Archive for the ‘Health Information Management (HIM)’ Category

Don’t Forget to Budget for ICD-10 in 2011

December 18, 2010

Yes, we have until 2013.  However, the more I take part in ICD-10 planning committees, the more I realize that this is going to take a huge amount of preparation time.

It’s time to get started now.

Obviously, since we’re still in the process of training the trainers on ICD-10, I’m not referring to training your team on the actual ICD-10 codes.  But, since ICD-10 will place a significant emphasis on specificity and anatomy, I do believe that it is time to start training your providers and coders on:

  1. Documenting every detail  (providers)
  2. Understanding what they will be reading (coders)

This means some form of Clinical Documentation Improvement (CDI) program across your organization.  It also means training or retraining your coders on Anatomy.

These things take tremendous amounts of time, and the time to train on the actual codes is quickly approaching.  The best way to avoid a training logjam at the end is to begin soon.  (Logjams in coding tend to be a major financial problem)

The time is now.  Don’t forget to budget for it.


About the Author:

Aaron is one of the leaders of the HIM Circle movement and former HIM Director at multiple hospitals.  Join the free HIM Circle for further discussion about ICD-10 on these various forums:


What a Year in HIM!

November 11, 2010

Happy HIT Week!  The past year has been a tough one!

We thought it would be great to take a moment and consider all the issues we’ve dealt with  together over the last year.  We tackled RAC’s, dealt with the new HITECH and HIPAA rules, handled coding changes, many of us continued mastering our EMR projects, and we’re all starting to learn about and prepare for ICD-10.

The nice thing is that over the last year, we haven’t had to do it alone.  Through the HIM Circle, we’ve answered more than 200 peer questions on our free peer support forums on facebook, Linkedin, and twitter.  It’s been amazing!

Thank you for being a part of the HIM Circle, and we can’t wait to see what the next year has in store for us all. 

Enjoy the week!

Motivation for Clinical Documentation Improvement (CDI)?

October 1, 2010

As we continue to build our Clinical Documentation Improvement (CDI) program in preparation for ICD-10 and a continued increase in audits (RAC, MIC, and Commercial Insurance), we’ve been doing a lot of discussing and research related to what objectives a CDI program might have.

  • Is it to increase reimbursement through assignment of CC’s and MCC’s?
  • Is it to improve coding productivity?
  • Is it to reduce the potential risk from recovery audits?
  • Is it to improve patient care?

Or, should it be a combination of the above?  Glenn Kraus, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS had some interesting thoughts on why we shouldn’t only focus on the reimbursement. 

There is almost always an opportunity to improve clinical documentation in any medical record chart from both a resource intensive reimbursement standpoint and quality of care and clinical outcomes standpoint. 

But just as the profession is gaining momentum and increased recognition in the business facet of healthcare, we have reached a crossroads and may be going down the wrong path.

The crossroads

For those of us who have been in the clinical documentation improvement arena for a long time, it is eye-opening to view the advertisements and promotional materials for clinical documentation improvement projects readily available at trade shows and appearing in prominent trade journals. The common promotional theme is increased reimbursement for the hospital, which is not surprising given the fact these clinical documentation improvement programs are marketed strictly on the basis of “reimbursement enhancement.”

Let’s not kid ourselves, every healthcare expenditure that is not direct patient care related must provide for a reasonable chance of return on investment, contributing to the organization’s financial performance in some form or fashion, whether it be additional revenue or at least cost avoidance.  But there has been some talk in the industry that some firms have worked into their CDIP contracts a guarantee of specified amount of increased reimbursement for the hospital with the implementation of their programs. 

The aftermath

Clinical documentation improvement programs can be structured to meet the documentation requirements required in the health record to financially sustain the hospital from a financial accounting and quality of care reporting perspective.  How the program is structured can dictate success or failure in the rollout and acceptance of the program by physicians and other ancillary service providers.

In speaking with a fellow colleague recently, I heard a valid concern that is worth mentioning regarding where the CDIS profession is now, and where it may be going. Once again it may be going down the wrong route. My colleague pointed out that in some instances, the clinical documentation improvement specialists appear to be focusing on reviewing the record solely for identification and documentation of “missed CCs and MCCs,” almost as if they were “CC/MCC scroungers.”

The very idea of CDIPs being promoted primarily as reimbursement mechanisms perpetuates and drives the ever-increasing viewpoint of CDIS as CC/MCC identifiers. In order to be directed down the right path, we need to stay attuned to the mission of the profession, which is to affect positive change in physician’s patterns of clinical documentation over the long term through provisions and actions of continued physician education. This relentless pursuit of physician clinical documentation education embraces a holistic approach with an emphasis upon the direct correlation between clinical documentation and the continued business financial viability of the both the hospital as well as the physician. A primary focus upon “getting that CC/MCC” documented in the record represents a very small cross sectional piece of what the CDIS can fundamentally contribute to a successful program.


Which way do you think it should go?

We are at the crossroads for CDI.  The direction we as an industry decide to take will guide the future.  Decisions made today will impact all of us in HIM and finance both tomorrow and well into the future.

Feds propose stronger patient privacy rights

July 11, 2010

We just saw this on the HIM Circle facebook page (


The U.S. Department of Health and Human Services (HHS) proposed a new federal healthcare information privacy rule yesterday that would expand patients’ rights to access their information and restrict certain types of disclosures of protected health information to health plans, according to InformationWeek.

The proposed rule is part of the Obama administration’s plan for every citizen to have an electronic medical record by 2014.

The changes are also a response to the Health Information Technology for Economic and Clinical Health (HITECH) Act, which requires HHS to change the Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules by strengthening the privacy and security protections for health information.

The proposed rule would strengthen and expand HIPAA privacy, security and enforcement rules by:

• Expanding individuals’ rights to access their information and to restrict certain kinds of disclosures of protected health information to health plans;
• Requiring business associates of HIPAA-covered entities to follow most of the same rules as the covered entities;
• Setting new limitations on the use and disclosure of protected health information for marketing and fund raising; and
• Prohibiting the sale of protected health information without patient authorization.

For more information check out the new HHS Website:

January CMS Updates

December 19, 2009

Below are January CMS updates compiled by Sheila at the RWHC:

Here is a link to the January Integrated OCE

Here is the link to the January PPS updates – for both the Medicare Benefit Policy Manual and Claims Processing Manual

Here is a link to the Consult EM changes information

Health Information Bill of Rights

December 2, 2009

Consumers are familiar with HIPAA and aware that it protects access to personal health information at a national level.  Consumers may be surprised to discover that only “covered entities” (healthcare providers, health plans and health clearinghouses) are required to comply with these regulations.  Many entities that access and use the same information are not bound by the same regulations.  Each state has its own regulations regarding health information.  These regulations vary and there is no uniform national standard.

As the country moves closer and closer to full digitalization of all health information, security becomes a greater concern and patients deserve to know who has access to their information and how their information is protected.

In light of this, the American Health Information Management Association (AHIMA) designed a Health Information (HI) Bill of Rights as a model for protecting personal health information.  The Bill contains seven rights “for the sole purpose of protecting healthcare consumers”:

  1. The right to access your health information free of charge
  2. The right to access your health information during the course of treatment
  3. The right to expect that your health information is accurate and as complete as possible
  4. The right for you or your personal representative(s) to know who provides, accesses, and updates your health information, except as precluded by law or regulation
  5. The right to expect health care professionals and others with lawful access to your health information to be held accountable for violations of all privacy and security laws, policies, and procedures, including the sharing of user IDs and passwords
  6. The right to expect equivalent health information privacy and security protections to be available to all healthcare consumers regardless of state or geographic boundaries or the location (jurisdiction) of where the treatment occurs
  7. The right to the opportunity for private legal recourse in the event of a breach of one’s health information that causes harm

Vera Rulon, AHIMA president, said the bill was made necessary by “Repeated abuses of access, accuracy, privacy and security of the most basic rights of individuals whose trust has been betrayed and dignity compromised.”  The seven point bill eases patient’s fears about security by increasing transparency and encouraging providers to give the strictest protections to personal health information.

Posters featuring the HI Bill are already making their way into health facilities and physicians offices.  Wallet sized cards with the Health Information Bill of Rights Preamble on one side and the seven rights on the other are being developed.  The card will give consumers easy access to their HI rights whenever or wherever they are.

Unfortunately at this time the HI Bill of Rights is only a model.  It has not been signed into law and until it is or something comparable is, there will continue to be fears and concerns about the safety of personal health information.  However, the HI Bill of Rights is a step toward making consumers more informed about their health information and confident in how that information is managed; it is a step in the right direction.

Questions: What do you think about the HIM Bill of Rights?  Do you think there are any key points missing?  

About the Author: Erika Christenson is a Staff Writer with the Clear Medical Solutions Communication Team.  Her work is regularly shared on the Clear Medical Agency newsletter and the blog.

AHIMA Health Information Bill of Rights

AHIMA Rights Bill Sets Ideal Standard for Protecting Consumer Health Information

The Clear Medical Network

November 25, 2009

With rapid improvements in technology and communication, social networking is thriving and full of potential.  Sites like Facebook, Twitter and LinkedIn are known among all people, young and old.  As the dynamics of online communication are growing, companies are adapting to the trends.  One example is the Clear Medical Network.  

It was formed to provide an avenue for networking among all different healthcare professionals as well as provide career opportunities through consulting projects, leadership positions, and per diem work to all its members.  It’s also a great resource if you are looking for full time or per diem coders or transcriptionists in your area at a wholesale rate.  

Registered members are also informed of any upcoming fun events in their area.  One upcoming event is  a really great deal for an 8 day/7 night cruise next year to the Mexican Riviera! 

In case you are wondering, joining the network is free and takes less than a minute.  Once registered, members are informed of different forums they can join to network with other healthcare professionals within HIM as well as other areas of healthcare. 

If you are interested in joining, the site is  

This is definitely a new way to keep all healthcare professionals connected in one primary location.  Personally, I’m really excited about all the opportunities this could provide!

Questions: What do you think of the Clear Medical Network?

About the Author: Sarah Fore is a Staff Writer with the Clear Medical Solutions Communication Team.  Her work is regularly shared on the Clear Medical Agency newsletter and the blog.

Health Information Technology and the Stimulus Package: Information and Changes for the Public and Employment Opportunities

November 16, 2009

Health information technology (HIT) is a broad term used to describe the digital storage, management, and secure exchange of health information between patients, providers, government, and insurers.  The information being exchange primarily refers to but is not limited to Electronic Health Records (EHRs are sometimes called electronic medical records (EMRs)).

Earlier this year, Obama’s American Recovery and Reinvestment Act of 2009 (the Stimulus Bill) was signed into law.  One part of the Stimulus Bill; the Health Information Technology for Economic and Clinical Health (HITECH) Act, aims to increase the use of an EHR by doctors and hospitals by:

  • “Requiring the government to take a leadership role to develop standards by 2010 that allow for the nationwide electronic exchange and use of health information to improve quality and coordination of care.”
  • “Investing $20 billion in health information technology infrastructure and Medicare and Medicaid incentives to encourage doctors and hospitals to use HIT to electronically exchange patients’ health information.”
  • “Saving the government $10 billion, and generating additional savings throughout the health sector, through improvements in the quality of care and care coordination, and reductions in medical errors and duplicative care.”
  • “Strengthening Federal privacy and security law to protect identifiable health information from misuse as the health care sector increases use of Health IT.”

Information and Changes for the Public:
Health information technology and electronic health records will not only improve patient care but also change the way we experience health care.   Even the best doctors can make mistakes or unintentionally overlook important details; an EHR will reduce the risk of these errors.   EHRs negate mistakes made due to sloppy handwritten notes.  They have automatic drug-drug/ drug-food interaction and allergy checks, and since they are online, standard drug dosage information and educational patient information can also be accessed.  Built- in alerts remind doctors of preventive care timelines, and can track referrals and test results.

Another major advantage of EHRs is they are maintained digitally and once they progress to their full potential, they can be accessed from anywhere.  Because it is simple to back-up this data to another location, EHRs also guarantee information will never be lost or damaged as a result of a natural disaster.  In the event of an emergency hospital visit or sickness while away from home, a doctor will immediately be able to pull up a patient’s chart and access information potentially crucial in diagnosing and treatment.  Referral doctors will be able to see any treatment a patient is undergoing by other doctors and make decisions that will not interfere with that treatment.

Though there are many benefits, HIT is not without its drawbacks.  Advocacy groups like the ACLU are wary of HIT and question how secure confidential medical records will really be if they are kept digitally online.  The potential for online medical records to be hacked is real and very serious; electronic databases and servers regularly experience hack attempts and an EHR would be no different. 

It is easy to placate the fear of EHRs being hacked and find comfort in the idea that “if someone really wanted my medical file they could just as easily break into my doctor’s office.”  This leads to the conclusion that “nobody would break into my doctor’s office to steal my records, because I am simply not that important.”  However, hacking into an EHR system is not the same as breaking into your doctors.  The threat of your EHR being attacked is not only about your personal health information; hacking into an EHR means gaining access to everyone’s valuable health information.  Hackers could sell the information found in the nation’s family histories, mental health history, test results, current medication, etc… or use it to bribe and blackmail people in countless ways for countless amounts of money.  Even worse, they could change the EHR causing unimaginable damage.

However, the benefits of an EHR far surpass the risks.  The government is working hard to minimize the threat of hacking.  Part of the HITECH is to strengthen “Federal privacy and security law to protect identifiable health information for misuse as the health care sector increases use of Health IT.”

Information and Changes for Employment:
Employment for medical records and health information technicians is very good and is expected to grow faster than the average professional field.  The projected employment for 2016 is 200,000.  That is 30,000 more than 2006 or an 18% increase.  Physicians’ offices, home health care services, outpatient care centers, and nursing and residential care facilities will have the most job growth and creation of new jobs.  Job growth in hospitals will not be as great but new jobs will still be created.

The growth of HIT and increased use of EHR will benefit everyone and is not something to be scared of.

Questions: Does anyone work in a facility that has already implemented an EHR?  Have you experienced or do you foresee any other problems or risks with an EHR other than hacking?

About the Author: Erika Christenson is a Staff Writer with the Clear Medical Solutions Communication Team.  Her work is regularly shared on the Clear Medical Agency newsletter and the blog. 

Bureau of Labor Statistics.  Occupational Outlook Handbook, 2008-2009 Edition.  Medical Records and Health Information Technicians.

Title IV- Health Information Technology for Economic and Clinical Health Act.  January 16, 2009.

HIPAA and Its Implications

November 2, 2009

From its birth in the U.S. Congress in 1996, HIPAA has played both normative and authoritative roles with respect to patient privacy as well as health insurance security.  The Health Insurance Portability and Accountability Act (HIPAA) is composed of two separate Titles, each pertaining to issues of health insurance proteHIPAAction for employees and their families during a change or loss of occupation, and medical record privacy.  This article will consider Title II of the Act and some of the ways in which it affects both health care workers and patients.

Title II, Administrative Simplification (AS) provisions, calls for and prescribes the establishment of nationally cohesive standards for all health care transactions, or rather, the use and dissemination of health care information.  Its primary intention is to help protect and retain the privacy of such health care information.  (I.e.: medical records, payment history, etc.)  The AS is comprised of five sets of rules, two of which are relevant to our purposes.  The Privacy Rule pertains to both paper and electronic health care files, and prescribes regulatory measures for both the use and disclosure of protected health information (PHI), being “any information held be a covered entity which concerns health status, providers of health care, or payment for health care that can be linked to an individual”.  This particular rule also requires the training of all individuals working within a medical establishment with regard to the proper procedures concerning both PHI and HIPAA.

Another relevant aspect of HIPAA, with respect to privacy, is a subsection of the Security Rule, a rule that is concerned only with electronic data, known as the Physical Safeguards. This facet of the Act itself attends to the control of physical access in order to protect against any inappropriate entrance into classified data.

HIPAA violations are far from uncommon.  Many are reported, but few are actually prosecuted.  This was not the case, however, in a recent incident involving a nurse in a midsize regional medical establishment.  This individual, Ms. A (whose actual name shall not be disclosed), had been employed by her respective clinic for 5 years and, as of late, was married to a man who had been involved in a car accident for which he was being sued.  She came upon the file of her husband’s plaintiff at her office during the course of the lawsuit, took some notes that had been kept in the plaintiff’s medical file, and brought them home to her husband.  In turn, Mr. A contacted the plaintiff urging him to drop the lawsuit given certain facts regarding what had surfaced in his medical record.  The plaintiff immediately contacted the clinic as well as his attorney.  Ms. A was subsequently and instantaneously fired from her job.  The couple were indicted a month later and charged with violating HIPAA, with “conspiracy to wrongfully disclose individual health information for personal gain with maliciously harmful intent in a personal dispute”, and with witness tampering (which was charged to her husband exclusively).  The charge against Mr. A was dropped after negotiations.  However, Ms. A still faces up to 10 years in prison and up to $250,000 in fines.  Not only this, but the nursing board in her respective state is attempting to have her nursing license revoked.  For the full story, visit

This case is a blatant and highly perceptible situation in which a health care employee violated the boundaries of normative ethical privacy practices in the pursuit of personal gain.  However, no malicious intent need be present in order to carry out such violations.

Though HIPAA has undoubtedly protected innumerable individuals’ health care privacy, it has also raised certain complications as well as costs.  Training with respect to HIPAA has proved to be insufficient and toilsome as a staggering majority of health care workers report being uncertain of its scope and needless to say, its more specific mandates.  Not only this, but costs for medical institutions have significantly increased in tandem with the increase in paperwork required by the Act.  Due to the deducible detriments that have, and may very well continue to occur as a result of such confusion and costs, it is imperative that these matters are resolved by both legislators and by those who manage health care institutions.  

Questions: Do you think Mrs. A and Mr. A faced a fair punishment?  Should Ms. A be subject to high fines and 10 years in prison for her actions?

About the Author: Patricia Heise is a Staff Writer with the Clear Medical Solutions Communication Team.  Her work is regularly shared on the Clear Medical Agency newsletter and the blog. 


“Staff Nurse Faces Jail Time for HIPAA Violations.” Ann W. Latner, JD. October 1, 2008.

“Health Insurance Portability and Accountability Act of 1996.” 104th Congress. August 21, 1996.

“Health Insurance Portability and Accountability Act.”

The Fate of Medical Transcriptionists and the Advancements of Voice Recognition Technology

September 29, 2009

GetAttachmentMedical transcription is a lesser-known profession to the general public in spite of the fact that medical transcriptionists (MTs) are a part of everyone’s health care.  Medical transcriptionists transcribe the dictated recordings made by doctors or health care professionals into reports, correspondence, and other administrative documents.  An example, familiar to anyone who has watched one of the highly popular crime dramas on television is when a medical examiner is seen saying the findings of an autopsy out loud; it is a MT who turns that recording into a written report.  In addition to autopsy reports, MTs are also responsible for referral letters, discharge summaries, diagnostic imaging studies, medical histories, physical examination reports, operative reports, and consultation reports.  The completed transcript is returned to the professional who dictated it for review, signature, and movement into the patients file.

The future and security of MT’s jobs has begun to be questioned as voice recognition (VR) technology becomes increasingly refined.  VR converts spoken words into text, potentially eliminating the need for MTs.  Proponents for VR advertise how VR will save medical professionals thousands of dollars over employing MTs.  However, the reality is VR is nowhere near refined enough to replace MTs. 

VR technology would need to be able to “understand” different accents, separate background noise from what is being dictated, and convert any abbreviations used into their full form.  In addition, context plays a large role in understanding spoken language.  VR needs to “understand” context to differentiate between: urine vs. you’re in, cauterize vs. caught her eyes, align vs. a line, dilate vs. die late, and so on before it can replace MTs.

Currently, VR for the purpose of medical transcription is being used in two ways, front-end VR and back-end or deferred VR.  Front-end VR creates a report that rarely goes through an MT but is more time consuming for the medical professional.  Medical professionals using front-end VR dictate into a recognition system and the words are displayed on a monitor as they are spoken; the dictator is responsible for catching mistakes, editing, and completing the document for sign off.  The question for professionals using front-end VR is; is editing reports a better use of their time than seeing additional patients?

Back-end VR is when a recording of what is being dictated is played and a draft document is created.  Both the draft document and voice recording are sent to an MT who listens to the recording, edits the draft, and finalizes the report for sign off.  Back-end VR is the most common form of VR being used in medical transcription.  Back-end VR has made medical transcription more efficient and helps MTs generate more reports in less time.

VR will not make MTs obsolete. The duties and responsibilities of MTs may change due to advancements in VR technology but the day when VR completely eliminates the need for MTs is not in the foreseeable future.  According to the Bureau of Labor Statistics, the outlook for job opportunities for MTs is good. The aging baby boomer population will increase the demand for MTs.  Employment opportunities for MTs are projected to grow faster than the average.  A 14 percent growth is expected between 2006- 2016; in 2006 98,000 MTs were employed, by 2016 112,000 MTs are expected to be employed.  MTs jobs are secure and they should view VR as a tool to aid them in their job, not as threat.

About the Author: Erika Christenson is a Staff Writer with the Clear Medical Solutions Communication Team.  Her work is regularly shared on the Clear Medical Agency newsletter and the blog. 


Bureau of Labor Statistics “Occupational Outlook Handbook, 2008-09 Edition.”

 MedGenMed “Voice Recognition and Medical Transcription” August 27, 2004.

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