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Updating Organizational Policies and Procedures for Information Governance. Case Study #6: Enterprise Information Management at Children’s Health System of Texas

Author: Fahy, Kristi; Hermann, Michelle

Source: Journal of AHIMA

Publication Date: June 2017



Editor’s Note: This article is the sixth installment in an ongoing series highlighting information governance case studies.


AHIMA defines information governance (IG) as “an organization-wide framework for managing information throughout its life cycle and for supp....

New Study Illuminates the Ongoing Road to ICD-10 Productivity and Optimization

Author: Alakrawi, Zahraa M; Watzlaf, Valerie J.M.; Nemchik, Scot; Sheridan, Patty Thierry

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

Publication Date: March 2017



To quantify the impact of ICD-10-CM/PCS (ICD-10) on coding productivity, Ciox Health, in partnership with the University of Pittsburgh’s Department of Health Information Management, School of Health and Rehabilitation Sciences, conducted a previous study published in the August 2016....

Skilled Nursing Facility (SNF/NF) Clinical Documentation Improvement (CDI) Tip Sheets

Author: AHIMA Long Term Care CDI Workgroup

Source: AHIMA Task Force

Publication Date: February 2017

These tips focus on the language and/or wording that will garner greater details and specificity of the coded data for a given diagnosis, condition, and disease. In addition to the focus on coded data, these tips also include information to reflect quality care, frequency of documentation requirements, and documentation sources. These tips are meant to provide guidance in recognizing gaps in the clinical documentation.

Information Asset Inventory for Information Governance - Retired

Author: Downing, Kathy; Fahy, Kristi; Foster, MeShawn; Hermann, Michelle; Meehan, Ann M.; Washington, Lydia; Woebkenberg, Jami

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: February 2017


When an organization begins to implement an enterprise information governance (IG) program, one of the major initial tasks is to understand the scope and types of information in its possession. An inventory of an organization’s information is necessary in order to facilitate decision maki....

Does Your Forms Committee Need a Facelift? Standardizing Best Practices for HIM-focused Committees—A Case Study in the Physician Practice Setting

Author: Chou, Edgar; Montroy, Tami

Source: Journal of AHIMA

Publication Date: February 2017



In most healthcare settings, health information management (HIM) initiatives are led by HIM professionals with collaboration from other organizational leaders. At Drexel University College of Medicine, it is no different. Representatives with expertise in risk management, privacy, complian....

Coding Roundtable Coordinators Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: 2017

The goals of the coding roundtable coordinator include:

  • Improving coding skills through education
  • Providing local networking opportunities
  • Attracting new members to the coding and HIM profession
  • Creating an environment that facilitates mentoring
  • Sharing coding practices, challenges, and requirements to affect policy in the industry

Provider’s Condensed Resource for Revenue Cycle, Coding Tools, and More

Author: Clack, Crystal; Freeman, Rae; Lewis, Laquette

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: January 2017


A cyclone of regulatory requirements for providers has officially touched down in the United States. The Affordable Care Act (ACA), Medicare Access and CHIP Reauthorization Act (MACRA), patient-centered medical home (PCMH), and value-based purchasing (VBP) initiatives are contributing to dramat....

American Health Information Management Association Standards of Ethical Coding [2016 version]

Author: AHIMA House of Delegates

Source: AHIMA

Publication Date: December 2016

The AHIMA Standards of Ethical Coding are intended to assist and guide coding professionals whether credentialed or not; including but not limited to coding staff, coding auditors, coding educators, clinical documentation improvement (CDI) professionals, and managers responsible for decision-making processes and operations as well as HIM/coding students. The standards outline expectations for making ethical decisions in the workplace and demonstrate coding professionals' commitment to integrity during the coding process, regardless of the purpose for which the codes are being reported.

Managing a Data Dictionary (2016 update) - Retired

Author: Davoudi, Sion; Flanigan, Jill; Houser, Shannon H.; Kadlec, Lesley; Kirby, Annessa; VanSlyke, Daniel; Wendicke, Annemarie

Source: AHIMA practice brief

Publication Date: December 2016


This update supplants the 2012 practice brief “Managing a Data Dictionary.”


As healthcare organizations move to the electronic environment, the large volume and complexity of data collected is growing at unprecedented rates. While access to data has the potential to en....

Facility Closure: How to Get In, Get Out, and Get What Is Important

Author: Lail, Pamela J; Laird, Sarah S; McCall, Kris; Naretto, Joe; York, April

Source: Perspectives in Health Information Management

Publication Date: October 2016


Abstract


This article examines the current state of affairs of the health information management role in facility closure as well as the impact on revenue cycle operations. Health information management professionals are uniquely positioned to assist an organization in closure eff....

Improving the Collection of Race, Ethnicity, and Language Data to Reduce Healthcare Disparities: A Case Study from an Academic Medical Center

Author: Lee, Wei-Chen; Veeranki, Sreenivas P; Serag, Hani; Eschbach, Karl; Smith, Kenneth D

Source: Perspectives in Health Information Management

Publication Date: October 2016


Abstract


Well-designed electronic health records (EHRs) must integrate a variety of accurate information to support efforts to improve quality of care, particularly equity-in-care initiatives. This case study provides insight into the challenges those initiatives may face in colle....

Improving Coding and Documentation Quality Through Real-Time Collaboration: Nurses and Coding Professionals Team Up to Tackle Documentation Issues

Author: Horn, Kelli; Younger, Adrienne; Snow, Trevor

Source: Journal of AHIMA

Publication Date: August 2016



While working through the recent implementation of ICD-10, leaders at Ardent Health Services began to focus on the re-bill process and what it would look like in the months following use of the new code set. Re-billing means submitting a corrected bill to the payer after it has been rejec....

Understanding Publicly Available Healthcare Data (2016) - Retired

Author: Buttner, Patty; Houser, Shannon H.; Flanigan, Jill; Mikaelian, Raymound; Ryznar, Barbara; Smith, Clarice Pittillo

Source: AHIMA practice brief

Publication Date: June 2016


This update supersedes the September 2013 practice brief, Understanding Publicly Available Healthcare Data, which replaced the January 2010 practice brief with the same title.


Healthcare organizations increasingly collect and utilize data for internal and external reporting on pa....

Guidelines for Achieving a Compliant ICD-10-PCS Query

Author: Combs, Tammy; DeVault, Kathryn; Easterling, Sharon; Endicott, Melanie; Isom, Crystal; Lojewski, Tedi; Simmons, Cortnie R.; Wolf, Beth

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: June 2016



Editor’s Note. This Practice Brief has been updated. See the latest version at Guidelines for Achieving a Compliant ICD-10-PCS Query
. This version is made available for historical purposes only.




The complex and highly specific nature of ICD-10-PCS has changed....

Ethical Standards for Clinical Documentation Improvement (CDI) Professionals (2016)

Author: AHIMA

Source: AHIMA

Publication Date: June 2016

The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity. They are relevant to all clinical documentation improvement professionals and to those who manage the clinical documentation improvement (CDI) function, regardless of the healthcare setting in which they work.

Patient Portal Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: March 2016

The purpose of this toolkit is to provide guidance on the issues and challenges that should be considered when implementing a patient portal, such as the types of policies and procedures that will need to be put into place, workforce and consumer education and training, and the legal requirements and considerations that must be accounted for a successful portal implementation. Sample forms, portal use agreement, and patient portal FAQs are also included.

Measuring CDI Productivity

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: March 23, 2016



When calculating the productivity guidelines for a clinical documentation improvement (CDI) program it is important to remember both quantitative and qualitative perspectives. Sometimes it is very easy to focus solely on the quantity of reviews that are performed. If the quality of those r....

Consumer Engagement Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: 2016

This toolkit provides a wide variety of resources and tools for HIM and other healthcare professionals who are developing procedures to support the goals of a consumer engagement initiative.

Understanding CDI Metrics

Author: Combs, Tammy

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: February 24, 2016


Understanding clinical documentation improvement (CDI) metrics can be confusing, especially when you first start reviewing them.


Let’s dive a little deeper into the topic and take a closer look at some frequently reported CDI metrics and evaluate how these measures can reflect the....

Enhancing Practice Efficiency and Patient Care by Sharing Electronic Health Records

Author: Keller, Megan E; Kelling, Sarah E; Cornelius, Douglas C; Oni, Hafusat A; Bright, David R

Source: Perspectives in Health Information Management

Publication Date: 2015


Abstract


One primary function of community pharmacies is to dispense medications to patients. In doing so, pharmacists frequently communicate with physicians’ offices to clarify prescription orders and obtain additional information to ensure the safe and accurate dispensing of med....

Data Quality Management Model (2015 Update) - Retired

Author: Davoudi, Sion; Dooling, Julie A; Glondys, Barbara; Jones, Theresa D.; Kadlec, Lesley; Overgaard, Shauna M; Ruben, Kerry; Wendicke, Annemarie

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: October 2015


Editor’s Note: This Practice Brief supersedes the July 2012 “Data Quality Management Model (Updated),” the March 1998 “Checklist to Assess Data Quality Management Efforts,” and the June 1998 “Data Quality Management Model” Practice Briefs.


Physician Coding Toolkit

Author: AHIMA Work Group

Source: AHIMA toolkit

Publication Date: September 2015

This provider practice coding toolkit provides multiple tools and resources to help providers successfully navigate through the many changes in today’s healthcare environment.

Breaking Down Healthcare's Silos: University of Kansas Medical Center's Interprofessional Education Fostering 'HIM Without Walls'

Author: O'Dell, Rosann M; Belz, Norbert; Bielby, Judy A; Folck, Kay; Moqbel, Murad; Pulino, Lauren

Source: Journal of AHIMA

Publication Date: September 2015



A faculty member in the health information management (HIM) department at the University of Kansas Medical Center (KUMC) attended a campus retreat in June 2011 that not only energized his personal perspective of HIM, but also shed new light on the future of HIM at the university.

HIM Best Practices for Engaging Consumers in Their Overall Healthcare

Author: Kadlec, Lesley; Kirby, Annessa; Shaffer, Heidi; Warren, Paula

Source: AHIMA practice brief | Journal of AHIMA

Publication Date: September 2015


As a nation, the United States has been focused heavily on engaging consumers in their overall health and wellness. This has been propelled by federal initiatives such as the “meaningful use” Electronic Health Record (EHR) Incentive Program, mandated clinical quality measures based....

Policy and Procedure Considerations for Health Information Exchange Organizations

Author: Bowen, Rita K.; Chestler, Alisa; Coomes, Donna; Dooling, Julie A; Fuller, Brenda; Grijalva, Christine; Kirby, Annessa; Kuehnast, Tanya; Stewart, Elizabeth

Source: Journal of AHIMA

Publication Date: August 2015


Policies and procedures govern the operations of health information exchange (HIE), and many factors must be taken into consideration during their development or revision. They set expectations for the workforce, delineate staff training and accountability, and must be part of an ongoing educat....

Clinical Definition Standards Case Study

Author: Lusk, Katherine

Source: Journal of AHIMA

Publication Date: July 2015



With the October 1, 2014 date for prospective payment for inpatient pediatric Medicaid discharges looming, Children’s Health System of Texas identified an organizational need to reboot and formalize its clinical documentation improvement (CDI) program. The journey began with three co....

Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center

Author: Rizer, Milisa K; Kaufman, Beth; Sieck, Cynthia J; Hefner, Jennifer L; McAlearney, Ann Scheck

Source: Perspectives in Health Information Management

Publication Date: July 2015


Abstract


Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple s....

New Health Information Management (HIM) Competencies? Teaching Critical Thinking Using an Unfolding Case Study

Author: Tyczkowski, Brenda

Source: Educational Perspectives in Health Informatics and Information Management

Publication Date: May 2015


Abstract


With the AHIMA Foundation’s establishment of new professional competencies for health information management (HIM) comes the opportunity to reimagine how lessons are presented to students. The use of unfolding case studies fosters a learner-centered classroom, where the s....

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