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: 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: Burrington-Brown, Jill

Source: Journal of AHIMA

Publication Date: February 2005

Hospice Challenges

When asked about challenges in HIM in the hospice care setting, Myers notes that the challenges in ensuring hospice records are complete and reflect the care given are very similar to those in other healthcare facilities. In fact, another member of the CoP, Susan Torzew....

Author: Piselli, Caroline

Source: Journal of AHIMA

Publication Date: February 2005

What’s your plan for implementing ICD-10? A new study asked this question to 500 healthcare managers and executives. Here are the highlights, with recommendations from those who have been there.

If it’s sometimes unwelcome to hear, it’s true all the same: w....

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: February 2005

A major frustration among coding professionals, particularly in the inpatient setting, is the difficulty in translating physician documentation into diagnostic related group (DRG) data. Some hospitals have attempted to improve their coding effectiveness by establishing time-consuming physician....

Author: Rollins, Gina

Source: Journal of AHIMA

Publication Date: February 2005

As evidence-based medicine systems proliferate, organizations are grappling with the question of when—or whether—to document them in the legal record. So far, the prompts are many, but the answers are few.
A physician enters a medication order in a computerized physician orde....

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: Hull, Susan

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2005

For 2005, CPT added a number of codes to reflect the continuing evolution of reconstructive knee procedures, especially those that address resurfacing of the articular surface of the joint following loss of normal chondral tissue. The fact that chondral tissue is avascular and has limited rege....

Author: Haines, Pamela T.

Source: Journal of AHIMA

Publication Date: March 2005

HIPAA’s privacy rule has heightened awareness about confidentiality of healthcare information among the general public. However, pockets of confusion still exist. Misunderstandings between healthcare providers and law enforcement officials (LEOs) abound about the laws governing protected....

Author: Hofler, Linda D.; Hardee, Joy; Dildy, Kenneth; Burleson, Deeanna; Grady, Jamie

Source: Journal of AHIMA

Publication Date: March 2005

The privacy and security rules require audits and system activity reviews. Here is one health system's process, a systematic approach that focuses on areas of greatest risk.
Ensuring the privacy and confidentiality of patient information is fundamental to HIM, but it has taken on a new le....

Author: Abdelhak, Mervat N.

Source: Journal of AHIMA

Publication Date: March 2005

Leadership’s responsibility is to advance the organization it serves by delivering on its mission and promises. It should build a better future for its membership. Great leaders are intent on continuing the organization’s legacy of success and sustained performance. They are commit....

Author: Brown, Karen

Source: Journal of AHIMA

Publication Date: March 2005

With HIPAA’s security rule compliance date right around the corner, many HIM professionals are still trying to determine if they have adequate safeguards in place to ensure the confidentiality, integrity, and availability of electronic protected health information (ePHI).

Many....

Author: Fenton, Susan H.; Williams, Margaret

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: March 2005

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

Author: Amatayakul, Margret

Source: Journal of AHIMA

Publication Date: March 2005

HIPAA requires covered entities “implement policies and procedures to address security incidents.” There is one implementation specification: to “identify and respond to suspected or known security incidents; mitigate, to the extent practical, harmful effects of security inci....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: March 2005

The Office of the National Coordinator for Health Information Technology issued a request for information (RFI) to gather broad input about how the US national health information network (NHIN) should be designed. In just six short weeks, hundreds of organizations and thousands of stakeholders....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2005

HIPAA has taught us that standardization is hard. When the act was signed into law in 1996, the optimists among us believed that within four years the healthcare industry would be using a variety of uniform national administrative transactions, most associated with what we now call the revenue....

Author: Zender, Anne

Source: Journal of AHIMA

Publication Date: March 2005

The electronic health record (EHR) is making inroads in healthcare organizations, and many HIM professionals say they are ready. More than 40 percent of respondents to a new survey indicate that their organizations are extensively or partially implementing an EHR, and almost 70 percent say the....

Author: Doll, Barbara A.

Source: Journal of AHIMA

Publication Date: March 2005

In previous columns we described early project steps, from developing the charter to creating the scope statement and work breakdown structure. This month we will look at the Project Management Institute’s knowledge areas of time, cost, and quality.
Time Management

Managin....

Author: Koval, Dianne

Source: Journal of AHIMA

Publication Date: March 2005

By distributing costs and benefits among providers and payers, a regional physician association is creating a data exchange network with an ambitious goal: interoperable EHR systems in every physician’s office.
Mark Foster, MD, of Hudson Valley Primary Care in Wappingers Falls, NY,....

Author: Fernandes, Lorraine M.

Source: Journal of AHIMA

Publication Date: March 2005

As stewards of the data housed within our organizations, HIM professionals must be cognizant of ongoing work to facilitate sharing of data across networks. Such activities will gather momentum in the coming years as electronic health records become common practice. HIM professionals must endea....

Author: Rode, Dan

Source: Journal of AHIMA

Publication Date: March 2005

In January we discussed how AHIMA members can get involved in local health information and advocacy projects. In February we examined 2004 federal legislative activities. This month we will review AHIMA’s federal agenda for 2005.
The Ball Is Rolling on NHIN

In November the....

Author: Walsh, Tom

Source: Journal of AHIMA

Publication Date: March 2005

The race to security compliance is a marathon, not a dash. Here’s how to gauge your progress.
With implementation of the HIPAA security rule next month, many organizations are preparing to sprint toward the deadline. However, compliance is more like a marathon than a 100-meter dash....

Author: Featheringham, Meg

Source: Journal of AHIMA

Publication Date: March 2005

For Gail Kraft, RHIA, CHPS, a patient’s medical information is sacred. “For me, and I believe this is true for other health information professionals, we’ve always been passionate about protecting the privacy of our patients and their medical information,” she says. As....

Author: Mahoney, Robert J.

Source: Journal of AHIMA - Coding Notes

Publication Date: March 2005

Last issue’s article presented some ways that DRG criteria redefine well-established clinical entities such as respiratory failure and sepsis. This article will discuss two other incompatibilities between DRG criteria and clinical practice: the clinical distinctions required by the DRG s....

Author: Quinsey, Carol Ann

Source: Journal of AHIMA

Publication Date: March 2005

In 2003 the American Society for Testing and Materials (ASTM) kicked off the development of the Continuity of Care Record (CCR) standard, which was finalized in that year and passed by ASTM in April 2004. Sponsorship of the CCR brought together ASTM International, the Massachusetts Medical....

Author: Rollins, Gina

Source: Journal of AHIMA

Publication Date: April 2005

John Halamka has a history of matching patient records in a large health system. How can that be done in regional networks of unaffiliated organizations?
John Halamka, MD, is chief information officer at CareGroup Healthcare System, a Boston-based integrated delivery system with six hosp....

Author: Kloss, Linda L

Source: Journal of AHIMA

Publication Date: April 2005

In recent remarks to Connecting for Health’s steering group, David Brailer, MD, PhD, the national health information technology coordinator, noted that if this is the decade of health IT adoption, 2005 could well turn out to be the year of “maximum flexion.” Brailer urged the....

Author: Friedman, Beth

Source: Journal of AHIMA

Publication Date: April 2005

In this panel discussion, four experts discuss the big picture and the fine grain of document management now and in the years ahead.
Document imaging, document management, electronic document management systems (EDMS)... these terms have all been part of the HIM vernacular for more than....

Author: Woloszyn, William

Source: Journal of AHIMA

Publication Date: April 2005

Two years after the HIPAA privacy compliance date, is it time for your organization to reassess your efforts and recommit to enforcing HIPAA?
Revisiting HIPAA’s Roots

The HIPAA privacy regulation was created in response to public healthcare concerns about the privacy of pa....

Author: Hanson, Susan P.

Source: Journal of AHIMA

Publication Date: April 2005

In order for the nation’s health IT strategy to succeed, small physician practices must adopt electronic health records (EHRs). The transition of the paper-based small physician practice to the digital world will require a fundamental understanding of the practice and the deployment and....

Author: Bowman, Sue E

Source: Journal of AHIMA

Publication Date: April 2005

Two recent developments highlight the need for improvement in medical record documentation, coding, and hospital compliance programs.
CMS Fails to Meet 2004 Payment Error Rate Performance Goal

One of the Centers for Medicare and Medicaid Services’ (CMS) Medicare performan....

Author: Bellenghi, G. Michael

Source: Journal of AHIMA

Publication Date: April 2005

Governed by state and federal regulations, release of information (ROI) is a time-consuming and sensitive process. Failure to fulfill requests accurately and on time can have painful ramifications, affecting quality of patient care and prompting irate phone calls and legal action or fines. Not....

Author: Giannangelo, Kathy; Berkowitz, Lyle

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2005

With the advent of electronic health record (EHR) systems, IT solutions are needed to ease the recording of standard codes for clinical encounters. The basis for these products is a standard terminology, without which the full benefits of an EHR are unlikely to be realized. One expert notes th....