Ahimajournal 2015 05 DL

MAY 2015
Workaday
Informatics
HOW HEALTHCARE IS APPLYING
PRACTICAL INFORMATICS TO
SAVE DOLLARS AND LIVES
22 Data Analysis Starter Kit

28 Middlewares Role in Connecting
Disparate EHRs
38 Scanning the HIM Environment
Welcome
TO THE DIGITAL EDITION OF THE
JOURNAL AHIMA
OF
Video ExtraInformatics Elevator Speech
Just what is HIMs role in informatics? Nathan Patrick

Taylor, clinical informatics consultant at Symphony Post-Acute
Network, weighs in.
Connecting the Disparate
Middlewares Role in Solving Healthcares EHR Interoperability Problems
How to Use the Digital Journal

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WEVE BEEN PREPARING FOR YEARS

With ICD-10 right around the corner we continue to recruit, train and support the most
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Contents May 2015
Cover
18
Workaday Informatics
How healthcare is applying practical informatics to save dollars and lives

By Mary Butler
Vol. 86, no. 5

Departments
Presidents Message
The Evolving Practice of
Health Informatics
10
Bulletin Board
pg. 34
Features
Job candidates must have the essential pieces

employers are looking for.
22
Data Analysis Starter Kit

How to apply informatics and analyze ROI
as an e-HIM professional
By Diane Dolezel, MSCS, RHIA
28

Middlewares role in solving healthcares
EHR interoperability problems
By Donald M. Voltz, MD
34
e-HIM Professionals Wanted

Steps to land a job and build a career in
todays modern HIM job market
14
Word from Washington

We Are Ready! ICD-10 Coalition
Asks Congress to Avoid Another
Implementation Delay
17
Inside Look
Informatics Poses Challenges,
But Promises Rewards
72
Calendar
73
Keep Informed
74
By Priscilla Keeton, MS, RHIT, and Patricia Pierson, RHIA
Volunteer Leaders
38
77
Scanning the HIM Environment

AHIMAs 2015 report offers insight on
emerging industry trends and challenges
By Anna Desai, MHA, CAE
AHIMA Career Center
80
Addendum
Beware the Dark Side of the Web
Contents May 2015

Working Smart
44
Navigating Privacy and Security

Responding to Requests from
Law Enforcement Officials for
Release of PHI
By Dana DeMasters, MN, RN, CHPS
48
e-HIM Best Practices

Application of Search Analytics
in the Healthcare Profession
50
Standards Strategies
The Standardization of Standards
By Anna Orlova, PhD
54
Quality Care
Healthcare Moving Toward an
Information Ecosystem
By Christine Kowalski, EdD, RHIA, CP-EHR
By Daniel L. Regard and Ron Hedges, JD
Coding Notes
Quizzes
66
AHIMA members may earn continuing

education credits by successfully completing
the following quizzes at www.ahimastore.org
ICD-10 Gap Analysis Points to Revenue

Neutral Transition
By Ann Barta, MSA, RHIA, CDIP
68
National Correct Coding Initiative: A Valuable

Resource in Outpatient Coding Compliance
33

Domain: Technology
43
By Suzanne P. Drake, RHIT, CCS
Scanning the HIM Environment

Domain: Technology
Practice Brief
67
58
Assessing and Improving EHR Data Quality

(Updated)
4/Journal of AHIMA May 15
ICD-10 Gap Analysis Points to Revenue

Neutral Transition
Domain: Clinical Data Management
http://journal.ahima.org
Risk Management in EHR
ImplementationThis
article describes the Failure
Mode and Effects Analysis
risk management method and
illustrates how to apply this
tool using an example scenario
for a classroom setting.
Video: Informatics Elevator Speech

Just what is HIMs role in informatics? Nathan
Patrick Taylor, clinical informatics consultant at
Symphony Post-Acute Network, weighs in.
Legal e-Speaking
Legal consequences flow from the use or abuse of

electronic health records. This monthly web-only column
presents examples of what those consequences can be.
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Journal of AHIMA May 15/5
The Journal of AHIMA is an official publication of AHIMA
AHIMA CEO
EDITORIAL DIRECTOR
EDITOR-IN-CHIEF
Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA

Anne Zender, MA
Chris Dimick

ASSISTANT EDITOR/
ADVERTISING COORDINATOR Sarah Sheber

ASSOCIATE EDITOR
Mary Butler

CONTRIBUTING EDITORS
Sue Bowman, MJ, RHIA, CCS, FAHIMA

Patricia Buttner, RHIA, CDIP, CCS

`
Angie Comfort, RHIA, CDIP, CCS

Crystal Clack, MS, RHIA, CCS

Julie Dooling, RHIA, CHDA

Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, CDIP,

FAHIMA

Katherine Downing, MA, RHIA, CHP, PMP

Deborah Green, MBA, RHIA

Jewelle Hicks

Lesley Kadlec, MA, RHIA

Carol Maimone, RHIT, CCS

Paula Mauro

Anna Orlova, PhD

Kim Osborne, RHIA, PMP

Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA

Angela Rose, MHA, RHIA, CHPS, FAHIMA

Maria Ward, MEd, RHIT, CCS-P

Diana Warner, MS, RHIA, CHPS, FAHIMA

Lydia Washington, MS, RHIA

Lou Ann Wiedemann, MS, RHIA, CHDA, CDIP, CPEHR,

FAHIMA

ART DIRECTOR Graham Simpson

GRAPHIC DESIGNER
Jill A. Blacketer
EDITORIAL ADVISORY BOARD

Linda Belli, RHIA

Gerry Berenholz, MPH, RHIA

Carol A. Campbell, DBA, RHIA

Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FAHIMA

Teri Jorwic, RHIA, CCS

Diane A. Kriewall, RHIA

Frances Wickham Lee, DBA, RHIA

Glenda Lyle, RHIA

Susan R. Mitchell, RHIA

Daniel J. Pothen, MS, RHIA

Cheryl Tabatabai Stachura, RHIA

Tricia Truscott, MBA, RHIA, CHP

Carolyn R. Valo, MS, RHIT, FAHIMA

Valerie Watzlaf, PhD, RHIA, FAHIMA
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The Journal of AHIMA serves as a professional development tool
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issues that affect the practice of health information management.
Furthermore, the Journal contributes to the field by publishing work
that disseminates best practices and presents new knowledge.
Articles are grounded in experience or applied research, and they
represent the diversity of health information management roles and
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of the American Health Information Management Association.
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The Commission on Accreditation for Health Informatics and
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www.hicareers.com.
Journal of AHIMA (ISSN 1060-5487) is published monthly, except for the combined issue of November/December, by the American Health Information Management Association, 233 North Michigan
Avenue, 21st Floor, Chicago, IL 60601-5800. Subscription Rates: Included in AHIMA membership dues is a subscription to the Journal. The annual member subscription rate is $22.00 for active and
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are not to be construed as endorsing any particular product or service. Advertisingproducts, services, and educational institutions advertised in the Journal do not imply endorsement by the Association.
Copyright 2015 American Health Information Management Association Reg. US Pat. Off.
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Presidents Message
The Evolving Practice of Health Informatics

By Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
WHEN I DECIDED to pursue my graduate

education in health information management (HIM) and informatics seven years
ago, adoption rates for advanced electronic health record (EHR) systems were
evolving, data was siloed, and interoperability was far from reality. Organizations
were up to their elbows in a hybrid record
state, working on document imaging, defining the legal record, and data integrity
issues stemming from a lack of standardized definitions, discrete fields, copy-andpaste mania, and data integration efforts.
The conceptual definition of health informatics is the utilization of information
technologies and information management tactics to enhance process efficiency
and reduce costs, according to the Oregon
Institute of Technology. The practical application of health informatics establishes
data capture, analysis, and reporting that
is stored in HIMsystems to create knowledge. Health informatics is concerned
with the manipulation and interpretation of
enterprise-wide data to create a story of
outcomes, process, and cost.
AHIMAs health informatics strategic
initiative provides the healthcare industry with a blueprint to seamlessly convert
data into health intelligence to propel
the improvement of population health.
It is our goal to provide our members
with the training, tools, standards, and
credentialing to support the analytical
and reporting requirements of accountable care organizations and value-based
purchasing so we embraceand not get
run over byBig Data. Approximately 80
percent of data is unstructured, according to a white paper from DATAMARK,
and resides in multiple places in EHRs
and other clinical systems. Additional
challenges include data interoperability
and securing data across EHR systems.
AHIMAs strategic focus for this year is to
ensure that we support the current state
of coding and clinical documentation improvement (CDI) as we prepare for the

transition to ICD-10-CM/PCS.
Recognizing that the advancement of
technology contributes to the evolving
role of the coder in healthcare today and
tomorrow, AHIMAs education and certification track will facilitate retraining
closely tied to the future roles of supporting data validation, CDI, informatics,
and analytics. The House of Delegates,
AHIMA Board of Directors, and Council
for Excellence in Education will be working collaboratively to develop a vision for
the future state of the role of coders and
a pathway to achieving success.
Some additional critical initiatives will
focus on building AHIMAs HIM Body of
Knowledge, encouraging industry adoption of health intelligence drawn from
data analytics, increasing the use of clinical data for secondary purposes (including public health), and promoting the
value of the CHDA credential and education/experience in the informatics field.
HIM professionals contribute to sound
healthcare decision-making through
analytics, informatics, and decision support. Healthcare organizations will depend on HIM professionals as leaders
across all healthcare sectors, with expertise in predictive modeling of clinical
information, trend analysis, and revenue
cycle management.
Health informatics is about making a
difference one patient at a time. The utilization of health informatics will facilitate
the improvement of patient outcomes, a
reduction in costs, and more meaningful
strategies to improve the health of a community. Now is the time to realize this vision by embracing health informatics.
Cassi Birnbaum (cassi.birnbaum@ahima.org) is
senior vice president of HIM and consulting at
Peak Health Solutions.
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Bulletin Board whats happening in healthcare
AHIMA Comments on ONCs Federal Health IT Strategic Plan

Hundreds of healthcare IT stakeholders have responded to the recently
released Federal Health IT Strategic
Plan 2015-2020, including AHIMA.
The plan, which was released by the
Office of the National Coordinator for
Health IT (ONC), outlines the agencys
major goals:
Expanding the adoption of health IT
Advancing secure and interoperable health information
Strengthening healthcare delivery
Advancing the health and well-being of individuals and communities

A dvancing research, scientific
knowledge, and innovation
The plan details the contributions
and efforts of 35 additional federal

agencies needed to enact the plan.
ONC will review public comments and
issue a revised version later this year.
For its part, AHIMA wrote in comments submitted to ONC that the
agencys overarching framework is
closely aligned with AHIMAs own
work of the past several years.
AHIMA agrees that the document is
the appropriate foundation for a visionary, far-reaching plan to address
the health needs of the US population
with health IT, AHIMA noted. Importantly, this strategic plan implicitly recognizes that it is the data and information, rather than the technology used
to create it, that is most critical.
What ONCs approach lacks, however, is a broader information governance or data governance strategy.
Without the integration of information
and data governance in this plan, the
US will be hampered in its sharing,
use, and protection of health information, AHIMA warns. AHIMA commented that the association would like to
see the following issues addressed
with more specificity:
The use of standards that support
interoperability, particularly those
that address terminologies, classification (ICD-10-CM, SNOMED,
LOINC, etc.), and common metadata structures. Currently, the
plan understates the need for
Patients Less Anxious and Confused After

Reading Their Records
CHIME Holds Patient

Identity Contest
Although patients who are able to

view their electronic health records
(EHRs) while in the hospital do not
understand their conditions better or
better comprehend their doctors instructions, they are less worried and
less confused about their care, according to a small study.
Researchers recently gave 50 hospitalized individuals access to their
EHRs via tablet computers with the
hope that patients would be more
engaged in their care, ask more questions, or catch errors, according to a
study published in the Journal of the
American Medical Association.
The hope is that increased transparency achieved by sharing electronic
medical records with patients while
theyre in the hospital would make
them more engaged in their care, more
satisfied, and more likely to ask questions and catch errors, said lead study
author Dr. Jonathan Pell, an assistant
professor at the University of Colorado
in Denver, in an interview with Reuters.
In a move to spur innovation in patient

identity matching, the College of Healthcare Information Management Executives (CHIME) has launched a competition to design a unique patient identifier
system. CHIME is setting aside $1 million
for the National Patient ID Challenge.
There is a growing consensus among
payers and providers that a unique patient ID would radically reduce medical
errors and save lives, CHIME CEO and
President Russell P. Branzell said in a
press release. Incomplete or duplicate health records present significant
issues in terms of patient safety, and
there is a pressing need for preventing,
detecting and removing inaccurate records so hospitals can positively match
the right data with the right patient in order to provide the best possible care.
According to a 2012 CHIME survey of
healthcare CIOs, more than three fulltime employees are needed to reconcile disparate or duplicate information
from patient health records, Healthcare IT News reported.
Before reviewing their records, 92

percent of participants said they expected to understand their conditions
better, and 80 percent expected to
understand their physicians instructions more accurately. But after reading their charts these rates fell to 82
percent and 60 percent respectively.
The patients were pleasantly surprised, though, when they found out
that reading their charts did not make
them more anxious or confused about
their healthcare experience. According
to Reuters, the proportion of patients
who were worried dropped to 18 percent from 42 percent, and confusion
fell from 52 percent to 32 percent.
Although the sample size of the
study was small, and the participants
engaged with their records the way
investigators expected, the study author uncovered several implications.
Its encouraging there doesnt appear to be a major signal of harm for the
patients and it didnt create more work
for the doctors and nurses, Pell said.
standards, both in terms of an

approach to developing, adopting, and implementing them as
well as how vendors and other
stakeholders will be encouraged
to use them.

Protections that recognize the
balance that must be struck between individual privacy rights
and the common good that results from sharing health information. This will be crucial for
the plans objectives that address
transparency and the use of personal health information, aimed
at advancing public health and
improving scientific research,
knowledge, and innovation.
C
oordination of laws relating to
privacy and security between the
federal government and the states
to remove confusion, inconsistency, and conflicting laws and regulations in a world in which health
data and information must follow
the individual without respect to
state jurisdictions.
At its core, effective information governance is about managing the costs
and risks associated with information
management and enabling the entities
that collect, use, and share it to extract
maximum value from the information as
well as the technology used to create
it, AHIMA concluded.
Doctor, Thats None of Your Business
A new study published in the Journal of General Internal Medicine found

that almost half of patients will withhold clinically sensitive information in
their health records from some or all of their healthcare providers if given
the chance. Researchers first interviewed patients about their privacy and
sharing preferences, and used this information to design a user interface
that allowed patients to control how and with whom their medical data was
shared. During the six-month trial, 105 patients were able to control whether
or not clinicians saw sensitive information in their electronic health records,
such as information on sexually-transmitted diseases, substance abuse, or
mental health. In the trial, 49 percent of patients who participated elected
to withhold information contained in their health records from some or all of
their healthcare providers, according to a press release on the study. Patients
strongly desired such control, while their providers had mixed reactions.
More thanhalf of providers believed it was OK for patients to withhold some
health information, while a quarter felt very uncomfortable about not being
able to see all of the information in their patients records, worrying that it
could jeopardize care.
Number of Patients Who Withheld Information from Doctors
The findings from billing and payment

solutions vendor Navicures third ICD10-CM/PCS readiness survey found
that physician practices dont think
there will be another implementation
delay, the potential impacts on revenue
and cash flow represent the greatest
related concern, and the biggest challenge respondents anticipate is dealing
with unprepared payers.
The global electronic health record
market is expected to reach $23.98
billion by 2020, according to a report
from Transparency Market Research.
Cedars-Sinai Health System is integrating
the patient engagement platform from
HealthLoop into its electronic health
record system as a move to help shift
to value-based care.
Epic has partnered with Vocera Communications to equip Epics electronic
health record platform with two-way
communications functions, which will
allow housekeeping staff to provide
updates on bed availability and
cleaning status.
The Joint Commission has issued an alert
that sentinel events related to health IT
can pose safety risks to patients.
MEDITECH, Kareo, and Merge have
become contributing members of the
CommonWell Health Alliance, and Surgical
Information Systems and PointClickCare
have become general members.
Summa Health System, based in Ohio,
has partnered with InTouch Health for the
launch of a telehealth stroke program.
Data from Leavitt Partners indicates that
about 120 organizations have become accountable care organizations
(ACOs) over the past year, 4.5 million
additional patients have gained ACO
coverage, and every state has at least
one ACO.
49%
Source: Mullen, Brian M. Study: 49 percent of patients withhold clinically sensitive information. Clemson University media release. December 17, 2014. http://newsstand.clemson.edu/mediarelations/study-49-percent-of-patients-withholdclinically-sensitive-information/.
Bulletin Board whats happening in healthcare
Lack of Data Standards Hindering

Research Network
PROGRESS AND CHALLENGES IN ELECTRONIC
HEALTH RECORD ADOPTION: FINDINGS FROM
A NATIONAL SURVEY OF PHYSICIANS
http://annals.org/article.
aspx?articleid=2173522
A survey from the American Academy
of Family Physicians, published in Annals of Internal Medicine, takes a look
at those providers who refuse to adopt
electronic health records (EHRs). According to the survey, physicians that
do not adopt EHRs are usually older
and work in independent practices
with one or two physicians. Approximately nine percent of respondents
indicated that they had no plans to
adopt an EHR within either period
included in the survey.
ICD-10 TESTING WHITE PAPER
www.wedi.org/docs/resources/testingfor-small-providers-white-paper.
pdf?sfvrsn=0
The Workgroup for Electronic Data Interchange has released a white paper
that provides a starting point for small
physician practices performing ICD-10
testing. According to the paper, testing can help minimize the risk of claim
denials or delays, cash flow, and the
inability of EHRs to generate ICD-10
claims. The paper also notes the challenges associated with undertaking
ICD-10 testing and recommended
areas to consider for testing.
RACE/ETHNICITY, PERSONAL HEALTH RECORD
ACCESS, AND QUALITY OF CARE
www.ajmc.com/publications/
issue/2015/2015-vol21-n2/RaceEthnicity-Personal-Health-Record-Access-and-Quality-of-Care
A study published in the American
Journal of Managed Care evaluates
the impact of ethnicity and written
language preference on ones likelihood to register for a personal health
record (PHR), which would include the
ability to communicate with providers
via e-mail, view lab results, and refill
prescriptions. The study found that
minority, male, and Spanish speaking patients were less likely to adopt
PHRs.
A recent Government Accountability Office (GAO) report found that the

Patient-Centered Outcomes Research
Institutes (PCORIs) plan to create a
healthcare research network is being
hindered by a lack of interoperable
health data standards.
PCORI was created under the Affordable Care Act (ACA) to fund comparative-effectiveness research, according
to an article in iHealthBeat. An initial
funding round of $93.5 million was announced by PCORI in December 2013
to build the research-oriented data exchange network, called PCORnet.
According to iHealthBeat, the funding went to 18 research networks focused on patients with specific health
conditions and who are willing to share
their health data, as well as 11 clinical
data research networks tied to healthcare systems collecting data during
care delivery. In December 2014, PCORI announced a new funding round for
phase two of PCORI that would grant

22 patient-powered research networks
a three-year $1.2 million award to
launch efforts, as well as funding for up
to 13 clinical data research networks.
But in the GAO report, which was
mandated by ACA, researchers said
that a lack of widely used data standards in electronic health record
(EHR) systems would make it very
difficult for PCORnets research networks to collect and analyze clinical
information.
PCORI officials predicted that this
problem could be solved by creating a
common data model, as well as requiring that all clinical data research networks hire staff with standardization
expertise to help advance EHR standards in the industry.
But due to the lack of interoperability,
the report said stakeholders had concerns about the research networks not
getting sufficient data for analysis.
IT Roadmap Update Includes Good News

for Patient Engagement
Patient engagement, payment models, data harmonization, and exchange
and innovative encounter models have
been identified as key areas of importance for the advancement of electronic data exchange in the recently issued
update to the 2013 WEDI Report &
Roadmap for the Future of Healthcare
Exchange by the Louis W. Sullivan Institute for Healthcare Innovation.
While some of these key areas have
shown good progress, according to the
update, others still have some catching
up to do. Areas that received a positive
green progress rating include patient
engagement, with continued momentum in patient information capture and
patient identification noted, and innovative encounter models. Areas that
received a yellow progress rating,
indicating more room for improvement,
include payment models, with the uncertain success and sustainability of

ACOs noted, and data harmonization
and exchange. The authors call for a
renewed focus on further standardization to enable interoperable exchange.
As initially envisioned more than
twenty years ago, the healthcare industry continues to progress towards
a healthcare system that leverages
technology to improve care and lower
costs, the authors wrote. Looking
ahead to 2015, new regulations and
legislation are expected to further
guide stakeholders towards a sustainable health IT infrastructure.
Innovative technologies will continue to be developed, implemented, and
scaled across the public and private
sectors that reshape the healthcare
landscape.
Blue Button Struggles to Raise Awareness

The federal health information exchange program Blue Button has failed
to gain traction in US healthcare despite recent efforts to increase awareness and encourage adoption, according to a recent survey by the Workgroup
for Electronic Data Interchange (WEDI).
Blue Button found its beginnings in the
Veterans Affairs Department, where
the idea was developed as a pathway
to interoperability between providers
by enabling veterans to obtain copies
of their medical records via an online
personal health record.
This most recent survey by WEDI
was conducted at the end of 2014 as
a follow-up on the organizations first
survey on Blue Button in 2013. For
the survey results, WEDI gathered responses from 274 providers, health
plans, vendors, and clearinghouses.
The number of respondents who indicated they were familiar with the Blue
Button initiative decreased this year,
down from 37 percent in 2013 to 33

percent in 2014.
Key observations from the survey
results, according to WEDIs website,
include:

Reliance on integrated electronic
health record (EHR) and medical
device data to populate personal
health records increased.

Opportunities remain to ensure
awareness of Blue Button as an
industry-wide tool.
Enabling patients to retain control
over personal health record privacy controls remains important.

Data transmissions to patients,
providers, or authorized third parties appears to occur through the
DIRECT protocol.
The full survey results are available
online in the Comment Letters & Testimony section of the Knowledge Center
on WEDIs website, www.wedi.org.
Policy Brief Says Feds Should Re-Think

Meaningful Use
Current federal health IT policy is keeping electronic health records (EHRs) from
helping the US transition to value-based
payment models, a new policy brief said.
The meaningful use EHR Incentive
Program needs to be re-evaluated, according to researchers at the Brookings
Institution. In a policy paper they note
that while adoption of EHRs has soared
in recent years, the burden of being interoperable and meeting mandatory
process measures under meaningful
use (MU) is hindering care delivery.
In an effort to keep MU and the EHR
certification program simple, these
programs have relied on a specific set
of requirements and process measures
for all providers, regardless of specialty
or scope of practice, the authors wrote.
However, this uniform approach does
not support the different realities of clini-
cal care, which require varying health IT

functionalities and tools across different
specialty and scope of practice areas.
The authors instead advocate for an
approach to health IT that would enable providers to avoid MU penalties by
reporting on meaningful performance
measures in their area of clinical practice. A more positive incentive, they
suggest, would be a bonus payment
for reporting on such measures and/or
participating in alternative payment systems based on such measures.
A value-based payment system, in
which providers whose scope of practice includes cardiovascular screening
and risk reduction, [and] are paid for
achieving these results would reinforce
the relevant providers support for these
complex health IT capabilities, the paper states.
TEXTBOOK FOR CONTEMPORARY INFORMATICS

www.ahimastore.org
A new textbook from AHIMA Press,
Contemporary Informatics, is divided
into four sections: background on the
US healthcare system and federal
policies intended to re-engineer it; the
core technologies of health information technology; the application of
these technologies in state-of-the-art
real-world products and solutions; and
the mining, analysis, and visualization
of the vast amounts of newly available digital health data in order to gain
knowledge and improve care delivery.
STATE INNOVATION MODEL HEALTH IT
RESOURCE CENTER
www.healthit.gov/providers-professionals/state-innovation-model-healthit-resource-center
The Centers for Medicare and Medicaid Services Centers for Medicare and
Medicaid Innovation have partnered
with the Office of the National Coordinator for Health IT to release a
comprehensive set of tools that provide technical support and expertise
to states participating in the State
Innovation Models initiative. The tools
are designed to help providers use
health IT to manage both primary and
behavioral healthcare, and are available to all states.
HEALTH IT GUIDANCE FOR PHARMACISTS
www.pharmacyhit.org
A subgroup of the American Pharmacists Association (APhA), the Pharmacy HIT Collaborative, has released
seven guidance documents with information and standards for pharmacists
to use technology. These documents
inform pharmacists on how they can
electronically document patient care
services encounters and share meaningful information to other providers
and payers, said Michael H. Ghobrial,
PharmD, JD, APhA Associate Director
of Health Policy, in a press release.
We Are Ready! ICD-10 Coalition

Asks Congress to Avoid Another
Implementation Delay
By AHIMAs Advocacy and Policy Team
WE NEED ITand we are ready! That

was the main message from speakers
who voiced support for making the ICD10-CM/PCS transition at a briefing by
the Coalition for ICD-10 in February.
The following are interviews with several speakers at the briefing on why policymakers need to stick with the October 1,
2015 transition date, and what providers
can do to maintain their readiness.
More Affordable than Many Think

Those who still oppose the ICD-10 transition may be guided by misconceptions, says Karen Blanchette, MBA,
director at the Professional Association of Health Care Office Management (PAHCOM), based in Lady Lake,
FL. One particular pain pointthe cost
to small practiceshas been exaggerated, she says. A PAHCOM study of 276
practices with six or fewer physicians
found that the average cost associated
with ICD-10 was approximately $8,100
per practice, and the average cost per
provider was slightly more than $3,400.
Blanchette says these figures are in
line with other studies from 3M and
the American Academy of Professional
Coders (AAPC), suggesting that ICD-10
implementation costs are manageable.
Blanchette says it is time to end the
stop-and-go cycle of ICD-10 implementation. I cant stress enough how
the delay itself is the problem at this
point, she says. Small practices have
to pick and choose which initiatives they
take on, and they cannot afford to spend
time on an initiative that will be delayed
again. Continue to penalize practices
for being prepared, and you may as well
take food off their familys table.
Blanchette believes that adhering to
the October 1, 2015 implementation
target will help patients, physician practices, and the broader healthcare com14/Journal of AHIMA May 15
munity. ICD-10 will benefit us all, and

the transition can be managed so that
it is not particularly costly or disruptive
compared with any other change in how
we do business.
To prepare for the transition, Blanchette recommends that managers in
small practices take advantage of lowcost training from vendors as well as
free resources from the Centers for
Medicare and Medicaid Services, like
the Road to 10 resource, available at
www.roadto10.org.
Busting Myths About ICD-10

The idea that ICD-10s code specificity creates undue burden for providers
needs to be debunked, says Richard
F. Averill, MS, director of public policy
at 3M Health Information Systems,
based in Wallingford, CT. Much of
the increase in ICD-10 codes is due
to obvious, easy-to-document attributes of the patient, Averill says. This
includes new codes that document
greater anatomic specificity, as well
as left-right laterality.
The larger number of codes is actually
a benefit, not a burden, Averill says. The
act of coding is easier when theres more
specificity. The confusion comes when
the code is vague, he says. When the
information is in the codes, the claims
adjudication process can be more
straightforward and less time consuming. The net of it all is that the system
just works better.
Although some contend that the average physician practice will find it difficult
to deal with ICD-10 codes that are rarely needed, Averill views ICD-10 as the
global dictionary from which providers
select the codes that best represent their
business. The fact that there are codes
that will rarely be used reflects the fact
that ICD-10 serves a lot of stakehold-
ers, and the needs of all those stakeholders should be met,

Averill says.
Averill also believes that moving forward with ICD-10 this
year is critical for the success of value-based payment
models that are taking shape across the industry. Under
these models, judgments will be made about providers
ability to deliver high quality care and manage costs that
will impact their reputation and financial viability. Having
accurate data will be essential to make these judgments
fairly, he says. The whole idea of value-based payment
is dependent upon the ability to do comparisons of performance on an accurate and reliable basis, and I simply
dont believe you can do that with ICD-9. You really need
the precision that is in ICD-10.
Making Research on Rare Conditions Possible

Delaying the ICD-10 transition further also has a negative
impact on research efforts. For example, another delay
would compromise providers efforts to treat children with
rare conditions, says David W. West, MD, medical director,
health informatics and business partners, at Nemours Childrens Health System, based in Wilmington, DE. The problem
is that rare conditions lack specific codes, which makes it
difficult for researchers to share data across organizations in
the United States and abroad.
The ICD-10 codes have a common coding structure
that will allow us to extract data about children with rare
conditions from multiple organizations, which allows researchers to have a big enough cohort to determine their
natural history, potentially effective interventions, comparison groups, and so forth, West says. The fact that
Europe is on ICD-10 also would allow for greater collaboration internationally.
West offers one example of how ICD-9s lack of specificity can cloud pediatric research efforts: Bickers-Adams syndrome, a hereditary form of hydrocephalus, and Alport syndrome, a genetic condition that leads to kidney failure and
hearing loss, are coded exactly the same in ICD-9. However,
ICD-10 includes separate diagnosis codes for these rare and
distinct conditions, which will allow researchers to pull data
on each specific patient population.
By providing more specific terminology, ICD-10 codes also
will enhance how data on birth defects is shared via statewide registries, West says. Without proper codes for certain
birth defects, these registries rely on text fields to classify
patients. With more specific codes, researchers can more
easily get to the data of interest, such as how often birth
defects occur in our population and what are the risk factors, he says.
Helping Providers Prepare

Providers have many avenues of support for making the
switch to ICD-10. Florida Blue, based in Jacksonville, FL,
is one health plan helping physician practices and institutions as they prepare for the transition. Since October 2013,
Florida Blue has conducted extensive end-to-end testing
in which providers re-code previously processed claims to
ICD-10 using the original medical record.
We wanted to make it as simple as possible for physicians
and providers who rely on us for their revenue stream to be
able to test easily without creating heartburn on their side,
says George Vancore, Florida Blues senior manager of delivery systems, mandates, and compliance. Vancore is encouraged that recent testing has revealed no financial anomalies
for physician practices.
To promote better knowledge of ICD-10, Florida Blue
conducts monthly calls with physicians, providers, and
even other payers. Known as ICD-10 Open Line Friday,
these calls provide case studies and other resources to
help stakeholders prepare for the transition. We want to
create a mindset for ICD-10 around the three Cscollaboration, coordination, and cooperationacross the industry, Vancore says.
Additionally, Florida Blue has been working with industry
associations and medical societies to educate and engage
physicians. In 18 months, Vancore has visited 70 groups to
help support providers across Florida. During his visits, Vancore conveys one clear message: We have solutions, and at
the end of the day, we can and must do this.
AHIMA Testifies Before Congress

At a House Energy and Commerce Committee Subcommittee on Health hearing the day after the briefing, AHIMAs
Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of
coding policy and compliance at AHIMA, testified that further implementation delays would be at considerable cost
to the industry.
All segments of the healthcare industry have dedicated
significant time and resources in financing, training, and
implementing the necessary changes to workflow and clinical documentation, Bowman said during the hearing. The
repeated ICD-10 delays have been disruptive and costly
for healthcare delivery innovation, payment reform, public
health, and healthcare spending.
Given that the industry has had more than six years to prepare for the transition, Bowman told policymakers that the
time is now to move forward. It is time to stop delaying the
transition to ICD-10 so that the US can start reaping the benefits of a more modern code set that the rest of the world has
enjoyed for a number of years now, she said.
During the hearing, Chairman Joseph R. Pitts (R-PA) was
one of several subcommittee members who voiced support
to keep the October 1, 2015 transition date.
The AHIMA Advocacy and Policy Team (advocacyandpolicy@ahima.org)
is based in Washington, DC.
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Inside Look
Informatics Poses Challenges,

But Promises Rewards
By Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA, chief executive officer
INFORMATICS IS ONE of the pillars of

AHIMAs strategy. And many people
agree that its a critical part of the profession. But when were in the middle of
doing our daily work, its easy to think of
informatics as something thats done by
somebody else.
Its getting easier to find examples of
informatics in action. We frequently see
headlines about new initiatives that aim
to use health data to effect transformational change. For instance, earlier
this year the Obama administration announced its Precision Medicine Initiative, which aims to produce more individualized treatments based on factors
such as genetics, the environment, and
lifestyles. The Presidents 2016 budget
proposes to invest $215 million to pioneer patient-powered research, with
an initial focus on cancer.1 The initiative
proposes to engage a million or more
citizens to volunteer to contribute their
health data to improve health outcomes.
This initiative depends on health data.
Francis Collins, director of the National
Institutes of Health, said as much in an
interview with Reuters, noting that the key
to success would be using medical records from different systems and making
them work together. That doesnt necessarily mean all of the data is in one place
being operated by the same software,
but the data must be exquisite, Collins
said in the interview. Thats not easy.2
These developments, and others, signal that its time for a change. Its time for
HIM professionals to step up to do the
work that can help transform data into
knowledge and drive decisions.
Everything we do is related to informatics. But many of us still need education
in this area in order to do the work. The
articles in this months Journal start to
show us the way. In Workaday Informatics, Mary Butler provides examples of
informatics that are being used in healthcare facilities every day to improve care
processes and information management.
In Data Analysis Starter Kit, Diane
Dolezel, MSCS, RHIA, helps demystify
some of the tools used in data analysis
and provides a practical starting point.
Donald M. Voltz, MD, suggests the industry take another look at middleware
as a solution to the perennial problem of
connecting disconnected EHR systems
in Connecting the Disparate: Middlewares Role in Solving Healthcares EHR
Interoperability Problems.
Priscilla Keeton, MS, RHIT, and Patricia Pierson, RHIA, offer practical steps
everyone can use to land the HIM jobs
of the future in e-HIM Professionals
Wanted. And for the 50,000-foot view,
Scanning the HIM Environment, by
Anna Desai, MHA, CAE, summarizes the
latest environmental scan report created
by the House of Delegates Envisioning
Collaborative.
Informatics is more than a buzzword. It
poses new challenges but also promises
great rewards. With our knowledge and
insights into data, HIM professionals can
help make the promise a reality.
Notes
1. The White House, Office of the
Press Secretary. Fact Sheet:
President Obamas Precision Medicine Initiative. January 30, 2015.
www.whitehouse.gov/the-pressoffice/2015/01/30/fact-sheet-president-obama-s-precision-medicineinitiative.
2. Steenhuysen, Julie. NIH director sees solving data puzzle as
key to U.S. precision medicine.
Reuters. March 6, 2015. www.
reuters.com/ar ticle/2015/03/07/
us-usa-health-precision-idUSKBN0M302520150307.
Workaday
Informatics
HOW HEALTHCARE IS APPLYING
PRACTICAL INFORMATICS TO SAVE
DOLLARS AND LIVES
By Mary Butler
WATCH AND LEARN. For clinical informaticist Nathan Patrick

Taylor, MPH, MS, CHDA, and others like him, watching patientphysician encounters and learning from them is just as important as knowing how to query data in a health IT system. Because as technical as informatics can get, at its heart is the use of
data and systems processes to make physician encounters with
patients better.
Taylor has a background in computer science and software
engineering, but his love of information and data analytics has
drawn him to the frontlines of healthcare. He has shadowed
neurosurgeons, participated in their stand-up meetings and
morning huddles, observed med passes in nursing homes, and
sat next to physician consultations with patients.
When carefully observing these patient-doctor encounters,
Taylor pays close attention to exactly how physicians interact
with their patients. Maybe the doctor enters his review of systems into the electronic health record (EHR) during the appointment, or maybe he waits until later. Maybe the physician
shows the patient their EHR on the computer screen while hes
working, or maybe they give the patient their full attention. All
of this is relevant to Taylor and his role as a clinical informaticist.
When Taylor explains this part of his job to other people, he often hears Well that doesnt sound like data analytics to me. His
response is, Yeah, all of that together, in order to be good at this
job and in this role, I have to understand how both sides work.
Taylor works as a consultant with Symphony Post-Acute Network. As an informaticist he must be able to take those clinical
observations and use them to help build better physician workflows, capture better information for billers and coders, and,
most importantly, improve the quality of care being delivered.
Informatics is an emerging workforce focus for health information management (HIM) professionalsalongwith the subdomain of data analytics. Yet many peopleincluding HIM
practitionersstruggle with understanding the role of informatics in their profession even as it becomes an increasingly
important part of their future. Informaticists can come from
computer science backgrounds, like Taylor, from nursing and
other clinical backgrounds, or even HIM and IT.
As healthcare organizations continue to generate enormous
amounts of datadue to demands such as the meaningful
use EHR Incentive Program, accountable care organizations
(ACOs) quality reporting requirements, ICD-10-CM/PCS transition data, and moreHIM professionals need to familiarize
themselves with informatics, and fast. They can do this by understanding the role of informaticists in organizations, acquiring more skills in data analytics by obtaining a certified health
data analyst (CHDA) credential, and by getting a firm grasp on
what exactly informaticists do all day. Its time for HIM professionals to move from having just a theoretical understanding of
informatics to finally wrapping their brains around it.
Defining Informatics Not Easy

If you ask five informaticists to try and define what the term informatics means, youll get as many different definitions, according to Taylor and Anna Orlova, PhD, AHIMAs senior director of standards.
Im not sure that I hear a clear understanding among AHIMA

members about what informatics is, Orlova says. This is not
strange, because, in fact, in fields like medical informatics and
other kinds of informatics, its still a debatable question.
Orlova sees informatics as a modeling discipline or modeling tool because it explains the themes of healthcare to the
computer system, to the machine. And the computer is a model. If the computer systemssuch as EHRs, clinical decision
support programs, etc.are designed to capture information as
well as they possibly can, then providers can make better decisions with them.
The best example of this dynamic is in clinical documentation improvement (CDI) programs, Orlova says. She shared
the example of a childrens hospital where a physician leads
the CDI program. The doctor, in concert with clinical guidelines, works with HIM and CDI professionals to ask: What is
the best way to document a clinical encounter to get the best
information possible?
Informaticists look at ways of collecting the best patient registration data, triage data, and the data that flows out of an EHR to
create workflow documents and templates.
In this case of the childrens hospital, informatics is a joint endeavor between HIM and the clinical side, which is consistent
with how Vi Shaffer, vice president of research for healthcare at
Gartner, describes the role of informatics. Informaticists are the
liaisons between the clinical and the health IT realms. And due
to the move to EHRs, the line between these realms has started
to blur, Shaffer says.
In the days before EHRs, IT took care of building networks,
infrastructure, software coding, and engineering. Now, however, youre not just creating a system for physician order entry, but for orders management, so youre looking at the whole
flow among physicians, pharmacists, nurses, Shaffer explains.
Youre looking at how the information is used and how it
touches each of those parties. The informatics role, as we call it,
starts as a group that does the heavy lifting work, from planning
to lifecycle management.
Its the bridge between the technical stuff that IT does and
the business or clinical stuff that the end users do, for complex
systems.
David Marc, MBS, CHDA, the health informatics graduate
program director and assistant professor of HIM and informatics at the College of St. Scholastica, says that when students ask
him about whether they should pursue HIM or informatics, he
responds by discussing the available jobs theyll be pursuing
when they finish the program.
What I tell them is that HIM is more about the management
of personal health information and is primarily the role to use
and manage that information to support quality and efficient
care delivery, Marc says. And health informatics is more about
advancement of health information technology and the use of
data to support improvement in quality, efficiency, and the cost
of healthcare.
Healthcares Triple Aim Needs Data

The US healthcare systems drive to improve quality, lower costs,
and improve outcomes, known as the Triple Aim, is part of the

reason informatics is an emerging field, experts say. Federal
initiatives like ICD-10-CM/PCS, meaningful use, and ACOs are
all intended to help achieve the Triple Aim, and they all need
dataclean, accurate, and reliable datato do it. Informaticists
are going to be instrumental in helping to make these transitions easier for physicians, according to Shaffer.
She says that informaticists historically have reported to chief
information officers (CIOs), but thats starting to change as they
are increasingly reporting to chief medical officers (CMOs) or
chief medical information officers (CMIOs).
One of the things that really brought it to a head was that
CMIOs were expected to take an active role in making sure ICD10 works. Because, of course, the whole process of conversion,
one of the biggest things physicians have to understand is how
documentation changes under ICD-10, Shaffer says.
The ICD-10 conversion will require better documentation
and, for many facilities, implementation of computer-assisted
coding (CAC) programs, which Shaffer says will allow providers
to pull more insights about the well-being of a providers population. But in order for a provider to make the best use of CAC
systems, physicians will need to improve their documentation.
Thats not just HIM folks going to doctors and saying, Improve this. No, its medical informatics and HIM and quality
going to the doctors together and saying, We want improved
documentation for research and analysis purposes, for clinical
communication purposes, and for revenue, Shaffer says.
She notes that for those kinds of CDI efforts to be effective and
persuasive to physicians, informaticists are better positioned to
make an impact. If physicians have to field documentation suggestions from HIM, IT, and revenue cycle departments, theyre
more likely to be overwhelmed by unproductive ideas.
One of the key components of the Centers for Medicare and
Medicaid Services (CMS) Triple Aim initiative is reducing hospital readmissions for nursing home and assisted living residents
for conditions such as congestive heart failure.1 To keep providers compliant, CMS has instituted penalties in the form of reimbursement cuts to facilities that dont lower readmission rates.
Symphonys Taylor says that in the long-term care sector in
which he works, informaticists are using data to help post-acute
providers reduce readmission and fall rates, and monitor pressure ulcers. Post-acute providers are facing growing pressure by
Medicare to lower these rates and data analytics is one direction
in which they are turning to solve these problems.
The big thing to me, and it seems simple and common sense,
but a lot just dont do ityou have to talk about the data and we,
at Symphony, do it every week, Taylor says.
Symphonys president, along with Taylor, has what they call
red alarm meetings with their long-term care clients where
they will discuss the data theyve been collecting on fall and readmission rates and pressure ulcers.
Well be in a meeting and my boss will say, Your return to
hospital rate is 45 percent, whats going on? And they [longterm care facility administrators and nursing directors] have to
explain it and come to the meeting prepared. We send the data
out ahead of time so they have time to prepare and get their in20/Journal of AHIMA May 15
formation together, Taylor explains.

By looking at and comparing a facilitys historical data, using
systems and programs built by Taylor and his team, Symphony can identify which periods throughout a month a patient is
most likely to be readmitted to the hospital. This helps nurses
and administrators track risk factors and develop interventions.
Similarly, Symphony can help gather data on fall rates in a facility, which can identify which residents fall the most often. Once
this information is reviewed, staff can look for risk factors in
these patients. For instance, residents whose walking speed has
declined are at a greater risk for a fall. If this type of information
is tracked, nursing staff can put measures in place that reduce
falls, such as better observation and motion sensors.
For pressure ulcers, nursing staff can use Palm Pilotsor
iPhone and Android smartphone appsto take pictures of a
patients pressure sores and track any changes over time. Obviously, if a wound worsens or one develops post-admission,
Taylor and his team will bring it to the providers attention
during a red alarm meeting so the facility can take steps to improve wound care practices.
You have to find out whats going on. Staff could be entering
the data wrong and there really is no problem but the data is
incorrect. There could be a serious clinical issue like not having
enough staff. But you dont know until you drill into the details
[of the data], Taylor says.
Informatics Role in HIM

The College of St. Scholasticas Marc emphasizes to his students,
as well as to those within the HIM profession, that the line between health IT and HIM is becoming pretty gray, and a lot of
HIM professionals are taking on roles that demand familiarity
with data analytics. This trend, he says, is going to require more
education in order to keep HIM professionals up to speed.
Many of the advancements in health IT are the result of work
with data. HIM professionals are those that are taking on the
majority of that work, Marc says. Thats where a greater education around health informatics is really required, and youre
seeing that through AHIMAs career mapping.
Marc says that in the undergrad data analytics course hes
teaching, some HIM students really develop a passion for data
and analytics and are motivated to pursue more data-driven,
informatics-centric careers. But, he notes, there is still a lot of
uncertainty about what data analytics actually is for students
and even HIM practitioners since the field is evolving so rapidly.
By educating students more about what data analytics is all
about, were seeing more and more of our students taking on
this role and becoming excited about it, Marc says.
HIM students at St. Scholastica today are taking courses in statistics, health data analytics, database management, computer
programming, and other classes that help teach them the language of health IT.
Students with an informatics background are finding jobs with
titles like chief data analyst or senior data analyst, Marc says. But
hes also seeing people in traditional HIM roles like information
officers and privacy and security officers pursuing data analytics opportunities. He says undergrad courses are being closely
NLP Offers Many Practical Informatics Applications

HEALTHCARE PROVIDERS THAT are forward-thinking about
documentation infrastructure and data analytics should consider the benefits of technologies such as natural language
processing (NLP) for population health and clinical decisionmaking, says Steve Bonney, executive vice president of business development and strategy at RecordsOne.
NLP is a practical application of informatics in that it processes the free-text or dictated portions of an EHR, which
has much richer clinical value to researchers and clinical
decision-makers than claims data. Providers can use NLP
to identify weaknesses in clinical documentation, screen for
clinical trial patients, and track the health of the population
that they treat much more easily. Structured EHR data, as
captured by drop-down boxes, checked or unchecked boxes, and pre-filled templates provides a lot of information but
also presents an incomplete picture, says Bonney. NLP, he
says, takes the text from the free-text fields to create data
where there is no data.
Researchers and clinical documentation improvement specialists need the actionable data from records that NLP
helps generate, according to Bonney.
To me informatics is all about actionable information. Not
just being able to go look for it and find it, but have the infor-
aligned with AHIMAs CHDA credential. Since the credential is

so new, not many students have taken the credentialing exam,
but Marc is seeing a lot of interest from students wanting to pursue the more data-centric side of HIM.
Its such an undefined, diverse area, in that the roles that are
taking on analytics have informatics components. However,
that being said, Ill say this: If you just do a job search today and
search informatics, youre going to have job titles that have informatics in the name, a health informatics specialist or informatician or informaticist. They tend to have more of these,
traditionally defined health informatics roles, Marc notes.
The fast-paced nature of informatics and health IT is part of
the confusion around job titles such as nurse informaticist,
physician informaticist, clinical informaticist, and medical informaticist. Because its still a burgeoning career path, finding
candidates who can meet all the desired experience for those
roles is difficult. Taylors role at Symphony was originally written
as a nurse informaticist. My boss said, I dont care that youre
not an RN, but you have to play this balancing act, Taylor says.
He notes that for his boss, not having a clinical background
wasnt a dealbreaker because he had the technical skills to get
the tech side set up properlyto get a data warehouse built and
the infrastructure that supports the companys automated reporting services.
I dont for sure know the difference between nurse informaticists and physician informaticists, but theyre really hard to find.
Id say if youre a person who loves the tech side and the details
of the data, then you spend a little time in statistics, a little time
in programming, and probably database query language, you
mation find you, Bonney says.

Currently, RecordsOne is working with the Austin Cancer
Center in Austin, TX, to identify prostate cancer patients
who fit the criteria for an experimental drug. The researchers
work with the vendors NLP software to hunt through patient
records in real time in search of certain words and phrases
that meet the drug trials inclusion criteria. When the system
recognizes a patient who meets the trial criteria, it automatically sends an e-mail to the centers researchers, saving them
from having to review charts manually.
Bonney says some hospital CDI departments have adopted
NLP for the purposes of case identification, to help track patients with conditions such as diabetes or heart failure, which
put them at a higher risk for being readmitted to the hospital
after an inpatient stay. Just like NLP helped the Austin Cancer
Center screen patients for clinical trial inclusion, it can do the
same for keywords written or dictated into a patients chart.
We cant read the doctors mind. So when the doctor documents history, current issues, and that information flows to our
system, we can say This patient has COPD, is on this particular inhaler, this patient hasnt had a history of whatever. If they
meet eight or 10 of these criteria, thats enough to trigger an
alert to a researcher as case identification, Bonney says.
should be able to dive in pretty quickly, Taylor says.

Interoperability is another issue thats top of mind for HIM
professionals today, since EHRs cant fulfill their mission in facilitating better care coordination if health information isnt interoperable when its exchanged. HIM professionals have been
among those leading the way in trying to implement and develop interoperable systems, but its also becoming a key focus
for informaticists.
Gartners Shaffer says interoperability is very important nationally, as the newly published Office of the National Coordinator for Health IT (ONC) Interoperability Roadmap demonstrates. Shaffer says interoperability is also a core responsibility
for the IT and informatics communities, with HIM making up
the third leg of the stool.
Data integration, data stewardship and information governance are compellingly important, Shaffer emphasizes.
Theyre the other piece of whats important for health systems if
you look at the trilogy of HIM, clinical informatics, and IT. Thats
the future. But the new core competency in the health system is
data and how to use it. And so if youre thinking interoperability,
youre missing an awful lot of the sea change thats going on.
Note
1. Berwick, Donald M. et al. The Triple AIM: Care, Health
and Cost. Health Affairs 27, no. 3 (May 2008): 759-769.
http://content.healthaffairs.org/content/27/3/759.full.
Mary Butler (mary.butler@ahima.org) is associate editor at the Journal of
AHIMA.
DATA
A
N
STAR ALYSIS
TER K
IT
HOW TO APPLY INFORMATICS
AND ANALYZE ROI AS AN
E-HIM PROFESSIONAL
By Diane Dolezel, MSCS, RHIA
THE DIGITAL ERA of Big Data has generated a growing need

for more electronic health information management (e-HIM)
professionals who can assume the emerging role of data analyst.1 This new role requires learning how to analyze data and
perform statistical calculations to support informed decisionmaking and enable information governance.2 However, acquiring these new skillsets can be daunting since an e-HIM professional must learn to use unfamiliar software features to create
graphs and generate statistics. This article will demystify those
features, and provide a practical starter kit for applied informatics analysis.
Figure 1: File Options
Importance of Data Analysis

In order to support enterprise level information governance,
a typical healthcare facility must collect, analyze, and present
large volumes of data rapidly and accurately.3 Data sources
could include electronic health records (EHRs), computerized
physician order entry (CPOE), or electronic insurance billing.4
Additional data collection is necessary to support the mandatory reporting for the Centers for Medicare and Medicaid Services (CMS) pay-for-performance program, and the Affordable
Care Act, which rewards facilities for providing quality care and
demonstrating improved clinical outcomes.5,6
Raw data must be converted into meaningful information
with data analysis in order to provide useful health intelligence.
Thus, it is not surprising that AHIMA endorses data capture and
analysis as essential HIM quality and safety practices.7 In fact,
the typical HIM professional is already facilitating data capture
by using their knowledge of health data content, data storage,
and data standards to design CPOE input screens, map data
flows from ancillary systems into EHRs, and create data dictionaries to standardize patient data.8
HIM professionals should also be performing data analysis
to support quality and performance initiatives. They can check
compliance with CMS national patient safety goals, track chart
coding accuracy, and assess History and Physical completion
and accuracy. Unfortunately, many HIM professionals lack the
skills to perform these applied informatics tasks.9,10
Steps for Data Analysis

Suppose you are an e-HIM manager tasked with reporting the
current state of the electronic release of information (e-ROI)
process concerning costs and ability to provide electronic copies of patient information within four business days, as required
by the meaningful use Stage 2 EHR Incentive Program.11,12
The data analysis process begins with these steps:
1. Enable Excel Data Analysis ToolPak
2. Analyze with descriptive statistics
3. Graph with a histogram
4. Summarize with a PivotTable
5. Present with a PivotChart
Enable Excel Data Analysis ToolPak

Assume you have 10 weeks of e-ROI data collected showing the
average business days per week to fulfill requests, and total costs
for e-ROI. This data can provide an overview of the e-ROI process for identifying problem areas.
First, locate the Microsoft Excel 2013 software in the Microsoft Office suite.13 Start the software, add three column headers
labeled Weeks, Average Business Days Per Week to Fulfill Requests, and Total Costs for e-ROI. Second, label the week rows 1
through 10, and type your data into the other columns.14
Now, you must enable the Excel Data Analysis ToolPak, which
is a powerhouse tool that allows the analyst to accomplish multiple statistical functions at one time. For this example, that process will be illustrated with pictures created on the computer
desktop of the author of this article (see Figures 1 to 13).
The process to enable the TookPak consists of these steps:15
1. In Excel, select the File Tab.
2. From the File menu on the right, click Options, as

shown in Figure 1.
3. On the Excel Options pop-up sidebar, select Add-Ins to
get the pop-up shown in Figure 2. If the Analysis ToolPak is listed under Active Application Add-Ins, as it is
in Figure 2, then you can proceed to use it.16 However, if
the Analysis ToolPak is not listed under Active Application Add-Ins, then click the Go button by the dropdown
menu labeled Manage illustrated in Figure 2.
4. From the resulting Add-Ins pop-up, click the checkbox by
Analysis ToolPak, then click the OK button as shown in
Figure 3. You will be returned to Excel Options and the
ToolPak should be listed under Active Application AddIns.17
5. A fter the ToolPak is enabled, a new icon will be added to
the Data tab in the Analysis section, shown in Figure 4.
Analyze with Descriptive Statistics

To analyze total e-ROI costs, select the Data tab, click the Data
Analysis icon in the Analysis section, and select Descriptive

Statistics from the pop-up, as shown in Figure 5.18
Click on Input Range, then select the Total e-ROI Costs
data and column headers, and select the other options as shown
in Figure 6. Also, be sure to select Labels in the First Row or
you may get an error message.19
Click the OK button to see the resulting descriptive statistics
for the total charge data shown in Figure 7.
The descriptive statistics values reported most often are the
mean (i.e., average), standard deviation, and sum. By looking
at the results in Figure 7, you will see the average ROI weekly
cost is $770, the sum is $7,700, and the standard deviation,
which measures dispersion from the center, is approximately
$333.50.20
Other uses of this feature would be calculating average percentage of operative reports having acceptable accuracy, median number of medication errors, or most frequently occurring
length of stay (i.e., mode). Note that if the data has outliers the
median, also called the midpoint, is more appropriate than the
mean because outlier values affect the mean.21
Graph with a Histogram

Groups of continuous data, called categories, can be compared
with histograms.21 To create a histogram for the average number of business days needed to fulfill requests, first define the
groups by creating and populating an Excel column called a
bin. Next, select the Data Analysis icon, select Histogram
from the ToolPak pop-up, select the data, and make the other
option selections shown in Figure 8.
Click the OK button to see the unfinished histogram in Figure 9. This histogram is unfinished because a histogram has
no space between the bars; therefore there is some cleanup
work needed.
Complete the following to get the finished results illustrated
in Figure 10:
1. Delete the More row in the bins listing.
2. Click on a blue histogram data bar.
3. Right mouse-click and select Format Data Series.
4. Under Series Options, set the Gap width to zero.
5. Notice that there is now no space between the bars in the
histogram.
6. Continue the cleanup by adding appropriate labels and

deleting the legend.
An examination of the graph shows two weeks where the average clinic e-ROI process took more than the recommended four
business days, which indicates a need to inspect the detail data
for those weeks. Other quantitative data suitable for categorizing and comparing with histograms are total costs, charges, or
length of stay.
Summarize with a PivotTable

As an e-HIM analyst works on data collection, there is often a
need to compare the performance of two clinics for decision24/Journal of AHIMA May 15
making. Excel has a powerful tool called a PivotTable that efficiently summarizes worksheet data into a table by fields.23
An e-HIM analyst should ensure that all data columns have
headers, and that the data selected for analysis does not have
any empty cells. To begin, select all the table data, including the
headers, click the Insert tab, and click on Recommended PivotTables to see the pop-up shown in Figure 11, which allows
you to see how the recommended chart(s) would look.
Scroll until the chart shown in Figure 11 is displayed, then
click the OK button.
The PivotTable in Figure 12, which summarizes the data, will
be displayed on a separate worksheet.
In summary, this is a powerful, highly customizable tool
that facilitates comparing different categories of data such as
length of stay in days and age group, or age group and payer
class. This PivotTable provides an easy method for summarizing data for multiple clinics for the same time in order to visualize their differences.
For example, Figure 12 indicates that Clinic 1 had a higher
total of e-ROI costs (i.e., $7,700) than Clinic 2 (i.e., $7,100) during this 10-week stretch. At this point, descriptive statistics
(i.e., average ROI weekly costs) and histograms showing average business days to fulfill requests could be completed for
both clinics in order to further analyze the differences.
Present with a PivotChart

The e-HIM analyst that creates a PivotTable will be rewarded by
the ease with which a PivotChart can be generated from the PivotTable. Here are the steps:24
1. Select the data in the PivotTable.
2. Click on the Insert tab.
3. Click on the Recommended Charts icon.
4. Select the Bar chart.
5. Select the gray buttons, right mouse-click and select Hide
All Field Buttons and Legend.
6. Label the axis and create a chart title.
7. The resulting chart is shown in Figure 13.
8. Label the axes and create a chart title.
The PivotChart provides a quick way to spot problem areas.
For example, one can see in Figure 13 that for weeks one, two,
eight, and nine the e-ROI costs were much higher than usual.
Analytics Skills are Necessary Today, Not Tomorrow

Data analytics is an emerging role for HIM professionals, especially with the advent of Big Data, the demands of the Health
Information Technology for Economic and Clinical Health (HITECH) Act, and the need for greater accountability in healthcare for providing quality outcomes.
HIM professionals should equip themselves to meet these
challenges by obtaining the CHDA credential, which demonstrates competency in data analytics, as well as learning and
practicing the basic data analysis techniques discussed in this
data analysis starter toolkit.25
Figure 2: Excel with ToolPak Enabled
Figure 5: Descriptive Statistics Selection
Figure 3: Select Analysis ToolPak to Enable
Figure 6: Descriptive Statistics Options
Figure 4: Data Analysis ToolPak Icon
Figure 7: Descriptive Statistics Results
Figure 8: Histogram Options
Figure 11: Recommended Pivot Table
Figure 9: Unfinished Histogram
Figure 12: Summarize by Average

Business Days to Fulfill Requests
Figure 10: Finished Histogram Chart
Figure 13: PivotChart of Total e-ROI Costs
Notes
1. Orlova, Anna and Harold Lehmann. Informatics Education for HIM Professionals in the Era of Interoperable
Standards-Based HIEs. Journal of AHIMA 86, no. 2 (February 2015): 48-51.
2. Dimick, Chris. Health Information Management 2025:
Current Health IT Revolution Drastically Changes HIM
in the Near Future. Journal of AHIMA 83, no. 8 (August
2012): 24-31.
3. Fernandes, Lorraine, OConnor, Michele, and Victoria
Weaver. Big Data, Bigger Outcomes. Journal of AHIMA
83, no. 10 (October 2012): 38-43.
4. Ibid.
5. Centers for Medicare and Medicaid Services. Affordable
Care Act Implementation FAQs Set 1. Center for Consumer Information and Insurance Oversight. www.cms.
gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs.html.
6. Centers for Medicare and Medicaid Services. Pay-forPerformance/Quality Incentives. May 24, 2005. www.cms.
gov/Regulations-and-Guidance/Guidance/FACA/downloads/tab_H.pdf.
7. AHIMA. HIM Functions in Healthcare Quality and Patient Safety. Journal of AHIMA 82, no. 8 (August 2011):
42-45.
8. Shaw, Patricia L. and Chris Elliot. Quality and Performance Improvement Healthcare: A Tool for Programmed Learning. 5th ed. Chicago, IL: AHIMA
Press, 2012.
9. Joint Commission. 2015 Hospital National Patient Safety
Goals. www.jointcommission.org/assets/1/6/2015_HAP_
NPSG_ER.pdf.
10. Sandefer, Ryan H. et al. Keeping Current in the Electronic
Era: Data Age Transforming HIMs Mandatory Workforce
Competencies. Journal of AHIMA 85, no. 11 (November
December 2014): 38-44.
11. Office of the National Coordinator for Health IT.
Patient Ability to Electronically View, Download &
Transmit (VDT) Health Information. February 2014.
w w w.healthit.gov/providers-professionals/achievemeaning f u l-use/core-measures-2/pat ient-abilit yelectronically-view-download-transmit-vdt-healthinformation.
12. Centers for Medicare and Medicaid Services. Eligible Professional Meaningful Use Core Measures, Measure 7 of 17.
August 2014. www.cms.gov/Regulations-and-Guidance/
Legislation/EHRIncentivePrograms/downloads/Stage2_
EPCore_7_PatientElectronicAccess.pdf.
13. Microsoft. Excel when and where you need it. 2015.
http://products.office.com/en-us/excel.
14. Microsoft. Basic tasks in Excel 2013. https://support.
office.microsoft.com/en-us/article/Basic-tasks-in-Excel2013-363600c5-55be-4d6e-82cf-b0a41e294054?Correla
tionId=484fa17b-4e38-4109-b9c4-f47af572112c&ui=enUS&rs=en-US&ad=US.
15. Microsoft. Use the Analysis TookPak to perform com-
plex data analysis. https://support.office.microsoft.

com/en-US/article/Use-the-Analysis-ToolPak-to-perform-complex-data-analysis-b0f0a249-11af-4570-a9ccbecfa6bc0c31?ui=en-US&rs=en-US&ad=US.
16. Ibid.
17. Ibid.
18. Ibid.
19. Ibid.
20. LaTour, Kathleen M. and Shirley Eichenwald-Maki. Health
Information Management Concepts, Principles, and Practice. 4th ed. Chicago, IL: AHIMA Press, 2013.
21. Ibid.
22. Ibid.
23. Microsoft. Create a PivotTable to analyze your
data. https://support.office.com/en-us/article/Create-a-PivotTable-and-analyze-your-data-7810597d0 8 37- 41f 7-9 699 -5911aa 2 8276 0? u i= en-US& r s = enUS&ad=US.
24. Ibid.
25. Butler, Mary. Mind the Gap: HIM Rushes to Bridge Educational and Professional Gaps Caused by a Quickly Advancing Industry. Journal of AHIMA 86, no. 2 (February
2015): 20-24.
Diane Dolezel (dd30@txstate.edu) is an assistant professor in the health
information management department at Texas State University, based in
San Marcos, TX.
Connecting
the Disparate
MIDDLEWARES ROLE IN SOLVING HEALTHCARES

EHR INTEROPERABILITY PROBLEMS
By Donald M. Voltz, MD
ACCORDING TO DATA published on HealthIT.gov, 173 health

IT vendors are supplying certified electronic health record
(EHR) products to more than 4,500 hospitals. Despite wide
penetration of EHRs in hospitals, clinics, and physician offices, a lack of access to patient information between systems
continues to plague the US healthcare system.
Most physicians feel they have a duty to provide the best
care that addresses patients health needs with the least
possible risk of adverse events. Physicians can look at the
EHR implementation history from a similar perspective.
EHRs should offer the ability to collect, store, and allow for
timely, accurate, and appropriate access to patient health
information from any and all healthcare providers who require the information to meet the needs of their patients.
Medicine is a data-intensive field involved in risk assessment and reduction and/or mitigation of risks during the
course of treatment. At the same time the medical field
must be cognizant of the limited resources available and
the costs incurred by patients, employers, and the entire

health system.
No matter what area of healthcare or what role one plays in
the care of patients, all have a stake in the art and science of
medicine as well as the economic implications of physicians
decisions. The same requirements and limitations placed on
healthcare providers from the care delivery side are impacting
all providers on the technology side with the requirements put
in place for EHR use.
In the past, the vast majority of healthcare providers were
not tech savvy. Many have worked very hard to overcome
their discomfort with computer charting and other technical
requirements that are now omnipresent in medicine. Access
to patient information, not only that which is individually collected, but all of the information collected across a care continuum, not only adds value and accuracy to the decisions
made in the management of a patient, but also impacts the
cost of care to the patient and system.
MiddlewareThe Missing Link in EHRs?

MIDDLEWARE IS SOFTWARE that is used to connect one or more different software applications. It has been simplified as
the glue or plumbing used to pass data between applications. Middleware is currently being used to connect completely unrelated software into a single user-friendly interface, and also to connect legacy and emerging technology that have been developed using different designs, data models, or architectures. Much of the Internet has been connected using a middleware
framework. As a software concept, it has existed for some timeespecially in large, complex enterprise software applications
such as those used in the financial and retail industries.
The other side of middleware is the development of mainframe systems where data and integration comes from importing
and exporting data in some standardized way. Distributed computing, supported by changes in data centers, information, and
communication technologies, has led to new platforms and the need for integration.
Health information exchanges (HIEs) are more akin to the mainframe systems of old and require duplication of data in a
centralized, non-distributed manner. In contrast, middleware solves the problem of interoperability by building a platform to
connect current EHR systems while allowing for a single path to add additional emerging healthcare technologies. Middleware
also supports development on access and display of the information in a unified manner so healthcare providers can obtain
health data that are supportive of their workflow without the need to switch between applications or understand how the data
are brought together.
Healthcare stakeholders have learned a great deal about

technology from other industries that has direct implications
for their industry. Competitive advantage does not come directly from the implementation of technology, but instead from
the information that is enabled by the technology. EHRs alone
will not solve the needs of patients or providers. But they do
have the potential to greatly impact the way care is delivered,
and help to realize the value contained in patients health data,

both for the acute illness as well as the chronic medical conditions that can span a lifetime. The question of how to best realize the value contained in the rapidly expanding database is
still open for debate.
The most promising value from health data comes from
connecting the pieces. Now software called middleware
Healthcare Middleware is Open Architecture that Facilitates Data Exchange
is beginning to help connect those pieces and finally make

disparate EHRs interoperable. It is not a day too soon. Enabling real-time access to patient data by the providers who
are making decisions in the office, in the emergency department, on the wards, or in the operating room is no longer a
luxury, but a requirement for patient safety, quality, and cost
effective care.
To do this requires one of two approaches: collect every
piece of patient health data in a single or tightly coupled set
of databases, or develop an interface to the various EHRs.
The decision cannot be taken lightly given the inherent risks
as well as the unforeseen consequences that can occur as
healthcare providers scale data.
Cost and risk are two of the major determinants of how we
solve the data access problem for healthcare. A third issue, often downplayed, is the ability to respond to new technology.
In the era of Big Data, one is easily fooled about the integrity,
providence, and accuracy of data that are moved from one system to another. Knowing where a piece of information originated can make all the difference in catching and addressing an issue before a negative outcome or missed diagnosis is
made.
Solving the healthcare interoperability challenge by establishing large data warehouses where all patient data eventually is stored leads to duplication of data. This is a cumbersome,
risk-prone solution where issues are often not realized until
they are questioned at the point of care, where accuracy and
trust in the data source is a requirement.
Middleware More than Simple System Glue

Middleware, software that serves to connect previously disconnected systems, has shown value in many data-intensive
sectors outside of healthcare. Middleware goes beyond the
simple gluing together of two disconnected systems. It often
serves to synergize and produce more than the sum of the two
systems together.
Expanding the functionality of EHRs is an attractive
thought for many in healthcare. However, EHR technology
takes time to advance. There is no question that establishing and maintaining a robust, secure, and fault-tolerant
back end database is an absolute requirement for EHR
systems. However, the need to focus on the back end solution slows the ability to add additional features that are required by patients, providers, administrators, and leaders
in healthcare.
Healthcare 2.0 vendors have demonstrated that middlewarebased EHRs go far beyond the limitations present in non-interoperable EHRs. Adding additional functionality to patient
data has been accomplished with a seamless connection to disparate EHR systems. An additional benefit of this technology is
that frontline providers no longer need to worry about accessing
many different systems to manually utilize data for patient care.
Those with open application programming interfaces (APIs)
have the ability to develop health IT solutions once and then
deploy them to various EHRs at a fraction of the cost and with
much less risk than doing the same development directly on
top of the EHR code base.
APIs Role in Connecting EHRs

An application program interface (API) is an interface that enables programmers to work with apps in a standardized way
much like a key interacts with a lock to open a door. The API
allows programmers to extend an application developed by
someone else without having to get into the code of the initial
application, which could also risk corrupting the code. As a
key component of middlewares service-oriented architecture
(SOA), APIs are a software-to-software interface allowing two
pieces of software to communicate.
For example, if you have a software application requiring users to sign in and authenticate themselves, you could utilize
an API developed by Google to do this. When a user logs in to
your program, it contacts the Google Server to authenticate
the information entered by the user. When Google returns a
successful authentication of the user, your application can
then allow access.
In an EHR using middleware, medical application developers can interact with EHR data in a standardized manner. This SOA software architecture allows different EHR
systems to connect, creating interoperability. A middleware
API connecting various EHR systems allows developers to
build customized applications that interact with EHRs
without needing to rewrite code for each individual EHR
system. The applications are endlessfrom an iPhone and
iPad dashboard screen view of patient data to alert escalation apps ensuring data is sent to the right place at the right
time.
HL7 vs. Middleware

Health Level Seven (HL7) also addresses interoperability
through its standards work, but some feel middleware has
distinct advantages. HL7 is a standard protocol to decode
message interactions. Middleware uses an open API as a
programmable interface to applications. While HL7 can

wrap and compile data, each medical facility receiving
that data would still have to create its own interface with
the data from the sender in order to communicate. This
defeats the purpose of the seamless interoperability provided by middleware.
HL7 is an interface defined through specific end points;
Hospital A to Hospital B, not EHR vendor 1 to EHR vendor 2.
Hospitals C and D, even with the same EHRs, could still not
communicate with Hospitals A and B. To achieve middleware
style interoperability, HL7 developers would have to build a
customized solution for each healthcare facility rather than
one overall commercial solution.
To overcome this obstacle, developers wrapped HL7 with
JavaScript Open Notation (JSON), an open format that
useshuman-readable text to transmit data between a server
and web application. However, this is seen by many as yet another cumbersome step. A middleware open API does not tie
developers to specific hospitals or EHRs.
Potential Downsides to Middlewares Use in EHRs

Employing a middleware architecture has been shown to reduce risk as well as cost of development, but it is not without
critics. Opponents of middleware raise concerns about having
to learn the middleware development platform before seeing
the benefits of the platform.
With respect to EHRs, non-vendor development is not possible or scalable. Although vendors with high market penetration have introduced APIs and development platforms for
their systems, development requires new strategies, code, and
resources for each system.
This alone limits widespread implementation of solutions
that sit on top of EHR systems or access health data stored in
their databases.
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Middleware Allows User Interface Standardization

Across EHR Systems
Well designed middleware architecture allows a user interface development to be easily standardized across EHR systems to provide visual consistency for healthcare providers,
something that has been demonstrated to aid in safety and
efficiency. And the good news is it is an easy plug and play
type of IT application.
Service Oriented Architecture is known for its plug-andplay approach on existing legacy software solutions. Its
approach is to extract features and functionalities from
the legacy software solutions and extend them to more focused, fast cycle solutions. Many popular cloud-hosting
services can extend such SOA applications in a pluggable
approach to the IT operational environment for quick and
easy installations. It also solves specific needs at a fraction
of the cost required for development for each EHR platform
and should be embedded with the healthcare applications.
Its pricing is based on its embedding application. Middleware can offer significant value-added capabilities to EHR
systems in medical error reduction at a fraction of the overall EHR system cost. While prices vary, a cost example from
one Healthcare 2.0 middleware vendor is about two to four
percent of the entire application.
Increasingly, organizations in all sectors are realizing that
software, platforms, and architecture offer services that significantly decrease business costs. No longer does a company
have to do all of the development themselves, but instead is
able to rely on off the shelf applications to solve its problems
while allowing for middleware to connect the various systems
where data resides.
Middleware brings an application-agnostic approach to
connect EHRs to one another while allowing for specific
development to enhance the significant investment by hospitals, health systems, and physicians. The approach also
Journal of AHIMA Continuing Education Quiz

Quiz ID: Q1518605 | EXPIRATION DATE: MAY 1, 2016
HIM Domain Area: Technology
ArticleConnecting the Disparate
allows for scaling, something that centralized or federated

health information exchanges (HIEs) will continue to have
issue with in solving and dealing with data access.
Middleware has Potential to End Interoperability Issues

The healthcare industry is still early in the overall lifecycle
of its EHRs. Although implementation has been widespread
through government incentives, healthcare stakeholders are
still struggling to find efficient and effective ways to utilize
these systems. The search for high quality and effective patient
care continues, along with the need to develop solutions to
meet the needs of patients so they become engaged with their
data and their care.
These issues will require the creative and innovative connection of data to bring meaning and insight into that data.
Middleware allows for the spreading standard of software as
a service (SaaS) as the mindset for EHR platforms. The benefits are great while preserving value on the infrastructure already in existence. As consumers have seen in the retail and
financial industries, middleware has transformed technology
to bring about uses of data to solve problems. Credit card point
of sale terminals can be connected across global retail chains
and banks just as EHRs can be connected across the healthcare continuum, on any mobile platform. While middleware is
very new to the healthcare sector, there is hope by proponents
that its use will make healthcare the next new frontier to end
its lack of interoperability.
Donald M. Voltz (donald.voltz@gmail.com) is medical director of the
main operating room in the department of anesthesiology at Aultman
Hospital, and assistant professor of anesthesiology at Case Western
Reserve University and Northeast Ohio Medical University. Boardcertified in anesthesiology and clinical informatics, Dr. Voltz is a researcher, medical educator, and entrepreneur. Thanh Tran, CEO of
Zoeticx, also contributed to this article.
TAKE THE QUIZ AT WWW.AHIMASTORE.ORG

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LONGER BE ACCEPTED
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e-HIM
Professionals
WANTED
STEPS TO LAND A JOB AND
BUILD A CAREER IN TODAYS
MODERN HIM JOB MARKET
By Priscilla Keeton, MS, RHIT, and Patricia Pierson, RHIA
THE RAPID EVOLUTION of health information management

(HIM) has created enormous opportunity for those individuals
who are up for the challenge and prepared for the work. With the
emergence of electronic health records (EHRs) and supporting
technologies, the roles of HIM specialists are under reconstruction. Both new and seasoned professionals are required to obtain the knowledge and possess the skills to navigate through
the new world of HIM. A plan to traverse the road ahead is necessary to build a successful career in HIM, and begins with determining and taking that first step. As Winston Churchill once
wisely said, He who fails to plan is planning to fail.
STEP 1
MAKE THE MOST OF YOUR

DEGREE PROGRAM
HIM degree programs are essential to the

development of tomorrows workforce.
They prepare future graduates with the
latest domains of knowledge that will be necessary to appreciate
various facets of HIM. Beyond the A&P flashcards and stack of
coding books, there is a shining light of opportunity in the Professional Practice Experience (PPE). However, program directors
report that it is increasingly difficult to establish PPEs for their
students due to shrinking HIM departments and the increasing
number of staff working remotely. Despite these challenges, HIM
directors and leadership teams are remiss in not taking this occasion to train the next generation of HIM specialists.
This is an equal opportunity for HIM students and directors to
take advantage of this unique juncture to learn from and interview each other. And make no mistakea PPE is an interview.
It is an extended interview for the students to demonstrate their
skills, learn about the various functions of the HIM department in
order to discover their ideal fit, and examine the culture of a company to see if this is where they would ultimately like to be employed. HIM directors devote their time to host PPEs for students
with the hope of finding the best candidates for future positions.
Every aspect of the PPE is under surveillancetimeliness,
professional dress, teamwork, work ethic, time management,
critical thinking, and work standards. Take advantage of this
opportunity to promote your value. Over-deliver when you can
and do what is expectedboth before its expected and better
than its expected. These are the students that directors want to
hire and the employees that will advance.
With this unique opportunity to make all the right moves
comes the prospect of also making the wrong ones. There are
some common mistakes that can land you on the do not hire
list. Among the top offenses are those related to inappropriate
use of social media, the Internet, and smartphones. The world
is certainly technology driven and people are increasingly consumed by the need to stay connected, but there is a time and
a place for these activities. During work hours and/or the PPE,
personal use of apps, sites, and gadgets should be minimal. Employers will also make note of inappropriate attire as a reason
that someone may not be hirable in the future. It is widely assumed that the way a person shows up for an interview is the
best they will ever look at the job. Even though this is a PPE, remember that it is still an interview and one should put his or her
best foot forward in all areas, including professional attire.

Another way to gain visibility as a student is to demonstrate
interest in the profession. Participate in AHIMA activities and a
state and local HIM association when possible. Volunteering is a
great way to meet professionals and it can also be highlighted on
your resume and during your interview. Mention the things you
did, new information learned, speakers you heard, topics you
enjoyed, and whom you met (chances are your interviewer may
know them). Remark that you stay abreast of the professional
literature and cite the journals and websites that you follow.
There are many free journals and e-newsletters you can sign
up for, as well as AHIMA e-Alerts, to stay informed of current
trends. Networking with industry professionals is also an ideal
way to find out about employment opportunities.
Social media can be a powerful tool a student can use to begin
networking. Create a LinkedIn account and profile that highlights your skills and strengths. Be sure to include industry keywords and information about achievements, associations, and
professional goals. This ensures that employers will be able to
find you on LinkedIn and take that all important next step of requesting your resume. But beware the blunders of social media
as well. While employers use social media to find candidates,
they use it to screen candidates as well. Facebook profiles that
lack discretion or are not in line with a companys image can
prevent employers from recruiting someone.
Now that you have obtained your degree and made some professional contacts, you need to commit your qualifications to paper.
WRITE AN EFFECTIVE RESUME

Large companies typically utilize search
tools that electronically comb though submitted resumes for keyword matches to a
particular job description. It is important
to carefully read the job description and extract key phrases that
you can include on your resume to increase your chance of being selected for review by hiring managers. The next part of the
recruitment process is generally focused on accomplishments
and results. Be clear about your qualifications and experience.
Resumes should follow some general guidelines:
Demonstrate the value you bring to the company. Resume
screens are typically done in seconds, so your resume should
highlight what you are good at and what you want to do, as
well as clearly outline how you fit the jobs requirements.
Highlight your accomplishments. Employers prefer resumes that are accomplishment-oriented rather than those
written with general resume language. Employers want
motivated candidates that consistently perform past their
basic job functions. Focus on demonstrating how you were
able to save time or money, gain efficiencies, build relationships, or solve a problem.
Place job-relevant skills near the top of your resume.
Specific skills relevant to HIM should be included in the
summary section at the top of the resume.
Utilize a bulleted format. Bulleted lists are more readerfriendly and widely preferred by employers. Be consistent
with the use of bullets to prevent the reader from ques-
STEP 2
Landing a Different Job Within Your

Current Organization
WITH THE CONSOLIDATION of HIM departments across
the industry, many HIM professionals are finding themselves having to re-interview for new jobs within their organization. To make the transition to the new roles, it is necessary to understand what employers are looking for as they
restructure their HIM departments with staff that will help
them meet the demands of the EHR, the meaningful use
EHR Incentive Program, and regulatory requirements.
In this scenario, it is important to show enthusiasm for the
changing environment, establish that you understand the
needs of the new job and have a willingness to grow, and
provide examples of how you have met challenges in the
past. As a bonus, demonstrate your passion for the profession by discussing how you stay current on HIM topics by
reading industry magazines and how you are involved in
local organizations for networking opportunities.
everything you can about their mission, their range of services,

locations, history, news stories, etc. The information you gather
will help you converse with the interviewer and ask intelligent
questions that will demonstrate you have done your homework.
Familiarize yourself with the job description so you know what
the employer is looking for in the person they hire. Highlight the
skills you possess that are aligned with the job description using
examples from your coursework or previous work experience to
validate your competency. Practice responding to anticipated
interview questions so you can develop concise answers with
sufficient detail. Carefully choose interview clothing that depicts your professionalism and demonstrates you are serious
about the position. Prepare a notepad or portfolio to take with
you to the interview that contains extra copies of your resume
for distribution, questions that you would like to ask, and extra
paper to take notes during the interview. Remember that an interview is just as much about you determining if the company
and the position is a good fit. Ask the questions that you need
answered to decide if this is the right place for you.
LAND THE JOB

tioning why some material is not bulleted or indented.
Dont list references on your resume. These should be listed
on a separate sheet if you choose to submit them. However,
references are generally not submitted unless requested by
the employer.
Verify the formatting of your resume. Formatting on email attachments varies from computer to computer, so
it is recommended to experiment by sending the e-mail
to various users to verify that format is consistent. Using a
text version of the resume is generally the most common
format for e-mail.
PREPARE FOR THE INTERVIEW

If you have written an effective resume and
your skills are a good match for the position,
you are likely a promising candidate for an
interview. Large organizations commonly
schedule a phone interview with a recruiter
as a first step. During this phase, the recruiter will ask a series of
questions to determine why you are interested in the position,
what your salary requirements are, and if you would be a good fit
for the culture of the company. Although this feels very informal, it
is important to take this step seriously. Make sure you are in a quiet
environment during the phone call with your resume at hand.
If you pass through this initial filter, you may finally be granted the
official job interview. You may not be the only candidate that interviews for a particular position so you need to make sure that you
stand out from the crowd. The number one thing you can do is prepare. Preparation not only shows that you are very serious about the
position, but it helps to alleviate nerves that may otherwise hinder
your ability to exhibit that you are the right candidate for the job.
Begin by learning everything you can about the company.
With the abundance of information available online, there is no
excuse to show up to the interview with little to no knowledge
about the company. Scour the companys website and find out
STEP 3
While interviewing can be nerve-wracking,

most interviews will contain some common
STEP 4
questions that you can prepare for in advance.
One of the most common interview questions
is Tell me about yourself. Be prepared to answer this concisely and with focus on what the interviewer would
like to know about you with respect to the open position. This is
not about where you grew up or your hobbies but rather about
how you would fit into the job you are interviewing for. Focus on
strengths and skills that directly pertain to the open position. You
need to demonstrate that you are the exact person they are looking
for. Provide examples with results such as I increased productivity
by 10 percent over a nine month period by .
If you are a new graduate with limited experience, dont let your
lack of relevant experience trip you up. Discuss any exposure you
had to similar functions during your PPE and demonstrate that
you are knowledgeable about the function. If you had access to
EHR applications during your degree program or during your
PPE, be prepared to establish that you were able to quickly adapt
to the software and provide examples of what you were able to accomplish with those tools. Just remember, what the interviewer is
really looking for is your ability to evaluate a situation, determine
what needs to be done, and think ahead to the next steps. Think
about examples you can use during your interview that illustrate
this critical thinking, regardless of the context.
In addition to HIM knowledge and computer skills, employers
are increasingly seeking soft skills such as critical thinking and
problem solving. Interpersonal skills (how well you work with others) and communication skills (the ability to effectively communicate with various groups) are among the qualities most sought after
by employers. These skills, along with time management and work
ethic, indicate higher functioning employees that will get the job
done quickly, effectively, and with minimal supervision.
At the conclusion of the interview, be sure to reiterate your excitement for the position to illustrate your enthusiasm and moti-
vation. When the interviewer asks if you have any questions, refer
to the list of questions you prepared ahead of time and see if there
are any outstanding topics you would like to discuss. Finally, remember to thank the interviewer for his or her time and ask when
you might hear back from them or what the next step will be.
TAKING THE NEXT STEP

IN YOUR CAREER
STEP 5
It is not very often that someone new to a

career lands their dream job right out of the
gate. For new graduates and career changers, there is a process for getting to where
you want to be. The key is to plan out your next career step. Do
you have aspirations of becoming an HIM director? More education and/or further certifications may be necessary to reach
that goal, so look at the road ahead and plan accordingly. Are you
looking for advancement opportunities at your current organization? Networking is a valuable tool for finding out about opportunities. Make others aware of your goals so that they can let you
know when they hear about open positions that may interest you.
By letting your manager know about your career goals, they may
be able to help you gain the knowledge and skills you will need to
take that next step. Seek out an HIM mentor in the organization
that can guide you to the next level.
The employment opportunities in HIM are endlessinformation governance, data analytics, and clinical documentation improvement are just a few of the new HIM roles that need
skilled professionals. HIM professionals possess a unique range
of skills that make them valuable in so many different facets of
healthcare. When new opportunities become available, remember to speak up and let employers know you are up to the task.
There are numerous avenues to get to where you want to be
but you have to know which direction you want to take. If you
know you want to advance but dont really know what that entails, there are career planning tools available through AHIMA
visit www.ahima.org/careersand other organizations that can
help a person visualize where they want to be and how to get

there. Stay connected with local, state, and national HIM organizations. Through networking and giving back to the profession
a person can learn a lot more about available opportunities.
The above steps will help you navigate the evolving roles in
HIM and map out a successful career path. Make the most of
your PPE, write a professional resume, prepare for the interview, and network and utilize professional resources. You are
now ready to step into the HIM profession, land the job that you
want, and map out the career of your dreams.
References
Bowe, Hertencia. Developing Skills for a New Era. For The
Record 23, no. 3 (February 2011): 8.
Hansen, Katherine. Avoid These 10 Resume Mistakes.
QuintCareers. www.quintcareers.com/resume_mistakes.html.
Polk-Lepson Research Group. 2013 National Professionalism
Survey Workplace Report. Center for Professional
Excellence at York College of Pennsylvania. January 2013.
w w w.ycp.edu/media/york-website/cpe/York-CollegeProfessionalism-in-the-Workplace-Study-2013.pdf.
Sundberg, Jorgen. How Interviewers Know When to
Hire You in 90 Seconds. Undercover Recruiter. http://
theundercoverrecruiter.com/infographic-how-interviewersknow-when-hire-you-90-seconds/.
Thompson, Greg. Building a Better Resume. Advance for
Health Information Professionals. March 26, 2013. http://
health-information.advanceweb.com/Student-New-GradCenter/Student-and-New-Grad-Center/Student-Top-Story/
Building-a-Better-Resume.aspx.
Priscilla Keeton (priscillakeeton@texashealth.org) is project analyst for
health information management services at Texas Health Resources, located
in Arlington, TX. Patricia Pierson (ppierson@collin.edu) is a full-time faculty
member in the health information management department at Collin College, located in McKinney, TX.
Study online
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SCANNING
the HIM
ENVIRONMENT
AHIMAS 2015 REPORT OFFERS INSIGHT
ON EMERGING INDUSTRY TRENDS
AND CHALLENGES
By Anna Desai, MHA, CAE
Scanning HIM Environment
TODAYS HEALTHCARE ENVIRONMENT is driven by various

economic and regulatory forces and technological advancements that bring both opportunities and challenges. Healthcare
organizations need the right information at the right time to
make accurate decisions regarding patient care and to optimize
business processes. Yet the role of information and the way an
organizations leaders, frontline staff, patients, and consumers
are interacting with that information is rapidly changing.
Organizations with a focus on the future develop planning
processes that take into account the trends, issues, and dynamics that ultimately drive, influence, and shape the strategy and
goals of their business. This is called an environmental scan.
Successful environmental scanning requires continuous monitoring and acquiring of information that helps organizational
leaders identify and interpret potential trends and priorities.
Understanding the key forces and trends serves as a foundation
for what is needed to shape strategy. Environmental scanning is
an essential component to the vitality and success of leading an
organization to a rapidly changing future.
The AHIMA House of Delegates (HoD), a deliberative assembly comprised of delegates from each of the 52 Component
State Associations (CSA), and the AHIMA Board of Directors
have been actively involved with environmental scanning for
the health information management (HIM) profession over the
last several years. Members of the Envisioning Collaborative, a
subgroup under the HoD comprised of delegates and subject
matter experts, are responsible for conducting scanning activities and leading the development of the environmental scan
report. The report offers an analysis of HIM issues and trends
impacting and influencing the profession and healthcare.
What AHIMA Saw Through the Telescope
Technology Reinventing Healthcare Delivery System

The healthcare delivery system is being reinvented, in part by
the ability to transform data into actions that are customized for
consumers. Technology is making it easier and more enjoyable
for people to become active participants in their health, providing the ability to access information at their fingertips and for
providers to create a more seamless healthcare experience. According to a trend report from PricewaterhouseCoopers (PwC),
social, mobile, analytics, and cloud technologies are the underpinnings of new business models in which health organizations
will be paid based on value rather than volume.1
Cloud Services Growing in Popularity for Health Data

There are a growing number of healthcare organizations who
have started to use cloud services to host applications and data
using a software as a service (SaaS) model. A recent survey by
the Healthcare Information and Management Systems Society
(HIMSS) found that 83 percent of IT departments housed within
healthcare organizations, such as medical practices, hospitals,
and corporate offices of healthcare systems, are currently using
cloud services, and 9.3 percent plan to in the near future.2
While in aggregate, a large majority of healthcare providers now and in the future see the value of cloud services.3 Still,
healthcare organizations remain in the early stages of determining how cloud services fit into the HIM and technology ecosystem. SearchHealthIT conducted a study of healthcare organizations and found only 21 percent of respondents said they use
cloud functions for business intelligence and clinical data analytics.4 Organizations will need to understand and calculate how
to balance the possible benefits of cloud computing in healthcare with security, technical, and legal risks.
The first step of scanning the environment is thorough input

and research, discussing the opportunities and potential threats
facing the healthcare and HIM professions.
The environmental scan report aims to:

Identify technological, business/economy, demographic/workforce, legislation/regulatory issues, trends, and
events important to AHIMA and its members
Spot potential opportunities or threats implied by issues,
trends, and/or events
Promote a futuristic orientation for AHIMA activities, including product and service development
Inform public policy, government relations, and advocacy
plans and priorities
Big Data can Save Big Dollars
Earlier this year, the environmental scan report was utilized

during the AHIMA Board of Directors annual review of AHIMAs strategic planning session. The AHIMA HoD also utilizes
this report to help frame forum topics, team agendas, and HoD
discussion that can, according to Laura Pait, RHIA, CDIP, CCS,
2015 Speaker of the House and Co-Chair of the Envisioning Collaborative, create strategic direction required to govern the
profession on the opportunities and threats that are forecasted
to impact our members. The following provides some highlights from the current Environmental Scan report.
An estimated 80 percent of medical data is unstructured and

is clinically relevant.7 This data resides in multiple places such
as individual EHRs, lab and imaging systems, physician notes,
medical correspondence, claims, and finance. Data interoperability and securing data across EHR systems remains a challenge. By 2020, nearly half (42 percent) of digital healthcare
data will be unprotected, but needs to be as more providers and
stakeholders depend on bigger and robust data sets for decision
making.8 It is estimated that by the end of 2015, half of healthcare organizations will have experienced between one and five
An analysis published by McKinsey and Company explains that

Big Data could help US citizens save as much as $450 billion in
healthcare costs, but fundamental change is necessary to meet
such goals.5 Big Data will likely increase opportunities for HIM
professionals and create new and emerging roles such as data
governance analyst, data mapping specialist, and clinical informatics reporting analyst.6 However, as healthcare organizations
seek to capitalize on Big Data, they face significant information
technology challenges, ranging from the basic need for an electronic health record (EHR) to the intensive process of combining data from multiple systems.
Security Breaches Likely to Increase
cyber attacks in the previous 12 monthswith a third of those

attacks successful. This will necessitate investments and resources in a strategy to avoid disruptions to business operations
and to prevent incurring fines and notification costs.9
mHealth Revolutionizing HIM Practice

Social media and mobile devices like smartphones and tablets (with downloadable apps) will continue to revolutionize
the field and practice of HIM. As of December 2014, there were
more than 100,000 mobile health (mHealth) apps dedicated
to healthcare, which has doubled over the last two years.10 Research2Guidance predicts that 1.7 billion people will have
downloaded a health app by 2017, generating $26 billion in
revenue.11 More opportunities to communicate using a variety
of different methods and tools will help consumers seek advice
and gain knowledge. The apps may allow for greater control in
health management, from tracking exercise to scheduling doctor appointments.12 For physicians and other care providers,
apps can assist in day-to-day medical care, as well as allow for
health-related tasks in remote areas without access to traditional healthcare infrastructure. The use of mHealth will have a significant impact on the healthcare industry and how healthcare
is going to be delivered.
Consumers Gaining Control of Their Record

Consumers today increasingly want control of both the financial side (health insurance, health accounts) and wellness side
(fitness trackers, health management apps) of their own healthcare. A report by the National Partnership for Women and Families shows that consumers want even more robust online access
functionality and features than are available today, including
the ability to e-mail providers (56 percent); review treatment
plans (56 percent); see doctors notes (58 percent) and test results (75 percent); schedule appointments (64 percent); and
submit medication refill requests (59 percent).13 Patient trust in
the privacy and security of EHRs has increased since 2011, and
patients with online access to their health information have a
much higher level of trust in their doctor and medical staff (77
percent) than those with EHRs that dont include online access.
Tight Budgets, Change Leading Leaders to

Business Strategy
There have been a multitude of changes in the healthcare landscape over the past few years. These changes have put pressure on and presented challenges to healthcare organizations
and their leaders. Strategic plans are top priority as healthcare
leaders prepare for whats ahead. The combined effects of the
Affordable Care Acts (ACAs) coverage expansions, improved
economic growth, and an aging population are expected to fuel
health spending growth for the next several years.14
Healthcare Costs Will Outpace Inflation

A report from PricewaterhouseCooperss Health Research Institute has forecasted a modest 6.8 percent increase in healthcare
spending in 2015.15 A report from the Centers for Medicare and
Medicaid Services (CMS) Office of the Actuary also forecasts
that the average growth rate for 2015-2023 would be six percent.
That is up slightly from 2014.16 These findings also suggest that
healthcare will outpace growth in the gross domestic product
(GDP) over the next decade. Healthcares share of the GDP,
which has remained stable since 2009, will increase from 17
percent in 2012 to more than 19 percent in 2023.17
Health Information Exchange Use Growing

Thirty percent of hospitals and 10 percent of ambulatory practices participated in one of 119 operational health information
exchange (HIE) efforts.18 That is more than double the early
2010 participation rate. Also, the number of fully operational
HIEs has more than doubled from 2010 to 2012, showing that
the organizations are gaining a foothold in the healthcare market (see Figure 1 on page 41).
Challenges to Interoperability Remain

While there has been substantial progress, 74 percent of HIE efforts identified developing a sustainable business model as a
barrier to success.19 HIE projects can vary widely, but all share
similar implementation challenges. The Agency for Healthcare
Research and Quality (AHRQ) cites funding, staffing, governance, achieving buy-in, technical issues, reporting, and policy
as the most common issues found among HIE initiatives.20 According to a 2014 eHealth Initiative survey on Health Data Exchange, cost and technical challenges were indicated as the key
barriers to interoperability (see Figure 2 on page 42).
Shifting Workforce Demographics Indicate Coming

Shortage of HIM Professionals
The roles of HIM are rapidly changing and will require individuals to expand their scope of work and learn new skills in order to
adapt and lead. Settings and sites of care are also evolving. Here
are some key findings of how the supply of HIM professionals
could evolve in the coming years and how this compares to expected demand for HIM in different settings.
Millennials
In 2015, millennials are set to become the largest percentage of
the workforce for the first time.21 Millennials will play a pivotal
role in changing the culture of traditional employment. The top
three choices millennials view as most important regarding career choices are:
1. Work/life balance
2. Health benefits
3. Compensation
A generation that is vocal about their demand for a better
work/life balance have and will continue to place a higher value
on a flexible and mobile work environment. Many companies
are investing in virtual project management tools that aim to
streamline the logistics of managing virtual teams.
Baby Boomers
The baby boomer retirement wave will continue to have a significant effect on organizational workloads. Also the aging work-
Figure 1: Number of Fully Operational Health Information Exchange Initiatives
26
2006
42
2008
57
2010
119
2012
20
40
60
80
100
120
140
Sources: eHealth Initiative. The State of Health Information Exchange in 2010: Connecting the Nation to Achieve Meaningful Use. 2010. http://ihealthtran.
com/pdf/eHI%20-%20HIE%20Final%20Report.pdf; Operational Health Information Exchanges Show Substantial Growth, But Long-Term Funding Remains
a Concern. Health Affairs 32, no. 8 (August 2013): 1486-1492. http://content.healthaffairs.org/content/32/8/1486.full?keytype=ref&siteid=healthaff&ijkey=d
EAYexYtxoPP.
force will continue to have an impact on supply and demand for

HIM professionals. It is projected that 6,000 HIM professionals
will be needed each year to fill new positions and replace vacant
positions. However, only approximately 2,000 new graduates
enter the HIM field each year.22 There will be twice as many jobs
created by retirements than new jobs; however, the profession
has been slow to replace and prepare younger members to fill
their vacant spots. On average, health informatics positions stay
open for 35 daystwo days longer than the national average
posting duration of 33 days.23 In addition, new and emerging
health positions stay open twice as long as replacement postings. For example, a posting for a medical records clerk will stay
open for 18 days on average, compared to 38 days for its newer
successor, clinical analyst.24
HIM Roles Evolving

HIM professionals hold a number of diverse roles and responsibilities such as revenue cycle management, database coordination, EHR management and user support, quality management,
patient safety compliance, HIE staffers, and other functions
where specialized data and information skills are needed. It is
estimated that 50,000 health informatics workers will be needed
in the next five to seven years due to an increase in the adoption
and complexity of EHR systems.25
The market will likely emphasize coding skills (clinical documentation improvement (CDI), revenue cycle, and registry);
data governance skills (data integrity, analytics, fraud and
abuse, privacy and security); information governance skills (ediscovery, enterprise information management, meaningful
use, regulatory requirements, and data standards); and leadership skills (chief knowledge officer, chief learning officer).26
These expanded roles will require further education and analytical and critical thinking skills, and more clinical knowledge
in order to compete in tomorrows job market.
Legislation and Regulation Continue to Change HIM

Shifts in the US healthcare delivery system, including a convergence of laws, rules, and regulations, are driving change in information management practices. For example, new models of
care promoted by legislation offer opportunities for AHIMA and
its members. This will be a revelatory year for the health sector
as the industry begins to understand the population of newly
insured individuals granted access through ACA, their health
status, and consumer preferences. At a time where there is a
shortage in primary care physicians (PCPs),27 the ACA focuses
on PCPs, placing greater emphasis on their role in improving
the health of Americans and lowering overall healthcare costs.
ACA has required shifts and updated practices in the use and
management of health information. The ACA required work is
likely to improve efficiency and value in healthcare, but the HIM
framework must be reconfigured to provide optimal support for
the essential features of accountable care, including close coordination of care, quality measurement, and patient-centeredness.28
HIM strategies will need to address:29
Greater integration of healthcare information across the
continuum of care
Processes and systems that promote understanding and
use of health information by patients and families
Reframing the way coded data and information is used to
obtain payment in a system that rewards quality and efficiency of services over the traditional emphasis on the
quantity of services
Agency Collaboration at an All-time High

Efforts from various agencies such as CMS, the Office of the
National Coordinator for Health IT (ONC), National Quality
Forum (NQF), and AHRQ are converging and overlapping
one another with an aim to provide better quality healthcare
Figure 2: Challenges Related to Achieving Health IT Interoperability
Troubleshooting errors 4%
Patient matching 21%
Normalizing data fees 22%
Unrealistic end user expectations 26%
Identifying/implementing standards 31%
Technical challenges 48%
Consistent and timely response from EHR 64%
Financial costs 74%
10%
20%
30%
40%
50%
60%
70%
80%
Source: eHealth Initiative. 2014 Results from Survey on Health Data Exchange. October 8, 2014. http://assets.fiercemarkets.com/public/healthit/ehidataexchange2014.pdf.
for Americans. Issues include patient safety, better, wider access to care, quality measures, and cost reduction. Health IT
and EHRs are tools to achieve these goals and HIM professionals are right in the middle. Many of these federal agencies are working together to become more coordinated than
in the past.
Now You Know, But Whats Next?

A number of forces will continue to play a key role in our
changing healthcare system. Environmental scanning offers
an objective review of the current and anticipated factors
that can impact and inform the needs of today and tomorrow. The intent is to begin discussion, build on these trends/
issues, and determine how HIM professionals can actively
influence their environment and thereby create and actively
manage their future.
Judi Hofman, CHPS, BCRT, CAP, CHSS, H-CHP, co-chair of
the Envisioning Collaborative, says the scan is just the beginning of the work that needs to be done. The work that is
driven by the Environmental Scan is reliant upon our members and their subject matter expertise and engagement.This
Environmental Scan must be used to impact how HIM influences and drives innovations now, with a keen eye on the
future of HIM, she says.CSA members and their HoD delegate representatives must be involved to continue building
towards the success of our HIM future through this rapidly
changing time.
Notes
1. PricewaterhouseCoopers Health Research Institute. Top
Health Industry Issues of 2014: A New Health Economy
Takes Shape. December 2013. www.pwc.com/en_US/
us/health-industries/assets/pwc-top-health-industryissues-of-2014.pdf.
2. HIMSS Analytics. 2014 HIMSS Analytics Cloud Survey.
June 2014. http://apps.himss.org/content/files/HIMSSAnalytics2014CloudSurvey.pdf.
3. Ibid.
4. TechTarget. Analytics: Moving health care forward.
SearchHealthIT.com. www.techtarget.com/downloads/
Health_IT_BI_report.pdf.
5. Groves, Peter et al. The Big Data Revolution in Healthcare: Accelerating Value and Innovation. Center for US
Health System Reform Business Technology Office. January 2013.
6. Eramo, Lisa A. Healthcares Data Revolution: How Data is
Changing the Industry and Reshaping HIMs Roles. Journal of AHIMA 84, no. 9 (Sept 2013): 26-32.
7. IBM. Big Data at the Speed of Business. www-01.ibm.
com/software/data/bigdata/industry-healthcare.html.
8. Miliard, Mike. Top Ten Health IT Predictions for 2015.
Healthcare IT News. November 26, 2014. www.healthcareitnews.com/news/top-10-health-it-predictions-2015.
9. Ibid.
10. mHealth App Developer Economics 2014: The State of
the Art of mHealth App Publishing. research2guidance

mHealth App Developer Economics survey. May 2014.
11. Research2Guidance. Mobile Health Market Report 20132017: The Commercialization of mHealth Applications
(Vol. 3). March 4, 2013. www.research2guidance.com/
shop/index.php/downloadable/download/sample/sample_id/262/.
12. mHealth and FDA Guidance. Health Affairs 32, no. 12
(December 2013).
13. National Partnership for Women and Families. Engaging Patients and Families: How Consumers Value and
Use Health IT. December 2014. http://hitconsultant.net/
wp-content/uploads/2014/12/engaging-patients-andfamilies.pdf.
14. Sisko, Andrea et al. National Health Expenditure Projections, 2013-23: Faster Growth Expected with Expanded
Coverage and Improving Economy. Health Affairs 33, no.
10 (September 2014). http://content.healthaffairs.org/
content/early/2014/08/27/hlthaff.2014.0560.

15.
PricewaterhouseCoopers Health Research Institute.
Medical cost trend: Behind the numbers 2015. June 2014.
www.pwc.com/en_US/us/health-industries/behind-thenumbers/assets/hri-behind-the-numbers-2014-chartpack.pdf.
16. Sisko, Andrea et al. National Health Expenditure Projection, 2013-23: Faster Growth Expected with Expanded
Coverage and Improving Economy.
17. Ibid.
18. Milstein, Julia Adler et al. Operational Health Information Exchanges Show Substantial Growth, But Long-Term
Funding Remains a Concern. Health Affairs 32, no. 8 (August 2013): 1486-1492.
19. Ibid.
20. Agency for Healthcare Research and Quality. Emerging Lessons: Health Information Exchange. http://healthit.ahrq.gov/ahrq-funded-projects/emerging-lessons/
health-information-exchange.

HIM Domain Area: Technology
ArticleScanning the HIM Environment

21.
PricewaterhouseCoopers Health Research Institute.
Medical cost trend: Behind the numbers 2015.
22. AHIMA. Embracing the Future: New Times, New Opportunities for Health Information Managers. Summary Findings from the HIM Workforce Study. 2005. http://library.
ahima.org/xpedio/groups/public/documents/ahima/
bok1_027397.hcsp?dDocName=bok1_027397.
23. Burning Glass Technologies. Missed Opportunities? The
Labor Market in Health Informatics, 2014. December 10,
2014. www.burning-glass.com/research/health-informatics-2014/.
24. Ibid.
25. University of Illinois at Chicago. Health Informatics. http://
healthinformatics.uic.edu/intersection-of-healthcare-it/.
26. AHIMA Foundation. Reality 2016: The Council for Excellence in Educations Recommendation for HIM Education. September 26, 2012. www.ecu.edu/cs-dhs/hsim/
upload/Reality_2016_Presentation-9_26_12_NC.pdf.
27. Health Resources and Services Administration Bureau of
Health Professions. Projecting the Supply and Demand
for Primary Care Practitioners Through 2020. National
Center for Health Workforce Analysis. November 2013.
http://bhpr.hrsa.gov/healthworkforce/supplydemand/
usworkforce/primarycare/projectingprimarycare.pdf.
28. Viola, Allison and Lydia Washington. Accountable Care:
Implications for Managing Health Information. AHIMA
Thought Leadership Series. 2011.
29. Ibid.
Anna Desai (anna.desai@ahima.org) is manager of profession governance at AHIMA.
Read More
Read the Full 2015 Environment Scan Report
http://engage.ahima.org
To access the 2015 Environmental Scan report, visit the Engage topic
Environmental Scan Reports.

LONGER BE ACCEPTED

Working Smart a professional practice forum

Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / Quality Care
Responding to
Requests from
Law Enforcement
Officials for
Release of PHI
By Dana DeMasters, MN, RN, CHPS
A POLICE OFFICER arrives in the emergency department of a

hospital at 2 a.m. seeking information about a patient who was
recently admitted following a motor vehicle accident. The officer suspects the patient was intoxicated while driving and assertively asks the nurse to tell him the results of the patients
urine drug screen. What would you tell your staff to do?
HIPAA allows covered entities (CEs) to release limited protected health information (PHI) to a law enforcement official without patient authorization under certain circumstances. HIPAA
defines a law enforcement official as any governmental agency
or official authorized to investigate, prosecute, or conduct an inquiry into a potential violation of law.1,2
An authority figure such as police officer or state trooper requesting patient informationin uniform with a badge and
guncan be an intimidating experience for staff. An officer may
pressure staff to release the PHI, informing them they may be
obstructing an investigation if they do not cooperate. It is important for staff to know how to manage these requests and know
who to contact to help them make decisions about whether to
release the information.
The purpose of this article is to assist CEs in responding to requests from law enforcement officials and to provide a tool for
managing and approving these requests.
Competing Mandates of ROI

CEs do not want to interfere with important law enforcement
functions. However, they are also obligated by law to prevent
unauthorized disclosures of patient information. For the scenario above, the officer would need to follow a legal process and
provide a document, such as a court order, before this information could be released.3
Although the HIPAA standards provide specifics concerning

what can be released to law enforcement officials and when,
implementing these standards can be complex because of the
varied scenarios that may occur. One officer may request a drug
screen result; another might be investigating a child abuse case
or victim of a crime; a detective may wish to interview staff
about a suspect who is a patient; a police department could request to be informed when a patient is discharged, and so on.
There is also the challenge of state laws, which might be stricter
and could preempt HIPAA.
Use Form for Release Evaluation

The use of a tool such as the Request from Law Enforcement
for Release of PHI form (see Figure 1 on page 45) can be helpful in responding to these requests. Implementing a form and
having expert resources readily available, such as a privacy officer or legal counsel with a thorough understanding of HIPAA
regulations and respective state laws, is recommended. This
will help ensure that the request process goes smoothly, the
law enforcement official obtains the information if allowed,
and the covered entity remains HIPAA-compliant concerning
disclosures of PHI.
The Request from Law Enforcement for Release of PHI form
provides the following assistance with these requests:
Guides staff in obtaining the needed information from the
law enforcement official
Verifies the officers identity and obtains the officers signature
Requires the officer to list the specific information needed
Confirms that a case number, warrant number, or incident report is associated with the request
Requires the officer to read and select the appropriate le-
Figure 1: Request from Law Enforcement for Release of Protected Health Information (PHI)
Used with permission from Barb Beckett, RHIT, CHPS, system privacy officer at Saint Lukes Health System, based in Kansas City, MO.

gal exception and certify that the information requested is

needed for this legal exception
A ssists the privacy officer or designee in determining if
release is allowed by specifically referencing the HIPAA
standard and listing the HIPAA legal exception
Provides a document for accounting of disclosures
ment officials can be a daunting task. Providing staff education,

implementing the Request from Law Enforcement for Release of
PHI form and policy, and consulting the CEs privacy officer or
legal counsel will help ensure that the patients privacy is protected, investigations will not be impeded, and disclosures are
compliant with HIPAA standards.
The officer will complete the upper portion of the form, check
the appropriate legal exception, and sign the form. The privacy
officer or designee would then review the request to ensure it
aligns with what may be released. If approved, the individual
who releases the information to the officer signs the form and
places it in the patients record. An associated policy that lists
the regulations in detail and notes what limited information
may be released should also be in place.
Its important to note that staff must understand that the form
is used to gather information to evaluate whether PHI may be
released. An officer merely completing and signing the form
does not equate to an immediate release and/or release of all
requested information.
Notes
Prepare for Requests in Advance
Dana DeMasters (dana.demasters@libertyhospital.org) is a privacy and

security officer at Liberty Hospital, in Liberty, MO.
Navigating complex situations and requests from law enforce-
D I S C E R N I N G
1. United States Department of Health and Human Services.

HIPAA Privacy Rule, 164.512(f ); 164.501. June 5, 2013.
www.hhs.gov/ocr/privacy/hipaa/understanding/special/
research/.
Frequently Asked Questions. August 8, 2005. www.hhs.
gov/ocr/privacy/hipaa/faq/disclosures_for_law_enforcement_purposes/505.html.
HIPAA Privacy Rule, 45 CFR 164.512(f )(1)(ii) (A) and (B).
June 5, 2013. www.hhs.gov/ocr/privacy/hipaa/understanding/special/research/.
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47

Application of Search Analytics

in the Healthcare Profession
By Daniel L. Regard and Ron Hedges, JD
AS THE HEALTHCARE industry moves into an electronic

health record (EHR)-only environment, practitioners increasingly have to search electronically stored information
(ESI). They may need to do this to find, for example, the date
on which a patient was given a specific drug and the dosage
given. It sounds simple to look through a given volume of ESI
for a specific bit of information, but is it simple across a large
data set?
As EHR use grows, the variety of sources of ESI multiply
consider wearable monitoring devices and the accelerating velocity of the flow of ESI into records-keeping systems. Analytics, defined as a variety of data mining and machine learning
techniques, may offer answers to these perplexing questions.
Use the Right Tool for the Right Search

Over the past few years there has been a dramatic increase
of interest in the area of Big Data. Big Data is a broad term for
data sets so large or complex that traditional data processing
applications are inadequate. This has stimulated the emergence of new tools for storing, managing, and searching very
large data sets.
A natural question for health information management
(HIM) professionals is whether or not these tools and techniques will benefit the healthcare arena, and if so, how. The
emergence of Big Dataand the ever-increasing volume
and variety of electronic information which that trend encompassesimposes obligations on HIM personnel to embrace appropriate tools and techniques in order to make
sense out of Big Data and to manage electronic information
for the benefit of everyone.
The short answer is Yes, emerging tools and techniques
will help. But the devil is in the details. The truth is there are
many different types of data involved in healthcareindividual healthcare records, large databases of pharmaceutical trials, and multi-decade collections of prescriptions and
outcomes data.
Data sets are expected to grow with the popularity of fitness
trackers such as the Fitbit, Nike Fuelband, and soon-to-be-released Apple Watch. In addition to variances in the data sets,
different users may pose dramatically different questions and
analyses to their data sets. Not surprisingly, not all tools or all
techniques work for all data sets and all questions.
Before organizations look for the best tools, they should start
by understanding their data. Some key considerations include:
Quantity. Does data size exceed recommended specifications for standard storage, computer memory, or database
record counts?
Structure. Is the data highly structured, such as a database with well defined fields of information, or highly unstructured, such as physician notes and e-mail communications?
Integrity. Is the data clean? Was it collected in a manner
that had sufficient controls that maintained consistent
and accurate values or use of fields in the data?
Once an organization has assessed its data, it should also
consider what its looking to get out of the data. Data searches
could include the following, many of which come from the field
of data mining:
Retrieval. Are users trying to retrieve known records?
Classification. Can certain patient behaviors be classified
as more risky or less risky?
P
rediction. Are users trying to forecast outcomes
from inputs?
Exploration. Are users trying to understand trends and
segments within a data set?
A ffinity. Are there two or more activities that are correlated? Is there a query as to causation?
ingthe timely, accurate, and efficient retrieval of information may be better addressed by referring to the science of
information retrieval.
The Language of Information Retrieval
As one might assume, there are different tools and techniques

for these data characteristics and data mining objectives. Some
real world choices might be:
Single search. Users only want a single record, and it has
to be the right one.
Single-best search. Users want to retrieve many candidates for their search, but ranked in a list of most-likely to
least-likely.
Groupings search. Users need to retrieve all records that
meet a certain criteria and all of these will be used for a
secondary purpose.
The science of information retrieval has developed a rich language of tools and techniques to facilitate the timely, accurate, and efficient retrieval of information. The terminology
of information retrieval is a great place to find ways to implement timely, accurate, and efficient processes based on
the IGPHC.
In information retrieval, accuracy is determined by measuring
recall and precision. These concepts can be confusing to the
uninitiated, but, essentially, they represent the questions: Did
you find ALL of what you were looking for (recall) and did you
find ONLY what you were looking for (precision).
If you are searching for patients admitted after midnight and
you identify 4 out of 5 of those patients, but also identify another
4 who were admitted before midnight, then your recall was 80
percent (you found most but not all) and your precision was 50
percent (you found most, but not only).
In practice, it is very possible to have 100 percent recall or 100
percent precision, but it is difficult to have both. This is where
trade-offs occur. The need for timeliness and efficiency can
affect recall and precision. Wanting results faster, or cheaper,
can result in lowering the recall, lowering the precision, or
lowering both.
Returning to our example of searching for patients admitted after midnight, you may be able to quickly identify many of
the patients admitted after midnight, but to find both ALL and
ONLY those patients may take more time or resources.
Availability Under the IGPHC
Using Search Options to Improve Performance
In 2014, the American Health Information Management Association (AHIMA) published the Information Governance
Principles for Healthcare (IGPHC), which outlines broad and
comprehensive principles of information governance for
healthcare. One of those principles is the Principle of Availability, which states that [a]n organization shall maintain
information in a manner that ensures timely, accurate, and
efficient retrieval.
The language and context of the IGPHC imply that the principles contemplate only a simple retrieval. But different organizations have different needs that may be more complex.
Either way, a given organizations data characteristics will still
impact their choices regarding tools and techniques.
The IGPHC expands on these concepts, but each one touches
on a much larger discipline of knowledge that goes far beyond
the 2014 publication. Whereas the principles appropriately
identify the value of metadata and disaster recovery, as well as
the challenges of conducting federated searches across multiple
independently designed systems, its overall guidance speaks
more to goals than specific techniques.
The actual techniques for measuringand then improv-
How should the right tool or mechanism for a record review

be selected? The first key to selection is an understanding of
the nature of the available ESI, how the ESI is maintained,
and exactly what ESI is sought. The second key is leveraging
information retrieval to measure and improve your performance. Together, these will allow organizations to make
value-added choices of tools and techniques in this era of exponentially growing ESI.
ESI is now the bread-and-butter of health information
management. ESI must be understood and retrieved to manage and improve healthcare. That understanding and retrieval
are central to the role of the HIM professional today and into
the future.
The understanding and

retrieval of electronically stored
information are central to the
role of the health information
management professional both
today and into the future.
Dan Regard (dregard@idiscoverysolutions.com) is the CEO of iDiscovery

Solutions, an electronic discovery consulting firm based in Washington,
DC. He has national and international experience advising on such issues
as electronic discovery, computer forensics, structured data, and information management. Ron Hedges (r_hedges@live.com) is a former US Magistrate Judge in the District of New Jersey and is currently a writer, lecturer,
and consultant on topics related to electronic information.

The Standardization of Standards

By Anna Orlova, PhD
IN 1898 YALE University graduate Charles Dudley, PhD, looked

for a solution to the seemingly intractable problem of building a
consensus on standards for industrial materials used on the Pennsylvania Railroad. To sooth the antagonistic attitudes that marred
relationships between the Pennsylvania Railroad and its suppliers,
Dudley proposed the creation of an innovative system of technical
committees. These committees provided representatives from the
primary parties with a forum to discuss every aspect of specifications and testing procedures for a given material (steel, paint, etc.).
The goal was to reach a consensus that was acceptable to
both producers and to the customers of the railroad. Although
many initial meetings ended in failure due to the inflexibility of the parties involved, Dudleys system held considerable
promise and later formed the basis for the International Association for Testing Materials (IATM). The association encouraged members to form national chapters. On June 16, 1898, 70
IATM members met in Philadelphia, PA to form the American
Section of the International Association for Testing Materials
(ASTM). Dudleys call for consensus building, which he articulated in meetings of the American Chemical Society and the
International Railway Congress, fell on fertile ground in the
engineering community.
ASTM dedicated itself to the development and unification
of standard methods of testing; the examination of technically important properties of materials of construction. The
members grappled with two questions that were widely discussed throughout the engineering community at the turn of
the 20th century. First, How could standards for materials
contribute to industrial progress? And second, How could
producers and users of industrial materials reach a consensus on standards?
Standards Emerge in Healthcare

Following Dudleys innovation in creating a standards development approach, standards emerged in healthcare as well.
Various public and private entities have been involved in developing standards in healthcare, including the professional
medical associations that created best practice standards such
as clinical and public health guidelines and protocols, as well
as business standards.
Many of these professional associations were accredited by
the American National Standards Institute (ANSI), formed
in 1918, and became standards development organizations
(SDOs). For example, the College of American Pathologists
originally developed the Systematic Nomenclature for Medicine (SNOMED); the American Medical Association developed the Current Procedural Terminology (CPT) standard;
the American Nursing Association developed nursing terminology standards; the Association for the Advancement of
Medical Instrumentation created medical device standards;
and so on. Governmental agencies also participate in standard development activities, such as the National Library of
Medicine, which developed the Unified Medical Language
Systems (UMLS).
With the rise of health informatics, the ASTM Committee
E31 on Healthcare Informatics was established in 1970 to develop standards related to the architecture, content, storage,
security, confidentiality, functionality, and communication of
information used within healthcare.
Other specialized healthcare SDOs were created to standardize the use of information and communication technology in healthcare. These include Health Level Seven
(HL7); Accredited Standards Committee ACS X12 (admin-
Figure 1: Examples of Data Standards in Healthcare

BELOW ARE EXAMPLES of standards developed specifically for the Data Standards category, one of seven standards categories that includes: Data Standards; Information Content Standards; Information Exchange Standards; Identifier Standards; Privacy and Security Standards; Functional Standards; and Other Standards such as Business Standards (clinical
guidelines) and ICT Standards.
istrative data standards); Digital Imaging and Communications in Medicine (DICOM); National Council for Prescription Drug Programs (NCPDP); Clinical Data Interchange
Standards Consortium (CDISC) for clinical research standards; and others.
At the International Organization for Standardization
(ISO), founded in 1946, the Technical Committee 215 Health
Informatics was created in 1998 for standardization in the
field of health informatics, to facilitate the coherent and consistent interchange and use of health-related data, information, and knowledge to support and enable all aspects of the
health system.1
International agencies also develop standards. For example, the World Health Organization (WHO) develops the
family of International Classification of Diseases (ICD) standards. International organizations originally focused on
information and communication technology, such as the
International Telecommunication Union (ITU) and the International Electrotechnical Commission (IEC), have also
begun working on standards for healthcare, creating liaisons
with healthcare SDOs.
Each of these entities operates various committees and
workgroups of experts that produce a variety of standardsrelated documents, such as guidelines, standard specifications, technical reports, technical specifications, and implementation guides. Each standard is developed through
a consensus-based process that consists of the following
three phases:
1. Propose New Standard
2. Develop Standard
3. Maintain Standard
All these standards are produced as books, that is, published documents originally distributed as books and now
available for download from correspondent SDO websites
in PDF format. Some documents are free, others are for
sale. Figure 1 above presents examples of data standards
(volcabularies and terminology standards) in healthcare.
Thousands of various standards in health information technology (HIT) and health informatics have been published in
the past 40 years.
The adoption of standards in HIT products has been slow and
inconsistent. As the adoption of non-standards based HIT products grew, a critical tipping point was reached when the global

Figure 2: Standardization of Standards Approach: HIT Standardization Phases,

Examples of Standardization Entities and their Products
community of standards developers and adopters began to

realize that this disjointed approach for developing standards
should be reconsidered.
Industry Efforts for Standardization of Standards

In 1999, based on the success of standardization and interoperability of digital imaging in DICOM, Integrating the
Healthcare Enterprise (IHE) was created as a collaborative
of HIT vendors, professional associations, and governmental
entities. The approach was to assemble individual standards
into a portfolio of standards, or technical frameworks, that
could work together to support data exchanges for a specific
clinical scenario, or use case. In this new approach, the standards portfolio undergoes the following standardization
phases as follows:
1. Identify Needs and Priorities for Standards

2. Develop and Maintain Standards
3. Select and Harmonize Standards
4. Test Standards
5. Certify Standards-based HIT Products
6. Deploy Standards-based HIT Products
Adding new phasesSelect and Harmonize and Test
Standardsbecame critical to improving the quality of the
individual standards developed by various SDOs. The Select
and Harmonize Standards phase enabled comparison of individual standards to identify overlaps and gaps in existing
standards and provide feedback to the SDOs to improve their
standards. The Test Standards phase allowed the SDOs to
validate the ability of individual standards to work together.
The Certify Standards-based HIT Products phase is aimed

at verifying that HIT products use standards. The Deploy
Standards-based HIT Products phase validates whether the
standards-based HIT product supports user needs for information. Feedback from the latter phase helps to validate the
HIT solution and identify the needs and priorities for new
standards as needed.
Additional standards documents emerged under these phases, including technical frameworks, integration profiles, content
profiles, testing scenarios and reports (integration statements),
and certification criteria and statements. Figure 2 on page 52
presents the Standardization of Standards approach depicting
HIT standardization phases, examples of standardized entities,
and their products.
Governmental Efforts to Facilitate Standardization

Governments across the globe undertake a range of national
approaches to boost the development and adoption of HIT
standards. In 2005 the United States Office of the National
Coordinator for Health IT (ONC) adopted an industry approach for the Standardization of Standards from the IHE
by creating the American Health Information Community
(AHIC), Health Information Technology Standards Panel
(HITSP), and Certification Commission for HIT (CCHIT)
entities responsible for standardization efforts by phase:
Identify Needs and Priorities for Standards, AHIC: Development of the National Use Cases that defined needs and
priorities for standards in the context of clinical or public
health activities.
Select, Harmonize and Test Standards, HITSP: Building
Interoperability Specifications that defined standards portfolio (technical framework in IHE terms) for these use cases
to enable systems interoperability (i.e., ability to share data).
The IHE Connectathon has become the industry testing event for standards. Today, Connectathons are held
throughout the globe in North America, Europe, Asia, and
Australia.
Certify Standards-based HIT Products, CCHIT: Creating an approach and infrastructure for the certification of
standards-based HIT products.
By 2010, 152 national use cases were developed by AHIC, various interoperability specifications were developed by HITSP,
and a certification criteria and approach were developed by
CCHIT. ONC further continued standardization efforts under
the Standards and Interoperability (S&I) Framework initiative formed in 2010. In the National Interoperability Roadmap,
and the 2015 Interoperability Standards Advisory published for
public comments in January 2015, ONC has been furthering the
approach for standardization of standards through public and
private partnership of the HIT industry, healthcare stakeholders, and SDOs.
Anna Orlova (anna.orlova@ahima.org) is the senior director of standards
at AHIMA.
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Healthcare Moving Toward an

Information Ecosystem
By Christine Kowalski, EdD, RHIA, CP-EHR
JUST AS THE world is held together and shaped by a delicate

and intricate global ecosystem, the US healthcare systems community of connected components, surviving and thriving when
working together toward common goals, represents its own sort
of ecosystem. As healthcare moves toward an informatics-driven environment, this system may be moving towards becoming
an information ecosystem.
Textbooks define this as a network that is continuously sharing information, optimizing decisions, communicating results,
and generating new insights for businesses.1 The emphasis is
on sharing information and communicating in order to generate ideas and optimize business decisions. Healthcare today is a
big business, and quality information is needed to support decisions at every level.
The industry is slowly moving away from the concept that informatics is synonymous with computer literacy in managing
health informationmost know it is more complex than that.
Today, technology supports our purchases, travel, and banking.
Consumers of healthcare expect similar experiences with their
healthcare providers and technology. Health informatics and
information management (HIIM) professionals play a significant role in this information ecosystem, as they are the experts
in rules and requirements governing health information. Its not
just about using computers, but how quality information is produced to attain quality outcomes.
Framing the Discussion

Healthcare informatics is defined in the book Health Information Management: Principles and Practice as the field of information science concerned with the management of all aspects
of health data and information through the application of com54/Journal of AHIMA May 15
puters and computer technology.2 It explains that the practice

of healthcare informatics also includes how data is generated,
collected, organized, validated, analyzed, stored, and integrated. Here, the quality component becomes even more critical to
the process. Healthcare informatics also includes how information is disseminated, communicated, presented, used, transmitted, and safeguarded.
The Patient Protection and Affordable Care Act, signed into
law in 2010, defined initiatives directly influencing informatics
and the need for quality information. The ability to disseminate
and communicate quality health information is foundational
to the various government mandates. Some examples are accountable care organizations (ACO), health information exchanges (HIE), patient-centered medical homes (PCMH), and
population health initiatives. So how is quality defined?
The International Standards Organization (ISO) defines quality as the totality of features and characteristics of an entity that
bears on its ability to satisfy stated and implied needs. Another
expert says quality information needs to meet the expectations
and fit the tasks of the stakeholder.3 Considering the needs and
expectations of our stakeholders, HIIM professionals assume
responsibility in the information production process.
Today, HIIM professionals are managing clinical documentation improvement programs, launching patient portals, and
working with IT staff on organizational projects. They are taking an active role with clinicians, directing patients on entering healthcare data into personal health records, downloading
medical data from home-based monitors, or tracking lifestyle
information on mobile applications. Data analytics and predictive modeling are professional niches clearly moving us toward
the information ecosystem. When HIIM professionals are in-
volved, quality information is the foundational framework for

all these activities.
Expose HIIM Students to Quality Data Generation

It is important for educators in both academic and professional practice settings to expose students to quality data and
information generation in the professions daily work. There
is a solid foundation in the AHIMA Data Quality Model. This
comprehensive framework is for designing information management processes and measuring data quality.2 Students
learn the information production process by considering all
participants who generate health information. This includes
providers at all levels, nurses, allied health professionals,
laboratory, pharmacy, and imaging staff, as well as data such
as reimbursement information and patient data for administrative purposes. This Big Data supports the requirements for
government incentive programs and quality initiatives of external and internal stakeholders.
Quality Information/Informatics Role

The process of managing information quality starts at the very
beginning of information production:
Who is generating the information?
What activity is being assessed?
W hat goals are to be accomplished by evaluating the
quality of this information?
How should the evaluation be conducted?
Most organizations are already focusing on quality outcomes.
Informatics processes are necessary for the production of quality information, and this is a cycle of continuous improvement.
Quality information production is supported by organizational,
behavioral, and technological factors. There is a symbiotic dependence hereand they complement each other.
Organizational factors for the production of quality information include:
Leadership
User involvement
Continuous quality improvement processes
Information governance team promoting quality information
Clinical workflow processes
Information production generated at the point of care
Defined quality information requirements, such as standards, definitions, and logical database designs
Defined best practices in information production
Technological factors for the production of quality information include:
Information systems with a user interface thats self-explanatory and efficient
Easy navigation, intuitive access to content
Efficient program queries, appropriate algorithms to produce accurate and reliable patient data
Systems functional design supports end users; satisfied
staff results in greater use of systems, supporting quality

information
Quality of service from IT department
Technology development and upgrades supported by organizational leaders
Vendor responsiveness
Behavioral factors for the production of quality information
include:
Belief that the information system will improve job performance (greater efficiency, less error) and facilitates
system use
Making ongoing training essentialcompetency leads to
greater use
Super-users and knowledgeable colleagues for quick troubleshooting improves compliance in using a system
According to an article in the Journal of Evaluation in Clinical
Practice, Education and training on quality medical information, quality awareness, and motivation to produce quality information will support use of the information systems for their
intended purposes.3 Motivating staff to generate quality information at all touch points along the continuum is promoted through
frequent data audits, data validation, and meetings with stakeholders to discuss processes. The quality information process is
supported by identifying factors influencing quality information
production, and making changes based on feedback from users.
This includes human processes and technology factors.
Growing the Information Ecosystem

The current healthcare ecosystem has administrative complexities, an enormous burden of regulations, and significant problems with fraud. Many patients are over-treated, while certain
populations are underserved. Coordination of care is a focus of
many government initiatives, but much work lies ahead.
Producing quality information is critical at this time as the
healthcare industry moves from the fee-for-service model toward value-based care. The Centers for Medicare and Medicaid
Services emphasized three objectives identified as the Triple
Aim for healthcare.5 With time, as well as a robust information
ecosystem, this trifecta of quality care could become our reality:
1. Improve the overall health of the population being served.

Combine patient/clinical data and payer information,
analyzing data using sophisticated technologies to riskstratify the population
Informatics processes can target sub-populations of patients most likely to benefit from care management support through the use of predictive modeling 6
2 . Improve the care experience, which goes beyond simply
providing the right type of care.
The PCMH includes patients in their care teams healthcare decisions, coordinating medical and behavioral
health activities5

T
elemedicine utilization is increasing due to faster Internet
connections, better software, and improved video conferencing capabilities; communicating with mobile devices and
remote patient monitoring improves the care experience8
3 . Provide the best care possible while lowering the per-capita
cost of care over time
Practice evidence-based care
Avoid duplication of services
Use technology to share information
HIIM Quality is Heating Up

HIIM professionals are in a digital environment and theres no
turning back. As the industry shifts to value-based outcomes,
reporting specifications will gradually change, based on requirements of the Physician Quality Reporting System (PQRS),
PCMH certification, and meaningful use EHR Incentive Program compliance.
The ACO model will move healthcare toward greater interoperability of information systems and population health
management by linking providers with long-term care centers,
home health agencies, mental health centers, and other ancillary providers. HIEs also play a critical role. Administrators look
to the HIIM profession to be the leaders across the continuum
of quality information production.
HIIM professionals will benefit from keeping their focus on the
thought leaders and successful innovators who have integrated
quality information production through informatics into every
aspect of their enterprise, and learning from their successes
and challenges. Educators in academic environments and professional practices can be role models for students in squarely
meeting the professional challenges of transforming into an information ecosystem. HIIM professionals are best equipped to
facilitate the changes ahead.
THE BEST
PRODUCTIVITY
SOFTWARE
UNIQUE KEY FEATURES
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Call 1 800 355 5251
Notes
1. Liaw, S. Clinical decision support systems: data quality
management and governance. Studies in Health Technology and Informatics 193 (2013): 362-369.
2. LaTour, Kathleen M. et al. Health Information Management: Concepts, Principles, and Practice. 4th edition. Chicago, IL: AHIMA Press, 2013.
3. Mohammed, Siti and Maryati Yusof. Towards an evaluation framework for information quality management
(IQM) practices for health information systemsEvaluation criteria for effective IQM practices. Journal of Evaluation in Clinical Practice 19, no. 2 (2013): 379-387.
4. Halamka, John. Connecting patients, providers, and payers improves quality, safety, and efficiency. Journal of
General Internal Medicine 28, no. 2 (2013): 167-168.
5. Matthews, Christopher. Healthcares Triple Aim: How
technology is facilitating collaboration among members,
providers and payers. Health Management Technology.
January 2013. www.healthmgttech.com/articles/201301/
healthcares-triple-aim.php.
6. Barrington, Randy. Navigating an Ocean of Information:
How Community Care of North Carolina Uses Data to Improve Care and Control Costs. North Carolina Medical
Journal 75, no. 3 (May/June 2014): 183-187. www.ncmedicaljournal.com/wp-content/uploads/2014/05/75305.pdf.
7. Congdon, Ken. Moving Beyond the EHR. Health IT Outcomes. January 23, 2015. www.healthitoutcomes.com/
doc/moving-beyond-the-ehr-0001.
8. Congdon, Ken. Telemedicine: The Next Big Thing in Health IT.
Health IT Outcomes. January 23, 2015. www.healthitoutcomes.
com/doc/telemedicine-the-next-big-thing-in-health-it-0001.
Christine Kowalski (christine.kowalski@wgu.edu) is a HIM program
course mentor at Western Governors University, in Salt Lake City, UT.
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PRACTICE BRIEF
practice guidelines for managing health information
Assessing and Improving EHR

Data Quality (Updated)
Editors Note: This Practice Brief supersedes the March 2007 Practice Brief Assessing and Improving EHR Data Quality.
THE UNITED STATES-BASED Institute of Medicine (IOM) reported in 1999 that at least 44,000 people, and perhaps as many
as 98,000 people, die in hospitals each year as a result of medical
errors that could have been prevented, according to estimates
from two major studies.1 A new study published in 2013 by the
Journal of Patient Safety states that four times as many people
die from preventable medical errors than originally thoughtas
many as 440,000 a year.2
The delivery of quality healthcare depends on the availability
of quality data. Poor documentation, inaccurate data, and insufficient communication can result in errors and adverse incidents.3 Inaccurate data threatens patient safety and can lead to
increased costs, inefficiencies, and poor financial performance.
Furthermore, inaccurate or insufficient data also inhibits reimbursement, payments, and health information exchange (HIE),
and hinders clinical research, performance improvement, and
quality measurement initiatives. The impact of poor data on
care will only increase with the implementation of ICD-10-CM/
PCS, as well as the roll out of the meaningful use EHR Incentive Program. In addition, introduction of new payment reform
models such as accountable care organizations (ACOs) and value-based purchasing emphasize the need for more specific and
meaningful data collection, sharing, and reporting.
An electronic health record (EHR) has the potential to minimize medical errors if the data are accurate and meet quality
criteria. The goal is for EHRs to help healthcare professionals
use quality data for evidence-based knowledge management
and decision making for patient care.
EHRs can have a positive impact on quality of care, patient
safety, and efficiency. Without accurate and appropriate information in a usable and accessible form, however, these benefits
will not be realized. Integrity of information is directly related to
the organizations ability to prove that information is authentic,
timely, accurate, and complete.
This Practice Brief discusses the challenges of maintaining
quality data in the EHR and offers best practice guidance for ensuring the integrity of the healthcare data. It is designed to support and guide organizations, health information management
(HIM) professionals, and providers to better assess, improve,
and maintain the integrity of electronic health information.
New Focus on Data Capture Required

The ability of healthcare organizations to share electronic health
information both internally and externally has been accepted as

a method to improve the quality and delivery of care, according
to AHIMAs Information Governance Principles for Healthcare.4
Data integrity is critical to meeting these expectations. A single
error in an electronic environment presents a risk that can be
magnified as the data transmits further downstream to data
sets, interfaced systems, decision support systems, and data
warehouses.5 Accurate data leads to quality information that is
required for quality decision making and patient care.
The quality of clinical documentation at the point of entry is critical for all data flowing downstream. EHR quality
is dependent upon the data collected at the source. Clinical
documentation practices need to be developed and standardized to facilitate data quality, accurate data capture, and
encoding. In an EHR, it is imperative these content standards
are built into the foundation of the data being captured. Examples of content standards include the Health Level Seven
(HL7) Reference Information Model (RIM), which is a visual
representation of clinical content as discrete objects and
data elements that can be generated, shared, and used in a
lifecycle of events between participants.6
Practices such as repurposing data from the primary source
may create redundancies throughout a patients health information. Redundancies can cause navigation difficulty such as
trying to find essential components like a specific date or time.
EHR design and development should focus on modular and
reusable documentation components which can improve efficiency, eliminate duplicative documentation, and reduce the
effort required to write and capture meaningful, useful, and
pertinent documentation.7
For example, templates and scripts that are designed to contain a mixture of free-text fields and dynamic system data (i.e.,
a blood pressure result or lab value) discourage the copying of
an entire narrative note repeatedly from day to day into the narrative section of an EHR, since the system data would become
outdated and irrelevant.8
In addition, establishing consistent data models will ensure
the integrity and quality of the data maintained in the EHR. A
data model is a representation of the data to be stored in a database and the relationships between the tables and data fields
which can then be carried out using object-oriented or entity
relationship approaches.9 Data models can describe the behavior of a system from a functional perspective and provide a com-
Practice Brief
mon basis upon which EHR functions are communicated.10

Standardization of data definitions and structure for clinical
content may include the use of smart text or text expanders and
limit the use of free text as much as possible. These approaches
will allow for a more robust analysis and utilization of the database tools and resources that make up these systems. Quality
checkpoints coupled with traditional auditing procedures help
ensure quality data is captured. Productivity and effectiveness
of new tools such as natural language processing (NLP) and
computer-assisted coding (CAC) can be enhanced when these
controls are in place.
AHIMAs Data Quality Management Model discusses the business processes that ensure the integrity of an organizations data
throughout the information lifecyclefrom collection, application, and warehousing to analysis.11 The model is available online in AHIMAs HIM Body of Knowledge at www.ahima.org.
Ensuring Data Accuracy

The EHR is a compilation of clinical and clinically-related
information and is used as the primary communication tool
for planning and delivering patient care. Quality patient care
and safety improvement goals can be enhanced and better
achieved through the application of documentation guidelines and data standards.
Documentation and data content within an EHR must be accurate, complete, concise, consistent, and universally understood by data users, as well as support the legal business record
of the organization by maintaining these parameters. It is critical that both structured and unstructured data meet a standard
of quality if they are to be meaningful for internal and external
use, such as for continuum of care and secondary purposes.
Factors such as ease of use and design can facilitate adherence
to documentation guidelines and standards.12 For more information, refer to AHIMAs Practice Brief titled Fundamentals of
the Legal Health Record and Designated Record Set.
Documentation policies and guidelines must be established
in compliance with governmental, regulatory, accreditation,
and industry standardsincluding those for accuracy, timeliness, and copy functionalityand should apply to paper and
electronic formats. Strong facility controls and governance can
help ensure documentation guidelines are followed and compliance requirements are met. For example, consider the varying use of abbreviations and acronyms across facilities and
states. The phrases below all have multiple meanings for the
same acronym:
A BGaortic bifurcation graft OR aortobifemoral graft
OR arterial blood gases

A SCVDarteriosclerotic cardiovascular disease OR
arteriosclerotic cerebrovascular disease
CHDcongenital heart disease OR congestive heart
disease OR coronary heart disease
DOAdate of admission OR dead on arrival
It is imperative that abbreviations are used in the same man-
ner throughout documentation so that the patient is treated appropriately. Healthcare organizations should have an approved
abbreviation list as part of their internal policies and procedures. It should be noted that some organizations are going to
an unapproved list. For example, The Joint Commission has a
Do Not Use abbreviation list.13
Data integrity policies and procedures must be followed. These
policies may include (but are not limited to) registration processes, standards for handling duplicate records, and processes
for addressing overlays. It is important to implement policies
and procedures to maintain the integrity of the data throughout the patient encounter for all information entered into the
EHR, whether by people or systems. Individuals dedicated to
the continuous auditing of the record, as well as EHR correction
processes that monitor the system proactively and correct errors as they are identified, play an important role in fine-tuning
processes and ensuring the overall quality of the data.
Data Quality Best Practices

To further assist the industry in the combined goals of improving quality of care and ensuring the financial integrity of the
organization, the following best practices for ensuring quality healthcare data are recommended. An accompanying illustrative case study is included in the online version of this
Practice Brief in AHIMAs HIM Body of Knowledge, titled Appendix A: How One Hospital Improved Healthcare Data Quality in its EHR.
Role-based access, or role-based security, to the datasometimes referred to as create, read, update, and delete authority
must be defined, enforced, and built into system security functionalities. Clear policies on what information access is needed
by a specific role or relationship to patient types must be developed. For example, only staff who work in the psychiatric clinic
would have access to those patients seen in that clinic as opposed to enterprise-wide patient access. This is determined by
the role and location of staff. The healthcare professional identifies the roles and what access is given based on the Health Insurance Portability and Accountability Acts (HIPAA) minimum
necessary standards, which states that staff should only have
access to the information they need to do their job. Technology
can assist with access control, but there still needs to be coordination with individual stakeholders and processes to ensure
accuracy and availability of the data for patient care.
A data dictionary should exist for each health information system, with standard data field definitions for each data element.
For example, the naming convention field on the front end
where the user sees it could be Patient Age, while back end database users may see PT_AGE or something else completely
different. The data dictionary typically captures other information such as a definition. For instance, Age of the patient calculated by using most recent birthday attained before or on same
day as discharge. The data dictionary will also include many
other details of how to capture each data field such as data type,
format, field size, values, source system, date first entered, and
Practice Brief
why the item is included.

The key focus of the data dictionary is to support and adopt
more consistent use of data elements and terminology to improve the use of data in reporting. An up-to-date data dictionary will aid in better reporting and maintaining the quality
of data. These definitions should be clearly communicated
to all staff accessing the record; especially those responsible
for reporting data. The data dictionary can also be built into
various information systems in an effort to remain compliant
throughout the enterprise. In support of information governance, ongoing ownership and maintenance of the data dictionary should be established.
Inconsistent naming conventions, definitions, varying field
length for the same data element, and/or varied element values
can all lead to problems including poor data quality and misuse
of data in reporting. For example, the date of a patients admission may be referred to as the date of admission in one system
and admit date in another.
In addition, the distinction between ethnicity and race should
be understood and consistently applied during the registration
process. Selection options for these fields should be limited to
choices that are in adherence with the data dictionary.
EHRs are comprised of many different technologies, although
there may be many modules purchased together from one vendor to create an EHR. For all of these systems that feed the EHR,
clear policies, standards, procedures, and functionalities should
be established to define who owns and has responsibility for
maintaining and creating the data dictionary for each system
and module. Having a single owner over the various dictionaries is helpful in reducing reporting errors. The consistent capture of standardized key data, whether demographic or statistical, is crucial.
A standardized format is used to ensure consistency. For example, to satisfy requirements of the federal meaningful use
EHR Incentive Program, the problem list must be developed using SNOMED CT to record current, active, and past diagnoses.
Additionally, the use of standardized templates, data collection
forms, or patient record forms should be required to the greatest extent possible for provider documentation. This too can be
built into the functionality within a system, but should be developed with the appropriate key stakeholders and with compliance input.
Use of structured standardized data or use of auto-format
functionality is important to enable the sharing and exchange
of health information with HIEs and other organizations. For
example, consider entering information, such as vital signs, as
discrete data into correctly formatted fields, versus allowing free
text entry of the vital signs into a field. It does not matter which
system is used to enter a temperature or blood pressure; the format is always the same and can be more easily shared across
systems. If the information was entered as free text, the formatting might be lost and the information misinterpreted.
State and federal laws and regulations; accreditation standards; medical staff bylaws, rules, and regulations; and orga60/Journal of AHIMA May 15
nizational policies and procedures mirror standardization decisions and should be followed by designated staff. The Joint
Commissions Information Management and Record of Care
standards, HIPAA standards, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, and Federal
Rules of Civil Procedure related to electronic discovery are just a
few of the standards that should be kept in mind when developing ones own facility standards and procedures.
Awareness Factors for EHR Data Quality

In order to fully leverage the potential of an EHR systems ability
to improve data quality, and to understand the potential limitations a particular system might have, it is imperative that the
HIM professional have a thorough understanding of their specific EHR system functionality as well as a broad understanding
of EHR functionality in general. Data strategies and an effective
data quality program that incorporate data integrity processes
must be in place to ensure optimal data quality.
In addition to the importance of an information governance
program and the necessity of executive sponsorship, consideration should be given to the following areas for data quality
monitoring.
1. Patient Identification
Ensuring that health information is associated with the patient
to whom it pertains is a key component to ensuring patient
safety. EHR systems should have alerts and prompts that notify
the user when the potential for an incorrect association exists.
For example, the EHR system should alert users when several
patients have similar names and dates of birth, such as in the
case of multiple birth siblings. Access controls strictly limiting
who can enter and update/change key enduring demographic
elements (such as name, date of birth, or place of birth) must
also be in place. Capabilities to limit medical identity theft must
also be implemented.
Simply matching demographic information supplied by the
patient is not sufficient. Additional identifiers or biometrics,
such as patient photographs, palm vein scanning, or fingerprinting should be utilized when possible. Standardized naming
convention policies or formats for using the patients legal name
must also be developed and employed (i.e., standardizing the
spelling of suffixes such as Jr., Junior, and JR) to help minimize the risk for error. Policies and procedures for baby naming,
for unidentified emergency patients, for the use and exclusions
of hyphens, and for handling celebrities or notable individuals
(and the additional complication of considering whether to use
an alias for the patient) should also be developed.
Thorough training for all front-end usersespecially those
in registration and scheduling rolesand proactive surveillance by data integrity analysts for any patient identification
errors should be given the utmost attention to ensure proper
patient identification.
For more information on patient identification and patient
matching, refer to the Practice Brief Managing the Integrity
Practice Brief
of Patient Identity in Health Information Exchange, available

online in AHIMAs HIM Body of Knowledge, or the white paper
Patient Matching in Health Information Exchanges, published
in Perspectives in Health Information Management.
2. Copy Functionality
In early 2014, the Department of Health and Human Services
Office of Inspector General (OIG) highlighted copy and paste
as a common practice in EHR documentation practices, noting
that it can lead to adding false or irrelevant documentation.15
Since bringing this to light, many EHRs have started evaluating and addressing copy/paste functionality. The importance
of strong information governance and internal policy and procedures regarding the use of copy and paste is critical. Organizational policies and procedures should be developed for
proper use of EHR documentation to ensure compliance with
governmental, regulatory, and industry standards, including
acceptable copy/paste practices. Such practices include identification of origin and author of copied information, provider
responsibility, error notification, and sanctions for violating
copy/paste policies.16
Use of copy functionality (also known as copy/paste, copy
forward, or cloning) has been promoted in the clinicians
EHR workflow to improve the ease of consistent use of static
health information, such as past medical history. But when
misused, copy functionality can lead to redundant, misleading,
inaccurate, irrelevant, inconsistent, and unnecessarily lengthy
documentation that may jeopardize quality of care, increase
risk for medical error, or result in allegationsand even chargesof fraud.
For example, problems occur when a clinician copies and
pastes progress notes from the patients first day of care to the
second day of care and does not take the time to review and edit
out procedures, medication, treatments administered, and/or
documents specific to that specific date of service (DOS). In addition to the impact on care quality, dangers extend to the audit
arena where retrospective case reviews may focus on the high
frequency of copy/paste use, which can indicate possible fraud.
The ability to limit copy functionality in an EHR system is vital
for the accuracy of data. Limitations of copy functionality must
include measures such as:
C learly labeling the information as copied from another source
L imiting the ability for data to be copied and pasted from
other systems
L imiting the ability of one author to copy from another authors documentation
Allowing a provider to mark specific results as reviewed
A llowing only key predefined elements of reports and results to be copied or imported
The ability to monitor a clinicians use of copy and paste
Monitoring the EHR audit trail
More information on policies and procedures related to copy
functionality is available in the Copy Functionality Toolkit in

AHIMAs HIM Body of Knowledge.
3. Corrections and Amendments

Policies must outline who may amend records, when record
amendments can be made, and how records may be amended
(not amendments related to patient requests under HIPAA).
Each organization may develop specific guidelines that outline
what the HIM staff may amend versus what must be sent back
to the provider for correction. For example, HIM staff may be allowed to change demographic data such as a date of birth upon
verification, but all clinical amendment requests must be sent
back to the provider for updates.
Regardless of the type of change, any amendments to the
content of the health record must be approved by the provider
and previous versions should be accessible through a revision
history or audit process. More information on policies and procedures related to corrections and/or deletions is available in
AHIMAs Amendments in the Electronic Health Record Toolkit, available online in AHIMAs HIM Body of Knowledge.
4. Standalone Devices
Whenever possible, quality information from standalone devices should be incorporated into the EHR. However, certain devices or equipment that contain health data might not interface
with the EHR. The lack of availability of health information contained in standalone devices can potentially impact data quality by restricting certain types of data from view or making the
viewing of data difficult. In such cases it is important to assess
what standalone data is not integrated into a single EHR view
and ensure those who have a need to know such information
have the ability to access it.
Organizations must closely monitor standalone systems to
ensure data quality and accuracy between the EHR and the
standalone system. For example, scanning results into a document imaging system for viewing, or possibly embedding a link
from the EHR directly to the standalone system, may be considered to ensure that all the data is available when needed. Having
information in disparate systems with no link or viewing ability
could lead to patient safety concerns.
5. Legacy Systems
Legacy systems must be carefully evaluated before undergoing
a data transmission to the EHR. Many organizations have legacy
systems that contain patient information or that feed information into the current EHR. Prior to retiring a legacy system, a
thorough assessment of stored data must be undertaken and a
plan to transition required data elements must be developed.
A legacy system may also feed data to an EHR or be retired via
converting data into an EHR to eliminate system redundancy.
When errors in data are discovered, they must be corrected at
the source as well as in any and all systems that contain the erroneous data, such as a data mart or data warehouse that feeds
other information systems in the enterprise. Clear policies and
Practice Brief
procedures for determining the source of truth when differences exist between interfaced and integrated systems is critical.
This includes any legacy systems that have not been evaluated,
cleansed, and converted.
6. Hybrid Health Record

The move toward a more integrated EHR may be occurring in
stages, due to the cost and significant impact a big bang implementation can have on an organization. This creates inconsistent methods for inputting documentationwith some residing in the EHR and some remaining on paper. Providers locating
documentation for patient care and other staff performing data
review, data abstraction, and coding of services also face inconsistency in finding pertinent information. In such cases, a concise training plan must be established to clearly communicate
and manage the data while in a hybrid state.
HIM and Many Others Now Ensure EHR Data Quality

The healthcare industry is made up of diverse professions that
look at the issue of data quality from different perspectives.
However all agree that quality data is critical for patient care
and safety, reimbursement, accreditation, quality initiatives,
and research. Yet there has been little discussion about who in
healthcare is responsible for ensuring data quality in the electronic environment.
In the past, the data quality role has fallen largely on HIM professionals as the custodians of the paper record. In the electronic environment, everyone from administrative and support staff
responsible for specialty applications to direct caregivers who
document inpatient records will be tasked with ensuring data
quality. It is a break in tradition that each individual in the array of caregivers that treat and interact with a patient has a role
in creating and maintaining quality data in the patients record.
The importance of HIM contributions to development decisions cannot be overstated. HIM professionals will continue to
be regarded as the data stewards, coordinating the multidisciplinary approach to EHR development and education. One
design decision can potentially impact release of information
integrity, regulatory compliance, and/or reimbursement denials due to inadequate documentation. These are not always factors clinicians will readily recognize. In addition, data entry now
occurs in many different non-traditional forms (i.e., telephone
encounters, patient portal messaging, and e-mail), which must
find a place in the organizations legal health record. Maintaining integrity through an information governance plan is critical.
The Ripple Effect

In a networked environment, health record data affects a myriad of internal data sets, operational and transactional systems,
repositories, external databases, and shared networks. For example, consider when an organizations EHR interfaces with an
affiliate EHR. Decisions on what data are brought into the main
organizations EHR and whether the interfaces are bidirectional
will have a significant impact on how much auditing and main62/Journal of AHIMA May 15
tenance is required by the data integrity team. In the instance

where a patient name change creates inconsistencies, the importance of stringent policies and standardized workflows is
critical. For instance, if one organization uses the insurance
card to validate a patients name, and an affiliate uses the patients drivers license. Educating personnel who collect patient
data at all points of entry is crucial to data integrity. Evaluating
the various approaches of collecting data and ensuring there
are policies and standardized workflows are important as well
as validating compatibility with information system upgrades.
With the constantly changing and growing healthcare environment, ensuring the quality and integrity of the data moving
through multiple systems has never been more important. EHR
technology enables HIM and other healthcare professionals to
improve the quality of patient care through influence over quality design and quality improvement functions.
The health record is progressing from paper to electronic at
a time when attention to quality of care is intense. Traditional
quality improvement programs and new quality measurement
initiatives and regulations have helped healthcare professionals focus on process and workflow. The Joint Commission and
CMS survey approach have supplemented this focus on quality with attention to record completeness. But a move to more
point-of-care observation and documentation is needed. Other healthcare professionals are beginning to understand what
HIM professionals have known all alongthat the quality and
integrity of the health record depends on the front-end collection of quality data.
HIMs Evolving Role

The role of the HIM professional is evolving from managing the
content of the health record to contributing to EHR data standardization and harmonization, both inside and outside their
organizations. The future role of the HIM professional will involve the development of information governance programs,
EHR quality models within the organization, and performing
auditing and monitoring checkpoints. Audit programs will help
identify points throughout the data collection process that are
at risk. HIM professionals will facilitate resolution by providing
ongoing feedback and taking a more active role in root cause
analysis. EHR audits at the organizational level will provide
valuable information for inter- and intra-organizational data
harmonization efforts that affect health information exchange.
HIM professionals can contribute positively to all these efforts
through their understanding of the processes underlying the
clinical and financial data streams that comprise the EHR. Many
HIM professionals will continue to find a natural migration to
leadership roles in technology departments or vendor environments to contribute their knowledge from another perspective.
HIM professionals have always worked to ensure that data in
the health record meets quality standards for accuracy, timeliness, consistency, and completeness. The ability to use these
skills in the electronic environment elevates the importance
of HIM engagement in auditing and monitoring documenta-
Practice Brief
tion practices contributing to critical EHR design decisions,

as well as discussions surrounding data output and reporting.
Information governance functions and stewardship ensure
the use and management of health information is compliant
with jurisdictional law, regulations, standards, and organizational policies. As stewards of health information, HIM roles
and functions strive to protect and ensure the ethical use of
health information.17
HIM professionals can now leverage their knowledge in clinical content and EHR data quality to help organizations define governance programs and understand the front-end and
throughput processes that create EHR data. The migration of
healthcare records from paper to electronic puts HIM professionals in a unique position to lead efforts to evaluate and improve EHR data, which will be central to the acceptance of the
EHR and the migration to a future state with new technologies
and interoperability.
Notes
1. Kohn, Linda T. et al. To Err Is Human: Building a Safer
Health System. Institute of Medicine. November 1999.
www.iom.edu/~/media/Files/Report%20Files/1999/ToErr-is-Human/To%20Err%20is%20Human%201999%20
%20report%20brief.pdf.
2. Binder, Leah. Stunning News On Preventable Deaths In
Hospitals. September 23, 2013. www.forbes.com/sites/
leahbinder/2013/09/23/stunning-news-on-preventabledeaths-in-hospitals/.
3. Kohn, Linda T. et al. To Err Is Human: Building a Safer
Health System.
4. AHIMA. Information Governance Principles for Healthcare. 2014. www.ahima.org/~/media/AHIMA/Files/HIMTrends/IG_Principles.ashx.
5. Committee on Data Standards for Patient Safety. Key Capabilities of an Electronic Health Record System: Letter
Report. Institute of Medicine. 2003. www.nap.edu/catalog.php?record_id=10781.
6. Markle. T5: Background Issues on Data Quality. April
2006. www.markle.org/health/markle-common-framework/connecting-professionals/t5.
7. Orlova, Anna. An Overview of Health IT Standards. Journal of AHIMA 86, no. 3 (March 2015): 38-40. http://library.
ahima.org/xpedio/groups/secure/documents/ahima/
bok1_050860.hcsp?dDocName=bok1_050860.
8. Wrenn, Jesse O. et al. Quantifying Clinical Narrative Redundancy in an Electronic Health Record. Journal of
the American Medical Informatics Association 17, no. 1
(January/February 2010): 49-53. www.ncbi.nlm.nih.gov/
pubmed/20064801.
9. Hahn, Jin et al. Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital. Applied Clinical Informatics 3, no. 2 (2012): 175-185.
www.ncbi.nlm.nih.gov/pmc/articles/PMC3613016/.
10. White, Susan. A Practical Approach to Analyzing Healthcare
Data. 2nd ed. Chicago, IL: AHIMA Press, 2013.

11. Health Level Seven. HL7 EHR System Functional Model:
A Major Development Towards Consensus on Electronic Health Record System Functionality. www.hl7.org/
documentcenter/public_temp_FB6B9C43-1C23-BA170CCA469BCDFCC763/wg/ehr/EHR-SWhitePaper.pdf.
12. AHIMA. Data Quality Management Model (Updated).
Journal of AHIMA 83, no. 7 (July 2012): 62-67.
13. Williams, Adrian. Design for Better Data: How Software
and Users Interact Onscreen Matters to Data Quality.
Journal of AHIMA 77, no. 2 (February 2006): 56-60.
14. The Joint Commission. Facts about the Official Do Not
Use List. www.jointcommission.org/assets/1/18/Do_
Not_Use_List.pdf.
15. Mathews, Anna Wilde and Danny Yadron. Health Insurer
Anthem Hit by Hackers. Wall Street Journal. February 4,
2015. www.wsj.com/articles/health-insurer-anthem-hitby-hackers-1423103720.
16. McCann, Erin. CMS called out for EHR fraud failings. Healthcare IT News. January 9, 2014. www.healthcareitnews.com/news/cms-called-out-ehr-fraudfailings?topic=08,28,29.
17. Office of the National Coordinator for Health Information Technology. CMS-ONC Listening Session on Coding and Billing. May 3, 2013. www.cms.gov/ehealth/
downloads/cmsandonc_may3_billingandcodingsessionppt.pdf.
18. AHIMA Board of Directors. New View of HIM: Introducing the Core Model. AHIMA Report. 2011.
References
AHIMA. Health Data Analysis Toolkit. 2014. http://library.
ahima.org/xpedio/groups/secure/documents/ahima/
bok1_050751.pdf.
Bowman, Sue. Impact of Electronic Health Record Systems
on Information Integrity: Quality and Safety Implications.
Perspectives in Health Information Management. October
1, 2013 (Fall 2013). www.ncbi.nlm.nih.gov/pmc/articles/
PMC3797550/.
Brown, Linda et al. Amendments in the Electronic Health
Record Toolkit. Chicago, IL: AHIMA Press, 2012. http://
librar y.ahima.org/xpedio/groups/secure/documents/
ahima/bok1_049731.pdf.
Gelzer, Reed et al. Copy Functionality Toolkit. Chicago, IL:
AHIMA Press, 2012. http://library.ahima.org/xpedio/
groups/secure/documents/ahima/bok1_049706.pdf.
Lusk, Katherine G. et al. Patient Matching in Health
Information Exchange. Perspectives in Health Information
Management. 2014. http://perspectives.ahima.org/wpcontent/uploads/2014/12/PatientMatchinginHIEs.pdf.
Practice Brief
Prepared by (Update)
Sion Davoudi
Julie A. Dooling, RHIA, CHDA
Lisa Kogan, MS, MHA, CCS-P, CDIP
Kerry Ruben, RN, BSN, PHN
Kathleen E. Wall, MS, RHIA
Annemarie Wendicke, MPH
Acknowledgements (Update)
Kathleen Addison, CHIM
Patricia Buttner, RHIA, CDIP, CCS
Jill S. Clark, MBA, RHIA, CHDA
Susan Clark, BS, RHIT, CHTS-PW, CHTS-IM
Katherine Downing, MA, RHIA, CHPS, PMP
Suzanne P. Drake, RHIT, CCS
Terri Eichelmann, MBA, RHIA
Elisa R. Gorton, MSHSM, RHIA, CHPS
Lesley Kadlec, MA, RHIA
Jeanne E. Mansell, RHIT, RAC-CT
Raymound Mikaelian, RHIA
Cindy C. Parman, CPC, CPC-H, RCC
Angela Rose, MHA, RHIA, CHPS, FAHIMA
Bibiana VonMalder, RHIT
Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA
Henri Wynne, MA, RHIT
Previously Prepared by (Updated)

Jill S. Clark, MBA, RHIA, CHDA
Vicki A. Delgado, RHIT, CTR
Susan Demorsky, MHSA, RHIA, FHIMSS, CPHIMS
Elizabeth A. Dunagan, RHIA
Theresa A. Eichelmann, RHIA
Lois A. Hooper, RHIT
Grant Landsbach, RHIA
Ann M. Meehan, RHIA
Deborah L. Neville, RHIA, CCS-P
Sandra L. Nunn, MA, RHIA, CHP
Previous Acknowledgements (Updated)

Cecilia Backman, MBA, RHIA, CPHQ
Gloryanne Bryant, RHIA, CCS, CDIP
Linda Darvill, RHIT
Julie A. Dooling, RHIT
Kim Dudgeon, RHIT, HIT Pro IS/TS, CMT
Sasha Goodwin, RHIA
Deborah K. Green, MBA, RHIA
Diane Hanson, RHIT
Sandra Huyck, RHIT, CCS-P, CPC, CPC-H
Theresa L. Jones, MSEd, RHIA
Stacy Jowers Dorris, MBA, RHIA, CPHQ
Sandra Kersten, MPH, RHIA
Doreen Koch, RHIT
Katherine Kremer, BA, RHIT

Ann Meehan, RHIA
Christina Merle, MS, RHIA
Monna Nabers, RHIA, MBA
Susan Parker, MEd. RHIA
Kim Baldwin-Stried Reich, MBA, MJ, PBCI
Theresa Rihanek, MHA, RHIA, CCS
Lisa Roat, RHIT, CCS, CCDS
Angela Dinh Rose, MHA, RHIA, CHPS, CDIP
M. Beth Shanholtzer, MAEd, RHIA
Sharon Slivochka
Diana Warner, MS, RHIA, CHPS, FAHIMA
Lydia Washington, MS, RHIA, CPHIMS
Traci Waugh, RHIA
Jane DeSpiegelaere-Wegner, MBA, RHIA, CCS, FAHIMA
Lou Ann Wiedemann, MS, RHIA, CDIP, CPEHR, FAHIMA
Gail Woytek, RHIA
Originally Prepared by
Catherine Baxter
Regina Dell, RHIT, CCS
Sylvia Publ, RHIA
Ranae Race, RHIT
Original Contributors
Ashley Austin, RHIT
Stacie Durkin, MBA, RN, RHIA
Kathy Giannangelo, MA, RHIA, CCS
Pawan Goyal, MD, MHA, MS, PMP, CPHIMS
Shelly Hurst, RHIA, CCS
Karl Koob, RHIA
Karanne Lambton, CCHRA(C)
Therese McCarthy
Mary Rausch-Walter, RHIT
Kathy Schleis, RHIT, CHP
Jennifer Schunke, MS, RHIA
Sonya Stasiuk, CCHRA(C)
Dolores Stephens, MS, RHIT
Doreen Swadley, RHIA, MA, MBA, FACHE
Maggie Williams
Original Acknowledgments
Crystal Kallem, RHIT
Don Mon, PhD, FHIMSS
Michael Putkovich, RHIA
Rita Scichilone, MHSA, RHIA, CCS, CCS-P
The information contained in this Practice Brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.
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Coding Notes
ICD-10 Gap Analysis Points to

Revenue Neutral Transition
By Ann Barta, MSA, RHIA, CDIP
THE IMPLICATIONS OF ICD-10-CM/PCS for healthcare reimbursement is a topic at the top of everyones mind in the
healthcare industry these days. As healthcare organizations
continue to prepare for the transition to ICD-10-CM/PCS on
October 1, 2015, an essential and important element of a successful transition is the understanding of the implications
that this transition will have on reimbursement for healthcare organizations.
United Audit Systems, Inc. (UASI), a vendor specializing
in coding and revenue cycle solutions, has been performing ICD-10-CM/PCS documentation gap analysis projects
for the past three years. In addition to assisting healthcare
organizations with identifying and understanding specific
gaps in their clinical documentation, these projects also included the performance of a financial simulation comparing the ICD-9-CM MS-DRG assignment to the ICD-10-CM/
PCS MS-DRG assignment. Overall, the financial simulation
findings for various healthcare organizations have revealed
only modest changes in the organizations case mix index
(CMI), holding consistent with the Centers for Medicare
and Medicaid Services goal of a revenue neutral transition
to ICD-10-CM/PCS.
This article will discuss some potential MS-DRG changes related to the organization and structure of ICD-10-CM/PCS, as
well as the native MS-DRG grouper logic.
Analysis for Supraventricular Tachycardia

The code for supraventricular tachycardia in ICD-9-CM is
427.89, Other specified cardiac arrhythmias. The code 427.89
is listed neither as a major complication or comorbidity (MCC)

nor as a complication or comorbidity (CC) when assigned as
a secondary diagnosis in ICD-9-CM. In comparison, ICD-10CM has a specific code for supraventricular tachycardia, I47.1,
which is listed as a CC.
This change has the potential of resulting in a higher MS-DRG
being assigned in ICD-10 if supraventricular tachycardia is the
only secondary diagnosis qualifying as either a MCC or CC. The
following is an example scenario that illustrates the resulting MS-DRG change.
A patient is admitted to the hospital with a principal diagnosis of congestive heart failure and a secondary diagnosis of supraventricular tachycardia. In ICD-9-CM this
case would be grouped to MS-DRG 293 (RW 0.6762). In
ICD-10-CM/PCS this case would be grouped to MS-DRG
292 (RW 0.9824).
Analysis for Urinary Calculus with Hydronephrosis

The diagnosis of a urinary calculus with hydronephrosis results in two codes being assigned in ICD-9-CM. One code is
assigned for the calculus and another code is assigned for the
hydronephrosis. Although the urinary calculus code is a nonCC code, the hydronephrosis code is a CC code. ICD-10-CM
has new combination codes for urinary calculus and hydronephrosis. These new combination codes often result in the loss
of a secondary CC code for the hydronephrosis. The following
are two example scenarios illustrating the loss of the secondary CC code.
In the first scenario, a patient is admitted with right ure-
Coding Notes
teral calculus with hydronephrosis and undergoes a transurethral removal of the ureteral calculus with an insertion
of a ureteral stent. In ICD-9-CM the MS-DRG assigned to this
case is 669 (RW 1.2662). In ICD-10-CM/PCS the MS-DRG assigned is 670 (RW 0.8957). The reason for the lower MS-DRG
assignment is the result of the loss of the CC for the secondary diagnosis of hydronephrosis.
For the second scenario, a patient is admitted with a right
ureteral calculus with hydronephrosis and undergoes extracorporeal shock wave lithotripsy. In ICD-9-CM the MS-DRG
assignment for this case is 691 (RW 1.6238). In ICD-10-CM/PCS
the MS-DRG assignment is 692 (RW 1.1286). Again, the reason
for the lower MS-DRG assignment is the result of the loss of the
CC for the secondary diagnosis of hydronephrosis.
Analysis for Neutropenic Fever with Leukemia

In ICD-9-CM, if the reason for an admission is neutropenic fever and the patient has leukemia, the principal diagnosis is the
appropriate ICD-9-CM diagnosis code for the type of leukemia.
The leukemia code is the principal diagnosis code as a result of
an Excludes note located under category 288, Diseases of the
white blood cells, stating Excludes: leukemia (204.0 208.9).
No such Excludes note appears in the ICD-10-CM Tabular allowing the code for neutropenic fever to be assigned as the principal diagnosis for the same case scenario.
The following is an example scenario that illustrates the
resulting MS-DRG change. A patient with acute lymphoblastic leukemia is admitted with neutropenic fever. In ICD9-CM a code for the type of leukemia would be assigned as
the principal diagnosis resulting in the assignment of MSDRG 836 (RW 1.1693).
In comparison, in ICD-10-CM a code for the neutropenic
fever would be assigned as the principal diagnosis with a
secondary diagnosis code being assigned for the type of
leukemia, resulting in the assignment of MS-DRG 809 (RW
1.2037). Note that the ICD-10-CM code for leukemia is a sec-

HIM Domain Area: Clinical Data Management
ArticleICD-10 Gap Analysis Points to Revenue Neutral Transition
ondary CC code.
In ICD-9-CM, the above case scenario with a CC secondary
diagnosis code results in the assignment of MS-DRG 835 (RW
2.1042) and a MCC secondary diagnosis code results in the
assignment of MS-DRG 834 (RW 5.2735). In comparison, the
above case scenario coded in ICD-10-CM with a secondary
MCC diagnosis code results in the assignment of MS-DRG
808 (RW 2.226).
Analysis of Mastectomy with Excision of Regional

Lymph Nodes
Code 85.43, Unilateral extended simple mastectomy, is an
ICD-9-CM combination code assigned for the performance
of a total simple mastectomy with the removal of regional
lymph nodes. ICD-10-PCS requires assignment of two codes
for this same procedure, a code for the total mastectomy and
a code for the removal of the regional lymph nodes. The following example illustrates the resulting MS-DRG change for
this case scenario.
A patient with carcinoma of the right breast undergoes
a total right mastectomy with removal of regional lymph
nodes. The MS-DRG assignment for this case is 583 (RW
1.0932) in ICD-9-CM and MS-DRG 581 (RW 1.1338) in ICD10-CM/PCS.
Atrial Fibrillation Coding

ICD-9-CM has only one code for classifying atrial fibrillation,
427.31, Atrial fibrillation. The code 427.31 is neither a MCC or
CC when assigned as a secondary diagnosis in ICD-9-CM. In
comparison, the ICD-10-CM category for atrial fibrillation has
been expanded to include the following specific types of atrial
fibrillation:
I48.0, Paroxysmal atrial fibrillation
I48.1, Persistent atrial fibrillation
[continued on page 70]

LONGER BE ACCEPTED

Coding Notes
National Correct Coding Initiative:

A Valuable Resource in Outpatient
Coding Compliance
By Suzanne P. Drake, RHIT, CCS
THE ORGANIZATIONS HEALTH information management

professionals serve are reliant on their understanding of outpatient coding and reporting conventions to ensure that the reimbursement received by facilities is accurate and not subject to
improper payment audits.
The National Correct Coding Initiative (NCCI) is a helpful tool
for maintaining coding and reporting compliance. A free resource, NCCI is available on the Centers for Medicare and Medicaid Services (CMS) website. The tool was developed to mitigate
improper coding and payments to Medicare outpatient Part B
claims. The NCCI manual is updated annually and is published
in chapters that are in alignment with the chapters and conventions of the American Medical Associations (AMAs) Current Procedural Terminology (CPT) coding system for that same year.
The content of the CPT system serves as the basis for NCCI
edits involving comprehensive and component service pairs. It
helps to establish what components of a procedure are packaged and not reported separately, illustrates examples that provide guidance on when it is appropriate or inappropriate to report separate procedures, and provides insights into Medically
Unlikely services.
General Policy Guidelines Included in the NCCI

Chapter one of the NCCI manual provides the platform for all
subsequent chapters in the manual and discusses some recurrent policy provisions that should be applied in most instances.
CMS clarifies that their use of the term physician in the National Correct Coding Policy and Procedure Manual is intended
to be applied to all healthcare practitioners, hospitals, provid68/Journal of AHIMA May 15
ers, or suppliers eligible to bill with HCPCS.

Commensurate with the CPT Surgical Package Definition in
the CPT manual, CMS also provides a list of services that are
considered to be integral to the surgical package.
One element listed as a part of the surgical package in the NCCI
manual includes the verbiage that debridement of traumatized
tissue and lysis of adhesions are part of the surgical package.
This guidance regarding the lysis of adhesions is consistent
throughout the NCCI manual.
Chapter six, which covers the digestive system, notes that
open lysis of adhesions (44005) and laparoscopic lysis of adhesions (44200) are both designated as separate procedures
which should not be reported in addition to the code for the
total procedure or service, per the CPT manual. A separate lysis procedure can be reported separately only in instances that
the surgeon performs and documents an extensive and time
consuming lysis procedure performed in conjunction with another procedure.
With regard to laparoscopic lysis of adhesions, chapters six,
seven, and eight of the NCCI manual all state that it is not
appropriate to report a laparoscopic lysis of adhesions separately when any other surgical laparoscopic procedure has
been performed.
Guidance involving debridement services is also consistent in the manual. In most instances, even when the debridement is performed to remove diseased tissue at the
surgical access site, the debridement is considered integral
to the total service and would not be reported separately.
See chapters three and four for additional discussions in-
Coding Notes
volving the reporting of debridement procedures, and note

examples of when the reporting of a separate debridement
procedure is allowed.
operative hemorrhage. If the control of the hemorrhage

does not require a return to the operating room, the service would not be reported separately.
Other Notable Guidance Available from the NCCI
NCCI Coding Edits and Tables
Each chapter of the NCCI manual contains extensive discussions and guidance on appropriate reporting for the specific
CPT code range/chapter represented.
Some useful guidance that is discussed across multiple chapters and applies to multiple services includes:
Scout procedures are discussed in multiple chapters
of the NCCI manual including chapters one and four
through nine for surgical and radiological scout procedures. Each chapter notes that scout procedures performed prior to another procedure to assess the surgical field and visualize the anatomic landmarks are not
reported separately.
I f a biopsy of a lesion is performed, and then a more extensive procedure is performed at that same site, the
biopsy procedure cannot be reported separately unless
that biopsy result was the determining factor used by
the physician to perform the more extensive procedure.
This guidance is repeated in almost every chapter of the
NCCI manual.
-- If a biopsy of one lesion is performed and a more extensive procedure is performed on a separate lesion,
both services can be reported. One good example is a
colonoscopy with biopsy of one lesion, then polypectomy of another. In that instance both the biopsy and
the polypectomy would be appropriate to report.
T he use of multiple approaches to complete the same
procedure should not be reported separately. One example provided in chapter one of the manual includes
a vaginal and abdominal hysterectomy. Chapters four
and six also have detailed discussions involving arthroscopic and laparoscopic procedures converted to
open procedures, and in keeping with this provision instruct that only an open procedure should be reported
in these instances.
Complications that occur during the primary surgical
procedure can sometimes be reported; but, caution the
reader, the surgical package includes all of the services
necessary to perform a procedure, including the postoperative period. If the complication results in the performance of an additional procedure significantly outside
of the scope of the planned procedure, that additional
procedure would be appropriate to report. However,
if the procedures performed to treat the complication
are usual and customary components of the primary
service, or if a complication occurs postoperatively but
does not require a return to the operating room, the procedure should not be reported separately. One example
discussed in multiple chapters is the control of a post-
In addition to the NCCI manual, CMS provides NCCI Coding

Edit Tables on their website. The tables provide helpful guidance in determining if certain code pairs are appropriate to
report together for both hospitals and physicians.
There are two tables each for hospitals and physicians, each
table encompassing a code range to manage the size of the
files. The physician tables are appropriate for use by physician and non-physician healthcare providers, as well as ambulatory surgical centers. The hospital tables are appropriate
for use by hospitals, skilled nursing facilities, home health
agencies, outpatient physical therapy and speech-language
pathology providers, and comprehensive outpatient rehabilitation facilities.
Note that each procedure code will be listed as many times
as there is a secondary code associated with that primary
code in which an NCCI edit exists. For example, HCPCS code
A4263 is listed only once in Column A, with only one code
pair. In contrast, CPT code 40490 is listed in Column A 154
times, with a different component code listed in Column B
on each different line.
When using the tool, first find the primary procedure in Column A, then scroll through to see if the secondary/component
procedure is listed in Column B.
If the secondary procedure is not listed, it means that no NCCI
edit exists for the pair, and both procedures could be reported.
When the secondary procedure is listed, look to Column
F to see what modifier exists for that pair. There are three
possible modifiers that will appear in Column F: 0, 9, or 1.
In instances that the modifier is 0, under no circumstance
should this pair be reported. Even if a modifier is applied to
the secondary procedure, the secondary procedure will not
be paid. When the modifier is 9, the NCCI edit does not
apply to this code pair and the edit for this code pair was
deleted retroactively.
In instances when the modifier is reflected as 1, there are
circumstances that this pair could be reported together using
an appropriate modifier to indicate that the procedure was
separate in nature and should be paid separately.
Make certain that it is correct to report modifier 59 or one of
the expanded X {EPSU} modifiers to the Column B procedure
before appending. Improper reporting of modifier 59 has
been identified as a compliance issue since the reporting of
modifier 59 results in additional reimbursement to the facility.
See Transmittal 1422 for additional discussions.
The CPT manual defines a separate procedure as one that
involves a different session, different procedure or surgery,
different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extenJournal of AHIMA May 15/69
Coding Notes
sive injuries) not ordinarily encountered or performed on the

same day by the same individual.
The NCCI manual and Edit tables

have tremendous value in assisting
in the prevention of reporting of
improper claims.
To circumvent misuse of modifier 59, CMS developed a subset of modifier 59 referred to as the X {EPSU} modifiers that
went into effect January 1, 2015. Those modifiers include XE to
report a separate encounter, XS to report a separate structure,
XP to report a separate practitioner, and XU for unusual overlapping procedures.
The NCCI manual and Edit tables have tremendous value
in assisting all healthcare settings in the prevention of reporting improper claims. Review those chapters that are
applicable to the services being coded to ensure compliance in the reporting of comprehensive and component
service pairs.
[continued from page 67]

I48.2, Chronic atrial fibrillation
I48.91, Unspecified atrial fibrillation
Code I48.1, Persistent atrial fibrillation, qualifies as a CC
code and has the potential of resulting in the assignment of
a higher weight MS-DRG if persistent atrial fibrillation is the
only secondary diagnosis qualifying as either a MCC or CC.
The following is an example scenario that illustrates the resulting MS-DRG change.
A patient is admitted for treatment of acute on chronic diastolic congestive heart failure. Review of documentation indicates
that the patient is also being treated for a secondary diagnosis
of persistent atrial fibrillation. The MS-DRG assignment for this
case scenario is 293 (RW 0.6762) in ICD-9-CM and 292 (RW
0.9824) in ICD-10-CM/PCS.
Analysis for Rib Fractures

ICD-9-CM has the following codes for classification of a rib
fracture:
807.00, Rib fracture, unspecified
807.01, Rib fracture, one
807.02, Rib fracture, two
807.03, Rib fracture, three
References
American Medical Association. CPT 2015 Professional Edition.
Chicago, IL: American Medical Association, 2015.
Centers for Medicare and Medicaid Services. How to Use
the Medicare National Correct Coding Initiative (NCCI)
Tools. January 2013. http://www.cms.gov/Outreacha nd-Educat ion/Med ica re-L ea r n i ng-Net work-ML N/
MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf.
Centers for Medicare and Medicaid Services. Modifier
59
Article.
http://www.cms.gov/Medicare/Coding/
NationalCorrectCodInitEd/downloads/modifier59.pdf.
Centers for Medicare and Medicaid Services. National
Correct Coding Initiative Edits. December 8, 2014. www.
cms.gov/Medicare/Coding/NationalCorrectCodInitEd/
index.html?redirect=/nationalcorrectcodinited/.
Centers for Medicare and Medicaid Services. Specific
Modifiers for Distinct Procedural Services. CMS Manual
System, Transmittal 1422. August 15, 2014. www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/
downloads/R1422OTN.pdf.
Suzanne P. Drake (Suzanne_Drake@Bshsi.org) is coding quality and RAC
coordinator at Bon Secours Health System, based in Richmond, VA.
807.04, Rib fracture, four

807.05, Rib fracture, five
807.06, Rib fracture, six
807.07, Rib fracture, seven
807.08, Rib fracture, eight
807.09, Multiple rib fracture, unspecified
ICD-10-CM has only two subcategories for the classification

of rib fractures:
S22.3, Fracture of one rib
S22.4, Fracture of multiple ribs
Both of these subcategories are further expanded by the laterality of the rib fracture(s) and the encounter episode.
Despite the difference in the coding specificity between ICD9-CM and ICD-10-CM for fractured rib(s), if the reason for the
admission is for treatment of fractures, the MS-DRG remains
the same for ICD-10-CM/PCS as for ICD-9-CMexcept in the
case when the patients principal diagnosis is for the fracture
of two ribs. The principal diagnosis of a fracture of two ribs results in the assignment of MS-DRG 206 (RW 0.7942) in ICD-9CM and MS-DRG 185 (RW 0.6628) in ICD-10-CM/PCS.
Ann Barta (ann.barta@uasisolutions.com) is a senior HIM consultant at
UASI.
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Service
17
18
CSA MEETINGS:
OREGON, Portland, OR
RHODE ISLAND,
Warwick, RI
19
20
21
22
23
28
29
30
WEBINAR:
CSA MEETING:
UTAH, Salt Lake City, UT
Patient
Engagement
vs. Patient
Education
Whats the
Difference?
AHIMA ICD-10 Academy: Building Expertise in

Coding, Chicago, IL
CSA MEETING:
COLORADO, Denver, CO
24
25
26
27
Advanced ICD-10-PCS Skills Workshop, Edison, NJ

Coding, Columbus, OH
CSA MEETING:
HAWAII, Honolulu, HI
31
AHIMA Annual Convention

2016 Baltimore, MD
October 15-20
A Look Ahead
Keep Informed
JUNE
Certified Health Data Analyst (CHDA) Exam

Prep Workshop Available
Upcoming AHIMA Institutes, Seminars, Workshops,

and Webinars
12
CSA Meeting: Kentucky, Lexington, KY
Webinar: ICD-10: The Impact on OP Coding for

Certain High Volume Diagnoses
35

Coding, Seattle, WA
Webinar: Bringing Predictive Analytics to the Point

of Care
45
CDIP Exam Prep Workshop, Seattle, WA
45
Faculty Development Regional Meeting, Miami, FL
45
CSA Meeting: Puerto Rico, San Juan, PR
46
CSA Meeting: Arizona, Scottsdale, AZ
710
CSA Meeting: California, Palm Springs, CA
710
CSA Meeting: New York, Syracuse, NY
1012
Advanced ICD-10-PCS Skills Workshop,

Indianapolis, IN
1012

Coding, Chicago, IL
1012
CDI Academy, Chicago, IL
11
Webinar: Building Data Driven Workflows in HIM:

More Than Just an EHR
1517
AHIMA Academy for ICD-10-CM/PCS: Building

Expert Trainers in Diagnosis and Procedure
Coding, Raleigh, NC
16
Webinar: Evolving and Adapting: The Changing

Role of the CDI Professional
1719
CSA Meeting: Mississippi, Hattiesburg, MS
1819
Faculty Development Regional Meeting,

Wilmington, DE
2123
Long-Term and Post-Acute Care Health IT Summit,

Baltimore, MD
2425

Coding CM Only, Baltimore, MD
2426
Advanced ICD-10-PCS Skills Workshop, Denver, CO
2426
CSA Meeting: New Jersey, Atlantic City, NJ
25
Webinar: Coding Injuries in ICD-10-CM
2830
CSA Meeting: Texas, San Marcos, TX
UPCOMING INSTITUTES, SEMINARS,

WORKSHOPS, AND WEBINARS
July 79
Advanced ICD-10-PCS Skills Workshop, Chicago, IL
Check www.ahima.org/events for the latest schedule of

institutes, seminars, and workshops.
Resources and News from AHIMA
This extensive two-day face-to-face workshop is

designed to prepare healthcare professionals to sit
for the Certified Health Data Analyst (CHDA) examination. Through in-depth examples and exercises
in the classroom, workshop participants will review
the three domains covered in the exam:
Data management
Data analytics
Data reporting
Visit www.ahima.org/events for more information.
Webinar Covers Coding for High

Volume Diagnoses
www.ahimastore.org
A webinar on June 2 will discuss the impact of ICD10 on outpatient coding for certain high volume
diagnoses. With the October 2015 implementation
date of ICD-10-CM/PCS on the horizon, there is a
push for increased specificity in documentation in
order to process a claim appropriately and compliantly. Documentation must reflect appropriate
levels of services provided as well as accurate assignment of codes, therefore reducing the risk from
incomplete or unclear information, and support
high-quality patient care in the process.
This webinar will focus on the impact of ICD-10
from the outpatient perspective and identify the
anatomical specificity required for certain high volume diagnoses. Participants will also learn the differences between ICD-9 and ICD-10 with regards
to outpatient coding and documentation.
New Issue of Perspectives Now Available
A new issue of AHIMAs scholarly journal Perspectives in Health Information Management is now
available. The Spring 2015 issue of Perspectives
features the latest research on topics such as meaningful use, patient matching, and mobile health.
To read the full issue and to learn more about submission guidelines, visit http://perspectives.ahima.org.
AHIMA Volunteer Leaders
AHIMA BOARD OF DIRECTORS

President/Chair
Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
Senior Vice President of Health Information
Management and Consulting Services,
Peak Health Solutions, Inc.
San Diego, CA
(858) 746-7298
cassi.birnbaum@ahima.org
President/Chair-elect
Melissa M. Martin, RHIA, CCS, CHTS-IM
Chief Privacy Officer and Director of Health
Information Management, West Virginia
University Hospitals
Morgantown, WV
(304) 598-4109 x73716
melissa.martin@ahima.org
Past President/Chair
Angela C. Kennedy, EdD, MBA, RHIA
Head and Professor, LA Tech University
Ruston, LA
(318) 257-2854
angela.kennedy@ahima.org
Speaker of the House of Delegates

Laura W. Pait, RHIA, CDIP, CCS
Chief Operating Officer, Health Information
Management Shared Service Center, Parallon
Business Performance Group, Atlanta Shared
Service Center
Norcross, GA
(678) 421-7681
laura.pait@parallon.com
CEO, AHIMA
Lynne Thomas Gordon, MBA, RHIA, CAE,
FACHE, FAHIMA
Chicago, IL
(312) 233-1165
lynne.thomasgordon@ahima.org
TERM ENDS 2015DIRECTORS
Treasurer
Susan J. Carey, RHIT, PMP
System Director, HIM, Norton Healthcare
Louisville, KY
(502) 629-8913
susan.carey@nortonhealthcare.org
Dana C. McWay, JD, RHIA
Court Executive/Clerk of Court, US Bankruptcy
Court for the Eastern District of Missouri
(314) 244-4600
danahimlaw@aol.com
Cindy Zak, MS, RHIA, PMP, FAHIMA

Executive Director Corporate HIM,
Admitting and Outpatient Access,
Yale New Haven Health System
Woodbridge, CT
(203) 688-5466
cindy.zak@ynhh.org
Zinethia L. Clemmons, MBA, MHA, RHIA, PMP
Senior Health Information Privacy Specialist,
Department of Health and Human Services/OCR
Washington, DC
(202) 495-0533
zinethia.clemmons@hhs.gov
Secretary
Ginna E. Evans, MBA, RHIA, FAHIMA
Business Analyst, Revenue Cycle Development,
Emory Healthcare
Avondale Estates, GA
(404) 778-7960
ginna.evans@emoryhealthcare.org
Colleen A. Goethals, MS, RHIA, FAHIMA
HIM Consultant, Cardone Record Services, Inc.
Belvidere, IL
(815) 378-2632
cgoethals@mmrainc.com

Barbara J. Manor, MA, RHIA
Vice President of HIM, SCL Health
Aurora, CO
(303) 403-7511
barbara.manor@sclhs.net
Dwan A. Thomas-Flowers, MBA, RHIA, CCS
HIM Consultant
Jacksonville, FL
(904) 220-2486
HIMprofexcel@bellsouth.net
Susan E. White, PhD, RHIA, CHDA
Associate Professor, Clinical HRS HIM and
Systems Division, School of Health and
Rehabilitation Sciences, Ohio State University
(614) 247-2495
Columbus, OH
white.2@osu.edu
Advisor to the Board
David S. Muntz, CHCIO, FCHIME, LCHIME,
FHIMSS
Senior Vice President/CIO, GetWellNetwork
Bethesda, MD
(240) 482-3192
david.muntz@getwellnetwork.com
2015 CHAIRS OF AHIMA VOLUNTEER GROUPS

AHIMA Grace Awards Committee
Ann F. Chenoweth, MBA, RHIA
(801) 712-4537
afchenoweth@mmm.com
Engage Advisory Committee

Thomas J. Hunt, MBA, RHIA
(989) 725-8279
thunt@davenport.edu
Nominating Committee
Jill A. Finkelstein, MBA, RHIA, CHTS-TR
(954) 418-0938
jfinkelstein@browardhealth.org
State Advocacy Council

Debra K. Primeau, MA, RHIA, FAHIMA
(310) 617-0042
dprimeau@primeauconsultinggroup.com
AHIMA Triumph Awards Committee

Judith A. Gizinski, MPH, RHIA
(321) 757-5226
judy.gizinski@health-first.org
Exhibit Advisory Committee

Steve Sonn, MS
(312) 229-7197
ssonn@care-communications.com
Professional Ethics Committee

Diann H. Smith, MS, RHIA, CHP, FAHIMA
(817) 457-8911
diannhsmith@texashealth.org
Virtual Lab Strategic Advisory Committee

John Richey, MBA, RHIA
(419) 447-9352
richey@findlay.edu
Annual Convention Program Committee

Kimberly D. Theodos, JD, MS, RHIA
(318) 257-2854
ktheodos@latech.edu
Fellowship Committee
Mona Y. Calhoun, MEd, MS, RHIA, FAHIMA
(301) 352-0304
mcalhoun@coppin.edu
2015 CHAIRS OF AFFILIATE VOLUNTEER GROUPS

AHIMA Foundation
Torrey Barnhouse
(312) 233-1131
Torrey.Barnhouse@TrustHCS.com
Commission on Accreditation for

Health Informatics and Information
Management Education
Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS
(312) 233-1548
bonnie.cassidy@nuance.com
Commission on Certification for Health

Informatics and Information Management
Kay Merriweather, RHIA, CHDA, CDIP, CCS,
CCS-P, CPC-H
(404) 849-0459
wdmerr@earthlink.net
Council for Excellence in Education

Ryan H. Sandefer, MA, CPHIT
(218) 625-4931
rsandefe@css.edu
Envisioning Collaborative
(336) 946-1750
lpait@novanthealth.org
House Leadership
Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
edelahoussaye@iodincorporated.com
Judi G. Hofman, CHPS, BCRT, CAP, CHSS,

H-CAP
(541) 706-7760
jhofman@stcharleshealthcare.org
Susie L. James, RHIT, CCS

(205) 941-1105
sjames@mmplusinc.com
20152016 HOUSE OF DELEGATES

Speaker of the House of Delegates
Chief Operating Officer, Health Information
Management Shared Service Center, Parallon
Business Performance Group, Atlanta Shared
Service Center
Norcross, GA
(678) 421-7681
laura.pait@parallon.com
Speaker-elect of the House of Delegates

Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
edelahoussaye@iodincorporated.com
2015 PRACTICE COUNCIL VOLUNTEER CONTACTS

Clinical Terminology & Classification
Cheryl Gregg Fahrenholz, RHIA, CCS-P
(937) 848-6080
Cheryl@phs4you.com
Enterprise Information Management

Kathleen Addison
(403) 943-0940
kathleen.addison@albertahealthservices.ca
Health Information Exchange

Neysa I. Noreen, RHIA
(507) 645-0715
neysa.noreen@childrensmn.org
Gail Garrett, RHIT

(615) 344-6247
Gail.Garrett@HCAHealthcare.com
Sharon Slivochka, RHIA

(440) 937-5532
sks622@roadrunner.com
Katherine Lusk, MHSM, RHIA

(214) 456-8576
Katherine.Lusk@childrens.com
Privacy and Security

Sharon Lewis, MBA, RHIA, CHPS, CPHQ,
FAHIMA
(805) 542-0160
sharonlewisrhia@att.net
Deanna Peterson, MHA, RHIA, CHPS
(314) 209-7800
Deanna.Peterson@firstclasssolutions.com
AHIMA volunteers also make valuable contributions as facilitators for Engage Online Communities. To locate the facilitator(s), go to a particular community, click on the Members tab, then click on the
community administrator link.
AHIMA Volunteer Leaders
COMPONENT STATE ASSOCIATION PRESIDENTS

Alabama
Sharon Horton-Woodruff, RHIT
Cullman, AL
(256) 352-8337
sharon.horton@wallacestate.edu
Indiana
Deborah Grider, CDIP, CCS-P
McCordsville, IN
(317) 908-5992
deborahgrider@mac.com
Nevada
Gregory Schultz, RHIA
North Las Vegas, NV
(702) 526-8361
gschultz00@aol.com
South Dakota
Sheila Hargens, MSHI, CMT
Parkston, SD
(605) 928-3741
sheila.hargens@avera.org
Alaska
Janie Batres, RHIA, CDIP
Anchorage, AK
(907) 252-7228
janieleigh44@hotmail.com
Iowa
Mari Beth Schneider Lane, MS, RHIA
Sheldon, IA
(712) 324-5061
mlane@nwicc.edu
New Hampshire
Jean Wolf, RHIT, CHP
Gorham, NH
(603) 466-5406
jean.wolf@avhnh.org
Tennessee
Lela McFerrin, RHIA
Chattanooga, TN
(423) 493-1637
lela.mcferrin@hcahealthcare.com
Arizona
Christine Steigerwald, RHIA
Gilbert, AZ
(480) 292-8293
Christine.Steigerwald@bannerhealth.com
Kansas
Julie Hatesohl, RHIA
Junction City, KS
(785) 210-3498
phoebehat@cox.net
New Jersey
Carolyn Magnotta, RHIA
New Egypt, NJ
(609) 758-8890
magnottac@deborah.org
Texas
Terri Frnka, RHIT
Bryan, TX
terrifrnka@yahoo.com
Arkansas
Marilynn Frazier, RHIA, CHPS
Ozark, AR
(479) 667-5153
mfrazier@ftsm.mercy.net
Kentucky
Diba Thakali, RHIA
Lexington, KY
(859) 979-3049
diba.thakali@bhsi.com
New Mexico
Vicki Delgado, RHIT
Albuquerque, NM
(505) 948-6711
vicki.delgado@kindredhealthcare.com
California
Shirley Lewis, DPA, RHIA, CCS, CPHQ
Upland, CA
(909) 608-7657
shirley.lewis5@verizon.net
Louisiana
Lisa Delhomme, MHA, RHIA
Rayne, LA
(337) 277-5544
delhomme@louisiana.edu
New York
Sandra Macica, RHIA
Saratoga Springs, NY
(518) 584-0389
s.macica@elsevier.com
Colorado
Melinda Patten, CDIP, CHPS
Aurora, CO
(720) 777-6657
melinda.patten@childrenscolorado.org
Maine
Nora Brennen, RHIT
Topsham, ME
(207) 751-1853
Nora.Brennen@va.gov
North Carolina
Jolene Jarrell, RHIA, CCS
Apex, NC
jolene@drgreview.com
Connecticut
Elizabeth A. Taylor, MS, RHIT
East Hartford, CT
(860) 364-4417
liz.taylor@sharonhospital.com
Maryland
Sarah Allinson, RHIA
Baltimore, MD
(410) 499-7281
sarahballinson@gmail.com
Delaware
Marion Gentul, RHIA, CCS
Lewes, DE
(302) 827-1098
mgs60mga@yahoo.com
Massachusetts
Walter Houlihan, MBA, RHIA, CCS
Springfield, MA
(413) 322-4309
Walter.Houlihan@bhs.org
District of Columbia
Jeanne Mansell, RHIT, CHTS-CP, CHTS-PW,
CHTS-IM, CHTS-IS, CHTS-TS, CHTS-TR
Washington, DC
(202) 421-5172
jeanne87@hotmail.com
Michigan
Thomas Hunt, RHIA
Owosso, MI
(989) 725-8279
thunt@davenport.edu
Florida
Anita Doupnik, RHIA
Tampa, FL
(813) 907-9380
anita.doupnik@nuance.com
Minnesota
Jean MacDonell, RHIA
Grand Rapids, MN
(612) 719-3697
jean.macdonell@granditasca.org
Georgia
Allyson Welsh, MHA/INF
Decatur, GA
Allysonwelsh@gmail.com
Mississippi
Phyllis Spiers, RHIT
Carriere, MS
(601) 347-6318
pspiers@forrestgeneral.com
Hawaii
Marlisa Coloso, RHIA, CCS
Wailuku, HI
(808) 442-5509
mcoloso@hhsc.org
Missouri
Angela Talton, RHIA, CCS
Florissant, MO
(314) 276-4180
afranks@swbell.net
Idaho
Mona P. Doan, RHIT, CCS-P
Boise, ID
(208) 484-7076
monadoan@hotmail.com
Montana
Vicki Willcut, RHIA
Kalispell, MT
(406) 756-4758
vwillcut@krmc.org
Illinois
Teresa Phillips, RHIA
Effingham, IL
(217) 347-2806
teri.phillips@hshs.org
Nebraska
Shirley Carmichael, RHIT
Fairbury, NE
(402) 729-6854
shirley.carmichael@jchc.us
Utah
Vickie Griffin, RHIT, CCS
Bountiful, UT
vickie.griffin@Parallon.com
Vermont
Charmaine S. Vinton, RHIT, CCS, CPC
West Chesterfield, NH
(603) 357-0170
cvinto@bmhvt.org
Virginia
Darcell Campbell, RHIA
Hampton, VA
(757) 788-0052
DACampbell@cox.net
North Dakota
Tracey Regimbal, RHIT
Grand Forks, ND
traceyregimbal@hotmail.com
Washington
Sheryl Rose, RHIT
Spokane, WA
(509) 624-4109
sherylrose622@hotmail.com
Ohio
Pamela Greenstone, MEd, RHIA
Mason, OH
(513) 403-9014
Pamela.Greenstone@uc.edu
West Virgnia
Kathy Johnson, RHIA
Sinks Grove, WV
(304) 772-5312
kjohnson@care-communications.com
Oklahoma
Christy Hileman, MBA, RHIA, CCS
Mustang, OK
(405) 954-2824
christy.hileman@faa.gov
Wisconsin
Susan Casperson, RHIT
Cecil, WI
(715) 853-1370
susan.casperson@thedacare.org
Oregon
William Watkins, RHIA
Oregon City, OR
(503) 867-5173
william.w.watkins@kp.org
Wyoming
Kimberle Johnson, RHIA
Gillette, WY
(307) 682-1251
kim.johnson@ccmh.net
Pennsylvania
Laurine Johnson, MS, RHIA, FAHIMA
Sarver, PA
(724) 295-9429
ljohnson@peakhs.com
Puerto Rico
Brunilda Velazquez, RHIA, CCS
Guayanilla, PR
(787) 505-1433
Rhode Island
Patti Nenna, RHIT
Bristol, RI
(401) 253-1686
pnenna@cox.net
South Carolina
Karen B. Farmer, RHIT
Greenville, SC
(864) 277-1982
kfarmer@ghs.org
E-mail changes to your listing to journal@journal.ahima.org

QualCode provides cost-effective solutions

for all your coding, reimbursement and
educational concerns.
Coding Compliance Audits
DRG/Coding Quality Audits
Evaluation & Management Audits
- Emergency Room
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Advertising Index
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Medical Coding Services

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AHIMA Thanks Its Loyalty Program Members
MedData, Inc..................................................... back cover
EXECUTIVE LEVEL
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School of Professional Studies....................................... 37
DIRECTOR LEVEL
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MANAGER LEVEL
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AHIMA Career Center

For classified advertising information, call Alyssa Blackwell: 410-584-1961 | e-mail: ablackwell@networkmediapartners.com
While the ads in this section are deemed to be from reputable sources, the publisher accepts no responsibility for the offers made.
All copy must conform to equal employment opportunity guidelines, and the publisher reserves the right to reject, withdraw, or modify copy.
A current rate card is available on request.
QualCode is looking for:

Inpatient Coders
Project Manager (NY Office)
Must have minimum of 3 years inpatient coding

experience in an acute care setting.
RHIA, RHIT, CCS credentials is required.
Must be PC proficient.
Must have knowledge of ICD-10-CM/PCS,
including coding conventions and guidelines
Remote and onsite opportunities
Full-time position to be responsible for

management and oversight of all coding and data
quality services provided by QualCode consultants.
Minimum of 5 years experience in inpatient &
outpatient coding.
RHIA, RHIT, CCS, CPC credentials required.
Remote DRG Validators

Must have minimum of 5 years experience in
inpatient coding and minimum of 3 years
experience in DRG validation.
RHIA, RHIT, CCS credentials required.
We Offer:
Excellent Pay
401K Profit-Sharing Plan
Medical/Dental/Vision
PTO
Earn Free CEUs
Exclusively Specializing
in HIM for
almost 25 years!
We assist both
job seekers and employers
in the following specialties:
Executive Level | Consultants
Coders | Auditors | CDI
Directors | Managers | Vendors
We Offer:
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Apply Online:
www.qualcodeinc.com/careers/ or contact
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QualCode delivering quality-focused people, responses and results.
Find the perfect

employee.
Advertise in the AHIMA Career Center!
Contact us in confidence:
Doug Ellie or
Perry Ellie, MA, RHIA, Fellow AHIMA
Careers@HIMjobs.com
800-248-6989
Health Information Technology

Instructor
Applicant must have Bachelors
degree in health information
technology or related field along
with RHIA or RHIT certification.
Please refer to our website:
http://www.sjrstate.edu/
onlinejobpostings.html.
Contact Alyssa Blackwell at 410-584-1961 for pricing and options,

or leave her an email at ablackwell@NetworkMediaPartners.com.
Journal
Journal of
of AHIMA
AHIMA May
May 15/77
15 / 77
AHIMA Career Center

DIRECTOR OF CODING
CCS Medical Coder
oder (DRG Auditor) Opening
DataMetrix is a healthcare cost containment company specializing in preand post-payment services. We are currently looking for a CCS Medical
Coder (DRG Auditor) to join our team.
At DataMetrix, we pride ourselves in leading with experience, expertise,
and industry knowledge and were known and highly regarded as an
expert in our practice areas. We offer a tremendous array of work life
benefits including:
Remote work
Flexible schedule
Company provided laptop
Full benefits
Paid time off
Paid holidays
Job Summary:
The CCS Medical Coder (DRG Auditor) will be responsible for auditing
the accuracy and completeness of diagnosis and procedure coding, MS
DRG & APR DRG assignment, and abstracted data (POA, Discharge
Disposition, etc.) to support the appropriate reimbursement.
Job Requirements:
Must have at least 5+ years of MS DRG and/or APR DRG coding
experience.
Must have CCS and RHIT/RHIA.
Extensive understanding of MS DRG & APR DRG grouping
methodologies.
Must be a team player and maintain close attention to detail.
Knowledge of CMS regulations and statutes.
Must be highly motivated with excellent prioritization skills.
Excellent written and verbal communication skills.
For more information or to apply online visit www.data-metrix.com or
contact Emily Dance at emily.dance@data-metrix.com or 801-441-0616.
78/Journal
15
78
/ Journal of AHIMA May 1
5
for 17 hospitals
Ofce in Irving, TX
Great Benefts!
Salary + Annual Bonus
Paid AHIMA Credentials/Membership
ICD-10 Training
Also Hiring:
Observation/Surgical Day Care Coders
Manager of Inpatient Coding
Inpatient Coders
Work at Home with Dual Monitors
Performance Bonus and ICD-10 Retention Bonus
Guaranteed Hours and Flexible Schedules
Subsidiary of HCA
www.parallon.com/careersor
prescott.boase@parallon.com
Want to fill your open position, or promote

your office as a great place to work?
Advertise in the AHIMA Career Center!
Contact Alyssa Blackwell at 410-584-1961 for pricing and options, or leave her an email at
ABlackwell@NetworkMediaPartners.com.
Upcoming Issues:
June
ICD-10-CM/PCS
July
Clinical Documentation
Improvement
August
Special Issue:
Information Governance
September
Consumer Engagement
Limited space available!
Contact Alyssa Blackwell at
410-584-1961 to reserve your space.
Custom Packages available to fit your
goals and budget.
Journal
Journal of
of AHIMA
AHIMA May
May 15/79
15 / 79
Beware the Dark Side of the Web
UNLESS THEY KNOW EXACTLY WHAT to look for, most Internet users wouldnt know that a Dark Web
exists or what it islet alone the potential for harm that can be done with it.
But the dark side of the web is out there, and its proprietors want your medical information.
In short, the Dark Webor deep web, as it is known to cyber security professionalsrefers to a class of
content that has been intentionally hidden and is not indexed by search engines like Google, according to a
new report titled The Impact of the Dark Web on Internet Governance and Cyber Security.1
Websites on the Dark Web have addresses that end with .su and .so, rather than .com or .org. As one might
suspect, these sites are hidden because would-be criminals use them to sell illegal productsincluding Social
Security numbers, weapons, drugs, and pornography.
Even though the Dark Web hasnt become an epidemic problem yet, the healthcare industry does need to be on
alert, according to security experts. The Dark Web has become a popular domain for sales of protected health
information (PHI) and Medicare numbers. A recent National Public Radio (NPR) story about healthcare data on
the Dark Web offered dire predictions about the security of that information.2 The financial services sector has
made strides in protecting financial data, but at least one expert says healthcare is nowhere near as prepared.
In the NPR piece, healthcare security expert Jeanie Larson warned that cyber security standards for hospitals and other healthcare providers are too low. They dont have the internal cyber security operations,
Larson says, noting that some providers interpret HIPAA too loosely and avoid encryption practices. A lot of
healthcare organizations that Ive talked to do not encrypt data within their own networks, in their internal
networks, she said.
If healthcare security professionals dont take the proper steps to protect their data, the industry can expect
to see breaches as big as the recent Anthem breachwhich exposed the health information of 80 million
peopleto become much more common, and possibly see that data float onto the Dark Web for sale.
Notes
1. Chertoff, Michael and Tobby Simon. The Impact of the Dark Web on Internet Governance and Cyber Security. Global Commission on Internet Governance. February 2015. https://ourinternet-files.s3.amazonaws.
com/publications/GCIG_Paper_No6.pdf.
2. National Public Radio. The Black Market For Stolen Health Care Data. February 13, 2015. www.npr.org/
blogs/alltechconsidered/2015/02/13/385901377/the-black-market-for-stolen-health-care-data.
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MAY 2015

22 Data Analysis Starter Kit

38 Scanning the HIM Environment

Video ExtraInformatics Elevator Speech

Just what is HIMs role in informatics? Nathan Patrick

Connecting the Disparate

Middlewares Role in Solving Healthcares EHR Interoperability Problems

How to Use the Digital Journal

WEVE BEEN PREPARING FOR YEARS

Compliance Reviews Education Coding Services

Contents May 2015

How healthcare is applying practical informatics to save dollars and lives

Vol. 86, no. 5

Job candidates must have the essential pieces

Data Analysis Starter Kit

Connecting the Disparate

e-HIM Professionals Wanted

Word from Washington

By Priscilla Keeton, MS, RHIT, and Patricia Pierson, RHIA

Scanning the HIM Environment

AHIMA Career Center

Contents May 2015

Navigating Privacy and Security

e-HIM Best Practices

By Daniel L. Regard and Ron Hedges, JD

AHIMA members may earn continuing

ICD-10 Gap Analysis Points to Revenue

National Correct Coding Initiative: A Valuable

Connecting the Disparate

By Suzanne P. Drake, RHIT, CCS

Scanning the HIM Environment

Assessing and Improving EHR Data Quality

4/Journal of AHIMA May 15

ICD-10 Gap Analysis Points to Revenue

Video: Informatics Elevator Speech

Legal consequences flow from the use or abuse of

Share and Connect with AHIMA

Journal of AHIMA May 15/5

The Journal of AHIMA is an official publication of AHIMA

Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA

ART DIRECTOR Graham Simpson

EDITORIAL ADVISORY BOARD

6/Journal of AHIMA May 15

The Evolving Practice of Health Informatics

WHEN I DECIDED to pursue my graduate

of coding and clinical documentation improvement (CDI) as we prepare for the

All audit requests are

HealthPort best practices are used to

You will have peace of mind with:

Unlimited capacity to handle

For more information, visit healthport.com/auditrelief

Bulletin Board whats happening in healthcare

AHIMA Comments on ONCs Federal Health IT Strategic Plan

and efforts of 35 additional federal

Patients Less Anxious and Confused After

CHIME Holds Patient

Although patients who are able to

In a move to spur innovation in patient

10/Journal of AHIMA May 15

Before reviewing their records, 92

standards, both in terms of an

Doctor, Thats None of Your Business

A new study published in the Journal of General Internal Medicine found

ART DIRECTOR Graham Simpson