Ahimajournal 2014 09 DL

SEPTEMBER 2014
Healthcare
DIY
EMPOWERING CONSUMERS TO OPTIMIZE THEIR

HEALTHCARE THROUGH HEALTH INFORMATION
Welcome
TO THE DIGITAL EDITION OF THE
JOURNAL AHIMA
OF
The Role of Informatics in Healthcare
Anupam Goel, MD, MBA, vice president of clinical information

at Advocate Health Care and a board certified health informatician,
explains how informatics intersects with HIM.
Sign Up Today for the 86th AHIMA Convention and Exhibit

September 27 to October 2 | San Diego, CA
www.ahima.org/convention
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Contents September 2014
Cover
20
Healthcare DIY
Empowering consumers to optimize their healthcare

through health information
By Mary Butler; Illustration by Marla Campbell
Vol. 85, no. 9

Departments
10
Presidents Message
Personal Health Information is
Saving Grace
12
Bulletin Board
pg. 44
AHIMAs 86th Convention and Exhibit kicks off in San Diego, CA, this month.
Features
26
Healthcare On Demand
An expanding world of telemedicine raises
new questions for HIM professionals
By Lisa A. Eramo
32
Who Are You?

Authenticating consumer identity is becoming increasingly important in healthcare
By Tim McKay, PhD, CISSP
40
HIPAAs Place in Court-Ordered Discovery

Determining whats legal during litigation
health record requests
By Ron Hedges, JD, and Kevin Brady, Esq
In Addition
44
2014 AHIMA Convention Preview
16
Word from Washington

Health Intelligence Revolution Coming to
Long-Term and Post-Acute Care
19
Inside Look
Meeting the Needs of Increasingly
Connected Consumers
78
Calendar
79
Keep Informed
80
Volunteer Leaders
84
AHIMA Career Center
88
Addendum
Fast As You Can

Working Smart
48
54
By Harry Rhodes, MBA, RHIA, CHPS, CDIP,

CPHIMS, FAHIMA
By Diana Warner, MS, RHIA, CHPS, FAHIMA
Navigating Privacy and Security

Accessing and Using Data from
Wearable Fitness Devices
Standards Strategies
Why Standards Should Matter
to HIM Professionals
56
52
e-HIM Best Practices

How and Why to Preserve
Health Records During Litigation
The Sound Record

Curing Inherited EHR Ailments
By Michelle Wieczorek, RN, RHIT, CPHQ, and Jill S.

Clark, MBA, RHIA, CHDA, FAHIMA
By Ron Hedges, JD
Coding Notes
Quizzes
68
AHIMA members may earn continuing

education credits by successfully completing
the following quizzes in this issue.
ACA Risk Adjustment Models Emerge in

Commercial Care
By Janet Franklin, RHIT, CCS, CCS-P, CHC
72
Coding ICD-10-PCS Procedures in the Ancillary

Sections
Understanding Physical Rehabilitation and
Diagnostic Audiology, Mental Health, and
Substance Abuse Treatment
By Karen Kostick, RHIT, CCS, CCS-P, and Gina Sanvik, RHIA
Practice Brief
60
Defining the Basics of Health Informatics for

HIM Professionals
4/Journal of AHIMA September 14
30
Domain: Technology
38
Who Are You?

Domain: Privacy and Security
76
Coding ICD-10-PCS Procedures in the Ancillary

Sections: Understanding Physical Rehabilitation and
Diagnostic Audiology, Mental Health, and Substance
Abuse Treatment
Domain: Clinical Data Management
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http://journal.ahima.org
Patient Engagement
Initiatives and the Future
of HIE Marc Perlman, global
vice president for healthcare,
life sciences, and education
and research industries at
Oracle, discusses his work
on the Patient Engagement
Framework and the future of
HIE.
Video: The Role of Informatics in

Healthcare Anupam Goel, MD, MBA, vice
president of clinical information at Advocate Health

Care and a board certified health informatician,
explains how informatics intersects with HIM.
Live AHIMA Convention Coverage
Keep up on the latest news coming out of the 86th

Annual AHIMA Convention and Exhibit, taking place
September 27 to October 2 in San Diego, CA.
Share and Connect with AHIMA

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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

CONTRIBUTING EDITORS

`

Mary Butler
Sue Bowman, MJ, RHIA, CCS, FAHIMA
Patricia Buttner, RHIA, CCS
Angie Comfort, RHIT, CDIP, CCS
Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA
Julie Dooling, RHIA
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
Paula Mauro
Anna Orlova, PhD
Kim Osborne, RHIA, PMP
Harry Rhodes, MBA, RHIA, CHPS
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
EDITORIAL ADVISORY BOARD

Linda Belli, RHIA

Gerry Berenholz, RHIA, MPH
Carol A. Campbell, DBA, RHIA
Rose T. Dunn, CPA, RHIA, FACHE
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, FAHIMAc
ADVERTISING REPRESENTATIVES
Network Media Partners
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(410) 584-1940; Fax: (410) 584-8353
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bsullivan@networkmediapartners.com
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AHIMA ONLINE: www.ahima.org
JOURNAL OF AHIMA: journal@ahima.org
JOURNAL OF AHIMA MISSION
The Journal of AHIMA serves as a professional development tool
for health information managers. It keeps its readers current on
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
healthcare settings. Finally, the Journal contains news on the work
of the American Health Information Management Association.
EDUCATIONAL PROGRAMS
The Commission on Accreditation for Health Informatics and
Information Management Education (www.cahiim.org) accredits
degree-granting programs at the associate, baccalaureate, and
masters degree levels.
AHIMA recognizes coding certificate programs approved by the
Approval Committee for Certificate Programs. For a complete list of
AHIMA-approved coding programs and HIM career pathways go to
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
graduate members, and $10.00 for student members. Subscription for nonmembers is $100 (domestic), $110 (Canada), $120 (all other outside the U.S.). Postmaster: Send address changes to Journal
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Notice of Policy
Editorialviews expressed in articles contributed to the Journal of AHIMA are those of the author(s) and do not necessarily reflect the policies and opinions of the Association, editorial review
board, or staff. Articles 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 2014 American Health Information Management Association Reg. US Pat. Off.
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Presidents Message
Personal Health Information is

Saving Grace
By Angela C. Kennedy, EdD, MBA, RHIA
AS A HEALTH informatics and information management professional and a

parent of two adopted children, my desire for complete and accurate medical
information rocks the top of my Mom
to-do list. My children, Zach and Grace,
are siblings, adopted at the ages of two
and four. State laws vary on the provision
of medical information and the provision
of family medical history to parents of
adopted children. We acquired a limited
medical history for each child and almost no family medical history. Through
diligent searching, I have been able to
access additional information and recreate missing medical information through
claims data.
My children have been treated for asthma and allergies most of their lives. With
each visit Im quick to tell every physician and medical professional that we
encounter that my children are adopted
and I dont have a family medical history for them. This is a statement that I
have always believed to be valuable to
the care and treatment of my children,
but recently the impact of that statement
and the importance of carefully maintaining their personal health information has
become paramount.
In January, at the request of my physician, we changed asthma and allergy
specialists. After a review of Zach and
Graces past medical history, the physician requested a follow up appointment
for additional allergy testing. The second
visit changed our world forever. With no
known family history of autoimmune disease, Grace was sent for a sweat test as
a precaution when she failed to respond
to the allergy testing.
Grace was diagnosed with cystic fibrosis at the age of 11. Cystic fibrosis
is usually diagnosed shortly after birth.
Grace was immediately seen by a pulmonary pediatric research specialist at
Texas Childrens Hospital. Armed with

a thumb drive and a five-inch binder of
medical informationwhich included
copies of every pulmonary function test
and every doctors visit since she was
twowe presented for our first visit.
When we returned for the second visit,
our physician had analyzed the data and
concluded that Grace never had asthma
or allergies and removed her from those
medications. Her analysis of the data
also helped her determine a correlation
between seasons and when Graces pulmonary functions declined, finding that
past episodes that were labeled upper
respiratory infection were due to her
lungs not clearing properly during periods of lower activity.
Genetic testing revealed that she has a
rare form of cystic fibrosis. Her plan of
treatment focuses on wellness. Grace
wears a Nike FuelBand to track her levels of activity. The data collected helps
to keep Grace well. When you meet my
daughter, she appears to be the picture
of wellness. Thats a picture that we want
to see every day, a picture that tracking
data helps us to keep.
Todays models of healthcare demand
a commitment to wellness. The Blue
Button Pledge aims to encourage consumers to access and use their health
information to meet health goals. AHIMA
supports the Blue Button Initiative, and I
encourage you and your organization to
take the pledge. Be an advocate for the
use of personal health information. Create opportunities at your organization to
educate consumers on the benefits of
personal health information. And, as always, dream big, believe, and lead!
Angela Kennedy (angela.kennedy@ahima.org) is
head and professor, department of health informatics and information management, at Louisiana Tech University.
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Bulletin Board whats happening in healthcare
FDA Announces End to Medical Device Regulation Enforcement

Hoping to spur, and not hamper, innovation with medical device data
systems (MDDS), the US Food and
Drug Administration (FDA) announced
that it will no longer enforce regulations placed on the technology. The
new policy outlined in draft guidance
released June 20 is a reversal from
previous FDA positions as recently as
January 2011, when they considered
medical devices and software that
enable the flow and storage of health
data to be high risk.
The new guidance states that because MDDS now pose such a low
risk to the public, the FDA will not enforce compliance with the regulatory
controls that apply to MDDS devices,
medical image storage devices, and

medical image communications devices, said Bakul Patel, senior policy
advisor at the FDAs Center for Devices and Radiological Health, who
helped draft the policy.
The shift in policy started in February 2011 when the FDA issued a regulation down-classifying MDDS from
high risk to low risk. Since 2011
the FDA has been working with the
Office of the National Coordinator for
Health IT (ONC), the Department of
Health and Human Services, and the
Federal Communications Commission (FCC) on a proposed risk-based
regulatory framework for health IT
that promotes innovation, protects
Initiatives Ease Accessing, Exchanging

Mental Health Data
Two separate pilot projects have attempted to make mental health information more accessible to patients
and to other healthcare providers.
The first project involved a consortium of states including Alabama,
Florida, Kentucky, Michigan, New
Mexico, Nebraska, and Iowa, working in conjunction with the Office of
the National Coordinator for Health IT
(ONC) and the Substance Abuse and
Mental Health Services Administration.
The pilot was intended to address
legal and technical barriers to exchanging healthcare information and
to create policies and procedures
that could be replicated in other
states and regions, according to the
authors of a report issued on the pilot.
As ONC officials pointed out in a
blog post about the pilot, many providers are interested in electronically
exchanging behavioral health data,
but federal and state laws present
significant barriers.
Highlights from the report include

a set of policies and procedures
that can be used by providers to exchange behavioral health information
with other providers in different states
using Direct exchange protocols, a
description of multiple efforts to test
and execute the policies and procedures, and educational materials for
providers who want to electronically
exchange behavioral health data.
Another pilot program involves 700
mental health patients at Beth Israel
Deaconess Medical Center in Boston, MA, who are able to view office
visit notes written by their therapists, which include licensed clinical
social workers, psychologists, and
psychiatrists. According to the New
York Times, the Beth Israel pilot grew
out of the OpenNotes Project, which
more readily gives patients access to
their physicians office notes. Despite
some reservations from doctors,
OpenNotes has shown to increase
patient engagement in their care.
patient safety, and avoids regulatory

duplication, Patel wrote in a blog post
discussing the new policy.
During the course of that work on
the proposed framework, the FDA received feedback from industry stakeholders that their regulations were too
restrictive and that they were tamping
down innovation in the field. Today,
given the low level of patient risk, we
are proposing a compliance policy
under which medical device data
systems should see their burdens reduced, Patel wrote.
A key concern was that the oversight
was limiting the ability for devices to
be interoperable with various types of
health information technology. The
Patient Engagement a
Focus of Most Wired
Hospitals
The nations most wired hospitals
have their sights set on expanding
patient engagement, according to the
16th annual Most Wired Survey, conducted by Hospitals and Health Networks in partnership with the American
Hospital Association, CHIME, McKesson, and AT&T. The data collected from
the 375 hospitals offers insight into how
they currently use health IT to support
care, plans they have for the future, and
challenges they have faced. Many of
the hospitals are currently looking at
further developing patient engagement
efforts, an area of increasing focus as
the US healthcare landscape continues
to evolve. According to the survey:
82 percent of hospitals allow patients
to check test results via a portal
53 percent offer self-management
tools via portals for patients with
chronic conditions
58 percent offer an mHealth app
with portal access
[FDA] recognizes that the progression

to digital health offers the potential
for better, more efficient patient care
and improved health outcomes. To
achieve this goal requires that many
medical devices be interoperable with
other types of medical devices and
with various types of health information technology, the draft FDA guidance states. The foundation for such
inter-communication is hardware and
software that transfer, store, convert
formats, and display medical device
data or medical imaging data.
The change in policy will allow developers of MDDS to focus on making these products better able to operate amongst various devices and
technology systemsresulting in
stronger products, the policy states.
[The] FDA believes that this [policy]
will encourage greater innovation in
the development and maturation of
these systems.
MDDSs are off-the-shelf or custom
hardware or software products that
transfer, store, convert, format, and
display medical device data without
modifying it, and without controlling
or altering the functions or parameters
of any connected medical devices.
These systems can be used in hospitals to collect information from bedside monitors and infusion pumps, for
example, then store the data in a patients electronic health record.
Consumers Trust Hospitals More When It

Comes to Personal Data
A recent survey administered by analytics software company FICO found that
smartphone users have higher trust in hospitals than other industries when it
comes to protecting their personal data. The survey asked respondents to rank
the level of trustlow trust, neutral, or high trustthey had in various industries, including hospitals, banks, insurance companies, government services,
retailers, social networks, and others. Hospitals came in ahead of banks by
two percent for the largest number of high trust responses in the survey.
Social networks received the lowest marks from survey respondents.
Percentage of Respondents with High Trust for Data Protection

60
n
50
Hospital
n Banks
40
n Insurance Companies
30
Major Retailers
Social Networks
20
10
0
56%
54%
42%
34%
17%
The Centers for Medicare and Medicaid

Services has issued a final rule that sets
October 1, 2015 as the new implementation date for ICD-10-CM/PCS.
The Journal of AHIMA won four awards in
the Upper Midwest Region category
from the American Society of Business
Publication Editors: a Gold Award for Editorial Excellence/Government Coverage, a Silver Award for Online Excellence/How-To Tips, a Silver Award for
Online Excellence/Video Tutorial, and a
Bronze Award for Graphics Excellence/
Opening Page Spread/Illustration.
Google has partnered with Novartis on
developing smart lens technology,
originally intended to continuously
monitor glucose levels through tear
fluid in the eye.
Italian cruise line MSC Cruises will offer
24/7 pediatric telemedicine services
for guests on board beginning this fall.
The American Academy of Family Physicians
Center for Health Information Technology
plans to focus efforts on helping members optimize electronic health record
technology.
The University of California, Los Angeles
plans to develop and use online and
mobile applications to support treatment for addiction or depression.
Johns Hopkins Medicine and Kaiser Permanente have formed a partnership to
share electronic health record adoption
best practices.
Investment company Rock Health
recently reported that venture capital
funding for healthcare information
technology companies will reach $2.4
billion in 2014, well beyond the $1.9
billion that was invested in health IT in
2013.
A new survey from Black Book has
found that 71 percent of US hospitals
plan to hire consultants to aid with
their transition to ICD-10-CM/PCS by
October 2015.
Source: Fair Isaac Corporation. Mobile Thought Leadership Survey. 2013. http://www.fico.com/mobileiq/.
Journal of AHIMA September 14/13
Bulletin Board whats happening in healthcare
ONC Renews Efforts to Promote Use of Blue

Button
REDIRECTING INNOVATION IN U.S. HEALTH
CARE: OPTIONS TO DECREASE SPENDING AND
INCREASE VALUE
http://www.rand.org/content/dam/
rand/pubs/research_reports/RR300/
RR308/RAND_RR308.casestudies.
pdf#page=49
A report from the RAND Corporation
found that there are several technologies that could significantly improve
health outcomes and lower costs for
patients. The report cites interoperability as an issue that stands in the way
of obtaining this goal, including some
systems that specifically stand in the
way of information sharing. Eight case
studies are included in the report.
THE EFFECT OF THE ELECTRONIC TRANSMISSION OF PRESCRIPTIONS ON DISPENSING ERRORS AND PRESCRIPTION ENHANCEMENTS
MADE IN ENGLISH COMMUNITY PHARMACIES:
A NATURALISTIC STEPPED WEDGE STUDY
http://qualitysafety.bmj.com/
content/23/8/629?etoc
A study in BMJ Quality and Safety
finds that e-prescriptions do not
necessarily result in fewer prescription
errors than paper-based prescriptions.
Researchers examined labeling errors,
content errors, and pharmacist label
enhancements for prescriptions in 15
community pharmacies in England for
the study. E-prescriptions had labeling
errors for 7.4 percent of items while
4.8 percent of paper prescriptions had
labeling errors, according to the study.
There was no difference for the other
factors examined.
E-PRESCRIBING TRENDS IN THE UNITED
STATES
http://healthit.gov/sites/default/files/
oncdatabriefe-prescribingincreases2014.pdf
A Data Brief from the Office of the National Coordinator for Health IT (ONC)
shows that e-prescribing is on the rise
in the US. Marking significant growth
in e-prescribing since 2008, ONC
reports that 70 percent of physicians
were using the e-prescribing function
with an electronic health record as of
April 2014.
This month the Office of the National

Coordinator for Health IT (ONC) will
launch a national campaign to increase
awareness and consumer use of Blue
Button technology, which gives patients the ability to electronically access their health records.
The national Blue Button campaign
will run from September 15 to October
6 and will include public service announcements posted on partner websites that explain how to offer or use
Blue Button and the consumer benefits
of doing so. AHIMA will run the public service announcements on www.
ahima.org as well as on its consumerfacing website myPHR.com.
Blue Button was originally launched
in 2010 by the Department of Veterans Affairs, the Centers for Medicare
and Medicaid Services (CMS), and the
Department of Defense as a way for
patients and their caregivers to easily
view, download, share, and use their

personal health information. The initiative has expanded to provider organizations, health plans, and pharmacies
since then, and ONC is now working
to provide every healthcare consumer
access to their records through the initiative, according to an article in Health
Data Management.
Expanding Blue Button to more providers would also bolster stage 2 of the
meaningful use EHR Incentive Programthe CMS initiative that requires
providers to give patients the ability
to electronically view, download, and
transmit their health data via the Internet. In the near future CMS also hopes
third-party developers will build apps
and other tools connected to Blue Button that will collect, present, and share
data that makes health information
more actionable for patients, according to Health Data Management.
Electronic Messaging Provides Pitfalls,

Opportunities
Patients and physicians are increasingly using secure messaging platforms to communicate between in-person visits, thanks to federal health IT
initiatives. But cultural differences and
lack of reimbursement for this activity
is preventing wider adoption, experts
say.
Approximately 41 percent of hospitals were able to send and receive secure messages in 2013, according to
the Office of the National Coordinator
for Health IT (ONC), while Centers for
Disease Control and Prevention statistics note similar rates for physicians,
Modern Healthcare reported. Low
rates of adoption of electronic messaging among minorities and the elderly is
due partially to fears that secure messaging might not just be complementary to a physician visit, but replace
face-to-face time with doctors.
Experts expect secure messaging to

become more popular and pervasive
as initiatives such as the meaningful
use EHR Incentive Program doles out
payments to physicians and hospitals
that meet secure messaging targets.
For consumers whose usual provider
doesnt offer such services yet, theres
First Opinion, a smartphone application that matches users to physicians.
First Opinion allows patients to text
message a medical doctor at any time
of the day or night, semi-anonymously, according to McKay Thomas, First
Opinions founder.
The physicians who respond to First
Opinion users are not allowed to prescribe medications over text message,
nor do they diagnose consumers. What
they can help with is determining how
urgently an individual needs to see a
doctor in person.
NIH Launches Initiative to Harness Big Data

The National Institutes of Health (NIH)
has launched an initiative that asks
healthcare industry stakeholders to
help scale and mine the mountain of
Big Data created each day by healthcare organizations in order to improve
care.
The Big Data to Knowledge Initiative aims to engage stakeholders like
biomedical researchers, patients, clinicians, data scientists, and publishers
to design studies and conduct data
analyses that address Big Data issues,
train Big Data practitioners to tame and
use the currently unwieldy information,
and create data-discovery capabilities
for biomedical data, according to an
article published by NIH officials in the
Journal of the American Medical Informatics Association.
Currently the use of biomedical data
is limited because of a lack of tools,
accessibility, and training, according to
the article. The Big Data to Knowledge
Initiative hopes to overcome these barriers. One of the first projects of the
initiative is to create a Data Discovery
Index (DDI), where stakeholders will be

asked to conduct short-term trails to
find best practices for indexing existing datasets, according to an article in
FierceHealthIT.
Inherent in data discovery is the
need for a sustainable and scalable
plan to create and maintain a discovery
system that allows researchers to readily find and cite biomedical data, the
authors wrote, according to an article
in iHealthBeat. Indeed, sustainability
and scalability are two intertwined issues that must be addressed in order
for the advances made possible by
[this initative] to have a lasting effect.
Creating a DDI is a required first step
that will enable the discovery of relevant, existing datasets through the
use of metadata and index terms, the
article said.
According to NIH officials, the Big
Data to Knowledge Initiative will also
offer workshops and grants, and create conversations among thought
leaders on ways to best leverage and
use Big Data.
CMS Proposes Changes to ACO Quality

Measures
The Centers for Medicare and Medicaid Services (CMS) has proposed
changes to quality measures that evaluate accountable care organizations
(ACOs) and Medicare shared savings
program (MSSP) participants. The proposed modifications will increase the
number of quality measures from 33 to
37, with 12 new measures being added
and eight being eliminated, according
to CMS.
The new metrics from CMS shift the
focus of the quality measure program
from process to outcomes. For example, according to Medscape, one
new measure estimates the risk-standardized rate of all-cause, unplanned,
hospital readmissions for patients who

have been admitted to a skilled nursing facility within 30 days of discharge
from a prior inpatient admission to a
hospital, [critical access hospital], or a
psychiatric hospital.
Some of the proposed measures
evaluate the rate of all-cause, unplanned admissions for patients with
diabetes mellitus, heart failure, and
multiple chronic conditions.
Additionally, CMS is proposing
changes to medication reconciliation
practices in electronic health records,
and is now asking ACO staff to discuss
prescription medication costs with patients.
IMPLEMENTING HEALTH INFORMATION

GOVERNANCE
www.ahimastore.org/ProductDetailBooks.aspx?ProductID=17528
Available for pre-order, this book from
AHIMA Press outlines lessons from
healthcare organizations that have
made progress in formalizing information governance. Authored by former
AHIMA CEO Linda L. Kloss, MA, RHIA,
FAHIMA, the text includes practices for
aligning governance to organization
goals, organizing and staffing governance and enterprise management,
building on what is working, and guiding incremental information governance
improvement.
CLINICAL DECISION SUPPORT COULD CUT
WAIT TIMES
www.genevahealthcare.com/suite
A clinical decision support module
from Geneva Healthcare standardizes
patients cardiac device data within a
dashboard that is accessible anywhere
at any time. The dashboard enables
management of remote monitoring,
clinical uploads, and interrogations, and
can be accessed remotely or within a
providers electronic health record. Clinicians at the University of CaliforniaSan Diego Medical Centers emergency
department were able to cut wait times
by an average of 92 minutes using the
Geneva Healthcare Suite.
CLINICAL QUALITY MEASURE TESTING TOOL
https://bonnie.healthit.gov/
The Office of the National Coordinator for Health IT has updated the Bonnie Clinical Quality Measure Testing
Tool, developed to support pretesting
of electronic clinical quality measures
for the meaningful use EHR Incentive Programs and co-sponsored by
the Centers for Medicare and Medicaid
Services.
Health Intelligence Revolution Coming to

Long-Term and Post-Acute Care
By AHIMAs Advocacy and Policy Team
Health information and health intelligence are beginning to have an impact

on the daily lives and health of everyone.
Technology-enabled, person-centered
care is taking hold and transforming the
healthcare delivery system, enabling accountability for the patient and challenging providers to incorporate new types of
data into the health record. This was the
message of the keynote session of the
10th annual Long-Term and Post-Acute
Care (LTPAC) Health IT Summit, held this
June in Baltimore, MD.
AHIMA partnered with the LTPAC Health
IT Collaborative and strategic partners to
host the summit, which brought together
over 250 key stakeholders, policymakers, researchers, and other professionals
from across the spectrum of healthcare
to collaborate on healthcare strategy and
address issues facing the LTPAC care
setting. This two-day summit is the only
one of its kind, with thought-provoking,
interactive sessions, panel presentations, poster sessions, and exhibits.
One key highlight of the summit was
the LTPAC Interoperability and Innovation Showcase. This unique open forum
consisting of multiple interactive sessions highlighted innovative approaches to health information exchange with
standards-based technology. Of particular interest was the impact of health information exchange on health outcomes,
cost, quality of care, utilization, and hospital readmissions.
Health intelligence was the topic of the
opening keynote presented by Patricia
Flatley Brennan, PhD, RN, the Lillian L.
Moehlman Bascom professor for the
school of nursing and college of engineering at University of Wisconsin-Madison and program director for Project
HealthDesign. Brennan explained that
healthcare outcomes will be improved
through data-driven information from
technology and tools. The abundance of

data created from health IT provides significant opportunities for its analysis and
transformation into health intelligence.
Brennan was joined by Michael S.
Weiner, DO, MSM, MSIST, director of
healthcare strategic services at IBM, in
a panel presentation on the health intelligence revolution. Together they explored
the latest developments and tools in
quality measurement, cognitive computing tools, analytics, and governance. The
proliferation of health IT data provides
opportunities for improved health outcomes when that data is captured, managed, and analyzed to create knowledge
and support decision making. Information governance in healthcare is also an
essential tool in the management of accumulated health data.
David R. Hunt, MD, FACS, medical director of health IT adoption and patient
safety at the Office of the National Coordinator for Health IT (ONC), shared
how the LTPAC community can leverage
the current regulatory conditions and
the Centers for Medicare and Medicaid
Services meaningful use EHR Incentive Program to advance the continuity
of care and reduce hospital readmissions. ONC has developed tools to help
consumers and issued guidelines and
recommended strategies for providers
in the hope of advancing interoperable
electronic healthcare.
Even though stimulus dollars from the
ARRA-HITECH Act were not allocated to
LTPAC, standards in health IT have had a
positive impact on the safety, efficiency,
and quality of the delivery of healthcare
in the LTPAC community.
Other popular topics at the LTPAC
Summit included policy and legislative
updates, payment and service delivery
reforms, ICD-10-CM/PCS, interoperability and health information exchange,
clinical decision support, and health IT technology progress

over the last 10 years.
One example of the progress that has come from health IT
was given in a presentation by representatives of the Improving Massachusetts Post-Acute Care Transitions (IMPACT)
project. Representatives announced at the summit that their
LAND and SEE tool, which helps with the exchange of health
information, has reduced hospital readmissions. Massachusetts also has a universal transfer form which has contributed to improved healthcare in the state.
Another session at the LTPAC Summit focused on emerging best practices in digital health IT to facilitate coordination of care and reduce or prevent readmissions. This was
presented by Andrey Ostrovsky, MD, CEO of Care at Hand,
based in San Francisco, CA. Driven by the shift from fee-forservice to value-based care, their community-based care
transitions program uses mobile technology to empower
caregivers.
Deborah Green, MBA, RHIA, COO and executive vice
president at AHIMA, and Peter Kress, vice president and
chief information officer at ACTS Retirement-Life Communities, presented the LTPAC HIT Collaboratives 20142016
Road Map. The latest version of the Road Map is designed to
provide guidance to stakeholders in the industry on national

strategic goals and includes plans for laying the groundwork
for a fully connected health system that uses smart data to
deploy new delivery and payment systems. The final Road
Map is now available at www.LTPACHealthIT.org.
National Health IT Week Raises Awareness with

Local, Regional Events
This month will mark the ninth year of National Health
IT Week (NHIT Week). During the week of September 1519 over 400 partners, including AHIMA, will work to bring
awareness to the importance of health IT through local and
regional events. AHIMAs goal in NHIT Week is to promote
and advocate for high quality research, best practices, and
effective standards in health information and to actively
contribute to the development and advancement of health
information professionals worldwide. Through the advancement of health information, especially from electronic health
records (EHRs), the quality, efficiency, and effectiveness of
healthcare is improving.
The AHIMA Advocacy and Policy Team (advocacyandpolicy@ahima.org)
is based in Washington, DC.
Data: Its all about quality!

For nearly 40 years, Care Communications has been committed to enhancing the
quality of data. We offer a wide range of experience, customized solutions and a lifelong
commitment to improving health care by enhancing data qualityour lifes work.
Visit us in booth 1113 at the AHIMA Convention.
800-458-3544
info@care-communications.com
www.carecommunications.com
facebook.com/CareCommunications
twitter.com/CareComms
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Information Governance
Meaningful Use
ICD-10
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And others
DONT MISS:
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Opportunities for networking and collaboration

Appreciation Celebration: Rockin in the Park:
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Sunny San Diegos fine dining, culture, entertainment,
and world-class shopping!
Register by September 26, and save $200 with pre-registration savings!
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Inside Look
Meeting the Needs of Increasingly

Connected Consumers
By Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA, chief executive officer
HAVE YOU HEARD of the Conversation

Project?
Started by journalist Ellen Goodman,
the Conversation Project provides tools
and resources to families to have conversations about end-of-life wishesincluding a starter kit that contains probing
questions for families to explore that can
make it easier to make crucial care decisions when the time comes.
While its main outreach is to consumers, the project, in conjunction with the
Institute for Healthcare Improvement,
also works with healthcare organizations
to ensure that they, too, are conversation ready and willing to listen and respect peoples wishes and preferences.1
The project is an example of how, as
patients become increasingly empowered, were seeing an emergence of programs in which health care organizations
structure themselves to meet patients
needs and preferencesand in which
those preferences help to shape broader
responses on a societal scale, a Health
Affairs policy brief noted last year.2
AHIMA has long supported the rights
of patients when it comes to accessing their health information. For example, its been more than 10 years since
we launched the consumer-oriented
myPHR.com. And last fall AHIMA announced its awareness campaign for the
Blue Button Initiative, a cross-industry
collection of data-sharing applications
that connect patients to their records.
We encourage members and component
state associations to take the Blue Button pledge and post the Blue Button link
on their respective web sites.
The initiative continues to be a high
priority for the Office of the National Coordinator for Health IT, which this month
will launch a national campaign to boost
consumer use of Blue Button technology. AHIMA is participating in this re-
newed effort, so watch for special public

service announcements on ahima.org
and on myPHR.com.
The articles in this months Journal offer a wide range of perspectives on this
topic. Our cover story Healthcare DIY
explores how HIM professionals can
help consumers use new tools becoming available to them to optimize their
healthcare through health information.
In Healthcare On Demand, Lisa Eramo
explores some of the questions we must
sort through as telemedicine technology
increases consumer access to healthcare. Ron Hedges and Kevin Brady offer
guidance on how confidential information
can be used and misused in litigation in
HIPAAs Place in Court-Ordered Discovery. And in Who Are You? Tim McKay
discusses how authenticating medical
consumer identity has become increasingly important and highlights the latest
technologies emerging to prevent medical identity theft, such as Kaiser Permanentes digital membership card.
All of these topics represent part of the
conversations that healthcare is starting
to have with consumers. Its long overdue. I hope youll join the conversation,
too.
Notes
1. Institute for Healthcare Improvement.
With The Launch of the Conversation Project, IHI Commits to Helping Health Care Providers Develop
Systems to Honor Patients End-OfLife Wishes. Press release, August
20, 2012. http://www.ihi.org/about/
news/Documents/IHIPressRelease_
ConversationReady_Aug12.pdf.
2. James, Julia. Health Policy Brief:
Patient Engagement. Health Affairs, February 14, 2013. http://www.
healthaffairs.org/healthpolicybriefs/
brief.php?brief_id=86.
Healthcare
DIY
EMPOWERING CONSUMERS TO
OPTIMIZE THEIR HEALTHCARE
THROUGH HEALTH INFORMATION
By Mary Butler Illustration by Marla Campbell
Healthcare DIY
THERES NO DOUBT that consumers of a certain age take comfort in going to the doctor, agreeing with their diagnosis, and
following his or her treatment plan to the letter without doubts
or hesitation. But this paternalistic approach to healthcare is
starting to erode as younger generations of patients are beginning to handle the provision of care as they do any other major
purchase.
These new engaged patients frequently take a list of questions to the doctor with themperhaps after first performing
an Internet search on the physicians background and their
symptomscheck their lab and imaging reports through their
online patient portal, and compare treatments on diseasespecific message boards. The Internets democratizing effect
has given consumers more access to healthcare information
than ever before, and the results have been as diverse as consumers themselves.
Online patient portals give patients an opportunity to spot
mistakes in their health records and can prompt patients with
chronic conditions to schedule needed tests and checkups. Image-enabled health information exchanges (HIEs) are helping
to reduce redundant diagnostic procedures such as CT scans
and X-rays, and interoperable electronic health records (EHRs)
are saving patients and providers valuable time and effort by
digitizing personal health information.
But there are downfalls of having a wealth of unfiltered medical information. Giving patients access to all of their health
datalab values, procedure notes, testswithout context can
induce anxiety and confusion when wrongly interpreted by a
layperson. For example, myths about vaccinations are rampant
on the Internet, leading parents to ignore what used to be routine inoculations against measles, polio, and other infectious
diseases. Subsequently, outbreaks of once-rare diseases are
popping up at an alarming rate.
Health IT is outpacing health literacy in some, but not all,
cases. So many new tools are available to consumers who dont
know how to use them. Health information management (HIM)
professionals, however, can help bridge the information gap
for healthcare consumers and practitioners. Their understanding of both the clinical and reimbursement sides of healthcare
makes them ideal ambassadors to serve providers and consumers, and there is no shortage of ways to do it.
The Rise of the Engaged Patient

As healthcare reform efforts increasingly shift consumers away
from employer-paid insurance plans, and more Americans
become self-employed, many consumers have been forced
to shop for services and health plans on their own for the first
time. This is especially true for young people. And just like any
other service, such as streaming and downloading movies and
books, buying groceries, and even tracking biking and running
mileage, these consumers want their healthcare and health information available on demand. Providers are responding to
these calls with help from the meaningful use EHR Incentive
Program and HIPAA modificationswhich both incentivize

providers to give patients better, and more electronic, access to
health information.
Providers and consultants refer to this provider-patient interaction as consumer engagement or patient engagement.
Kimberly Hume, MSN, RN, patient engagement coordinator
at Wolters Kluwer Clinical Drug Information, says patient engagement is just a new buzzword for the way healthcare always
should have been done, and how it is delivered today. It needs
to be two-way communication that should take place in whatever format the patient wants: verbal, written, e-mail, through
looking at a chart, an online portal, whatever format works best
for the patient, Hume says.
Hume and Elizabeth Tomsik, PharmD, RPh, senior director of
content at Wolters Kluwer Clinical Drug Information, says that
its only been within the last 10 to 15 years that patients have
started coming in to see their doctors armed with information
and questions. But because a lot of the information patients are
finding comes from websites with flimsy evidence and research,
consumers are also more likely to make poor decisions based
on poor information.
HIM professionals can help combat this by providing educational information to patients before an office visit or procedure,
potentially by pushing educational materials through patient
portals when an appointment is scheduled.
I think the characteristics of the newly engaged patient are
they want to know more, get results in a timely fashion. These
people are busy. They want to schedule things at their own
convenience, whether at 10 oclock at night, they want to do
that. They want to ask their doctor questions, Hume says. In
a world of instant gratification, we expect the same thing from
our healthcare.
Even aside from providing patients with their records and
more interactive office visits, Tomsik says hospitals are trying
very hard to take a more humanized approach to their interactions with patients. So its not just about empowering patients,
but I think patients are also looking for nicer facilities when
theyre in the hospital, Tomsik says. You can see hospitals addressing this by improving their environment and the services
they provide to patients in an inpatient setting and an outpatient setting. Youll see cooking classes for people with heart disease. Focus groups for people with a specific disease.
Participation in payment reform initiatives, such as accountable care organizations (ACOs), bundled payments, and patient-centered medical homes, demand a high degree of patient
education. An increase in tying payment to quality measures
has also improved patient engagement. Hospitals face penalties
for readmitting patients within 30 days of a discharge, so it pays
to make sure that patients and their caregivers understand the
importance of medication compliance and preventive care. The
Centers for Medicare and Medicaid Services in 2012 launched
a program to fine hospitals with high rates of patient readmissions. The upper levels of this penalty could be up to a 2 percent
Healthcare DIY
cut in Medicare reimbursements.

These are things that can be managed with thorough patient
education, combined with the teach-back process, Hume explains. Evaluate what they do know. By doing that, youre able
to ensure they really do know what to do in an emergency, know
how to take care of their loved one. I think [due to] the Affordable Care Act, ACOs are really going to be driving better patient
education.
Lygeia Riccardi, EdM, who recently stepped down from her
position as director of consumer eHealth in the Office of the National Coordinator for Health IT (ONC), says she can relate to
the old model of healthcare, to an extent.
My grandmother was very strongly in the camp of the doctor
knows what hes doing, Riccardi says, adding that there was a
certain appeal in really seeing this doctor almost as like a medicine man, someone whos imbued with this ability to heal thats
superhuman in some way.
According to Riccardi, consumer engagement also includes
activities that occur outside the bounds of the traditional patient-physician relationship or the health system. So it could be
things like using an app on your smartphone to track your calories or fitness, or participating in an online community to talk
with other individuals who have a shared interest in a particular
condition. I define it pretty broadly, Riccardi says.
A recent article in the New Yorker titled How to Tell Someone that She is Dying also notes the drift from physician-directed care to an era of empowered patients.1 As recently as
the nineteen-seventies, medical decision-making in the United
States was largely a doctor-knows-best endeavor. Physicians
dictated clinical care without feeling compelled to tell patients
about their treatment alternatives. Frequently, in fact, they did
not even inform patients of their diagnoses, author Peter Ubel
notes. Medical practice has since undergone a paradigm shift.
Physicians now recognize that patients not only have a right to
information but also have the right to refuse medical care.
HIMs Role in Consumer Engagement

While HIM professionals are well positioned to work on patient
or consumer engagement projects and strategies, they often get
shut out of the planning phase. Kim Murphy-Abdouch, MPH,
RHIA, FACHE, clinical assistant professor and clinical coordinator of HIM at Texas State University, and member of AHIMAs
Consumer Engagement Practice Council, says that often HIM
department representatives too frequently are an afterthought
when it comes to implementing consumer-facing EHRs and patient portals.
The HIM department in many cases is [brought in] after the
fact, when a portal has already been implemented, MurphyAbdouch says. My opinion about why this happens is that in
many facilities, EHR and portal implementation is an IT project. That the knowledge of the actual contents of the record, and
how it can be used and how to be more helpful to patients, isnt
necessarily thought of.
When consumers have questions about using the portal,
theyre sometimes referred to the patient registration specialist,

and they arent necessarily the best people to inform and advise
patients about portals in the hospital setting. In the physician
office, its often front desk personnel to whom consumers direct
their questions. And again, front desk staff may not be trained to
address these questions, Murphy-Abdouch says.
While Murphy-Abdouch favors giving patients full access to
their EHRs, she notes that much of the contents of an individuals EHR are viewed and used by other healthcare professionals caring for the patient and is information the patient doesnt
necessarily need.
Im a proponent that HIM should thoughtfully develop a
standardized list of the pertinent information thats in a patients record, whether paper or electronic, Murphy-Abdouch
says. [HIM] should help them [patients] understand what those
important pieces mean, such as lab results, radiology reports,
consultations, operative reportsthings that can help inform
them about whats taken place and also the important measures
of their own health.
Studies have shown that when providers make patients records available to them, it benefits the patient and the provider.
A year-long study funded by the Robert Wood Johnson Foundation tracked three major health systems, encompassing 105
physicians and 19,000 patients, and found that when patients
had complete access to their records they felt more in control
and satisfied with their care. The program, known as the OpenNotes Project, reached three conclusions, according to research
published in Annals of Internal Medicine. Patients involved in
the study:
Reported improved understanding of their care
Were better able to remember and follow their care plans
Were more compliant with their medications
Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and
virtually all patients wanted the practice to continue, concluded the study authors.2 With doctors experiencing no more than
a modest effect on their work lives, open notes seem worthy of
widespread adoption.
Riccardi acknowledges that the lack of health literacy among
consumers can make physicians anxious about complying
with ROI requests. For example, a patient might see the acronym S.O.B. in a progress note and take offense. But physicians
and HIM professionals know the acronym means shortness of
breath.
But I actually see greater risks in not giving people access to
their information... the risks of not engaging people are incredibly high, Riccardi adds.
For instance, when patients can view their own records, they
might find drug allergies and potential interactions that arent
noted. HIM and physicians can then correct these errors.
Closing the Information Gap

Sherri Loeb, BSN, RN, patient engagement strategist at Emmi
Healthcare DIY
The Hustle and Flow of Health Information

ONE OF THE DRIVING forces of patient engagement initiatives is making health information available where and when
patients need or want it. That desire and demand is whats
helping to make HIEs work. But many HIEs are only able to
exchange part of a patients record, and are incapable of exchanging video or images. However, this gap in information
exchange is starting to be filled at some HIEs and provider
networks who have turned to cloud computing to help with
large file transfers like images.
Provider and individual state participation in HIEs have
the potential to significantly improve how patients and physicians share health information and lower costs for all involvedespecially if they can share images, video, and other
lab results. Colorado has two HIEs: the Colorado Regional
Health Information Organization (CORHIO) and the Quality
Health Network (QHN). Both are working with vendor GNAX
Health, and the Colorado Telehealth Network (CTN)a statewide broadband networkto image-enable their physician
portals so that images and diagnostic reports will be available through the HIEs. George Robbie, general manager and
vice president of sales for GNAX Health, says the primary
way that hospitals and physicians currently share imaging
reports is by giving the patient a compact disc (CD) with the
reports burned onto it. While Robbie rates the effectiveness
of the CD method as pretty good, theres still a chance that
multiple providers wont be able to read the images from the
CD. Image quality can also often be poor.
To combat this, GNAX has developed a system that renders images and videos into a normalized vendor-neutral format called a DICOM (Digital Imaging and Communications
in Medicine)similar to the standardization for documents
such as PDFsthat can be stored securely in a cloud archive. It supports all the major imaging types including radiology, cardiology, ultrasound, and nuclear medicine. GNAX
writes the images into two places for safekeeping and di-
Solutions, has worked as a nurse in multiple types of healthcare

settings for over 30 years. Loeb felt that, given her background,
she was as healthcare literate as an individual could be. Yet when
her husband was diagnosed with Stage IV metastatic prostate
cancer in August 2011, Loeb was struck by how frustrating and
confusing it was to navigate the healthcare system from the patients side. Many of the difficulties Loeb and her husband faced
could have been eased by more responsive patient engagement
programs and a reliable health IT infrastructure.
For example, the experience of waiting for crucial lab results
with a disease as grave as cancer provoked almost as much anxiety as the diagnosis itself, Loeb says. As a seasoned nurse, Loeb
knows approximately how long it takes for a lab to process and
analyze blood tests, so waiting, sometimes days or even weeks
for a result was excruciating.
saster recovery purposes. A unique aspect of Colorados

HIEs and GNAXs services is that they have brought together
health systems that would typically view other systems as
competitors but instead collaborate to make this information
exchange possible, Robbie says. For example, if a patient is
injured in a skiing accident in Aspen and needs an X-ray or
CT scan, their home physician could easily access the scan
when they follow up with an office visit in Denver through one
of Colorados HIEs.
Robbie says HIM professionals need to have an awareness
of these technologies because of the release of information
component. When it comes to moving a patients information from one provider to another provider, or to an HIE in another state, which could very well have different regulations,
HIM needs to track whether the appropriate consent has
been signed and obtained. The direction were starting on
right now, the topic is how do we share information? What is
the value of that information across hospital settings? How
does that benefit the patients so they dont have duplicate
studies so they arent exposed to more radiation than they
need to be, and in which they can see information readily,
Robbie says.
Image-enabled HIEs will also provide the flow of information that is needed to make ACOswho depend on sharing
all types of data in order to lower costswork. Look at Boulder, and look at the flow patterns from the payers. And how
theyre moving inside the Boulder community, Robbie says.
Very few times do they go outside that area for care. They
stay inside that hold pattern, inside that ACO environment
where people are sharing information and patients arent
moving as broadly.
He suspects that ACOs will encourage rural community
access hospitals and clinics to exchange information more
freely. Were not seeing that as being a major adoption just
yet, but Im sure that it may happen soon.
When you have labs and imaging, theyre usually done and in
the electronic record in hours, but consumers have to wait days
or weeks to receive them, Loeb says. The way most are set up is
that results have to go through the doctor and the doctor has to
release them. Some have automatic releases, where if the physician hasnt released them after seven days [the system releases
it]. This makes it easier for consumers to access their own info.
She adds that EHRs and patient portals need to be integrated
so that as soon as a test result is available the patient can log in
and read it. Its also important for providers to find out each patients preferred method of communication. If the patient prefers to be called with the results, thats how clinical staff should
relay new information. If a patient prefers portal access or even
an e-mail, the provider should account for that as well.
Loeb also encountered frequent care coordination roadblocks
Healthcare DIY
because she took her husband out of state for certain treatments
and became frustrated when multiple providers couldnt sync
her husbands medications and medical history. This is a common complaint about the interoperability of EHR platforms, but
Loeb says that even when different care teams were using the
same health IT vendor the problem persisted.
While its really nice to have physicians pick up the phone
and really talk to each other, thats pretty difficult, Loeb says.
To get a physician to be available at the same time as another
physician is like pulling teeth. And it really impacts the continuity of care and it ultimately affects your experience.
Like other patient advocates, Loeb believes patient engagement begins even before an office visit or prior to a procedure to
ensure shared decision-making between a provider, the patient,
and a caregiver. They need to educate their patients across the
whole continuum of care, creating multi-modal programs to
help educate people, Loeb says. Were not in a world anymore
where nobody wants to know about their illnesses. If you have
no idea about what youre going into, you cant even ask the
right questions.
Patient education also includes explaining the reason behind
patient safety checks. For example, Loeb was alarmed that during many of her husbands hospitalizations, a nurse would come
into the room to check vital signs or administer medications
without verifying her husbands name. As a nurse, Loeb knows
that asking a patient to verify information like their name and
age is a safety measure to prevent medication errors and allergic
reactions. But a less savvy hospital patient might find multiple
requests to verify identifiers rude if its not explained to them as
a safety measure.
I hate to keep bringing up shared decisions but you need to
bring up different options because not everybodys the same.
Whats good for patient A isnt good for patient B, Loeb says.
essence, Blue Button turns consumers into their own personal

HIE, Riccardi notes.
Riccardi also worked on patient engagement aspects of
meaningful use and HIPAA. Stage 2 of the meaningful use
program requires that patients be able to view, download, and
transmit their data through an online portala requirement
with which both providers and vendors are still struggling to
comply. Riccardi maintains that its too early to tell if meaningful uses patient portal requirement is meeting its intended
patient engagement targets.
I will say its a challenge for them, trying to figure out how
to navigate and do it, not just technically but for some of them
it is a workflow change, its potentially a cultural change, Riccardi says.
She also points to provider compliance with updates to the
HITECH Omnibus Final Rule, which went into effect in September 2013 and was a major step forward in patient engagement.
The rules updates make it easier and cheaper for patients to
obtain copies of their health records, request changes, and give
consent as to how their health information is used by a provider.
While older HIPAA rules gave providers anywhere from 30 to 60
days to respond to a patients release of information request,
HITECHs updates to HIPAA attempt to streamline the process.
HITECH says give the patient their health record within 72
hours. Thats a lot tighter and consistent with consumer expectations in a digital age, Riccardi says.
These changes directly impact HIM professionals workflow
and processes, but are necessary, experts say, to steer healthcare away from the days of doctor-knows-best and toward a
more patient-centered healthcare system where patients play
a role in their healthand use their health information to improve their care.
Federal Patient Engagement Efforts Advancing
1. Ubel, Peter. How to Tell Someone that She is Dying.

New Yorker, July 7, 2014. http://www.newyorker.com/
online/blogs/elements/2014/07/cancer-chats.html?utm_
source=tny.
2. Delbanco, Tom. Inviting Patients to Read Their Doctors
Notes: A Quasi-experimental Study and Look Ahead. Annals of Internal Medicine 157, no. 7 (2012):461-470.
While at ONC, Riccardi oversaw several health IT initiatives

aimed at providing consumers and providers with tools that
simultaneously lower costs and improve patient safety. Chief
among these projects is the Blue Button Initiative, which aims
to help consumers download their health information from participating insurance companies, pharmacies, and health systemsincluding the Veterans Administration and other Medicare providers. Healthcare organizations participating in Blue
Button include an icon on their websites alerting consumers to
the availability of their secured personal health information.
The Blue Button Initiative is aiming to overcome the lack of
interoperability among EHRs by suggesting a subset of national standards, developed by the Standards & Interoperability
Framework, to support the sharing of information in a structured way. Ideally Blue Button will make it possible for patients
to take their smartphone to the doctors office and share medication lists, lab and imaging results, and other components of
their health history in a format any physician can access. In
Notes
Mary Butler (mary.butler@ahima.org) is associate editor at the Journal of

AHIMA.
Read More
Patient Engagement Initiatives and
the Future of HIE
journal.ahima.org
Marc Perlman, global vice president for healthcare, life sciences, and
education and research industries at Oracle, discusses his work on the
Patient Engagement Framework and the future of HIE.
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HEALTHCARE
On Demand
AN EXPANDING WORLD
OF TELEMEDICINE RAISES
NEW QUESTIONS FOR
HIM PROFESSIONALS
By Lisa A. Eramo
Doctors Office
Pharmacy
Immediate Care
Hospital
ITS MIDNIGHT, AND your cough has been unrelenting. You

power up your laptop and visit one of the many websites that
feature online access to physicians 24/7. Within minutes, youre
engaging in a video consultation with a board-certified physician who evaluates you, provides clinical instruction, and prescribes medication. Minutes later, youre back in bed resting
with a prescription on your nightstand that youll fill first thing
the next morning.
You have other options, too. You can see a specialist located
miles away via high-definition video from the comfort of an
exam room at your local clinic. You can also walk into a freestanding kiosk at your local pharmacy and interact via video
with a physician in a nearby city. If things take a turn for the
worse and youre admitted to the intensive care unit of a hospital, you may even have the comfort of knowing that youre being monitored by ICU nurses around the clock from a remote
location.
Welcome to the world of telemedicinewhere the use of electronic information and telecommunications technologies support long-distance clinical care. These technologies typically
include video-conferencing, the Internet, store-and-forward
devices, streaming media, and terrestrial and wireless communications. It is a world in which access to healthcare is paramount and simple. Distance is no longer a barrier to services
because technology is there to fill the gap.
However, it is also a world where new questions arise for HIM
professionals. How does the format of the record change when
providers engage in telemedicine? How can information be integrated from the telemedicine device or application and into
an electronic health record (EHR)? Should there be a seamless
integration? What about authentication, privacy, and security?
Most of these questions still need answersand need HIM professionals to provide them.
Telehealth is a Growing Trend

The use of telemedicine has been increasing steadily over the
last few years, and it is poised to explode in growth in the near
future. According to a study by Parks Associates, the number of
households using video consultations will grow from 900,000 in
2013 to 22.6 million in 2018. Today, patients between the ages of
18 and 34 who have an annual household income of $50,000 or
more are currently the heaviest users of online healthcare communication tools, according to the study.
The Veterans Health Administration (VHA) has been using
telemedicine since 2003 to target chronically ill veterans. According to a report titled Scaling Telehealth Programs: Lessons
from Early Adopters, which was published in 2013 by the Commonwealth Fund, the VHA reported reductions in bed days of
care for eight different targeted chronic conditions. This included a 20 percent drop for nearly 9,000 enrolled diabetes patients,
a 56 percent decrease for nearly 340 patients then receiving
home health monitoring for depression, and a 45 percent drop
for nearly 140 patients with post-traumatic stress disorder.
Even entities in the private healthcare industry are tapping
into telemedicines power. For example, ADT, the home security firm, announced last year that it would partner with Ideal
Life to integrate their health and monitoring technology into an
interactive home management system, ADT Pulse. Pulse allows
customers to remotely arm and disarm their security systems,
provide real-time video feeds from electronic devices, lock and
unlock doors, and receive notifications and alerts. Through their
partnership with Ideal Life, customers and their caregivers and
medical providers can now also use Pulse to monitor and track
health and wellness in real time.
Additionally, Verizon announced in June that it would offer
Virtual Visits during which providers who contract with Verizon
could engage with patients via a phone, tablet, or laptop to discuss simple acute conditions.
Telemedicine is expanding at lightning speed primarily because patients want this technology, says Sherilyn Pruitt, director of the Office for the Advancement of Telehealth at the
Department of Health and Human Services. They [healthcare
consumers] arent afraid of video because theyre familiar with
Skype, Tango, and Snapchat, she says, adding that smartphones
have revolutionized the way in which consumers interact with
technology of all kinds.
Telemedicine technology is moving beyond its traditional
application in rural areas to include larger metropolitan areas
where travel barriers can also exist, Pruitt says. In an urban
area, particularly in medically underserved areas, even though
a patient might live within 10 miles of a major medical facility,
in order for them to get there they need to take three buses and
a train, she says. This could take them three hours. Telemedicine allows the specialists to be where the patient is when that
patient needs the care.
However, one of the biggest barriers to the expansion of telemedicine is the fact that providers must be licensed in the state
in which the patient is located. This takes time, and it costs
money, says Pruitt.
Fight Ongoing to Convince Payers, Providers to

Embrace Telemedicine
Reimbursement is another barrier. Not all insurance providers
pay for telemedicine. Medicare has perhaps the most restrictive
payment guidelines. Although Medicare will pay for remote test
interpretations (i.e., for radiology or pathology), it will only pay
for video interactions when a patient is located in a non-metropolitan area. Changing this could open up telemedicine options
to hundreds of thousands of patientsand possibly be the catalyst that moves telemedicine from novel to everyday medicine.
Jonathan D. Linkous, CEO of the American Telemedicine Association (ATA), says that Medicares payment stipulations,
which were implemented 15 years ago, are antiquated and dont
support the growth of these services. Weve been in the 21st
century for 14 years. Medicare is still moving at the speed of a
glacier, he says.
Medicares resistance could be rooted in a perceived fear of
fraudthat is, providers billing for virtual encounters that never
occur. But Linkous says this fear is unfounded and not based
in any reality. Medicare may also be receiving pushback from
physicians, some of whom could fear the competition inherent
in telemedicine expansion.
Telemedicine allows doctors to see patients from [all areas of
the country], Linkous says. This means patients can get access
to any doctor they want. A patient may end up leaving their doctor for a better doctor. Its a good thing for consumers and the
public, but not so good for the bad doctors.
The ATA and others have pushed Medicare to reconsider its
payment policies to include coverage for telemedicine regardless of a patients geographic location, the services provided,
or the real-time nature of the service. Linkous hopes that there
may be enough momentum in Congress to change these rules
within the next two years.
Pruitt says that HHS already has several initiatives underway
to build an evidence base for the efficacy of telemedicine services. On September 1, HHS was expected to announce five
provider recipients of an evidence-based tele-emergency grant
program that will provide each site with $400,000 per year for
three years to develop and measure the outcomes of telemedicine services. The goal is to more closely examine costs and
benefits of telemedicine in the hopes of eventually expanding
coverage for these services.
Despite Medicares resistance, other payers have welcomed
telemedicine with open arms. Dozens of state Medicaid programs currently pay for some form of telemedicine, and 30
states have proposed legislation to expand coverage, says Linkous. Various large private payers and employers pay for telemedicine both in rural and metropolitan areas, he adds.
Breaking New Virtual Ground

Many providers arent waiting for Medicare to expand coverage
for telemedicine. Consider Mercy Health System, which operJournal of AHIMA September 14/27
ates acute care, specialty care, and critical access hospitals in

Arkansas, Kansas, Missouri, and Oklahoma. In May, Mercy officially broke ground on the first virtual care center in the United States. The four-story, 120,000 square foot center located in
Chesterfield, MO, will open in 2015 and provide an estimated
three million telehealth visits in the next five years.
Essentially, its all about access. We dont have enough providers, says Tom Hale, MD, executive medical director for Mercys telehealth services. It has been difficult to get providers to
where our patients are. Many of our patients are in rural areas.
Its also the case that we have to find a less expensive way to deliver healthcare.
Mercys virtual care center will include more than 75 service
lines, including telestroke, pediatric telecardiology, telesepsis,
teleradiology, telepathology, home monitoring, and more. All
providers who render telemedicine services must be credentialed and licensed through Mercy Virtual, a business entity under the Mercy umbrella.
Hale says Mercys foray into telemedicine began with its SafeWatch eICUa program in which Mercy doctors and nurses
provide around-the-clock monitoring for hospital ICU patients
from a remote location. Launched in 2006, Mercy specialists
monitor more than 450 beds in 28 ICUs throughout a five-state
region, including non-Mercy facilities in South Carolina. Highdefinition cameras and sophisticated technology allow providers to zoom in on patients and see details as small as pupil dilation.
It has been very successful from a quality standpoint, Hale
says. Weve decreased mortality and length of stay. It has also
been widely accepted by our patients.
Questions Arise on Telemedicines Information Impact

However, Mercys telemedicine offerings initially raised questions about information management. Hale says HIM professionals provided input at the onset of the program to address
important questions related to storage and integration. For example, Mercy had to decide whether it would store the video
portion of the telemedicine encounter within its EHR. Hale says
the health system ultimately decided not to do so, citing storage
and liability as primary concerns.
If you do telehealth and save the video, then why wouldnt
you have to set up video within the operating room and everywhere else? Hale says. To me, its not only a storage nightmare,
but its an incredible barrier for people to feel like they can be
open and honest.
Daniel Z. Sands, MD, MPH, a Boston-based consultant specializing in health IT transformation, non-visit based care, and
participatory medicine, agrees with Mercys approach. If you
store it in the record, youre going to need mountains of memory. Youre going to need special servers just to manage this
information, he says. However, he admits that storing single
video recordings of a function or demonstration might be more
useful than storing the recording of an entire visit.
Theres just so much you can do when you start thinking

about adding in these multimedia objects. It probably does add
a certain richness to the record, he says. Storing the recordings
of entire visits would only be helpful if providers could tag words
or phrases so they could easily find discussions that take place,
he adds. Ideally, providers could also generate a note based on
an audio or video recording.
Still, as telemedicine evolves, experts agree that HIM professionals must be able to work collaboratively with IT professionals and others to answer questions related to the logistics of
storing video and audio files within the health record. Today,
the record typically only includes images and text.
Another HIM question that Mercy had to address was where
it would store clinical information produced during the actual
telemedicine encounterthat is, whether it would integrate
the telemedicine technology directly with the EHR or keep the
two technologies separate. This was particularly important for
Mercys external clients because it would mean that Mercy providers would need direct access to the external clients EHR for
order entry and documentation.
Mercy decided that any providers would document directly
into the sites EHR as they engage in telemedicine with patients
via video rather than automatically stream information. Hale
says this ensures that there is only one source of the truth for the
information: the EHR.
Telemedicine Increases Patient Engagement

The Cleveland Clinic is another site at which telemedicine services are taking off with lightning speed. In particular, the clinic
began a year-long pilot program last May to offer walk-in kiosks
called HealthSpot stations in three of its family health centers.
These 8-by-5 foot enclosures are outfitted with touch screens,
integrated medical devices, and two-way video-conferencing
abilities. During the pilot program, the clinic averaged 20 visits
per month at each station.
Christopher Soska, chief operating officer at Cleveland Clinics Community Hospitals and Family Health Centers, says he is
already working on expanding kiosk locations beyond the clinics walls to include community centers, retail shops, churches,
businesses, universities, and schools. Patients can conveniently
walk up to a kiosk without scheduling an appointment and be
treated for low acuity conditions, such as fever, cold, flu, rashes,
eye conditions, ear aches, sore throat, sinus infections, respiratory infections, or allergies.
Heres how it works. An LPN attendant helps patients enter basic demographic information into the kiosk, such as name and
address, using a touch screen. No other personal information
such as a Social Security number or clinical information is stored
within the kiosk itself. No information is exchanged between the
kiosk and the EHR, Soska explains. As with Mercy, providers who
are located hours away document directly into the EHR while
they interact with a patient via video technology. This video is
not recorded, and thus its not part of the health record.
Whats unique about the Cleveland Clinic HealthSpot stations is that patients are expected to participate in the exam. If
a provider, for example, wants to check a patients heart beat,
a stethoscope is accessible within the unit. The patient places
the device on his or her body and follows the providers instructions. This information is streamed in real-time to the provider
for interpretation and so that he or she can input the data into
the EHR.
We thought wed get more traction from the younger patients,
but its a mix, Soska says. People like the technology. Theyre
fascinated by it.
Questions Remain on Information Integrity,

Integration
Although telemedicine can benefit patients significantly, it also
raises a variety of other questions for HIM professionals. For
example, if a patient uses a health systems kiosk as a new patient who has never seen a provider within that system, how will
identity authentication and insurance verification occur? Can
this ever be truly automated? Who will subsequently ensure that
there arent identity duplicates if and when that same patient
returns for a face-to-face visit with a provider?
For new patients who access the Cleveland Clinics kiosks, an
LPN will verify whether a patient is new or established via a laptop connected to the EHR before that patient enters the kiosk.
If the patient is new, the LPN will assist with registration and
assign that individual a clinic medical record number that he or
she will use upon return to the kiosk or the actual facility.
With online telemedicine there are other challenges as well.
In particular, there is no doctor-patient relationship, says Pruitt,
which could call into question the quality of the care provided.
Youre seeing a patient virtually for the first time, and you end
up prescribing medicines based on the persons own description of their symptoms and not based on any lab tests.
The same could be true for independent kiosks or retail health
clinics that arent part of a health system, such as the kiosks currently popping up in Walmart and CVS, Sands says. Clinical decisions are made somewhat in isolation.
Experts agree, however, that the same could be said for the
disparate and uncoordinated care that happens even without
telemedicine, as patients see providers in different systems in
which there is a lack of interoperability. Without a patients full
history, providers are left to make decisions based on information they can glean in the moment. Telemedicine makes it
easier for people to get access to care, which is a great thing,
but care that is uncoordinated may not be such a great thing,
Pruitt says.
HIM professionals must be able to contribute to conversations about the integration of health information generated
from these types of encounters, Pruitt says. Will this interaction
be documented? If so, how? Will it become the patients responsibility to ensure that this information eventually finds its way
into the providers record as well?
Privacy and Security Concerns

As with any medical encounter, those encounters performed
using telemedicine technology are vulnerable to privacy and
security threats. Interception of audio or video technology is a
concern. Also, because visits can occur anywhere and anytime,
it does raise questions about the settings in which these encounters take place. Because the provider is actually communicating
with the patient and looking at the patient, its important that the
provider do so in an area thats secured from prying eyes, Sands
says. Patients need to think about this as well, he adds.
Mobile devices and apps that store patient data and facilitate
telemedicine are also certainly subject to theft. Interestingly, the
Food and Drug Administration issued draft guidance, available
at
http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm401785.htm, in June
stating that it considers medical-device data systems (i.e., hardware or software products that transfer, store, convert formats,
and display medical device data) to be so safe that it declined
to oversee them. This guidance contradicts previous FDA rulings that occurred as recently as January 2011 in which the FDA
stated it considers these devices to be among the highest-risk
technologies in healthcare.
HIM professionals can help ensure that patients understand
the importance of securing these devices as much as possible.
The integrity of ones health information depends on this privacy and security.
HIMs Evolving Role in Telemedicine

Telemedicine will only continue to grow commensurate with
population health management and other initiatives aimed at
improving the quality of care, and its going to be paramount for
HIM to be at the table when important decisions are made.
Its our belief that fee-for-service is dead and that were moving to a population heath management payment methodology,
Hale says. If we manage our populations effectively, we keep
patients healthy and ultimately reduce costs.
As telemedicine offerings continue to expand, HIM professionals must not only be able to answer questions about integration and privacy and security, but they must also serve as
patient advocates. In lieu of true interoperability, telemedicine
places an incredible amount of responsibility on patients to coordinate their own care. HIM can help educate patients about
the importance of their health information and the important
role they play as true care coordinators.
Telemedicine is a good thing, Sands says. Its a way for us to
expand the reach of our healthcare system and be more patientcentered. Were in a state of evolution, and health information
management professionals are going to need to be a part of all
of this.
Lisa A. Eramo (leramo@hotmail.com) is a freelance writer and editor
based in Cranston, RI, who specializes in healthcare regulatory topics,
HIM, and medical coding.
EXPIRATION DATE: MARCH 1, 2015

Take quizzes online at https://www.ahimastore.org
Journal of AHIMA
Continuing Education Quiz
NOTE: BEGINNING JANUARY 1, 2015, MAILED/PAPER CE

QUIZZES WILL NO LONGER BE ACCEPTED. CE QUIZZES WILL
ONLY BE ADMINISTERED ONLINE AT WWW.AHIMASTORE.ORG.
Quiz ID: Q1418509 | HIM Domain Area: Technology | ArticleHealthcare On Demand
For an opportunity to receive CE credit

of 1 clock hour, mail this form with the
appropriate processing fee to:
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Journal of AHIMA CE Quiz
PO Box 77-2735
Forms must be received by the
Expiration Date above.
First Name (please print)
Last Name
AHIMA Membership ID Number
Address
City
REFER TO THE ARTICLE for the one best answer to each question. Questions are based solely on the
content of the article.
1. Telemedicine is the use of electronic
information and:

a. telecommunication technologies

b. telecommunication companies

c. telecommunication databases
d. telecommunication definitions
6. One of the biggest barriers to

telemedicine is:

a. physician state licensure
b. physician noncompliance

c. lack of physician usage

d. physician understanding
2. Telemedicine makes access to

healthcare complex.

a. true

b. false
7. Despite Medicares concern with

reimbursing for telemedicine, other
payers are less stringent in their
reimbursement guidelines.

a. true

b. false
3. The Veterans Administration began

using telemedicine in:

a. 2000
b. 2001

c. 2002

d. 2003
4. Telemedicine is expanding rapidly
because:

a. physicians want it

b. patients want it

c. government wants it
d. no one wants it
5. Telemedicine is rapidly expanding
to new areas not originally targeted,
including:

a. rural areas
b. offshore areas

c. urban areas

d. none of the above
8. Mercy ensures that the EHR is the

source of truth for information by
having providers document directly
into the EHR as they engage in
telemedicine activities.

a. true

b. false
9. At Mercy and Cleveland Clinic, video is
stored in the EHR as doctors engage in
telemedicine interactions.

a. true

b. false
10. E
ncounters associated with
telemedicine are often vulnerable to:

a. loss of Internet services

b. long wait times

c. privacy and security
d. confidentiality
State, Zip Code
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AHIMA is enclosed for:
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WHO ARE YOU?

AUTHENTICATING CONSUMER IDENTITY IS BECOMING
INCREASINGLY IMPORTANT IN HEALTHCARE
By Tim McKay, PhD, CISSP
FOR CONSUMERS IN the United States, the answer

to the question Who are you? is becoming increasingly important, especially in relation to ones
healthcare. Safe and secure access to a persons
health information hinges on how their online identity is established and usedespecially as more and
more healthcare providers transition to electronic
health record systems (EHRs) and offer patient portals. Understanding how patient identity is authenticated can help HIM professionals better secure electronically stored health information.
For US healthcare consumers, creating and using online identities is increasingly necessary to
effectively manage ones health. Mobile and webbased tools and portals can provide individualized
information and services as well as offer a means
to connect with others about health issues through
social media. Healthcare organizations that are
implementing EHR systems to achieve certification
through the meaningful use EHR Incentive Program have obligations to provide online services that
promote patient engagementincluding online access to health record information and secure messaging services between patients and providers.
Establishing secure online identities for consumers is key to these efforts, but creating and implementing patient identity systems is challenging.
Within healthcare, systems need to account for appropriate levels of identity assurance, and need to
find the difficult balance of security and usability
to support a wide range of users. This balance needs
to account for individual, societal, and generational differences in determining methods and operational workflows for identity creation and ongoing
user authentication.
Measuring Identity Security

Online health identities for consumers fall into two
categoriesanonymous and verified.
Most health management software and apps, such
as fitness trackers and food diaries, can be accessed
with an anonymous account. These types of accounts are set up online through self-service where
an e-mail address serves as a user ID. After creating
a password, the system then creates an account. As
long as the same user ID and password are accurately entered for the account, the system will give
perpetual online access to the app and to any information the individual creates after establishing the
account. The actual identity of the person in any absolute sense does not matter.
In contrast, to establish an account to use a patient health portal, who you are is vitally important.
Patient portals give access to health information
that is pre-existing, and such systems must know
exactly who is requesting a release health information. The system must establish that the person
making the request is legitimate and authorized to
view and use the health information the account
contains.
To establish an online identity with a high degree of
certainty, the potential account holder must be identity proofed. The National Institute of Standards and
Technology (NIST), a division of the US Department
of Commerce, has established a four-level identity
assurance systemwith each increase in level offering greater assurance.
At NIST Level 1, the entity providing identity credentials (which could be an app development company, healthcare provider, or a third party) does not
need to confirm any user information. This level of
assurance is appropriate for anonymous accounts.
At Level 2, an identity provider collects and verifies
information that backs up an identity claim. This involves asking for information that, while not secret,
is not generally known to the public at large. For example, a health system patient portal may ask for a
medical record number and other demographic information that is checked in real-time against demographics databases maintained by the health system.
If the information is validated, there are additional
steps added to the workflow to improve identity asJournal of AHIMA September 14/33
Who Are You?
surance, including the use of knowledge-based authentication

(KBA). KBA involves asking challenge questions which use publicly accessible, albeit obscure, information maintained by data
aggregators such as credit bureaus. To pass a KBA challenge,
an individual needs to answer a series of multiple choice questions accurately involving things such as prior addresses and
mortgage lenders. From a NIST point of view, adding KBA to the
workflowwhile providing stronger assurance than document
verification aloneis considered Level 2 identity assurance.
However, some within the identity community consider the
addition of KBA to an identity proofing workflow to offer assurance at Level 2.5.
To establish an online identity

with a high degree of certainty,
the potential account holder
must be identity proofed.
NIST Level 3 is initially similar to Level 2 but to complete the
identity proofing workflow an out-of-band passcode is sent to
an address of record, usually a mailing address. The passcode
may be sent to other types of addresses as well (if already known
by the credentialing system) such as by sending the code via text
message or e-mail. As a final step, the individual needs to retrieve the one-time code and enter it into a web or mobile form
to prove they are who they claim to be.
NIST Level 4 requires an in-person inspection of identity credentials, although initial steps to verify account and address information may begin online.
So is it a good idea to always require Level 4, or at least Level 3,
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when an online patient service needs to know a persons identity with a high degree of assurance? Not necessarily. In reference
to patient portal accounts, while Level 1 and 2 provide insufficient identity assurance, there may be little practical difference
in identity assurance between accounts using Level 2.5, Level 3,
and Level 4 identity proofing.
Medical Identity is Valuable and Must Be Protected

The most common attack vector for identity spoofingpretending to be someone youre notfor online health accounts is the
same for both Level 2.5 and Level 3 and is not random. That is,
accounts are not created online by patients themselves, but by
family members. In most cases this is done benignly when an
identity system does not support the creation of caregiver accounts, such as when someone needs portal access to better
care for an elderly parent. And, albeit rare, the second most
common form of spoofing involves an adult setting up a portal
account to spy on a partner; however, even Level 4 identity assurance is not immune to this type of coercive attack, as people
can be forced to turn over their online account credentials to an
abusive party after an account has been created by a very secure
method.
Unless someone is a celebrity, hackers are not generally interested in the specific health information about an individual
that can be accessed through a portal account. To establish a
patient portal account online, a system needs a name, date of
birth, and health record number. Additional identity proofing
follows accurate entry of this information. However, if a hacker knows someones name, date of birth, insurer, and health
record number, they already have what they need for financial gainusing this information to create a portal account is
tangential to their primary goal. In fact, setting up an account
may only draw attention to the fact that a medical identity has
used by thousands of users to achieve
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Who Are You?
Converging Online and In-Person Identities through Digital Membership Cards

MOST NATIONAL HEALTH plans now provide a digital membership card (DMC) to their members. A basic DMC copies
the information on physical membership cards, rendering
the information as an image or PDF which is available on a
smartphone.
Kaiser Permanente recently launched their DMC in its Southern California region, covering 3.3 million patients. It plans to
complete the rollout of DMCs to all of its 9.3 million members
in 2015. More than just a static image, the Kaiser Permanente
DMC is interactive and integrated into its consumer mobile
flagship app, available on iOS and Android platforms, and is
designed to bridge physical and online identity. To access
the DMC feature, a member must first sign in to use the flagship app using their online identity credentials. After sign-
been compromised.
Medical demographic information is valuable. On the black
market, illegally obtained information that contains a name
and credit card information currently sells in bulk for about
30 cents a record. In contrast, an individuals name paired
with an insurer name, medical record number, and date of
birth can sell for $50 or more.1 The reason for the difference
in cost is that the information shown on a health record card
can provide at least one medical visit when used by an identity
spoofer, and usually more than one. When credit card information is compromised, a card is typically cancelled and reissued, which blocks the ability of someone to illegally use the
card beyond the point of cancellation.
However, if a medical identity is lost or stolen an individual
will rarely think to contact their health insurance company
to make a report. Even if they do, an insurer will not typically
change a persons medical record number as its extremely difficult to globally change this number in the myriad of administrative and care systems which use it. As a result, insurance
card information can be presented, for example, in different
emergency rooms to receive medical care over an extended
period of time, and the fraud is only discovered well after the
fact.
Usability and Security Usually at Odds

Authentication refers to using identity credentials to prove you
have a right to access account information. Online accounts can
be protected by three classes of user authentication factors:
Something you know
Something you are
Something you have
Something you know is typically a password. Something
you have could be a cell phone, to which an out-of-band code is
sent as a text message. Something you are involves a personal
ing in, members can access their own DMC and those of all
their proxy subjects. Kaiser Permanente also plans to add a
member picture to the DMC by the end of 2014. The picture
displayed will be one that has been validated by staff during
an office visit, and will be the same picture that is displayed
within the members electronic health record. This allows the
DMC to be a valid form of photo ID for members checking
in for medical appointments, which greatly reduces risks of
misidentification and medical identity theft.
In 2015 the DMC platform will let members take selfies
and upload their own photos for inclusion in their medical
record with their smartphones. Validation of self-taken photos will use the same workflow as when a picture is taken by
Kaiser Permanente staff.
biometric measurement such as a fingerprint or voice sample

that a system compares to a stored reference. Authentication of
identity is strengthened when factors are combined.
One-factor authentication, which involves using passwords
(something you know), is the most common form of online authentication. This holds true for most patient health portals. The
use of passwords is familiar to most everyone who uses the Internet, but passwords are prone to compromise, and are easy to
forget when an account is not used often.
Introducing a second factor strengthens user authentication.
Although not often used with online consumer accounts, the
use of two-factor authentication is increasing. For example,
both Google and eBay allow their account holders to set an
account profile value so that two factors are required for gaining account access. Under this schema, an account holder first
must correctly enter an account password. They then receive a
text message with a code that is sent to a phone number registered in the system prior to the authentication attempt. Entry
of the code is needed before access to account information is
permitted.
The use of a biometric as a second factor for authentication is
relatively rare for online consumer accounts. This is because a
biometric sample needs to be collected and stored by the entity
providing authentication services, which means the user needs
equipment that will read their biometrics, such as a fingerprint
or a voice. This adds both time and cost to the authentication
process. Yet, the use of biometrics in authentication may become more common as mobile devices can capture and transmit biometric information through published services.
Is the use of two-factor authentication practical for health portal accounts? The answer to this question relates to consumer
preferences, system usability, and population characteristics.
The security of a system and its usability are generally at odds.
At extremes the more secure a system is the less usable it is, and
the more usable a system is, the less secure it is. While consumJournal of AHIMA September 14/35
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Who Are You?
ers want both security and convenience, they typically will tip
towards convenience. In addition, security and privacy judgments are personal.
For example, while one individual may never want their HIV
status to be revealed, another may post a positive HIV status
on Facebook. Adding stronger security controls can be seen by
some as irrelevant. Privacy decisions are also influenced by usabilityif an authentication workflow involves too many steps
or if it is perceived as hard, two-factor authentication will generally not be chosen when given an option.
Finding the right balance of security and usability is nuanced,
and the best balance is achieved when both the nature of the
protected information and the characteristics of the users of a
system are considered. To be effective, account creation and authentication workflows must be validated against the intended
population and ideally usability tested with these populations.
For example, in older generations people may not have a cell
phone, share a single cell phone with a spouse, or turn on their
cell phone only when leaving their home. If a two-factor authentication system only uses text messaging as a second required
factor, the method may block health portal access for the people
who would normally most frequently use it.
Future of Consumer Health Identities Relies on

Standards
In the near term, working to achieve industry consensus around
standards for identity systems that allow access to patient portals is strongly advised. Standards need to be comprehensive
and applicable to a wide range of identity services. If standards
are not comprehensive, identity systems can be inadvertently
made insecurefor example, by using two-factor authentication but having methods for resetting passwords that can be
exploited through both automated processes and social engineering. Areas that consumer health identity standards should
address include:
Account creation and identity provisioning
-- Identity proofing
-- User ID rules
-- Password rules

Authentication, including multi-factor authentication
and biometric use
-- Proxy access
-- Account maintenance
--
Account recovery (forgotten password, locked account)
-- Account de-provisioning and reinstatement
-- Suspected fraudulent use
Standards are a necessary step in moving toward the interoperability of consumer health identity credentials. In 2011,
President Obama signed into law a program called the National
Strategy for Trusted Identities in Cyberspace (NSTIC), which
promotes the development of secure consumer identities that
can be used in multiple online services.

NSTIC revolves around four guiding principles, where identity
solutions are:
Privacy-enhancing and voluntary
Secure and resilient
Interoperable
Cost-effective and easy to use
The Identity Ecosystems Steering Group (IDESG), a two-yearold organization, is attempting to promote NSTIC-centric standards development through promotion of pilot programs and
cooperative work between different industry segments such as
finance, government, and healthcare. IDESG meets in plenary
sessions four times a year and between plenaries work is moved
forward through committees, including an active healthcare
committee. In addition, the Healthcare Information and Management Systems Society (HIMSS) has an active workgroup focused on patient identity.
Many have found it encouraging that conversations have begun to align work between IDESG and HIMSS, which may move
standards efforts forward more quickly and begin to provide
consumers the ability to use a single online identity with the
patient portals of many health systems. Interoperable identities need not be limited to healthcare alone. For example, one
set of identity credentials could give access to online banking
accounts as well as to multiple patient health portals. However,
identities that cross domains will likely need stronger protections, requiring higher levels of identity proofing and two-factor
authentication, as they need to be robust in addressing a larger
number of risks related to compromised identities.
Standards Needed to Secure Healthcare Information

Efforts to promote consumer identity standards in healthcare
will benefit both consumers and providers. Standards promote
common workflows and, when critiqued by communities of
interest, make the building of systems more secure. Consumers benefit when common methods promote ease of use, and
authentication methods follow recognizable, repeated patterns.
Promotion of interoperable identities also benefits both consumers and providers. Consumers benefit when one set of identity credentials can give access to multiple services and health
portals. Providers benefit when costs related to the establishment and maintenance of identities are spread among a broader system with less duplication.
Note
1. Medical Identity Fraud Alliance. The Growing Threat of
Medical Identity Fraud: A Call to Action. July 2013. http://
medidfraud.org/wp-content/uploads/2013/07/MIFAGrowing-Threat-07232013.pdf.
Tim McKay (Tim.A.Mckay@kp.org) is a principal technology consultant
at Kaiser Permanentes Health IT Strategy and Policy Group.

Journal of AHIMA

Quiz ID: Q1428509 | HIM Domain Area: Privacy and Security | ArticleWho Are You?

AHIMA
PO Box 77-2735
Last Name
Address
City
State, Zip Code
1. Creating and using online identities is
increasingly necessary to effectively
manage ones health.

a. true

b. false
2. Which division of the US Department of
Commerce has established a four-level
identity assurance system?

a. CMS

b. FDA

c. NIST

d. OCR
3. An individuals name paired with an
insurer name, medical record number,
and date of birth can sell for _____ on
the black market.

a. $20
b. $30

c. $40

d. $50
4. For authentication purposes
something you know is typically:

a. biometric reading

b. voice activation

c. password
d. personal question
5. The more secure a system is, the more
usable it is.

a. true

b. false
6. Which national strategy promotes

the development of secure consumer
identities that can be used in multiple
online services?

a. CMS

b. IDESG

c. HIMSS

d. NSTIC
7. Which NIST Level requires an identity
provider to collect and verify
information that backs up an identity
claim?

a. Level 1

b. Level 2

c. Level 2.5

d. Level 3
8. Introducing a second factor
strengthens user authentication.

a. true

b. false
9. ________ for identity systems that allow
access need to be comprehensive and
applicable to a wide range of identity
services.

a. Standards

b. Securities

c. Privacy

d. Strategies
10. E
fforts to promote consumer
identity standards in healthcare will
not benefit both consumers and
providers.

a. true

b. false

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HIPAAS PLACE IN
COURT-ORDERED
DISCOVERY
DETERMINING WHATS LEGAL DURING
LITIGATION HEALTH RECORD REQUESTS
By Ron Hedges, JD, and Kevin Brady, Esq
EVERY HEALTH INFORMATION MANAGEMENT (HIM) professional, lawyer, and healthcare consumer should be familiar
with the Health Insurance Portability and Accountability Act
(HIPAA). For healthcare consumers, HIPAA offers protections
and rights of access to personal health information. For HIM
professionals and lawyers, HIPAA is a federal law that governs
how protected personal health information can be accessed or
exchanged, and sometimes its regulations impact the way lawsuits are litigated.
The following article takes a closer look at the legal aspects of
protecting and releasing confidential information, and discusses how it can be used, and misused, in litigation.
HIPAA Means Business

When a person is hospitalized and being treated by staff, it is not
uncommon for them to have a computer screen within view that
displays the names and identifiers of fellow patients. The same
can happen while getting blood drawn at a labthe patient
can view names and identifiers of others on computer screens.
While this access to information was not done on purpose by
the healthcare facility, it still constitutes a HIPAA violation.
HIPAA established a set of national standards for the protection of certain health information. Failure to comply with HIPAA
can have serious consequences. For example, New York-Presbyterian Hospital recently agreed to pay $3.3 million to the Department of Health and Human Services Office for Civil Rights
HIPAAs Place in CourtOrdered Discovery
(OCR) and undertake corrective action to settle potential HIPAA

violations arising out of the wrongful disclosure of its patients
electronic protected health information. In extreme situations
HIPAA violations can also lead to criminal prosecution.
For these reasons, a healthcare provider must be vigilant to
prevent or mitigate any potential HIPAA violation no matter
how subtle. In the fall of 2013, a six-office dermatology practice
agreed to pay OCR a fine of $150,000 for not reasonably safeguarding a thumb drive that contained the electronic health
records of over 2,000 patients, according to an OCR press release. The unencrypted thumb drive was stolen from a computer bag in a locked car at the home of one of the employees
of the dermatology practice. OCR did not point to the fact that
the thumb drive was not encrypted as the reason for the fine,
instead saying that the procedures that the dermatology practice had in place did not reasonably safeguard the protected
health information of patients.
HIM professionals are the first line of defense in preventing a
breach of HIPAA-protected information. Since HIM is charged
with maintaining this vigilance, they are the individuals who
may be called upon to identify, preserve, collect, review, and
transmit electronic health records (EHR) to their employers attorneys for use in litigation. Attorneys are business associates
now covered under HIPAA due to a recent change in law, and
have the same duty of vigilance as HIM professionals and their
employers. Each step in the litigation process, including the initial hand-off of records, can pose significant risks for maintaining the confidentiality of the EHR.
had an adverse reaction to a drug, and is also suing the prescribing doctor and the hospital in which the drug was administered.
Again, the plaintiff might seek records of other patients, including any information stored in the EHR. These discovery requests
require attorneys for the defendants to work carefully in order to
comply with HIPAA.
To explain just how this should be done, one first needs to distinguish events that take place in courtrooms and documents
that are filed with courts from materials exchanged in discovery.
There is a basic difference with discovery materials: As a general
proposition these are not filed and the public has no right to see
them. On the other hand, a party that receives discovery materials is free to share these with anyone. How can these principles
be overcome and HIPAA-protected information kept for public
view? The answer is a protective order.
Rule 26(c) of the Federal Rules of Civil Procedure allows a party (or a non-party served with a subpoena) to move for a protective order. On a showing of good causea valid reason that is
Confidentiality in Litigation
There is no real confidentiality in litigation unless an attorney
specifically seeks to protect information. Courts are public institutions and, as a general rule, are open to the public and operate
in the sunshine. If an individual wished, they could walk into
any federal or state court, sit in a courtroom, and listen to whatever is transpiring therewith some exceptions. This tradition
of public access can best be described as follows: The public
has a qualified right of access to trials that can only be overcome
in compelling circumstances, according to Sedona Conference
Guidelines. Similarly, an individual could walk into the office of
a court clerk and review any document that had been filed in a
particular civil action as well as the docket sheet that describes
that actionagain, with some exceptions. However, these principles of public access are inverted during the discovery processthe first steps lawyers take during litigation to seek information from adversaries or non-parties that the party will then
use to prove or disprove claims.
There can be a lot of discovery undertaken in a civil action,
which means access to confidential information. For example,
lets say there is a medical malpractice action pending and that
the attorney for the plaintiff, the alleged victim of malpractice,
wants to prove that the defendant doctor had committed similar
acts in the past. Assuming that the plaintiff is allowed to make
such proofs, the plaintiff might demand records pertaining to
other patients. Or a plaintiff could bring a products liability action against a pharmaceutical manufacturer because the patient
HIPAAs Place in CourtOrdered Discovery
proven to exista court may issue an order to protect a party or

person from annoyance, embarrassment, oppression, or undue
burden or expense, according to the procedure rules. One reason for such an order is that the information sought is subject to
protection under HIPAA. Regarding the examples above, a protective order could be issued that requires:
Information about other patients to be rendered anonymous
Information about other patients to be disclosed only if
the party who requested the information kept it confidential
A ny deposition in which information about other patients
was discussed to be kept confidential
Not surprisingly, information about the plaintiff would likely
not be kept confidential. After all, once the plaintiff chose to put
his or her medical history in issue by filing a complaint, he or
she likely waived any protection under HIPAA that is provided
to information relevant to the claims asserted.
There certainly are nuances for any attorney to consider when
HIPAA-protected information is produced during discovery. For
example, that information may be used by both the plaintiffs
and defendants experts in evaluating the claims and expressing opinions. Those experts would likely fall within the scope
of the confidentiality provision of a protective order, as would
their reports.
While there is no constitutional right to look at discovery materials, there is a constitutional right to sit in a courtroom, listen to what is going on there, and to read a filed document. It
is doubtful that a judge would close a public court proceeding
so that, for example, an expert could compare what happened
to a plaintiff with other patients even when the information is
HIPAA-protected.
What this Means for the HIM Professional

While some HIM professionals are pulled into court to testify
as part of litigation, the average HIM professionals involvement
is typically through their role as a records custodian. There are
some actions that an HIM professional could take that would
help ensure personal and companywide compliance with
HIPAA while also meeting the requests made through discovery
and other legal actions. These include:
Consult with your in-house attorney (if you have one available) to clarify what information you have been asked to
identify, preserve, review, or produce and remind the attorney that what you collect may be subject to HIPAA.
Document each step of the processand suggest that
everyone else in the process do the sameso you have a
record of the steps that were taken to protect the confidentiality of health records.

Conspicuously mark every appropriate document as
HIPAA-protected. This will be a reminder to your attorney and the opposing counsel that disclosure of the
requested documents should be restricted. Mark the containers (DVDs, thumb drives, etc.) of electronic data as
well and include the markings in any correspondence that
transmits the information.

T
ake reasonable steps to protect the confidentiality of
documents and limit access when the information is requested and transmitted to your attorney.
Make sure any transmission of data, whether via the Internet or though storage devices, maintains confidentiality
by using secured, encrypted, password-protected methodologies with two-step verification on secured websites
(i.e., https in the URL).
A sk questions. Specifically ask your attorney what he or
she is going to do to protect the confidentiality of the data
you are providing while it is in their possession during the
litigation. Also ask your attorney to ask the opposing attorney what he or she is going to do to protect your organizations confidential data while it is in their possession
during the litigation, especially if it is going to be kept by a
third-party vendor.
Make a note to follow up after the litigation is over and ask
that the confidential information you provided to your attorney and the opposing partys attorney be returned to
you or properly destroyed.
Check with any discovery vendors used during the litigation to make sure that they do not have your organizations
confidential data and if they do, ask how they are protecting it. Make sure that the vendor returns any health information when the case is over as well.
Health Information Protection Should Extend

Through Litigation
Make no mistake, protected health information is subject to
discovery if it is relevant. The question is whether access to that
information can be kept confidential, whether the information
can be shared only with the opposing party during discovery
and/or kept sealed in a court file or a court proceeding. While
these are mainly the concerns of an attorney, health information professionals should be aware that health information is,
indeed, protected and should always be treated that way by a
facilityespecially during litigation.
References
Department of Health and Human Services. Dermatology
practice
settles
potential
HIPAA
violations.
December
26,
2013.
http://www.hhs.gov/news/
press/2013pres/12/20131226a.html.
Office for Civil Rights. Summary of the HIPAA Privacy Rule.
OCR Privacy Brief. http://www.hhs.gov/ocr/privacy/hipaa/
understanding/srsummary.html.
The Sedona Conference. The Sedona Guidelines on
Confidentiality and Public Access March 2007. https://
thesedonaconference.org/download-pub/478.
Ron Hedges (r_hedges@live.com) is a former United States Magistrate
Judge in the District of New Jersey and is currently a writer, lecturer, and
consultant on topics related to electronic information. Kevin Brady
(KBrady@eckertseamans.com) is a partner in the commercial litigation
group at Eckert Seamans Cherin & Mellott, LLC, based in Wilmington, DE.
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2014
CONVENTION
PREVIEW
SEPTEMBER 27 OCTOBER 2, 2014
SAN DIEGO CONVENTION CENTER, UPPER LEVEL, SAN DIEGO, CA
PRE-CONVENTION EVENTS
SEPTEMBER 27-28, 2014
CONVENTION AND EXHIBIT
SEPTEMBER 29-OCTOBER 1, 2014
LOOKING AHEAD AT CONVENTION 2014
This year has been both an exciting and challenging one for the healthcare industry. Therefore, the
86th Annual AHIMA Convention and Exhibit has been designed to provide a space where health
information management (HIM) professionals can address the challenges and opportunities that face
the healthcare industryboth now and in the future. The theme for this years meeting, Leading the
Way to Health Intelligence, serves as a guideline for the discussions that will take place as industry
and government thought leaders and experts facilitate thought-provoking sessions and panels with
a focus on how HIM is transforming the healthcare industry.
Attendees can expect to gain new insights on the evolution of the HIM field and HIMs role in
healthcare, connect the dots on how HIM roles are likely to evolve, and gather information that will
support efforts to move organizations forward in embracing the benefits of expanded HIM roles.
Some highlights of the convention include:
Exhibit hall showcasing the latest technologies and solutions for healthcare
AHIMA Foundation Thought Leaders Lecture Series
Educational site visits
Professional Development and Career Center
AHIMA, AHIMA Foundation, and Journal of AHIMA Booths
IFHIMA Business Meeting
AHIMA Foundation Silent Auction
Networking events
Educational sessions on a variety of topics
Visit www.ahima.org/convention for the latest updates to the convention program, and to view
an informational video on the event.
BREAKING NEWS DELIVERED ONLINE
Whether at the event or back home, you can follow all of the convention action online. Look for
special e-Alert announcements linking you to a full online edition of AHIMA Today, the on-site
convention newspaper. Also, visit the Journal of AHIMAs website, http://journal.ahima.org, for
special convention coverage in the days leading up to convention and during the event.
To get news by the minute, follow the convention on Twitter with the hashtag #AHIMACon14 as
staff and attendees post updates you can receive on your computer or phone. Sign up at http://
twitter.com/ahimaresources.
Learn about the Latest HIM

Products and Services in the
Exhibit Hall
The exhibit hall will feature

approximately 200 exhibitors.
Discover leading-edge products and
services and earn 1 CEU by visiting the
exhibit hall. An exhibitor Scavenger
Hunt game features the chance to
win a $500 AmEx gift cheque.
The following is a list of exhibitors
as of August 5. Check for convention
updates in the October Journal
of AHIMA or at www.ahima.org/
convention.
3M Health Information
Systems
A2iA
ABT Medical Inc.
Access
Addison Group
AGS Health
AHA Central Office
AHDI
AHIMA
Altegra Health, Inc.
American Healthcare
Documentation
Professionals Group
American Medical
Association
Amphion Medical
Solutions
Anthelio Healthcare
Solutions
ARGO
Art2link
Artificial Medical
Intelligence, Inc.
Asante Alliance
Ashford University
Aviacode
BACTES Imaging
Solutions
Beacon Partners, Inc.
Berkeley Research Group
Bottomline Technologies
Caban Resources
CAHIIM
Care Communications
Inc.
Career Step
CCHIIM
CCK City Network, Inc.
CDIMD - Falcom
Consulting Group
Channel Publishing, Ltd.
Chartmaxx By Quest
Diagnostics
ChartWise Medical
Systems
Coastal Healthcare
Consulting
CODEMED, Inc.
Coding Network, LLC
(The)
CodingAID
College of St. Scholastica
COMFORCE
CynergisTek, Inc.
Data Distributing, LLC
Decision Health
Dell, Inc.
Digital Transcription
Systems, Inc.
Diskriter, Inc.
Diversified Medical
Records Services
Dolbey
Driversavers Data
Recovery
East Carolina University
eCatalyst Healthcare
Solutions, Inc.
Eclat Health Solutions
EDCO Health Information
Solutions
Elsevier
Elsevier | MC Strategies
Enovative
EPSON
eSolutions
Excite Health Partners
FairWarning, Inc.
Find-A-Code
For The Record
FormFast
Fujitsu Computer
Products of America
FutureNet Technologies
Corporation
GeBBS Healthcare
Solutions
GRM Document
Management
H.I.M. Recruiters
HCPro
Health Data Consortium
Health Data
Management
Health Information
Associates (HIA)
Healthcare Coding and
Consulting Services
(HCCS)
Healthcare Cost Solutions
Healthcare Resource
GENERAL SESSION AND SPEAKER HIGHLIGHTS

Rob Lowe
Actor and cancer awareness advocate Rob Lowe will

present the closing keynote address at AHIMAs 86th
Convention and Exhibit on Wednesday, October 1.
Most recently seen as the lead role in the political
thriller Knife Fight (2013), Lowe had a leading role
on NBCs Parks and Recreation and Showtimes
Californication series. Lowe is also the author of Stories I Only Tell
my Friends. This year, Lowe published his second memoir, Love Life.
After his presentation, Lowe will participate in a book signing.
Karen B. DeSalvo, MD, MPH, MSc, National

Coordinator for Health Information Technology
Karen B. DeSalvo, MD, MPH, MSc, has focused her 20year career toward improving access to affordable,
high-quality care for all people with a focus on
vulnerable populations and to improving overall
health. A physician, DeSalvo has done this through
direct patient care, medical education, policy and administrative roles,
and as a researcher. As the national coordinator for health information
technology, she is leading the nations charge to promote, adopt, and
meaningfully use health information technology in order to achieve
better care, lower costs in healthcare, and improve the overall health
of everyone in the US.
Inspired Leadership
Rich Bluni, RN
Sometimes the very qualities that make healthcare

leadership so deeply rewarding can also make it a
challenge over time to sustain energy and passion.
In this presentation, Rich Bluni, RN, author of Inspired
Nurse and Oh No! Not More of That Fluffy Stuff,
provides a wealth of action-oriented spiritual stretches that helps
more fully integrate the rewarding gifts of healthcare into healthcare
professionals daily lives. Inspired Leadership is a welcome validation
that when professionals stay engaged and committed, theyre more
likely to achieve the best results in terms of both clinical outcomes and
human compassion.
AHIMA Healthcare Here and Now Speaker

Jeff Arnold, Chairman and CEO of Sharecare
Jeff Arnold founded health and wellness platform

Sharecare with Dr. Oz, in conjunction with Harpo
Productions, Sony Pictures Television, and Discovery
Communications. Sharecare helps people maximize
their human potential by connecting them with
medical experts, support tools, and interactive programs. Join Arnold
as he leads discussions and shares with the AHIMA audience the latest
topics in healthcare.
AHIMA Foundation Thought Leaders

Speaker
Eric Topol, MD
Healthcare futurist Eric Topol, MD, cardiologist and
chief academic officer at Scripps Health, gives a tour
of the advances in medical technology happening
all around todays healthcare professionals and their
business. Topol communicates the thrill of working in such exciting,
transformational timesand the urgency of not being left behind. He
was voted the #1 Most Influential Physician Executive in the United
States in a poll conducted by Modern Healthcare.
WHATS NEW IN 2014?
Attendees can look forward to new features at this years convention,

such as new education tracks and additional opportunities for students.
New Education Tracks
Two new education tracks will be added at this years convention, an

Executive Sessions Track and a Policy and Hot Topics Track.
The executive sessions track will include a question and answer
session on Monday with Eric Topol, MD. In addition, information
governance (IG) experts inside and outside of healthcare will discuss
the need to adopt IG in healthcare. AHIMA will share a high-level
review of findings from the first survey on Information Governance in
Healthcare, conducted earlier this year in partnership with Cohasset
Associates, and share its plan for moving IG forward in healthcare.
The policy and hot topics track will feature sessions on Saturday,
Sunday, and Monday, offering the latest policy updates on hot topics in
healthcare. Government, health information, and health IT experts will
facilitate educational sessions and panel discussions.
New Opportunities for Students
This year, student teams from around the country will compete against
one another in an HIM-themed Jeopardy-style competition. A trophy
and $5,000 scholarship are at stake. There will also be a student lounge
this year on the exhibit hall floor, open during exhibit hours.
AHIMA Early Riser and Setting Sun Yoga Sessions
This year, AHIMA invites convention attendees to begin and/or end

the day with yoga sessions that will help create a sense of mindfulness
and increase brain functionto retain all the education and information
activity attendees are experiencing throughout the day. A registration
fee of $30 per session applies and includes the use of a yoga mat.
On-site registrations will not be accommodated for the morning yoga
sessions.
AHIMA CONVENTION APP
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Working Smart a professional practice forum

Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / The Sound Record
Accessing and
Using Data from
Wearable Fitness
Devices
By Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA
A RAPIDLY AGING global population in many industrialized

countries accompanied by an increase in chronic diseases and
the high cost of managing such diseases has led many to turn to
a technological solution to ease the burden on healthcare professionals and provide useful tools to the elderly and chronically
ill. An increased emphasis on preventing hospital admissions
and allowing patients to receive care in their own homes also
has encouraged the healthcare industry to evaluate how remote
mobile technology implementations can help.
All of these socio-economic forces, and many more, are driving the development of personal health devices that allow people to not only monitor their own conditions but communicate
health information obtained through devices to healthcare professionals and other caregivers.
One rapidly growing segment of this mobile health market is
wearable consumer devices. With Google Fit, Apple HealthKit,
Samsung Gear, and others all rolling out wearable consumer
devices, there exists a genuine state of hype surrounding the
ability of empowered health consumers to track, manage, and
seize control of their own health issues and goals. For HIM
professionals, the question remains of how to access this new
health information, and whether or not it should become part
of a patients formal health record.
ket in general. Activity in the health and fitness sector has

shown a 62 percent increase over the past six months on the
Flurry platform alone, according to an article published in
Health Data Management.1
The same article says Mike Mytych, principal at Health Information Consulting, believes the real benefits of mobile/
wearable applications will result from the socialization and
education of healthcare consumers coping with similar medical conditions. These connected and empowered consumers,
bolstered by the insight and support of online communities,
will embrace the opportunity to manage their health information in the long run and ultimately benefit from access to this
health data. As a result, consumers might feel more empowered. Mytych believes the healthcare industry is witnessing
an evolution of the personal health record (PHR), which will
allow whole families of healthcare consumers to access and
control their personal health information. Access by medical
researchers to the data captured by wearable consumer devices, and the resulting aggregated health data across all device
owners, will have a direct impact on individual health, wellness, care planning and medication compliance, the article
concludes.
The Quick Rise of Wearables
In early 2013, the Pew Foundations Tracking for Health study

found that 69 percent of Americans track some form of healthrelated information and 21 percent of them use some form of
digital device to do so.2
Individuals are tracking a variety of health-related data via
a growing number of wearable devices and smartphone apps.
More data relevant to health are also being captured passively
A recent study of 6,800 iPhone and iPad health and fitness

app users conducted by the mobile analytics and optimization vendor Flurry revealed that use of health and fitness apps
is growing 87 percent faster than the entire mobile industry.
Consumer use of mobile health and fitness apps in the first
half of 2014 is almost double that of the mobile platform mar48/Journal of AHIMA September 14
Wearable Devices Could Transform Medicine
as individuals communicate with one another through social

networks while shopping, working, or any number of other activities that leave digital footprints.
Eric Topol, MD, chief academic officer of Scripps Health and
professor of genomics at the Scripps Research Institute, recently told the Wall Street Journal what he predicts the healthcare
landscape will look like in 20 years.3
Hospitals, except for certain key functions like intensivecare units and operating rooms, will be completely transformed
to data-surveillance centers. People will look back and laugh
about the old physical office visit and the iconic stethoscope
along with the way so much of health care was rendered in the
pre-digital era, Topol said.
Almost all of these forms of personal health data are outside
of the mainstream of traditional healthcare, public health, or
health research. Traditional sources of medical, behavioral, social, and public health research still largely dominate as sources
of health data, such as those collected in clinical trials. Data is
still primarily collected by sifting through electronic health records or conducting periodic surveys.
The immediate benefit of self-tracking data is that it can provide better measures of everyday behavior and lifestyle, filling
the gaps in more traditional clinical data collection and presenting a more complete picture of health.
Healthcare consumers embracing the use of digital self-tracking data tend to have more education and higher household incomes than the general population, research shows. Research
also reveals a population that is more inclined to be white,
Asian, and female than the general population.4
The social trend of participating in online communities devoted to sharing health and disease experience is called biosociality by researchers. Biosociality also includes self-tracking data
and sharing this information amongst participants.
Individuals willing to share their self-tracking data for research
believe the data will advance knowledge in the fields related to
personal health data such as general healthcare, public health,
computer science, and social and behavioral science. However,
the majority of self-tracking participants do so with the expectation that their information only be shared anonymously. Among
consumers no singular privacy consensus exists. Instead researchers must contend with a wide range of privacy policies,
opinions, and concerns.
SmallStepsLab serves as an intermediary between the datarich company Fitbit and academic researchers via a preferred
status application programming held by Fitbit. Researchers
pay SmallStepsLab for this access as well as other enhancements that they might want.
These promising early examples foreshadow a much larger
set of activities with the potential to transform how research is
conducted in medicine, public health, and the social and behavioral sciences, according to findings from The Health Data
Exploration Projecta study performed by the California Insti-
tute for Telecommunications and Information Technology and

supported by the Robert Wood Johnson Foundation.5
Work Remains to Optimize Personal Health Data

With so many vendors competing in the personal health data
space, and no real effort to establish a common set of interoperable standards, healthcare consumers will quickly come face
to face with a very real interoperable barrier preventing the exchange of their health data across disparate platforms or with
provider health IT systems.
There is still work to be done to enhance mobile interoperability and standards before the full knowledge potential of personal health data is realized, say researchers from the Health Data
Exploration Project. As part of the project, they identified key
areas that need to be addressed in order to optimize all forms
of health data:
Privacy and Data Ownership

While many consumers were not concerned about the ownership of the data they generated, the vast preponderance of consumers insisted on sole ownership or at least shared ownership
of the data with a mobile device company that collected it.6 Customer surveys revealed that among individuals that agreed to
make their personal health data available for research, 57 percent would only do so on the condition that their privacy would
be protected. Over 90 percent of respondents indicated the importance of anonymity of the data contributor.
Informed Consent
Consider that most privacy policies are provided on the device
vendors terms and conditions contract. Colloquial wisdom
indicates that the majority of consumers will click through
product terms and conditions without reviewing them. The
straightforward question becomes: Does informed consent
exist at all? Presently, consumer excitement over the potential
of personal health data has blinded the public to potential privacy risks. Meanwhile, the industry assures us that a variety of
new informed consent constructs are being evaluated to ensure favorable outcomes for all stakeholders.
Data Sharing and Access

One cultural driver of personal health data research is a growing appeal, enthusiasm, and occasion to share data with an
ever expanding audience of individuals interested in learning
more about specific health conditions. One common trend is
sharing data with others with similar medical conditions on
Internet-based groups such as PatientsLikeMe or Crohnology.
The immediate benefit is an increased knowledge about mutual
health concerns, as well as participation in an intrinsic emotional brotherhood of shared experiences. In the online health
information sharing environment, the decision to share informationand to what degreeinvolves the same individual

cognitive mental process involved in making a decision about

revealing private information in an interpersonal context.7
Data Quality
The lack of consensus on industry standards and information
governance conformance criteria highlights some healthcare
experts concerns about the validity of personal health data. Industry leaders believe that concerns regarding standardization
and information governance will be addressed as the wearable
consumer health device, apps, and services market matures.
Considering the rapid growth of this mobile device market segment, the industry is rapidly reaching a tipping point. The exponential growth in the number of people tracking their health,
and the growing number of tracking apps and devices on the
market, will soon force the issue of industry standards and information governance to be addressed.
Wearable Device Data and Information Governance

To maximize personal health data for the public good, the industry must develop creative solutions that provide individual
privacy and security safeguards while ensuring access to highquality, timely, and relevant personal health data for research.
Going forward, standardization is paramount to the establishment of transparent and open public, private, and academic
sector collaborations that will balance the needs and concerns
of privacy, confidentiality, security, intellectual property, and
science.
One additional indicator of the momentum behind the movement to produce and collect data about our personal health
experiences is evident in the small but growing Quantified Self
Initiative, which has brought together proponents of self tracking
activities. Quantified Self is a driver in the growing relevance, eagerness, and occasion to share personal health data with others.
One common denominator in all of the current data aggregation activities is that the devices, apps, and service that capture
and store them are owned by entities that are outside of the
mainstream of traditional healthcare, public health, or health
research. This includes everything from small start-ups to globally active consumer electronics, telecommunications, computer, and social network corporations.
Medical, behavioral, social, and public health research still
largely relies on traditional sources of health data, such as those
collected in clinical trials funded by the pharmaceutical industry or the National Institutes of Health, sifting through electronic health records, or conducting periodic surveys of representative samples of individuals to make inferences about broader
behavioral, social, or public health trends. But almost by definition these traditional methods of health research cant capture
the multidimensional and continuous nature of the behavioral,
social, and environmental influences that are increasingly recognized as critical to human health.
Proponents of consumer health devices have come to realize
that incompatible systems are a barrier to their widespread use

and acceptance. With the slow roll-out of useful personal health
devices, proponents have begun to embrace interoperability
and functionality standardization.
AHIMA has said it is committed to the growth of the personal mobile health market through standardization and
development of information governance principles. AHIMA
has been working on initiatives at Health Level Seven and
the International Organization for Standardization (ISO).
In addition AHIMA supports the work underway at the IEEE
Standards Association, and the IEEE-EMBS affiliated 11073
Personal Health Data Working Group, which is formulating
standards for data formats and communications to ensure device interoperability.
Notes
1. Goedert, Joseph. Can Google Succeed with Health Apps?
Health Data Management. July 2014. http://www.healthdatamanagement.com/news/Can-Google-Succeed-withHealth-Apps-48247-1.html.
2. Duggan, Maeve and Susannah Fox. Tracking For Health.
Pew Research Internet Project. November 26, 2013. http://
www.pewinternet.org/2013/11/26/part-three-trackingfor-health/.
3. Wall Street Journal. Eric Topol on the Future of Medicine.
July 7, 2014. http://online.wsj.com/articles/eric-topol-onthe-future-of-medicine-1404765024.
4. Duggan, Maeve and Susannah Fox. Tracking for Health.
5. California Institute for Telecommunications and Information Technology. The Health Data Exploration Project
(2014) Personal Data for the Public Good. http://hdexplore.calit2.net/index.html.
6. Xu, Heng et al. Information Privacy Concerns: Linking
Individual Perceptions With Institutional Privacy Assurances. Journal of the Association for Information Systems
12, no. 12 (December 2011): 798-824.
7. Ibid.
References
Rabinow, Paul. Artificiality and Enlightenment: From
Sociobiology to Biosociality. The Science Studies Reader
New York: Routledge, 1999, p. 407.
Clarke, Malcolm et. al. Developing a Standard for Personal
Health Devices based on 11073. 29th Annual International
Conference of the IEEE (2007): 61756177.
Glass, Thomas A. and Matthew J. McAtee. Behavioral Science
at the Crossroads in Public Health: Extending Horizons,
Envisioning the Future. Social Science & Medicine 62
(2006): 16501671.
Harry Rhodes (harry.rhodes@ahima.org) is a director of HIM practice excellence at AHIMA.
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How and Why to Preserve Health

Records During Litigation
By Ron Hedges, JD
THE TERM PRESERVATION, when used in a legal context, refers to placing information identified as relevant to a civil or
criminal US court case in a legal hold to ensure the data is not
destroyed or tampered with.
Health information managers, or anyone who works with
records, will likely become embroiled in litigation when their
employerbe it a hospital system, a medical practice, an insurer, or another entity involved in healthcareis involved in
a legal case. The employer may be a plaintiff, a defendant, or a
nonparty that has information sought by others for use in their
litigation. Health information managers may have to locate,
collect, and process information relevant to that litigation, and
should understand how to preserve information and when such
preservation is appropriate. Health information management
(HIM) professionals should also know what to do if something
goes wrong with their processes.
Duty to Preserve Data

HIM professionals have a duty to preserve information that has
been identified as important in a court case. But it is first important to distinguish that duty from a separate question: Why does
a healthcare organization create and retain records?
An organization may create records for different reasons.
These include:
Business reasons: records related to how business is conducted
Medical reasons: records related to the care and treatment of patients
Billing reasons: a subset of business reasons that can be
related to direct charges and/or to seeking reimbursement from third-party payers
R
egulatory reasons: records that the organization is required to create under federal, state, or local laws or regulations
Once a record is created it is presumably retained. Remember
this distinction: retention is distinct from preservation. Presumably, healthcare organizations have a records retention schedule or schedules that specify how a particular record is classified, where it is kept, and when it can be destroyed.
Records retention or records destruction requirements,
which dictate the time that a given record must be retained,
can be driven by the reason the records are created. For example, Equal Employment Opportunities Commission rules
require that certain employee information be retained for a
number of years.
With this background it is easier to explain why it is important
to keep in mind the distinction between retention and preservation and the duty to preserve. The duty to preserve trumps
retention requirements. What that means is simple: When required to preserve certain information, that information is no
longer subject to records retention rules. Records managers
must preserve that information regardless of whether a records
retention schedule allows its destruction.
This is because the US, with one exception, is a common law
country. That means that many of the countrys litigation-related rules did not originate in statutes or regulatory codes but,
rather, were derived from judicial decisions. The duty to preserve arose from one of those decisions, rendered in England
in the early 1700s. The reason for preservation is to ensureor
attempt to ensurethat relevant information can be produced
and used in a civil action.
When to Preserve Information

The question of when does the duty to preserve arise is vital
for an HIM professional to understand. If preservation begins
too late, bad things can happen. The decision to preserve will
presumably be made by an attorney, but it never hurts to know
what his or her thought processes are behind the decision.
Think of a triggerthis word is often used when answering the question of when to begin preservation, and refers to a
triggering event that sends preservation into action. Generally
speaking, the triggering event is when an organization knows
of litigation or reasonably anticipates that litigation will commence. This can be a simple event. For example a trigger can
occur when:
An organization is served with a summons and complaint
An organization is served with a subpoena
The question of when does

the duty to preserve arise is
vital for an HIM professional to
understand.
However, everything is not black or white when deciding what
a triggering event might be. That decision might be very factsensitive. For example:
A disgruntled employee tells his supervisor that the employee has been passed over for a promotion because of
his age
The same employee submits a letter to the employers human resources department
The employee hires a lawyer who writes a letter to the employer suggesting an informal resolution of the problem
The employee goes to the state Equal Employment Opportunity Commission, which commences litigation against
the employer
This example suggests a continuum of events. Which of these
events might trigger the employers duty to preserve? Again, this
is a decision that ones attorney will presumably make and inform healthcare staff on how to proceed.
Determining What Data to Preserve

A duty to preserve exists and you have been instructed to preserve relevant information. The next question, once the duty has
arisen, is to decide what to preserve. This is known as the scope
of preservation.
The duty to preserve extends to physical objects as well as
things that exist in computer systems, including electronic
health records. The content stored in electronic health records
is best defined for litigation purposes as electronically stored information (ESI). The term comes from the Federal Rules of Civil
Procedure, the rules that govern civil litigation in federal courts.

Companies can easily become involved in litigation that has
nothing to do with any electronic health records. For example, a
dispute about the late delivery of toilet supplies or the number
of vacation days a group of employees are entitled to would not
involve health records.
But when cases do involve information stored in the medical
record, a few basic questions need to be answered by health records managers, the organizations that employ them, and the
organizations attorney before preserving information:
What time period or periods are concerned?
What ESI needs preserving?
W ho is the custodian of specific ESI that must be preserved?
How should decision-makers answer these scope questions?
The answer to that last question, at least in theory, is parties
may obtain discovery that is relevant to any partys claim or
defense, according to the Federal Rules of Civil Procedure. In
other words, scope is defined by what a party states they want
and is approved by the court. A partys claims or defenses also
define the time periods in issue. The scope of what must be produced and hence preserved may be broader than that [which]
is relevant.
The duty to preserve may go beyond what is located in an organizations file room or the server in the basement. The Federal Rules of Civil Procedure also speak of production of things
within a partys possession, custody, or control. For example,
assume a company has some records in the cloud and those
records are relevant to a claim the employer has asserted. The
duty to produce and hence preserve the information likely extends to that cloud-based data. A warning makes sense here: the
duty to preserve is broader than the obligation to produce. Generally speaking, you only produce in response to requests from
the other side. You may sit on relevant data and never produce
it. But that doesnt mean that you dont have to preserve it.
Three Things to Consider with Preservation

When considering litigation and the need to preserve data, HIM
professionals should consider three things:
Why content might need preserving
What event might trigger preservation
What is the scope of preservation
The October issues e-HIM Best Practices will explore potential consequences if information is not preserved and is instead
spoiled.
Ron Hedges (r_hedges@live.com) is a former United States Magistrate
Judge in the District of New Jersey and is currently a writer, lecturer, and
consultant on topics related to electronic information. This article is intended solely for educational purposes; it is not intended to provide legal
advice.

Why Standards Should Matter to HIM

Professionals
By Diana Warner, MS, RHIA, CHPS, FAHIMA
Editors note: This article introduces Standards Strategies, a new Journal of AHIMA department that will provide guidance to HIM
professionals on applying health data standards in areas including business, clinical care, and compliance.
AHIMA HAS ALWAYS been committed to working collaboratively with others to develop standards relevant to the management of health information and data. The associations stated
mission says AHIMA leads the health informatics and information management community to advance professional practice
and standards.
As such, AHIMA is partnering with healthcare industry stakeholders, including other associations, employers, universities,
government agencies, and consumer groups, to increase the
use of health data in professional practice, create standards for
interoperability, and advocate for their consistent application
across the healthcare domain.
This new Standards Strategies column is designed to offer
practical applications and best practices for health data standards in business, clinical care, and compliance areas, as well
as for legal and evidentiary purposes. This column will convey
to HIM professionals the importance of standards in health information management (HIM) practices, including electronic
health record (EHR) documentation, compatibility and consistency of health information and data, and reducing the duplication of effort and redundancies in data creation.
As a matter of practical application to support information exchange, EHRs and other data-driven clinical tools must present
data in standardized ways, and separate organizations providing services for the same patient need to share information securely. Standards Strategies article topics will aim to synthesize
and align with AHIMAs informatics strategy and other goals
relating to datasuch as appropriate data use, standards and
interoperability, population health, eMeasure quality reporting,
and eDiscovery.
Standards Do Matter
Technology has created an unavoidable global economy and
has provided easy access to digital information without regard
to where a person may be located. Because of this, information
must be managed in new ways, including the consolidation
of data and its meta-tagging for search functionality and usability. Standards are essential if healthcare hopes to improve.
They help reduce medical errors and risks to patient safety,
and improve use of and access to EHRs and personal health
records.
Appropriate and thoughtful adoption of standards also support innovations in care to enable data aggregation from disparate sources and glean knowledge that can inform life-saving
clinical decisions, new procedures, and productssuch as new
medicines and healthcare equipment. Governments and agencies are now capitalizing on the availability of health information to identify trends in the occurrence, prevalence, and management of health conditions. Better standardization, quality,
and accuracy of health information will make it easier to measure changes in population health over time.
The future state of health information is electronic, patientcentered, comprehensive, longitudinal, accessible, and credible. Therefore AHIMA is taking the lead in defining standards
for electronic health information. The healthcare industry recognizes HIM professionals as the experts in providing consistent management, guidance, policies, and processes to ensure
accurate, accessible health information and improved longitudinal coordination of care.
Standardization in the field of health informatics aims to improve the consistency of health information and data, as well
as reduce duplication of effort and redundancies in areas such
Role of Clinical Documentation Coach

PUBLISHED IN 2013, ISO/22857: 2013 Health informaticsGuidelines on data protection to facilitate trans-border flows of personal health data provides important and
much-needed guidance on data protection requirements
that facilitate the transfer of personal health data across national or jurisdictional borders. In todays world where people can travel across the globe in a day, there is a need for
their data to be accessible and secure wherever they are.
This standard is informative with respect to the protection
of health information within national/jurisdictional boundaries and provides assistance to national or jurisdictional
bodies involved in the development and implementation of
data protection principles. This standard and many others
are available for sale at the ANSI Online Standards Store at
http://webstore.ansi.org.
as healthcare delivery, disease prevention and wellness promotion, public health and surveillance, and clinical research related to health service.
AHIMAs Participation in Standards
Standards are Needed Now, Not Tomorrow

Healthcare is shifting from the ability to simplify the collection
of data to the ability to govern and use it effectively in an electronic environment. HIM professionals are needed more than
ever, and engagement of HIM professionals in health-related
standards development and harmonization will help ensure
that the standards match the reality of the health information
data, creation, use, and management.
The need for formal standards has been identified by the AHIMA membership as an important way to recognize principles
and best practices that enable effective management and governance of health information. Future installments of Standards
Strategies will highlight HIM practice standards or guidelines
recognized across the healthcare industry as well as international standards that currently impact the HIM profession.
Reference
AHIMA. 2014-2017 Strategic Plan. http://library.ahima.org/
xpedio/groups/public/documents/ahima/bok1_050165.
pdf.
Diana Warner (Diana.warner@ahima.org) is a director of HIM practice
excellence at AHIMA.
AHIMA actively participates in standards development organizations (SDOs). AHIMA is responsible for the leadership, administrative organization, and management of ISO Technical
Committee 215 for Health Informatics for the International Organization for Standardization (ISO). ISO is the worlds largest
developer and publisher of international standards. Working in
a private-public model, ISO brings together over 160 countries
to create consensus-based standards. In the United States, the
American National Standards Institute (ANSI) is the US representative and a founding member of ISO. Through ANSI, the US
has immediate access and input into globally important standards development processes. ANSI coordinates the US voluntary consensus standards system.
Appointed by ANSI through a competitive process in 2011,
AHIMA holds the prestigious designation to provide the Secretariat office to ISO/TC215 and serve as administrator of the
United States Technical Advisory Group (US TAG). In these
dual roles, AHIMA leads the operations of ISO/TC215 and the
US TAG. AHIMA also provides expertise by participating in
the standards development processes within ISO and other
SDOs such as Health Level Seven, World Health Organization, and International Health Terminology Standards Development Organisation. These are important components of
AHIMAs vision and strategic work to advance HIM and health
informatics to enhance the delivery of efficient, safe, and quality healthcare. See the side bar for an example of work recently
done through ISO.

Curing Inherited EHR Ailments

EHR Remediation Fixes System Issues and Better Aligns Clinical Workflow with
Clinical Documentation
By Michelle Wieczorek, RN, RHIT, CPHQ, and Jill S. Clark, MBA, RHIA, CHDA, FAHIMA
IN RECENT YEARS the introduction of the American Recovery and Reinvestment Acts (ARRAs) meaningful use EHR
Incentive Program has encouraged more healthcare entities
to chart their course toward electronic health record (EHR)
system implementation, taking advantage of the opportunity
for incentive payments to support the high price tag of an EHR.
Though most expect a high return on their investment in, at
least, the form of improved healthcare quality, one of the core
problems with EHRs has yet to be addressedimplementation
without value.
A 2014 survey report by Medical Economics states, Poor EHR
usability, time consuming data entry, interference with faceto-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR
products, and degradation of clinical documentation were
prominent sources of professional dissatisfaction.1 Typically
EHR vendors create solutions on a standardized platform, and
customers usually implement them with limited resources, insufficient timelines, and inefficient clinical workflowswhich
provides further issues.
For example, the problem list requirement of meaningful use
has become a problem of its own for healthcare providers due
to a lack of functionality in EHR systems. Historically inpatient
clinical systems have not focused on problem-oriented charting, in clear opposition to their ambulatory counterparts. And
while the ambulatory systems have done a better job at focusing on the problem list as a component of the functionality
they deliver, they have not addressed the issue of reconciliation of the currency or latency of diagnosis within the problem
list as part of the clinical workflow, which clearly complicates
diagnosis coding.
Consider the following scenario: A physician is seeing a patient in the emergency department with new shortness of breath
and peripheral edema. The physician assesses the patient, orders appropriate diagnostic and therapeutic interventions, and
writes an admission order based upon the medical decision
making model. The physician typically composes a history and
physical prior to the patient being transitioned to the inpatient
unit. The EHR is designed at this point to help the physician navigate general documentation concepts of the presenting problem, and to clinically address the broad manifestations of congestive heart failure (CHF) from a diagnostic perspective. At no
time does the EHR prompt the physician to add specificity to the
diagnosis of CHF, nor ensure that it is added to the problem list
as a new diagnosis. This gap in documentation will inevitably
result in a query to the physicians if the diagnosis clarity is not
present by discharge and potentially leave an important clinical
documentation gap in the problem list which could impact care
continuity and proper depiction of severity of illness and risk of
mortality.
In this example, the physician documentation likely focused
on two facets. First is ensuring that the note contains a sufficient
number of body systems and components of the medical history
to support the evaluation and management level. Additionally,
the physician likely documented how the patient responded to
the treatment and why the decision to admit them was made.
Often understated is the clinical clarity of the diagnosis, as it is
conveyed in the impression portion of the note. Documenting
New onset heart failure leaves much to be clarified for the
coder of this case.
Moreover, the EHR templates created for this purpose are
lacking in substantial ways to aid the clinician in bringing forth
the required gap in the clinical workflow mediated by the EHR.

Remediating the EHR to match the clinical workflow is a health
information management professionals best opportunity to aid
physicians in documenting what is required across the healthcare continuum.
Further, physician documentation is typically formatted in
EHRs to support a professional reimbursement methodology
where more interventions and assessment components yield
greater patient acuity, as opposed to clinical clarity of comorbidities and complications in the inpatient setting. The risks herein
are great and beyond the realm of reimbursement. An incomplete or outdated problem list can adversely impact patient care.
Role of Clinical Documentation Coach

The below graphic illustrates the ongoing responsibilities of
the clinical documentation coach, starting with data analysis and reporting and continuing through to EHR remediation activity.
Remediation Case Studies

As the EHR becomes an enabler to the longitudinal health record, clinical documentation improvement (CDI) efforts should
not be limited to the inpatient setting. For one community hospital, the opportunity to improve clinical workflow was realized
within the office setting and aligned with their clinical documentation approach. In this example, key physician leaders for
a variety of professional offices (primary and specialty included) agreed to proceed with a pilot that included all providers
from two chosen offices. Clinical documentation was reviewed,
and opportunities were identified to improve both documentation and clinical workflow.
A substantial component of this data gathering exercise was
the discovery of deficient mapping of clinical diagnosis-to-diagnosis codes in multiple templates. This information was not
only shared with the leadership team, but a work effort ensued
to remediate the templates and clinical workflow to support a
more specific code selection and to update the mappings provided by the EHR vendor.
Shoulder-to-shoulder education was then offered with each
of the providers in the two offices to ensure they had an opportunity to ask questions and provide input into the process.
The physicians were particularly responsive to the idea that the
content of the problem list is important beyond care continuity
purposes, and improved quality of the problem list could help
them in risk adjusted reimbursement programs. Items to consider when developing a physician favorites/common diagnosis
list would include:
Involve a credentialed coding professional in the implementation process
Work with the vendor during planning and design phases
to clearly understand and configure provider functionality
in a manner that supports documentation specificity goals
Develop a procedure for provider usage of favorite/common diagnosis list
Define a data quality monitoring and maintenance policy
Ensure that body systems of greatest importance to the
specialist are presented first in the user interface
The success of the pilot has drawn interest and plans are in
place to continue the effort with the remaining providers across
Graphic provided by e4 Services.
all professional offices in this organization. This effort includes

EHR remediation work and a defined CDI education plan,
which includes one-on-one provider education and feedback.
In another example, EHR remediation is a commitment
made to physicians implementing the EHR in the ambulatory
setting. The rollout required thoughtful consideration to how
to avoid productivity loss and information gaps that are common to EHR implementations. To achieve this goal, the organization created a new role, the clinical documentation coach.
As shown in the graph on this page, the clinical documentation coach functions as both an embedded resource within
the clinical environment to coach physicians through documentation in the office setting, and also translates the clinical
workflow needs of physicians into requirements for the EHR
solution. This information is given to the organizations IT team
who help implement the changes.
This role also reviews the aggregate data output from the
compliance and internal audit findings and assesses ways that
concurrent coaching, broader education, and additional EHR
remediation can mitigate risk for the organization.
Clinical Documentation Oriented Across Service Lines

Another innovative approach to aligning EHR requirements
with clinical workflow is to organize the CDI and coding teams
around clinical service lines in an effort to coordinate all organizational efforts at improving coding and documentation in confined areas of expertisewhere the clinical workflow of physicians is often unique by the specialty. In one organization, the
HIM coders, CDI specialists, and performance improvement

nurses all function within a single clinical service and are able to
work collaboratively with physicians on how the implementation of EHR templates, including documentation clarifications,
can be fashioned to support the documentation requirements
for each unique setting.
A great benefit of this approach is that working with the physicians to educate them on the documentation concepts, the coding rules, and the indications for clarification has translated into
opportunities to finely tune documentation in the EHR.
nity to align efforts to improve clinical documentation where

it originateswithin the clinical workflow of the EHR.
EHR implementation and efforts related to clinical workflow
design should not just be an IT project. HIM professionals bring
a valuable skill set, including knowledge of rules, regulations,
and standards that affect the quality of clinical documentation.
Their involvement is critical to the clinical documentation and
clinical workflow improvement process within and beyond the
inpatient setting.
Strategy for Remediation Success
Notes
The HIM profession has long defined characteristics of data

quality. AHIMAs Updated Data Quality Management Model
describes this further stating, The various methods of documentation in electronic health records can be unreliable for
patient care if documentation guidelines and best practices
are not followed. HIM professionals have intimate knowledge of these documentation guidelines and are invaluable
resources when it comes to helping providers determine how
they will create templates, formats, notes, and other data elements in the EHR.2
Industry events such as the March announcement of a delay
in the ICD-10 compliance date allow the industry the opportu-
1. Verdon, Daniel R. Physician Outcry on EHR Functionality Cost Will Shake the Health Information Technology Sector. Medical Economics. February 10, 2014. http://
medicaleconomics.modernmedicine.com/medical-economics/news/physician-outcry-ehr-functionality-costwill-shake-health-information-technol?page=full.
2. AHIMA. Data Quality Management Model (updated).
Journal of AHIMA 83, no. 7 (July 2012): 62-67.
D I S C E R N I N G
Michelle Wieczorek (mwieczorek@e4-services.com) is a senior consultant,

CDI practice lead, at e4 Services. Jill S. Clark (jclark@e4-services) is a senior
consultant at e4 Services.
Identities
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PRACTICE BRIEF
practice guidelines for managing health information
Defining the Basics of Health Informatics for

HIM Professionals
ALL DATA ARE not created equal and technology implementation alone is not enough to improve the healthcare provided
to patients. Providers and organizations must be able to distinguish between an abundance of data, meaningful data, and
integration of data. Healthcare organizations are challenged to
meet these data dilemmas in their daily practices and workflow,
where new technologies and treatment modalities are changing
and evolving at a rapid rate.
The process of organizing, storing, integrating, and retrieving
medical and patient information has traditionally been managed through paper-based systems. The dilemma is that paperbased systems have evolved into disparate and proprietary systems with limited functionality. Healthcare has done a good job
capturing data, but the unintended consequence is that the proliferation of electronic data and the expanded use of electronic
health records (EHRs) have vastly increased the volume of available health information and the speed at which it is communicated. The human capacity to digest, interpret, and act on such
information in an efficient manner, however, has not evolved as
quickly. The need for health informatics has never been greater.
This practice brief provides an overview of health informatics
basics and includes a glossary of terms that are commonly associated with the field.
Defining Health Informatics

Health informatics can be defined in two different ways:
A scientific discipline that is concerned with the cognitive, information-processing, and communication tasks
of healthcare practice, education, and research, including
the information science and technology to support these
tasks1
A field of information science concerned with the management of all aspects of health data and information
through the application of computers and computer technology 2
The American Medical Informatics Association (AMIA) has
defined clinical informatics as the application of informatics
and information technology to deliver healthcare services.3 It
includes a wide range of topics from clinical documentation to
provider order entry systems and from system design to system
implementation and adoption issues.4 The field of informatics
includes a number of related areas such as translational bioin60/Journal of AHIMA September 14
formatics, clinical research informatics, consumer health informatics, and public health informatics.5
Each discipline-specific areasuch as nursing or pharmacywithin the overall sphere of informatics in healthcare has
specific needs. Informatics in nursing, for example, focuses on
issues such as tracking and documenting nursing care by using
information technology.
Having too much data may be worse than not having enough
when it comes to making strategic healthcare decisions. Health
informatics enables health information management professionals to gather and analyze large amounts of data into useful information and is poised for a period of rapid growth and
expansion as the healthcare industry continues to evolve and
produce an increasing amount of yet-unharnessed data power.
A multitude of external forces and trends such as pressure to
contain rising healthcare costs, expansion of information exchange, tracking and reporting meaningful use of EHR criteria,
and reduction of medical errors all call for the application of informatics.
Informatics Helps Harness the Power of Data for

Healthcare Improvement
Health informatics is an interdisciplinary field of study that
utilizes technology to organize, analyze, manage, and use information to improve healthcare. Its chief goals are to develop
standards and clinical care guidelines that enhance electronic
health records by facilitating information management.
Health informatics as a discipline traces its roots back to the
1940s in Europe, but it did not begin to take root in the United
States until the mid 1970s. Today, many organizations recognize informatics as an important field in medicine and health
sciences.
Applied health informatics has the potential for extensive
benefits for the healthcare industry, from decreasing admission
wait times to reducing duplication of tests. Public health informatics will become increasingly important to the management
of public and population health. More data will be available for
analysis with the increase of electronically generated and stored
data.
Assisting with the Triple Aim

In 2006 the Agency for Healthcare Research and Quality (AHRQ)
Practice Brief
received a report from the Southern California Evidenced-based

Practice Center stating that approximately 50 percent of the nations healthcare costs were wasted on inefficient processes.
Health informatics can assist with improving the patient experience of care, improving the health of populations, and reducing
the per capita cost of healthcarethree goals also known as the
Triple Aim.6
As a multidisciplinary field, gathering data from multiple
clinical, financial, and administrative systems is important to
be able to sort through volumes of data for health intelligence
purposes. Some other advantages of health informatics are the
ability to improve EHR functionality, improve information exchange that follows the patient through the continuum of care,
and analyze trends from a larger population mass.
Management of Health Data Continues to Pose

Challenges
The modern healthcare industry struggles to manage data. In the
quest for data, EHRs have been created to import large amounts
of data, storing every keystroke and data point. In fact, in todays
era of Big Data, frivolous, meaningless, and unstructured data is
collected and stored next to meaningful data. While computers
and hard drives are exceptional at sorting through mounds of
structured data, humans are not. Computers cannot distinguish
good data from bad data and unstructured data is more difficult
to parse. Human interaction is required to interpret the data. It
is essential to balance usability with functionality.
In addition, healthcare professionals lack background and
understanding of data science. This fact further complicates the
copious amounts of data entered without the appreciation for
the potential that data could yield.
Critical challenges in health informatics are evolving today
in the United States. Challenges include inadequate staffing
resources, lack of alignment, abstract financial incentives, and
lack of system integration and interoperability. These challenges must be overcome in order to successfully achieve healthcare
reform and patient safety initiatives, and to demonstrate improved quality of care with reduced cost in the United States.
Notes
1. AHIMA. Pocket Glossary of Health Information Management and Technology, Fourth Edition. Chicago, IL: AHIMA
Press, 2014.
2. Fenton, Susan and Sue Biedermann. Introduction to
Healthcare Informatics. Chicago, IL: AHIMA Press, 2014.
3. American Medical Informatics Association. Clinical Informatics. http://www.amia.org/applications-informatics/clinical-informatics.
4. Ibid.
5. Ibid.
6. 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.abstract.
7. Office of the National Coordinator for Health IT. Beacon
Basic Conceptual Framework of Health

Informatics
Technology
Informatics
Financial
Clinical
Community Program. HealthIT.gov. http://www.healthit.

gov/policy-researchers-implementers/beacon-community-program.
8. Shortliffe, E. et al. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. New York, NY:
Springer, 2006.
9. Warner, Diana. IG 101: What is Information Governance?
Journal of AHIMA website. December 4, 2013. http://journal.ahima.org/2013/12/04/ig-101-what-is-informationgovernance/.
10. LaTour, Kathleen M. et al. Health Information Management Concepts, Principles, and Practice. Chicago, IL: AHIMA Press, 2010.
11. Gartner. IT Governance (ITG). 2013. http://www.gartner.
com/it-glossary/it-governance/.
12. LaTour, Kathleen M. et al. Health Information Management Concepts, Principles, and Practice.
References
Adler-Milstein, Julia and David W. Bates. Paperless
healthcare: Progress and challenges of an IT-enabled
healthcare system. Business Horizons 53, no. 2 (2010): 119103.
Agency for Healthcare Research and Quality. Medical
Informatics for Better and Safer Health Care. Research
in Action 6 (June 2002). http://www.ahrq.gov/research/
findings/factsheets/informatic/informatics/index.html.
AHIMA. Information Governance Glossary. 2014. http://
www.ahima.org/topics/infogovernance.
HIMSS. 2012 HIMSS Leadership Survey. 2012. www.himss.
org.
Denton, David M. Doctors Are Drowning In Data. Information
Week. April 1, 2014. http://www.informationweek.com/
Practice Brief
Potential Career Progression for a Health Informatics Professional

HEALTH INFORMATICS PROFESSIONALS can provide organizations and providers with the experience and knowledge required to pull meaningful information from a multitude of sources. These professionals are chiefly responsible for gathering
and analyzing patient health details and compiling them for review by clinical care providers. In addition, the health informatics professional can ensure that the correct data is collected and presented in a readable format. This graphic shows what
degrees HIM professionals need to work in various areas of the profession, including informatics.
ADVANCED DEGREE
BACHELOR DEGREE
R
egistered Health Information
Administrator
Informatics Nurse Specialist
System Data Analyst
M
aster Degree or Certificate in
Master Degree in Health Informatics
Certified Health Data Analyst
(CHDA) Credential
Epidemiologist
Statistician
Informaticist
ASSOCIATE DEGREE
Registered Health
Information Technician
Medical Transcriptionist
Data Entry Specialist
hea lt hca re/elec t ron ic-hea lt h-records/doc tors-a redrowning-in-data/d/d-id/1141595.

Hornby, Sydney. The Advantages of Using Health
Informatics. Livestrong.com. July 25, 2010. http://www.
livestrong.com/article/184044-the-advantages-of-usinghealth-informatics/.
Jacobs, Alexis. Critical challenges in Health informatics?
Health Technology Trends. March 27, 2013. http://www.
healthtechtrends.com/patient/critical-challenges-inhealth-informatics.
Prepared by
Julie A. Dooling, RHIA, CHDA
Kim Osborne, RHIA, PMP
Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR,
FAHIMA
Acknowledgements
Cecilia Backman, MBA, RHIA, CPHQ, FHIMSS
Linda Bailey-Woods, RHIA, CPHIMS
Jill S. Clark, MBA, RHIA, CHDA, FAHIMA
Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA
Marsha Dolan, MBA, RHIA, FAHIMA

Katherine Downing, MA, RHIA, CHPS, PMP
Leah A. Grebner, PhD, RHIA, CCS, FAHIMA
Judi Hofman, BCRT, CHPS, CAP, CHP, CHSS
Beth Just, MBA, RHIA, FAHIMA
Lesley Kadlec, MA, RHIA
Susan Lucci, RHIA, CHPS, CHDS, AHDI-F
Stephanie Luthi-Terry, MA, RHIA, FAHIMA
Rosann M. ODell, D.H.Sc., MS, RHIA, CDIP
Cindy C. Parman, CPC, CPC-H, RCC
Kathleen Paterson, MS, RHIA, CCS
Harry B. Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA
Dan Rode, MBA, CHPS, FHFMA, FAHIMA
Bryanna Schoeffel, RHIA
Diana Warner, MS, RHIA, CHPS, FAHIMA
Traci Waugh, RHIA, CHPS, CHC
Practice Brief
Glossary of Terms Relevant to Health Informatics

Agency for Healthcare Research and Quality (AHRQ)
The branch of the United States Public Health Service that
supports general health research and distributes research
findings and treatment guidelines with the goal of improving
the quality, appropriateness, and effectiveness of healthcare
services.
American Recovery and Reinvestment Act of 2009 (ARRA)

The purposes of this act include:
Preserve and create jobs and promote economic recovery.
Assist those most impacted by the recession.
Provide investments needed to increase economic efficiency by spurring technological advances in science
and health.
Invest in transportation, environmental protection, and
other infrastructures that will provide long-term economic benefits.
Stabilize state and local government budgets in order to
minimize and avoid reductions in essential services and
counterproductive state and local tax increases.
Analysis
Review of the health record for proper documentation and
adherence to regulatory and accreditation standards.
Beacon Community Cooperative Agreement Program

This program demonstrates how health IT investments and
meaningful use of EHRs advance the vision of patient-centered care, while achieving the three-part aim of better health,
better care, and lower cost. The Office of the National Coordinator for Health IT (ONC) is providing $250 million over
three years to 17 selected communities throughout the United States that have already made inroads in the development
of secure, private, and accurate systems of EHR adoption
and health information exchange.7
A field of study concerned with the broad range of issues
in the management and use of biomedical information, including biomedical computing and the study of the nature
of biomedical information itself. Formerly called medical informatics, the new name is intended to clarify that the domain encompasses biological and biomolecular informatics
as well as clinical, imaging, and public health informatics.8
Biomedical informatics is the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving,
and decision making, motivated by efforts to improve human
health.9 Its the use of information technology for assimilating,
gathering, organizing, analyzing, and presenting healthcarerelated data to produce information for decision support to
improve quality of care, decrease costs, enhance patient
safety, and increase interoperability. Health information technology is the tool and information is the outcome.
Biomedical Research
The process of systematically investigating subjects related
to the functioning of the human body.
Centers for Disease Control and Prevention (CDC)

A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of
disease, injury, and disability. Committed to programs that
reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long,
productive, and healthy life for all people.
Centers for Medicare and Medicaid Services (CMS)

The Department of Health and Human Services (HHS) agency
responsible for Medicare and parts of Medicaid. Historically,
CMS has maintained the UB-92 institutional electronic media claims (EMC) format specifications, the professional EMC
NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid
programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health
identifiers, and security standards. CMS also maintains the
HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.
Certification Commission for Healthcare Information

Technology (CCHIT)
An independent voluntary private-sector initiative organized
as a limited liability corporation that has been awarded a contract by HHS to develop, create prototypes for, and evaluate
the certification criteria and inspection process for electronic
health record (EHR) products.
Certified Health Data Analyst (CHDA)

AHIMA credential awarded to individuals who have demonstrated skills and expertise in health data analysis.
Certified in Healthcare Privacy and Security (CHPS)

AHIMA credential that recognizes advanced competency
in designing, implementing, and administering comprehensive privacy and security protection programs in all types of
healthcare organizations. Requires successful completion of
the CHPS exam sponsored by AHIMA.
Practice Brief
Glossary of Terms Relevant to Health Informatics (cont.)

Clinical Analytics
The process of gathering and examining data in order to help
gain greater insight about patients.
Clinical Data Analytics

The process by which health information is captured, reviewed, and used to measure quality.
Clinical Decision Support

The process in which individual data elements are represented in the computer by a special code to be used in making
comparisons, trending results, and supplying clinical reminders and alerts.
Clinical Document Architecture (CDA)

A Health Level Seven (HL7) XML-based document markup
standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes).
The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from
HL7, Integrating the Healthcare Enterprise, and Health Information Technology Standards Panel (HITSP). It includes all
required CDA templates for stage 1 of the meaningful use
EHR Incentive Program and HITECH final rule. It is commonly
referred to as Consolidate CDA or C-CDA.
Clinical Documentation Improvement (CDI)

The process an organization undertakes that will improve
clinical specificity and documentation that will allow coders
to assign more concise disease classification codes.
Clinical Documentation Improvement Plan

A program in which specialists concurrently review health records for incomplete documentation, prompting clinical staff
to clarify ambiguity which allows coders to assign more concise disease classification codes.
information management educational programs.
Commission on Certification for Health Informatics and Information Management (CCHIIM)

An independent body within AHIMA that establishes and enforces standards for the certification and certification maintenance of health informatics and information management
professionals.
Comparative Effectiveness Research (CER)

Research that generates and synthesizes evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to
improve the delivery of care.
Computer-Assisted Coding (CAC)

The process of extracting and translating dictated and then
transcribed free-text data (or dictated and then computergenerated discrete data) into ICD-9-CM and CPT evaluation
and management codes for billing and coding purposes.
Computerized Provider Order Entry (CPOE)

Electronic prescribing systems that allow physicians to write
prescriptions and transmit them electronically. These systems usually contain error prevention software that provides
the user with prompts that warn against the possibility of drug
interaction, allergy, overdose, and other relevant information.
Covered Entity (CE)

As amended by HITECH, a covered entity may be defined
as a health plan, a healthcare clearinghouse, or a healthcare
provider who transmits any health information in electronic
form in connection with a transaction covered by HITECH.
Data Analytics
AHIMA credential awarded to individuals who have achieved

specialized skills in clinical documentation improvement.
The science of examining raw data with the purpose of drawing conclusions about that information. This includes data
mining, machine language, development of models, and statistical measurements. Analytics can be descriptive, predictive, or prescriptive.
Clinical Terminology
Data Dictionary
A set of standardized terms and their synonyms that record

patient findings, circumstances, events, and interventions
with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement.
A descriptive list of the names, definitions, and attributes of

data elements to be collected in an information system or
database whose purpose is to standardize definitions and
ensure consistent use.
Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM)
Data Governance
Clinical Document Improvement Practitioner (CDIP)
An independent accrediting organization whose mission is to

serve the public interest by establishing and enforcing quality accreditation standards for health informatics and health
The overall management of the availability, usability, integrity, and security of the data employed in an organization or
enterprise.9
Practice Brief

Data Mapping
Data mapping allows for connections between two systems.
This connection allows for data initially captured for one purpose to be translated and used for another purpose. One
system in a map is identified as the source while the other
is the target. It is a process by which two distinct data models are created and a link between these models is defined.
This process is used in data warehousing by which different
data models are linked to each other using a defined set of
methods to characterize the data in a specific definition. This
definition can be any atomic unit, such as a unit of metadata or any other semantic. This data linking follows a set of
standards, which depends on the domain value of the data
model used. Data mapping serves as the initial step in data
integration.
Data Mining
The process of extracting and analyzing large volumes of
data from a database for the purpose of identifying hidden
and sometimes subtle relationships or patterns and using
those relationships to predict behaviors.
Data Stewardship
The responsibilities and accountabilities associated with
managing, collecting, viewing, storing, sharing, disclosing, or
otherwise making use of personal health information.
Decision Support System (DSS)
mation science and technology to support these tasks.
Health Informatics and Information Management (HIIM)

Refers to the individuals responsible for the management of
healthcare data and information in paper or electronic form
and control the collection, access, use, exchange, and protection of the information through the application of health
information technology.
Health Information Technology

A term that encompasses the technical roles that process
health data and records, such as classification, abstracting,
and retrieval.10 Under HITECH, health IT is defined as hardware, software, integrated technologies or related licenses,
intellectual property, upgrades, or packaged solutions sold
as services that are designed for, or support the use by,
healthcare entities or patients for the electronic creation,
maintenance, access, or exchange of health information.
Healthcare Cost and Utilization Project (HCUP)

A family of databases and related software tools and products developed through a federal-state-industry partnership
and sponsored by AHRQ. HCUP databases are derived from
administrative data and contain encounter-level, clinical, and
nonclinical information including all listed diagnoses and procedures, discharge status, patient demographics, and charges for all patients, regardless of payer, beginning in 1988.
A computer-based system that gathers data from a variety

of sources and assists in providing structure to the data by
using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision making
tasks associated with non-routine and non-repetitive problems.
Healthcare Effectiveness Data and Information Set (HEDIS)
Descriptive Statistics
Informatics
A set of statistical techniques used to describe data such

as means, frequency distributions, and standard deviations;
statistical information that describes the characteristics of a
specified group or a population.
A field of study that focuses on the use of technology to improve access to, and utilization of, information.
Enterprise Information Management (EIM)

Ensuring the value of information assets, requiring an organization-wide perspective of information management functions, calls for explicit structures, policies, processes, technology, and controls. EIM is the infrastructure and processes
in place to ensure information is trustworthy and actionable.
Health Informatics
Scientific discipline that is concerned with the cognitive,
information-processing, and communication tasks of healthcare practice, education, and research, including the infor-
A set of standard performance measures that can give an

individual information about the quality of a health plan. One
can find out about the quality of care, access, cost, and other
measures to compared managed care plans. CMS collects
HEDIS data for Medicare plans.
Information Governance (IG)

The accountability framework and decision rights to achieve
enterprise information management (EIM). IG is the responsibility of executive leadership for developing and driving the IG
strategy throughout the organization. IG encompasses both
data governance and information technology governance.
Information Technology Governance (ITG)

Led by the chief information officer (CIO), the process to
ensure the effective evaluation, selection, prioritization, and
funding of competing IT investments. ITG oversees the implementation of these investments and extracts business
benefits.11
Practice Brief

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
The coding classification system that will replace ICD-9-CM,
Volumes 1 and 2, on October 1, 2015. ICD-10-CM is the
United States clinical modification of the World Health Organizations ICD-10. ICD-10-CM has a total of 21 chapters and
contains significantly more codes than ICD-9-CM, providing
the ability to code with a greater level of specificity.
International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)

The coding classification system that will replace ICD-9-CM,
Volume 3, on October 1, 2015. ICD-10-PCS has 16 sections
and contains significantly more procedure codes than ICD-9CM, providing the ability to code procedures with a greater
level of specificity.
Interoperability
The capability of different information systems and software
applications to communicate and exchange data.
Machine Learning
An area of computer science that studies algorithms and
computer programs that improve employee performance on
some task by exposure to training or learning experience.
Medical Informatics
A field of information science concerned with the management of data and information used to diagnose, treat, cure,
and prevent disease through the application of computers
and computer technologies.12
Natural Language Processing (NLP)

A technology that converts human language (structured or
unstructured) into data that can be translated and then manipulated by computer systems; a branch of artificial intelligence.
Office of the National Coordinator for Health Information

Technology (ONC)
The principle federal entity charged with coordination of nationwide efforts to implement and use the most advanced
health information technology and the electronic exchange of
health information. The position of the National Coordinator
was created in 2004, through an Executive Order, and legislatively mandated in the HITECH Act of 2009.
Predictive Modeling
A process used to identify patterns that can be used to predict the odds of a particular outcome based on the observed
data.
Semantic Interoperability
Mutual understanding of the meaning of data exchanged between information systems.
Telehealth
A telecommunications system that links healthcare organizations and patients from diverse geographic locations and
transmits text and images for medical consultation and treatment.
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Coding Notes
ACA Risk Adjustment Models

Emerge in Commercial Care
By Janet Franklin, RHIT, CCS, CCS-P, CHC
KNOWN AS THE Three Rs, three mechanisms were included

with the implementation of the Affordable Care Act (ACA) to reduce incentives insurers may have for avoiding the enrollment
of high-cost members.
The Three Rs are:
1. Risk corridors
2. Reinsurance
3. Risk adjustment
Two of these programs, risk corridors and reinsurance, are
temporary measures and will only remain in effect for three
years. This article addresses risk adjustment, which is a permanent program. Under the ACA, the goal of the risk adjustment program is to level the playing field by spreading the risk
of adverse patient selection among plans.
Risk adjustment is currently utilized by various payers including Medicare, Medicaid, and some private insurers. The
risk adjustment models in use, however, vary among different
groups and states. The Centers for Medicare and Medicaid Services (CMS) utilizes the CMS Hierarchical Condition Category
(HCC) model to risk adjust its Medicare Advantage (Part C)
population. The Department of Health and Human Services
(HHS), the agency responsible for the ACA risk adjustment
program, has designed the program based on the Medicare
HCC model.
While there are many similarities between the ACA program
and HCC model, some very significant differences arise between the two out of the necessity for the ACA risk adjustment
program to address a broader patient population.
CMS-HCC Model Provides a Working Foundation

The CMS-HCC model was first implemented in 2004 and uses
both demographic information, such as sex, age, Medicaid dual
eligibility, and disability status, and the disease burden of the
member to calculate a risk score for each member. The disease
burden component of the risk score is calculated based on the
HCCs assigned to the member. HCCs are groups of similar conditions, identified by ICD-9-CM diagnosis codes, with similar
resource consumption.
Where a member may have the same diagnosis code assigned
multiple times in the year, the assignment of that diagnosis will
count only once toward the patients risk score for the year.
While multiple codes mapping to the same HCC are assigned
during the year, the HCC will count only once for the year. While
many of the HCCs are additive, several HCCs fall into hierarchies. When a patient has two or more diagnosis codes that
map to two or more HCCs within the same hierarchy, only the
HCC with the highest weight is considered. For example, there
are five CMS-HCCs in the cancer hierarchy (008, 009, 010, 011,
012). If a patient has a diagnosis of breast cancer (CMS-HCC
012) which has metastasized to the lung (CMS-HCC 008), only
CMS-HCC 008 will be considered in the patients risk score as it
supersedes CMS-HCC 012 in the hierarchy.
The CMS-HCC model is a prospective model where diagnoses/HCCs captured in the current year inform reimbursement
for the following year. While not all diagnoses are included in
the model, those that are included are considered conditions
that would have an impact on the patients care in the following
year. Most of the diagnoses included are chronic, such as chron-
Coding Notes
ic kidney disease or diabetes, but the model does contain acute

conditions as well such as sepsis and hip fracture. Each new data
year requires recapture of chronic condition HCCs as well as any
new acute conditions/HCCs that may occur in order to impact
reimbursement for the following payment year. This is a different
financial impact than that found in the HHS-HCC model.
HHS-HCC Adds Complexity to CMS Model

The HHS-HCC commercial risk adjustment model is specific to
non-grandfathered individuals and small groups, both on and
off the insurance exchangesboth federally- and state-created
ACA exchanges. The commercial model is a concurrent model
with diagnoses captured in a benefit year applicable to that benefit year. Data capture is used to calculate average risk scores
and affects payment transfers going in and out of the risk pool
in support of risk sharing.
In the HHS commercial model, plans receive funds from
member premiums and copayments. Risk adjustment, as stated earlier, is meant to level the playing field by spreading the
risk of adverse patient selection among plans. HHS uses the
plan members individual risk scores to calculate the plans
average risk score and applies a payment transfer formula in
order to determine risk adjustment payments and charges between plans within a risk pool within a market within a state,
according to CMS.1 Simply put, if a plans average risk score is
lower than the average risk score within the plans market in
that plans state, then the plan will pay into the risk pool. If the
plans average risk score is higher than the average market risk
score within the state, then the plan will receive funds from
the risk pool.
The HHS-HCC model builds upon the CMS-HCC model,
with similarities that include the use of demographics as well
as the illness burden of the patient in calculating the patients
risk score. But the HHS-HCC model is more complex. Instead
of a separate demographic score being added to the HCC risk
score, the demographics are built into the HCCs themselves.
There are three different HHS-HCC models based on the age
of the patient:
The adult model (ages 21+)
The child model (ages 2-20)
The infant model (ages 0-1)
The applicable model is determined by the age of the member at the end of the benefit year. The one exception is for infants who are born in one benefit year and discharged from the
hospital in the next benefit year. In this circumstance, the infant
will be considered age 0 for both years. In addition, each HCC
is weighted differently based on the metal level in which the
member is enrolled. There are five metal levels:
Platinum
Gold
Silver
Bronze
Catastrophic
Demographics can impact HCCs in other ways. For instance
some HCCs are bandedrestricted to a particular criteriaaccording to age or sex. Pregnancy-related HCCs cross both the
adult and child models but are limited to females age 12 to 55;
therefore, these HCCs are considered banded across age and
sex. Age/sex banding can also apply at the diagnosis level. Malignant neoplasm of the breast in patients age 50 and over is assigned to HHS-HCC 012 (Breast (Age 50+) and Prostate Cancer,
Benign/Uncertain Brain Tumors, and Other Cancers and Tumors), while patients under 50 with the same diagnosis are assigned to HHS-HCC 011 (Colorectal, Breast (Age < 50), Kidney,
and Other Cancers).
Congenital factor VIII disorder maps to HHS-HCC 066 (Hemophilia) for males and HHS-HCC 075 (Coagulation Defects
and Other Specified Hematological Disorders) for females. As
in the Medicare model, the HHS-HCCs do not roll over from one
benefit year to the next. Each new benefit year requires recapture of chronic condition HCCs as well as any new conditions or
HCCs that may occur in order to impact the new benefit years
average risk score.
While the HHS-HCC model does not contain all of the diagnoses found in the CMS model, it does contain many additional conditions that are not present in the CMS-HCC model
as it applies to a more diverse population. There are a total
of 3,518 ICD-9-CM diagnosis codes with 3,479 of those being
unique codes. Some codes appear in the model twice as the
age/sex variables can result in unique codes mapping to multiple HHS-HCCs.
There are a total of 127 HHS-HCCs as compared to 83 in the
CMS model. Additions to the HHS commercial model include
656 pregnancy codes mapping to six different HHS-HCCs.
Other examples are diagnoses specific to newborns including birth weight, weeks of gestation, newborn sepsis, neonatal
neutropenia, and many others. Missing from the HHS model
is alcohol dependence and acute intoxication, but complications from alcohol dependence are included. There has been
an extreme reduction in the number of injury codes with only
24 injury codes in the HHS-HCC model compared to 640 in
the CMS model. These are just small examples of some of the
changes.
The commercial model utilizes hierarchies and, in addition,
also utilizes groups. Groups are similar HCCs that may or may
not be in a hierarchy but have been assigned the same weights.
When a member is assigned one or more HCC(s) in the same
group, the weight of each HCC is not additive, but instead the
member receives the group weight which is always equal to
a single HCC weight. For example, Group G03 contains two
HCCs, HHS-HCC 054 (Necrotizing Fasciitis) and HHS-HCC 055
(Bone/Joint/Muscle Infections/Necrosis). Each HCC, as well as
the group, is weighted at 7.508. Whether the patient is assigned
one or both of the HCCs the patient will only receive the group
weight of 7.508.
While the risk scores for the adult and child models are based
on HHS-HCCs, the risk score for the infant model is based on
a combination of the infants maturity category at birth (i.e.,
term, premature, extreme immaturity) or one year of age and
the highest level of severity assigned to the infant from the five
Coding Notes
available levels, with a five representing the highest level. A diagnosis of hypoplastic left heart syndrome would be assigned a
severity level of five. If the infant is delivered at term, with a normal birth weight, the resulting combination is Term * Severity
Level 5 with a risk score weight of 130.511. This example uses
the Infant Model, Silver Metal weight.
Note
1. Centers for Medicare and Medicaid Services. HHS-Developed Risk Adjustment Model Algorithm Instructions. 2013.
https://www.cms.gov/CCIIO/Resources/Regulationsand-Guidance/Downloads/ra-instructions-4-16-13.pdf.
References
Centers for Medicare and Medicaid Services. Advance Notice
of Methodological Changes for Calendar Year (CY) 2014
for Medicare Advantage (MA) Capitation Rates, Part C and
Part D Payment Policies and 2014 Call Letter. February
15, 2013. http://www.cms.gov/Medicare/Health-Plans/
MedicareAdvtgSpecRateStats/Downloads/Advance2014.pdf.
Centers for Medicare and Medicaid Services. Announcement
of Calendar Year (CY) 2014 Medicare Advantage Capitation
Rates and Medicare Advantage and Part D Payment Policies
and Final Call Letter. April 2013. https://www.cms.gov/
Medicare/Health-Plans/MedicareAdvtgSpecRateStats/
Downloads/Announcement2014.pdf.
PJ &A
Centers for Medicare and Medicaid Services. HHS-Developed

Risk Adjustment Model Algorithm Instructions. 2013.
http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/Downloads/ra-instructions-4-16-13.pdf.
Centers for Medicare and Medicaid Services. HHS-Developed
Risk Adjustment Model Algorithm Instructions. 2014.
http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/Downloads/DIY-instructions-5-20-14.pdf.
Centers for Medicare and Medicaid Services. Table 1. Model
Membership. Retrieved from CCIIO, Premium Stabilization
Programs, Regulations and Guidance. 2014. http://www.
cms.gov/CCIIO/Resources/Regulations-and-Guidance/
Downloads/ra-tables-03-27-2014.xlsx.
Kaiser Family Foundation. Explaining Health Care Reform:
Risk Adjustment, Reinsurance, and Risk Corridors.
January 22, 2014. http://kff.org/health-reform/issuebrief/explaining-health-care-reform-risk-adjustmentreinsurance-and-risk-corridors/.
RTI International. Evaluation of the CMS-HCC Risk Adjustment
Model, Final Report. March 2011. https://www.cms.gov/
Medicare/Health-Plans/MedicareAdvtgSpecRateStats/
downloads/Evaluation_Risk_Adj_Model_2011.pdf.
Janet Franklin (Janet.D.Franklin@kp.org) is compliance manager for risk
adjustment, government audit, and reimbursement team, national compliance, ethics, and integrity office at Kaiser Permanente.
Perry Johnson & Associates, Inc.

A Global Leader in Health Information Solutions
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NAME
71
Coding Notes
Coding ICD-10-PCS Procedures in

the Ancillary Sections
UNDERSTANDING PHYSICAL REHABILITATION AND DIAGNOSTIC
AUDIOLOGY, MENTAL HEALTH, AND SUBSTANCE ABUSE TREATMENT
By Karen Kostick, RHIT, CCS, CCS-P, and Gina Sanvik, RHIA
Editors note: This is the second in a two-part series of articles discussing the six Ancillary sections of ICD-10-PCS.
THIS ARTICLE CONTINUES the Journal of AHIMAs exploration of the different sections of ICD-10-PCS, focusing on the last
three Ancillary sections. The side bar at the right displays all six
of the Ancillary sections; this article will focus on sections F-H.
Some of the Ancillary section character definitions differ from
other sections such as the Medical and Surgical section. For example, the Ancillary sections do not include root operations,
but rather the root type of the procedure for these sections. Additional differences include:
Section C specifies the fifth character as radionuclide
Section D specifies the fifth character as modality qualifier and the sixth character as isotope
Section F specifies the fifth character as type qualifier and
the sixth character as equipment
Sections G and H specify the fourth character as a type
qualifier
Physical Rehabilitation and Diagnostic Audiology:

Section Value F
The Physical Rehabilitation and Diagnostic Audiology section
consists of 1,380 codes and classifies procedures by treatment,
assessment, fitting(s), and caregiver training. The Physical Rehabilitation section represents physical therapy, occupational
therapy, and speech-language pathology procedures. This
sections first character value is F and the second character is
a section qualifier which specifies the procedures as either Rehabilitation or Diagnostic Audiology. The third character, root
type, specifies the general procedure. The fourth character indicates the body system or body region studied which can be
The Six Ancillary Sections of ICD-10-PCS

Section Value
Description
Imaging
Nuclear Medicine
Radiation Therapy
Physical Rehabilitation and Diagnostic Audiology
Mental Health
Substance Abuse Treatment
combined where applicable. The fifth character, type qualifier,

further specifies the type of procedure, such as a precise test or
method employed. The sixth character specifies the equipment
used if applicable for the procedure. The seventh character is a
qualifier that is not specified in this section and has no value.
Character 3Root Type for Section Value F

Section value F includes 14 root types. The ICD-10-PCS Reference Manual provides the following root type definitions:
Speech Assessment: Measurement of speech and related
functions
Motor and/or Nerve Function Assessment: Measurement
of motor, nerve, and related functions
Activities of Daily Living Assessment: Measurement of
Coding Notes
Physical Rehabilitation and Diagnostic Audiology Coding Examples in ICD-10-PCS

THE FOLLOWING ARE two examples of coding for physical rehabilitation and diagnostic audiology in ICD-10-PCS.
Wound care treatment of upper back ulcer (staged to muscle) using pulsatile lavage, F08K5BZ
Character 1
Section
Character 2
Section
Qualifier
Character 3
Root Type
Character 4
Body System/
Region
Character 5
Type Qualifier
Character 6
Equipment
Character 7
Qualifier
Physical Rehab
and Dx Audiology
Rehabilitation
Activities of Daily
Living Treatment
Musculoskeletal
System Upper
Back/Upper
Extremity
Wound Management
Physical Agents
None
Individual fitting of right eye prosthesis, F0DZ8UZ

Character 1
Section
Character 2
Section
Qualifier
Character 3
Root Type
Character 4
Body System/
Region
Character 5
Type Qualifier
Character 6
Equipment
Character 7
Qualifier
Physical Rehab
and Dx Audiology
Rehabilitation
Device Fitting
None
Prosthesis
Prosthesis
None
functional level for activities of daily living

H
earing Assessment: Measurement of hearing and related functions
Hearing Aid Assessment: Measurement of the appropriateness and/or effectiveness of a hearing device
Vestibular Assessment: Measurement of the vestibular
system and related functions
Speech Treatment: Application of techniques to improve,
augment, or compensate for speech and related functional impairment
Motor Treatment: Exercise or activities to increase or facilitate motor function
Activities of Daily Living Treatment: Exercise or activities
to facilitate functional competence for activities of daily
living
Hearing Treatment: Application of techniques to improve,
augment, or compensate for hearing and related functional impairment
Cochlear Implant Treatment: Application of techniques to
improve the communication abilities of individuals with
a cochlear implant
Vestibular Treatment: Application of techniques to improve, augment, or compensate for vestibular and related
functional impairment
Device Fitting: Fitting of a device designed to facilitate or
support achievement of a higher level of function
Caregiver Training: Training in activities to support optimal level of function for patients
Character 5Type Qualifier for Section Value F

All the Physical Rehabilitation and Diagnostic Audiology root
types include type qualifiers to further specify the procedure
type. For example, activities of daily living treatment includes
type qualifiers such as wound management, bathing/showering techniques, dressing techniques, and feeding/eating activities.
Character 6Equipment for Section Value F

In ICD-10-PCS, equipment used to assist in the performance of
the procedure is not coded in PCS. The only exception to this
rule occurs in the Rehabilitation and Diagnostic Audiology section, where the sixth character is specified as equipment. The
sixth character values in this section are used to capture information about the machine, physical aid, or other equipment
used to assist in performing the procedure.
Mental Health: Section Value G

The Mental Health section consists of 30 codes and classifies
procedures by crisis intervention, family psychotherapy, and
biofeedback. The first character for the mental health section
is G. Since the body system doesnt apply in this section, the
second character is assigned the value Z, none. The third character, root type, describes the type of mental health procedure
and character four, type qualifier, further specifies the root
type. The fifth, sixth, and seventh characters are not specified in the Mental Health section and are assigned the value
Z, none.
Coding Notes
Mental Health Coding Example in ICD-10-PCS

THE FOLLOWING IS an example of coding for the Mental Health section of ICD-10-PCS.
ECT, unilateral, single seizure, GZB0ZZZ

Character 1
Section
Character 2
Body System
Character 3
Root Type
Character 4
Type Qualifier
Character 5
Qualifier
Character 6
Qualifier
Character 7
Qualifier
Mental Health
None
Electroconvulsive
Therapy
Unilateral single
seizure
None
None
None
Character 3Root Type for Section Value G

The Mental Health section includes 12 root types. The ICD-10PCS Reference Manual gives the following root type definitions:
Psychological Tests: The administration and interpretation of standardized psychological tests and measurement instruments for the assessment of psychological
function
Crisis Intervention: Treatment of a traumatized, acutely
disturbed, or distressed individual for the purpose of
short-term stabilization
Medication Management: Monitoring and adjusting the
use of medications for the treatment of a mental health
disorder
I
ndividual Psychotherapy: Treatment of an individual
with a mental health disorder by behavioral, cognitive,
psychoanalytic, psychodynamic, or psychophysiological
means to improve functioning or well-being
Counseling: The application of psychological methods to
treat an individual with normal developmental issues and
psychological problems in order to increase function, improve well-being, alleviate distress or maladjustment, or
resolve crises
Family Psychotherapy: Treatment that includes one or
more family members of an individual with a mental
health disorder by behavioral, cognitive, psychoanalytic,
psychodynamic, or psychophysiological means to improve functioning or well-being
Electroconvulsive Therapy: The application of controlled
electrical voltages to treat a mental health disorder
Biofeedback: Provision of information from the monitoring and regulating of physiological processes in conjunction with cognitive-behavioral techniques to improve
patient functioning or well-being. Biofeedback procedure
examples include electroencephalography, blood pressure, skin temperature or peripheral blood flow, electrocardiogram, electrooculogram, electromyogram, respirometry or capnometry, galvanic skin response GSR/
electrodermal response, perineometry to monitor/regulate bowel/bladder activity, and electrogastrogram to
monitor/regulate gastric motility.
Hypnosis: Induction of a state of heightened suggestibility by auditory, visual, and tactile techniques to elicit an
emotional or behavioral response

N
arcosynthesis: Administration of intravenous barbiturates in order to release suppressed or repressed thoughts
Group Therapy: Treatment of two or more individuals
psychoanalytic, psychodynamic, or psychophysiological
L ight Therapy: Application of specialized light treatments
to improve functioning or well-being
Character 4Type Qualifier for Section Value G

Six of the 12 Mental Health section root types include type
qualifiers to further specify the mental health procedure. For
example, electroconvulsive therapy is further classified by
unilateral-single seizure, unilateral-multiple seizure, bilateral
single-seizure, bilateral-multiple seizure, and other electroconvulsive therapy.
Substance Abuse Treatment: Section Value H

The Substance Abuse Treatment section consists of 59 codes and
classifies treatment by detoxification, counseling, and pharmacotherapy. The first character for the substance abuse section is
H. Similar to the Mental Health section, the second character,
body system, doesnt apply for this section and is assigned the
value Z, none. The third character, root type, describes the type
of substance abuse treatment and character four, type qualifier,
further specifies the root type. The fifth, sixth, and seventh characters are not specified in the Mental Health section and are not
specified in the Substance Abuse Treatment section and are assigned the value Z, none.
Character 3Root Types for Section Value H

The Substance Abuse Treatment section includes seven root
types and the ICD-10-PCS Reference Manual provides the following root type definitions:
Detoxification Services: Detoxification from alcohol and/
or drugs
Individual Counseling: The application of psychological
methods to treat an individual with addictive behavior

Group Counseling: The application of psychological
methods to treat two or more individuals with addictive
behavior
Coding Notes
Examples of Coding Substance Abuse Treatment

THE FOLLOWING ARE two examples of coding for Substance Abuse Treatment in ICD-10-PCS.
Individual counseling for drug abuse, continuing care, HZ39ZZZ

Character 1
Section
Character 2
Body System
Character 3
Root Type
Character 4
Type Qualifier
Character 5
Qualifier
Character 6
Qualifier
Character 7
Qualifier
Substance Abuse
Treatment
None
Individual
Counseling
Continuing Care
None
None
None
Detoxification Services, for substance abuse, HZ2ZZZZ

Character 1
Section
Character 2
Body System
Character 3
Root Type
Character 4
Type Qualifier
Character 5
Qualifier
Character 6
Qualifier
Character 7
Qualifier
Substance Abuse
Treatment
None
Detoxification
Services
None
None
None
None
Individual Psychotherapy: Treatment of an individual

psychoanalytic, psychodynamic or psychophysiological

Family Counseling: The application of psychological
methods that includes one or more family members to
treat an individual with addictive behavior
Medication Management: Monitoring and adjusting the
use of replacement medications for the treatment of addiction
Pharmacotherapy: The use of replacement medications
for the treatment of addiction
Character 4Type Qualifier for Section Value H

Six of the seven root types in this section include type qualifiers to further specify the substance abuse treatment. For
example, individual counseling is further classified by cognitive, behavioral, cognitive-behavioral, 12-step, interpersonal,
vocational, psychoeducation, motivational enhancement,
confrontational, continuing care, spiritual, and pre/post-test
infectious disease.
Resources
Barta, Ann et al. 2014 ICD-10-PCS Coder Training Manual:
Instructors Edition. Chicago, IL: AHIMA Press, 2013.
Centers for Medicare and Medicaid Services. 2015 Code
Tables and Index. 2014. http://www.cms.gov/Medicare/
Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.
Centers for Medicare and Medicaid Services. 2015 ICD-10-PCS
Reference Manual. 2014. http://www.cms.gov/Medicare/
Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.
Centers for Medicare and Medicaid Services. 2015 ICD-10-PCS
Official Guidelines for Coding and Reporting. 2014. http://
www.cms.gov/Medicare/Coding/ICD10/Downloads/2015-
PCS-guidelines.pdf.
Karen Kostick (Karen.Kostick@nuance.com) is technical business analyst,
CLU and CAC content, and Gina Sanvik (Gina.Sanvik@nuance.com) is
manager, CLU and CAC content, at Nuance Communications, Inc.
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SS10064
Presidents Message

Journal of AHIMA

Quiz ID: Q1438509 | HIM Domain Area: Clinical Data Management | ArticleCoding in ICD-10-PCS Procedures in the
Ancillary Sections: Audiology, Mental Health,
and Substance Abuse Treatment.

AHIMA
PO Box 77-2735
1. How many sections are found in the
Ancillary section of ICD-10-PCS?

a. 2

b. 6

c. 10

d. 31
2. Mental Health is not one of the
Ancillary sections of ICD-10-PCS.

a. true

b. false
3. How many root types are in the
Physical Rehabilitation and Diagnostic
Audiology section?

a. 6
b. 8

c. 14

d. 16
Last Name
Address
City
4. Which of the following is not a

qualifier for Character 5 in the
Physical Rehabilitation and Diagnostic
Audiology section?

a. bathing techniques

b. dressing techniques

c. wound suturing
d. feeding/eating activities
5. There are 12 diagnostic and
therapeutic procedures listed in
the root types in the Mental Health
section.

a. true

b. false
6. The root type Biofeedback in the

Mental Health section includes which
of the following?

a. monitor gastric mobility
b. electromyogram (EMG)

c. electrocardiogram (ECG)

d. all of the above
7. The second character of all Mental
Health section codes will always be a
value of Z because the body system
does not apply in this section.

a. true

b. false
8. The definition of Individual
Psychotherapy in the Substance Abuse
Treatment section is the application
of psychological methods to treat an
individual with addictive behavior.

a. true

b. false
9. The code for substance abuse
detoxification services is HZ2ZZZZ.

a. true

b. false
10. W
hich of the following is not a
qualifier classification for Character
4 of individual counseling in the
Substance Abuse Treatment section?

a. 12-step

b. behavioral

c. group therapy

d. vocational
State, Zip Code

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AHIMA Annual Convention

2015 New Orleans, LA September 26October 1
A Look Ahead
Upcoming AHIMA Institutes, Seminars, Workshops,

and Webinars
OCTOBER
16
Webinar: Using Social Media to Resolve Healthcare Issues Within and Across Organizations
22-24
AHIMA Academy for ICD-10-CM/PCS: Building

Expert Trainers in Diagnosis and Procedure Coding, Orlando, FL
23
Webinar: How to Avoid Greatly Increased Liability

in the Business Associate Relationship
27

Expert Trainers in Diagnosis and Procedure Coding, Seattle, WA
Keep Informed
Resources and News from AHIMA

Actor and Cancer
Awareness Advocate Rob
Lowe to Keynote AHIMA
Convention
November
13
Webinar: Six Strategies to Protect Your EHR

Investment
November
17-18
AHIMA Academy for ICD-10-CM: Building Expert

Trainers in Diagnosis Coding: Chicago, IL
Actor and cancer awareness

advocate Rob Lowe will present
the closing keynote address at
AHIMAs 86th Convention and
Exhibit on Wednesday, October 1. Most recently seen as the lead role in the
political thriller Knife Fight (2013), Glide (2013)
and Lifetime televisions The Drew Peterson Story
(2012), Lowe had a leading role on NBCs Parks
and Recreation and Showtimes Californication
series. Lowe is also the author of Stories I Only
Tell My Friends, which spent consecutive weeks
in the top four of the New York Times bestsellers
list, and made it onto GQs Best of 2011 book list.
This year, Lowe published his second memoir, Love
Life. After his presentation, Lowe will participate in
a book signing. More details are available at www.
ahima.org/convention.
November
17-19

Expert Trainers in Diagnosis and Procedure Coding, Chicago, IL
CCHIIM Relaunches Certified Coding

Specialist Examination
December
1-3
CHPS Exam Prep Workshop, Las Vegas, NV
December
1-3

Expert Trainers in Diagnosis and Procedure Training, Las Vegas, NV
December
9
Webinar: Stop the Madness! Simplify Healthcare

Provider Business Intelligence
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WORKSHOPS, AND WEBINARS
Check www.ahima.org/events for the latest schedule of

institutes, seminars, and workshops.
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AHIMAs Commission on Certification for Health

Informatics and Information Management (CCHIIM)
announced in July that the Certified Coding Specialist (CCS) examination would once again be
available beginning August 1, 2014. On March 31,
2014, CCHIIM suspended the administration of the
exam in all US and international Pearson Professional Centers due to concerns over exam security and integrity. These issues have since been resolved in the US. There is no further information for
when the exam will once again be offered at testing
centers in Asia.
To register for the exam, visit AHIMAs online store
at www.ahimastore.org. Following registration, an
Authorization to Test letter will be sent allowing you
to schedule an exam date. For a list of available
testing centers (US and international), please visit
http://www.pearsonvue.com/ahima/.
AHIMA Celebrates Member Appreciation

Week this November
AHIMAs annual Member Appreciation Week will
take place November 1014. The week will consist
of activities, webinars, and prizes. For more information on the event, visit www.ahima.org/memberweek. All members will be e-mailed a coupon code
for 15 percent off AHIMA products during Member
Appreciation Week. Member engagement coordinator Erin Duvic can be reached at erin.duvic@
ahima.org with any questions.
AHIMA Volunteer Leaders
AHIMA BOARD OF DIRECTORS

President/Chair
Angela C. Kennedy, EdD, MBA, RHIA
Head and Professor, LA Tech University
Ruston, LA
(318) 257-2854
angela.kennedy@ahima.org
President/Chair-elect
Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
Senior Vice President of Health Information
Management and Consulting,
Peak Health Solutions, Inc.
San Diego, CA
(858) 746-7298
cassi.birnbaum@ahima.org
Speaker of the House of Delegates
Jennifer A. McManis, RHIT
Healthcare Consultant, Crowley Fleck Attorneys
Bozeman, MT
(406) 522-4501
jmcmanis@crowleyfleck.com
CEO, AHIMA
Lynne Thomas Gordon, MBA, RHIA, CAE,
FACHE, FAHIMA
Chicago, IL
(312) 233-1165
lynne.thomasgordon@ahima.org
TERM ENDS 2014DIRECTORS

Ann Chenoweth, MBA, RHIA
Senior Director of Industry Relations and
Market Research, 3M Health Information
Systems
Murray, UT
(801) 265-4390
afchenoweth@mmm.com
Dwayne M. Lewis, RHIT, CCS
President/CEO, DML Consulting, Inc.
Broken Arrow, OK
(918) 249-0101
dmlewisconsult@hotmail.com
Treasurer
Melissa M. Martin, RHIA, CCS
Chief Privacy Officer and Director of Health
Information Management, West Virginia
University Hospitals
Morgantown, WV
(304) 598-4109 x73716
martinme@wvuhealthcare.com

Secretary
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
Susan J. Carey, RHIT, PMP
System Director, HIM, Norton Healthcare
Louisville, KY
(502) 629-8913
susan.carey@nortonhealthcare.org
Cindy Zak, MS, RHIA, PMP, FAHIMA
Executive Director Corporate HIM,
Yale New Haven Health System
Woodbridge, CT
(203) 688-5466
cindy.zak@ynhh.org
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
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

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
2014 CHAIRS OF AHIMA VOLUNTEER GROUPS

AHIMA Grace Awards Committee
Mark S. Dietz, RHIA
(763) 377-6720
markdietz2@msn.com
Engage Advisory Committee

Seth J. Katz, RHIA, MPH
(913) 526-4987
SJKatz5@hotmail.com
Nominating Committee
Tim J. Keough, MPA, RHIA, FAHIMA
(609) 936-2222
tkeo2@aol.com
AHIMA Triumph Awards Committee

Marion K. Gentul, RHIA, CCS
(302) 827-1098
mgs60mga@yahoo.com
Exhibit Advisory Committee

Julie W. Clark
(770) 205-6198
jclark@creativelyclark.com
Professional Ethics Committee

Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA
(614) 292-3694
Laurie.Rinehart-Thompson@osumc.edu
Annual Convention Program Committee

Adrienne A. Beauvois, RHIT
(626) 836-6634
abeauvois@coh.org
Fellowship Review Committee

Julie Wolter, MA, RHIA, FAHIMA
(314) 977-8720
wolterjl@slu.edu
State Advocacy Council

Sue (Jensen) Nathe, RHIT
(320) 231-3655
sue@medsuppliestrucare.com
2014 CHAIRS OF AFFILIATE VOLUNTEER GROUPS

AHIMA Foundation
Warren A. Jones, MD, FAAFP
(312) 233-1131
drwajones@bellsouth.net
Commission on Accreditation for

Health Informatics and Information
Management Education
Mervat Abdelhak, PhD, RHIA, FAHIMA
(312) 233-1548
info@cahiim.org
Commission on Certification for Health

Informatics and Information Management
Donna Rugg, RHIT, CCS
(585) 396-6784
donna.rugg@thompsonhealth.org
Council for Excellence in Education

Ellen Shakespeare Karl, MBA, RHIA, CHDA,
FAHIMA
(646) 344-7324
ellen.shakespeare@mail.cuny.edu
Envisioning Collaborative
(406) 522-4501
House Leadership
Laura W. Pait, RHIA, CDIP, CCS
(336) 946-1750
lpait@novanthealth.org
20142015 HOUSE OF DELEGATES

Speaker of the House of Delegates
(406) 522-4501
Speaker-elect of the House of Delegates

Laura W. Pait, RHIA, CDIP, CCS
(336) 946-1750
lpait@novanthealth.org
2014 PRACTICE COUNCIL VOLUNTEER CONTACTS

Care Coordination
Lee A. Wise, RHIA
(760) 880-7518
leewise2008@hotmail.com
Consumer Engagement
Anne L. Tegen, MHA, HRM
(952) 474-1780
anne.tegen@childrensmn.org
Clinical Terminology & Classification

Tammy R. Love, RHIA, CDIP, CCS
(501) 472-6634
Tammy.Love@hcahealthcare.com
Beth A. Friedman, RHIT

(770) 335-8570
beth@ten22pr.com
Dwan A. Thomas-Flowers, MBA, RHIA, CCS

(904) 607-6610
HIMprofexcel@bellsouth.net
Enterprise Information Management

Kathleen Addison
(403) 943-0940
kathleen.addison@albertahealthservices.ca
Jill S. Clark, MBA, RHIA, CHDA, FAHIMA

(717) 246-9472
jclark@e4-services.com
Lori McNeil Tolley, MEd, BS, RHIA
(508) 822-1432
loriamcneil@gmail.com
Health Information Exchange
Sheldon Wolf
(701) 328-1991
shwolf@nd.gov
Privacy and Security

Sharon Lewis, MBA, RHIA, CHPS, CPHQ,
FAHIMA
(805) 542-0160
sharonlewisrhia@att.net
Susan M. Lucci, RHIT, CHPS, CMT, AHDI-F
(303) 646-3355
slucci128@hotmail.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, 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
(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
New Jersey
Carolyn Magnotta, RHIA
New Egypt, NJ
(609) 758-8890
magnottac@deborah.org
Texas
Terri Frnka, RHIT
Bryan, TX
terrifrnka@yahoo.com
Arizona
Christine Steigerwald, RHIA
Gilbert, AZ
(480) 292-8293
Christine.Steigerwald@bannerhealth.com
Arkansas
Marilynn Frazier, RHIA, CHPS
Ozark, AR
(479) 667-5153
mfrazier@ftsm.mercy.net
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Shirley Lewis, RHIA, CCS
Upland, CA
(909) 608-7657
shirley.lewis5@verizon.net
Colorado
Melinda Patten, CDIP, CHPS
Aurora, CO
(720) 777-6657
melinda.patten@childrenscolorado.org
Kansas
Julie Hatesohl, RHIA
Junction City, KS
(785) 210-3498
phoebehat@cox.net
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Meloney Mantsch, RHIA
Pittsburgh, PA
(603) 494-3429
mmantsch@css.edu
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Lisa Delhomme, MHA, RHIA
Rayne, LA
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delhomme@louisiana.edu
Maine
Nora Brennen, RHIT
Topsham, ME
(207) 751-1853
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Connecticut
Elizabeth A. Taylor, MS, RHIT
(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
Sandra Johnson, RHIT
Rigby, ID
(208) 317-4987
brynnesmum@gmail.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
New Mexico
Vicki Delgado, RHIT
Albuquerque, NM
(505) 948-6711
vicki.delgado@kindredhealthcare.com
New York
Sandra Macica, RHIA
Saratoga Springs, NY
(518) 584-0389
s.macica@elsevier.com
Utah
Vickie Griffin, RHIT, CCS
Bountiful, UT
vickie.griffin@Parallon.com
Vermont
Charmaine S. Vinton, RHIT, CCS, CPC
(603) 357-0170
cvinto@bmhvt.org
Virginia
Darcell Campbell, RHIA
Hampton, VA
(757) 788-0052
DACampbell@cox.net
North Carolina
Jolene Jarrell, RHIA, CCS
Apex, NC
jolene@drgreview.com
North Dakota
Tracey Regimbal, RHIT
Grand Forks, ND
traceyregimbal@hotmail.com
Ohio
Gail Wright, RHIT
Mansfield, OH
(419) 526-0439
gail.wright@kindred.com
Oklahoma
Christy Hileman, RHIA, CCS
Mustang, OK
(405) 954-2824
christy.hileman@faa.gov
Oregon
William Watkins, RHIA
Oregon City, OR
(503) 867-5173
william.w.watkins@kp.org
Washington
Sheryl Rose, RHIT
Spokane, WA
(509) 624-4109
sherylrose622@hotmail.com
West Virgnia
Kathy Johnson, RHIA
Sinks Grove, WV
(304) 772-5312
kjohnson@care-communications.com
Wisconsin
Susan Casperson, RHIT
Cecil, WI
(715) 853-1370
susan.casperson@thedacare.org
Wyoming
Kimberle Johnson, RHIA
Gillette, WY
(307) 682-1251
kim.johnson@ccmh.net
Pennsylvania
Laurine Johnson, RHIA, FAHIMA
Sarver, PA
(724) 295-9429
ljohnson@peakhs.com
Puerto Rico
Yanet Soto
Arecibo, PR
(787) 879-2835
ysoto@wilmamed.com
Rhode Island
Patti Nenna, RHIT
Bristol, RI
(401) 253-1686
pnenna@cox.net
South Carolina
Karen B. Farmer, RHIT
(864) 277-1982
kfarmer@ghs.org
E-mail changes to your listing to journal@ahima.org

13.QC.2371_1_13.QC.2371_1 7/8/13 12:14 PM Page 1
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CAC/NLP & Associated Technologies.

Price/Return on Investment, Delivery
Unparalleled Interpersonal Attention & Service.
Artificial Medical Intelligence Inc. 10 Industrial Way East Eatontown, New Jersey 07724
Toll Free: 866-415-6112 Email: info@artificialmed.com Fax: 732-544-1009
Website: www.artificialmed.com
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.
Want to fill your open position,

or promote your office as a
great place to work?
Contact Alyssa Blackwell at 410-584-1961 for pricing and options, or
leave her an email at ABlackwell@NetworkMediaPartners.com.
Adreima is seeking FT/PT

experienced coders to join our
team. Adreima partners with
more than 600 hospitals and
offers: sign-on bonus/ medical/
dental/ vision/ 401K.
www.adreima.com/careers/
Upcoming Issues:
October
Information Governance
Advertise in
the AHIMA
Career Center!
November/December
E-Compliance
Contact Alyssa Blackwell at 410-584-1961

or ablackwell@networkmediapartners.com
Custom Packages available to fit your goals and budget.

84/Journal
4
84
/ Journal of AHIMA September 1
14
Director of Health Information Management

Ridgecrest Regional Hospital is seeking a Director for our
Health Information Management Department. The ideal
candidate will have a B.S. degree in Health Information
Management, a minimum of two years experience managing
a H.I.M. department, experience with an electronic medical
record system, the ability to interpret statistical and financial
data, ability to communicate effectively with physicians, and
be registered as a Health Information Administrator (RHIA)
issued by the American Health Information Management
Association (AHIMA).
If you are seeking to be part of a health care team which
is committed to delivering high quality patient-centered
care, we invite you to pursue employment opportunities
with us. Our benefits include hospital subsidized
Medical, dental, and vision benefits, paid time off (PTO),
403b plan with matching contribution, cafeteria privileges
at bargain prices, and gym reimbursement.
Applicants should apply online at our web site www.rrh.org.
EOE.
Find the
perfect employee.
Advertise in the
AHIMA Career Center!
Contact Alyssa Blackwell
at 410-584-1961
IMMEDIATE JOB OPENINGS

Credentaled Coding Professionals
Adreima, the natons largest, independent revenue cycle
services company, is seeking full tme experienced coders
and auditors to join our team of more than 1,100 employees
natonwide. Adreima partners with more than 600+
hospitals and healtah systems to help them capture full
value for the services they oer.
Requirements:
Knowledge and experience with ICD-9/10 CM and CPT4/HCPCS coding
rules and federal guidelines
Seeking experienced Coders with a minimum of 3 years
acute care inpatent/ outpatent experience.
Must be AHIMA credentaled with one of the following:
CCS, RHIT, RHIA
Also seeking IR coders must have CIRCC credental
Apply now, work within a week at
www.adreima.com/careers
Recruiter- Jena Ford
602-636-5531
jena.ford@adreima.com
Immediate Positons
Compettve Pay
Excellent Benets
Great Place to Work!
Coding Job Overview

This positon codes all charts including
Inpatent, ER, OP Surgery, Diagnostc and
Observaton charts.Coder assigns the
appropriate diagnostc and procedural
(ICD-9-CM and CPT-4) codes to individual
patent health informaton for data
retrieval, analysis, and claims processing.
May also perform audit functon
depending on scope of client agreement.
JournalofofAHIMA
AHIMASeptember
September1414/85
Journal
/ 85
AHIMA Career Center
Cutting-edge clinical
documentation company
Competitive salary and
benefts
Work from home with
the latest technology
Hire Calling.
Elevate Your Job Satisfaction.
Join The M*Modal Medical
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mmodal.com/codingcareers
jobs@mmodal.com 919-867-3521
2014 MModal IP LLC. All rights reserved.
86/Journal
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86
/ Journal of AHIMA September 1
14
2014
AdANNUAL
Space
CLINICAL CODING MEETING

SEPTEMBER 2728, 2014
SAN DIEGO, CA
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Register now and save $100
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Essential Information for All Stakeholders in the Coding Industry!
Delve into emerging industry issues and critical topics, and gather vital insight from
cutting-edge speakers as they address the changing environment related to ICD-10 and
other initiatives driving healthcare.
Not-to-miss sessions include:
Challenges in Clinical Documentation: Stories from the Front Line by Jonathan Elion,
MD, President and CEO, ChartWise Medical Systems Inc., Wakefield, RI
Leading in Times of Change by Scott Carbonara, MA, Prosci Psych/Communications;
Change Management Certified, Spiritus Communications, Hillsborough, NC
The Evolution of Rebuilding Coders to Optimal Performance Using ICD-10 by Joanne
Schade-Boyce, BSDH, MS, CPC, ACS, CodeMed Solutions, LLC, Germantown, MD
Jonathan Elion
Scott Carbonara
Joanne Schade-Boyce
I had a wonderful time at the Clinical Coding Meeting, and learned a lot! In his presentation, Dr. Jon Elion
stated, If you pursue a high quality medical record, correct reimbursement will follow. The meeting was
also a great networking opportunity. I took away ideas I could implement and was able to share what has
been working for me.
Kathy A. Completa, CCS, Coding and Documentation Educator
For more information and to register visit ahima.org/clinicalcoding today!

MX9849
Addendum
Fast As You Can

US Lagging Behind in Broadband Internet Access
AT A TIME WHEN TECHNOLOGY has been able to facilitate advancement in so many other areas, the United
States is coming up surprisingly short when it comes to meeting its citizens Internet speed needs.
According to a new report from Akamai, the US has seen improvement in broadband speed from year to year. But
even though the broadband speed in the US recently jumped 31 percent in its national average connection rate,
the country is a laggard behind other global leaders, according to Akamais 2014 report The State of the Internet.
Globally, the US came in 12th place in broadband access and speed, with an average connection speed of 10.5
megabits per second (Mbps). To compare, South Koreas rate leaped by 145 percent to 23.6 Mbps. This is alarming
to health IT stakeholders that rely on high broadband speeds to facilitate health information exchange (HIE) and
other health initiatives, such as the meaningful use EHR Incentive Program.
Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA, a director of HIM practice excellence at AHIMA, says a
Health Level Seven (HL7) workgroup is working to tackle the slow speeds and lack of strong broadband service
outside of urban areas. He adds that the workgroups are looking into how to adjust message and file sizes and
formats to speed up performance without causing care coordination and data accuracy and integrity to suffer.
Poor access to high-speed broadband puts rural healthcare providers and patients at a disadvantage when it
comes to providing and obtaining much needed telehealth services.
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ROBUST BROADBAND ARE:
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Netherlands
6. Latvia
7. Sweden
8. Czech Republic
9. Finland
10. Ireland
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SEPTEMBER 2014

EMPOWERING CONSUMERS TO OPTIMIZE THEIR

The Role of Informatics in Healthcare

Anupam Goel, MD, MBA, vice president of clinical information

Sign Up Today for the 86th AHIMA Convention and Exhibit

Contents September 2014

Empowering consumers to optimize their healthcare

Vol. 85, no. 9

Who Are You?

HIPAAs Place in Court-Ordered Discovery

2014 AHIMA Convention Preview

Word from Washington

AHIMA Career Center

Contents September 2014

By Harry Rhodes, MBA, RHIA, CHPS, CDIP,

By Diana Warner, MS, RHIA, CHPS, FAHIMA

Navigating Privacy and Security

e-HIM Best Practices

The Sound Record

By Michelle Wieczorek, RN, RHIT, CPHQ, and Jill S.

AHIMA members may earn continuing

ACA Risk Adjustment Models Emerge in

Coding ICD-10-PCS Procedures in the Ancillary

Defining the Basics of Health Informatics for

4/Journal of AHIMA September 14

Who Are You?

Coding ICD-10-PCS Procedures in the Ancillary

Meet a CAC vendor that has been

as any other indexed code set, even research variants

We dont rely on mapping tables, so ICD-10-CM for

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Contents September 2014

Video: The Role of Informatics in

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Keep up on the latest news coming out of the 86th

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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

Linda Belli, RHIA

8/Journal of AHIMA September 14

Reinventing Clinical Documentation

Personal Health Information is

AS A HEALTH informatics and information management professional and a

Texas Childrens Hospital. Armed with

HOSPITALS and CLINICS

Look for HealthPort at

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