Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: October 2013

Sink or swim. These are the two choices participants of the "meaningful use" EHR Incentive Program will soon face now that the federal government has opened up the program's deeper, more complex second stage.


Though physician and hospital involvement in the program has incre....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: January 2015

Human beings have been fascinated by birds—their flight patterns, colors, and songs—for centuries. In the ancient world, “augurs,” Roman practitioners of “augury,” looked for clues about the past and future by observing birds in flight, hoping for omens.....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2014

On April 1 health IT stakeholders that had been diligently speeding down the road to ICD-10-CM/PCS compliance were once again forced to pull over.



This time, the mother of all gapers’ delays didn’t come from the Centers for Medicare and Medicaid Services (CMS....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: February 2015

American high school students approaching their senior year have good reason to envy their European counterparts who enjoy the more common experience of a “gap year” between high school and college.


A gap year, at least in Europe, is a socially accepted opportuni....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: January 2014

On New Year’s Eve, waiting for the Times Square ball to drop, optimistic individuals focus on starting fresh with their resolutions for the new year. Meanwhile, it’s easy to get caught up in the boozy lyrics of “Auld Lang Syne” and reflect on the year that was and w....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2019

By Mary Butler


As text messaging has come to replace telephone calls as the primary means of interpersonal communication, apps such as SwiftKey have popped up to help those with less than nimble thumbs. SwiftKey and other “intelligent keyboards” quickly learn a user&rs....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: March 2019

By Mary Butler


Steve Giles, chief information officer (CIO) at Hollywood Presbyterian Medical Center, says the experience of his organization’s 2016 high-profile ransomware attack was among the top three most terrible events he has lived through in his professional and p....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: February 2019

By Mary Butler


Being told “there’s going to be an audit” triggers a fight or flight reaction of sorts. Visions of G-men in suits and ties, ominously wielding briefcases and calculators, spring to mind before the bearer of the bad news can clarify the context or minimize the i....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: February 2019

By Mary Butler


Patient privacy is at a true premium in retail pharmacies. Patients can choose to present at a drive-thru window, a desk that shares space with a cash register or two, a consultation window, or a script drop-off area where the only privacy barrier is behind the coun....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: September 2019

By Mary Butler


In the film The Farewell, Chinese-American actress and comedian Awkwafina plays a woman torn between two cultural approaches to death and dying when her character, Billi, learns that her grandmother has terminal lung cancer. Billi's grief is compounded when she....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: April 2014

Have a spare 32.8 million hours? The US Department of Health and Human Services (HHS) sure hopes so.


As noted in the Federal Register, that figure is the total number of hours the HHS Office for Civil Rights (OCR) estimated it would take all HIPAA-covered entities combined....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: August 2015

Information governance doesn’t look the same from organization to organization, or even industry to industry. Even if all healthcare organizations followed AHIMA’s Information Governance Principles for Healthcare™ (IGPHC) to the letter, every organization will inte....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: September 2015

Without a doubt, patient privacy rights have improved in recent years.


In the 1950s and 60s, and even well into the 1980s, it was standard for small-town newspapers to publish lists of the names of people, regardless of age, who were admitted or discharged from the hospital.....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: August 28, 2015

For many health IT stakeholders tackling the bugaboo of making electronic health records (EHRs) interoperable, it’s easy to imagine many of them thinking, This would be so simple without HIPAA or reimbursement. When it comes to the “one system, many providers” approach to EHR interoperabil....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: May 2016

Health information management (HIM) and coding professionals intent on keeping their jobs and their skills relevant would do well to study the career prospects of medical transcriptionists, their healthcare documentation brethren. As providers started transitioning to electronic health rec....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: April 2016

It is a dark and stormy night at a mid-sized regional trauma center when an EMS team brings in a 30-year-old man who is suffering from a prescription narcotics overdose. The patient is conscious but disoriented when he arrives on a gurney. When he wakes up, his loved ones, dutifully at his....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: March 2014

Sometimes one must call back into the past to understand the present and future.


When it comes to current challenges and successes with electronic health records (EHRs), the ongoing countrywide implementation mirrors that of another revolutionary wired device.

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2019

By Mary Butler


On the most widely used job search websites, listings for clinical documentation improvement (CDI) specialists typically look something like this:



Description: The clinical documentation improvement specialist provides support of clinical docume....

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2019

By Mary Butler


When you see a list of letters after a health information management (HIM) professional’s last name, it’s sometimes too easy to take for granted all the long, hard hours that went into earning and creating those acronyms. For both the credential earner and the certi....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: July 01, 2017

Wellness-obsessed consumers now have more tools at their disposal than ever before to help them “live their best lives,” as Oprah might say.


While employer-sponsored health insurance helps individuals gain access to access to care, employer-provided wellness programs can help....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: May 10, 2017

The journey from coding professional to C-suite executive isn’t really as far as it seems—just ask Cheryl Harmon, MBA, COO of St. Vincent Indiana, which is headquartered in Indianapolis, IN. Last year, Harmon—who started her health information management (HIM) career as a coder for an ambu....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: January 2017

While the healthcare industry plays “wait and see” with regard to what a Trump Administration means for the regulatory landscape of the last eight years, the events of this past year offer a few hints as to what we might expect in 2017.


Two major pieces of legislation passed....

Author: Butler, Mary

Source: Journal of AHIMA - website

Publication Date: December 2016

When people ask Davi Trotti, MA, RHIA, what it was like to live onboard the hospital ship Africa Mercy, she tells them “During the week I live in Europe and on the weekends I live in Africa.”


That’s because for three years, Trotti was the only person with a health information....

Author: Butler, Rhonda R.

Source: Journal of AHIMA

Publication Date: November 2009

Like the rest of us, MS-DRGs have to transition to ICD-10-CM/PCS. The conversion is off to a good start, with a preliminary version already available. The project offered an early test of the General Equivalence Mappings and provides a conversion process for other applications.

In m....

Author: Butler, Rhonda R.

Source: Journal of AHIMA

Publication Date: October 2007

In healthcare, diagnosis and procedure codes and their attached descriptions are the currency for many critical data transactions. Healthcare organizations rely heavily on coded data to govern reimbursement, monitor the health of the population, track trends in disease and treatment, and....

Author: Butler, Rhonda R.

Source: Journal of AHIMA

Publication Date: March 2008

A recurring theme in the ongoing ICD-10 implementation debate has been the need for a crosswalk between the old and new code sets to help the industry make the transition. The lack of an “official” mapping between ICD-9-CM and ICD-10-CM/-PCS has long been seen as a major challe....

Author: Butler, Rhonda R.; Mills, Ronald E

Source: Journal of AHIMA - Coding Notes

Publication Date: April 2009

Starting October 1, 2013, healthcare claims will be submitted to payers using ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. Some payers such as the Centers for Medicare and Medicaid Services (CMS) are converting their reimbursement systems to use ICD-10 codes directly. However, som....

Author: Butler, Rhonda R.; Mills, Ronald E; Averill, Richard F.

Source: Journal of AHIMA

Publication Date: June 2011

Automation is a major help in converting to the ICD-10 code set, but it is not a magical solution. In fact, skipping a human review of converted systems exposes an organization to legal and financial risk.

People who are secondary users of coded medical records-who see only the resul....

Author: Butterfield, Blair

Source: Journal of AHIMA

Publication Date: November 2012

Physician practices have made great strides in the last several years toward adopting EHRs, but even in the era of the HITECH Act and the “meaningful use” EHR Incentive Program, a large percentage of practices continue to drag their feet. Cost is certainly a factor for many practices, as is t....

Author: Buttner, Patty

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

Publication Date: February 2015

On January 1, 2015, the updates to the American Medical Association’s Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new Category II codes and 39 new Category III codes. There are a total of 129 revised codes and 137 deleted codes....

Author: Byrd, Katherine

Source: Journal of AHIMA

Publication Date: March 2001

Suppose you were asked to do something unethical on the job. What if you were asked by your supervisor to hide delinquent charts just prior to a Joint Commission survey? What would you do?

As a profession, HIM professionals understand our moral obligation to the patient to p....

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....

Author: Cacciatore, Victoria; Downing, Katherine

Source: Journal of AHIMA

Publication Date: June 2014

Release of information (ROI) has become a complex area for health information management (HIM) professionals. ROI staff and HIM management now must question and dissect every line on a request prior to release. Because of this, a quick reminder on some of the complex ROI risks is appropria....

Author: Cain, Jeannine Pugh; Clack, Lesley; Flanigan, Jill; Houser, Shannon H.; Kadlec, Lesley; VanSlyke, Daniel; Zeglen, Margie

Source: Journal of AHIMA

Publication Date: October 2017

Health informatics and information management (HIIM) is a rapidly changing profession. Core competencies of fundamental AHIMA certifications, such as the RHIA or RHIT, create a strong foundation for pursuing employment in a variety of high-demand positions. Today’s fast-paced technology l....

Author: Calhoun, Mona; Rudman, William J.; Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: August 2012

In collaboration with members and academic stakeholders, AHIMA proposes Reality 2016, a four-point plan for the future.

Author: Callan, Kathy; Fuller, Jan C.; Galterio, Louis; Just, Beth Haenke; Reich, Kimberly A. Baldwin-Stried ; Steigerwald, Christine; Turner-Combs, Mary Lou; Wolf, Sheldon H; Dooling, Julie A; Kirby, Annessa; Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: November 2014

Editor’s note: This article is part two of a two-part series analyzing the current state of health information exchange organizations and their operational models.


The question facing the healthcare industry is “will health information exchange organizations (HIOs....

Author: Callan, Kathy; Fuller, Jan C.; Galterio, Louis; Just, Beth Haenke; Reich, Kimberly A. Baldwin-Stried ; Steigerwald, Christine; Turner-Combs, Mary Lou; Wolf, Sheldon H; Dooling, Julie A; Kirby, Annessa; Rhodes, Harry B.

Source: Journal of AHIMA

Publication Date: October 2014

Editor’s note: This article is part one of a two-part series analyzing the current state of health information exchange organizations and their operational models.


Health information exchange (HIE) continues to be an embryonic domain—a swirling array of various pu....

Author: Campbell, Angela; D'Amato, Cheryl; Rugg, Donna

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2016

Editor’s Note: This Practice Brief is an update of the March 2010 version, which replaced the November 2007 Practice Brief “Planning for Present on Admission.”


Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to report patient primary and....

Author: Campbell, Angela; Houser, Shannon H.; Paulson, Dawn; Ryznar, Barbara; Smith, Clarice Pittillo; Woebkenberg, Jami; Hernandez, Sandra MSMIS, RHIA, CPHI, CCS, CHC; Pirie-St. Pierre, Mari RHIA, CPHI; Plimpton, Julie MSHI, RHIA, CPHI

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2018

Editor’s Note: This Practice Brief supersedes the September 2014 Practice Brief “Defining the Basics of Health Informatics for HIM Professionals.”


Data, data everywhere! We are living in the age of “Big Data” and healthcare informat....

Author: Campbell, James R.

Source: Journal of AHIMA

Publication Date: August 2019

By James R. Campbell, MD, FACP, FACMI


Editor’s Note: This article is an excerpt from Chapter 17 of Healthcare Code Sets, Terminologies, and Classification Systems, Fourth Edition, published by AHIMA Press.


In 2007, the Institute of Medicine set a vision for the....

Author: Campbell, Keith E.; Giannangelo, Kathy

Source: Journal of AHIMA

Publication Date: February 2007

Health IT is bogged down in a quagmire of unaligned classification and terminology systems. New recommendations from AHIMA and AMIA help point to the way out.

The healthcare industry is looking to IT to reduce costs, assess quality of care, and deliver services more effici....

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....

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: October 2013

A 75-year-old man sits uncomfortably on an examination table as his physician informs him that he needs to get a colonoscopy. The patient, an ex-cop, barks at the physician, “Why after all these years do I need to get a colonoscopy?” The physician coolly responds, “With a....

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: February 2013

[dih-fahy-ning] [helth] [in-fer-mat-iks]


adjective, noun, noun


1. An educator’s in-depth look at what informatics is and what it can do for HIM professionals



In the movie Annie Hall, Woody Allen finds himself in a movie theater line in....

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: November 2005

Linking PHRs and provider Web sites can connect consumers to relevant and reliable health information online. HIM professionals can help.
Each day more and more consumers are using the Internet to locate Web-based healthcare information. This activity has led to the rise of a new field o....

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: November 2013

Imagine having a friend who can identify the name of a song after hearing one or two notes, or an acquaintance who can identify a film from a single "still" frame taken from the movie. If this sounds familiar, maybe it's because of the way it reminds you of how a physician thinks about the....

Author: Campbell, Robert James

Source: Journal of AHIMA

Publication Date: June 2009

Lean thinking is the efficient use of staff, resources, and technology to provide the highest level of service possible to the ultimate healthcare customer: the patient.

In today’s volatile healthcare environment, health information managers are being asked to do more with less....

Author: Campbell, Robert James; Brantley, Jeffrey

Source: Journal of AHIMA

Publication Date: August 2011

HIM professionals need more than tools to manage information, they need tools to help manage the stress and anxiety a state of constant change can bring. "Mindfulness" offers a way to reduce anxiety and keep focused.

During times of change, people may react with fear, ange....

Author: Campbell, Susan E

Source: Journal of AHIMA

Publication Date: January 2016

Information for general health information managers about the standards development framework and process—with a focus on mobile health For Patient and Self Care

Author: Campbell, Thea

Source: Journal of AHIMA

Publication Date: November 2003

The pressure on all healthcare organizations for improved financial performance continued to grow in 2003. Many healthcare organizations experienced a financial loss in the first quarter of 2003, and disproportionate reimbursement-to-expenditure ratios in healthcare are straining all organizat....

Author: Camp, Michelle; Comfort, Angie; Endicott, Melanie; Howard, Artis; Kozee, Renee; Munive, Roberta; Novelli, Staci

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: November 2014

Whether it is a first job or a career change, finding that first health information management (HIM) job following graduation is one of the biggest challenges that new graduates face. While some may find that breaking into the HIM industry takes time and persistence, it is a career choice that....

Author: Cange, John R

Source: Journal of AHIMA

Publication Date: January 2016

To prevent a problem, however, requires that you understand the potential causes of the problem—and this understanding requires data. A complete understanding requires a complete dataset. In the case of HAIs, the ideal dataset would contain data concerning every type of HAI from ever....

Author: Cannon, Jay; Lucci, Susan

Source: Journal of AHIMA

Publication Date: February 2010

Mixing transcription and templates for physician documentation offers a practical way forward in organizations transitioning to electronic records.

One of the biggest roadblocks to successful adoption of electronic health record (EHR) systems concerns physician documentation; specifi....

Author: Cannon, Jeanne

Source: Journal of AHIMA

Publication Date: March 2003

HIPAA compliance might be one of the biggest challenges of the decade for covered entities—and not only because of all the new requirements. Simply reading and interpreting the regulations has proven to be a monumental task. So how can a HIPAA team leader make staff enthusiastic about lea....

Author: Carey, Susan

Source: Journal of AHIMA

Publication Date: May 2017

So far 2017 is shaping up to be the year of fear in the realm of healthcare cybersecurity. There was a 61 percent increase in healthcare cyberattacks in 2016. This followed two years of steadily increasing cyberthreats in healthcare, including 93 major cyberattacks in 2016 resulting in com....

Author: Carey, Susan

Source: Journal of AHIMA

Publication Date: January 2019

By Susan Carey, MHI, RHIT, PMP, FAHIMA


Outsourcing, whether delegating work to companies within the US or to other countries (offshore outsourcing), has become a strategic consideration and business model in many areas of the healthcare industry, including healthcare IT, health in....

Author: Carey, Susan; Beahan, Sally

Source: Journal of AHIMA

Publication Date: September 2016

Historically, health information management (HIM) staff has provided paper copies of medical records in response to authorized requests. No specialty patient education was needed because the paper record was essentially self-explanatory.


But with the ongoing industry trans....

Author: Carlson, April M; Goldman, Daniel JD; Milnes, Burke MPA; Otte, Kimberly JD; Schacht, Morgan JD

Source: Journal of AHIMA

Publication Date: June 2019

By April Carlson, MBA, HCISSP, CFE; Daniel Goldman, JD; Burke Milnes, MPA; Kimberly Otte, JD; and Morgan Schacht, JD


Hoping to balance the competing demands to share information while also protecting it, Mayo Clinic has developed a process to review disclosures of data that is ris....

Author: Carlson, April M; Goldman, Daniel JD; Milnes, Burke MPA; Schacht, Morgan HCISSP, CFE; Otte, Kimberly JD

Source: Journal of AHIMA

Publication Date: June 2019

Author: Carnrite, Michael; Sumner, Susan

Source: Journal of AHIMA

Publication Date: September 2012

The latest data from the Centers for Medicare and Medicaid Services report that Medicare and Medicaid incentive payments for the meaningful use of electronic health records (EHRs) have reached more than $5 billion. Medical transcription has played a role in providers’ attainment of these incen....

Author: Carnrite, Michael; Sumner, Susan

Source: Journal of AHIMA

Publication Date: October 2012

For decades Medical transcription has been an important fixture of the health information management (HIM) department. Compiling, managing, and retaining transcribed documents as a subset of the entire patient medical record is a foundational role for HIM professionals. And while the electron....

Author: Carolan, Katie

Source: Journal of AHIMA

Publication Date: February 2011

HIM professionals can help move their organizations' ICD-10-CM/PCS transitions off the back burner by working with their systems' vendors to establish upgrade schedules, training, and transition staffing.

The ramp-up to ICD-10-CM/PCS has been slow...at best. Focused on implement....

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: Carol, Ruth

Source: Journal of AHIMA

Publication Date: April 2004

The HIPAA privacy rule implementation is a year in the past. So what are privacy officers doing with all their spare time?
In the long, hectic months leading up to April 2003, privacy officers were preparing their organizations for the implementation of the HIPAA privacy rule. Not only w....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: April 2003

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: March 2007

Leaders from HIEs forming at the state level talk about their organizations’ unique potential and unique challenges.
Just as healthcare is local, the solutions for sharing patient data are often local, also. However, there is growing interest in the role of networki....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: April 2009

Reporting quality measures may become an easier and more fruitful task as technology’s ability to glean data from physician documentation matures.




Healthcare organizations have been asked to report quality measures since the 1990s. The activity wen....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: June 2003

Spending a lot of time with the IT department lately? As HIM processes become automated and demand increasingly sophisticated technology, HIM professionals are making IT professionals their closest allies.
Whether you’re acquiring an electronic master patient index, implementing a t....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: September 2006

Changing practice and new opportunities are sending HIM professionals back to school in degree-granting programs. The benefits begin immediately.
They do it to meet the demands of a changing workplace, move up the management ladder, or pursue new avenues in the field. Some do it for pers....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: July 2006

When Allyn Mavity, RHIT, became HIM director for Pattie A. Clay Regional Medical Center in Richmond, KY, 30 years ago, the notion that one day medical records would become electronic never entered her mind. But healthcare delivery and HIM have changed over the decades. When faced with a burgeon....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: October 2005

David Brailer and industry experts comment on ONC’s busy year and tell the Journal what they expect in the one to come.
Late in 2004 the Office of the National Coordinator for Health Information Technology (ONC) requested input from the healthcare industry on how best to develop an....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: January 2002

Employers find data valuable, but still seek other measures. In this article, experts assess the uneasy relationship between the business community, healthcare organizations, and accreditation.
Stirring in the healthcare arena is an alphabet soup of accrediting bodies. There’s the....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: January 2007

E-prescribing has long been a dream for many healthcare organizations. However, a pilot study on e-prescribing's effects on long-term care shows that it can easily become a reality for the industry.
A pilot project to study the effects of e-prescrib....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: November 2002

Collecting the data is just the beginning. Data quality managers turn patient care data into the information needed for research, quality reviews, and future planning. And it's a job for which HIM professionals are ideally suited.
An obstetrics department resident wants to know how many p....

Author: Carol, Ruth

Source: Journal of AHIMA

Publication Date: April 2006

EHRs demonstrated their promise during Hurricane Katrina. But the storm's greatest lesson for HIM is the necessity of contingency planning for health information.
By now we've heard numerous stories about the piles of pulp that used to be patient medical records and the shelves of mildewe....