74 results.
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....
How Deep Do You Dig into ICD-10-PCS Coding?
Author: Kostick, Karen M.; Sanvik, Gina
Source: Journal of AHIMA - Coding Notes | Journal of AHIMA
Publication Date: June 2015
All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.
ICD-10-PCS Scope of Work
On October 1, 2015, hospital inpatient pr....
Rules of the Road Differ for Inpatient and Outpatient Coding
Author: Quick, Tara; Hickman, Stephani
Source: Journal of AHIMA
Publication Date: June 2015
As facilities approach the final laps in the race towards implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), they should heed the yellow caution flag warning of basic challenges with the vast differences between inpatient and....
Survey of State Health Information Exchanges Regarding Inclusion of Continuity of Care Documents for Long-Term Post-Acute Care (LTPAC) Patient Assessment
Author: Hassol, Andrea; Goodman, Laura; Younkin, Jim; Honicker, Mary; Chaundy, Kimberly; Walker, James M
Source: Perspectives in Health Information Management
Publication Date: October 2014
Abstract
Objectives: This study aimed to measure awareness and interest among state health information exchanges (HIEs) in a tool that translates long-term post-acute care (LTPAC) patient assessment information to a Continuity of Care Document (CCD) format for sharing; whether any....
Reliable Coded Data Require a Reliable Coding Process Framework
Author: Bielby, Judy A
Source: Journal of AHIMA | Journal of AHIMA - Coding Notes
Publication Date: October 2014
A poorly managed coding process can thwart the effective use of coded diagnosis and procedure data. Take for example Hospital A, a fictitious hospital that does not effectively manage their coding processes. At this hospital, the coding professionals are concerned primarily with the impact....
Determining if Continuity of Care Documents are Part of the Health Record
Author: Dooling, Julie A; Warner, Diana
Source: Journal of AHIMA
Publication Date: February 2014
Continuity of care is front and center in healthcare today as a mechanism for reducing costs and improving patient care. The ability for information to seamlessly flow from one care setting to another is a critical component to the success of healthcare. The new standard in healthcare is t....
Giving Raw Data a Chance to Talk: A Demonstration of Exploratory Visual Analytics with a Pediatric Research Database Using Microsoft Live Labs Pivot to Promote Cohort Discovery, Research, and Quality Assessment
Author: Viangteeravat, Teeradache; Rao Nagisetty, Naga Satya V
Source: Perspectives in Health Information Management
Publication Date: January 2014
Abstract
Secondary use of large and open data sets provides researchers with an opportunity to address high-impact questions that would otherwise be prohibitively expensive and time consuming to study. Despite the availability of data, generating hypotheses from huge data sets i....
Getting from Here to There with Longitudinal Quality Metrics
Author: Derr, John F.; O’Malley, Terrence A
Source: Journal of AHIMA
Publication Date: February 2013
Editor’s note: This is the third and final installment of a series reviewing the current and desired state of longitudinal care, as well as the steps healthcare stakeholders need to take to embrace this emerging quality measurement process.
E-quality measures....
Managing a Data Dictionary - Retired
Author: AHIMA
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: January 2012
This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.
AHIMA Comments on CMS' Proposal for Reporting of ICD-10-PCS Codes in Place of ICD-9-CM Procedure Codes on the OASIS Data Set for Home Health Care
Author: Bowman, Sue E; St. Pierre, Mary
Source: AHIMA testimony and comments | AHIMA Advocacy and Policy
Publication Date: February 03, 2010
New Guidance for Home Health Coding
Author: Blevins, Ida K.
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2009
Sweeping PPS changes for home health went into effect January 2008, making much of the prior coding guidance issued by the Centers for Medicare and Medicaid Services (CMS) incompatible with changes in the revised data collection set. Home health coding professionals anxiously awaited further i....
Standards Development and HIM: HL7’s IT Standards Work and Its Uses in Health Information Management
Author: Edwards, Wannetta
Source: Journal of AHIMA
Publication Date: July 2008
Health Level Seven (HL7) is an American National Standards Institute-accredited standards developing agency that specializes in developing healthcare standards. Its vision is to “create the best and most widely used standards in healthcare.”
For HIM professionals, underst....
Data Content Standards: Part and Parcel of Data Integrity Management
Author: AHIMA
Source: AHIMA Advantage
Publication Date: March 2008
From Free Text to Continuity of Care Record: Resolving the Semantic Interoperability Dilemma with Natural Language Understanding Tools
Author: Casella dos Santos, Mariana; Doyle, Karen; Flanagan, James R.
Source: AHIMA Convention
Publication Date: October 10, 2007
Abstract
The continuity of care document (CCD) is an enabling technology that assures interoperability among RHIOS, IDNs, physician practices, and consultants down the street. The ASTM continuity of care record (CCR) answers the need for a transportable set of basic patient information ab....
Data Content for EHR Documentation
Author: Kallem, Crystal; Burrington-Brown, Jill; Dinh, Angela K.
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: July 2007
This practice brief has been retired. It is made available for historical purposes only.
Data Elements for EHR Documentation
Author: Kallem, Crystal; Burrington-Brown, Jill; Dinh, Angela K.
Source: AHIMA web extra
Publication Date: July 02, 2007
This practice brief has been retired. It is made available for historical purposes only.
What Mapping and Modeling Mean to the HIM Professional
Author: Wilson, Patricia S
Source: Perspectives in Health Information Management
Publication Date: March 2007
Language Barrier: Getting Past the Classifications and Terminologies Roadblock
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....
Unraveling the Data Set, an e-HIM Essential
Author: Giannangelo, Kathy
Source: Journal of AHIMA
Publication Date: February 2007
There is a great deal of talk about healthcare data and its potential uses once providers have implemented an EHR system. Without question, an EHR will collect more data in terms of volume. It will also, through standard clinical terminologies, capture a more granular level of detail. Th....
Unwrapping Data Standards
Author: Rollins, Gina
Source: Journal of AHIMA
Publication Date: January 2007
Data content standards affect a wide range of day-to-day HIM work. Here’s what you need to know.
They may sound like they belong up in the IT stratosphere, but data content standards-or the lack of them-affect a wide range of day-to-day HIM work right here on....
Guidelines for Developing a Data Dictionary
Author: AHIMA e-HIM Work Group on EHR Data Content
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: February 2006
This practice brief has been retired. It is made available for historical purposes only.
Data Standard Time: Data Content Standardization and the HIM Role
Author: AHIMA e-HIM Work Group on EHR Data Content
Source: Journal of AHIMA
Publication Date: February 2006
To efficiently and accurately share clinical information, EHRs must be interoperable—the IT systems and software applications used by various facilities and made by different vendors must be able to communicate so that usable data can be exchanged accurately, effectively, and consistentl....
Long-term Care's IT Agenda: Industry Summit Produces 11 Action Items for Health IT Adoption
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: January 2006
The benefits of health IT are particularly important to long-term care (LTC), yet to date little planning has taken place within or without the LTC community. That is beginning to change. An LTC industry summit last August produced 11 actions items to help shape and coordinate health IT a....
Public Health and E-HIM: How EHRs Can Provide Data to Help Monitor the Population's Health
Author: Fenton, Susan H.
Source: Journal of AHIMA
Publication Date: September 2005
As HIM professionals, we are well aware of the need for public, or population, health data. However, as we now enter the era of electronic health records (EHRs), our e-HIMTM and EHR implementations have not placed much emphasis on public health data. The 2001 anthrax attacks and the SARS outbr....
When the Doctor Calls: Opportunities in Ambulatory Care
Author: AHIMA
Source: AHIMA Advantage
Publication Date: August 2005
It wasn't too long ago that physicians could hire a file clerk to handle simple filing tasks and doctors themselves decided how patients could view their records. But today doctors' information needs are much more complex.
Just look at how many credentialed HIM professionals are bringing....
Problem List Coding in e-HIM
Author: Fraser, Greg
Source: Journal of AHIMA - Coding Notes
Publication Date: July 2005
In 1968 Larry Weed, MD, introduced the idea that a complete and accurate problem list is an essential component of the medical record.1 The problem-oriented medical record (POMR), in which all data contained in the medical record can be linked to a list of problems, has been almost universally....
Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems
Author: Bowman, Sue E
Source: AHIMA report | Perspectives in Health Information Management
Publication Date: May 2005
Executive Summary
A standard electronic health record (EHR) and interoperable national health information infrastructure require the use of uniform health information standards, including a common medical language. Data must be collected and maintained in a standardized format, u....
Introduction to the Unified Medical Language System
Author: Fenton, Susan H.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2005
Coded data is the basis for knowledge transfer in 21st-century healthcare. The Unified Medical Language System (UMLS) is often called the Rosetta stone of international terminologies used in healthcare worldwide.
The purpose of the UMLS is to “facilitate the development of com....
SNOMED CT Helps Drive EHR Success
Author: Giannangelo, Kathy; Berkowitz, Lyle
Source: Journal of AHIMA - Coding Notes
Publication Date: April 2005
With the advent of electronic health record (EHR) systems, IT solutions are needed to ease the recording of standard codes for clinical encounters. The basis for these products is a standard terminology, without which the full benefits of an EHR are unlikely to be realized. One expert notes th....
CCR--Not an EHR
Author: Quinsey, Carol Ann
Source: Journal of AHIMA
Publication Date: March 2005
In 2003 the American Society for Testing and Materials (ASTM) kicked off the development of the Continuity of Care Record (CCR) standard, which was finalized in that year and passed by ASTM in April 2004. Sponsorship of the CCR brought together ASTM International, the Massachusetts Medical....
EHR Development Steps in Long-term Care
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: January 2005
In the past year there has been a whirlwind of activity around the electronic health record (EHR). Hospitals and physician offices are in the forefront of planning for EHR development at the national level. However, long-term care (LTC) is often mentioned as the third area of priority. This ar....
Getting Better Data from the MDS: Improving Diagnostic Data Reporting in Long-term Care Facilities
Author: Dougherty, Michelle; Mitchell, Sue
Source: Journal of AHIMA
Publication Date: November 2004
Reporting diagnoses consistently can be a challenge in nursing homes. Analysis of the MDS by AHIMA suggests future improvements, but there are also ways to improve reporting today.
Consider the following scenario: a patient in a long-term care facility has many diagnoses, including one fo....
Data Dictionary Standardization in a Single or Multi-Hospital System
Author: Rynberg, Sally J.
Source: AHIMA Convention
Publication Date: October 15, 2004
Introduction
Healthcare is a very information-rich business. However, our ability to manage information has been difficult and has lagged behind many industries. Hospitals spend a great deal of their capital budgets on acquiring and installing information systems as well as many hours of....
Perioperative Nursing Data Set: a New Language for Documenting Care
Author: Kleinbeck, Susan V.M.; Dopp, Annette
Source: AHIMA Convention
Publication Date: October 15, 2004
Adoption and use of an electronic health record (EHR) holds the promise of improving the quality of patient care, promoting patient safety, controlling healthcare costs, and enhancing clinical research. Transforming healthcare documentation to an electronic format depends on the availability o....
Hospital Authority Clinical Vocabulary Table: the Past, the Present, and the Future
Author: Fung, V.; Cheung, N T; Szeto, K; Ngai, L; Lau, M; Kong, J HB
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Abstract
The use of standard clinical vocabulary to support the development of clinical information systems is well established. The ICD-9-CM was adopted locally to form the basis of the Hospital Authority Master Disease Code Table (HAMDCT) and incorporated for use into the Clinical Mana....
Assessment Across the Ages: Implications for the Electronic Health Record
Author: Garvin, Jennifer Hornung
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
Patients across the globe are using traditional and Western (allopathic) medicine to improve health. At the same time, the records of patients are being modified from paper-based documentation to an electronic format. This technical paper places some of the major medical tra....
Clinical Vocabularies: Essential to the Future of Health Information Management
Author: Fenton, Susan H.
Source: IFHRO Congress | AHIMA Convention
Publication Date: October 15, 2004
Introduction
The field of clinical vocabularies is incredibly dynamic. In this paper you will find topics and research from the past that support the principle of a clinical vocabulary as essential. The presentation at the conference will include the latest information regarding the avai....
E-HIM Strategic Initiative: Core Data Sets
Author: AHIMA Work Group on Core Data Sets as Standards for the Electronic Health Record
Source: AHIMA practice brief | Journal of AHIMA
Publication Date: September 2004
This practice brief has been retired. It is made available for historical purposes only.
E-HIM Strategic Initiative: Core Data Sets. Appendix 1: Core Data Sets as Standards for the EHR, Part 2: Healthcare Standards Organizations
Author: AHIMA Work Group on Core Data Sets as Standards for the Electronic Health Record
Source: AHIMA web extra
Publication Date: September 02, 2004
This practice brief appendix has been retired. It is made available for historical purposes only.
CCR Mapped to HL7: an Initial Draft from Preliminary Elements
Author:
Source: AHIMA practice brief attachment
Publication Date: September 2004
This practice brief has been retired. It is made available for historical purposes only.
E-HIM Strategic Initiative: Core Data Sets. Appendix 1: Core Data Sets as Standards for the EHR (pt.1)
Author: AHIMA Work Group on Core Data Sets as Standards for the Electronic Health Record
Source: AHIMA web extra
Publication Date: September 02, 2004
This practice brief appendix has been retired. It is made available for historical purposes only.
EHR and the CCR: Compatible or Competitive?
Author: Mon, Donald T.
Source: Journal of AHIMA
Publication Date: July 2004
Thus far, 2004 is turning out to be a remarkable year for health information management. The electronic health record draft standard for trial use (EHR DSTU) was approved and published by the EHR technical committee within Health Level 7 (HL7). The Continuity of Care Record (CCR) data specifi....
MDS 2.0 Manuals and Forms
Author: U.S. Centers for Medicare & Medicaid Services
Source: Government (U.S.)
Publication Date: June 02, 2004
Coding and HIM in Home Care: Up to the Challenge
Author: Blevins, Ida K.
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2004
Home care coding has always been a challenge given the fact that codes are assigned upon admission or on the “front end” of care provision. The luxury of having a complete medical record filled with physician documentation to support diagnoses (e.g., in acute-care facilities) is a....
Validating MDS and OASIS Data with DAVE
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: March 2004
In January 2004 the Center for Medicare and Medicaid Services (CMS) launched a new initiative to improve the accuracy and reliability of Minimum Data Set (MDS) data in long-term care. The Data Assessment and Verification program (DAVE) is a collaborative effort between multiple CMS program ar....
Standards for the Content of the Electronic Health Record
Author: Watzlaf, Valerie J.M.; Zeng, Xiaoming; Jarymowycz, Christine; Firouzan, Patricia Anania
Source: Perspectives in Health Information Management
Publication Date: January 2004
This research study was funded in part by the AHIMA Foundation for Research and Education. The authors would also like to acknowledge the University of Pittsburgh HIM students that participated in this research project: LaTonya Thompson, Brandi Long, Manisha Ghate, Leanne Borelli, Jul....
CEN/TC 251: European Standardization of Health Informatics
Author: CEN/TC 251
Source: External web site
Publication Date: January 02, 2004
DICOM: Digital Imaging and Communications in Medicine
Author:
Source: External web site
Publication Date: January 01, 2004
Checking the Numbers: Public Reporting of Quality Measures Puts Nursing Homes, HIM Professionals in Spotlight
Author: Slomski, Anita J.
Source: Journal of AHIMA
Publication Date: November 2003
Nursing homes have long been aware of how they stack up to other facilities in terms of clinical quality. Now, with Nursing Home Compare, the public is aware, too. Here’s how HIM professionals play a part in getting these data right.
Two years ago, if I had told our CQI team I wante....
Core Data Sets for the Physician Practice Electronic Health Record
Author: AHIMA Task Force
Source: AHIMA Task Force
Publication Date: October 20, 2003
This practice brief has been retired. It is made available for historical purposes only.
Logical Observation Identifiers Names and Codes (LOINC®)
Author: Regenstrief Institute
Source: External web site
Publication Date: October 06, 2003
Inventory of Health Care Information Standards Pertaining to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-191)
Author: American National Standards Institute. Healthcare Informatics Standards Board
Source: External web site
Publication Date: September 24, 2003
Basic Guide to Standards
Author: National Council for Prescription Drug Programs
Source: External web site
Publication Date: August 02, 2003
HIPAA Transaction Standards Force OASIS Changes for Home Health
Author: Abraham, Prinny
Source: AHIMA community resource
Publication Date: July 24, 2003
Most Home Health Agencies bill Medicare electronically for skilled care provided to beneficiaries. OASIS (Outcome and Assessment Information Set) is the standard instrument used to determine correct case mix assignment under Medicare prospective payment system regulations. The diagnoses used on....
ANA Recognized Standardizations
Author: American Nurses Association. Committee for Nursing Practice Information Infrastructure (CNPII)
Source: External web site
Publication Date: April 11, 2003
Minimum Data Set (MDS) Draft Version 3.0
Author: U.S. Centers for Medicare & Medicaid Services
Source: Government (U.S.)
Publication Date: April 02, 2003
Minimum Data Set (MDS) Draft Version 3.0
Author: U.S. Centers for Medicare & Medicaid Services
Source: Government (U.S.)
Publication Date: April 02, 2003
ISO/TC 215 Medical Informatics
Author: International Standards Organization (ISO)
Source: External web site
Publication Date: January 01, 2003
OASIS Data Sets
Author: Center for Health Services Research
Source: U.S. Centers for Medicare & Medicaid Services
Publication Date: December 02, 2002
The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services Research, Denver, Colorado. It is used with permission.
Documenting for Dollars: How to Code Minimum Data Set (MDS) Assessments to Ensure Accurate Medicare Reimbursement
Author: Galias, Delores
Source: AHIMA Convention
Publication Date: September 23, 2002
ICD-9 Raises Concerns for Home Health Information Managers
Author: Abraham, Prinny
Source: Journal of AHIMA - Coding Notes
Publication Date: May 2002
Home health information managers need to keep a keen eye on the prospective payment system (PPS) for home health to avoid coding conflicts and even financial loss. Many agencies did not pay attention to the quality of ICD-9-CM coding data prior to October 2000 when Medicare implemented the....
Journal Q&A (11/01)
Author: AHIMA Staff
Source: AHIMA Q and A
Publication Date: November 02, 2001
Q: Where can I find the updated data elements and data definitions for the Uniform Hospital Discharge Data Set (UHDDS)?
A: At this time, the 1986 UHDDS data elements and definitions are not available electronically though the information is considered to be in the public domain. The fi....
On the Line: Professional Practice Solutions
Author: Dougherty, Michelle; Hughes, Gwen
Source: Journal of AHIMA
Publication Date: September 2001
Q: My facility's records contain a variety of psychiatric documentation including therapists' notes from their treatment sessions with patients. How can I determine what requires special protection under HIPAA? Do I need to separate some of the documentation from the medical record? C....
Journal Q&A (9/01)
Author: AHIMA Staff
Source: AHIMA Q and A
Publication Date: September 02, 2001
Q: I work in a home care agency and am developing a procedure on correcting errors on OASIS to comply with the Centers for Medicare and Medicaid Services' (CMS, formerly HCFA) new correction policy. Is it necessary to make a separate entry in the medical record? Our agency would like to make the co....
Trends to Watch in Home Health Compliance
Author: Abraham, Prinny
Source: Journal of AHIMA
Publication Date: May 2001
The implementation of the Home Health Prospective Payment System (PPS) on October 1, 2001, has presented some unique compliance risks for HIM and billing managers. This article will briefly describe some of the compliance-related issues on the OIG's agenda that are of interest to HIM....
New PPS Proposed for Inpatient Rehabilitation Facilities
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: March 2001
It's time to take a look at HCFA's published proposed rules for a new prospective payment system (PPS) for inpatient rehabilitation facilities (IRFs).1,2 This new payment system applies to both rehabilitation hospitals and hospital-based rehab units for cost report periods beginning o....
Journal Q&A (2/01)
Author: AHIMA Staff
Source: AHIMA Q and A
Publication Date: February 02, 2001
Q: What are data sets?
A: Data sets support and encourage the uniform collection and reporting of data. They have been developed for different healthcare settings and are used to categorize patient data. Data sets are intended to describe significant minimal data about patients, residents....
New Home Care PPS Brings Major Changes
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: October 2000
The home care industry will undergo a significant shift in reimbursement methodology when HCFA implements a new prospective payment system (PPS) for Medicare claims on October 1, 2000. Under the new system, a Medicare beneficiary receiving covered home care services will be reimbursed for a 6....
Tools for Defining Data
Author: Shakir, Abdul-Malik
Source: Journal of AHIMA
Publication Date: September 1999
Similarly, data dictionaries, data sets, and data models have much in common, but many significant differences. Each can be used to define data, especially data that needs to get from point A to point B. This article describes each of these tools and the value they add to health information ma....
Post-acute PPS: Changing the Way We Code
Author: Dougherty, Michelle
Source: Journal of AHIMA
Publication Date: June 1999
HIM professionals in post-acute care are reinventing their roles to accommodate the new coding demands of a prospective payment system. Here are some of the developments that are creating new interest in coding issues for post-acute settings.
Three major forces -- the prospective payment....
Maximizing Data Quality of the Minimum Data Set
Author: Zender, Anne
Source: Journal of AHIMA
Publication Date: June 1998
HIM professionals who work in long term care settings are well acquainted with the Minimum Data Set 2.0 (MDS). Since 1990, it has been part of the standardized assessments that nursing homes participating in the Medicare and Medicaid programs must complete. Starting this summer, updated submis....
Outcome Assessment Information Set (OASIS) for Home Care
Author: Fletcher, Donna M.
Source: Journal of AHIMA
Publication Date: September 1997
On March 10, 1997, the Health Care Financing Administration (HCFA) published a proposal that would require the use of the Outcome Assessment Information Set (OASIS) in its revision to the Medicare home health Conditions of Participation. The proposal is designed so that home care quality moni....
Data Elements for Emergency Department Systems (DEEDS)
Author: U.S. Centers for Disease Control and Prevention
Source: U.S. Department of Health & Human Services
Publication Date: January 02, 1997
Core Health Data Elements: Report of the National Committee on Vital and Health Statistics
Author: National Committee on Vital and Health Statistics (NCVHS)
Source: External web site
Publication Date: August 02, 1996