Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: April 2017

Editor’s Note: The following is an excerpt from the new “External HIPAA Audit Readiness Toolkit” developed by AHIMA. The full toolkit is free for AHIMA members.


THE HITECH OMNIBUS Rule mandated that the US Department of Health and Human Services (HHS) condu....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2015

Do you analyze case mix? Have you been asked to run a report on patients seen in the emergency department with dog bites? Do you report monthly physician query trends? Have you ever been asked to “pull that information out of the EHR?” Do you know that revenue code 361 often re....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2011

Federal incentives provided for the meaningful use program under the American Recovery and Reinvestment Act are encouraging hospitals to adopt electronic health records (EHRs). Eighty percent of hospitals are planning to become meaningful users of EHR technologies in 2011, and the healthcare i....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: October 2014

Healthcare has become a data-rich field, and any data rich environment requires the ability to analyze large, complex data sets. The field of informatics provides tools to integrate data, information, knowledge, and wisdom when processing data. Good informatics includes many functions, and....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: April 2010

For most organizations, patient-identifiable source data include data from interpretations, summaries, or notes. These data are usually maintained within the originating department, separate from the HIM department and the health record, and sometimes in a different database. Examples incl....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: September 2010

Many types of documentation errors can occur in electronic health records (EHRs), such as incorrectly recording the sex of a patient, documenting in the wrong patient record, and incorrectly identifying the ordering physician on a laboratory report.


It is important to addres....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: June 2014

There is a growing hunger in healthcare today for attaining meaningful data. It is no longer an option to sift through large amounts of data stored in a variety of systems, spending valuable man hours to produce information that can be utilized to make good business decisions. Allowing fo....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2007

PEPPER data help facilities compare their Medicare payments with state and national averages. Here’s how to read yours.
Hospitals can take advantage of a report that helps them compare their Medicare reimbursement to state and national averages. What they learn can help them....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2013

Clinical documentation requirements are expected to increase as healthcare systems are challenged with complex new audits, ever-changing compliance rules, and a transition to ICD-10-CM/PCS. All of these initiatives will specifically challenge clinical documentation improvement (CDI) profes....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2012

Managing healthcare issues today places many HIM professionals in the role of consumer educator. This is especially true when consumers are coping with end-of-life issues. Legal documents are imperative for determining a patient's treatment care wishes, managing requests for information, and f....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2014

Patient matching and identity management has been a critical component of health information management (HIM) since the beginning of the profession, when master patient indices (MPI) were kept on 3x5 inch index cards. HIM professionals don’t have to be told about the challenges with dupli....

Author: Wiedemann, Lou Ann

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

Publication Date: July 2007

Section 5001(a) of the Deficit Reduction Act introduced a new data reporting standard for hospitals submitting Medicare claims. The present on admission (POA) indicator will be a requirement for inpatient Medicare claims submitted by all hospitals on October 1, 2007.

This a....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2010

This issue the Journal introduces a new “Working Smart” column offering best practices for working in the e-HIM environment.

Since the advent of the HIM profession many have struggled with the chart completion process. In the paper environment, the process began with assembling mount....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: May 2010

The laboratory system within an EHR automates the historical process in which technicians documented results on lab shingles and pasted them on pages in the health record. In the paper environment, shingles were numerous and often taped one on top of the other to condense the record.

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: November 2011

Understanding an organization's physician classifications is important. Physician classifications drive documentation requirements such as history and physicals, consultation reports, and discharge summaries. In addition, physician classifications often outline the extent of direct patient car....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: March 2011

Managing third-party requests for health information is a routine function for every HIM department. HIM professionals regularly receive record requests from third parties for a variety of reasons, such as revenue integrity audits or admission validation reviews.

Historically, fulfi....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2014

Reactions within the healthcare community to the ICD-10-CM/PCS implementation delay are varied. Many clinical documentation improvement (CDI) specialists are already well into ICD-10-CM/PCS code set education and may see the delay as a frustrating set back, while others view it as an oppor....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: January 2013

Clinical documentation is the foundation of every health record, specifically outlining the reasons for treatment and the quality of care provided to the patient. The lack of consistent and standard clinical content within the health record has been an ongoing challenge to health informati....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: September 2009

On February 17, 2009, President Barack Obama implemented sweeping healthcare legislation when he signed the American Recovery and Reinvestment Act of 2009 into law. ARRA includes many privacy, security, work force, and health IT provisions that will have a major impact on the healthcare in....

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: May 2019

By Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA


What do population health, disease management, predictive modeling, and surgical case indices have in common? They are all a part of bridging coded data to real-time data analytics. Coding professionals have a long history of tran....

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....

Author: Wieczorek, Michelle M.

Source: Journal of AHIMA

Publication Date: January 2004

Saint Vincent Health System’s HIM department checked its document imaging system into the emergency room. Together, the two departments saved nothing but time. The program’s success led to an enterprise-wide electronic document management system.
In 1988 Saint Vincent Health....

Author: Whittle, Kelly

Source: Journal of AHIMA

Publication Date: September 2016

It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....

Author: Whitney, Jo Ellen

Source: Journal of AHIMA

Publication Date: May 2007

Generally when an opposing party is seeking medical records from a care provider, the first request is accompanied by a subpoena, which can be difficult for an HIM department to assess in terms of what-if any-records can be produced.

A subpoena accompanied by a HIPAA-compliant consen....

Author: White, Susan E; Taylor, Lisa Brooks

Source: Journal of AHIMA

Publication Date: November 2012

Value-based purchasing of healthcare is transforming the US healthcare delivery system and payment methodologies. Spurred by commercial pay-for-performance initiatives and the roll out of the Centers for Medicare and Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP), accountable....

Author: White, Susan E; Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: July 2014

The health information management (HIM) field is growing and changing at a swift pace, with HIM professionals having to navigate value-based purchasing, quality metrics, health disparity and population health studies, and a never-ending stream of Big Data. As experienced HIM professionals....

Author: White, Susan E; Kallem, Crystal; Viola, Allison F.; Bronnert, June

Source: Journal of AHIMA

Publication Date: June 2011

In April the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking for the Medicare Shared Savings Program. The program was mandated by the Affordable Care Act to encourage the development of accountable care organizations (ACOs) in Medicare.

The....

Author: White, Susan E

Source: Journal of AHIMA

Publication Date: April 2013

One of the newest buzz words in data analytics is “Big Data,” and the data created through the healthcare industry is some of the “biggest” around. The widespread implementation of electronic health records (EHRs) and the need to share data to measure quality and ma....

Author: White, Susan E

Source: Journal of AHIMA

Publication Date: September 2011

In July the Centers for Medicare and Medicaid Services (CMS) began applying predictive modeling techniques to Medicare claims data to detect fraud. CMS contracted with Northrop Grumman, an information solutions company, to develop the technology. Northrop Grumman partnered with Verizon and Nat....

Author: White, Jim

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: April 20, 2017

One of the more significant healthcare trends we see today is the consolidation (mergers and acquisitions) of hospitals, physician groups, and insurance companies into larger integrated systems. The goal of this activity have been focused on: increased market share, increased financia....

Author: Whitaker, Paul

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

Publication Date: April 2007

With the recent talk of implementing a severity adjusted payment methodology, facilities must begin considering how they will prepare for this transition. Some healthcare organizations are concerned that the process is resource intensive, time consuming, and tedious.

Organi....

Author: Wheeler, Elizabeth

Source: Journal of AHIMA

Publication Date: February 1999

Is your organization ready for the Year 2000? The "millennium bug" offers some useful lessons in risk assessment. Here's how to build a contingency plan to ensure business continuity on January 1, 2000.

The information technology (IT) field may have generated Year 2000 concerns, but....

Author: Wheatley, Victoria

Source: Journal of AHIMA

Publication Date: February 2004

Whatever happened to the unique health identifier for individuals (UHI)? The UHI was one of four identifiers included in HIPAA. In July 1998 the Department of Health and Human Services (HHS) and the former Health Care Financing Administration (now the Centers for Medicare and Medicaid Services....

Author: Wheatley, Victoria

Source: Journal of AHIMA

Publication Date: October 2008

The master patient index (MPI) is HIM service’s lifeline to ensuring quality care in a healthcare organization. If MPI data are compromised, HIM’s contributions to many healthcare functions are slowed down or brought to a halt.

Over time, the MPI has evolved from a simple....

Author: Wheatley, Victoria

Source: Journal of AHIMA

Publication Date: May 2006

Despite a lack of funding or government mandate, debate and discussion about a national patient identifier (NPI) continues.
The NPI was one of four identifiers included in the original HIPAA objectives as part of a comprehensive plan to achieve uniform standards for the exchange of healt....

Author: Westhafer, Kathy J

Source: Journal of AHIMA

Publication Date: September 2005

Have you given any thought to how your medical record committee and forms management process need to transition with electronic health record (EHR) development? At the Christiana Care Health System, we have. Here’s our evolving story.

Christiana Care is a two-hospital health s....

Author: Wernick, Alan S.

Source: Journal of AHIMA

Publication Date: November 2006

Thirty-four states currently require that organizations notify individuals whose personal data have been exposed in a security breach. Healthcare entities should have policies and plans in place.
You can hardly pick up a newspaper or visit a major online news source without reading a....

Author: Wernick, Alan S.

Source: Journal of AHIMA

Publication Date: April 2007

Computing connectivity is usually equated with convenience. However, this convenience can prove to be a liability for healthcare organizations. Any employee can plug a USB memory device into the hospital network and download patient data. This type of transaction is quick, easy, and poten....

Author: Wendicke, Annemarie

Source: Journal of AHIMA

Publication Date: March 2016

Healthcare is striving for meaningful health data—something well noted in many recent industry articles and presentations. But how will the cultivation of meaningful data be accomplished in the healthcare industry’s complex environment?


Healthcare data comes from....

Author: Wells, Shawn

Source: Journal of AHIMA

Publication Date: February 2019

By Shawn Wells, RHIT, CHDA


As we move into the second month of the new year I am reminded of our optimistic, yet often-abandoned, list of New Year’s resolutions. These promises we make to ourselves every January originated as promises to the pagan gods over 4,000 years ago, with....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: April 1998

What does "managed care" really represent -- and what effect has managed care had on the healthcare market? The author describes how managed care came to be a critical market force, offers a snapshot of its proliferation, and examines its effects on the traditional payment system.
It's....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: January 1999

Q: I hear a lot of technical terms being used lately by information systems staff and I feel like I'm not speaking their "jargon." Could you clarify the meaning of some of these terms? Specifically, they are SQL, Java, TCP/IP, and IPX.
Q: What is "disease management"?
Article citati....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: September 1998

In April 1998, the Joint Commission on Accreditation of Healthcare Organizations' Board of Commissioners approved a more detailed definition of sentinel event occurrences that are reportable to the Joint Commission on a voluntary basis and adopted procedural revisions to assist organiz....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: April 2000

The portable PC market has been around for years, but early users had to put up with heavy machines, brief battery usage times, and quirky keyboards. Today, with high-capacity hard drives, Pentium chips, and corporate information systems support for palmtop, laptop, and notebook users,....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: September 1999

A computerized patient record (CPR) system benefits a healthcare organization in many ways. Just a few of these benefits include:
increased quality of patient care
reduction in paperwork
improved work flow processes
immediate access to real-time inform....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: March 1999

Electronic Signatures

The Department of Health and Human Services (HHS) published a proposed rule for electronic signatures (45 CFR Part 142, Security and Electronic Signature Standards) in the August 12, 1998, Federal Register. Its comment period ended October 13, 1998. When finalized, t....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: February 2000

Q: The ambulatory care facility where I work is considering implementing an electronic signature process. Is the use of electronic signature acceptable in ambulatory care? Also, what guidelines for this are available?

Q: What Internet security guidelines are available?
<....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: July 1998

Perhaps you are pondering the idea of going back to school. You may be filled with excitement at the prospect—or you may be asking yourself why you would want to do such a thing. Regardless of your level of education or job experience, lifelong learning can yield valuable rewards.....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: April 1998

Q: I have a deposition scheduled for next week. The issue at hand is whether a preprinted manufacturer's instruction sheet on how to use a piece of medical equipment should be a part of the medical record. Our position is that it should not be included because it does not reflect wha....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: February 1999

Telemedicine is "the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care."1 According to a recent report to Congress by the US Departments of....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: October 1998

Q: I work in a skilled nursing facility and want to know if it is mandatory for all states to use Resource Utilization Groups III (RUGS III). If so, when was the deadline?
Q: Where can I find information about a system that will allow for the electronic transmission of Minimum....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: May 2000

Q: Within what time frame are verbal orders required to be authenticated?

Q: Is electronic record storage legal?

Q: Does the Joint Commission require an RHIT or RHIA to be employed in a hospital's HIM department?

Julie Welch is an HIM practice manager at A....

Author: Welch, Julie J.

Source: Journal of AHIMA

Publication Date: May 1999

Today, HIM professionals are working more closely with information systems staff to develop and/or select computerized systems for the healthcare organization. This is because HIM professionals possess the critical knowledge of the users' needs, necessary inputs into the system, and needed out....

Author: Weintraub, Abner E.

Source: Journal of AHIMA

Publication Date: May 2003

With the April 14 HIPAA privacy deadline behind us, many covered entities are still struggling to become compliant. Limited budgets and staff, conflicting advice, and unforeseen delays have all conspired to keep many covered entities from meeting the deadline.


What do you tell....

Author: Weinberg, Jason; Peterson, Stephanie; Marc, David; Sandefer, Ryan

Source: Journal of AHIMA

Publication Date: October 2015

AHIMA defines information governance as “the enterprise-wide framework for managing information throughout its lifecycle and supporting the organization’s strategy, operations, regulatory, legal, risk and environmental requirements.”1 AHIMA recognizes that successful heal....

Author: Weinberg, Douglas D.

Source: Journal of AHIMA

Publication Date: November 2005

For many healthcare providers, the Web does not currently play a significant part in their marketing or business strategy. That is about to change as healthcare providers become increasingly aware of what other industries have known for some time—using the Web to communicate with consu....

Author: Weber, Joe

Source: Journal of AHIMA

Publication Date: March 2003

What does the future hold for the transcription industry? In the third installment of the Journal’s series on transcription, take a look at the new technology aimed at boosting productivity, improving accuracy, and, in some cases, asking physicians for direct information input.
The y....

Author: Waugh, Traci

Source: Journal of AHIMA

Publication Date: January 2018

By Traci Waugh, RHIA, CHPS, CHC

“Being inquisitive about other people’s affairs may get you in trouble.”

“Momma always said to mind your business.”

“Curiosity killed the cat.”

There are plenty of well-known, well-worn sayi....

Author: Watzlaf, Valerie J.M.; Nemchik, Scot; Hoerner, Mike; Sheridan, Patty Thierry

Source: Journal of AHIMA

Publication Date: August 2016

The implementation of ICD-10 has been compared to Y2K, with industry analysts noting that October 1, 2015 came and went with little fanfare. This commentary speaks volumes to the significant preparation that occurred in the months and years leading up to ICD-10. If you were in the trenches....

Author: Watzlaf, Valerie J.M.; Lares, Diane

Source: Journal of AHIMA

Publication Date: March 2002

From patients to providers, medical errors are on everyone’s mind. In this article, you’ll learn how HIM professionals can stop medical errors before patients are harmed.
The last thing a sick patient expects from a healthcare provider is further discomfort. So patients and pro....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: October 2019

Reflecting on a Year to Treasure

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


I cannot pick just one thing that I am most proud of from this year. I am extremely proud to have worked alongside an amazing board of directors, CEO, and AHIMA staff during my year as President and Ch....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: January 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


As AHIMA transitions into our strategy reset, it is more important than ever to keep our passion for the HIM profession strong, as well as align our passions with what is best for our profession and association. So, how do we find our voi....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: April 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


As leaders in the HIM profession, we must strive to reimagine our future and embrace the change that will accompany it. Looking back over the HIM Reimagined (HIMR) recommendations, I see areas where we have already made progress—and other....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: January 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


While I have not yet had the opportunity to do so, I am looking forward to participating in my first telehealth visit. While telehealth is an exciting new avenue for healthcare delivery, the success with which providers have deployed tele....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: May 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


Soft skills—empathy, communication, critical thinking, creative thinking, problem solving, interpersonal awareness, and more—are of vital importance in the HIM workforce. This consensus is one I have encountered over and over again, from....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: June 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


Dr. Amal Alzu’bi, a graduate of the doctoral program at University of Pittsburgh, just had part of her dissertation published in AHIMA’s online scholarly journal Perspectives in Health Information Management under the title “Genetic Varia....

Author: Watzlaf, Valerie J.M.

Source: Journal of AHIMA

Publication Date: June 2019

By Valerie Watzlaf, PhD, MPH, RHIA, FAHIMA


I have not coded a medical record in many years, but I love coding. I love to use the codes to examine all aspects of coding processes and disease-related research. In the past, I worked on a team that examined the computer-assisted codin....

Author: Watt, Ann; Williams, Scott; Lee, Kwan; Robertson, James; Koss, Richard D; Loeb, Jerod M

Source: Journal of AHIMA

Publication Date: November 2003

The Joint Commission has been collecting core measures data for more than a year. But how reliable are the data being collected? Strategies from successful organizations show how improving your documentation processes can improve the reporting of core measures.
In July 2002, the Joint Co....

Author: Watson, Phyllis J.

Source: Journal of AHIMA

Publication Date: October 2004

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

Author: Watson, Monica M

Source: Journal of AHIMA

Publication Date: October 2019

By Monica Watson, RHIA, CPC, CCS, CCS-P, CPMA, CIC, CRC, CDEO


Coding professionals will be relieved to find fewer changes in the fiscal year (FY) 2020 ICD-10-CM code changes, effective October 1, 2019, than the last several years. The trend in decreasing changes for annual updates....

Author: Watson, Monica M

Source: Journal of AHIMA | AHIMA practice brief

Publication Date: June 2018

Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories


Risk adjustment is a statistical process that considers the underlying health status and health spending of patients when examining their healthcare outcomes....

Author: Watkins, Sue

Source: Journal of AHIMA

Publication Date: July 1997

Introduction
The American Cancer Society estimates that about 1.38 million new cancer cases will be diagnosed, and about 560,000 Americans will die of cancer, in 1997.1 These estimates do not include carcinoma in situ or basal and squamous cell skin cancer. To monitor trends in cancer i....

Author: Watanabe, Chris Thorne

Source: Journal of AHIMA

Publication Date: August 2017

Editor’s Note: The following is a first-person account of an HIM professional embracing the “HIM without walls” concept and working as a vice president at an emergency medical service company.


In 2012 I responded to a blind ad looking for someone with health information mana....

Author: Washington, Lydia; Katsh, Ethan; Sondheimer, Norman

Source: Journal of AHIMA

Publication Date: November 2009

Healthcare providers receive relatively few patient requests to correct or change information in their records. In part, that has been because patients had poor access to their information. EHRs, PHRs, and private and public initiatives may change all that. Is healthcare ready?

A per....

Author: Washington, Lydia

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: September 08, 2016

As we talk with healthcare organizations around the country about information governance (IG), many tell us they have embarked on a data governance (DG) program. Most of these data governance programs seem to be emanating from the IT area and are driven by the need to improve data quality....