AHIMA BoK: Search for

Publication Date: January 2015

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

The role of the clinical documentation improvement (CDI) professional is ever-changing. When CDI programs first began in the late 1990s, the focus was almost....

Beyond Y2K: No Rest for the Weary

Author: Burghard, Cynthia; Duncan, Matt; Galimi, Joanne; Hieb, Barry; Young, Janice

Source: Journal of AHIMA

Publication Date: September 1999

When the dust of Y2K has settled, what information systems projects will be next on the to-do list? The authors look at four trends you won't be able to ignore.
The turn of the century is only three months away. By now, it is to be hoped, most healthcare organizations (HCOs) have complet....

Managing Amendments in an HIE Environment

Author: Burns, Janelle; Costello, Stephanie; Lewis, Sharon; Meyer, Melanie; Panzarella, Deanna; Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: January 2018

Managing Amendments in an HIE Environment

The era of electronic health information has increased the complexity of managing amended protected health information (PHI) and the designated record set (DRS). Historically, changes had to be made to handwritten and transcribed reports and then co....

Legal EHR FAQs

Source: AHIMA Q and A | Journal of AHIMA

Publication Date: October 2007

As healthcare organizations implement electronic health records (EHRs), more are re-examining the make-up of their legal health record. They frequently have questions about producing information from EHRs as well as how organizations should begin to define their legal health records.
....

Regulations Governing Research (2003)

Publication Date: March 2003

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

Practice Toolkit: Hospice

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....

On the Line: Professional Practice Solutions (5/03)

Source: Journal of AHIMA

Publication Date: May 2003

Q: What is an organized health care arrangement (OHCA) and what are its advantages?

Q: What is multi-factor authentication?

Jill Burrington-Brown (jill.burrington-brown@ahima.org) is an HIM practice manager at AHIMA.Article citation:
Burrington-Brown, Jill. "On the Line....

Leaping Ahead with Patient Safety

Source: Journal of AHIMA

Publication Date: April 2002

These days Leapfrog is more than just a child’s game. Since 1998, the Leapfrog Group, made up of more than 90 Fortune 500 companies and other large private and public healthcare purchasers, has worked toward improving the safety of healthcare for US consumers.

A 1999 repor....

The Arrest of a Nurse in Utah and Relevant Laws

Source: Journal of AHIMA

Publication Date: February 2018

By Jill Burrington-Brown, MS, RHIA, FAHIMA

On July 26, 2017, Alex Wubbels, a nurse in the burn unit at the University of Utah in Salt Lake City, was arrested in an incident that has since been viewed widely on video captured from police body cameras. She refused to let a police phlebotomist....

On the Line: Professional Practice Solutions (2/04)

Source: Journal of AHIMA

Publication Date: February 2004

Q: Can you explain the difference between the terms “addressable” and “required” as they are used in the final security rule?

Q: Our organization is building an electronic health record. What do we need to consider as we develop a printing policy?

J....

On the Line (June 2004)

Source: Journal of AHIMA

Publication Date: June 2004

Q: Why shouldn’t we document incidents or incident reports in the patient’s health record? Isn’t it a part of the documentation of the patient’s care? Don’t incident reports become evidence if there is legal action?

A: First, we should define “i....

Consumer Empowerment: Four Projects from AHIC Point to a New Direction in Healthcare

Source: Journal of AHIMA

Publication Date: March 2006

Consumer empowerment in healthcare is quickly becoming a national focus as a way to target rising healthcare expenditures, improve patient safety, and better healthcare information availability. Why is this movement of interest to the HIM community? There is much for us to contribute to the is....

Disaster Planning for a Mass-casualty Event

Publication Date: November 2002

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

Handling Complaints and Mitigation

Publication Date: November 2003

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

Tips for Successful Teamwork

Source: Journal of AHIMA

Publication Date: June 2006

AHIMA’s e-HIM work groups have had great success in bringing together groups of HIM professionals to explore and create guidance on cutting-edge e-HIM practices and technology. These groups also teach us lessons about the factors of successful teamwork that we can apply to our own work si....

Using Procedure-based Risk Adjustment to Better Predict Outcomes

Source: Journal of AHIMA

Publication Date: January 2003

When an organization assesses its quality of care, applying benchmarks can be difficult when the population of the organization is different from the benchmarking organizations. How can an organization use benchmarking data that reflects the reality of its population?

“Pr....

Six Sigma Makes Sense as Quality Initiative

Source: Journal of AHIMA

Publication Date: May 2002

Is the Six Sigma business management system the “new kid on the block” in terms of quality initiatives? It may be new to healthcare, but it has been in place at various manufacturers, most notably Motorola, since the 1980s.

This article examines how Six Sigma is bein....

In Search of Document Imaging Best Practices

Source: Journal of AHIMA

Publication Date: September 2008

The number of healthcare providers implementing document imaging as a part of their electronic health record solution is on the rise. In order to help others navigate the process, the following HIM professionals offer their experiences in planning, selecting, and implementing document imaging....

On the Line: Professional Practice Solutions

Source: Journal of AHIMA

Publication Date: January 2003

When is it legal to disclose protected health information (PHI) to clergy?
Is faxing patient information legal under HIPAA?
Does HIPAA allow clinicians in our home health facility to pull their own records?
What is a "shadow record?"
Jill Burrington-Brown (jill.burrington-b....

Working Online: Hazards Ahead

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....

PHR Effect

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....

Dictating for Dollars: Is It for You?

Source: Journal of AHIMA

Publication Date: April 2004

Even with increasingly automated systems, the dictation of discharge summaries in a timely manner is still an issue. Some managers report that physicians are requesting hospitals provide them relief by allowing them to hire nurses, physician assistants, or HIM professionals to dictate the disc....

Transforming Nursing through EHRs: An Overview of the TIGER Initiative

Source: Journal of AHIMA

Publication Date: February 2008

In February 2007 the Technology Informatics Guiding Educational Reform (TIGER) Initiative, a group of nursing and informatics leaders, released a report titled “Evidence and Informatics Transforming Nursing: 3-year Action Steps toward a 10-Year Vision.”1 The report describes ho....

VA Puget Sound Reaps Benefits of Automation

Source: Journal of AHIMA

Publication Date: March 2003

What is it like to work in a fully automated healthcare system? As a visitor, I was doubly curious, because the topic of my management practicum in 1977 was preparing the Veterans Affairs Puget Sound Health Care System MPI for computerization. This was a sophisticated practicum at the time bec....

On the Line: Professional Practice Solutions

Source: Journal of AHIMA

Publication Date: January 2002

Q: A couple were on vacation in my city when the husband suddenly became ill and died in our facility. The wife requested copies of the record to take home with her. She had listed herself as next of kin. Was it correct to give her a copy of the record?

Q: I am a manager of several d....

Power of Patient Access

Source: Journal of AHIMA

Publication Date: May 2005

As health information moves online, a debate has developed about whether patient access to medical information improves outcomes and patient satisfaction. Two recent studies indicate that patient access can both boost satisfaction and empower patients to take greater control of their healthcar....

Provider's Eye-View of PDAs

Source: Journal of AHIMA

Publication Date: January 2002

Personal digital assistants (PDAs) are becoming a more common sight in healthcare settings, but how are providers using them? We asked three experts to describe their experiences.

K. Meg Morrison, MD, ABFP, is the associate director of the Mount Carmel Family Practice Residency in....

Perfecting the Communication Process

Source: Journal of AHIMA

Publication Date: January 2003

Most of us do not think of communication as a process but rather as a talent or ability that only a few people possess. But when communication is considered a process, anyone can be an effective communicator.

The work of Stanford University computer science professor Terry Wino....

What's Your EHR IQ?

Source: Journal of AHIMA

Publication Date: September 2007

HIM is becoming more automated and electronic every year. The basic skill set of the HIM professional has changed dramatically. The acronyms abound, from HL7 and CCHIT to HIEs. It can be hard to keep up with all the latest developments. Test your EHR IQ by answering the following questions....

Information Therapy: A New Interest for HIM

Source: Journal of AHIMA

Publication Date: June 2009

HIM professionals involved in patient advocacy and the personal health record will have an interest in information therapy: getting patients the information they need to better manage their health.

Information therapy (Ix) is of interest in health information management, particu....

Does the Privacy Rule Hinder Patient Care?

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....

Risk Assessment: Doing More With Less

Source: Journal of AHIMA

Publication Date: October 2003

In an October 2002 Journal article, eight out of 10 HIM managers interviewed mentioned trying to keep up with the workload with fewer resources as a top concern.1 In this time of rapid changes in healthcare, how do we decide what to prioritize when everything we do seems to be high priority? T....

Web-based System Improves Access

Source: Journal of AHIMA

Publication Date: March 2002

Does the idea of the paper medical record dying a natural death due to irrelevancy sound intriguing? This is the future of the paper medical record, according to Bruce Elkington, chief information officer of Overlake Hospital Medical Center in Bellevue, WA. The strategy at Overlake has been to....

On the Line: Professional Practice Solutions

Source: Journal of AHIMA

Publication Date: July 2002

Q: I work in a clinic setting. An attorney has requested copies of a patient's entire record. The record includes reports dictated by one of the clinic physicians at a local hospital during the patient's hospitalization. The attorney has the patient's permission. Are we allowed under HIPAA to....

On the Line (November-December 2004)

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....

Practical Disaster Planning for Healthcare Facilities

Source: Journal of AHIMA

Publication Date: February 2002

Disaster planning relies on imagining events that we hope and often believe will never happen. After the tragedies of September 11, however, imagining a large-scale disaster is no longer difficult and disaster planning has come to the fore. In this article, we look at several important lessons....

Sorting Out Employee Sanctions

Source: Journal of AHIMA

Publication Date: June 2003

Has your organization addressed sanctions related to privacy and security issues? Both the final privacy rule and final security rule address this issue. The privacy rule states that the covered entity must “have and apply appropriate sanctions against members of its workforce who fail to....

On the Line: Professional Practice Solutions (10/03)

Source: AHIMA Q and A | Journal of AHIMA

Publication Date: October 2003

Q: Does the privacy rule allow us to release patient information over the telephone without authorization? How do I decide when I should ask for verification of a treatment relationship with the patient?

A: In the past, HIM professionals have carefully guarded the releasing of patient i....

Educating the Public about Personal Health Records

Author: Burrington-Brown, Jill; Friedman, Beth

Source: Journal of AHIMA

Publication Date: October 2005

AHIMA’s Community Education Campaign for personal health records (PHRs) is in full swing, and the response among AHIMA members has been enthusiastic. Demand for the campaign’s training programs has been so high that several states have waiting lists of those who want to be trained.....

Health Data Access, Use, and Control

Author: Burrington-Brown, Jill; Hjort, Beth M.; Washington, Lydia

Publication Date: May 2007

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

Author: Burrington-Brown, Jill; Rhodes, Harry B.

Publication Date: June 2002

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

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....

Making Amendments to Health Records (2017 Update)

Author: Burton, Ben; Downing, Katherine

Publication Date: April 2017

Editor’s Note: This Practice Brief update supplants part of the 2013 Practice Brief “Patient Access and Amendment to Health Records.”

Before April 2003, a patient’s legal right to amend his or her health records was limited to those patients treated at hea....

Life Cycle of a Project: How to Plan for Performance Improvements

Author: Burton, Lloyd R.

Source: Journal of AHIMA

Publication Date: October 2003

Many HIM professionals are finding project management in their job descriptions. This excerpt from AHIMA’s textbook, Quality and Performance Improvement in Healthcare: A Tool for Programmed Learning, provides a closer look at the phases of a project.
When a performance improvement (P....

Digging Out from Data Hoarding: Using Governance to Manage Information Assets and Prevent Digital Data Avalanches

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: October 2014

If a brazen television show producer were looking to cash in on the popularity of shows about hoarders, observing a health information management (HIM) department could be a good place to start.

Stories about hoarding records abound. Some hospitals have reinforced their fl....

AHIMA Releases Information Governance Graphic

Author: Butler, Mary

Publication Date: March 2015

For the uninitiated, information governance can be a somewhat abstract concept to explain and visualize. To help health information management (HIM) professionals grasp the importance of information governance—a set of principles designated to better organize and protect healthcare da....

Workaday Informatics: How Healthcare is Applying Practical Informatics to Save Dollars and Lives

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: May 2015

Watch and learn. For clinical informaticist Nathan Patrick Taylor, MPH, MS, CHDA, and others like him, watching patient-physician encounters and learning from them is just as important as knowing how to query data in a health IT system. Because as technical as informatics can get, at its....

Stocking HIM's Workbench for the Year Ahead

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: January 2016

By Mary Butler

As the old canard goes, "if all you have is a hammer then everything looks like a nail." Which is to say that specialists in a given area tend to only consider their specialty and miss the big picture. To personally disprove the idiom, one ideally has multiple too....

Information Governance’s Next Phase: Moving HIM From the 'Why' of IG to the 'How'

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: August 2015

Prior to the 2010 signing of the Patient Protection and Affordable Care Act (ACA) by President Obama, nearly anyone who had interacted with the American healthcare system could agree that it was, in many ways, broken. Millions of Americans were uninsured—due to either pre-existing co....

Preventing Healthcare's Top Four Documentation Disasters

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2015

One of the most famous cases in medical history that led to regulation of the number of hours that resident physicians are allowed to work is also a case study in clinical documentation failures.

In 1984, a college student in New York, NY named Libby Zion was admitted to a....

Life After ICD-10: How the Healthcare World Will Change After ICD-10's Implementation

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2015

Anyone who has bought a home has inevitably heard at some point along the way that “real estate is always a gamble.” That’s cold comfort for anyone who’s plunked down earnest money on a fixer upper. But smart buyers know that if they’ve done their research and invested in the right places....

Building an HIM Program for the Federal Aviation Administration

Author: Butler, Mary

Publication Date: July 2015

The HIM Problem: The Federal Aviation Administration (FAA) manages the autopsy records of hundreds of pilots killed in accidents every year, but until 2008, health information management (HIM) professionals weren’t leading the efforts.

The HIM Problem Solver: Christy Hileman....

Keeping Coding Skills Sharp and Spirits High During the ICD-10 Delay

Author: Butler, Mary

Publication Date: May 2015

The HIM Problem

The legislative and regulatory delays for the go-live date for ICD-10-CM/PCS have left some hospitals and physician practices skittish about investing in training and education programs. While a “boy who cried wolf” syndrome exists in some corners of healthcare, fo....

Preventing Fraud and Abuse in Clinical Documentation

Author: Butler, Mary

Publication Date: July 2015

The HIM Problem: The US Department of Health and Human Services’ Office of the Inspector General (OIG) is expected to increase enforcement activities surrounding clinical documentation and fraud. Training and awareness are key in preventing penalties.

The HIM Problem Solver:....

Why an Informatics Degree Matters

Author: Butler, Mary

Publication Date: April 2015

The HIM Problem

As HIM becomes increasingly data-centric, knowledge of informatics is becoming an essential tool.

Today, it’s hard to identify even one aspect of health information management (HIM) as a profession that isn’t profoundly affected by the use,....

Biggest Security Lapses for 2014-2015 and How to Handle Them

Author: Butler, Mary

Publication Date: April 2015

In the privacy and security world, whenever a big health data breach makes the news, HIPAA experts warn that it’s only the beginning and the news will only get worse. Over the last year that has certainly been the case as the size and scope of breaches has climbed.....

Mastering the Inbox Information Era: Patient-Generated Data and Mobile Health are Changing the Management of Health Information

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: September 2015

When Melissa Ziller’s daughter was diagnosed with type 1 diabetes three months before her third birthday, Ziller grappled with all the usual worries that come with the diagnosis. Chief among them was pricking her toddler’s fingers multiple times per day to test her glucose levels. Shortly....

Pokémon Go Poses Privacy and Security Concern for Healthcare Providers

Author: Butler, Mary

Publication Date: July 21, 2016

The mobile app game that has thousand of players roaming streets, parks, and even workplaces—healthcare providers included—has health privacy experts concerned.

Pokémon Go is a smartphone app that uses a phone’s GPS and camera to help players search for virtual chara....

Patient Safety Identifiers Could Improve Outcomes for John Does

Author: Butler, Mary

Publication Date: October 28, 2016

AHIMA’s advocacy work around accurate patient identification, particularly through this last year’s #MyHealthID campaign, is part of an effort to raise the public’s consciousness about the risks of inadequate patient identification. The campaign aimed to reach patients, lawmakers, and....

Cultivating Healthcare Information Governance: How to Grow Your Program Maturity

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: February 2016

Buying tomatoes at the grocery store or farmer’s market will suffice for most cooks. For others, particularly those with a green thumb, growing their own is the only way to fulfill all their salsa and marinara sauce fantasies.

These devotees understand that a garden ca....

Survey: Coding Productivity Dipped After ICD-10 Implementation

Author: Butler, Mary

Publication Date: June 13, 2016

The implementation of ICD-10 did result in a perceived loss of coding productivity, with a minimal dip in coding accuracy, according to a recent coding productivity and accuracy survey. The survey was conducted by the AHIMA Foundation in the first three weeks of May, and was released today....

Solving the Health IT Interoperability Quagmire

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: August 2016

As the sun begins to set on the Obama administration, Vice President Joe Biden has been leveraging the weight of his office to speak out on the health IT interoperability quagmire in which the nation currently finds itself. During a speech at the industry’s Health Datapalooza in May,....

Analyzing Eight Months of ICD-10

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: June 2016

Teachers know there are two kinds of students. Student A studies and does their assigned reading throughout the whole semester, earning extra credit where they can. When the final exam rolls up, they’re anxious but prepared—they did their homework. Student B, on the other hand, has the sa....

Don't Leave Money on the Table: Mastering MACRA, PQRS, and Value-Based Purchasing: How Quality Coding Impacts Quality Reporting

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: September 2016

Whenever there’s a flashy new piece of consumer technology, there are always holdouts who insist on sticking with the old, more comfortable way of doing things. Consider a grammarian who rejects online dictionaries for a cumbersome hard-bound book. Or the road tripper who prefers their an....

New ONC Chief Touts Importance of Standards Development Work

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: November 2016

The new National Coordinator for Health IT, Dr. Vindell Washington, MD, plans to focus on some old issues for the healthcare industry—a lack of universal standards, limited interoperability, and the difficulty present for both providers and consumers trying to exchange and access hea....

Information Release to Patient Families and Caregivers: What Does HITECH/HIPAA Actually Say?

Author: Butler, Mary

Publication Date: July 01, 2016

One of the most important objectives of the HIPAA Privacy Rule—and the HITECH Act in particular—was to ensure that consumers have easy and affordable access to their own protected health information. The regulations also clarified how and when medical information about a patien....

Managing a Part-Time Remote CDI Team

Author: Butler, Mary

Publication Date: July 29, 2016

As clinical documentation improvement (CDI) programs become more popular, providers are still struggling with implementing CDI programs for several different reasons, including: geographical location; a shortage of outpatient coders and CDI specialists; or even the lack of physi....

Making HIPAA Work for You: Discussing Record Access (and More) for Consumers

Author: Butler, Mary

Publication Date: August 01, 2016

The US Department of Health and Human Services (HHS) has taken many steps to try and clear up consumer confusion regarding the more consumer-centric aspects of HIPAA’s Privacy Rule and Security Rule. The most recent efforts include the Office of the National Coordinator’s Patien....

ICD-10 Has Arrived

Author: Butler, Mary

Publication Date: October 2015

Ready or not, Judgment Day is here—and if you’re reading this, then you have reached the historic go-live of ICD-10-CM/PCS in one piece. For at least the next month and a half, however, it will be a “hurry up and wait” situation before providers can say with any co....

"CDI: Miami" Hunts Down Documentation Offenders

Author: Butler, Mary

Publication Date: October 2015

The HIM Problem

To get physician buy-in on clinical documentation specificity, one provider formed an all-physician CDI team

The HIM Problem Solvers

Lorena Chicoye, MD, RPh, corporate medical director, managed care network development and medical....

ICD-10 Two Weeks In: How’s it Going?

Author: Butler, Mary

Publication Date: October 2015

Two-plus weeks into the transition to ICD-10-CM/PCS, the chaos predicted by many groups that protested the code sets’ implementation for years has not come to fruition. In fact, preliminary reports from providers, commercial payers, and coding consultants indicate quite the oppo....

DIY Privacy Risk Assessments

Author: Butler, Mary

Publication Date: November 2015

The HIM Problem

Completing regular privacy risk assessments is one of the most proactive ways of preventing healthcare privacy breaches. However, finding helpful tools for these assessments is hard to come by.

The HIM Problem Solver: Sharon Lewis, MBA, RHIA, CHPS, CP....

Access to Health Information: It Takes a Village

Author: Butler, Mary

Publication Date: December 2015

Obtaining access to one’s written or electronic medical records in a timely manner is one of the guarantees listed in AHIMA’s “Consumer Health Information Bill of Rights.” Yet, for one consumer, Amanda Michelle Jones, MS, AM, being on a first-name basis with medical records depa....

Tips for Preventing and Responding to a Ransomware Attack

Author: Butler, Mary

Publication Date: April 01, 2016

As predicted, 2016 is proving to be the year of ransomware, with multiple reported incidents making news as we approach April. As they become startlingly more common, it’s important that HIM professionals be aware of how preventable they are, says Tom Walsh, CISSP, founder and managing partner of tw-Security. Just as with other types of data breaches, ransomware attacks are the result of human intervention—that’s also where they end.

Patient "Privacy Numbers" Help Provider Share Info, Protect Privacy

Author: Butler, Mary