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Law Changes Patient Access to Clinical Lab Reports

Author: McLendon, Kelly

Source: Journal of AHIMA

Publication Date: October 2014



The US Department of Health and Human Services (HHS) continues to look for avenues to allow greater patient access to their own health information so that they may be more active in their healthcare management. HHS recently created final rules that remove the Clinical Laboratory Improveme....

Low-Tech Approach to High-Tech Problems

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: September 2014



The HIM Problem


Transitioning from paper to electronic transcription processes; integrating fetal monitoring into an electronic health record (EHR); implementing an enterprise EHR that includes emergency room, radiology, laboratory, and operating room systems—and assimilating....

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....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: September 2014



Editor’s note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the last three Ancillary sections. The side....

How and Why to Preserve Health Records During Litigation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: September 2014



The term preservation, when used in a legal context, refers to placing information identified as relevant to a civil or criminal US court case in a legal hold to ensure the data is not destroyed or tampered with.


Health information managers, or anyone who works with records....

Fast As You Can: US Lagging Behind in Broadband Internet Access

Author: AHIMA

Source: Journal of AHIMA

Publication Date: September 2014


At a time when technology has been able to facilitate advancement in so many other areas, the United States is coming up surprisingly short when it comes to meeting its citizens’ Internet speed needs.


According to a new report from Akamai, the US has seen improvement in broadban....

Personal Health Information is 'Saving Grace'

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: September 2014



As a health informatics and information management professional and a parent of two adopted children, my desire for complete and accurate medical information rocks the top of my “Mom to-do list.” My children, Zach and Grace, are siblings, adopted at the ages of two and four. State laws va....

Why Standards Should Matter to HIM Professionals

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: September 2014



Editor’s note: This article introduces Standards Strategies, a new Journal of AHIMA department that will provide guidance to HIM professionals on applying health data standards in areas including business, clinical care, and compliance.


AHIMA has always been committed t....

Curing Inherited EHR Ailments: EHR Remediation Fixes System Issues and Better Aligns Clinical Workflow with Clinical Documentation

Author: Wieczorek, Michelle M.; Clark, Jill S

Source: Journal of AHIMA

Publication Date: September 2014



In recent years the introduction of the American Recovery and Reinvestment Act’s (ARRA’s) “meaningful use” EHR Incentive Program has encouraged more healthcare entities to chart their course toward electronic health record (EHR) system implementation, taking advanta....

Patient Engagement: In it for the Long Haul

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: September 01, 2014





Marc Perlman, global vice president, healthcare and life sciences at Oracle, recalls being “blown away” by the Patient Engagement Framework. The framework was developed after the National eHealth Collaborative merged with the Healthcare Information and Management Systems....

Coping with Government Audits

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: August 2014





The HIM Problem: Medicare Auditor Scrutiny of Inpatient Claims


This spring, the Centers for Medicare and Medicaid Services (CMS) issued its “two midnight rule” which was intended to define and clarify what Medicare considers to be criteria justifying an inpatient st....

Realigning HIM to the New Healthcare Environment: Case Studies in HIM Transformation Due to Accountable Care and Pay-For-Outcomes Initiatives

Author: Bower-Jernigan, Patricia L; Chenoweth, Ann; James, Jaime

Source: Journal of AHIMA

Publication Date: August 2014



The Affordable Care Act has been a catalyst for the transition to pay for outcomes. Through the Centers for Medicare and Medicaid Services (CMS) Innovation Center, dozens of new payment and service models have emerged that promise to deliver better care throughout the United States at a l....

3 Myths of ICD-10-CM/PCS: Addressing Why it is Not Feasible to use SNOMED CT in Place of ICD-10 or Wait for ICD-11—and Other Misperceptions

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: August 2014



As the US healthcare industry experiences yet another delay in ICD-10-CM/PCS implementation, misunderstandings surrounding the ICD-10-CM/PCS transition continue to perpetuate. This article addresses a few of the most common misperceptions—myths that need to be exposed with fact-based....

Coming Soon to Your Healthcare Facility: Information Governance. A Look at Healthcare Information Governance Trends through Practical Case Studies

Author: Kadlec, Lesley

Source: Journal of AHIMA

Publication Date: August 2014



The growing momentum of information governance (IG) initiatives in healthcare provider organizations raises many questions. What are the goals of information governance? Why have some organizations decided they need formal IG programs? How do healthcare organizations expect to benefit from....

Using Our Influence to Lead for the Greater Good

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: August 2014



In a healthcare ecosystem where volume-based models are shifting to value-based ones, organizations will depend more and more on the use of informatics to drive decisions. Our success will depend on our ability to drill down to the level of detail required to support evidence-based medici....

Roles for HIM Professionals in HIOs

Author: Bailey-Woods, Linda; Dooling, Julie A; Fabian, Diane; Kuehnast, Tanya; Luthi-Terry, Stephanie; Raymond, Jackie; Rhodes, Harry B.; Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: August 2014



Simply stated the goal of health information exchange (HIE) is very clear-cut and easy to understand—establish networks that connect healthcare providers electronically in order to facilitate higher quality healthcare.


However, actual implementation of HIE business mod....

How to Lead Your Organization in Compliance, Ethics, and Customer Service: Health Information Management Professionals Can Help Organizations Create a Culture of Compliance

Author: Burton, Ben

Source: Journal of AHIMA

Publication Date: August 2014



Today’s healthcare organizations must field a constant bombardment of both new and evolving regulations that dictate how, when, or where patients may receive care. The changing regulatory landscape—combined with the fact that the government is recovering $16 for every dollar spent to comb....

Leveraging the Leader-Member Exchange Theory in HIM

Author: Hunt, T J

Source: Journal of AHIMA

Publication Date: August 2014



Editor’s note: This article is an excerpt from “Leader-Member Exchange Relationships in Health Information Management,” published in the Spring 2014 issue of AHIMA’s scholarly research journal Perspectives in Health Information Management.


Following the leader-member excha....

HIM Must Shoot for the Moon

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: August 2014



ONE OF MY father’s favorite sayings was: “Shoot for the moon. If you only get to the stars, it’s better than never having gone at all.”


It’s a saying that kept coming back to me as I was getting ready to write this column for the Journal issue o....

Practical Implications of Informatics

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 2014





For decades, most consumers relied on one physician for all of their healthcare needs—their primary care physician—and that one physician knew the patient’s entire health history and documented it in one place. This paradigm is starting to change, says Anupam Goel, MD, MBA, an in....

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....

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....

CDI's Promise and Possibilities

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2014




“The first job of a leader—at work or at home—is to inspire trust. It’s to bring out the best in people by entrusting them with meaningful stewardships, and to create an environment in which high-trust interaction inspires creativity and possibility.”

HIPAA Breach Enforcement Roundup

Author: Cacciatore, Victoria; Downing, Katherine

Source: Journal of AHIMA

Publication Date: July 2014



Criminal attacks on healthcare systems have risen 100 percent since 2010, according to a recent Ponemon study.1 This makes it obvious that the privacy and security of patient health information is vulnerable and highly susceptible to data breach. The HIPAA Breach Notification Rule became e....

Coding ICD-10-PCS Procedures in the Ancillary Sections: Understanding Imaging, Nuclear Medicine, and Radiation Therapy

Author: Kostick, Karen M.; Sanvik, Gina

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2014



Editor’s note: This is the first installment of a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.


This article continues the Journal of AHIMA’s exploration of the different sections of ICD-10-PCS, focusing on the six Ancillary sections. The....

Improve Data and Outcomes with CDI

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: July 2014



ICD-10-CM/PCS will require significantly more clinical detail than ICD-9-CM, making clinical documentation improvement (CDI) efforts paramount for healthcare providers across the continuum of care. While CDI programs aim to substantiate claims and improve revenue streams, CDI itself shoul....

Clinical Documentation Guidance for ICD-10-CM/PCS - Retired

Author: Bielby, Judy A; Comfort, Angie; Reed, Andretta; Wiedemann, Lou Ann

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: July 2014


Organizations were well on their way to an October 1, 2014 implementation of ICD-10-CM/PCS when Congress passed H.R. 4302, the Protecting Access to Medicare Act of 2014. This bill contained a section stating that the Department of Health and Human Services (HHS) could not adopt the new code set....

Use Data Mining Findings as a Tool to Support CDI Education

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2014



Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

Overcoming the Challenges of Adolescent EHRs

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: June 2014




In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems. This month features the conclusion to a two-part series discussing the unique challenges HIM professionals face in deploying EHRs customized to serve pediatric and adolesce....

ICD-9-CM Refresher

Author: Endicott, Melanie

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2014





Focus has been on training in ICD-10-CM/PCS for the past few years. With yet another delay, many organizations are slowing down their ICD-10 training and changing their focus back to ICD-9-CM.


The first quarter of 2014 was historic in “coder world” since t....

Cultivating Opportunities to Lead in the Face of Delay

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: June 2014



The International Classification of Diseases (ICD) is a language used to capture morbidity and mortality data and helps to provide a snapshot of population health around the world. ICD-9-CM was implemented in the United States in 1979 and is long overdue for replacement. The system is obs....

Bird’s Eye View of ICD-10 Documentation Gaps: Vendor analysis offers big picture look at nationwide documentation holes—and how to fill them

Author: Hinkle-Azzara, Barbara; Carr, Kimberly J

Source: Journal of AHIMA

Publication Date: June 2014



Increased clinical specificity is one of the greatest advantages of moving to ICD-10-CM/PCS. With specificity comes the ability to perform granular research that can help uncover significant trends and statistics to identify causes of diseases, links between diseases, and more. While heal....

'Recalculating' the Route to ICD-10

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: June 2014



Have you ever driven a car using a global positioning system? If so, you’ve heard what happens when you take a turn that’s not on the system’s expected route: an annoyed-sounding voice will say “Recalculating!”


Since early April, the entire healt....

Coding ICD-10-PCS Medical and Surgical-Related Sections: Understanding Osteopathic, Other Procedures, and Chiropractic

Author: Barta, Ann

Source: Journal of AHIMA | Journal of AHIMA - Coding Notes

Publication Date: June 2014


Editor’s note: This is the third in a series of three articles discussing the Medical and Surgical-related sections of ICD-10-PCS.

IN THIS ARTICLE, the Journal of AHIMA continues its three-part Coding Notes series focusing on the nine Medical and Surgical-related sections of ICD-10-PC....

Overcoming the Risks of Copy and Paste in EHRs

Author: Haugen, Heather

Source: Journal of AHIMA

Publication Date: June 2014



With warm weather comes allergy season and possibly hundreds of patients visiting a physician who have similar symptoms, diagnoses, and treatment recommendations. Challenged by the documentation processes in the electronic health record (EHR) and starved for time, the physician may resort....

Things Overheard at the ICD-10 Summit

Author: AHIMA

Source: Journal of AHIMA

Publication Date: June 2014


Coming on the heels of an unexpected delay of the implementation of the new code set, this year’s ICD-10-CM/PCS and Computer-Assisted Coding (CAC) Summit, held in Washington, DC from April 22–23, was rife with uncertainty and questions—as well as some zingers from federal health officials.

Navigating a Compliant Breach Management Process

Author: Downing, Katherine

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2014

The purpose of AHIMA’s new Breach Management Toolkit is to provide a comprehensive collection of resources and best practices to help healthcare organizations and health information management (HIM) professionals navigate their way through the Health Insurance Portability and Accountability Act (HIPAA) Breach Notification Rule and the overall breach management process. The toolkit is intended to raise awareness of the importance and responsibility of everyone within the organization to report HIPAA breaches to the appropriate designated personnel, as well as provide breach prevention education and training.

Don’t Deny the Denials: Experts Recommend Implementing a Strong Claims Denial Strategy to Offset ICD-10-based Coder Productivity Loss

Author: Eramo, Lisa A

Source: Journal of AHIMA

Publication Date: June 2014



As organizations prepare for the implementation of ICD-10-CM/PCS next year, many are looking for creative strategies to mitigate anticipated decreases in coder productivity that will come with the switch. Some are ramping up education, others hiring additional staff members or implementin....

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