Introduction and Table of Contents

Introduction

In early 2003, the American Health Information Management Association (AHIMA) appointed a task force of experts to develop a vision of the e-HIM future. The task force developed the following vision of the future of health information: "The future state of health information is electronic, patient-centered, comprehensive, longitudinal, accessible, and credible." The task force's vision is not only theoretical. It offers practical guidance for anyone traveling the road toward e-HIM. Advancing the recommendations of the e-HIM Task Force, AHIMA created workgroups to develop practice standards that focus on areas that play an integral role in the transition from paper to electronic health records. The standards included on this CD provide a roadmap for progress toward future e-HIM development.

The following issues were selected for the initial standards development, and the outcomes are presented in this series of documents.

  1. The Complete Medical Record in a Hybrid Electronic Health Record Environment
  2. Implementing Electronic Signatures
  3. E-mail as a Provider-Patient Electronic Communication Medium and Its Impact on the Electronic Health Record
  4. Electronic Document Management as a Component of the Electronic Health Record
  5. Core Data Sets for the Physician Practice Electronic Health Record
  6. Speech Recognition in the Electronic Health Record

Additional issues will be addressed as the e-HIM initiative continues in 2004. To view more information about the e-HIM initiatives, go to www.ahima.org and click on "HIM Resources."


Table of Contents

Introduction

Table of Contents

Part 1: The Complete Medical Record in a Hybrid Electronic Health Record Environment

Practice Brief Part I: Managing the Transition
Practice Brief Part II: Managing Access and Disclosure
Practice Brief Part III: Authorship of and Printing the Health Record
Appendix: Legal Source Legend

Part 2: Implementing Electronic Signatures

Practice Brief
Glossary
Appendix: State-by-State Review of Regulations Pertaining to Electronic Signature

Part 3: E-mail as a Provider-Patient Electronic Communication Medium and Its Impact on the Electronic Health Record

Practice Brief
Glossary
Appendix A: HIM Managers Task and Skills with Regard to Administrative-Medicolegal Risks
Appendix B: Documentation of Authorization to E-mail Discussion
Appendix C: Patient Authorization for E-mail Communication
Appendix D: Summary of Best Practices for Provider-Patient E-mail Communication

Part 4: Electronic Document Management as a Component of the Electronic Health Record

Practice Brief
Glossary
Appendix A: HIM Computer Applications
Appendix B: Specific Forms Characteristics
Appendix C: Bar Code Information and Guidelines
Appendix D: Helpful Justification and Return on Investment Statistics
Appendix E: Justification for an EDMS: Tangible and Intangible Benefits
Appendix F: e-HIM Imaging Sub Task Force on Planning--Planning Checklist
Appendix G: Project Plan Processes
Appendix H: Document Imaging Process Flow Discharges
Appendix I: Document Imaging Process Flow Outpatients/ Clinics and Ancillaries
Appendix J: Chart Completion Work Flow
Appendix K: Medical Records Retrieval Process
Appendix L: Position Summary--Indexing
Appendix M: Position Summary--Preparation
Appendix N: Position Summary--Quality Control
Appendix O: Position Summary--Scanning
Appendix P: Sample Course Plan
Appendix Q: Benchmark Productivity Standards

Part 5: Core Data Sets for the Physician Practice Electronic Health Record

Practice Brief
Appendix: Electronic HIM Knowledge and Associated Tasks Inventory

Part 6: Speech Recognition in the Electronic Health Record

Practice Brief
Glossary
Appendix A: Work Flow Diagram
Appendix B: Best Practices for Using Special Recognition
Appendix C: Tasks and Skills List


The e-HIM work groups are supported in part by grants to the Foundation of Research and Education (FORE)  from

     

The e-HIM Task Force Report is supported by a grant from