Health Information Management Technology
An Applied Approach
Fourth Edition
Nanette B. Sayles, EdD, RHIA, CHPS, CCS, CPHIMS, FAHIMA
Editor
system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher.
ISBN: 978-1-58426-352-7 AHIMA Product No.: AB103112 AHIMA Staff:
Jessica Block, MA, Assistant Editor Claire Blondeau, MBA, Managing Editor June E. Bronnert, RHIA, CCS, CCS-P Jill S. Clark, MBA, RHIA
Adrienne Cook, JD, Developmental Editor Kathryn A. DeVault, RHIA, CCS
Angela K. Dinh, MHA, RHIA, CHPS
Melanie A. Endicott, MBA, RHIA, CCS, CCS-P
Katie Greenock, MS, Editorial and Production Coordinator Karen M. Kostick, RHIT, CCS, CCS-P
Jason O. Malley, Director, Creative Content Development Diana M. Warner, MS, RHIA, CHPS
Lou Ann Wiedemann, MS, RHIA
All information contained within this book, including websites and regulatory information, was current and valid as of the date of publication. However, web page addresses and the information on them may change or disappear at any time and for any number of reasons. The user is encouraged to perform his or her own general web searches to locate information associated with addresses that are no longer valid.
All products mentioned in this book are either trademarks of the companies referenced in this book, registered trademarks of the companies referenced in this book, or neither.
This book is sold, as is, without warranty of any kind, either express or implied. While every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information or instructions contained herein. It is further stated that the publisher and author are not responsible for any damage or loss to your data or your equipment that results directly or indirectly from your use of this book.
American Health Information Management Association 233 North Michigan Avenue, 21st Floor
Chicago, Illinois 60601-5809
ahima.org
About the Editor and Authors . . . xxv Preface . . . xxxiii Acknowledgments. . . xxxvii Foreword . . . xli
Part 1 Healthcare Data Management
Chapter 1 Introduction to the HIM Profession . . . 3 Nanette B. Sayles, EdD, RHIA, CCS, CHPS, CPHIMS, FAHIMA
Chapter 2 Purpose and Function of the Health Record . . . 31 Cheryl V. Homan, MBA, RHIA
Chapter 3 Content and Structure of the Health Record. . . 67 Bonnie J. Petterson, PhD, RHIA
Chapter 4 Healthcare Data Sets and Standards . . . 139 Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
Chapter 5 Clinical Vocabularies and Classification Systems . . . 179 Karen S. Scott, MEd, RHIA, CCS-P, CPC
Chapter 6 Reimbursement Methodologies . . . 227 Anita C. Hazelwood, MLS, RHIA, FAHIMA
Carol A. Venable, MPH, RHIA, FAHIMA
Chapter 7 Health Information Functions. . . 315 Lisa A. Cerrato, MS, RHIA and Jane Roberts, MS, RHIA
Part 2 Health Statistics, Biomedical Research, and Quality Management
Chapter 8 Secondary Data Sources . . . 431 Marcia Sharp, EdD, RHIA
Chapter 9 Healthcare Statistics and Productivity . . . 469 Loretta A. Horton, MEd, RHIA
Chapter 10 Clinical Quality Performance Improvement and Management . . . 559
Chris R. Elliott, MS, RHIA
Part 3 Health Services Organization and Delivery
Chapter 11 Healthcare Delivery Systems . . . 637
Donald W. Kellogg, PhD, RHIA, CPEHR Chapter 12 Ethical Issues in Health Information Management. . . 715
Laurinda B. Harman, PhD, RHIA, FAHIMA Appendix A: Ethical Standards for Clinical Documentation Improvement (CDI) Professionals . . . 765
Chapter 13 Legal Issues in Health Information. . . 771
Laurie A. Rinehart-Thompson, JD, RHIA, CHP Part 4 Information Technology and Systems Chapter 14 Fundamentals of Electronic Information Systems . . . 845
Martin J. Smith, MEd, RHIT, CCA Chapter 15 Introduction to Electronic Health Information Systems . . . 905
Nanette B. Sayles, EdD, RHIA, CCS, CHPS, CPHIMS, FAHIMA Chapter 16 Electronic Health Records . . . 947
Margret K. Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS Chapter 17 Information Security . . . 1021
Sheila Carlon, PhD, RHIA, FAHIMA, CHPS Part 5 Organizational Resources Chapter 18 Principles of Organization and Work Planning. . . 1073
Donald W. Kellogg, PhD, RHIA, CPEHR Chapter 19 Envisioning the Future of the Health Information Management Profession . . . 1139
Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, 2011 President of AHIMA Appendix A Sample HIM Position Descriptions . . . 1155
Appendix B Sample Notice of Health Information Practices . . . 1157
Appendix C Check Your Understanding Key . . . 1161
Glossary . . . 1177
Index. . . 1259
About the Editor and Authors . . . xxv
Preface . . . xxxiii
Acknowledgments. . . xxxvii
Foreword . . . xli Part 1 Healthcare Data Management Chapter 1 Introduction to the HIM Profession . . . 3
Introduction. . . 4
Theory into Practice . . . 5
Early History of Health Information Management. . . 6
Hospital Standardization . . . 6
Organization of the Association of Record Librarians. . . 7
Approval of Formal Education and Certification Programs. . . 7
Evolution of Practice. . . 8
Traditional Practice . . . 9
Information-Oriented Management Practice . . . 10
Visioning the Future of HIM . . . 10
From Traditional Roles to New Opportunities . . . 12
Today’s Professional Organization . . . 16
Mission . . . 16
Membership . . . 17
Structure and Operation . . . 18
Health Information Management Specialty Professional Organizations . . . 24
Healthcare Information and Management Systems Society . . . 24
Association for Healthcare Documentation Integrity. . . 25
American Academy of Professional Coders. . . 25
National Cancer Registrars Association. . . 25
American Recovery and Reinvestment Act of 2009— Community College Consortia to Educate Health Information Technology Professionals . . . 25
Summary. . . 27
Real-World Case . . . 27
References. . . 28
Chapter 2 Purpose and Function of the Health Record . . . . 31
Introduction. . . 32
Theory into Practice . . . 33
Purposes of the Health Record . . . 35
Primary Purposes . . . 35
Secondary Purposes . . . 36
Users of the Health Record. . . 38
Individual Users . . . 39
Institutional Users . . . 43
Functions of the Health Record . . . 47
Storage of Patient Care Documentation . . . 47
Guidance in Clinical Problem Solving. . . 60
Real-World Case #1 . . . 63
Summary. . . 64
Real-World Case #2 . . . 64
References. . . 65
Additional Resources . . . 66
Chapter 3 Content and Structure of the Health Record . . . . 67
Introduction. . . 68
Theory into Practice . . . 69
Documentation Standards . . . 70
Types of Standards . . . 70
Standards Organizations. . . 71
Acute Care Health Record Documentation . . . 77
Basic Acute Care Content . . . 77
Clinical Data. . . 78
Administrative Data . . . 98
Consents, Authorizations, and Acknowledgments . . . 102
Specialized Health Record Documentation . . . 106
Emergency Care Documentation . . . 106
Ambulatory Care Documentation . . . 107
Ambulatory Surgical Care Documentation . . . 110
Long-term Care Documentation. . . 111
Home Healthcare Documentation . . . 113
Hospice Care Documentation. . . 114
Behavioral Healthcare Documentation . . . 114
Rehabilitation Services Documentation . . . 116
Documentation of Services Provided in Correctional Facilities. . . 117
End-stage Renal Disease Service Documentation . . . 117
Principles and Practices of Health Record Documentation . . . 119
Basic Documentation Principles . . . 119
Clinical Documentation Improvement . . . 120
Format of the Health Record. . . 125
Paper-Based Health Records . . . 125
Electronic Health Records . . . 128
Hybrid Records . . . 130
Personal Health Records . . . 131
Real-World Case . . . 134
Summary. . . 135
References. . . 136
Additional Resources . . . 136
Chapter 4 Healthcare Data Sets and Standards . . . . 139
Introduction. . . 140
History of Healthcare Data Collection . . . 141
Data Sets in the Electronic Environment . . . 142
Developing Standardized Data Sets and Standards . . . 142
Theory into Practice . . . 143
Data Sets . . . 145
Definition of Data Set. . . 145
Importance and Use of Data Sets . . . 145
Types of Data Sets . . . 146
Data Sets Required or Recommended by the Federal Government . . . 146
Data Sets for Interoperable Electronic Information Exchange . . . 156
Standards for Electronic Data and Electronic Data Interchange . . . 159
Definition of Data Standard for Electronic Data Exchange . . . 160
Data Needs in an Electronic Environment . . . 160
Benefits of Data Exchange Standards . . . 161
American Recovery and Reinvestment Act . . . 162
Standards Development, Coordination, Testing, and Harmonization . . . 163
Types of Standards . . . 167
Emerging Health Information Standards . . . 172
Extensible Markup Language (XML) . . . 172
Metadata Standards . . . 172
Summary. . . 173
Role of HIM Professional . . . 173
Real-World Case . . . 173
References. . . 175
Chapter 5 Clinical Vocabularies and Classification Systems . . . . 179
Introduction. . . 180
Theory into Practice . . . 180
History and Importance of Clinical Vocabularies . . . 181
Clinical Vocabularies, Classifications, and Nomenclatures . . . 181
International Classification of Diseases, Ninth Revision, Clinical Modification . . . 182
International Classification of Diseases, Tenth Revision, Clinical Modification . . . 190
International Classification of Diseases, Tenth Revision, Procedure Coding System . . . 193
Implementation of ICD-10 in the United States. . . 194
ICD-9-CM to ICD-10-CM Transition Issues . . . 195
International Classification of Functioning, Disability, and Health (ICF). . . 196
International Classification of Diseases for Oncology, Third Edition . . . 197
Healthcare Common Procedure Coding System . . . 199
Current Procedural Terminology, Version 4 . . . 201
Systematized Nomenclature of Medicine . . . 205
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. . . 208
Nursing Vocabularies . . . 210
The Coding Process . . . 212
Standards of Ethical Coding. . . 212
Elements of Coding Quality. . . 213
Coding Policies and Procedures. . . 214
Steps in the Coding Process . . . 214
Quality Assessment for the Coding Process. . . 215
Coding Technology. . . 217
Encoders . . . 217
Unifying Clinical Vocabularies . . . 221
National Library of Medicine UMLS Project . . . 221
Development of the Nosologist Role . . . 222
Real-world Case . . . 223
Summary. . . 224
References. . . 225
Additional Resources . . . 226
Chapter 6 Reimbursement Methodologies . . . . 227
Introduction. . . 230
Theory into Practice . . . 231
History of Healthcare Reimbursement in the United States . . . 231
Pre-Medicare/Medicaid Campaigns for National Health Insurance . . . 231
Medicare/Medicaid Programs . . . 232
Cost Management. . . 233
Development of Prepaid Health Plans . . . 233
Healthcare Reimbursement Systems. . . 237
Commercial Insurance . . . 237
Not-for-Profit and For-Profit Healthcare Plans . . . 238
Blue Cross and Blue Shield Plans . . . 238
Government-Sponsored Healthcare Programs . . . 239
Managed Care . . . 254
Healthcare Reimbursement Methodologies . . . 260
Fee-for-Service Reimbursement Methodologies . . . 261
Episode-of-Care Reimbursement Methodologies . . . 262
Capitation . . . 263
Global Payment . . . 263
Prospective Payment . . . 264
Medicare Prospective Payment Systems. . . 266
Medicare Acute Inpatient Prospective Payment System (IPPS) . . . 266
Resource-Based Relative Value Scale (RBRVS) System. . . 271
Skilled Nursing Facility Prospective Payment System . . . 273
Outpatient Prospective Payment System . . . 274
Ambulatory Surgery Center Prospective Payment System (ASC PPS). . . 277
Home Health Prospective Payment System (HH PPS) . . . 278
Ambulance Fee Schedule . . . 280
Inpatient Rehabilitation Facility (IRF) Prospective Payment System. . . 281
Long-Term Care Hospital (LTCH) Prospective Payment System. . . 282
Inpatient Psychiatric Facilities (IPFs) Prospective Payment System. . . 284
Processing of Reimbursement Claims . . . 288
Coordination of Benefits . . . 288
Submission of Claims. . . 288
Explanation of Benefits and Medicare Summary
Notice Remittance Advice . . . 289
National Correct Coding Initiative (NCCI) . . . 289
Electronic Data Interchange . . . 293
Reimbursement Support Processes. . . 295
Management of the Fee Schedules. . . 295
Management of the Chargemaster . . . 297
Maintenance of the Chargemaster . . . 299
Management of the Revenue Cycle . . . 300
Management of Documentation and Coding Quality . . . 301
Coding and Corporate Compliance. . . 302
History of Fraud and Abuse and Corporate Compliance in Healthcare . . . 302
Elements of Corporate Compliance . . . 304
Relationship between Coding Practice and Compliance . . . 305
Recovery Audit Contractor Program . . . 309
Real-World Case . . . 311
Streamlining the Revenue Cycle Management Process . . . 311
Summary. . . 312
Mapping the Process . . . 312
Ready for RCM . . . 312
References. . . 313
Additional Resources . . . 314
Chapter 7 Health Information Functions . . . . 315
Introduction. . . 317
Theory into Practice . . . 318
HIM Functions and Services. . . 318
Master Patient Index . . . 322
Maintenance of Master Patient Index. . . 324
Patient Identity in a Health Information Exchange Environment . . . 326
Identification Systems . . . 327
HIM Functions in a Paper-Based Environment . . . 331
Record Storage and Retrieval Functions . . . 331
Record Processing of Paper-Based Records. . . 349
Authorization and Access Control for Paper-Based Records. . . 354
Forms Design, Development, and Control for Paper-Based Records . . . 354
Quality Control Functions in Paper-Based Systems . . . 357
HIM Functions in a Hybrid Environment. . . 360
Storage, Retrieval, and Retention of Hybrid Records . . . 361
Authorization and Access Control for Hybrid Records . . . 366
Quality Control Functions for Hybrid Records . . . 366
Issues and Challenges with Hybrid Records . . . 367
HIM Functions in an Electronic Environment . . . 372
Transition Functions to an EHR. . . 374
Record Filing and Tracking of EHRs. . . 375
Record Processing of EHRs . . . 375
Version Control of EHRs . . . 376
Management of Free Text in EHRs . . . 376
Management and Integration of Digital Dictation, Transcription, and Voice Recognition . . . 377
Reconciliation Processes for EHRs . . . 377
Managing Other Electronic Documentation . . . 379
Handling Materials from Other Facilities . . . 380
Search, Retrieval, and Manipulation Functions of EHRs. . . 380
Access Control for EHRs . . . 381
Handling Amendments and Corrections in EHRs . . . 382
Purge and Destruction of EHRs . . . 383
Quality Control Functions for EHRs . . . 384
Medical Transcription . . . 388
Management of Medical Transcription . . . 388
Quality Control. . . 388
Release of Information (ROI) . . . 389
ROI Quality Control. . . 390
Legal Health Record . . . 391
Tracking and Reporting of Disclosures . . . 393
Clinical Coding . . . 393
Quality Control in Clinical Coding . . . 396
Revenue Cycle Management . . . 396
Other HIM Functions . . . 397
Data Reporting and Interpretation . . . 397
Maintenance of Indexes and Registries . . . 397
Birth Certificates . . . 399
HIM Interdepartmental Relationships . . . 399
Patient Registration . . . 399
Billing Department. . . 401
Patient Care Departments. . . 401
Information Systems . . . 402
Quality Management . . . 402
Participation on Medical Staff and Organizational Committees . . . 402
Managing Documentation Requirements. . . 403
Virtual HIM . . . 403
Accreditation and Licensing Documentation Requirements . . . 403
Monitoring of Accreditation, Licensure, and Standards Requirements . . . 405
Management and Supervisory Processes . . . 406
Policy and Procedure Development . . . 407
Future Directions in Health Information Management Technology. . . 413
Real-World Case . . . 418
Background . . . 418
The Planning Process . . . 419
Implementation. . . 422
Summary. . . 423
References. . . 424
Additional Resources . . . 427
Part 2 Health Statistics, Biomedical Research, and Quality Management Chapter 8 Secondary Data Sources . . . . 431
Introduction. . . 432
Theory into Practice . . . 433
Differences between Primary and Secondary Data Sources and Databases. . . 433
Purposes and Users of Secondary Data Sources. . . 434
Internal Users . . . 435
External Users . . . 435
Types of Secondary Data Sources. . . 436
Facility-Specific Indexes . . . 436
Registries . . . 437
Healthcare Databases . . . 450
Processing and Maintenance of Secondary Databases . . . 460
Manual versus Automated Methods of Data Collection . . . 460
Vendor Systems versus Facility-Specific Systems . . . 461
Data Stewardship Issues Associated with Secondary
Data Collection and Use . . . 461
Data Quality Issues. . . 461
Summary. . . 465
Real-World Case . . . 465
References. . . 466
Chapter 9 Healthcare Statistics and Productivity . . . . 469
Introduction to Measurement . . . 471
Discrete versus Continuous Data . . . 473
Common Statistical Measures Used in Healthcare. . . 474
Ratios, Proportions, and Rates: Three Common Examples of Ratio-Level Data Worth Knowing . . . 474
Statistical Data Used in Healthcare Facilities. . . 478
Acute Care Statistical Data . . . 478
Administrative Statistical Data. . . 478
Inpatient Census Data. . . 480
Inpatient Bed Occupancy Rate. . . 483
Bed Turnover Rate . . . 484
Length of Stay Data . . . 485
Patient Care and Clinical Statistical Data . . . 488
Hospital Death (Mortality) Rates . . . 488
Autopsy Rates . . . 493
Hospital Infection Rates . . . 497
Consultation Rates . . . 498
Case-Mix Statistical Data . . . 499
Ambulatory Care Statistical Data . . . 502
Public Health Statistics and Epidemiological Information. . . 504
National Vital Statistics System . . . 504
Population-Based Statistics . . . 506
National Notifiable Diseases Surveillance System . . . 517
Presentation of Statistical Data . . . 518
Tables . . . 520
Charts and Graphs . . . 522
Spreadsheets and Statistical Packages . . . 533
Descriptive Statistics. . . 536
Measures of Central Tendency—The Center of a Variable’s Values . . . 536
Measures of Variability—Spread of a Variable’s Values . . . 540
Normal Distribution . . . 544
Health Information Management Statistics . . . 546
Productivity . . . 546
Staffing Levels . . . 547
How to Analyze Information . . . 549
Real-World Case . . . 550
Real-World Case Discussion Questions . . . 550
Summary. . . 555
References. . . 557
Chapter 10 Clinical Quality Performance Improvement and Management . . . 559
Introduction. . . 561
Theory into Practice . . . 562
Performance Measurement and Quality Improvement . . . 563
Definition of Performance . . . 563
Performance Improvement . . . 565
Quality Dimensions . . . 568
Contemporary Approach to PI . . . 568
The Focus Is on the Customer . . . 569
Fundamental Principles of Continuous Performance Improvement. . . 571
The Problem Is Usually the System . . . 572
Variation Is Constant . . . 573
Data Must Support PI Activities and Decisions . . . 574
Support Must Come from the Top Down . . . 574
The Organization Must Have a Shared Vision . . . 574
Staff and Management Must Be Involved in the Process. . . 575
Setting Goals Is Crucial . . . 575
Effective Communication Is Important . . . 575
Success Should Be Celebrated . . . 576
Formal Performance Improvement Activities. . . 576
Performance Improvement Tools and Techniques . . . 578
Team-Based Performance Improvement Processes . . . 583
Establishing Ground Rules. . . 584
Stating the Team’s Purpose or Mission . . . 584
Identifying Customers and Their Requirements . . . 584
Documenting Current Processes and Identifying Barriers. . . 585
Collecting Current Process Data . . . 585
Analyzing Process Data . . . 588
Process Redesign . . . 592
Recommendations for Process Change . . . 594
Managing Quality and Performance Improvement. . . 596
Organizational Components of Performance Improvement. . . 597
Standards of Organizational Quality in Healthcare . . . 599
Utilization Management. . . 609
Risk Management. . . 612
Recent Clinical Quality Management Initiatives . . . 623
Accountable Care Organizations . . . 624
Six Sigma . . . 625
Virtuoso Teams. . . 627
ISO 9000 Certification . . . 627
Real-World Case . . . 628
Summary. . . 630
References. . . 631
Additional Resources . . . 632
Part 3 Health Services Organization and Delivery Chapter 11 Healthcare Delivery Systems . . . . 637
Introduction. . . 638
Theory into Practice . . . 639
History of Western Medicine . . . 640
North America’s First Hospitals. . . 640
Standardization of Medical Practice . . . 640
Standardization of Nursing Practice. . . 643
Standardization of Hospital Care . . . 644
Professionalization of the Allied Health Professions . . . 646
Modern Healthcare Delivery in the United States . . . 649
Effects of the Great Depression . . . 650
Postwar Efforts toward Improving Healthcare Access. . . 651
Influence of Federal Legislation. . . 651
Professional and Trade Associations Related to Healthcare. . . 664
American Medical Association (AMA) . . . 664
American Hospital Association (AHA) . . . 665
The Joint Commission . . . 665
Blue Cross and Blue Shield Association . . . 667
American College of Healthcare Executives . . . 667
American Nurses Association . . . 667
American Health Information Management Association. . . 668
Certification Commission for Health Information Technology
(CCHIT). . . 668
Other Healthcare-Related Associations . . . 669
Organization and Operation of Modern Hospitals . . . 671
Rise and Fall in Numbers of Hospitals. . . 671
Types of Hospitals . . . 672
Organization of Hospital Services . . . 674
Forces Affecting Healthcare Delivery. . . 682
Growth of Subacute Care . . . 682
Development of Peer Review and Quality Improvement Programs . . . 682
Growth of Managed Care . . . 683
Efforts at Healthcare Reengineering . . . 684
Emphasis on Patient-Focused Care . . . 684
Evidence-Based Best Practices and Outcomes . . . 685
Development of Integrated Healthcare Delivery Systems . . . 686
Licensure, Certification, and Accreditation of Healthcare Facilities. . . 687
Other Types of Healthcare Services . . . 690
Integrated Delivery Network/System . . . 690
Ambulatory Care . . . 691
Long-Term Care . . . 695
Reimbursement of Healthcare Expenditures . . . 700
Evolution of Third-Party Reimbursement . . . 700
Government-Sponsored Reimbursement Systems . . . 700
Managed Care . . . 703
Consumer-Driven Healthcare. . . 703
Healthcare Reform Initiatives. . . 704
Real-World Case . . . 706
Evolution from e-Health Task Force to e-HIM Task Force . . . 706
Vision for e-Health Information Management . . . 707
From HIM to e-HIM . . . 707
Career Opportunities for e-HIM professionals. . . 708
Roles, Resources, and Competencies in e-HIM. . . 709
Future of e-HIM and Where You Might Work . . . 709
Summary. . . 710
References. . . 711
Additional Resources . . . 714
Chapter 12 Ethical Issues in Health Information Management . . . . 715
Introduction. . . 716
Theory into Practice . . . 717
Moral Values and Ethical Competencies . . . 717
Ethical Foundations in Health Information Management. . . 719
Protection of Privacy, Maintenance of Confidentiality, and Assurance of Data Security . . . 719
Professional Code of Ethics . . . 721
Professional Values and Obligations . . . 724
Ethical Responsibilities of the HIM Professional. . . 736
Ethical Issues Related to Medical Identity Theft . . . 737
The Patient’s Perspective . . . 739
The HIM Professional’s Perspective . . . 739
Ethical Issues Related to Documentation and Privacy . . . 742
Ethical Issues Related to Release of Information. . . 743
Ethical Decision-Making Matrix . . . 745
Important Health Information Ethical Problems . . . 748
Ethical Issues Related to Coding . . . 748
Ethical Issues Related to Quality Management, Decision Support, Public Health, Managed Care, and Clinical Care . . . . 749
Ethical Issues Related to Sensitive Health Information . . . 750
Ethical Issues Related to Research. . . 752
Ethical Issues Related to Electronic Health Record Systems . . . . 753
Roles of Manager, Entrepreneur, and Advocate. . . 757
Real-World Case . . . 758
Summary. . . 759
References. . . 760
Additional Resources . . . 764
Appendix A: Ethical Standards for Clinical Documentation Improvement (CDI) Professionals . . . 765
Introduction. . . 765
Ethical Standards . . . 765
How to Interpret the Ethical Standards. . . 766
Resources . . . 770
Chapter 13 Legal Issues in Health Information . . . . 771
Introduction. . . 773
Theory into Practice . . . 773
Overview of Legal Issues in Health Information Management . . . 774
Compilation and Maintenance of Health Records . . . 774
Ownership and Control of Health Records, Including
Use and Disclosure . . . 775
Use of Health Records and Health Information in Judicial Proceedings. . . 776
Introduction to the US Legal System . . . 777
The Source and Making of Laws . . . 778
The Handling of Legal Disputes . . . 779
Legal Proceedings . . . 781
Professional Liability and the Physician–Patient Relationship . . . 782
Form and Content of the Health Record. . . 785
Legal Health Record . . . 787
Retention of the Health Record . . . 788
AHIMA Retention Recommendations . . . 789
The HIPAA Privacy Rule . . . 791
HIPAA Overview . . . 791
Historical Context of the HIPAA Privacy Rule . . . 791
American Recovery and Reinvestment Act of 2009 . . . 793
Applicability of the Privacy Rule . . . 793
Other Basic Concepts . . . 797
Individual Rights . . . 800
HIPAA Privacy Rule Documents . . . 808
Uses and Disclosures of Health Information . . . 813
Breach Notification . . . 826
HIPAA Requirements Related to Marketing and Fundraising . . . . 827
HIPAA Privacy Rule Administrative Requirements. . . 828
Enforcement of Federal Privacy Legislation and Rules . . . 830
Medical Identity Theft . . . 831
Definition of Medical Identity Theft . . . 831
Implications of Medical Identity Theft . . . 831
Fair and Accurate Credit Transactions Act (FACTA). . . 832
Meeting the Red Flags Rule . . . 833
Medical Staff Appointments and Privileges . . . 834
Labor Laws and Unionized Personnel . . . 835
Americans with Disabilities Act . . . 836
Real-World Case . . . 838
Summary. . . 839
References. . . 839
Part 4 Information Technology and Systems
Chapter 14 Fundamentals of Electronic Information Systems . . . . 845
Introduction. . . 847
Theory into Practice . . . 847
Basic Concepts of an Information System . . . 849
Information System Components. . . 850
Information System Activities . . . 850
Types of Information Systems . . . 851
Development of Information Systems . . . 857
Cloud Computing . . . 863
Turnkey Systems . . . 863
Information Architecture . . . 870
Computer Programming Languages and Software . . . 875
Databases . . . 879
Database Approach. . . 879
Database Purpose and Activities . . . 879
Relational Database . . . 880
Data Models . . . 881
Data Dictionary . . . 882
Techniques for Database Integrity . . . 885
Database Management Systems . . . 886
Data Warehouses . . . 886
Data Mining . . . 887
Telecommunications . . . 888
Network Fundamentals. . . 888
Clients, Peers, and Servers . . . 889
Network Architectures . . . 891
Network Topologies . . . 892
Data Transfer . . . 893
Electronic Commerce in Healthcare . . . 895
Management of Information Technology . . . 896
Personal Productivity Software. . . 897
Database Systems. . . 898
Spreadsheets . . . 898
Presentation Software. . . 898
Project Management Software . . . 899
Groupware . . . 899
Real-World Case . . . 899
Developing and Implementing Telehealth Program: The VA’s Story . . . 899
Summary. . . 900
References. . . 901
Additional Resources . . . 902
Chapter 15 Introduction to Electronic Health Information Systems . . . . 905
Introduction. . . 906
Theory into Practice . . . 907
Evolution of Information Systems in Healthcare . . . 908
Development of Clinical Systems . . . 909
Electronic Health Record Systems. . . 909
Electronic Healthcare Information Applications . . . 910
Clinical Information Systems . . . 912
Multimedia and Telematics Systems . . . 918
Toward an Electronic Health Record System . . . 919
Administrative Information Systems . . . 921
Financial Information Systems. . . 921
Human Resource Management Systems . . . 922
Materials Management Systems. . . 922
Facilities Management Systems . . . 922
Management Information Systems. . . 922
Strategic Decision Support System . . . 923
Executive Information Systems . . . 924
Research and Data Analytics Systems . . . 924
Data Warehouses . . . 924
Data Mart . . . 925
Data Mining . . . 925
Online Analytical Processing . . . 926
Overview of Electronic Clinical Information Applications in Nonacute Care Settings . . . 927
Ambulatory Care . . . 928
Long-Term Care . . . 929
Home Health . . . 930
Healthcare Information Resources Management . . . 931
Organizational Structures . . . 932
Enterprise Content and Records Management Department . . . 936
Roles of HIM Professionals in Electronic Health Information
Systems . . . 937
Data Management . . . 938
Data Quality . . . 938
Data Collection and Analysis . . . 938
Data Privacy . . . 938
Data Security . . . 939
Electronic System Design and Development . . . 939
Other HIM Roles . . . 939
Summary. . . 941
Real-World Case . . . 941
References. . . 942
Additional Resources . . . 945
Chapter 16 Electronic Health Records . . . . 947
Introduction. . . 950
Theory into Practice . . . 951
The EHR System . . . 952
EHR Definition. . . 953
HIT Definition . . . 954
EHR System Applications . . . 955
Source Systems . . . 955
Core EHR Applications . . . 959
Analytics and Reporting. . . 967
Specialty Systems and Automated Medical Devices . . . 968
Supporting Infrastructure . . . 969
Connectivity Systems . . . 969
Evolution of the Electronic Health Record. . . 971
Evolution of EHRs in Hospitals . . . 972
Evolution of EHR in Physician Practices. . . 974
Evolution of EHR in Other Care Settings . . . 975
Implementation versus Adoption versus Optimization . . . 976
Challenges to Implementation and Adoption . . . 977
Initiatives and Framework for the Electronic Health Record . . . 982
Governmental Initiatives . . . 982
Meaningful Use Incentives. . . 987
Initiatives Directed toward Consumers . . . 988
Technologies That Support Electronic Health Records . . . 992
Databases and Data Storage . . . 992
Hardware Infrastructure . . . 999
Acquisition of Electronic Health Record Systems . . . 1003 Readiness Assessment . . . 1003 Strategic and Tactical Plans . . . 1005 Information Management in an Electronic Environment . . . 1009 Data Quality . . . 1010 Future Directions in Information Technology . . . 1012 Real-World Case . . . 1013 Summary. . . 1014 References. . . 1015 Additional Resources . . . 1017 Chapter 17 Information Security . . . . 1021 Introduction. . . 1022 Theory into Practice . . . 1024 Confidentiality, Privacy, and Security. . . 1024 Privacy . . . 1024 Confidentiality . . . 1024 Elements of a Security Program . . . 1026 Protecting the Privacy of Data . . . 1026 Ensuring the Integrity of Data . . . 1026 Ensuring the Availability of Data . . . 1027 Data Security Threats . . . 1029 Threats Caused by People . . . 1030 Threats Caused by Environmental and Hardware or
Software Factors . . . 1030
Strategies for Minimizing Security Threats . . . 1032
Components of a Security Program . . . 1033
Coordinated Security Program . . . 1045
Data Security Challenges . . . 1047
Breaches . . . 1047
Managing Organizational Risk. . . 1049
HIPAA Security Provisions . . . 1049
American Recovery and Reinvestment Act of 2009 . . . 1050
HIPAA Security Provisions . . . 1051
Forensics . . . 1062
Enforcement and Accountability . . . 1063
External Enforcement. . . 1063
Internal Audits . . . 1064
Roles and Responsibilities of the
Health Information Technician . . . 1065 Real-World Case . . . 1066 Unauthorized Access/Disclosure from an EHR . . . 1066 Summary. . . 1067 References. . . 1067 Additional Resources . . . 1069
Part 5 Organizational Resources
Chapter 18 Principles of Organization and Work Planning . . . . 1073
Introduction. . . 1075
Theory into Practice . . . 1076
Principles of Organization . . . 1076
Nature of Organization . . . 1077
Organizational Structure . . . 1077
Management Levels . . . 1079
Roles of Teams and Committees . . . 1082
Organizational Tools . . . 1083
Organizational Charts. . . 1083
Mission, Vision, and Values Statements . . . 1086
Policies . . . 1088
Procedures . . . 1088
Human Resources . . . 1090
Leadership Principles . . . 1091
Recruitment, Orientation, and Training . . . 1095
Staff Retention . . . 1099
Delegation of Authority and Empowerment. . . 1100
Performance Management . . . 1101
Conflict Management. . . 1103
Employee Development . . . 1106
Fundamentals of Work Planning. . . 1110
Strategic Planning. . . 1111
Operational Planning . . . 1113
Expense Budgets . . . 1114
Supply Management. . . 1117
Staffing . . . 1118
Work Analysis and Design . . . 1123
Performance and Quality Improvement for HIM Functions. . . 1129 A Model for Quality Improvement . . . 1129 Change Management . . . 1132 Summary. . . 1134 Real-World Case . . . 1134 References. . . 1138 Additional Resources . . . 1138 Chapter 19 Envisioning the Future of the Health Information
Management Profession . . . 1139 Introduction. . . 1139 The e-HIM Transition . . . 1140 Changing Times: HIM and ICD-10-CM/PCS . . . 1142 Changing Times: HIM and Patient-Centered Care. . . 1143 Employment Outlook for HIM Professionals. . . 1144 HIM Expertise . . . 1145 Vision of the HIM Professional in the C-suite . . . 1148 Summary. . . 1149 References. . . 1151
Appendices, Glossary, and Index
Appendix A Sample HIM Position Descriptions . . . 1153
Appendix B Sample Notice of Health Information Practices . . . 1157
Appendix C Check Your Understanding Key . . . 1161
Glossary . . . 1177
Index. . . 1259
Nanette B . Sayles, EdD, RHIA, CCS, CHP, CPHIMS, FAHIMA, an associate profes- sor in the Health Information Management Program at East Central College in Union, Missouri, has a BS in medical record administration, an MS in health information manage- ment, a master’s in public administration, and a doctorate of education in adult education.
Dr. Sayles has more than 10 years of experience as a health information management prac- titioner with experience in hospitals, a consulting firm, and a computer vendor. She was the 2005 American Health Information Management Association Triumph Educator award winner. She has held numerous volunteer roles for the American Health Information Man- agement Association (AHIMA), the Georgia Health Information Management Associa- tion (GHIMA), the Alabama Association of Health Information Management (AAHIM), Middle Georgia Health Information Management Association (MGHIMA), and Birming- ham Regional Health Information Management Association (BRHIMA). These positions include: AHIMA Educational Strategies Committee, AHIMA co-chair RHIA Workgroup, GHIMA director, and president of MGHIMA. Dr. Sayles has published two books: Pro- fessional Review Guide for the CHP, CHS, and CHPS Examinations and Case Studies for Health Information Management. She is an editor for two chapters in the PRG Profes- sional Review Guide for the RHIA and RHIT Examinations.
Margret K . Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS, is presi- dent of Margret\A Consulting, LLC, in Schaumburg, Illinois, a consulting firm specializ- ing in computer-based patient records and associated HIM standards and regulations, such as HIPAA. She has more than 30 years of experience in national and international HIM.
A leading authority on electronic health record (EHR) strategies for healthcare organiza- tions, she has extensive experience in EHR selection and project management, and she formed and served as executive director of the Computer-based Patient Record Institute (CPRI). Other positions held include associate executive director of AHIMA, associate professor at the University of Illinois, and director of medical record services at the Illi- nois Eye and Ear Infirmary. She is a much sought-after speaker, has published extensively, and has earned several professional service awards. Amatayakul also serves as an adjunct faculty member of the College of St. Scholastica and the University of Illinois at Chicago.
Sheila Carlon, PhD, RHIA, FAHIMA, CHPS, has served as the director of the Division
of Health Services Administration at Regis University in Denver for twelve years. Prior
to that she was the HIM program director at Dakota State University in Madison, South
Dakota. Her industry experience includes consulting with Deloitte & Touche, HIM man-
agement at Stanford Hospital and Dominican Hospital in California, practice management
in California and additional HIM experience in various hospitals in Colorado. She has a
PhD in organization development from the Fielding Graduate Institute, an MS in health
services from San Jose State University, and bachelor’s degrees in health care management
and broadcast journalism and communications. She has served as chair of Education Strat- egy Committee for AHIMA, is on the CAHIIM Panel of Reviewers, and is a reviewer for Perspectives in HIM, and received the Educator’s Award in 2006. She is a frequent speaker on health information management and technology at the local, national, and international levels and is involved in international implementation of HIT in several countries.
Bonnie S . Cassidy, MPA, RHIA, FAHIMA, FHIMSS, was the 2011 President of AHIMA, serving as the Chairman of the AHIMA Board of Directors, and continues to serve on the Board as the 2012 Past President Director. Bonnie previously served on the AHIMA Board as a Director from 2006 to 2008. Bonnie is the Vice President of HIM Innovation for QuadraMed and previously served as the Vice President of HIM Product Management for QuadraMed. Bonnie is an AHIMA Academy ICD-10-CM/PCS Certifi- cate Holder and Ambassador.
Prior to joining QuadraMed, Bonnie served as an executive with the Certification Commission for Healthcare Information Technology (CCHIT). Bonnie is an experienced healthcare consultant and advisor, having worked for the national management consulting firms of Price Waterhouse and Ernst & Young, and she was an HIM administrator at two major teaching hospitals, including the Cleveland Clinic Foundation.
Bonnie was the president of the Ohio Health Information Management Association (OHIMA) and was honored to receive the OHIMA Distinguished Member Award. Ms.
Cassidy is the recipient of three AHIMA awards: Legacy Award, Volunteer Excellence Award, and Professional Achievement Award.
Lisa A . Cerrato, MS, RHIA, is the program coordinator of the health information man- agement technology department at Columbus State Community College (CSCC), in Columbus, Ohio. She received a BS in health information management administration from The Ohio State University. Upon graduation, Lisa became the director of the medical records department at Meridia Huron Hospital, part of the Cleveland Clinic Health System in Cleveland. She then earned an MS in allied health education. Lisa is now a full-time faculty member at CSCC. She led the development of CSCC’s online courses and certifi- cate programs in medical coding and medical transcription.
Chris Elliott, MS, RHIA, holds a master’s degree in information systems and has pursued significant graduate study in medical informatics at the University of Utah. He recently retired as director of health information services and privacy officer designee at San Fran- cisco General Hospital Medical Center after 40 years of public service in hospitals and health profession education settings.
Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, is a medical informaticist with Lan-
guage and Computing, Inc. In this position, she supports the ontology, modeling, sales,
and product development activities related to the creation and implementation of natural
language-processing applications where clinical terminology and classification systems
are utilized. Kathy has a comprehensive background in the field of clinical terminologies
and classification, with more than 30 years of experience in the health information man- agement (HIM) field. Prior to joining L&C, she was director of practice leadership with AHIMA in Chicago. Kathy has served as senior nosologist for a health information ser- vices company and worked in various HIM roles, including vice president of product development, education specialist, director of medical records, quality assurance coordi- nator, and manager of a Centers for Disease Control and Prevention research team. Kathy has developed classification, grouping, and reimbursement systems products for health- care providers; conducted seminars; and provided consulting assessments throughout the United States as well as in Canada, Australia, the United Kingdom, Ireland, and Bulgaria.
In addition, she has authored numerous articles and created online continuing education courses on clinical terminologies. As adjunct faculty at the College of St. Scholastica, she teaches the graduate-level course, Clinical Vocabularies and Classification Systems. In addition, she is actively involved as a volunteer in the HIM profession at the international, national, state, and local levels. Kathy holds a master’s degree in HIM from the College of St. Scholastica.
Laurinda B . Harman, PhD, RHIA, FAHIMA, Associate Professor Emeritus, Depart- ment of Health Information Management in the College of Health Professions and Social Work at Temple University in Philadelphia, has been an HIM professional and educator for over 40 years. She has directed HIM baccalaureate programs at Temple University, George Washington University in Washington, DC, and The Ohio State University in Columbus.
Dr. Harman was a faculty member in the health information technology program at North-
ern Virginia Community College and served as director of education and human resource
development for the Department of Health Care Sciences at George Washington Univer-
sity. She edited Ethical Challenges in the Management of Health Information in 2001,
the 2nd edition was published in 2006 and the 3rd edition is in progress. She contributed
chapters to Health Informatics Research: Practices and Innovative Approaches; Health
Information Management: Concepts, Principles, and Practice; and Health Information
Technology: An Applied Approach for the American Health Information Management
Association. Dr. Harman is on the editorial board of Perspectives in Health Informa-
tion Management, has contributed articles to the Journal of American Health Informa-
tion Management Association and has delivered presentations at international, national,
state and local association meetings on topics related to HIM and ethics. She received a
BS in biology with a concentration in medical record administration from Daemen Col-
lege in Buffalo, New York, an MS in education at Virginia Polytechnic and State Univer-
sity in Blacksburg, Virginia, and a PhD in human and organizational systems at Fielding
Graduate University in Santa Barbara, California. Dr. Harman received the AHIMA 2001
Triumph Legacy Award for Ethical Challenges in the Management of Health Information,
the 2011 Triumph Legacy Educator Award, and the 2011 Dorland Peoples Ethicist Award
for her textbook and its contribution to helping healthcare professionals deal with ever-
increasing ethical health information issues.
Anita C . Hazelwood, MLS, RHIA, FAHIMA, is a professor in the Health Informa- tion Management Department at the University of Louisiana at Lafayette and has been a credentialed registered health information administrator (RHIA) for more than 30 years.
Anita has actively consulted in hospitals, nursing homes, physician’s offices, clinics, facil- ities for the mentally retarded, and in other educational institutions. She has conducted numerous ICD-9-CM and CPT coding workshops throughout Louisiana for hospitals and physicians’ offices and has written numerous articles and coauthored chapters in several HIM textbooks. Anita has coauthored two books titled ICD-9-CM Coding and Reimburse- ment for Physicians’ Services and ICD-10-CM Preview for which she won AHIMA’s Leg- acy Award in 2003. Anita has been a member of AHIMA for 32 years and has served on various committees and boards. Anita is a member of the Louisiana Health Information Management Association (LHIMA) and was selected as its 1997 Distinguished Member.
She has served throughout the years as president, president-elect, treasurer, strategy man- ager, and board member and has directed numerous committees and projects.
Cheryl V . Homan, MBA, RHIA, is administrative director of information systems and biomedical engineering for the Lima Memorial Health System, located in Lima, Ohio.
She also serves as adjunct faculty for the Health Management Program at The Ohio State University at Lima. She received her MBA from Ashland University in Ashland, Ohio, and her BS in allied health professions from The Ohio State University. She has been an HIM professional for more than 30 years, served on AHIMA’s Board of Directors from 1997 to 1999, and is a former president of the Ohio Health Information Management Association.
Loretta A . Horton, MEd, RHIA, FAHIMA, received a medical record technician certifi- cate from Research Hospital and Medical Center and a bachelor’s degree in psychology from Rockhurst College, both in Kansas City, Missouri; a post-baccalaureate certificate in health information administration from Stephens College in Columbia, Missouri; and a master’s in education with an emphasis in curriculum and instruction from Wichita State University in Wichita, Kansas. She also has completed graduate work in sociology at the University of Nebraska in Omaha. Currently, Loretta is cochair of the Allied Health Department and coordinator of the Health Information Technology Program at Hutchinson Community College in Hutchinson, Kansas. Previously, she worked in a variety of health information settings, including acute care and mental health, and she has consulted with long-term care, mental retardation, home health, hospice, and prison systems. She is an AHIMA fellow.
Donald W . Kellogg, PhD, RHIA, CPEHR, is an assistant professor at University of Saint Mary in Leavenworth, Kansas, and is the coordinator of the bachelor of health science pro- gram as well as a faculty member in the health information technology program. He earned a bachelor’s degree in health information management at the University of Kansas Medical Center and his doctorate at the University of Kansas in higher education administration.
Kellogg has served the Kansas Health Information Management Association (KHIMA) as
a director for three years, a delegate to the AHIMA House of Delegates for four years, and
as President-Elect/President/Past-President as well as chairing multiple committees. He is a recipient of KHIMA’s Volunteer, Champion, and Achievement Awards. He was Kansas’s first liaison to the AHIMA Foundation and Community Education Coordinator (CEC), a state association leadership position on personal health record public outreach and edu- cation efforts. Kellogg has also served on AHIMA’s Educational Strategies Committee (ESC), for which he was chair in 2008; the “Increasing the RHIA-Credentialed Work- force” task force; and is currently a commissioner with the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
Bonnie J . Petterson, PhD, RHIA, recently formed HIM Educational Consulting after retirement as director of HIM programs at Phoenix College, part of the Maricopa Com- munity Colleges in Phoenix, Arizona. She has been a full-time HIM educator for over 25 years, serving first at the health information administration level and then working with health information technology and certificate students. In addition, she has held full-time positions as a health information manager in an acute care hospital, a home health care agency, and in a psychiatric care setting and consulted in ambulatory care, home health care, and long-term care. Petterson is coauthor of a textbook titled Using the Electronic Health Record in the Healthcare Provider Practice from Cengage Learning. She is a past Chair of AHIMA’s Commission on Certification for Informatics and Information Man- agement (CCHIIM), its Research Committee and the AOE Program Committee, and has served on the Education Strategy Committee as well as several AHIMA task forces. She has volunteered for a variety of roles in state health information associations, including election as an AHIMA delegate from both Wisconsin and Arizona. Petterson was the recip- ient of the mentor and the lifetime achievement awards from the state of Arizona. She holds a PhD in educational leadership and policy studies from Arizona State University and an MS in educational psychology and a BS in health information administration from the University of Wisconsin-Milwaukee.
Laurie A . Rinehart-Thompson, JD, RHIA, CHP, is an associate professor of clinical allied medicine in the Health Information Management and Systems program at The Ohio State University in Columbus. She earned her BS in medical record administration and her law degree from The Ohio State University. In addition to education, her professional experiences include behavioral health, home health, and acute care. She has served as an expert witness in civil litigation testifying as to the privacy and confidentiality of health information. She has served and continues to serve on AHIMA committees and is on the Board of Directors of the Ohio Health Information Management Association. A frequent speaker on the HIPAA privacy rule, she is a contributing author of Ethical Challenges in the Management of Health Information (AHIMA and Jones and Bartlett 2006) and Docu- mentation in Medical Practices (AHIMA 2011). She is a coeditor of Fundamentals of Law for Health Informatics and Information Management (AHIMA 2009).
Jane Roberts, MS, RHIA, is an associate professor in health information management
technology at Columbus State Community College, in Columbus, Ohio. She received a BS
degree from The Ohio State University in 1988 and an MS degree in 2004. Her prior work experience includes director of medical records in acute care facilities, supervisor of medi- cal records in a long-term care facility, and office manager in a physician office setting.
Karen S . Scott, MEd, RHIA, CCS-P, CPC, has more than 20 years’ experience in the healthcare field. Karen is the sole proprietor of Karen Scott Seminars and Consulting.
She has been an educator for many years, including teaching in the health information management programs at the University of Tennessee Health Science Center and Arkan- sas Tech University. She has worked as an HIM director in an acute care hospital setting, training director for a national transcription company, and reimbursement specialist for a regional physicians’ group. She holds a BS degree in health information management and a master’s degree of education in instructional technology from Arkansas Tech University in Russellville. She is past president of both the Tennessee and Arkansas Health Infor- mation Management Associations and is past chair of the AHIMA Council on Certifica- tion. Karen has won several awards, including the Tennessee Innovator Award. In 2005, THIMA recognized Karen for her achievements with its Distinguished Member Award.
Karen teaches seminars on coding, reimbursement, medical terminology, and management throughout the country for physician and hospital audiences. She has published numerous articles on various healthcare topics including chapters in HIM and coding textbooks. The 3rd edition of her textbook, Coding and Reimbursement for Hospital Inpatient Services, was published in 2010.
Marcia Y . Sharp, EdD, MBA, RHIA, is an assistant professor in the Department of Health Informatics and Information Management at the University of Tennessee Health Sciences Center. She has had an outstanding career in health information management and in human resource management. She is an active member of the Memphis Health Infor- mation Management Association, serving as former treasurer, and the Tennessee Health Information Management Association, serving as TN delegate to the AHIMA House of Delegates, and former member of the TN Nominating Committee. She is currently a member of the editorial review panel for Perspectives in Health Information Management (PHIM). She has contributed chapters to several AHIMA publications, Health Informa- tion Management Technology: An Applied Approach, and Fundamentals of Law for Health Informatics and Information Management.
Martin Smith, Med, RHIT, CCA has served as a professor in the HIM programs
at Hodges University in Naples, Florida, the Allen school in Brooklyn, New York, and
St. Petersburg College in St. Petersburg, Florida, for more than nine years. He has man-
aged several HIM programs in addition to serving as faculty. Prior to this he was a
police constable in London, working for New Scotland Yard, and a combat medic in the
US Army. He received his undergraduate degrees from St. Petersburg College and Ameri-
can Intercontinental University (AIU) before earning a master’s degree in education with
a concentration in instructional technology from AIU. He completed the healthcare infor-
matics graduate certificate program at the College of St. Scholastica in Duluth, Minnesota,
and is currently completing his master’s degree in health information management at the same school. He has authored several articles on healthcare topics and in 2011 completed his service as the cochair of the Florida Health Information Management Association (FHIMA) legislative committee after being voted to the board of directors in 2009. He has attended several Hill Day events in Tallahassee, Florida, and is a vocal advocate of the HIM profession. He has served at the local level on FHIMA’s bridging the gap and find, inspire, recruit, educate (FIRE) mentoring committees and regularly visits local middle and high schools to talk about the profession. He is currently teaching and mentoring the next generation of HIM professionals at Hodges University.
Carol A . Venable, MPH, RHIA, FAHIMA, is a professor and department head of HIM
at the University of Louisiana at Lafayette and has been an HIM professional for nearly
30 years. She is actively involved with AHIMA’s Assembly on Education (AOE), Panel of
Accreditation Surveyors, and several other committees, as well as the Louisiana Health
Information Management Association, where she has held many leadership positions and
was selected as Distinguished Member in 1991. In addition, she is a member of the Soci-
ety for Clinical Coding (SCC). Previously, she was director of medical records at Lafayette
General Medical Center, has consulted in a variety of healthcare facilities and educational
institutions, and conducts coding workshops for hospitals and physician offices. Venable
has written, coauthored, and edited numerous publications, including AHIMA’s ICD-9-CM
Diagnostic Coding and Reimbursement for Physician Services and ICD-10-CM Preview,
for which she was awarded AHIMA’s Legacy Award in 2003. She frequently serves as
a reviewer for publishers of HIM-related textbooks, certification exams, and electronic
materials.
Health information management (HIM) professionals are an integral part of the healthcare team. They serve the healthcare industry and the public by using best practices in manag- ing healthcare information to support quality healthcare delivery. Whether stored on paper or in electronic file form, reliable health information is critical to high-quality healthcare.
Enhancing individual patient care through timely and relevant information is one of the primary goals for the HIM profession.
The American Health Information Management Association (AHIMA) represents more than 64,000 HIM professionals who work throughout the healthcare industry.
AHIMA has a long history of commitment to HIM education. Among other contribu- tions, AHIMA has developed and maintained a rigorous accreditation process for aca- demic programs, continuously developed up-to-date curriculum models, supported faculty development, and continued to research and study the needs and future directions of HIM education.
This text, specifically developed for associate degree programs in health information technology (HIT), is an outgrowth of AHIMA’s ongoing effort to provide rich resources for the education and training of new HIM professionals. In addition, it offers a ready resource for current practitioners. Its subject matter is based on AHIMA’s HIM Associate Degree Program Entry-Level Competencies and Knowledge Clusters and AHIMA’s RHIT certification examination content domains. Following the prescribed curricular content found in the HIM Associate Degree Entry-Level Competencies, the text covers informa- tion and topics considered essential for every entry-level HIT practitioner. Although the text is directed primarily at students enrolled in two-year HIT programs, students in other HIM disciplines and allied health programs also will find its content highly useful.
The fundamental organization of the text is built on the curricular content of the HIM Associate Degree Entry-Level Competencies and Knowledge Clusters. Each of the con- tent areas is represented in the book except those relating to the biomedical sciences and to technical aspects of classification systems such as ICD. To provide maximum flexibility for instructional delivery, the content of each chapter is designed to stand on its own, pro- viding maximum coverage of specific domains and competencies. Because of the inter- dependency of content areas that support knowledge and skills for performing many of the competencies, this approach has necessitated duplication of some material throughout the text. In these cases, the predominant content is covered in depth and is supplemented by a high-level overview of other supporting knowledge. Where appropriate, students are referred to other chapters for additional information or detail to round out necessary knowledge.
The organizing framework for content of the text is arranged in order by the five
domains contained in the HIM Associate Degree Entry-Level Competencies and the
RHIT certification examination. This organization does not presuppose a pedagogical
progression of presenting basic foundations and then progressing to advanced concepts.
Therefore, given its student population, mission and goals, and other variables, each aca- demic program must assess the appropriate sequence of presentation of the chapters within its curriculum. Additional information and models of chapter sequencing can be found in the instructor’s manual.
The book’s underlying structure is to translate basic theory into practice. A review of the cognitive and competency levels of the Entry Level Competencies reveals that HIT programs are applied in nature. Outcome expectations are that students understand theory at a basic level with a major emphasis on skill building to perform day-to-day operational tasks in health information management.
Therefore, the features used throughout the book focus on translating basic theory into practice. To accomplish this, each chapter contains the following sections:
●
Theory into Practice: Located at the beginning of each chapter, this section pre- sents a case study that serves as an organizing framework for the theory presented in the chapter. This instructional design strategy “sets the stage” and “gains the learner’s attention,” two of the first and most basic steps in instructional design.
●
Check Your Understanding: These sections are content review exercises. These exercises are positioned throughout each chapter so that students can reinforce their understanding of the concepts they have just read before going on to the fol- lowing concepts. Multiple-choice, matching, and true-and-false formats are used.
●
Real-World Case: Located near the end of each chapter, this section presents an actual situation faced by healthcare enterprises as reported in current literature and periodicals. The case supports the preceding instruction and moves toward selec- tive perception.
Features in the accompanying workbook include:
●
Real-World Case Discussion Questions: The questions in this section are designed to initiate discussion of and elaboration on the concepts presented in the Real-World Case.
●
Application Exercises: The purpose of these exercises is to give students the opportunity to put theory into practice. Because skill building is an important part of the expected outcomes for HIT students, these exercises will bring the real world into their sphere.
●
