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Information is the future of healthcare, and the industry is developing an almost unquenchable thirst for it. The good news is that healthcare organizations are amassing data at an unprecedented pace. In order to make the next leap in the healthcare transformation journey, we require liquid data that can flow to where it is needed in a form that can be easily accessed, is semantically interoperable, and can be acted upon immediately.
This update to a previous web article gives HIM professionals more questions they should ask prospective computer-assisted coding vendors.
In this video extra, Commission on Accreditation for Health Informatics and Information Management Education Executive Director Claire Dixon-Lee, PhD, RHIA, FAHIMA, CPH, talks about the state of health informatics in HIM.
A query can be a powerful communication tool used to clarify documentation in the health record and achieve accurate code assignments. This Practice Brief In Addition provides examples of the different forms of queries available to HIM professionals.
Examples include: verbal query documentation, open-ended query, multiple choice query, and yes/no query.
Though the transition to the more granular ICD-10-CM/PCS code set may help, documentation processes at most hospitals will need an overhaul to support the type of pay-for-outcomes coding needed to reflect the care delivered and the severity of illness for patients.
The Baltimore Rescue Mission’s free clinic recently adopted a standardized electronic health record to collect and store information for homeless and uninsured patients. Developed by medical students at Johns Hopkins University and the University of Maryland using open-source software and customizations, the EHR system is modeled on the electronic medical records typically found in hospitals. The Baltimore Rescue Mission’s EHR monitors the same type of information that would be recorded in a typical hospital patient encounter—including patient’s prescribed medications, previous exam findings and diagnosis, family and medical history, and patient allergies.
A new white paper from AHIMA’s thought leadership series offers guidance on examining coding compliance policy and testing it against upcoming challenges in clinical documentation and associated coding. “Defining the Core Clinical Documentation Set for Coding Compliance,” authored by Bonnie Cassidy, MPA, RHIA, FHIMSS, FAHIMA, lays out strategies for organizations to take the next steps in that process. “Whether your medical record is paper-based, electronic, or hybrid, a high-integrity coding compliance policy should be written and updated at least once per year as part of an information governance framework,” Cassidy says.
The majority of clinicians believe that electronic exchange of health information will play a positive role in improving patient care quality, according to a recent survey released by the Washington, DC-based think tank Bipartisan Policy Center. “Clinician Perspectives on Electronic Health Information Sharing for Transitions of Care” represents what clinicians view as their needs and preferences when it comes to electronic health information, according to the report’s executive summary.
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