

In the story “Bridge Builders: HIM Professionals Blend Core Skills and New Opportunities to Meet the Fut....

Author: Fox, Leslie Ann

Source: Journal of AHIMA

Publication Date: January 2005

As healthcare organizations implement EHRs, effective HIM leadership becomes more important than ever. Key to establishing a defining role within your organization is appreciating how groups interact.
Despite the excitement surrounding the impending arrival of the electronic health recor....

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: January 2005

HIM professionals know that as we move from paper to an electronic environment, our mission of privacy and security remains the same. As the medium changes, however, we must evaluate new threats to information.

The growth of the Internet has been proportionate to the growth of its at....

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: January 2005

When Angela Lehman, RHIA, arrived at Oklahoma Heart Hospital, Oklahoma City, in April 2004, the facility was less than two years old. From day one, it had been nearly paperless. For Lehman, the director of health information, the hospital leadership’s full commitment to the EHR’s s....

Author: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2005

CPT changes for 2005 affect all portions of the manual, although there are very few changes in the pathology and laboratory section. This article will focus on the changes for the surgery section. The January and February 2005 issues of CodeWrite (available through the Coding Community of Prac....

Author:

Source: Journal of AHIMA

Publication Date: January 2005

2004 Convention Wrap-Up

AHIMA’s 76th National Convention and Exhibit was a resounding success, setting a new attendance record as 4,000 HIM professionals gathered in Washington, DC. In conjunction with the 14th Congress of the International Federation of Health Records Organizations,....

Author:

Source: Journal of AHIMA

Publication Date: January 2005

HIM professionals from around the world gathered on October 9 to discover ways they could work to increase collaboration and advance HIM practice. During the general assembly of the 14th Congress of the International Federation of Health Records Organizations (IFHRO), members addressed key HIM....

Author:

Source: Journal of AHIMA

Publication Date: January 2005

Lifelong learning and AHIMA certifications were at the top of the minds of members of AHIMA’s House of Delegates at the AHIMA convention.
Delegates voted on two action items, considered industry hot topics during issue forums, and honored recipients of this year’s Triumph Award....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: January 2005

Last year saw important progress in modernizing the data needs of the healthcare industry. With a good start under way, much work is ahead in 2005. This year offers HIM professionals many opportunities to put their education, expertise, and time into fulfilling the promise at hand.

A....

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: January 2005

Q: What is medical informatics, and is there a connection between it and health information management?

Q: Is there a standard addressing who should document in medical records?

Carol Ann Quinsey (carol.quinsy@ahima.org) is a professional practice manager at AHIMA.Article....

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: Gold, Robert S.; Brown, Margi

Source: Journal of AHIMA - Coding Notes

Publication Date: January 2005

Part 2 of 2: The Diagnosis Aspect and More CPT Notes


As noted in part 1 (Nov./Dec. 2004), lesion coding can be confusing. Terms are often vague or used interchangeably. Thus good documentation is absolutely crucial for the correct coding of both diagnosis and procedure. It’s go....

Author: Doll, Barbara A.

Source: Journal of AHIMA

Publication Date: January 2005

Part 1 of 4


As new technology spreads through healthcare organizations, traditional walls that divided departments are coming down. HIM professionals increasingly find themselves collaborating with IT and clinical colleagues to select, design, implement, test, and train staff on new....

Author: Gold, Robert S.; Brown, Margi

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2004

Part 1 of 2: The CPT Aspect

Concentrating on lesions in the integumentary system, this article provides some basic and user-friendly information for the coder to have at hand in the day-to-day world of coding.

Coding for lesions in the integumentary system requires a good under....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: November 2004

The HIPAA security rule includes a requirement for audit controls and to monitor and manage ongoing security for a variety of processes. But the requirement for internal audit was changed to “information security activity review,” and there is no other specific reference to auditin....

Author:

Source: Journal of AHIMA - Supplement

Publication Date: November 2004

Changing Roles and Responsibilities When Transitioning from Paper to Bytes



Long before the Institute of Medicine published in 1991 its watershed report, The Computer-Based Patient Record: An Essential Technology for Health Care, the information technology (IT) and the h....

Author: Haines, Pamela T.

Source: Journal of AHIMA

Publication Date: November 2004

According to the 2002 National Survey on Drug Use and Health, an estimated 22 million Americans age 12 and older were classified with substance dependence or abuse; that is 9.4 percent of the total US population. A new report from the Substance Abuse and Mental Health Services Administration (....

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: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: November 2004

The Health Level 7 electronic health record draft standard for trial use (HL7 EHR DSTU) passed convincingly in July 2004. As per the requirements of a draft standard, HL7 now has two years to refine it into a fully accredited standard. What are the next steps that will move the EHR closer to a....

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: November 2004

A classification is a system that groups together similar diseases and procedures and organizes related entities for easy retrieval.1 Since a single classification system cannot encompass all types of healthcare information or provide the level of detail desired for various uses of healthcare....

Author: AHIMA e-HIM Work Group on Computer-Assisted Coding

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2004

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Gilles, Kathy

Source: Journal of AHIMA

Publication Date: November 2004

More than 18 months after the HIPAA privacy rule compliance date, there is still one area that remains problematic for many covered entities—the use and disclosure of protected health information (PHI) for research purposes. One point of significant confusion is the relationship between....

Author: Fletcher, Donna M.

Source: Journal of AHIMA

Publication Date: November 2004

One such program exists at the Child Health Corporation of America (CHCA), a business alliance of 41 of the largest not-for-profit children’s hospitals and healthcare systems in the US and Canada. The alliance represents more than 20,000 physicians, 98,000 employees, and $11 billion in r....

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: November 2004

“It's important to have a network of colleagues at different organizations -- to have people you can call and ask, 'How are you doing this?'"     —Julie Bryant
Back in the late 1980s and early 1990s when Julie Bryant, RHIA, was in college, she started to hear the buzz about....

Author: Moore, Helen

Source: Journal of AHIMA

Publication Date: November 2004

Letter to the Editor, Journal of AHIMA


After reading the July-August 2004 Journal of AHIMA, I wanted to express my interest in the article by Jack Bowie, “Four Options for Implementing SNOMED.” It was pleasing to read an article on SNOMED that focused on HIM operatio....

Author: Brodnik, Melanie S.

Source: Journal of AHIMA

Publication Date: November 2004

As 2004 draws to a close, I would like to thank all who have helped to make the year a success. Our success this year stems from the collective work of our members, state leaders, volunteers, board members, and AHIMA staff who worked to further our goal of moving health information management....

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: November 2004

CMS Proposes Mandatory State Reporting of Medicaid and SCHIP Payment Errors


The Centers for Medicare and Medicaid Services (CMS) published a proposed rule in the August 27 Federal Register that would require state agencies to estimate improper payments in the Medicaid program an....

Author: Willard, Dianne; Worthington, Debbie; Ashley, Patti

Source: Journal of AHIMA - Coding Notes

Publication Date: November 2004

ICD-9-CM coding and DRG changes for fiscal year 2005 include 150 new diagnosis codes, 21 new V codes, 54 new procedure codes, 25 invalid diagnosis codes, and 3 new DRGs. The changes were released in the August 11 Federal Register and went into effect October 1, 2004, for discharges occurring o....

Author: Biedermann, Sue E.; Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: November 2004

HIM professionals are naturals for careers in research. Here’s how data management, analysis, and reporting skills can help make the transition.
HIM professionals know research is critical to the advancement and delivery of healthcare. Research is “a way to create knowledge.....

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: November 2004

Q:> As a covered entity, do I need to have satisfactory assurance (as required by HIPAA) that an individual has been notified when I am served with a search warrant for a patient's protected health information (PHI)?
Q: From a Washington State Community of Practice discussion thread: Wh....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: November 2004

"Paper kills” has become a catch phrase in certain political circles to dramatize the need for a digitized healthcare system. Former House Speaker Newt Gingrich, now head of the Center for Health Transformation, stated, “A paper-based system is an ignorant system” and the....

Author: McSwain, Rebecca A.

Source: Journal of AHIMA

Publication Date: November 2004

Choosing a different transcription format may save you hundreds of billable lines each day. But money isn’t everything. Clarity and readability can be priceless.
Most of us who are concerned with the cost of producing a transcribed medical narrative have considered the cost of vari....

Author: Laakso, Roz

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2004

Dementia is defined as “a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform activities of daily living.”1 Alzheimer’s disease is an age-related, irreversible brain disorder that occurs gradually and results in me....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: October 2004

We’re thrilled to host the 14th Congress of the International Federation of Health Records Organizations (IFHRO), the long-awaited gathering of HIM professionals from 30 countries, in Washington, DC. IFHRO was established in 1968 to advance professional practice, assist developing countries t....

Author: Giannangelo, Kathy

Source: Journal of AHIMA - Coding Notes

Publication Date: October 2004

Coding professionals in acute care hospitals know that ICD-9-CM code modifications are implemented every October 1. This year, however, changes taking place will have far-reaching effects. The reason? The diagnosis portion of ICD-9-CM named under HIPAA has become the standard code set for repo....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: October 2004

As committees meet, there is tension between gathering data and reworking process.
A summit is a high point. The problem is that many expect the road to be downhill all the way after a summit. In the case of this summer’s summit on health information technology, the nation isn&rsqu....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: October 2004

The 2004 Phoenix Health System/HIMSS HIPAA compliance survey indicates that providers find audit controls the most difficult of the HIPAA security standards to implement.
While it is recognized that every organization must conduct a risk analysis to determine the systems or activities th....

Author: Roberts, Rosemary; Innes, Kerry; Walker, Sue; Scott, Peter

Source: Journal of AHIMA

Publication Date: October 2004

With major changes under way worldwide, the evolving roles and relationships of classifications and terminologies are uncertain. But the future lies in collaboration, not competition.
Classifications and clinical terminologies have coexisted for decades. Both use clinical language, but t....

Author: Brodnik, Melanie S.

Source: Journal of AHIMA

Publication Date: October 2004

In February this column focused on an AHIMA Board of Directors strategic initiative for HIM outreach—increasing consumer and industry awareness of HIM professionals and practice at home and abroad. This month, efforts related to the international portion of the initiative will be realized as....

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: October 2004

As healthcare professionals have attempted to gain a better understanding of the electronic health record (EHR) over the last year, it is natural for them to compare and contrast past experiences with electronic records against the now-published Health Level 7 (HL7) EHR draft standard. Interes....

Author: Mogli, G. D.

Source: Journal of AHIMA

Publication Date: October 2004

In 1993 just 4 percent of hospitals in the Sultanate of Oman had an HIM department. Today’s transformation demonstrates that HIM is key to quality healthcare the world over.
In recent decades the Sultanate of Oman has undergone significant modernization of its healthcare system. Tw....

Author: Dorrel, Linda; Fernandes, Lorraine M.; Laskoski, Jeff

Source: Journal of AHIMA

Publication Date: October 2004

Electronic health records operate on a basic but crucial requirement: accurately identifying the patient and linking to his or her complete medical data. Canada aims for a nationwide solution to a universal challenge.
Public and private organizations worldwide are navigating the transiti....

Author: Rooney, Anne; vanOstenberg, Paul

Source: Journal of AHIMA

Publication Date: October 2004

Accreditation standards are powerful quality improvement tools. Now single standards that reflect the full scope of care and management are being applied to facilities worldwide.
The framework and philosophy of accreditation is a powerful quality improvement tool adopted by many countrie....

Author: AHIMA Work Group on Electronic Health Records Management

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2004

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Author: Featheringham, Meg

Source: Journal of AHIMA

Publication Date: October 2004

When asked how she came to be in her current position at the Wits University Donald Gordon Medical Center in Johannesburg, South Africa, Erin Truter, RHIA, admits that she “was in the right place at the right time.”

Although now a long way from the US, Truter began her c....

Author: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: October 2004

When covered entities implemented the HIPAA privacy rule more than a year ago, the intention was to strengthen patient privacy protection and improve provider access to information, thereby improving quality of care. At times that can be a difficult balancing act.

The mainstream and....

Author: Hjort, Beth M.

Source: AHIMA Q and A | Journal of AHIMA

Publication Date: October 2004

Q: We are concerned about listing reported abuse cases on the accounting of disclosures (AoD) due to potential retaliation against an alleged victim or one who accompanies a victim for treatment. Is it acceptable to exclude abuse cases from the AoD?

A: Abuse cases pose special HIPAA....

Author: Watson, Phyllis J.

Source: Journal of AHIMA

Publication Date: October 2004

In 1948—before e-mail and Web conferencing—two countries separated by half a globe jumpstarted a national HIM profession by sharing expertise in person—in the person of Edna K. Huffman.
By 1948 the medical record profession in the US was thriving, and many countries wer....

Author: Pierzchala, Dayna; Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: October 2004

HIM offers plenty of opportunities for self-starters. There is no single path to business ownership, but successful entrepreneurs share common character traits, and their paths trace a progression from expertise to ownership.
The diversity of the HIM field offers unlimited possibilities....

Author: Armstrong, Richard; Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: October 2004

Have you ever walked into a job knowing it was in your hands to turn back a tide of red ink and put the business back on its feet? If you have been in this situation, you know it can be overwhelming. However, with the artful application of basic change-management processes and skills, you can....

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: Brodnik, Melanie S.

Source: Journal of AHIMA

Publication Date: September 2004

What an exciting time for healthcare and our profession. Tremendous strides have been made toward transitioning healthcare from paper to an electronic environment. Many AHIMA staff and members have participated in key collaborations during the last two years to advance the implementation....

Author: Roth, Julie A.

Source: Journal of AHIMA

Publication Date: September 2004

When the HIPAA privacy rule went into effect, HIM professionals began juggling HIPAA standards along with all the other federal and state laws impacting health information privacy. While this juggling act is always difficult, the mix of HIPAA and the Family Educational Rights and Privacy Act....

Author: Raymond, Jacqueline; Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: September 2004

The integration of information technology and health information management is creating new career opportunities for HIM professionals.
The journey toward developing and implementing the electronic health record (EHR) continues all over the globe. As healthcare organizations and vendors....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: September 2004

The drive to create an interoperable health information system accelerated during the summer. Four major initiatives came together in the summer heat, and our nation is poised to move from talk to action about health information infrastructure. We have reached the tipping point.
Nationa....

Author: Wark, Cynthia G.; Insley, Marcia L; Tillery, Laura S; Orvis, Nancy J

Source: Journal of AHIMA

Publication Date: September 2004

The Consolidated Health Informatics initiative has given federal agencies a common language for exchanging health data. Now it is standard issue for new initiatives in agencies like the Department of Defense and the Department of Veterans Affairs.
With millions of health records t....

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: September 2004

Your healthcare facility is digitally capturing information at a staggering pace. But if a subpoena showed up tomorrow, could you produce the information you need?
While mounds of analog paper and film continue to overwhelm most healthcare organization record and film libraries, the fac....

Author: Sykes, Catherine

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2004

Classifications are an essential part of health information infrastructures—they "group and organize information meaningfully and systematically into a standard format that is useful for determining the similarity of ideas, events, objects or persons."1 Nationally endorsed classification....

Author: Barmettler, Jonathan; Bauer, Jeffrey C.

Source: Journal of AHIMA

Publication Date: September 2004

The electronic health record is accessible, portable, and invisible. So how do you protect the EHR in the real world?
The digital revolution is finally gaining momentum in health information management. Over the past few years, three well-publicized reports by the Institute of Medicine....

Author: Dougherty, Michelle

Source: Journal of AHIMA

Publication Date: September 2004

Q: We are having trouble with the discharge status codes on some of our claims. In order to get the claim paid, the fiscal intermediary (FI) requires the discharge status code be changed. If we change the code, it will not correspond with documentation in our medical record.
Q: We are h....

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: September 2004

An unfortunate result of the HIPAA privacy rule is the emerging use of HIPAA as a gatekeeper, restricting the appropriate fl ow of protected health information (PHI). HIPAA is being cited as a reason not to disclose information without patient permission when needed for treatment, payment, or....

Author: Bowman, Jim; Stanfill, Mary H

Source: Journal of AHIMA - Coding Notes

Publication Date: September 2004

An advanced type of e-HIM™ application, in late development, is a computer program that can automatically generate specific clinical codes from medical records variously termed computer-aided coding, computer-assisted coding, or computerized autocoding (CAC). CAC technology may be based....

Author: Mon, Donald T.

Source: Journal of AHIMA

Publication Date: September 2004

Previous “E-HIM Fundamentals” columns have outlined the common threads of the national health information infrastructure (NHII), the electronic health record (EHR), and the personal health record (PHR), which include: The NHII will not be a central database of medical records.

Author: Nayar, Madhavan; Miller, Sharon

Source: Journal of AHIMA

Publication Date: September 2004

In HIM, technology is only as good as the data it delivers. Information integrity offers a systematic way to identify where and how error can enter the electronic health record.
The electronic health record (EHR) offers crucial improvements to healthcare, including reduced medical error....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: September 2004

Without introduction, Department of Health and Human Services Secretary Tommy Thompson brought the room to a hush, announcing that the healthcare industry had reached its “tipping point” and now was the time to begin the industry’s movement into the decade of electronic heal....

Author: Cuellar, Ed

Source: Journal of AHIMA

Publication Date: September 2004

As the healthcare industry continues its steady move toward comprehensive electronic medical record-keeping, there is one solution that could easily be implemented now using current technologies, that offers several baseline benefits to patients, providers, and payers. That solution is a phys....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: July 2004

As the bar rises for coding, healthcare organizations require more education from coders—and they are willing to deliver it, too.
The bar has always been high for mdical coding, but recent years have seen it boosted higher. As a result, healthcare organizations need more from code....

Author: Bowie, Jack

Source: Journal of AHIMA

Publication Date: July 2004

HIM departments looking to employ SNOMED terminology have fourbasic application options. The final choice depends heavily on their ITdepartments.
SNOMED CT offers significant benefits in the structured codification of clinical activity, and it will be the foundation of many emerging app....

Author: Hughes, Gwen

Source: Journal of AHIMA

Publication Date: July 2004

Health information managers often find their capital requests near the bottom of the list when limited funds are distributed. Their requests just aren’t sexy enough to compete with those that enhance the organization’s image, increase revenue, or promise a more rapid payback.

Author: Bowman, Sue E; Zeisset, Ann M.

Source: Journal of AHIMA

Publication Date: July 2004

Editor’s note: An updated version of this checklist is available here.

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: July 2004

Many covered entities are just now starting to approach the compliance aspects of the HIPAA security rule. Why discuss “compliance aspects” and not standards or controls, as we did when preparing for the privacy rule? Privacy and security are long-standing concepts to healthcare,....

Author: Hicks, Jewelle E

Source: Journal of AHIMA

Publication Date: July 2004

As the director of medical records at RML Specialty Hospital in Hinsdale, IL, Donna Hofer, RHIA, is essentially responsible for all the functions of an HIM department. Coding, transcription, release of information, and compliance auditing all fall under Hofer’s jurisdiction. But her org....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: July 2004

Many healthcare decision makers do not understand the many ways coded data are used throughout healthcare and the urgency of moving forward with ICD-10. They also are unable to visualize how reference terminologies such as SNOMED CT are used in electronic health record systems and how these te....

Author: Brodnik, Melanie S.

Source: Journal of AHIMA

Publication Date: July 2004

HIM practitioners have a long history of contributing to education by serving as site preceptors. Today, however, increased work demands and changing practice patterns limit time to train new graduates onsite. These factors are raising the demand for graduates with higher levels of experience....

Author: Heubusch, Kevin

Source: Journal of AHIMA

Publication Date: July 2004

On the heels of new medical procedures and new devices come the new codes and new interpretations to describe them. That’s why Terry Tropin says that coding’s biggest challenge is “keeping up.”
Tropin, RHIA, CCS-P, CPC, is manager of coding education at the Ameri....

Author: Cooper, Steve

Source: Journal of AHIMA - Coding Notes

Publication Date: July 2004

Recent legislation included in both the Benefits Improvement and Protection Act (BIPA) and the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 has affected the content and implementation processes for Medicare coverage determinations. This column reviews differenc....

Author: Bowman, Sue E; Zeisset, Ann M.

Source: Journal of AHIMA

Publication Date: July 2004

Editor’s note: An updated version of this checklist is available here.