Ahimajournal 2015 02 DL

FEBRUARY 2015
HIM RUSHES TO BRIDGE EDUCATIONAL AND

PROFESSIONAL GAPS CAUSED BY A QUICKLY
ADVANCING INDUSTRY
Welcome
TO THE DIGITAL EDITION OF THE
JOURNAL AHIMA
OF
Match Made in HIM Heaven
AHIMAs Mentor Match program partners HIM leaders with

HIM students for a mutually beneficial mentoring opportunity.
Education and Professional Development Guide
The latest special advertising section from the Journal highlights

the top education and professional development services.
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Contents February 2015
Cover
20
Mind the Gap
HIM rushes to bridge

educational and professional
gaps caused by a quickly
advancing industry
By Mary Butler
Vol. 86, no. 2

Departments
10
Presidents Message
Meeting Evolving Workforce
Requirements
12
pg. 38
Retirees dont just have to sew to pass the time

many head back into the profession.
Features
26
Dissecting the Details

Documentation Based Coding model offers
advanced approach to workforce coding
training
By Diana Karff, RHIA, CCS
32
Optimizing PHI Disclosure Management in

the Age of Compliance
By Don Hardwick; Mariela Twiggs, MS, RHIA, CHP, FAHIMA; and
James H. Braden, MBA, RHIA
38
HIM After Retirement

No needlepoint for these retirees, who
are finding new ways to contribute to
the profession on their own terms
By Lisa A. Eramo
Bulletin Board
16
Word from Washington

Set Your Sights on ICD-10
and Meaningful Use in 2015
19
Inside Look
Education is Crucial for Our Future
66
Calendar
67
Keep Informed
68
Volunteer Leaders
71
AHIMA Career Center
84
Addendum
Privacy or Convenience?

Working Smart
42
Navigating Privacy and Security

FDA Offers Guidance on Cybersecurity and Medical Devices
By Liisa Thomas and Idara Udofia
44
48
Standards Strategies
Informatics Education for
HIM Professionals in the Era
of Interoperable StandardsBased HIEs
By Anna Orlova, PhD, and Harold Lehmann, MD, PhD
e-HIM Best Practices

Metadata Offers Roadmap to
Structured Data
52
The Sound Record

Evaluating the Information
Governance Principles for
Healthcare: Accountability
and Transparency
By Diane Dolezel, MSCS, RHIA
By Galina Datskovsky, PhD; Ron Hedges, JD;

and Sofia Empel, PhD
Coding Notes
Quizzes
58
AHIMA members may earn continuing

education credits by successfully completing
the following quizzes at www.ahimastore.org
Hospital Discharge Status Codes:

Risks and Rewards
By William E. Haik, MD, FCCP, CDIP
62
CPT Updates for CY 2015

By Patty Buttner, RHIA, CDIP, CCS
Practice Brief
54
Including Patient-Generated Health

Data in Electronic Health Records
4/Journal of AHIMA February 15
31

Domain: Clinical Data Management
37
Optimizing PHI Disclosure Management in the Age of

Compliance
Domain: Performance Improvement
64

Domain: Clinical Data Management
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http://journal.ahima.org
Hiring a Coding Ace for
Help with ICD-10HIM
directors and managers
need the reassurance of
knowing that any new team
members they bring on
board will be committed to
the organization for the long
haul. This article explores
seven strategies for recruiting
the best HIM candidates.
Video: Match Made in HIM Heaven
AHIMAs Mentor Match program partners HIM

leaders with HIM students for a mutually beneficial
mentoring opportunity.
Projects Help Students Prepare for e-HIM

Masters level HIM students are doing some revolutionary
things to prepare for work in an electronic environment.
Share and Connect with AHIMA

Follow AHIMA and Journal of AHIMA on these social media outlets.
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For the treatment of toxic plasma methotrexate

concentrations (>1 micromole per liter) in patients
with delayed methotrexate clearance due to impaired
renal function
Ad Space
Voraxaze New Technology Add-on Payment (NTAP) Extended
NAME
Receive up to an additional 50% payment on your MS-DRG submission.*

When you report a claim for Voraxaze you can be reimbursed up to half the cost of Voraxaze
in addition to the current MS-DRG payment
USE VORAXAZE
ICD-9-CM CODE 00.95
TO BE ELIGIBLE FOR NTAP
Payers may require the national drug code (NDC) to be submitted on the claim
Product
Voraxaze
NDC Number
50633021011 (11 digit)
Injection or infusion of glucarpidase
Call 1-866-369-9290 or email Voraxaze@thepinnaclehealthgroup.com with questions

Indication and Limitations of Use
Voraxaze is indicated for the treatment of toxic plasma methotrexate concentrations (>1 micromole per liter) in patients
with delayed methotrexate clearance due to impaired renal function1
Voraxaze is not indicated for use in patients who exhibit the expected clearance of methotrexate (plasma methotrexate
concentrations within 2 standard deviations of the mean methotrexate excretion curve specic for the dose of methotrexate
administered) or those with normal or mildly impaired renal function because of the potential risk of subtherapeutic exposure
to methotrexate1
Selected Safety Information

Serious allergic reactions, including anaphylactic reactions, may occur
The most common adverse reactions (incidence 1%) with Voraxaze are paresthesias, ushing, nausea and/or vomiting,
hypotension, and headache
Please see brief summary of prescribing information on adjacent page.

Please see full prescribing information, including important safety information, at www.voraxaze.com.
References: 1. Voraxaze [prescribing information]. Brentwood, TN: BTG International Inc. March 2013. 2. New Medical Services and New Technologies. February 2014. http://cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.html.
DISCLAIMER
*Procedure coding should be based upon medical necessity and procedures and supplies provided to the patient. Coding and reimbursement information is provided for educational purposes and does
not assure coverage of the specic item or service in a given case. This information makes no guarantee of coverage or reimbursement of fees. Contact a local Medicare Fiscal Intermediary, Carrier, or
CMS for specic information regarding coverage, coding, and payment. To the extent that cost information is submitted to Medicare, Medicaid, or any other reimbursement program to support claims for
services or items, there is an obligation to accurately report the actual price paid for such items, including any subsequent adjustments.
ICD-9-CM=International Classication of Diseases, Ninth Revision, Clinical Modication.
NTAP=New Technology Add-on Payment policy provides additional payments for cases with high costs involving eligible new technologies while preserving some of the incentives under the averagebased payment system. The payment mechanism is based on the cost to hospitals for the new technology and is determined on a case-by-case basis. Under 42 CFR 412.88 Medicare pays the
lesser of 50 percent of the cost in excess of the full DRG payment or 50 percent of the cost of the technology. If the actual costs of a NTAP case exceed the DRG payment by more than the estimated
costs of the new technology, Medicare payment is limited to the DRG payment plus 50 percent of the estimated costs of the new technology. 2
BTG International Inc.

All rights reserved US-VX-2014-1091 August 2014
BTG and the BTG roundel logo are registered trademarks of BTG International Ltd.
Voraxaze is a registered trademark of Protherics Medicines Development Ltd.,
a BTG International group company.
VORAXAZE (glucarpidase)
For Injection, for intravenous use
Initial U.S. Approval: 2012
Brief Summary of Prescribing Information.
For complete Prescribing Information,
consult offcial package insert.
INDICATIONS AND USAGE
Indication
VORAXAZE (glucarpidase) is indicated for
the treatment of toxic plasma methotrexate
concentrations (>1 micromole per liter) in
patients with delayed methotrexate clearance
due to impaired renal function.
Limitation of Use
VORAXAZE is not indicated for use in
patients who exhibit the expected clearance
of methotrexate (plasma methotrexate
concentrations within 2 standard deviations
of the mean methotrexate excretion curve
specifc for the dose of methotrexate administered) or those with normal or mildly impaired
renal function because of the potential risk of
subtherapeutic exposure to methotrexate.
CONTRAINDICATIONS
None
WARNINGS AND PRECAUTIONS
Serious Allergic Reactions
Serious allergic reactions occurred in less than
1% of patients [see Adverse Reactions].
Monitoring Methotrexate Concentration/
Interference with Assay
Methotrexate concentrations within 48
hours following administration of VORAXAZE
can only be reliably measured by a
chromatographic method. DAMPA (4deoxy-4-amino-N10-methylpteroic acid) is an
inactive metabolite of methotrexate resulting
from treatment with VORAXAZE. DAMPA
interferes with the measurement of
methotrexate concentration using
immunoassays resulting in an erroneous
measurement which overestimates the
methotrexate concentration. Due to the long
half-life of DAMPA (t1/2 of approximately
9 hours), measurement of methotrexate
using immunoassays is unreliable for samples
collected within 48 hours following VORAXAZE
administration.
Continuation and Timing of Leucovorin
Rescue
Continue to administer leucovorin after
VORAXAZE. Do not administer leucovorin
within 2 hours before or after a dose of
VORAXAZE because leucovorin is a substrate
for VORAXAZE [see Drug Interactions].
For the frst 48 hours after VORAXAZE,
administer the same leucovorin dose as
given prior to VORAXAZE [see Warnings
and Precautions]. Beyond 48 hours after
VORAXAZE, administer leucovorin based on
the measured methotrexate concentration. Do
not discontinue therapy with leucovorin based
on the determination of a single methotrexate
concentration below the leucovorin treatment
threshold. Therapy with leucovorin should be
continued until the methotrexate concentration
has been maintained below the leucovorin
treatment threshold for a minimum of 3 days.
Continue hydration and alkalinization of the
urine as indicated.
ADVERSE REACTIONS
Serious allergic reactions, including
anaphylactic reactions, may occur. The most
common adverse reactions (incidence >1%)
with VORAXAZE are paraesthesias, fushing,
nausea and/or vomiting, hypotension, and
headache.
Clinical Trials Experience
Because clinical trials are conducted under
controlled but widely varying conditions, adverse reaction rates observed in clinical trials
of VORAXAZE cannot be directly compared to
rates in the clinical trials of other drugs and

may not refect the rates observed in practice.
The evaluation of adverse reactions in patients
treated with VORAXAZE is confounded by the
population in which it was studied, patients
with toxic plasma methotrexate levels due to
impaired renal function. Adverse reactions
related to toxic methotrexate levels due to
prolonged methotrexate clearance include
myelosuppression, mucositis, acute hepatitis,
and renal dysfunction and failure.
The safety of VORAXAZE is based on data from
290 patients who were treated in 2 single-arm,
open-label, multicenter trials enrolling patients
who had markedly delayed methotrexate
clearance secondary to renal dysfunction.
Patients with osteosarcoma were eligible
for these studies if the plasma methotrexate
concentration was greater than 50 mol/L at
24 hours, greater than 5 mol/L at 48 hours,
or greater than 2 standard deviations above
the mean methotrexate elimination curve at
least 12 hours after methotrexate administration and there was a 2-fold or greater increase
in serum creatinine above baseline. All other
patients were eligible for these studies if the
plasma methotrexate level was greater than
10 mol/L more than 42 hours after the start
of the methotrexate or the plasma level was
greater than 2 standard deviations above the
mean methotrexate excretion curve at least 12
hours following methotrexate and the serum
creatinine was greater than 1.5 times the upper limit of normal or the creatinine clearance
was less than 60 mL/min at least 12 hours
following methotrexate administration.
Study 1, conducted by the National Cancer
Institute (NCI), enrolled 184 patients; safety
information is available for 149 patients.
VORAXAZE was given at a dose of 50 Units/
kg as an intravenous injection over 5 minutes.
Patients with pre-VORAXAZE methotrexate
concentrations >100 mol/L were to receive a
second dose of VORAXAZE 48 hours after the
frst dose. The protocol specifed that patients
continue receiving intravenous hydration,
urinary alkalinization and leucovorin, and
that leucovorin administration be adjusted to
ensure that it was not administered within two
hours before or after VORAXAZE.
In Study 1, VORAXAZE-related adverse
reactions were collected on a fow sheet with
a daily log of adverse reactions characterized
as glucarpidase toxicity. Additional safety
information was collected from clinical records submitted by treating physicians. This
information was abstracted and categorized
using the National Cancer Institute (NCI)
Common Terminology Criteria for Adverse
Events (CTCAE) version 3 scale.
The Study 1 population enrolled patients with
a median age of 18 years (1 month to 85
years); 63% were male, and the underlying
malignancies were osteosarcoma/sarcomas
in 32%, and leukemia or lymphoma in 63%
of patients. One (n=106) or 2 (n=30) doses of
VORAXAZE were administered intravenously;
the number of doses was not specifed in 13
patients. Doses ranged from 18 to 98 Units/
kg, with a median dose of 49 Units/kg.
Study 2 is an ongoing expanded access
program. At the time of data cut-off, 243
patients were enrolled and safety data was
available for 141 patients. VORAXAZE was
given at a dose of 50 Units/kg as an intravenous injection over 5 minutes. The criterion for
allowing patients to receive a second glucarpidase dose was not specifed in the protocol.
The protocol specifed that patients continue
receiving intravenous hydration, urinary alkalinization and leucovorin, and that leucovorin
administration be adjusted to ensure that it
was not administered within two hours before
or after VORAXAZE.
Study 2 enrolled patients with a median age
of 17 years (6 months to 85 years); 64% were
male, and the underlying malignancies were
osteogenic sarcoma in 32%, and leukemia or
lymphoma in 62% of patients. One (n=122) or 2
(n=18) doses of VORAXAZE were administered
intravenously; the number of doses was not
specifed for 1 patient. Doses ranged from

6 to 189 Units/kg, with a median dose of
50 Units/kg.
In Study 2 only VORAXAZE-related adverse
reactions were collected and severity was
graded according to NCI CTCAE version 3.
Among the 290 patients included in the
safety evaluation of VORAXAZE, there were 8
deaths within 30 days of VORAXAZE exposure
that were not related to progressive disease.
Twenty-one of 290 patients (7%) experienced
adverse reactions that were assessed as
related to VORAXAZE. Most were Grade 1 or 2
events. One patient experienced related Grade
3 fushing. The most common related adverse
reactions that were not hematologic, hepatic
or renal events were paresthesia, fushing, and
nausea and/or vomiting, which each occurred
in 2% of patients (Table 1).
Table 1: Per Patient Incidence of Grade
1 and 2 Adverse Reactions Assessed as
Possibly, Probably, or Defnitely Related
to VORAXAZE Excluding Hematologic,
Hepatic, or Renal Adverse Reactions
Adverse Reaction
N= 290
n (%)
Paresthesias
7 (2%)
Flushing1,2
5 (2%)
Nausea/Vomiting
5 (2%)
Headache
2 (1%)
Hypotension
2 (1%)
Blurred Vision
1 (<1%)
Diarrhea
1 (<1%)
Hypersensitivity
1 (<1%)
Hypertension
1 (<1%)
Rash
1 (<1%)
Throat irritation/
Throat tightness
1 (<1%)
Tremor
1 (<1%)
This incidence includes the following terms: fushing,

feeling hot, burning sensation.
One of these reactions was classifed as Grade 3

in severity.
Immunogenicity
As with all therapeutic proteins, there is
potential for immunogenicity. In clinical trials,
121 patients who received one (n=99), two
(n=21), or three (n=1) doses of VORAXAZE
were evaluated for anti-glucarpidase
antibodies. Twenty-fve of these 121 patients
(21%) had detectable anti-glucarpidase antibodies following VORAXAZE administration, of
which 19 received a single dose of VORAXAZE
and 6 received two doses of VORAXAZE.
Antibody titers were determined using a
bridging enzyme-linked immunosorbent assay
(ELISA) for anti-glucarpidase antibodies.
Neutralizing antibodies were detected in 11
of the 25 patients who tested positive for
anti-glucarpidase binding antibodies. Eight of
these 11 patients had received a single dose
of VORAXAZE. However, the development of
neutralizing antibodies may be underreported
due to lack of assay sensitivity.
The detection of antibody formation is highly
dependent on the sensitivity and specifcity of
the assay. Additionally, the observed incidence
of antibody (including neutralizing antibody)
positivity in an assay may be infuenced by
several factors, including assay methodology,
sample handling, timing of sample collection,
concomitant medications, and underlying
disease. For these reasons, comparison of
incidence of antibodies to VORAXAZE with the
incidence of antibodies to other products may
be misleading.
DRUG INTERACTIONS
Use of VORAXAZE with Leucovorin
Leucovorin is a substrate for VORAXAZE.
Do not administer leucovorin within 2 hours
before or after a dose of VORAXAZE. No dose
adjustment is recommended for the continuing leucovorin regimen because the leucovorin
dose is based on the patients pre-VORAXAZE
methotrexate concentration [see Warnings
and Precautions].
Other Substrate Interference
Other potential exogenous substrates of
VORAXAZE may include reduced folates and
folate antimetabolites.
USE IN SPECIFIC POPULATIONS
Pregnancy
Pregnancy category C.
There are no adequate and well controlled
studies with VORAXAZE in pregnant women
and animal reproduction studies have not
been conducted with VORAXAZE. Therefore, it
is not known whether VORAXAZE can cause
fetal harm when administered to a pregnant
woman. VORAXAZE should be given to a
pregnant woman only if clearly needed.
Nursing Mothers
It is not known if VORAXAZE is excreted in human milk. Because many drugs are excreted
in human milk, caution should be exercised
when VORAXAZE is administered to a nursing
woman.
Pediatric Use
The effectiveness of VORAXAZE in pediatric
patients was established in Study 1. Of the
22 patients in the effcacy dataset in Study 1,
12 were pediatric patients with ages ranging
from 5 to 16 years. Three of the six pediatric
patients with a pre-VORAXAZE methotrexate
concentration of 1-50 mol/L achieved a rapid
and sustained clinically important reduction
(RSCIR) in plasma methotrexate concentration,
while none of the six pediatric patients with a
pre-VORAXAZE methotrexate concentration
>50 mol/L achieved a RSCIR.
The pooled clinical safety database for
VORAXAZE included data for 147 patients
from 1 month up to 17 years of age. No overall
differences in safety were observed between
these patients and adult patients.
Geriatric Use
Of the total number of 290 patients in clinical
studies of VORAXAZE, 15% were 65 and
over, while 4% were 75 and over. No overall
differences in safety or effectiveness were
observed between these patients and younger
patients.
Renal Impairment
No dose adjustment of VORAXAZE is
recommended for patients with renal
impairment.
Hepatic Impairment
No specifc studies of VORAXAZE in patients
with hepatic impairment have been conducted.
OVERDOSAGE
There are no known cases of overdose with
VORAXAZE.
Manufactured by:
Brentwood, TN 37027
U.S. License No. 1861
Distributed by:
West Conshohocken, PA 19428
VORAXAZE is a registered trademark of
Protherics Medicines Development Ltd.
BTG and the BTG roundel logo are registered
trademarks of BTG International Ltd.
The Journal of AHIMA is an official publication of AHIMA
AHIMA CEO
EDITORIAL DIRECTOR
EDITOR-IN-CHIEF
Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA

Anne Zender, MA
Chris Dimick

ASSISTANT EDITOR/
ADVERTISING COORDINATOR Sarah Sheber

ASSOCIATE EDITOR
Mary Butler

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

Patricia Buttner, RHIA, CDIP, CCS

`
Angie Comfort, RHIT, CDIP, CCS

Angela Rose, MHA, RHIA, CHPS, FAHIMA

Julie Dooling, RHIA, CHDA

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

FAHIMA

Katherine Downing, MA, RHIA, CHP, PMP

Deborah Green, MBA, RHIA

Jewelle Hicks

Lesley Kadlec, MA, RHIA

Carol Maimone, RHIT, CCS

Paula Mauro

Anna Orlova, PhD

Kim Osborne, RHIA, PMP

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

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, MPH, RHIA

Carol A. Campbell, DBA, RHIA

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

Teri Jorwic, RHIA, CCS

Diane A. Kriewall, RHIA

Frances Wickham Lee, DBA, RHIA

Glenda Lyle, RHIA

Susan R. Mitchell, RHIA

Daniel J. Pothen, MS, RHIA

Cheryl Tabatabai Stachura, RHIA

Tricia Truscott, MBA, RHIA, CHP

Carolyn R. Valo, MS, RHIT, FAHIMA

Valerie Watzlaf, PhD, RHIA, FAHIMA
ADVERTISING REPRESENTATIVES
Network Media Partners
Jeff Rhodes
(410) 584-1940; Fax: (410) 584-8353
jrhodes@networkmediapartners.com
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bshoul@networkmediapartners.com
AHIMA OFFICES
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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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Periodicals postage is paid in Chicago, IL, and additional mailing offices.
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 2015 American Health Information Management Association Reg. US Pat. Off.
Presidents Message
Meeting Evolving Workforce Requirements

By Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA
NEW TECHNOLOGY, AN evolving regulatory environment, financial pressures,

and consolidation in the marketplace
have all emerged as factors that are
shaping the health information management (HIM) career path. Now is the time
to examine the maturity state of the electronic health record (EHR) and technology improvements that will impact conventional coding roles within the next five
to 10 years. This hits very close to home
for me, as my son is presently pursuing
an education in coding and documentation at a CAHIIM-approved program.
As the AHIMA House of Delegates
and Board of Directors examines the
future of coding, now is the time for reinventing and broadening your skills and
education to meet the evolving roles in
information governance, data integrity,
informatics, and analytics. AHIMA continues to update the HIM Career Map,
CCHIIM is exploring new certification
tracks, and CAHIIM is working with the
Council for Excellence in Education
(CEE) to define new HIM competencies
and workforce requirements.
A workforce study was conducted during the second quarter of 2014 to define
the nature of the HIM workforce and
forecast the future needs and requirements of the industry 10 to 20 years from
now. The preliminary report demonstrates that our members view of their
value to employers highly correlates to
healthcare executives. The ranking of
coding and clinical documentation core
competencies evolve in the future state
to data integrity positions associated
with EHRs, data analytics, and critical
thinking skills.
I have identified new roles in the executive suite and supporting positions at the
staff and leadership level, including:
Vice President of Population Health
Vice President of EHR and Innovation
Vice President of Patient Experience

Vice President of Information
Governance
Vice President of Health Informatics
Chief Data Officer
Recent research points to the demand
for data scientists growing in the future,
and the Big Data market will likely grow
anywhere from 20 to 40 percent annually
through 2017.1
I want to encourage AHIMA members
to push themselves out of their respective comfort zones to apply for these positions or to identify the skills and knowledge gaps that could preclude them
from consideration. As the walls come
tumbling down in HIM departments, replaced by virtual workplaces and services provided in non-traditional settings,
the need for traditional staff and leadership positions have changed as dramatically as our transformation from paper to
electronic records.
I pledge to you that AHIMA is here to
offer up heavy doses of mentoring and
coaching to ensure you realize your respective career goals, and fill the newly
created and expanding roles needed to
meet the increasing demand for knowledge workers in HIM. Together as an engaged HIM community I know that we
can realize our vision and motivate our
members to achieve their full potential
while advancing the practice of HIM.
Note
1. 10 Big Data Career Killers. Information Management. www.
information-management.com/
gallery/10-Big-Data-Scientist-Career-Killers-10026239-1.html.
Cassi Birnbaum (cassi.birnbaum@ahima.org) is
senior vice president of HIM and consulting at
Peak Health Solutions.
Audit Chaos
High volumes of audit requests arrive
and are delivered to various departments.
vs.
Audit Relief
All audit requests are
centralized through HealthPort.
DEPT.
DEPT.
DEPT.
DEPT.
DEPT.
Inundated departments
process the requests
using different methods..
No communication
between
departments,
no one knows
what the other
is doing.
Constant phone calls, faxes, and visits
from third party vendors distract
staff and increase HIPAA concerns.
!!!
HealthPort best practices are used to

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Bulletin Board whats happening in healthcare
Report: Expect More Healthcare Data Cyber Breaches in 2015

Healthcare organizations will likely
see another increase in data breaches this year, according to a data
breach industry forecast report released by Experian.
In the second annual Experian
Data Breach Resolution white paper,
the international information services
company stated that the expanding
number of access points to protected
health information (PHI) and other sensitive data via electronic health records
will make the healthcare industry a
vulnerable and attractive target for
cybercriminals, according to a press
release on the white paper. Several
factors suggest the healthcare industry will continue to be plagued with
data breach headlines in 2015.

The growing popularity of wearable health devices, for example, enhances the threat of a PHI breach for
both patients and providers, the report
states. Healthcare organizations face
the challenge of securing a significant
amount of sensitive information stored
on various networks, which combined
with the value of a medical identity
string makes them an attractive target, the report says.
The growing number of vulnerabilities and the sheer size of the healthcare industry led to an increase in
widely publicized security incidents [in
2014], representing about 42 percent
of all major data breaches reported in
2014, said Michael Bruemmer, vice

president at Experian Data Breach
Resolution. We expect this number
will continue to grow until the industry
comes up with a stronger solution to
improve its cybersecurity strategies.
Exasperating the breach threat is
that many doctors offices, clinics,
and hospitals may not have enough
resources to properly safeguard their
patients PHI, the report says. According to the Ponemon Institutes Fourth
Annual Benchmark Study on Patient
Privacy and Data Security, released
March 2014 and cited in the Experian
report, the potential cost of breaches
for the healthcare industry could be as
much as $5.6 billion each year.
Hospitals Continue EHR Improvements

Toward Meaningful Use
State HIEs Join Forces

for Trade Organization
Hospitals have leapt forward in electronic health record (EHR) upgrades

towards the meaningful use EHR
Incentive Program requirements, according to data released by the Centers for Medicare and Medicaid Services (CMS).
Although previous data released by
CMS earlier in 2014 indicated a poor
showing for meaningful use attestationparticularly for stage 2 of the
programthe numbers of attesting
hospitals have seen significant increases for both stage 1 and stage 2.
According to the data, a total of nearly
3,700 hospitals have attested to meeting the meaningful use requirements
through December 1, 2014. Of those
attesting hospitals, 1,681 hospitals
have attested to the requirements for
stage 2 meaningful use. This number
is of particular significance, as only 10
hospitals had attested to stage 2 by
July 2014.
The reporting deadline for hospital
attestation to meaningful use was ex-
A group of 20 state-level health information exchange organizations from

across the country have formed a national trade organization. Called the
Strategic Health Information Exchange
Collaborative (SHIEC), the organization
hopes to help member HIEs achieve
economies of scale, HIE sustainability,
raise awareness of HIEs among public
and private entities, establish joint ventures, and collaborate on legislative advocacy efforts, according to an article
in Healthcare IT News.
SHIEC has named a chair, Colorados Quality Health Network Executive
Director Dick Thompson, and has an
organizational structure in place with
an elected board of directors. The organization plans to name an executive
director early this year.
SHIEC members include the Arizona
Health-e Connection, HealtheLINK,
based in western New York, Nebraska
Health Information Initiative, Quality
Health Network, and the Utah Health
Information Network, among others.
tended by CMS to the end of December 2014. Earlier in 2014 a hardship

exemption was granted to program
participants due to implementation
delays caused by software developers
falling behind in incorporating changes
in their systems necessary for meeting
stage 2 requirements, according to an
article in Modern Healthcare.
As of press time, CMS officials
expect more to attest by the end of
the filing period, according to Elisabeth Myers from the CMS office of
e-health standards and services.
About 2,500 hospitals were originally expected to meet the stage 2
requirements, following two years of
attestation at stage 1, according to
Modern Healthcare.
A previous estimate from CMS
put the total of hospitals eligible to
participate in the program at 5,011,
according to the article. The meaningful use program has paid about
$15.5 billion in incentives to hospitals so far.
The issue of healthcare data

breaches has even caught the eye of
the Federal Bureau of Investigation
(FBI), who recently issued a private
notice to members of the healthcare
industry warning that their cybersecurity systems are lax compared to
other sectors.
The healthcare industry is not as
resilient to cyber intrusions compared
to financial and retail sectors, therefore the possibilities of increased cyber intrusions is likely, the FBI said in
the notice.
Despite the warnings, most healthcare providers may not be prepared
to defend against a cyber attack. The
Ponemon Institutes report also stated
that 72 percent of healthcare organizations said they are only somewhat

or not confident in the security and
privacy of patient data shared via
health information exchanges.
According to a 2013 Ponemon Institute report cited in the paper, more
than 1.8 million US residents have
suffered a cyber attack on residents
health records, granting hackers the
ability to commit medical identity
theft, illegally purchase drugs, and defraud insurers.
The Experian white paper suggested
that healthcare organizations step up
their security posture and data breach
preparedness or face the potential for
scrutiny from federal regulators.
Rural EHR Adoption Pacing Ahead of

Urban Areas
Electronic health record (EHR) adoption rates for office-based physician sites
are higher for those in rural areas than urban ones, according to new research
set to be published in the Journal of the American Medical Informatics Association. The study, which includes a survey of about 270,000 office-based
physician sites, found that EHR adoption in rural settings was seven percent
higher than those surveyed in urban areas. Analysis in the rural news outlet
Daily Yonder notes that the increase in rural EHR adoption may be a reflection
of the success of outreach efforts such as regional extension centers.
Rural EHR Adoption
56%
Urban EHR Adoption
49%
The Department of Veterans Affairs signed

a $6 million contract to use IBMs
Watson to advise doctors on posttraumatic stress disorder treatment.
After five years as a pilot program, the
Food and Drug Administrations Sentinel
surveillance system for the safety
of FDA-regulated drugs and other
medical products is transitioning to a
full-scale system.
The American Telemedicine Association has
introduced a new service for accrediting live direct-to-consumer telemedicine services.
Georgia Tech has launched a research
project to create electronic health
record phenotypes to classify specific
categories of records to help with such
tasks as identifying candidates for
clinical research or developing predictive models for health studies.
Chicago-based care collaborative
Medical Home Network reports that its
members have reduced 30-day readmissions by 25 percent.
Pioneer accountable care organizations saved more than $180 million
over two years, according to a Department of Health and Human Services report.
Electronic health record improvements ranked among the top 10
ssues that affected doctors in 2014,
according to a report from the American Medical Association.
A report from NORC at the University of
Chicago lists clinician engagement and
interoperability as top issues facing
health information exchange adoption.
The US Navy has approved Carestream
Health to provide its medical facilities
with picture archiving and communications systems.
The US Immigration and Customs Enforcement Agency has completed implementation of a centralized electronic health
record system.
Source: Whitacre, Brian E. Rural adoption rates of electronic records overtake those in urban areas; the gap is more pronounced for specialists. August 2014. http://agecon.okstate.edu/faculty/publications/4946._urban_emr_adoption.pdf.
Journal of AHIMA February 15/13
Bulletin Board whats happening in healthcare
Survey Finds Flagging Morale for Doctors

ENSURING THE INTEGRITY AND TRANSPARENCY OF PUBLIC REPORTS: HOW A
POSSIBLE OVERSIGHT MODEL COULD
BENEFIT HEALTHCARE
www.ajmc.com/publications/
ajac/2014/2014-1-vol2-n4/Ensuringthe-Integrity-and-Transparency-ofPublic-Reports-How-a-Possible-Oversight-Model-Could-Benefit-Healthcare
A paper published in the American
Journal for Accountable Care warns
that a lack of standards for public
performance can lead to conflicting
information that could cause confusion
and misinform patients and healthcare
providers. While efforts to advance
performance measurement should be
applauded, performance measurement experts and policy analysts have
raised concerns that many measures
in public reports, and the public
reports themselves, may not meet a
standard for quality, the authors write.
A survey of practicing physicians points

to a disillusioned workforce under pressure from administrative burdens and
growing demands on their time.
An e-mail survey of 630,000 physicians resulted in 13,575 responses to
the Boston-based organization Physicians Foundation as part of its Biennial
Physician Survey.
Some key findings include:
77 percent of respondents are pessimistic about the future of the
medical profession
84 percent agreed that the medical
profession is on a decline

58 percent responded that they
would not recommend the medical
profession to their children
Doctors are working six percent fewer hours than they did in 2008 resulting
in a loss of 44,250 full-time equivalents
from the physician workforce.
The good news is that 70 percent

of physicians surveyed said they have
implemented electronic health records
(EHRs), and of those, 30 percent believe EHRs have improved the quality of
care. Additionally, the number of hours
physicians spend on non-clinical work
such as charting, billing, and other paperwork has decreased in recent years.
In 2008, some 40 percent of physicians said they spent 10 hours a week
or less on non-clinical paperwork,
while 60 percent said they spent 11
hours or more a week on non-clinical
duties, the report states. In 2012, by
contrast, 58 percent of physicians said
they spent 10 hours or fewer on nonclinical paperwork, while 42 percent
said they spent 11 hours or more.
The authors attributed physician pessimism in the survey to recent dramatic
changes in the healthcare environment
and payment reform initiatives.
THE 2015 STATE OF THE U.S. HEALTH &

FITNESS APPS ECONOMY
http://documents.applause.com/
arc_360_health_fitness_report
JASON Report Urges Learning Health System
This report finds that, based on over

200 million app store ratings and reviews, the average quality score given
by consumers to mobile apps is 66.5
out of 100. The report includes recommendations for apps to improve their
rating, and calls out some of the most
consistently highly rated apps based
on customer reviews. The report seeks
to help people understand what the
best apps are for tracking their health
& fitness and medical goals.
A consortium of scientists that act as

an advisory group to the government,
collectively known as JASON, is urging federal health IT officials to improve
interoperability and move toward research-based care.
The Department of Health and Human Services enlisted JASON to produce a report, called Data for Individual Health, which was written in
cooperation with the Robert Wood
Johnson Foundation, the Agency for
Healthcare Research and Quality,
and the Office of the National Coordinator for Health IT (ONC).
While the JASON report also echoed
ONCs continuous push to make patient data more interoperable, it also
encouraged outside groups to advocate for the same.
It would be desirable to leverage the
work of various non-profit institutions
that focus, for example, on specific
medical conditions or on the overall
STAGE 1 OF THE MEANINGFUL USE INCENTIVE

PROGRAM FOR ELECTRONIC HEALTH RECORDS: A STUDY OF READINESS FOR CHANGE
IN AMBULATORY PRACTICE SETTINGS IN ONE
INTEGRATED DELIVERY SYSTEM
www.biomedcentral.com/14726947/14/119
A survey published in BMC Medical
Informatics and Decision Making finds
that doctors are less likely than other
staff to believe their department will
be able to overcome implementation
issues in the meaningful use EHR
Incentive Program.
health of certain population groups,

such as the American Heart Association or AARP. These organizations
could advocate for interchange of EHR
and health data, as well as encourage
the development of applications that
further their mission and promote overall health, the report states.
The JASON report authors explain
that the US lacks an adequate feedback loop between health outcomes
and clinical research.
To fix this, the US needs a Learning
Health System. According to JASON a
Learning Health System would connect the medical system with broader
societal inputs, creating important
links between health and wellness and
healthcare.
This concept highlights natural roles
for EHRs and PHRs, but also points to
a level of data access, integration, and
scalability that goes well beyond the interoperability of EHR systems.
Hospital-Acquired Conditions Down by

17 Percent
The recent work by hospitals to reduce
hospital-acquired conditions (HACs)
appears to have paid off. According to
a report released in December by the
Department of Health and Human Services (HHS), an estimated 50,000 fewer
patients died in hospitals and approximately $12 billion in healthcare costs
were saved as a result of a reduction in
HACs from 2010 to 2013.
The Agency for Healthcare Research
and Quality (AHRQ) said in a statement
this reduction occurred during a period of concerted attention by hospitals
throughout the country to reduce adverse events in part due to provisions
in the Affordable Care Act, such as tying Medicare payment incentives to the
improvement of care quality.
Preliminary estimates show that hospital patients experienced 1.3 million
fewer HACs from 2010 to 2013, accord-
ing to the HHS report. This translates

to a 17 percent decline in HACs over
the three-year study period.
The decrease represents substantial
progress made in improving patient safety at hospitals, with the report showing
the most significant gains occurring in
2012 and 2013in 2013 alone 35,000
fewer patients died in hospitals, and approximately 800,000 fewer incidents of
harm occurred, which saved hospitals
$8 billion, according to HHS.
HACs include adverse drug events,
catheter-associated urinary tract infections, pressure ulcers, and other avoidable incidents.
AHRQ cites an improvement in care
coordination and better patient engagement for helping drive down HAC
rates, as well as the use of tools and
resources they developed to help providers prevent HACs.
Purpose Outweighs Consent for Health Data

Sharing, Consumers Say
The purpose for which patients information is used factors more heavily than consent into patients comfort
levels regarding health data sharing,
according to a recent survey.
The results of the survey included
responses from 3,064 individuals who
rated the appropriateness of health information use in hypothetical scenarios on a scale of one to 10. With a rating
of one denoting not at all appropriate
and a rating of 10 denoting very appropriate, average ratings for marketing use of health information without
consent was 3.81. In contrast, participants rated research use with consent
obtained at 7.06.
Participants rated scenarios where
consent was obtained for health data
sharing as more appropriate overall,
but information used for research without consent still outranked consented
marketing use with respective ratings
of 5.65 and 4.52.

Although approaches to health information sharing emphasize consent,
public opinion also emphasizes purpose, which suggests a need to focus
more attention on the social value of information use, the researchers wrote.
The proliferation of electronic health
records has increased the availability of detailed health information, and
many current healthcare initiatives emphasize the importance of interoperability and the potential for the sharing
of information.
I think many of these policy discussions about privacy have come from
smart people sitting in a room and
what they think ethically and how people ought to be protected, but we dont
often go out and ask individuals how
they want it to be used, said David
Grande, MD, the studys lead researcher in a phone interview with Reuters.
WEBINAR: HOW A MOCK AUDIT CAN IDENTIFY

GAPS IN PREPAREDNESS
www.ahimastore.org
AHIMA offers webinars that provide reliable, expert, and timely information.
In February, How a Mock Audit Can
Identify Gaps in Preparedness will discuss what is at stake in the next round
of audits from the Office for Civil Rights.
The presenter will outline a step-by-step
process to resolve gaps identified by
conducting a mock audit. The presenter
will also identify likely areas of audit focus and help participants develop strategies for ongoing HIPAA compliance.
MOBILE APPLICATION TO ENHANCE PATIENT
EXPERIENCE
www.eclarifire.com
Mobile technology from CLARIFIRE
HEALTH was implemented at BayCare
Health System as part of organization
efforts to improve the service to and experience of hospital patients. The technology allows the nurse manager to use
handheld tablets to capture information
during nurse leader rounding, updating
information in real time. The technology
includes a note function to automatically send an e-mail alert when follow
up is needed.
COMORBIDITY INDEX TO IDENTIFY POTENTIAL
COSTS
www.plosone.org/article/
info%3Adoi%2F10.1371%2Fjournal.
pone.0112479
A study has found that the Charlson
comorbidity index, developed by Mary
Charlson, MD, executive director of
Weill Cornell Medical Colleges Center
for Integrative Medicine, can be used
to identify which patients will incur the
highest future costs in addition to predicting survival. This tool makes its predictions based on a patients total burden of key chronic diseases. According
to researchers, the index performed
as well as prior cost or DCG [diagnostic cost group] in identifying those who
would have higher costs.
Set Your Sights on ICD-10

and Meaningful Use in 2015
By AHIMAs Advocacy and Policy Team
NOW THAT THE new year is well underway, most of us have probably settled on
our resolutions and are working hard to
achieve them. Hopefully both ICD-10-CM/
PCS preparation and the meaningful use
EHR Incentive Program are high on the list
of priorities for healthcare providers.
At its meeting on September 23 and
September 24, 2014, the ICD-10 Coordination and Maintenance Committee
addressed a number of new proposed
ICD-10-CM and ICD-10-PCS codes and
other code modifications, as well as ICD10-CM/PCS implementation preparation
updates from the Centers for Medicare
and Medicaid Services (CMS). Highlights
of this meeting are described below.
ICD-10-CM/PCS MS-DRG Update

As the industry prepares for ICD-10-CM/
PCS implementation, organizations must
ensure that they use the most updated
resources for training, testing, and system integration.
The following important resources
are now available on the CMS website,
www.cms.gov:
ICD-10-CM/PCS MS-DRG V32.0
Definitions Manual. This manual
includes Major Diagnostic Category
groups as well as DRG maps and
CC/MCC designations. It also includes appendices A through J.

ICD-10-CM/PCS MS-DRG V32.0
Summary of Changes. This document outlines the proposed and
final DRG changes.

ICD-10-CM/PCS Definitions of
Medicare Code Edits. This document includes a description of each
coding edit with corresponding ICD10-CM and ICD-10-PCS code lists.
The official ICD-10-CM/PCS MS-DRG
v33 will be subject to formal rulemak16/Journal of AHIMA February 15
ing in the spring of 2015. Stay tuned

for AHIMA updates regarding important
changes to the code list.
Medicare ICD-10-CM/PCS Testing

Providers, suppliers, billing companies,
and clearinghouses are welcome to submit acknowledgement test claims anytime up until the October 1, 2015 implementation date of ICD-10-CM/PCS.
CMS will offer special acknowledgement testing weeks March 2 to March 6
and June 1 to June 5 this year, which will
give submitters access to real-time help
desk support. Registration for the special acknowledgement testing weeks is
not required.
CMS also indicated plans to offer providers the opportunity to participate in
end-to-end testing with Medicare Administrative Contractors (MACs) in January, April, and July of 2015. However,
only 850 providers will be able to participate during each testing period. Registration for each test period is available on
each MACs website.
FY 2017 ICD-10-PCS Updates

Regular updates to ICD-10-PCS will resume on October 1, 2016 (FY 2017). A
compilation of the ICD-10-PCS code proposals that have been discussed during
previous meetings but have been held
for implementation until after the end
of the partial code freeze will be shared
during the March 2016 Coordination and
Maintenance Committee meeting.
ICD-10-CM/PCS Proposed
Modifications
Although AHIMA generally supports
many of CMS PCS proposals, the association opposes the following changes:
minimally-invasive cardiac valve surgery,
face transplants, and administration of
Ceftazidime-Avibactam.
Nearly all of the new ICD-10-CM codes presented at the

September ICD-10 Coordination and Maintenance Committee meeting were proposed by physician groups, such as
medical specialty societies.
Highlights of AHIMAs comments on these ICD-10-CM/
PCS code proposals can be found on the Journal of AHIMA
website at journal.ahima.org.
AHIMA recommends delaying implementation of all new
codes approved at the September Coordination and Maintenance Committee meeting until October 1, 2016, after the
code set freeze ends. Any new codes or code changes implemented on October 1, 2015 could complicate the transition process.
2014 EHR Certification Criteria, Second

Release, Final Rule
Meaningful use attestation is another priority of the healthcare industry in 2015. Eligible hospitals that did not demonstrate meaningful use by July 1, 2014 will be subject to
a Medicare payment adjustment in fiscal year (FY) 2015.
This payment adjustment will equal 25 percent of the increase in the IPPS payment rate. According to the FY 2015
IPPS final rule, the net increase for the IPPS rate is 1.4 percent. This means that eligible hospitals that didnt attest
to meaningful use by the 2014 deadline will only receive
a 1.05 percent increase. Eligible hospitals that continually
dont meet meaningful use criteria in future years will only
see bigger reductions over time, including penalties of as
much as 75 percent of the IPPS rate increase. What once
was a carrot to move progress in health IT adoption has
now become a stick.
Theres no time like the present to ensure that physicians
and others understand the importance of these financial
incentives. The 2015 program year for the EHR incentive
programs began on October 1, 2014. Everyone within the
organizationparticularly those who document within the
EHRmust be aware of the meaningful use core and menu
objectives that the organization is targeting in order to comply with the program. Healthcare organizations and health information management (HIM) professionals are encouraged
to work with their EHR vendor to educate providers and ensure that the technology supports meaningful use compliance and attestation.
To successfully participate in the program in 2015, eligible
hospitals must use the 2014 Edition Certified EHR Technology (CEHRT). On August 29, 2014, the Department of
Health and Human Services and the Office of the National
Coordinator for Health IT published a final rule in the Federal Register that made several improvements to the current 2014 EHR certification criteria. This rule is available at
https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-21633.pdf.
Eligible hospitals and EHR technology developers dont
necessarily need to update and recertify their EHR technology based on this final rule, but HIM directors may want to
review some of the changes.
Certified EHR Technology Definition

In its 2014 Edition Release 2 Final Rule, CMS revised its definition of CEHRT to enable providers to implement only the
EHR technology they need to meet the specific meaningful use stage for which they seek attestation. However, for
EHR reporting periods during and after FY 2014, providers
must use the 2014 certification edition. This edition requires
a base amount of functionality, and it deters providers from
purchasing and implementing outdated products that cannot
be used to meet meaningful use in subsequent years.
Accounting of Disclosures Update

CMS had originally proposed to mandate that EHR developers ensure certified EHRs have the ability to support an accounting of disclosuresa list of all disclosures healthcare
providers made of a patients protected health information
(PHI). But in an effort to provide flexibility, clarity, and enhanced health information exchange, the agency decided
not to finalize the change.
Had it finalized this proposal, developers would have been
mandated to include the ability to electronically record disclosures made for all treatment, payment, and healthcare
operations in their systems. Relevant information would
have included the patients identification; the users identification; and the date, time, and description of each of these
types of disclosures.
Although technology developers may be relieved of the
developmental burden associated with making these
changes, those in HIM must now suffer the consequences
associated with having little ability to track these disclosures in which patients are increasingly interested. Individuals currently have the right to obtain a list of anyone who
has accessed their PHI. However, covered entities with an
electronic record are only required to track and provide
information related to disclosures of PHI made outside of
the covered entity and for purposes other than treatment,
payment, or healthcare operations. Until certified EHR vendors are required to include the ability to track all types
of disclosures, HIM professionals will need to continue to
explain these limitations to patients.
To complicate matters, the Office for Civil Rights recently
announced that its proposed rule on accounting of disclosuresoriginally issued on May 31, 2011wont be finalized
until 2015. Until then, HIM professionals must educate patients about their own right to PHI and how this information
may change in the future.
The AHIMA Advocacy and Policy Team (advocacyandpolicy@ahima.org)
is based in Washington, DC.
Read More
ICD-10-CM/PCS Proposed Modifications
journal.ahima.org
For highlights of AHIMAs responses to the proposed modifications to

ICD-10-CM and ICD-10-PCS, visit journal.ahima.org.
Why AHIMA
Ad Space
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AHIMA certification in HIM, coding,
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health data analysis is your guide to
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Investing in AHIMA certification is an
investment in yourself and your career.
To learn more visit ahima.org/certification.

MX10470
Inside Look
Education is Crucial for Our Future

By Lynne Thomas Gordon, MBA, RHIA, FACHE, CAE, FAHIMA, chief executive officer
THE AHIMA ARCHIVES contain a few

examples of long-ago medical records,
including a sample admission slip from
1916nearly a century ago. As fascinating as these artifacts are, we know that
the tools we use to do our jobs today will
seem just as outdated some day.
Consider this: Last year, researchers
at Oxford University published a paper
that examined the likelihood that certain
occupations would be replaced by computers. They concluded that around 47
percent of total US employment is in the
high risk category. We refer to these as
jobs at riski.e. jobs we expect could be
automated relatively soon, perhaps over
the next decade or two.1 When the authors ranked 700 occupations from most
to least resistant to replacement by technology, the majority were more secure
than medical records and health information technicians.
The phenomenon of the polarized labor
market, when jobs in the middle of the
skills and wage spectrum disappear, is
evident in our own economy and in many
other nations. And, as our profession becomes increasingly automated, it is becoming evident in HIM.
Its a disturbing thought. What can we
do? The Economist believes that society
as a whole can help people through this
disruptive period with education systems.2 The message of continued formal
education and lifelong learning has long
been one of AHIMAs mantras. Thats
why this months issue of the Journal,
covering education and workforce issues, is crucial reading.
In our cover story, Mind the Gap,
Mary Butler looks at ways HIM professionals can fill skills gaps in their resume
in areas such as data analytics and informatics. AHIMA tools, such as the Career
Map and the new HIM Professional Development Inventory, can help HIM pro-
fessionals in this process.

Changes in our work also mean changes in our understanding of retirement.
In HIM After Retirement Lisa Eramo
talks to HIM professionals who have
found that retirement creates more time
in their schedules for volunteering in the
industry or teaching the next generation.
Even familiar roles in the workplace
are changing. In Optimizing PHI Disclosure Management in the Age of Compliance, Don Hardwick, Mariela Twiggs,
and James H. Braden share best practices for streamlining the management of
protected health information disclosure
across an enterprise and how HIM professionals can lead a collaborative effort
to combat the trends that are making privacy and security compliance difficult.
Finally, Diana Karff explains how the
methods of Documentation Based Coding training can help coders better understand clinical documentation in tandem
with learning coding rules and guidelines
in Dissecting the Details.
What new HIM skills can you develop
for the workplace of tomorrow? Chances
are we all can think of a few. AHIMA is
here to help.
Notes
1. Frey, Carl and Michael Osborne.
The Future of Employment: How
Susceptible are Jobs to Computerisation? Oxford Martin School,
September 17, 2013. www.oxfordmartin.ox.ac.uk /downloads/
academic/The_Future_of_Employment.pdf.
2. Coming to an office near you.
The Economist. January 18,
2014. www.economist.com/news/
leaders/21594298-effect-todaystechnology-tomorrows-jobswill-be-immenseand-no-countryready.
HIM RUSHES TO BRIDGE EDUCATIONAL AND PROFESSIONAL

GAPS CAUSED BY A QUICKLY ADVANCING INDUSTRY
By Mary Butler
Mind the Gap
AMERICAN HIGH SCHOOL students approaching their senior

year have good reason to envy their European counterparts who
enjoy the more common experience of a gap year between
high school and college.
A gap year, at least in Europe, is a socially accepted opportunity to work, travelor bothfor the year after high school and
before entering college. The American Gap Association defines
a gap year as a structured period of time when students take a
break from formal education to increase self-awareness, challenge comfort zones, and experiment with possible careers.
Typically these are achieved by a combination of traveling, volunteering, interning, or working.
Health information management (HIM) professionalsstudents, current practitioners, and HIM educatorsare finding
themselves increasingly in need of a gap year. The notion that
they should refresh their skills through additional education,
volunteering, or internships is no longer just a suggestionits
a given in order to keep up with other medical disciplines, such
as nursing, physical therapy, and others that are already accustomed to continual retraining.
Just as incoming college freshman are assessing whether they
have the necessary hands-on experience with life and work to
optimize their college years, HIM professionals are doing the
same when it comes to the future of their careersand if they
arent, they should be, say HIM educators.
A widening gap between the HIM education and skills of old
(paper-based) and new (electronic-based) has led to a recent
dramatic update to the HIM curricula and a call by HIM leaders
that even seasoned professionals must build a bridge between
their current HIM skills and those needed in the future if the
profession wants to prosperand not plunge into the void.
Ryan Sandefer, MA, CPHIT, assistant professor and HIM department chair at the College of St. Scholastica, and a member
of the AHIMA Foundations Council for Excellence in Education
(CEE), says that even though any technology or informationrelated industry will have skill gaps in their workforce, its becoming more prominent in healthcare because of the very rapid
advancement of health IT.
I would argue that the amount of change thats happened in
health IT (HIT) in the last five years has really transformed the
way we do our work, Sandefer says. Its always changing. And
its even more pronounced in this profession.
The [meaningful use] EHR Incentive Program has catapulted the entire industry forward from one-fifth of the hospitals being electronic to over 90 percent in less than five years. That can
really change the game.
The question now is: How does the industry bridge that gap?
The CEE has done a new study to determine which HIM domains (or areas of expertise) need the most work. Theyve even
created a self-assessment that HIM professionals and educators
can use to take stock of their own skillsand determine what
they dont know.
Forward-thinking HIM professionals have already started to
do this to keep pace with the change and ensure career longevity. One example of this is AHIMAs Director of Practice Excellence Julie Dooling, who progressed from her RHIT to RHIA
in 2013 and will graduate with her masters in informatics this

yearall done to keep up with the advancing industry.
Additionally, part and parcel with the changing industry is the
evolution over where HIM professionals work within a healthcare organization. HIM professionals are handling much more
than medical records now, and need the data-oriented skills
to back it up, though many organizations are still struggling to
make the formal and progressive HIM department label stick.
Narrowing the Skills Gap

A number of years ago the CEE started work on what is now Reality 2016, a proposed plan for future HIM education and workforce development. Reality 2016 is an effort to transition HIM
to a graduate-level profession and realign HIM curriculum with
workforce needs. It also developed a set of curricular competencies for the associate, baccalaureate, and graduate degree levels,
CEE members explained in the November-December 2014 issue of the Journal of AHIMA.1
To help jump start the work Reality 2016 has embarked on,
Sandefer and fellow CEE member Ellen Shakespeare Karl, MBA,
RHIA, CHDA, FAHIMA, academic director of the HIM program
at City University of New York (CUNY), teamed up to conduct a
study of their own. They sought to find out what skills gaps the
HIM and HIT workforce has with relation to the new competencies outlined in Reality 2016.
Although the complete findings of Karl and Sandefers study
will be published in the March issue of the Journal of AHIMA,
Sandefer noted that preliminary results show many skills gaps
between professionals and emerging competencies that are
deemed required in the field both today and the near future. A
skills gap was also found in HIM instructors, and both educators
and professionals need to address these gaps as soon as possible, Sandefer notes.
Sandefer and Karl sent out their survey to 8,000 AHIMA members, including those with entry-level experience, associates
degrees, baccalaureate degrees, and masters degrees. They had
approximately a 10 percent response rate.
There were many areas where respondents had significant skill
and educational gaps, though Karl found none of them to be too
surprising, she says. Two areas that HIM professionals need to
work on is public health informatics and enterprise information
management (EIM), Karl says. She notes that at the associate degree level there is an educational gap when it comes to being
able to apply knowledge of database architecture and design.
Theres a skill gap between professionals and emerging competencies that are deemed required in the field now and the future. Thats also reflected in faculty, Sandefer says. So you have
this skills gap not only amongst professionals but among faculty
to address.
Sandefer notes that he and Karl found in their survey a relationship between experience level and competence in many
domains. There are some domains where less education is associated with higher perceived competence, particularly in areas
related to coding. Additionally, there seems to be a relationship
between education level and an individuals perception of how
strongly they feel that they can complete different tasks.
Mind the Gap
Name Game: Medical Records or

Health Information Management?
BECAUSE THE HIM industry is changing so quickly, some
HIM departments are facing an identity crisis of sorts with
regard to how to refer to themselves. Even though departments are becoming decentralized, theyre still doing battle
with administrators, staff, and the public over whether theyre
called health information management departments or the
more outdated medical records department.
For organizations who want to take a grassroots approach
to getting the HIM name to stick, HealthPorts Smith says
it should start from within. Even if your signage indicates
medical records, HIM employees should always refer to
themselves as HIM.
I think it starts internally. When people call, theyll say
Im looking for medical records, so its kind of putting on
that hat and teaching the public as well, and people dont
want to take that extra time, Smith says. And then also
getting your volunteers and your registration desk, anyone
whos asking for medical records, have them say Its called
HIM now.
She notes that hospitals can also help by handing out
brochures, though you run the risk of brochures making
their way to the waste bin. Catherine Valyi, HealthPorts
vice president of marketing, says a key is changing how the
patient population thinks. But this is easier said than done.
The funny thing is, a couple hospitals I visited had put the
signs up and had to take them down and change them because people were too confused. When you ask the front
desk, they wont know HIM, Valyi says.
Changing the terminology is like going on a diet, Smith
says. So if you start a diet and want just one M&M, its a
cheat, and youre only going to go back in. I think if were
going to allow medical records to be in the name, I think
well revert, Smith says. Its truly calling it HIM and using
it as an educational proposition as well.
So, for example, one of the things thats been talked about a
lot lately is data analytics, right? Youre looking at information
governance or data governance, information for a variety of purposes. You want to get the value out of that asset, and analytics
is how you do that, Sandefer says. So theres a clear relationship between education level and perceived competence. And
theres also a relationship between the number of years practicing and competence as well.
This wont come as a surprise to many, but in discussions about
the kinds of skills HIM professionals will need in the future, the
most frequent refrain, Karl says, is data, data, data. Whether its
pulling data, cleaning data up, analyzing data, storing it, or sharing it, experience with data is going to be a cornerstone for practitioners and students. If HIM professionals dont have a solid
grasp of data and how to use it, Karl warns that statisticians or
bio-informaticians could poach HIM jobs in those areas.
Kayce Dover, MSHI, RHIA, president and CEO of HIM Connections, a firm specializing in HIM recruiting and staffing, says
that the best way to bridge the skills gap is to get new graduates
working. She acknowledges that the paradox of organizations
looking for entry-level employees with hands-on experience
is a frustrating and tricky matter. Apprenticeships can be one
way around this. When her firm surveyed hospitals about onsite training and apprenticeship programs, they found that 52
percent indicated they have implemented, or considered implementing, an apprenticeship program for entry-level candidates.
Dover also strongly recommends that employers commit to
providing training across the spectrum of HIM workers. As traditional HIM positions continue to change, updating the skills
of employees will be extremely important, Dover says. Employers must be committed to helping team members develop
these new skills. The benefits of these programs are far greater
than simply helping your team be more productive.
The Rise of Data Analysts and Project Managers

According to Sandefer, theres little doubt that the role of data
analyst is going to be a big one for HIM, especially as concepts
such as information governance and enterprise information
management become more prevalent.
Respondents to Sandefer and Karls survey self-reported that
data analytics was a skill they needed improvement on, according to Karl. She says that shes seen evidence of this even outside
the context of the survey. Last year, CUNY received grant funding to produce a series of six free continuing education webinars
for HIM professionals, which Karl helped facilitate. They were
aimed at improving data analysis and database architecture
skills using Excel and Pivot. Karl says she was shocked that attendance for the webinars included 800 people. Its evidence,
she says, that HIM students and practitioners are recognizing
the importance of analyzing data.
I think data analytics and the experience that one has in utilizing data, and how to manipulate it and use it, is just so important, Karl says.
Sandefer says that the curriculum he helps facilitate at St.
Scholastica has been adding courses in data analytics and related subdomains to prepare students for the data-heavy world
theyll be graduating into.
Students in our program now get experience in statistics,
database programming, including simple programming, computer programming, Java, and then health statistics, Sandefer
says. Their experience and exposure to very sophisticated techniques of looking at data has increased considerably over the
last decade than people who graduated before them.
Alisha Smith, RHIA, a HIM educator for HealthPort, says she
would love to see more educators and HIM practitioners pushing for data analytics credentials and educational programs.
I think theres a gap there in people understanding truly
what the data analytic portion is and whos doing it, Smith
says. Its important because of patient outcomes. A lot of insurance companies have been using analytics for quite some
time, and claims data.
Smith says that her first job out of college was a data mining
position where she worked with biostatisticians. She spent a lot
of time teaching them about healthcare and coding, whereas
Mind the Gap
someone with a credential like AHIMAs Certified Health Data

Analyst (CHDA) is more equipped for that kind of role.
I think we need to start prepping our students more in school
[for data analytics]. I didnt have huge training in school in regards
to data analytics. And the interesting thing is that they did teach
you a little about it, but they dont teach you how to use the software when you get out, Smith says of statistical programs such as
SAS. Its very complex, complicated, and were not teaching our
associates how to use it. In order to obtain these roles theyve got
to get this experience before they can get the job.
The discipline of project management is also listed alongside
data analysis in the results of Sandefer and Karls study as a
competency many HIM professionals need to develop. Karl says
project management is an essential part of putting information
governance and enterprise information management programs
in placea role that will continue to redefine HIM professionals in the coming months.I personally have been pushing the
topics of project management and knowledge about databases
for our members for a long time, Karl says. When I came to
CUNY, I had those two courses as electives when I got here
and I pushed them into requirements in the curriculum. Everything is a project nowadays.
According to Patti Serson, RHIT, PMP, project manager, information services, at Central Maine Healthcare, the same people
who are drawn to HIM have the skill sets that make them good
at project management. She says attributes such as attention
to detail, organization, and an ability to multitask serve HIM
and project management well. Serson sought her Project Management Professional (PMP) certification to help advance her
careershe was a HIM director when she earned the credentialand describes herself as having fallen into the project
management domain.I realized it was my calling, Serson says.
The PMP certification requires 40 to 50 hours of intensive
classroom training as well as a pre-determined combination of
years spent in project management roles and two- to four-year
degree programs. Take everything youre doing on your dayto-day basis, from running a department, or bringing up a new
program, or redesigning your office layout, and you use all those
sorts of tools that a project manager uses, says Serson. Youve
been doing it without knowing that youre doing it, and there
are tools that can help you do it better.
She adds that having the PMP demonstrates to colleagues and
employers that she has the expertise in how to run a project or
program. Right now Im the project manager for [the conversion to] ICD-10, meaningful use, and clinical documentation
improvement, all those big things that are going on in the industry today, Serson says.
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HIM Without Walls

Sandefer confirms a trend that many industry professionals are
seeingthe decentralization of HIM departments within hospitals and integrated healthcare systems. Due to technology demands, HIM professionals can be found in IT, quality, billing,
revenue cycle, compliance, coding and CDI departments, and
many others. With no physical record to maintain, HIM professionals are no longer bound to the records room.
contact us today
800.499.6813
himonline.uc.edu/AHIMA
Mind the Gap
Another emerging area for HIM is informaticswhich also

happens to be one of AHIMAs strategic pillars. Andra Marino,
RHIA, is a clinical informaticist in the health information department at Rady Childrens Hospital in San Diego, CA, where
shes worked for more than 23 years. She started her career as
an assistant HIM director but came to work as an informaticist
through her extensive experience in helping hospitals implement computer systems.
She says that while she fell into informatics, she also chose to
stay in it rather than pursue more traditional HIM jobs. I enjoyed it much more. Its much more challenging, stimulating,
and interesting. And I knew that was one way that things were
going. Thats why I picked this route, instead of the leadership
route, Marino says.
Even though Marino didnt pursue informatics at the outset
of her career, shes certain that informatics is a domain with
which up and coming HIM professionals should be extremely
familiareven if its not called informatics. Sandefer and Karls
survey confirmed this with its finding that HIM practitioners are
lacking in skills related to public health informatics. Healthcare
organizations increasingly are being pushed to track patient
information to help optimize patient outcomes, comply with
accountable care organization regulations, and trend patients
across multiple care settings, Sandefer says. Its the discipline
of healthcare informatics that helps accomplish these activities.
Its about understanding the language, having the skill set to
be able to work professionally with programmers, health informatics professionals, your administration, and to present your
information visually, Sandefer says. HIM professionals need to
be able to interpret data and convey the results in any healthcare environment. Informatics leads to data analysis, but I
think [also] anything that has to do with systems. Understanding the systems side of health information and data integrity is
going to be a necessary skill, Marino says.
As an informaticist, Marino has her hand in a lot of HIM projects, analyzing systems data for DRGs and reimbursement, as
well as conducting gap analyses in preparation for ICD-10. The
quickly changing nature of Marinos job in the last several years
is indicative of trends that Sandefer and Karl have seen in their
research, as well as industry observations in general.
HIM is changing, Sandefer says. Its becoming more decentralized, but its becoming more important as a point of contact
and liaison to many different organizations, he continued, noting that HIM professionals need to grasp the many ways patient
information is being collected and managed.
Ways to Fill the Gap

Karl acknowledges that there is a long period of downtime between now and the new curriculums implementation deadline
of 2017, mostly because the internal processes for making the
changes at colleges and universities are time-consuming.
Here at my school, were in the process of evaluating where
we stand and creating a crosswalk from our old to our new so we
include everything for the new curriculum, Karl says.
There also exists the very real possibility that students graduating today and in the future will have more advanced skills
than their own supervisors when they land their first HIM jobs.
Thats why Karl says the CEE is encouraging AHIMAs House of
Delegates to think carefully about their offerings for continuing
education, because we feel like there are topics that the practitioner working in the field now may need to bump up their expertise on, Karl says.
Going forward, Karl explains, practitioners need to be recertified on the same domains the students will be learning in the
classroom. The hope is that theyll realize, Oh gosh, I need
to get experience or find a course about database architecture
and design so I can meet that domain. Its not going to be that
specific, but were at least going to be aligning the domains for
recertification with the domains the students are learning, Karl
says, noting that practitioners cant ignore the fact that theres a
danger in not updating their skills.
AHIMA has also offered to help individuals transition. Lou
Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR, FAHIMA,
AHIMAs vice president of HIM practice excellence, suggests HIM
professionals read the Journal of AHIMA to stay abreast of upand-coming topics, reference the HIM Body of Knowledge for
educational resources on various emerging topics, and attend
upcoming AHIMA webinars on vital topics like leadership, information governance, informatics, and privacy and security. Gaining an advanced degree or credential, like the RHIA or a masters
degree, as Dooling did, is also recommended, Wiedemann says.
Sandefer says healthcare organizations would be wise to develop a formal strategy for educating existing HIM practitioners
to keep their skills current with those of new students. He was
recently involved with a study that looked at how rural organizations trained employees on analytics.
Overwhelmingly organizations said they try and train their
own and hire from within, Sandefer says, because its so difficult to recruit people with these skills in rural communities.
When organizations train their own, theyre also more likely
to retain those individuals. Theres a lot of willingness amongst
employees to seek both formal and informal education to enhance their skill sets, Sandefer says. So yes, I do think organizations should have a strategy for doing that.
Note
1. Sandefer, Ryan H. et al. Keeping Current in the Electronic
Era: Data Age Transforming HIMs Mandatory Workforce
Competencies. Journal of AHIMA 85, no. 11 (NovemberDecember 2014): 38-44. http://library.ahima.org/
xpedio/groups/public/documents/ahima/bok1_050789.
hcsp?dDocName=bok1_050789.
Mary Butler (mary.butler@ahima.org) is associate editor at the Journal
of AHIMA.
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DISSECTING
THE DETAILS
DOCUMENTATION BASED CODING

MODEL OFFERS ADVANCED
APPROACH TO WORKFORCE
CODING TRAINING
By Diana Karff, RHIA, CCS
INPATIENT AND OUTPATIENT coders enter the HIM workforce only after they have taken medical terminology, procedural terminology, pharmacology, structural anatomy and physiology, disease and treatment, and all requisite coding courses.
These required courses earn academic credit in a classroom setting, but some feel these basic courses are not enough to excel
in a career centered on the art of medical coding. Why? Because
coding is complex, and many feel it requires real world health
records that are paired with skills learned not over a period of
days, but months of face-to-face or online training.
Documentation Based Coding (DBC) is a vocational method
that offers additional training, and while this approach to coding does not replace the classic academic curriculum, it has
been shown to be a successful addition to that education.
DBC can only be taught in non-credit bearing or vocational
settings. The workforce teaching and learning from this approach permits the coder to comprehend the key steps required
to increase understanding of clinical documentation in tandem
with associating coding rules and coding guidelines. Advocates
of DBC feel it provides coders the ability to objectively read the
health record in order to assign codes based solely on the recorded documentation.
A quick inventory of the workforce training challenges facing the HIM industry today in health information departments
identifies:
Training and concentrated feedback may be restricted
due to senior staff members having multiple responsibilities, thus feedback may be limited, untimely, or not completed
Current coding staff members are tasked with productivity and accuracy standards
Current coding staff may be working in a remote setting,
limiting peer-to-peer communication
Previous academic coding courses and prerequisites are
not learned in the context of reading medical documentation as it is presented in a chart
A shortage of qualified coders in the workforce has made
it difficult for facilities to hire and retain employees
By using chart-based documentation, the documentation
is explained objectively in a logical order focusing on the following individual six steps applied to the documentation and,
eventually, the assigned code:
1. Medical terminology
2. Structural anatomy
3. Clinical disease pathway
4. Treatment resources (such as medicinal, operative, therapeutic, or diagnostic)
5. Coding rules and additional guidelines pertaining to the
documentation scenario
6. Code assignment
Define and Comprehend Documentation

When training is conducted from this DBC model, it creates a
discipline for both the trainer and student. The trainers goal
is to increase the coders knowledge base and refine the learn-
ers judgment process. If a coder has a question or faces conflicting or minimal chart entries, they are taught to follow the
sequential pathway as a road map to objectively comprehend
the documentation. This process eliminates skipping over any
clinical terminology used by physicians that may not be fully
understood, and eliminates lone abstracting of diagnoses for
reporting while increasing a coders medical knowledge base in
a positive, proactive manner.
The coder is disciplined to seek coding rules and guidelines
relating to the documentation in DBC. Knowing the definition
of documentation is vital to understanding the rationale behind
using the term documentation in the title of DBC training. The
term documentation is defined by the Merriam-Webster Dictionary as the documents, records, etc., that are used to prove
something or make something official.
Using this definition of documentation in DBC stresses that
it is the coder who must understand the chart by reading multiple entries from the chart as a whole. By monitoring the clinical pathways and treatment, the coder will become more efficient and confident in accurate code assignment. All clinical
documentation can be applied to this process. Documentation
samples may be from operative notes, a history and physical,
consults, orders, progress notes, a discharge summary, or the
entire chart. The sample is objectively analyzed following the
six steps listed earlier in a recurrent DBC pattern. By applying
the pattern, a mandatory thinking framework occurs. The documentation analysis may be applied to ICD-9-CM, ICD-10-CM,
ICD-10-PCS, or CPT coding.
Emphasis on Reason for Admission in

Documentation Based Coding
When it comes to principal diagnosis selection utilization for
documentation based coding, nearly all coders can quote the
definition defined in the Uniform Hospital Discharge Data Set
(UHDDS): that condition established after study to be chiefly
responsible for occasioning the admission of the patient to the
hospital for care. Understanding the word occasioning defined as an event, a time, immediate cause, grounds, reason,
or requirement is the first step in DBC. The DBC coders goal is
the objective establishment of the correct reason for the clinical admission or reason for admission (RFA). This may be one
straightforward clinical issue, it may be vague symptomology,
or it may be numerous clinical reasons.
The history and physical and admission orders are used for
occasion or reason for admission. If an emergency room record
is present, final emergency room documentation is also considered. DBC coders must include a review of the discharge summary to identify the correct reason for admission. This is due to
Joint Commission criteria, which require:
Reason for hospitalization (this is also described as summary of the course of hospitalization)
Significant findings (this has been stated also as diagnoses)
Procedures and treatment provided
Patients discharge condition
Patient and family instructions (as appropriate)
Attending physicians signature
Example of Documentation Based Coding Model
GASTROINTESTINAL BLEEDING
Potential Documentation
Learning Instructions for Inpatient Coding

ICD-10-CM and ICD-10-PCS
Medical
Terminology
GI bleed Hematemesis
Melena
Hematochezia
BRBPR
EGD
NG
Gastrointestinal hemorrhage or bleeding; Vomiting of blood, also coffee-ground emesis

(CGE); Tarry, black stools;
Bright red blood per rectum
The presence of bold, red blood in the stool
Esophagastroduodenoscopy
Nasogastric
Structural
Anatomy
Basic, structural anatomy.

Anatomical pictures will also
aid the coder.
Upper gastrointestinal tract: Esophagus, stomach, small intestine segments (duodenum, jejunum, and ileum). Lower gastrointestinal tract: To the ascending or right large
intestine (colon), transverse large intestine (colon), descending or left large intestine
(colon), sigmoid colon, rectum and anus.
The practitioners and careClinical Disease

Pathway Education givers will never explain
Coffee-ground hematemesis or vomiting of blood indicates the patients blood has

been in contact with hydrochloric acid from the stomach thus identifying to the physician a potential upper GI bleed. Tarry stools are a clinical marker indicating fecal bacteria or stool has been mixed or in contact with blood, flagging physicians to diagnose
lower or upper GI bleeding. Hematochezia or BRBPR indicates blood that has surged
below any stool formation, may even include the anus. Coder is encouraged to seek
documentation of varices or ulcer formation. Investigate for documentation attributing the bleeding from the use of therapeutic non-steroidal anti-inflammatory drugs,
diverticulosis, neoplasms, Mallory Weiss tears, colitis, fissures and hemorrhoids. Coder
is encouraged to identify anemia with specific type and treatment pathway utilized.
Treatment:
Medicinal/
Procedural
Basic clinical guidelines are

taught. Coders are taught to
seek a relationship between
the orders and the progress
notes or consults.
Coders must understand the initial clinical treatment goal is to halt the bleeding.
The secondary goal is to identify the etiology of the bleeding.
Potential therapeutic fluids and drugs: Intravenous (IV) fluids, packed red blood cell
(PRBC) transfusion, proton pump inhibitors (PPI) such as IV omeprazole. Prokinetics
such as erythromycin and metoclopramide, anticoagulants and antiplatelet agents.
Potential therapeutic and diagnostic procedures: NG lavage, EGD (may include
biopsy), colonoscopy (may include biopsy), open surgery in critical patients.
Diagnosis Coding
Rules and
Guidelines
Identify all official guidelines

and additional coding rules.
This step in the learning
pathway should directly reflect the rules for the coding
type (ICD or CPT). This grid
reflects ICD-10-CM.
Principal diagnosis: Using approved provider documentation, identify the correct

reason for admission, next identify the established condition following studies to be
chiefly responsible for inpatient admission.
Review ICD-10-CM Official Coding Guidelines: Diseases of the Digestive System (K00K95).
Decide if documentation meets adverse effect guidelines in Chapter 19 Section E:
Adverse Effects, Poisoning, Underdosing and Toxic Effects. When coding an adverse
effect of a drug that has been correctly prescribed and properly administered, assign
the appropriate code for the nature of the adverse effect followed by the appropriate
code for the adverse effect of the drug (T36-T50). The code for the drug should have a
5th or 6th character 5 (for example, T36.0X5-).
Guidelines state codes in categories T36-T65 are combination codes that include the
substance that was taken as well as the intent. No additional external cause code is
required for poisonings, toxic effects, adverse effects, and underdosing codes.
Identify diagnoses that meet criteria for additional diagnoses:
Clinical evaluation
Therapeutic treatment
Diagnostic procedures
Extended length of hospital stay
Increased nursing care or monitoring
1. Do not survey data from laboratory results (including pathology) to assign any secondary diagnoses.
2. Query initiation should reflect conflicting or scant documentation only.
3. Lone entries without any UHDDS criteria met do not meet a documentation standard.
4. Query if anemia is documented for type and acuity.
5. Review present on admission (POA) guidelines.
all of this defined content in

a record. Coders task is to
comprehend the documented
terms and how they relate to
treating the patients illness
and utilization of facility
resources.
Example of Documentation Based Coding Model (continued)

Procedural Coding
Rules and
Guidelines
Identify all official guidelines

and additional coding rules.
This step in the learning
pathway should directly reflect the rules for the coding
type (ICD or CPT). This grid
reflects ICD-10-PCS.
Understanding third character root operation assignment in PCS: Depending on

the endoscopic procedure, the root operation character will be Biopsy -B- Excision or
Visualization Only -J- Inspection
Understanding fifth character surgical approach values in PCS: Colonoscopy and
EGD procedures are usually performed through natural anatomical openings. Reporting character 8- Via Natural or Artificial Opening, Endoscopic. Nasogastric lavage is
insertion of instrumentation through the nose. Reporting character 7- Via Natural or
Artificial Opening.
Do not rely solely on general equivalence mappings (GEMs) assignment for reporting of
ICD-10-PCS code(s).
Codes
From the documentation

sample, the correct codes
are offered. These codes are
hypothetical.
Unspecified gastrointestinal bleed: K92.2

Anemia: Query pending
Inspection of upper intestinal tract, via natural or artificial opening: 0DJD8ZZ
Inspection of lower intestinal tract, via natural or artificial opening: 0DJ08ZZ
Packed red blood cell transfusion via peripheral vein: 30230N1
It is important that coders remember that the Joint Commission discharge criteria do not require a statement reflecting the
UHDDS-defined principal diagnosis, although there are facilities with individual physician guidelines for privileges requiring
the principal diagnosis be documented in the discharge summary. The documented reason or reasons for admission begin
the process of correct principal diagnosis selection. Inpatient
coder auditing from this Joint Commission perspective requires
the medical or procedural reason for admission in the findings.
As for determining The condition established after study to
be chiefly responsible as defined in the UHDDS, this is arrived at by utilizing the record as a treatment process seeking
recognized results or outcomes. The coder appreciates the accepted clinical pathways and accepted documentation usage.
Typically coders trained from this DBC model do exceptionally
well in assigning and defending principal diagnosis assignment.
Emphasis on Secondary Diagnosis in

Documentation Based Coding
Documentation Based Coding can also be used to help with the
explanation of secondary diagnosis. Again, most coders can recite the UHDDS guidelines, but they must know how to properly
apply the following rules:
Clinical evaluation
Therapeutic treatment
Diagnostic procedures
Extended length of hospital stay
Increased nursing care or monitoring
When a coder applies the objective steps utilized in the DBC,
medical terminology, then structural anatomy, clinical disease
pathway, treatment, coding rules, and additional guidelines
pertaining to the documentation scenario secondary code reporting can be substantiated.
In order to reduce incorrect reporting from the beginning,
DBC coders are tasked to fully understand the documentation
and how it interfaces with coding.
Ground Rules Stressed During DBC Model Training

Over the past decade, DBC-trained coders have been taught
from the following foundations:
1. W ith regard to the chart entries, physicians are communicating with colleagues and facility caregivers in the record in order to restore the patients health. The documentation that coders encounter will never be explained from
a non-clinical perspective. Coders are responsible for understanding physician-authored clinical communication
and interpreting it for the reporting of codes. This fundamental is paramount. Sometimes the complaint of poor
documentation may be an indication the coder needs
increased knowledge of anatomy and established clinical
disease pathways or treatment methodologies, and how
they relate to the coding rules and guidelines.
2. Lone chart entries are not documentation. The presence
of a term in a chart is not defined as documentation.
3. Coding rules do not shadow or correlate to clinical strategies or treatment protocols.
4. Embrace coding and clinical references from the start. If
a coder learns the clinical pathways properly they can incorporate the same clinical and procedural pathways into
numerous records.
5. The need for queries will never disappear. Understanding the requirements of a meaningful query will lead to
correct reporting. Coders who possess a solid foundation
of understanding documented clinical pathways and the
treatment of disease will communicate in a more effective
manner with the physician.
Documentation Based Coding can be utilized for any level
of coder training and audit training as well, since it is also advantageous to audit processes. Auditing coded records from
this model generates improved coder feedback in respect to
deepening the understanding of the clinical framework and
weighing the genuine utilization of care with respect to facility resources.
Dawn Foerst, CCS, is an ICD-10 instructor with 17 years of experience in the medical billing and coding industry, and has
been involved with the development of a CDI program as well
as professional and facility coding. Foerst learned DBC six years
ago. After several years of working in the health information
management industry, I was introduced to and educated with
the Documentation Based Coding model. I truly believe this
model provides such clarity when coding, discussing, auditing,
and defending a medical record, Foerst says. The structure
and process of evaluating documentation follows a uniform
pathway to arrive at the most appropriate outcome. This model
is beneficial for new coders, providing direction to analyzing
complex documentation.
Of course all documented and reported diagnoses and procedures are evaluated, but do they sincerely warrant reporting by
coding guidelines? Did they require provider query? A procedure can be understood from the minds eye of the practitioners
guiding principles including all procedural terminology and
anatomy viewed in an organized manner with the coding rules.
With DBC, the coder learns from a logical perspective.
Applications of the Documentation Based Coding Model

Another advocate for the DBC model is Elaine Moore, MS, RHIA,
a senior director of coding quality and education at Piedmont
Health System in Atlanta, GA. She encountered this training
model in 2013 at the AHIMA Annual Clinical Coding Meeting.
D I S C E R N I N G
Since then, Moore and her management staff decided to implement DBC software for all apprentice and seasoned coders. I
believe that coders need a strong foundation in understanding the disease process in order to excel in becoming excellent
coders, she says. Especially in the world of copy and paste, we
have become aware that we cannot code based only on provider-listed diagnoses. As coders, we need to understand the clinical picture must support the diagnosis.
For example, understanding and knowing when to code metabolic encephalopathy and when not to code, as a secondary diagnosis. Metabolic encephalopathy is always due to an underlying cause, Moore says, and coders have to answer the questions
of whether or not the physician documentation reflects the underlying cause, treatment, etc. Sometimes, provider documentation as we know today does not always communicate the true
acuity level of the patient, she says. If a coder sees a diagnosis
documented only once, he/she should be able to understand
the disease process of the condition to know if this is a valid diagnosis or requires further clarification from the provider. This
model approach allows coders to understand the clinical picture of a disease and see firsthand how to apply codes to their
providers documentation.
Also, the DBC approach of coding education allows coders to
use actual patient data instead of practicing with test patient documents that a coder may never use. This model also allows coders to be cross-trained from one patient type to another as well as
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equip coders to become specialized coders, Moore says.

The documentation based system provides all the basic knowledge tools to make it a smoother transition for coders to enhance
their skill set using actual patient records from your own facility,
she says. This learning approach is a one-stop-shop because
you have the coding guidelines, clinical disease references, ICD9-CM, ICD-10-CM/PCS codes, and anatomy at your fingertips. I
truly believe that this approach speeds up the learning process
for coders.
Documentation Based Coding is a practical approach to workforce training. Todays HIM industry faces many challenges. If
the utilization of a seasoned model with a refined approach is
applied to coding and auditing, HIM professionals can strengthen their current professional workforce and realistically train
more subject matter experts in the industry.
References
Centers for Disease Control and Prevention. ICD-10-CM
Official Guidelines for Coding and Reporting, Chapter
19: Injury, poisoning, and certain other consequences of
external cause (S00-T88). 2013. www.cdc.gov/nchs/data/
icd/icd10cm_guidelines_2014.pdf.
Journal of AHIMA Continuing Education Quiz

Quiz ID: Q1518602 | EXPIRATION DATE: FEBRUARY 1, 2016
HIM Domain Area: Clinical Data Management
ArticleDissecting the Details
Official Guidelines for Coding and Reporting, Section II.

Selection of Principal Diagnosis. 2013. www.cdc.gov/nchs/
data/icd/icd10cm_guidelines_2014.pdf.
Official Guidelines for Coding and Reporting, Section III.
Reporting Additional Diagnoses. 2013. www.cdc.gov/nchs/
data/icd/icd10cm_guidelines_2014.pdf.
Centers for Medicare and Medicaid Services. ICD-10-CM
Official Guidelines for Coding and Reporting, 2015. 2014.
w w w.cms.gov/Medicare/Coding/ICD10/Dow nloads/
icd10cm-guidelines-2015.pdf.
Scott, Karen S. Coding Root Operations with ICD-10-PCS:
Understanding Excision and Resection. Journal of AHIMA
84, no. 4 (April 2013): 62-64.
The Joint Commission. Record of Care, Treatment, and
Services chapter (RC) Standard RC.02.04.01. 2015
Comprehensive Accreditation Manual for Hospitals. Oak
Brook, IL: Joint Commission Resources, 2014.
Diana Karff (Diana@americancodingschool.com) is the lead instructor
for the American Coding School. She is an ICD-10 trainer, has written coding curricula and designed software for training using the DBC model, and
has over 30 years of experience in health information.
TAKE THE QUIZ AT WWW.AHIMASTORE.ORG

NOTE: MAILED-IN PAPER QUIZZES WILL NO
LONGER BE ACCEPTED
REFER TO THE ARTICLE for the one best answer to each question. Questions are based solely on the content of the article.
1. Documentation Based Coding (DBC) can only be taught in
settings.

a. non-credit

b. undergrad

c. vocational

d. both a and c
2. T
he trainers goal in Documentation Based Coding is to increase
the coders knowledge base and refine their judgment process.

a. true

b. false
3. The Joint Commission discharge criteria require a statement
reflecting the UHDDS defined principle diagnosis.

a. true

b. false
4. By using chart-based documentation, the documentation
is explained objectively in a logical order focusing on
individual steps.

a. three

b. four

c. five

d. six
5. In order to reduce incorrect reporting, DBC coders must fully
understand how coding interfaces with:

a. Big Data

b. documentation

c. quality measures

d. clinical knowledge
6. DBC is a practical approach to:

a. coder recruitment

b. consumer engagement

c. workforce training

d. none of the above
7. Anatomical pictures are of no help to coders in understanding
structural anatomy.

a. true

b. false
8. DBC education can be utilized for any level of coder and is
advantageous to
processes?

a. medical

b. audit

c. quality

d. clinical
9. The DBC approach allows coders to use actual patient data instead
of practicing with test patient documents.

a. true

b. false
10. Workforce training challenges facing the HIM industry today
include:

a. productivity and accuracy standards

b. limited peer-to-peer communication

c. senior staff have multiple responsibilities

d. all of the above
Optimizing
PHI Disclosure
Management
in the Age of
Compliance
By Don Hardwick; Mariela Twiggs, MS, RHIA, CHP, FAHIMA; and James H. Braden, MBA, RHIA
Optimizing PHI Disclosure

in Age of Compliance
A MERE TWO decades ago, healthcare providers didnt face

significant penalties for improperly disclosing protected
health information (PHI). Since then, regulations surrounding
the privacy and security of PHI have evolved to include strict
requirements and corresponding steep financial penalties for
non-compliance.
Since the HIPAA breach notification requirement took effect
in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, more than 31 million
people have had their PHI compromised, and the Office for
Civil Rights (OCR) has levied more than $25 million in fines. In
addition to those fines, PHI breaches have incurred other unfavorable consequences that have had far-reaching effects on
providers, including: the cost and negative impact of notifying
individuals of a breach; civil monetary penalties imposed by
the United States Department of Health and Human Services
(HHS); civil lawsuits by patients; and damage to organization
reputation through media and public opinion.
In response to the highly impactful consequences of noncompliance, providers are more focused on compliance than
ever, and have charged health information management (HIM)
professionals with investigating ways to improve how their organizations protect patient privacy and security.
Although compliance is top-of-mind, a variety of factorsincluding new regulations, widespread use of electronic health
records (EHRs), organizational growth by acquisition (for instance, the addition of physician practices), and an imbalance
in information governance (IG) practicesmake compliance a
challenging undertaking. Many HIM professionals are addressing this situation through an enterprise-wide, standardized
approach to PHI disclosure management. With this approach,
all disclosure points throughout a healthcare enterprise can
achieve compliance by strictly adhering to state, federal, and
internally developed guidelines.
This article will address the current regulatory environment,
discuss trends making privacy and security compliance difficult, and provide details about how HIM professionals can lead
a collaborative effort to meet compliance challenges through
enterprise-wide disclosure management.
Todays Regulatory Environment: Omnibus and

OCR HIPAA Audits
Healthcare leaders are more motivated than ever to ensure
organizational compliance with federal privacy and security
regulations. Its critical to understand how the HITECH Acts
HITECH-HIPAA Omnibus Rule has changed HIPAA, and
how healthcare providers are being put to the test in the OCR
auditing process.
The HITECH-HIPAA Omnibus Rule

The HITECH-HIPAA Omnibus Final Rule, which went into effect
in 2013, changed HIPAA in a variety of ways. It provides individuals with the right to receive electronic copies of their health
information and allows them to restrict PHI disclosures to their
health plans if they fully pay for treatment out-of-pocket. It outlines new breach reporting requirements, making the business
associates (BAs) of covered entities (CEs) directly liable for compliance with certain HIPAA requirements. It also significantly
strengthens financial penalties for breaches.
The more stringent regulations regarding patient rights and
patient access have produced an advanced level of complexity for hospitals and physicians, which in turn requires a larger
scale effort to meet patient needs while achieving compliance.
For instance, the Omnibus Rule gives patients more rights related to receiving health information in the format they request
and in a demanding timeframeall while safeguarding their
privacy. Meeting these demands can be challenging for healthcare providers who are adjusting to new timeframes while also
accommodating a broader array of requests.
On the other hand, there are very legitimate reasons for denying access to health information. Factors such as mental health,
child abuse, or treatment related to a criminal assault can all influence how PHI should be handled. These many nuances can
create further compliance difficulties and necessitate an optimal combination of policies, processes, and technology, along
with training to safeguard against human error.
In addition to the updated patient rights, the Omnibus new
breach reporting requirements also add compliance complexity. Now, OCR presumes guiltin cases of improper disclosure it
is assumed that the providers improper disclosure has resulted
in a breach and providers must prove their patient data wasnt
compromised. This reality represents a 180-degree change from
the earlier regulatory environment.
This new standard of guilty until proven innocent makes all
components of PHI disclosure management critical, but one
area in particular stands outdocumentation. Even if a CE
properly addresses facets of PHI disclosure management such
as internal audits and policy and procedure reviews, a lack of
documentation can compromise compliance. As the old adage
goes: If it isnt documented, it didnt happen.
Documentation experts have traditionally resided within the
HIM department, so this critical need shouldnt seem unfamiliar. The difference, however, is in meeting new demands related
to patient access, the unknown terrain of health information exchanges (HIE), and the broadening scope of disclosure points.
Consequently, as HIMs role grows, it must also evolve to meet
a broader set of PHI disclosure management needs within the
healthcare organization.
OCR Audits Entering Second, Third Phases

Despite the extra preparation time gained when OCR postponed
its Phase 2 HIPAA audits, the abundance of initiatives necessary

for compliance has created complexitiesand a flurry of activityfor healthcare organizations. OCRs Phase 2 HIPAA audits
focus on the HIPAA Security Rule and risk analysis, the HIPAA
Privacy Rule and access issues, and the Breach Notification Rule.
Auditors are looking for comprehensive risk analysis, documentation of follow-up risk management activities, documentation of
policies and procedures and evidence of their implementation,
and ongoing education and enforcement.
Although healthcare organizations are now addressing Phase
2 audits, it isnt too early to begin preparing for Phase 3 audits.
The focus of Phase 3 audits will include encryption and decryption, plus facility and physical access control. Even as theyre
addressing Phase 2 requirements, organizations can concurrently address organization-wide encryption across all laptops,
mobile devices, and e-mail systems. Current training, policy
and procedure reviews, and internal audits can also incorporate
physical and facility access. For instance, audits can easily include checking for PHI in waste bins and ensuring charts arent
visible at nurses stations.
Keep in mind that OCR audits also address third-party business associates (BAs), over which healthcare organizations have
little control in regard to compliance responsiveness. Therefore
providers can benefit from being proactive with their BAs and
requesting documentation as early as possible. BAs should be
able to provide documented evidence of their own internal protocols and policies, such as:
Security Policies
-- Information Security Risk Analysis
-- Information Security Risk Management Program
-- Information Security Audit Controls
-- System Activity Review Policy
-- Security Incident Response Policy
-- Data Backup and Storage Policy
-- Data Disposal Policy
-- Media Re-Use Policy
-- Workstation Policy
-- Electronic PHI Movement Policy
Privacy Policies
-- PHI Uses and Disclosures
-- Patient Access
-- Accounting of Disclosures
-- Sanctions Policy
-- Breach Policies and Procedures
Healthcare Trends Bring New Compliance Challenges

The Omnibus Rules more stringent rules and penalties coupled
with the looming threat of OCR HIPAA privacy and security audits generate unprecedented compliance urgency. Compliance
must be an organizational priority for both hospitals and physician practices, backed by the leadership and resources necessary to accelerate efforts.
As providers ramp up compliance programs and conduct due
diligence, many of them will discover areas of risk. This risk
isnt necessarily due to carelessness or ignorance; rather, its
the result of industry trends. In particular, the widespread use
of EHRs, hospitals rapid acquisition of physician practices, and
the adoption of electronic health information exchange establish inherent risks that require new approaches to PHI disclosure management.
EHRs and Additional Points of Disclosure

Many hospitals have as many as 40 disclosure points. At face
value, this number may seem improbably high. However, the
meaningful use EHR Incentive Program (MU) has driven the
widespread adoption of EHRs. As of December 2013, nearly 90
percent of eligible hospitals attesting to MU stage 1 had a primary vendor meeting the ONCs base EHR definition.1 By April
2014, approximately 80 percent of all eligible hospitals received
an incentive payment for demonstrating MU requirements
through the use of an EHR.2 These numbers show just how
many hospitals are using EHRs, and as their use increases so too
do their disclosure points.
This rapid EHR adoption has improved care coordination and
patient engagement, but it most likely has achieved the opposite
effect with PHI disclosure management. To prevent improperly
disclosing data, many clinicians and staff using EHRs may require
specific training in compliance and the proper release of PHI.
Increased Risk from Physician Practice Acquisitions

Acquisition of physician practices increases points of disclosure
and risk to healthcare enterprises. A PricewaterhouseCoopers
report shows that healthcare industry consolidation has increased more than 50 percent since 2009.3 In many cases, hospitals are acquiring numerous physician practices and creating
large groups under their brand names. Growing a hospitalowned physician practice group can increase an organizations
footprint while enabling better care alignment. However, it can
also increase PHI disclosure management risk as hospitals take
on the responsibility and liability associated with properly disclosing health information. This can be particularly difficult
since physician practices can vary drastically when it comes to
technology, processes, standards for PHI disclosure management, and training of personnel. These variations can not only
create risk, but also make it harder to prove compliance since
tracking and reporting can be especially challenging.
HIE and Information Governance

The growing adoption of HIEs has caused traditional HIM information governance roles and responsibilities to shift to the
information technology (IT) department at some organizations.
Budget, resources, and the decision-making process around
HIE and PHI disclosure management have consequently become imbalanced.
Traditionally, IT and HIM have very different views of IG,
which makes it imperative that both parties voices are heard.
As HIE grows, increased collaboration between HIM and IT
becomes critical. ITs knowledge of technical security aspects
such as public key infrastructure, encryption, and data integrity
is a necessity, while HIM has in-depth experience with privacy,
compliance, breach, and risk management issues.
As providers and organizations are challenged to define optimal strategies and best practices for PHI disclosure manage-

ment, they also must establish an appropriate balance in IG that

will showcase each partys expertise and foster a new, deeper
partnership that will ultimately be integral to their hospitals
successful HIE practices.
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Broadening HIMs Role to Meet Evolving PHI

Disclosure Management Needs
HIM now has the opportunity to function in a more collaborative and consultative role, leveraging its core expertise with
compliance and IG. By serving as the catalyst for organizationwide standardization of policies, procedures, and training, HIM
can help ensure that the growing number of departments involved in PHI disclosure are doing so in a secure, compliant,
and efficient manner.
While HIM and IT collaboration is important, having a single
point of leadership and bottom line accountability for PHI disclosure management is also optimal. Enterprise-wide disclosure management enables quality control, standardization, and
better adherence to policies. It allows for the development of the
best possible processes, while also setting the stage for continuous improvement.
Overall, a centralized PHI disclosure management program
can mitigate opportunities for risk, improve compliance, and
better prepare an organization for audits. Below are four key
steps to compliance. Ideally, HIM can conduct these steps in
a centralized fashion, collaborating with IT and other departments as appropriate.
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In addition, the review should include policies related to the

HIE environment such as the Data Use and Reciprocal Support
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1. Policy and Procedure Review

A key component of OCR audit preparationand ensuring
proper PHI disclosure management on an ongoing basisis a
comprehensive review of policies and procedures. HIMs longstanding responsibility as the owner of PHI policies and procedures puts the department in an ideal position to offer this same
expertise across the organization.
The review should include policies and procedures related to
the following:
Patient Access (very important for OCR desk audits)
Accounting of Disclosures
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2. Internal Audits
Conducting internal audits in a variety of ways (planned, unplanned, or even mystery audits, when the staff doesnt know
its being audited) can promote better compliance. By going
on the offensive, organizations also ensure more thorough
preparation for possible OCR audits or state health department reviews. Internal audits at some facilities have revealed
dangerous practicesfor instance, nursing stations leaving patient information visible on a monitor, and emergency department (ED) clinicians burning CD copies of patient records for
unauthorized family members. That said, consider developing
an audit program that addresses various privacy and security issues. Develop a checklist and visit various areas of the hospital
to review the following:
Are printers and fax machines secured from public view?
Are waste bins free of PHI?
A re computer monitors equipped with privacy screens or
kept away from public view?
Can staff discussing PHI be overheard?
A re print capabilities limited to only the necessary departments?
If patient names are used in waiting rooms, do clinicians
and staff use only the minimum necessary? (i.e., Ms. Smith)
If sign-in sheets are used, is the minimal amount of PHI
requested?
A re doors locked and access limited to departments
housing PHI?
Is the Notice of Privacy Practices posted?
Also, conduct various tests to determine if staff is protecting PHI:
Walk through the nursing station to see if its possible to
remove a chart or access documents.
A sk IT to call a staff member to see if he or she will give out
password information.
Call Release of Information staff to ask how to obtain a
medical record.
Call the facility and attempt to find out verbal information
about a patient.
Call the HIM department to ask for a correction to your
patient record.
Verify the organization has revoked computer rights and
badge access for recently terminated employees.
3. Tools and Technology

While departmental and enterprise-wide IT systems have advanced, their capability to support proper PHI disclosure may
not be keeping up with increasingly stringent requirements.
Working with IT and other appropriate departments, HIM can
help ensure software is supporting the organizations enterprise-wide PHI disclosure management goals. Software enhancements such as flagging for minors records, computing
turnaround times for fulfilling requests, and adding access trails
within the platform can facilitate compliance.
Its also helpful to review departmental processes and see

where technology can be improved to support compliance,
or where it currently creates risk by being misused. For instance, in the previous example where ED staff burned patients records onto CDs for family members, the use of the
CD burner led to improper distribution of patient records. In
this case, the organizations replacement workstation didnt
have a CD burner.
4. Adequate Training
A sharp increase in PHI disclosure points and a more networked and complex digitized environment are two factors that
increase the importance of comprehensive, organization-wide
privacy and security training. Clinicians and staff have numerous opportunities each day to disclose PHI, and if they havent
received full, up-to-date training, they can unknowingly create
risk. The HIPAA privacy and security rules require healthcare
organizations to formally educate the workforce to ensure ongoing accountability for the handling of PHI, as well as documentation verifying that it was provided.
While there are no set guidelines for how to conduct training,
AHIMAs best practices include the following:
Provide annual training for all staff
Include education, training, and ongoing awareness and
cover PHI in all its forms (verbal, written, electronic)
Develop a repository of current policies and procedures
Test staff on information to ensure that they have completed training before they are able to access PHI
Role-based training is especially important, as it enables
trainees to focus on their daily responsibilities and specifically where they will encounter potential compliance risk. In
addition to comprehensive employee training, it is important
to work closely with BAs to ensure both thorough training and
documentation is conducted.
Characteristics of Successful Disclosure

Management Programs
The state of audit readiness among healthcare organizations
varies widely, and there are numerous paths to achieve compliance. Successful PHI disclosure management programs do,
however, share several commonalities.
Foremost, successful PHI disclosure management programs
are enterprise-wide, allowing for governance of policies, procedures, and technology across the entire organization. The entity
with oversight has both authority and ultimate accountability.
Therefore, the structure allows for standardization and optimization with an underlying buck stops here atmosphere. Its
important to note that staff can be decentralized as long as their
accountability is to one single entity.
In addition, these enterprise-wide policies must have visible
sponsorship and ongoing support by the highest levels of leadership. Clinicians and staff across all departments must under-

stand that all training activities, along with strict adherence to

policies and procedures, are a strategic priority for leadership.
Lastly, a successful program includes monitoring and measurement. Technology that embeds these capabilities can not
only simplify efforts but also facilitate frequent, ongoing oversight. Leadership can easily review departments that frequently disclose PHI. They can track metrics such as the timeframe
between the origin of a request until fulfillment, as well as determine who is managing turnaround times properly and who
might need additional help. Ongoing measurement also provides actionable information, showing leadership where they
may need to conduct additional training or internal audits.
With the myriad factors involved in ensuring proper PHI
disclosure, its critical to have a combination of the right processes, policies, and technology. Maintaining standards, governance, and accountability at the enterprise level is also critical, and HIMs expertise in these areas can help position the
organization for success.
Notes
1. Office of the National Coordinator for Health IT. Data
Analytics Update: Health IT Policy Committee Meeting,
January 14, 2014. www.healthit.gov/facas/sites/faca/
files/HITPC_DataAnalyticsUpdate_011414.pdf.
2. US Department of Health and Human Services. Doctors
and hospitals use of health IT more than doubles since
2012. HHS press release. May 22, 2013. www.hhs.gov/
news/press/2013pres/05/20130522a.html.
3. PricewaterhouseCoopers. Medical Cost Trend: Behind
the Numbers 2014. June 2013. www.pwc.com/en_us/us/
health-industries/behind-the-numbers/assets/medicalcost-trend-behind-the-numbers-2014.pdf.
Don Hardwick (DHardwick@mrocorp.com) is vice president of client relations and compliance and Mariela Twiggs is national director of training
and compliance for MRO. James H. Braden is senior consultant for The Advisory Board Company.

HIM Domain Area: Performance Improvement
ArticleOptimizing PHI Disclosure Management in the Age of Compliance

LONGER BE ACCEPTED
1. Many hospitals have as many as

a. 20

b. 30

c. 40

d. 50
disclosure points.
2. W
hich of the following is a key component of preparing for an OCR
audit?

a. comprehensive review of policies and procedures

b. meeting with medical staff

c. collaboration between IT and HIM

d. strategic planning
3. Since 2009, how many people have had their protected health
information compromised?

a. under seven million

b. about 28 million

c. exactly 30 million

d. more than 31 million
4. What is a foremost characteristic of successful PHI disclosure
management programs?

a. they are enterprise-wide

b. they have structure

c. they have leadership

d. they vary across the organization
6. OCR auditors are looking for evidence of implementation of

policies and procedures and ongoing education and enforcement.

a. true

b. false
7. Printers and fax machines never need to be secured from
public view.

a. true

b. false
8. One way to determine if staff is protecting PHI is:

a. ensuring the Notice of Privacy Practices is posted

b. reviewing the Sanctions Policy

c. assigning print capabilities limitations

d. calling the HIM staff to ask how to obtain a copy of a
health record
9. There are legitimate reasons for denying access to
health information.

a. true

b. false
10. Acquisition of physician practices does not increase points
of disclosure.

a. true

b. false
5. Traditionally, IT and HIM have very different views of

information governance.

a. true

b. false
HIM After
Retirement
NO NEEDLEPOINT FOR THESE RETIREES, WHO
ARE FINDING NEW WAYS TO CONTRIBUTE TO
THE PROFESSION ON THEIR OWN TERMS
By Lisa A. Eramo
WHEN SHERRY DOGGETT decided to retire in 2013 after a 30-year career in HIM,
the first thing she did was try to figure
out how she was going to spend her time.
Doggett, who spent her last year of work as
the corporate director of transcription at
the University of Cincinnati (UC) Academic Health Center assisting with a year-long
electronic health record (EHR) implementation, says it seemed daunting to transition from such an intense project to this
newand slow-pacedchapter of her life.
Because I was so passionate about my
job, I had friends who were worried about
me and what I was going to do in retirement, says Doggett, who also served as the
past president of the Association for Healthcare Documentation Integrity (AHDI). But
I think Ive approached retirement with the
same passion I had for my job and the same
passion I have as a mother and a wife.
Doggett, who admits she has few hobbies,
looked forward to the idea of volunteering
and staying active in the HIM profession
on her own terms and at her own pace.
For me, [work] is relaxing. I dont knit or
do needlepoint. I love to cook, but Im not
crafty. Work is my knitting, she says.
This is an attitude that many HIM retirees
adopt as the rapidly changing profession
increasingly looks to retirees for their continued help and support on special projects, volunteering opportunities, and in the
classroom teaching the next generation.
Finally Time for Pet Projects

Since retirement, Doggett has found various activities to keep her busy. Last fall,
she chaired a 17-member task force with
AHIMA and AHDI during which she and
others created a toolkit to help organizations monitor clinician-created documentation in the EHR. It was great to lead this
because I could devote a lot of time to it,
she says.
Her experience at UC Health Center
played a big role in her involvement with
the toolkit. Unlike other transcription departments that report to HIM, Doggetts
department reported to IT. Because of this
reporting structure, she was able to involve
transcriptionists in all aspects of EHR implementation, including front-end speech
recognition training for physicians, patient
portal support, application interface support, and quality assurance for cliniciancreated documentation.
Doggett also serves on an AHDI task force
to address best practices for transcriptionist compensation. Other activities include
speaking engagements at AHDI regional
conferences, serving as communications
chair for the northeast region of AHDI, and
performing webinars for a dictation and
transcription vendor. A longtime AHIMA
and AHDI member, Doggett is excited that
she gets to stay involved in a profession
that she is very passionate about. The best
part is that I can do it now and not worry
about my job, she says. I can have fun doing it. Theres no pressure.
Retirees Reap Benefits of Networking

Susan Pincus, CPC, CPC-I, CHC, also knows
the plight of facing retirement after a busy
and fulfilling career. This type of work gets
in your blood, she says. Its hard to just
stop it. You meet so many people through
this profession, and you have this camaraderie.
Pincus, who worked in coding for 28
years, began her career filing insurance
claims for a multi-specialty clinic in Baton Rouge, LA. In just five years, the clinic
expanded from 12 physicians in five specialties to 70 physicians in 29 specialties.
Pincus taught herself how to code and
eventually became certified through the
AAPC in 1991.
While working at the clinic in Baton
Rouge, she initiated a charge capture program in which physician coders stationed
in the hospital setting coded physician services, including surgeries, hospital visits,
and consultations. They obtained information directly from the hospital health record while the patient was in the hospital.
Pincus eventually moved to Atlanta, GA to
work at Emory University Department of
Medicine and initiated the same charge
capture program there. Later, she helped
establish the Office of Compliance Programs at Emory, and most recently served
as its director of billing compliance.
When Pincus retired in 2005, she moved
to West Palm Beach, FL where she did
some auditing and training for several local physician offices. She also got involved
with the local chapter of AAPC. It was through these connections that she met an attorney who notified her of an opportunity to serve as an Independent Review Organization (IRO). This
led her to come out of retirement and go back to workbut on
her own terms. As an IRO, Pincus performed audits of an organization that had been placed under a Corporate Integrity
Agreement with the Office of Inspector General.
Pincus also performs webinars and has recorded compliance
training sessions. She attributes many of these opportunities to
her involvement in AAPC at both the national and local levels.
Because I had so many years in the profession, people call me.
Im very lucky in that respect, she says.
Although she considered officially retiring before the ICD10-CM/PCS implementation wave hit the industry, Pincus says
she instead decided to make the decision independent of the
new coding system. She took some ICD-10 courses and passed
a proficiency assessment shortly thereafter. Today, she continues to work with a large consulting company performing coding
auditsan opportunity she came across while networking at a
regional Health Care Compliance Association conference.
Teaching After Retirement

Teaching is a common thread among many newly retired HIM
professionals. This is exactly the path that Rita Scichilone,
MHSA, RHIA, CCS, CCS-P, followed after she retired from AHIMA in 2013 following 14 years of service with the association.
Throughout her 40 plus-year career in healthcare-related positions, Scichilone worked in coding and reimbursement, clinical
data management, and healthcare compliance and served as a
director/manager of HIM for hospitals, an HIM consultant for
healthcare organizations, and an adjunct educator.
Most recently, Scichilone served as the senior advisor of global standards at AHIMA, a role in which she expanded AHIMAs
representation in Health Level Seven (HL7), the American
Medical Informatics Association (AMIA), the Healthcare Information and Management Systems Society (HIMSS), the World
Health Organization (WHO), the International Federation of
Health Information Management Associations (IFHIMA), and
the International Health Terminology Standards Development
Organization (IHTSDO).
It has been a wonderful profession, she says. I never could
have dreamed of the places I would travel to or the work I would
have done, particularly with AHIMA when it started its global
work. It was just a fabulous experience all around.
When Scichilone retired, she knew she wasnt ready to leave
the profession entirely. Having most recently taught bachelorslevel HIM courses as an adjunct faculty member at the College
of St. Scholastica, she decided she would continue to teach as a
way to give back to the profession. She currently teaches a graduate course on medical vocabulary and classification systems at
St. Scholastica. Teaching these courses allows her to capitalize
on her experiences working with AHIMA to advance the associations global presence.
I would encourage people who are still very active and who
want to contribute to the profession to teach, Scichilone says.

There is a significant shortage of people to teach at the baccalaureate level and definitely at the masters level. We need
teachers at all levels.
In addition to teaching, Scichilone helped the College of St.
Scholastica develop a free Massive Open Online Course about
SNOMED CT based on IHTSDOs starter guide. This course,
which included more than 1,200 students, took place from April
to June 2014. Due to personal matters, she planned to officially
retire at the end of 2014. My husband has been retired for more
than three years. We both want to travel and be more involved
with our seven grandchildren, she says. The HIM profession is
rapidly changing and adapting to new challenges. In my case,
now is the time to let someone else do this work.
Some Not Ready for Professional Isolation

Although many individuals enjoy the freedom associated with
an escape from the daily HIM grind, others find that it can be
socially isolating if not well planned.
I was financially ready at age 65 to retire, but I wasnt psychologically ready, says Shirley Eichenwald-Maki, MBA, RHIA,
FAHIMA, who spent most of her 40-plus-year career in HIM
education, including serving as the director of education and
accreditation at AHIMA and subsequently as the first director
of the HIM graduate program at the College of St. Scholastica.
Although she retired in 2012, Eichenwald-Maki has continued
to serve as an academic advisor for several masters-level students who are completing their thesis projects on topics such as
improving patient portal usage, reevaluating an EHR in a small
clinic, establishing a telemedicine framework in a nephrology
clinic, and developing a continuity of care program between a
small rural hospital and clinic.
These topics appeal to Eichenwald-Makis long-time interests in EHRs, health information technology, and data analysis.
While at the College of St. Scholastica, she was the project director for an eight-year effort to integrate an electronic health record into the colleges six health professions curricula. During
this project, she worked with faculty across each of the health
sciences programs to teach students in the schools physical
therapy, nursing, occupational therapy, exercise physiology,
and health information management programs how to document into the EHR. HIM students learned how to document in
and use an EHR in their respective workflows to support decision making, and learned how to build electronic assessment
and documentation tools as well as manage data in an electronic environment.
Making the transition to retirement has been a slow process,
she says. For Eichenwald-Maki, this process began by serving
as a mentor for a younger faculty member. I decided that I was
going to involve her in as many things as possible. This really
helped me let go. As I saw her develop, I thought, This place is
going to be just fine without me, she says. Im sure they would
have been fine anyway, but I think psychologically I was letting
go through my relationship with her.
Eichenwald-Maki says its important to make these connections as one retires. I think you have to envision how things
will be as you depart; knowing you have trust in the people
who are left behind to carry on, she says. She also stays connected with many of her colleagues and students through social media. I dont feel isolated from these important people,
she says.
Continuing her membership with AHIMA has allowed her to
maintain connections as well. She continues to receive publications, can vote in association elections, and is able to track
industry progress.
Financial Planning Very Important to Sustain Retirement

A financial plan for retirement is just as important as having a
social plan, says Nicole Mayer, of RPG-Life Transitions Specialists, a financial planning and wealth management company
that assists individuals through various life transitions. Todays
retirees face many challenges when determining the timing of
retirement and whether they can afford it, she says.
Not only are they trying to help their kids, but theyre also
helping their aging parents, says Mayer. Theyre in a tough spot
because they have these two generations to help. Figuring out
when to quit working is not easy.
The first step is to work with a financial planner to determine
whether youre on track to retire or whether you need to make
changes in terms of investments or savings. Mayer says retirees
typically spend 100 percent of their current income during the
first seven years of retirement. This amount decreases by 10 percent every few years after that. Although lifestyle expenses may
decrease over time, medical expenses actually increase.
Unknown medical expenses are a big concern, Mayer says.
Another fear is outliving ones money. One of the hardest things
for people is to not have money going into their account but
then constantly taking it out. Mayer suggests living on a practice retirement budget for three to six months to see how feasible it is. Ask yourself how much money you typically spend on
a Saturday. Every day during retirement is a Saturday, she says.
A lot of the time, youre going to spend the same if not more
especially during those first few months.
Individuals must think things through and not make a hasty
decision out of fear or unhappiness at work, she adds.
How to Stay Involved After Retirement

There are plenty of opportunities at AHIMA for those who want
to stay involved in the profession after retirement, says Carolyn
Guyton-Ringbloom, MBA, CAE, senior director of volunteer
leadership development at AHIMA. Although some opportunities require specific expertise, many simply require only an active AHIMA membership and an interest in the project.
Consider the following volunteer opportunities:
Committees. Review applications for awards; help plan
the next AHIMA convention; assist in maximizing membership engagement; provide oversight for virtual labs
and lesson development; work to enhance ethical guide-
lines; help grow the fellowship program, and more.

Practice councils. Serve in a year-long position on one of
the following councils: Clinical terminology and classification; enterprise information management; health information exchange; and privacy and security.
Task forces. Opportunities require a few hours per week
or month, depending on the project. Most projects require
a three-month commitment that includes conference
calls and independent work. Task force topics include
consumer engagement, clinical documentation improvement, care coordination, data and information analysis,
and standards.
A HIMA and AHIMA Foundation Board of Directors.
Terms are three years starting January 1 following the
year selected.
A HIMA Foundation Council for Excellence in Education work groups. Guide the academic community, assess and address workforce needs, develop a strategy for
building research in HIM and HIT, and more.
Retirees can also work with students, write articles for the
Journal of AHIMA and AHIMA newsletters, or actively advocate
for HIM issues like ICD-10. Guyton-Ringbloom says many retirees take advantage of these and other opportunities at AHIMA.
Its their way to continue to give back, she says. People who
are working might not have time. A retiree does have the time
and wants the interaction.
Individuals who have served in leadership positions or who
have performed strategic planning can continue to provide
valuable input for developing content for state and national association annual meetings, Guyton-Ringbloom says.
Retirees know what the HIM field really needs in terms of the
future, she says. A lot of the states are looking for officers, so I
think thats also a great way for people to stay involved.
It may be helpful to consider how ones HIM skills in project
management and facilitation can be put to good use in other
settings. You can take these skills and translate them to volunteer opportunities in the community, says Doggett, who serves
as a facilitator for a discussion group at her synagogue. For me,
its about helping people see something in a different light and
be open to new ideas, she says. Its also an opportunity to meet
new people.
Lisa Eramo (leramo@hotmail.com) is a freelance writer and editor based
in Cranston, RI, who specializes in healthcare regulatory topics, HIM, and
medical coding.
Link
List of AHIMA Volunteer Opportunities
http://engage.ahima.org/VolunteerOpportunities
To learn more about volunteer opportunities at AHIMA,

visit http://engage.ahima.org/VolunteerOpportunities or e-mail
volunteer.services@ahima.org.
Working Smart a professional practice forum

Navigating Privacy & Security / e-HIM Best Practices / Standards Strategies / The Sound Record
FDA Offers
Guidance on
Cybersecurity and
Medical Devices
By Liisa Thomas and Idara Udofia
THE FOOD AND DRUG Administration (FDA) has joined other

regulators in sounding a call for data protection and security in
our rapidly digitizing world.
Studies reveal that many health providers devices or systems
have been breached without their knowledge of such breach
or the associated vulnerabilities.1 According to SANS Institute,
medical devices are the primary cause for transferring malicious attacks to other networks or devices in the medical sector.2 Moreover, the Department of Health and Human Services
recent investigation revealed over two dozen devices were vulnerable to exploitation by hackers.3
In response to these concerns, the FDA issued guidelines on
cybersecurity for medical devices on October 2, 2014. The document, Content of Premarket Submissions for Management of
Cybersecurity in Medical Devices (guidelines), encourages
manufacturers to consider cybersecurity measures in developing medical devices.4 The guidelines are based on the National
Institute of Technologys (NIST) Core Framework.5 Although
not legally binding, the FDA has indicated that it will consider
compliance with the guidelines when engaging in its premarket
review of a medical device.
The FDA has indicated that it will expect to see specific information about cybersecurity in a companys premarket device
submissions, such as:
1. Hazard analysis, mitigations, and design considerations
about the device
2. A matrix that shows how the controls trace to those risks
3. A summary plan about updates and patches
4. A summary of controls in place to maintain device integrity
5. User instructions about product security controls (like using a firewall or having anti-virus software)
Five Core Functions Developed

When putting together this documentation, what should manufacturers consider? The FDA has provided a list of recognized
consensus standards which should be helpful to device manufacturers. That list will be updated at www.accessdata.fda.gov/
scripts/cdrh/cfdocs/cfStandards/search.cfm. The FDA has also
set out five core functions that need to be addressed by devices:
Identify
Protect
Detect
Respond
Recover
Identify, Understand, and Protect Against Cybersecurity Risks

The first step in developing secure medical devices is to identify potential exposure and then protect against that exposure.
For example, the FDA notes that devices capable of wirelessly
connecting to the Internet are more vulnerable to cybersecurity threats than devices that are not connected.6 The FDA
thus recommends in its guidelines that security be tailored to
the risk connected to the intended end-user and corresponding environment:
The extent to which security controls are needed will depend on
the devices intended use, the presence and intent of its electronic
data interfaces, its intended environment of use, the type of cybersecurity vulnerabilities present, the likelihood the vulnerability
will be exploited (either intentionally or unintentionally), and the
probable risk of patient harm due to a cybersecurity breach.7
Examples of security measures to consider include, among

other things: limiting access through user authentication;
having session timers; using layered authorization dependent

on a users role; providing physical locks; and ensuring trusted
content by having, for example, updates that require an authentication code.
The goal is to design secure medical devices using security
measures that can efficiently handle actual, high-priority future risk. The FDA further emphasizes this point by recommending that manufacturers submit a traceability matrix that
connects the cybersecurity controls to the considered risks.
Notwithstanding, the FDA acknowledges that the security
controls should be appropriate for the intended end-user, illustrating that overly burdensome controls in an emergency
situation should be avoided.8
Understanding the specific cybersecurity needs compliments
the next recommendation: to provide compatible controls. In
fact, the FDA goes a step further and recommends manufacturers justify chosen controls during the premarket submission
process, further highlighting the agencys desire for customized
security measures.9 For instance, to limit access the agency recommended strengthening password protection by avoiding passwords that are hardcoded or commonly used. The agency also
pointed to encryptions to secure data transfers to and from devices to maintain secure content.
Detect Vulnerabilities and Threats, Then Respond

and Recover
In addition to proactively reducing the risk of cyber threats,
the FDA guidelines also recommend equipping devices with
cybersecurity measures that can detect, respond, and recover
from vulnerabilities and threats while operating in its environment. In making its recommendation, the FDA recognizes the
need to preserve functionality while managing threats or resolving security loops. It recommends implementing features that
recognize, log, and address security breaches during normal
use and features that protect critical functionality, despite a
breach in security.10
In keeping with the premise that all stakeholders share a responsibility in establishing effective cybersecurity, the FDA further suggests using a feature that informs end-users of security
compromises, where such notice would guide end-users to respond and resolve the cybersecurity issue.11
Although the listed approaches are recommendations, the
FDA expressly states that if manufacturers decide to use other
measures to achieve these goals, they should provide justification, indicating that the FDA has a vested interest in features
that detect, respond, and recover from cybersecurity vulnerabilities and threats.
Ongoing Device Protection

The FDA has indicated that during the premarket review it will
consider the extent to which cybersecurity controls manage and
mitigate risk over the lifecycle of the device. For instance, the
FDA guidelines suggest that manufacturers include a plan for
providing software updates and patches throughout the lifecy-
cle of the medical device to assure safety and effectiveness.

The FDA further advises manufacturers to submit a list of recommended security controls, such as anti-virus software or firewalls that are appropriate for the environments in which the devices will be used. Moreover, in the guidelines the FDA encourages
manufacturers to provide a summary that describes how the cybersecurity in the device will be maintained over time.12
Read and Heed the Guidelines

Companies that develop products subject to FDA review will
need to read and heed these new guidelines. The intended
consequence is safer devices. There may be unintended consequences as well, beyond increased security compliance costs.
For example, disclosing cybersecurity risks may impact manufacturer liability. The guidelines may also lead to the centralization within the FDA of information about cybersecurity risks
and resolutions for medical devices.
Notes
1. Finkle, Jim. U.S. government probes medical devices for
possible cyber flaws. Reuters. October 22, 2014. www.
reuters.com/article/2014/10/22/us-cybersecurity-medicaldevices-insight-idUSKCN0IB0DQ20141022.
2. Paganini, Pierluigi. Risks and Cyber Threats to the Healthcare Industry. Infosec Institute. September 16, 2014. http://
resources.infosecinstitute.com/risks-cyber-threats-healthcare-industry/.
3. Finkle, Jim. U.S. government probes medical devices for
possible cyber flaws.
4. US Food and Drug Administration. Content of Premarket
Submissions for Management of Cybersecurity in Medical
Devices: Guidance for Industry and Food and Drug Administration Staff. October 2. 2014. www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/
GuidanceDocuments/UCM356190.pdf.
5. National Institute of Standards and Technology. Draft
Framework Core. www.nist.gov/itl/upload/draft_framework_core.pdf.
6. US Food and Drug Administration. Content of Premarket
Submissions for Management of Cybersecurity in Medical
Devices..., pg. 4.
7. Ibid.
8. Ibid.
9. Ibid.
10. Ibid, pg. 5.
11. Ibid.
12. Ibid, pg. 6.
Liisa Thomas (lmthomas@winston.com) is a partner at Winston and
Strawn, and chair of the firms privacy and data security practice. She is
an adjunct professor of privacy law, and the author of Thomas on Data
Breach: A Practical Guide to Handling Worldwide Data Breach Notifications. Idara Udofia (iudofia@winston.com) is an associate in the Chicago office of Winston and Strawn.

Metadata Offers Roadmap to

Structured Data
By Diane Dolezel, MSCS, RHIA
DATABASE METADATA PROVIDES a valuable roadmap for locating the structured data stored in healthcare databases. However, many electronic health information management (e-HIM)
professionals do not possess the necessary basic understandings of where to find the metadata and how to use it after it is located. This article discusses how to find the metadata, describes
the contents of typical systems and user metadata repositories,
and explores the relationship of metadata to data quality in the
context of e-HIM development.
A single facility often maintains multiple database repositories
to handle the flood of data from clinical applications, mobile
monitoring devices, user interfaces, and electronic health records (EHRs). This proliferation of stored data makes it difficult
for healthcare professionals to know where to find the data they
need. Additionally, e-HIM developers are challenged to create
high-quality interfaces referencing the correct data field definitions. The National Information Standards Organization (NISO)
endorses the use of metadata to locate database data, and to
support interoperability.1 Moreover, the Office of the National
Coordinator for Health IT (ONC) recommends using metadata
to increase data integrity for health data exchange.2
Steps for Using Database Metadata

So, what is metadata, where is it located, and how can you use
it? Metadata is information about database data. It is stored in
searchable online catalogs that list the name, definition, data
type, and location of the data, and is analogous to a data dictionary for the database.3 Structured metadata supports the
meaningful use EHR Incentive Program because the rules
in a referential database help ensure unique data definitions.4
This reduces data redundancy and increases data integrity.
Thus, a metadata catalog is useful as a roadmap for locating a

data element.5
The process of understanding the metadata roadmap unfolds
with these five steps:
1. Find the metadata catalogs
2. Explore system metadata
3. Examine user metadata
4. Survey organization-wide metadata
Find the Metadata Catalogs

Imagine you are an e-HIM project manager for a data integration project for a large hospital. You must work with the project
developers to design a database interface that will accept input
from a web-based form. To maintain data quality, the users
form data must be validated against the database definitions
before the user is allowed to submit the form. You know that
there are metadata system catalogs that describe each row and
column (i.e., field) in the database tables. However, you do not
know where to find them or how to obtain access.
Explore System Metadata

First, consider metadata creation. When the database administrator installs the database software on the server, the installation process creates the database management system (DBMS)
metadata catalogs automatically. These system catalogs, which
are actually a set of tables stored in the database, are updated
automatically by the DBMS when changes occur, like creating
a new table or user.6 However, metadata catalogs are accessible
only to database administrators and super users.
To get access for the integration project, the project manager or project lead should meet with a database administrator
Table 1: ALL_TAB_COLUMNS Catalog Table Example

THIS TABLE PROVIDES a list of all the tables, columns, and other database objects that are available to the current user.
Column
Datatype
NULL ALLOWED
Description
OWNER
VARCHAR2(128)
No
User name of owner of the table, view, or cluster
TABLE_NAME
VARCHAR2(128)
No
Table, view, or cluster name
COLUMN_NAME
VARCHAR2(128)
No
Column name
DATA_TYPE
VARCHAR2(30)
Yes
Datatype of the column
DATA_LENGTH
NUMBER(10)
Yes
Length of the column in bytes
DATA_PRECISION
NUMBER(10)
Yes
Decimal precision for NUMERIC and DECIMAL datatype; binary precision

for FLOAT, REAL, and DOUBLE datatype; NULL for all other datatypes
DATA_SCALE
NUMBER(10)
Yes
Digits to the right of decimal point in a NUMERIC or DECIMAL
NULLABLE
VARCHAR2(1)
Yes
Indicates if the column allows NULLs. Value is N, if there is a NOT NULL

constraint on the column or if the column is part of a primary key
Source: Oracle. A.1.11 ALL_TAB_COLUMNS. https://docs.oracle.com/html/B10100_01/wncat.htm#i631886.
(DBA) and explain what data they needed access to, and whether the developers will need to view the data or make changes
to the data (i.e., update or insert new data). The DBA will then
query the system catalog to locate the information and will provide appropriate access as well as documentation on the table
definitions.
A copy of the metadata definitions for the project objects, such
as tables or procedures, should be distributed to all developers.
It should be referenced designing the users web form validation. This will help guarantee that interfaces are sending correctly validated data to the database.
For example, if the gender field is defined as M or F, then
these codes must be used to validate the web form so that a form
input value of a 1 or 0 would be not be submitted. Moreover,
the user would get an error message with examples of the correct data format for that input field.
Typical information in a DBMS systems catalog is:7
User names, roles, privileges
Names of all tables, columns, indexes, constraints
Names of user created procedures or indexes
Audit trail of updates, edits, deletions
Oracle and IBM DB2 are well-established corporate databases. For a visual example of the IBM database, visit the developerWorks website at www.ibm.com/developerworks/data/
library/techarticle/dm-0411melnyk/.8 The Oracle system catalog interface has a similar design.
Examine User Metadata and Survey Organization-wide Metadata

As developers work on the project they will create test tables
and load them with test data in the development database in
order to test the forms. Those data definitions will appear in the
users data catalog, and in the systems catalog. For example, if
the developer creates a test table Patient, in an Oracle test database, then the Oracle DBMS catalog tables ALL_TABLES, and
ALL_TAB_COLUMNS would be updated.9 This is similar to what
happens when a person creates a new file on their computer
and the directory listing is updated.
To ensure that the developers code works in the production
systems, it is essential that the development database tables
have the same column definitions, primary keys, indexes, etc.,
as the production tables. Specifically, the development area
should match the production area as closely as possible.
This can be achieved efficiently by having the developers, or
system designers, refer to their copy of the system metadata definitions when creating objects in their development database.
Failing to take this action substantially increases the likelihood
of problems when the web screen goes into production. A portion of the ALL_TAB_COLUMNS catalog table that lists all tables
or views accessible to a user is available for review above.10 In
many settings, the user will have permission to view this table.
Lastly, an e-HIM developer or designer may be working on
a small project integral to health information management
(HIM), like tracking HIM employee credentials that will not be
implemented in the companys production area. In this case,
there is a relational database called Microsoft Access that is
commonly used for this type of small-scale development. It has
many benefits, such as a system catalog. It includes a rich tool
set for querying and creating objects, and the data stored in the
system is easily exportable for upload to Oracle or DB2, should
that be desired later.
Table 2 on page 46 shows a view of the system catalog for the

Table 2: Example of System Catalog for Table Patient in Microsoft Access Database
THIS TABLE IS created automatically by the database management system when the user creates a new table.
table Patient in a Microsoft Access database, created on the

computer desktop of the author of this article. The field names
are listed (i.e., ptmrn, ptfname), and the data types are still the
default type of text. The primary key, which is ptmrn, is of data
type autonumber, indicating that a new incremented number
will be associated with a record when it is added to the database.
At the bottom of the page under the General tab, one can see
information about the ptmrn column, which is the field name
selected at the top. For example, the ptmrn column is a long integer, with an index, and no duplicates are allowed.
Learn to Navigate Metadata

Metadata is useful for finding structured data in a database.
HIM professionals should learn how to navigate the metadata,
or system catalogs, because they provide information about the
data in the database that is needed for designing and developing electronic interfaces. Metadata also helps maintain data
quality in a database.
Notes
1. National Information Standards Organization. Understanding Metadata. Bethesda, MD: NISO Press, 2004.
www.niso.org/publications/press/UnderstandingMetadata.pdf.
2. Office of the National Coordinator for Health Information
Technology. Metadata Standards to Support Nationwide
Electronic Health Information Exchange. Federal Register

76, no. 153 (Aug. 9, 2011): 4876976. www.gpo.gov/fdsys/
pkg/FR-2011-08-09/pdf/2011- 20219.pdf.
3. Ibid.
4. Viola, Allison and Shefali Mookencherry. Metadata and
Meaningful Use. Journal of AHIMA 83, no. 2 (February
2012): 32-38.
5. Milstead, J. and S. Feldman. Metadata cataloging by any
other name. Online 23, no. 1 (1999): 24.
6. Ibid.
7. Oracle. Oracle9i Lite Developers Guide for Windows CE/
Pocket PC, Release 5.0.2, System Catalog Views. 2002.
http://docs.oracle.com/html/B10100_01/wncat.htm.
8. Melnyk, Roman. DB2 Basics: How to get useful information from the DB2 UDB system catalog. developerWorks.
November 2, 2004. www.ibm.com/developerworks/data/
library/techarticle/dm-0411melnyk/.
9. Oracle. Oracle9i Lite Developers Guide for Windows CE/
Pocket PC Release 5.0.2, System Catalog Views, A.1.11
ALL_TAB_COLUMNS. 2002. https://docs.oracle.com/
html/B10100_01/wncat.htm#i631886.
10. Ibid.
Diane Dolezel (dd30@txstate.edu) is an assistant professor in the health
information management department at Texas State University, based in
San Marcos, TX.

Informatics Education for HIM

Professionals in the Era of
Interoperable Standards-Based HIEs
By Anna Orlova, PhD, and Harold Lehmann, MD, PhD
ELECTRONIC SHARING OF health information, both within

and between organizational boundaries, requires the adoption
of interoperable health information technology (HIT) solutions
such as electronic health record (EHR) systems, laboratory information management systems (LIMS), radiology and pharmacy information systems, public health and research information systems, and numerous growing mobile HIT products.
Interoperability, which is the ability to share and exchange data
between information systems, is the key to achieving efficiencies
in healthcare with health information and communication technology. This article is focused on an urgent need to strengthen
the current curricula for training informaticians and HIM professionals to support work in the new era of standardized interoperable electronic data exchanges. This need includes developing
competencies, training courses, and programs focused on standardization of health information technology, health information
systems interoperability, and information governance.
Based on the authors five years of experience offering the online
course HIT Standards and Systems Interoperability for clinicians and public health professionals at Johns Hopkins University,
this article will discuss emerging roles for HIM professionals and
the way of expanding current academic informatics and HIM curricula for professionals in healthcare, public health, IT, and law.1
Enabling Interoperability
As defined by Health Level Seven (HL7), interoperability is
based on the following three pillars:
1. Semantic interoperabilityshared content
2. Technical interoperabilityshared information exchange
infrastructure
3. Functional interoperabilityshared rules of information
exchanges (i.e., business rules, information governance)
Though today interoperability has proven to be very difficult

to establish, standards development organizations (SDOs) have
been developing numerous HIT standards under these three interoperability components, including:2
1. Standards for representation of clinical and population
health content in HIT products (data and information
content, data structures and formats, etc.)
2. Standards for IT infrastructure for information exchanges
and sharing (message-based point-to-point communication, shared document-based exchanges, secure e-mails,
portable (mobile) devices, etc.)
3. Standards for information governance rules (i.e., business
rules, privacy and security, identifiers, medical record
management, etc.)
Fundamental to the interoperability efforts are the alignment of various HIT standardization activities conducted to
date via ad hoc endeavors under a common HIT Standardization Framework as well as a HIT Interoperability Framework
focused on standardization of content, information exchange
infrastructure, and information governance.3
There is a need for the development of a skilled health information management (HIM) workforce capable in the adoption,
operation, and use of the interoperable HIT products.
New Workforce Needed

HIM professionals are starting to recognize that their profession
intersects with informatics in many ways. Facilities that adopted EHR technology had been utilizing informatics methods for
codification of health information in EHR systems and clinical
documentation improvement (CDI), ensuring patients access
to their own information (consumer empowerment and en-
gagement), data analytics and population health analysis, data

reporting, and other applications.4
HIM professionals and informaticians are frequently engaged
at the provider or payer level to ensure the fidelity of patientrelated data that flow into or from EHRs and other information
systems involved in the generation of patient-encounter data
(i.e., LIMS, radiology, pharmacy, public health, data warehouses, financial systems, etc.).
The emerging roles for HIM professionals in the new interoperable electronic data sharing environment include:5
Standard setters
Educators
Consumer advocates
Experts in data structure
Brokers of information
Advocates of quality data
Informaticians supporting clinical and business decisions
Data analysts
The US Bureau of Labor Statistics estimated the addition of
35,100 new HIM positions by 2018 for a total of 207,600 employeda 17 percent increase.6 The Office of the National Coordinator for Health IT (ONC) made an assessment of workforce
roles and competencies for EHR adoption in 2010, identifying
roles such as health information management and exchange
specialist and health information privacy and security specialist for permanent staff of healthcare and public health organizations such as office practices, hospitals, health centers,
long-term care facilities, health information exchange organizations, and state or city public health agencies.7 These roles have
not been defined within the Department of Labor (DOL) Standard Occupational Classification (SOC) scheme.8
The United Kingdom National Health Service showed that
in the electronic environment health records and information
management professions will have 27 percent of jobs, compared to 37 percent of information technology and communication (ICT) jobs and three percent of informatics jobs.9 In
Canada, HIM occupations will account for roughly 16 percent
of the projected 39,000 hiring requirements between 2014 and
2019. In addition to the traditional HIM roles of coders and record managers, a high risk of shortage of HIM professionals in
Canada was noted in the following roles:10
Senior Health Information Management
Privacy
Standards
Data Quality Management
Information Governance
Standards were identified as an emerging HIM field that will
increase in importance with the adoption of interoperable HIT
applications.11 In a 2014 private sector survey in Canada, 67 percent of industry employers said they make a specialized HIM
qualification a requirement or preference in hiring and 69 percent reported that standards training/certification in areas like
information exchange standards, such as HL7 and DICOM, and

content standards, such as LOINC and SNOMED, is either a hiring preference or a hiring requirement.12
Information governance is a new and senior HIM professional
role focused on responsibilities for defining and implementing
strategies and procedures for generating, managing, analyzing,
and using data, as well as for ensuring compliance with quality, integrity, custodianship, privacy, and security standards
and access and usability goals.13,14 Information governance is
closely linked with the field of e-discovery, which introduced
into healthcare a new category of legally discoverable information, electronically stored information (ESI), which describes
information stored in EHR systems and health information exchanges (HIEs). Information in EHRs and HIEs is now viewed
the same way as paper-based health records by courts.15
In todays healthcare system, there are a few individuals in
these new and highly specialized roles responsible for standards, including interoperability, information governance, and
e-discovery. However, the demand for this expertise in healthcare and public health is expected to increase.16 Taking into account the complexity of the information and communication
technologies environment, robust cross-training between HIM,
IT, and law areas is needed.
Figure 1 on page 50 graphically presents the emerging HIM
roles needed to support interoperability between information
systems in the context of the HIT Interoperability Framework.17
These roles include the management of the semantic (content),
technical (IT infrastructure), and functional (information governance) interoperability components of a healthcare information system. New HIM roles for the operation of semantic interoperability resources include content managers, standards
setters (developers), and data analysts.
New HIM roles for enabling functional interoperability (i.e.,
information governance services) include information governance specialists, information brokers, and consumer advocates. Professionals needed for enabling technical interoperability (IT infrastructure for data sharing/exchange) include IT
and computer science specialists and vendors of EHRs, LIMS,
and other HIT solutions.
New Training Needed to Educate New Workforce

Academic and continuing education programs in medicine,
public health, IT, HIM, and law need to be extended to train the
new workforce required to support standard-based interoperable HIT products. The required skilled workforce must be proficient in newly emerging areas of interaction among HIM, IT,
health informatics, and law, as shown in Figure 1 on page 50.
Despite the increase of informatics programs in the US in the
past decade, a review of 35 masters degree curricula showed
only three programs that currently offer courses on HIT standards and systems interoperability (Johns Hopkins University,
Northwestern University, and Oregon Health Services University). Three universities include courses on standards (Northeastern University, Indiana University, University of Utah); and

Figure 1: New HIM Workforce Professions for Interoperability Infrastructure
Health IT Interoperability Framework

WORKFORCE
Semantic
Interoperability
Technical
Interoperability
Functional
Interoperability
Content
IT Infrastructure
Information
Governance
IT Specialists
EHRs, LIMS and Other IT Vendors
HIM & IT
C
ontent Managers (Specialists in
Vocabulary and Terminology Services,
Data Structures, Decision Support, etc.)
Standards Setters
Data Analysts
three other universities include topics on standards as part of

their courses (Columbia University, University of Mississippi,
and University of San Francisco). Only one of these programs,
Johns Hopkins University, offers its course on HIT standards
and systems interoperability in the open course learning environment, called Johns Hopkins Opencourseware, where any interested professional may access all course materials online for
free and without enrollment in the program.
Operation of an interoperable health information exchange infrastructure will require a highly skilled workforce for supporting
pillars of semantic (content), technical (information exchange
infrastructure), and functional (information governance) interoperability illustrated in Figure 1. Based on the business needs of
healthcare and public health organizations, two new areas of HIM
training may emerge:
Specialty 1Content Managers; a bridge between traditional HIM and IT
Specialty 2Information Governance Specialists; a bridge
between IT and law
The first specialty, Content Managers, will include training
HIM specialists to develop and use standards-based tools for
semantic interoperability (i.e., vocabulary and terminology services, tools for data structure, ontologies, computer-based coding, etc.). This will require a skilled workforce with competen50/Journal of AHIMA February 15
IT & Law
Information Governance Specialists

Information Brokers
Consumer Advocates
cies in HIM, coding, informatics, HIT standards, data analysis,

and computer science. This specialty will support vocabulary
and terminology services as well as data analytics services to
address the needs of semantic interoperability between information systems in healthcare, public health, social services, and
e-government initiatives at large.
The second specialty, Information Governance Specialists,
will require a workforce with competencies in HIM, hospital administration, HIT standards, computer sciences, and law. This
specialty will support business processes and information governance practices under the Health Insurance Portability and
Accountability Act (HIPAA); the Internal Review Board (IRB)
protections, including data breaches protection; Joint Commission regulations; and e-discovery and other regulations when
using EHRs, LIMS, pharmacy systems, public health surveillance systems, personal health records, etc.
This specialized training should be offered to HIM as well as
legal professionals working in the area of protecting data integrity, privacy, security, transparency, and accountability.18
Leaders in HIM, IT, informatics, public health, and legal training are invited to join AHIMA in developing competencies as
well as specific training for HIM professionals for these two new
specialties. AHIMA also invites these leaders to contribute to
updating AHIMAs HIM Career Map to depict growing needs
for HIM professionals in current and new roles that will support
electronic health information sharing.

For more information regarding education for the electronic
and interoperable environment, please contact Anna Orlova,
PhD, AHIMAs senior director of standards, at anna.orlova@
ahima.org.
The authors would like to acknowledge Kersti Winny, academic programs administrator, division of health sciences informatics, school of medicine, at Johns Hopkins University, for help
with the informatics program syllabus review.
Notes
1. Johns Hopkins University. Health Information Technology Standards and Systems Interoperability Course.
http://ocw.jhsph.edu/index.cfm/go/viewCourse/course/
InfStandards/coursePage/index/.
2. Thune, J., L. Alexander, P. Roberts, R. Burr, T. Coburn, and
M. Enzi. Reboot: Re-Examining the Strategies Needed to
Successfully Adopt Health IT. United States Senate White
Paper. April 13, 2013. www.thune.senate.gov/public/index.cfm/files/serve?File_id=0cf0490e-76af-4934-b53483f5613c7370.
3. Orlova, A. and N. Lipskyi. Health IT Standardization
Framework and Public Health. Presentation at the Public
Health Informatics Conference, Centers for Disease Control and Prevention, April 30, 2014.
4. Lusk, K. and L. Fackrell. Coding and CDI with Technology
Backbone. Pre-conference workshop, AHIMA Convention, September 27, 2014.
5. Van Dolan, Paul. Reframing Roles. AHIMA Leadership
Symposium, July 11-12, 2014.
6. Hersh, W. The Health Information Technology Workforce.
Applied Clinical Informatics 1, no. 2 (June 2010): 197212.
www.ncbi.nlm.nih.gov/pmc/articles/PMC3632279/.
7. Ibid.
8. US Department of Labor. Standard Occupational Classification. www.bls.gov/soc.
9. Eardley, Tony. NHS Informatics Workforce Survey. ASSIST. August 2, 2006. www.bcs.org/upload/pdf/finalreport_20061120102537.pdf.
10. Canada Health Infoway, Canadian Health Information Management Association et al. Health Informatics and Health
Information Management: Human Resources Outlook 20142019. June 2014. www.echima.ca/uploaded/pdf/reports/HIHIM-HR-Outlook-Report-Final-w-design.pdf.
11. Canadian Health Information Management Association.
Transforming Health Information Management: The Evolution of the HIM Professional. 2012. www.echima.ca/uploaded/pdf/Workforce%20Transformation_FINAL_WEB.pdf.
12. Canada Health Infoway, Canadian Health Information
Management Association et al. Health Informatics and
Health Information Management: Human Resources Outlook 2014-2019.
13. Irving, Richard. Do you have an Information Governance
Strategy? Canadian Healthcare Technology 18, no. 13
(April 2013): 10. www.canhealth.com/images/PDF/Canadian%20Healthcare%20Technology%202013-03.pdf.

14. AHIMA and Cohasset Associates. 2014 Information Governance in Healthcare Benchmarking White Paper: A
Call to Adopt Information Governance Practices. 2014.
www.ahima.org/~/media/AHIMA/Files/HIM-Trends/
IG_Benchmarking.ashx.
15. Baldwin-Stried Reich, Kimberly. E-Discovery in Healthcare
A Crucial Role for HIM Professionals in the Information
Governance Era. Presentation at Illinois Health Information
Management Association Annual Meeting, March 28, 2014.
16. Canada Health Infoway, Canadian Health Information
Management Association et al. Health Informatics and
Health Information Management: Human Resources Outlook 2014-2019.
17. Orlova, A. and N. Lipskyi. Health IT Standardization
Framework and Public Health.
18. Collins, S. ANI Emerging Leaders Project: Clinical Informatics Governance & Nursing Leadership. CIN 32, no. 9
(September 2014): 420-423.
Anna Orlova (anna.orlova@ahima.org) is senior director of standards
at AHIMA. Harold Lehmann (lehmann@jhmi.edu) is a professor and director of the divison of health sciences informatics, school of medicine, at
Johns Hopkins University.

Evaluating the Information

Governance Principles for Healthcare:
Accountability and Transparency
By Galina Datskovsky, PhD; Ron Hedges, JD; and Sofia Empel, PhD
Editors note: This is the first in a series of four articles that will discuss the eight Information Governance Principles for Healthcare.
AHIMAS NEWLY INTRODUCED Information Governance

Principles for Healthcare (IGPHC) provides a framework for
healthcare organizations to conduct their operations effectively, while ensuring compliance with legal requirements and
other duties and responsibilities. IGPHC is a set of eight principles that, when considered in whole or in part, are intended to
inform an organizations information strategy. This article is the
first in a series of four articles that will explore the meaning and
intent of the principles, two at a time.
Accountability Principle
At the heart of the principle of accountability is a senior leader

who is formally designated as responsible for overall information governance (IG) program development and its implementation. According to IGPHC, an information governance program should:
Establish an information governance structure for program development and implementation
Designate a qualified accountable person to develop and
implement the program
Document and approve policies and procedures to guide
its implementation
Remediate identified issues
Enable auditing as a means of demonstrating the organization is meeting its obligations to both internal and external parties
One question that arises with the development of the IG principles is: Why a senior leader? Only a person situated at the
top level of an organizations hierarchy can be held accountable
for all of the elements of an information governance program as
described above. Likewise, only a senior leader could be expected to secure the input of stakeholders, business process owners,
and domain experts for the IG program.
The senior leader of an IG program does not do tactical
work. Instead, through the collaborative approach espoused
by the principle of accountability, the senior leader should
help appropriate parties build, implement, and update a
comprehensive IG program. Accountability equates to responsibility and signals that, ideally, the buck should stop
with one person. In other words, senior-level accountability
demonstrates that an organization following this IG principle supports holistic information governance from the top
down. Some examples of possible senior leaders are CEOs,
chief technology officers, head of legal or compliance, or the
chief medical officers, while in a small practice it can be the
partner(s) themselves.
Transparency Principle
Hand in hand with accountability is the IGPHC principle of
transparency, which states: [a]n organizations processes and
activities relating to information governance shall be documented in an open and verifiable manner. Documentation
should be available to an organizations workforce and other
appropriate interested parties, according to the principle. Furthermore, the best evidence of an organizations operations,
decisions, activities, and performance are its records and information. Hence, records should be of such character as to instill
confidence. According to IGPHC, records demonstrating transparency of the information governance program should:
D ocument the principles and processes that govern
the program
A
ccurately and completely record the activities undertaken to implement the program
Be available to legitimately interested parties in a timely
and reasonable manner
In being transparent, however, healthcare organizations
must take into account obligations to protect confidential and
proprietary information and to control access to such information. Transparency equates to trust. Here, trust is not
related to the integrity of information. Instead, the principle of
transparency is focused on trust that an organizations information governance processes are understood by, and visible
to, all legitimately interested parties. Additionally, transparency refers to organizational processes. In healthcare, this is
particularly critical as patient information should be handled
in a manner transparent to the consumer.
Accountability and Transparency are Related

Transparency is another word for openness. Openness requires
oversight in the design, implementation, and monitoring of any
program, whether or not related to information governance.
Oversight implies that someone internally will watch over design, implementation, and monitoring and will be in a position
within the organization to supervise the program. The relationship between accountability and transparency is thus a simple
oneboth are interrelated. Accountability ensures that transparency flourishes.
Accountability and Transparency Improve

Information Governance
At its basic level, governance requires trust in decision makers
and the decisions they make. Without that trust, there is no buyin for decisions regarding information created and used by an
organization in its everyday affairs. Trust in who supports an information governance program and the processes used to carry
out that program are particularly important to stakeholders.
Information governance has a synergistic relationship with
accountability and transparency, just as accountability and
transparency have a similar relationship with each other. AHIMA defines information governance as an organization-wide
framework for managing information throughout its lifecycle
and for supporting the organizations strategy, operations, regulatory, legal, risk, and environmental requirements. Accountability and transparency encompass trust, so that records are
created and maintained in an understandable manner and are
available when needed.
In fact, information shows what an organization does and
how the organization accomplishes its tasks. When considered
together or separately, accountability and transparency provide
buy-in that an organization governs its information responsibly
and openly. This in turn increases trust in the overall information governance program.
Galina Datskovsky (gdatskovsky@gmail.com) is CEO, North America, at Covertix. Ron Hedges (r_hedges@live.com) is a former US Magistrate Judge in
the District of New Jersey and is currently a writer, lecturer, and consultant on
topics related to electronic information. Sofia Empel (sofia.empel@connolly.
com) is director, information governance, at Connolly iHealth.
Link
Read the Full IGPHC Principles
www.ahima.org/topics/infogovernance
For a detailed look at all eight Information Governance Principles for

Healthcare, as well as other information governance resources, visit
www.ahima.org/topics/infogovernance.
Educating for life.

Earn your degree online with Saint Josephs College
Our online program ofers:
Flexible online courses designed for working adults with bus

busy schedules
Experienced faculty with extensive knowledge in the feld of HIM
Supportive advisors who understand your needs
Preparation for the Registered Health Information Administrator
Administ
exam
Fast-track option to the Master of Health Administration degree
BS in Health
Information Management
Visit online.sjcme.edu/AHIMA or call 800-752-4723 for more information.

PRACTICE BRIEF
practice guidelines for managing health information
Including Patient-Generated Health

Data in Electronic Health Records
HEALTHCARE PROVIDERS AND health information technology (HIT) suppliers across the country have been busy preparing
for what could be one of the most significant proposals for stage
3 of the meaningful use EHR Incentive Programa proposal
that has wide implications for healthcare providers as well as for
health information management (HIM) professionals.
The proposal under discussion is for the incorporation of patient-generated health data (PGHD) into electronic health records (EHRs). Meaningful use is not the sole driver for PGHD;
this focus also includes the impact on patient care and the potential to drive better patient outcomes. This Practice Brief will
assist in defining PGHD and outlining some important considerations for the inclusion of PGHD in EHR systems.
What is Patient-Generated Health Data?

According to HealthIT.gov, PGHD is comprised of health-related
data created, recorded, or gathered by or from patients (or family
members and other caregivers) to help address a health concern.1
PGHD may include such information as:
Health history recorded through a portal by the patient
B iometric data obtained from home health monitoring equipment
Lifestyle information, such as the information captured
from exercise or fitness devices or recorded on mobile apps
Health data generated in clinical settings or through encounters with providers is distinguishable from PGHD in two ways:
1. W ith PGHD, patients have the primary responsibility for
recording the data.
2. The patient decides when and with whom to share PGHD.
Consumer Interest in PGHD Growing

Patients and consumers are beginning to see the value of participating in their own healthcare. According to a white paper published by the Institute for Patient- and Family-Centered Care:
Patients and families have experience, expertise, insights, and
perspectives that can be invaluable to bringing about transformational change in healthcare and enhancing quality and safety.
With that being said a variety of clearly defined roles for patients
and families to participate as partners in quality improvement and
in the redesign of healthcare needs to be in place in all types of
healthcare organizations.2
Achieving healthcares Triple Aim of improving the qual54/Journal of AHIMA February 15
ity of care, improving the health of populations, and reducing

healthcare costs depends on patients taking an active role in
their own healthcare.
Patients are reporting that they value health data, and the
amount of PGHD being collected is growing rapidly. According
to a recent Pew Research report, seven in 10 US adults say they
track at least one health indicator:
60 percent of US adults track data on weight, diet, or exercise routine
33 percent of US adults track data on health indicators
or symptoms such as blood pressure, blood sugar, headaches, and sleep patterns
12 percent of US adults track data on a health indicator on
behalf of someone for whom they care3
The growth of consumer interest in healthcare can be seen in
the increased availability and adoption of home monitoring devices, fitness trackers, and mobile applications for various types
of activity or lifestyle monitoring. It can only be anticipated that
the proliferation of these types of products will increase, and as
this occurs, the provision of this type of information by patients
to their clinicians may increase as well.
Preparing Organizations for PGHD

Historical information is the type of information that clinicians
are familiar with obtaining from patients. It typically includes
items such as the patients past medical history, allergies, medications, family history, and social history.
Most clinicians have experience collecting information from
patients who use home medical devices, such as glucose meters or blood pressure monitors. But biometric data such as
the data gathered from consumer-owned fitness trackers also
have the potential to be incorporated into the health record.
This data, as well as other types of PGHD, could be made available for care decisions if the technology is in place to capture
and store it.
The advisability of incorporating PGHD may seem like a
relatively straightforward decision, but the implications for
managing this data are rather complex. If clinical decision
making is to be made on the basis of data that is supplied by
patients and documented in the EHR, clinicians must also be
certain that the data are accurate and trustworthy. Though
the patient may have the power to control the entry of PGHD
Practice Brief
into the EHR, the clinician could ultimately be responsible

for ensuring that it is reliable and actionable.
With the anticipated growth in use and availability of mobile
apps and data collection devices, strategic planning for incorporating this type of PGHD should start now.
Regardless of the challenges, incorporating PGHD is an important step in the advancement of consumer-driven healthcare. Well-designed and properly executed systems that both
incorporate and present PGHD in a usable fashion have the
potential to improve decision making and enable patients to
become active participants in their own healthcare.
Preparing to Incorporate PGHD into the EHR
Forms of PGHD
HIM professionals should work with their EHR vendor and

technology partners to ensure that information from personal
health records, mobile applications, and other interactive websites are able to be incorporated into the EHR. It is essential
to consider how the information will be designated or stored
within the recordespecially if it has not been actively used for
clinical decision making.
There is an expanding array of electronic tools that patients

and their families can utilize to assist them in managing their
health. Clinicians are increasingly promoting the use of remote monitoring devices for managing patients with chronic
diseases such as congestive heart failure, chronic lung disease, and diabetes. Information gathered from these remote
devices can be captured in the EHR and used for patient care
and monitoring.
Some other examples of PGHD include data from a patients
standalone personal health record (PHR), data gathered from
fitness devices, data obtained from a home blood glucose monitor, blood pressure readings done outside the clinicians office,
or information obtained from the patient about their functional
status at home or work.
Managing Ongoing Patient Communications

There are significant concerns about including PGHD in the
health record and the liability that clinicians bear for reviewing
it. When PGHD is received, providers will need to address how
to handle the receipt of the information, workflow challenges,
and liability issues to ensure the information is handled effectively. The organization should address the use of PGHD for
treatment purposes in their legal health record and designated
record set policies.
Sound record keeping principles suggest that any documents
or information filed, maintained, or scanned into a patients
health recordincluding PGHDare part of the legal health
record (see the Fundamentals of the Legal Health Record and
Designated Record Set Practice Brief, available online in AHIMAs HIM Body of Knowledge).4 These records are then subject
to all applicable state and federal regulations concerning privacy, security, use, maintenance, and disclosure. Legal implications and liability issues must be considered when making
retention decisions about PGHD.
Many healthcare organizations currently do not include
PGHD as part of their designated record set because it is not
used to make healthcare decisions. It may therefore be kept
with the health record, but with a mark of distinction that it is
not part of the legal record, such as a different folder or tab in
the EHR.
With the momentum increasing for greater patient engagement,

efforts to improve population health have driven a shift towards
value-based care. With the implementation of new tools to meet
EHR incentive program requirements and the rapid expansion
in both the quantity of applications available and capabilities
of mobile health applications, the challenge of how to manage
PGHD will be a growing concern for HIM professionals. The following are some considerations for HIM professionals as they
embark on the PGHD journey.
Collecting Data from Personal Health Devices/Mobile Apps
Engaging Clinicians in Culture Change

Clinicians need to be engaged in the concept of incorporating
PGHD into patient care delivery. Some payment and care delivery approaches now tie reimbursement to the attainment of
positive health outcomes for patients. It is important to foster a
culture that recognizes that PGHD is beneficial and to gain buyin from healthcare providers for any additional work that may
be required to obtain and validate the information.
Addressing Safety and Risk Through Policy

Policies and procedures should be developed and implemented
that outline the conditions for when and how PGHD will be incorporated into the record. For example, policies should outline
the inclusion of PGHD in the health record when it is used by
clinicians and whether it will be flagged in the record as PGHD.
The role of HIM in developing policies and procedures that allow the incorporation of PGHD into health records, and the
provision of education around those policies and procedures,
will expand as the demand grows for the inclusion of PGHD in
health records.
PGHD Functions as a Collaboration Tool

With PGHD in the picture, EHRs can be leveraged as a powerful collaborative healthcare tool. With the ever rising numbers of smartphones, tablets, fitness trackers, and devices for
remote monitoring of chronic conditions, the incorporation of
PGHD into the EHR can provide new ways for providers to interact with their patients and increase consumer engagement
in their healthcare.
It should be noted that there is a significant amount of work
going on currently at the Office of the National Coordinator
for Health IT (ONC) and other organizations relative to PGHD.
ONC has developed a fact sheet that provides information and
Practice Brief
guidance on PGHD.5 In addition, Health Level Seven (HL7) has

introduced an implementation guide that outlines a standard
method for capturing PGHD, recording PGHD, and making
PGHD interoperable within the current framework of structured documents.6 There has even been some recent discussion
on developing standards for incorporating PGHD into the EHR.7
An Issue Brief from ONC on PGHD and information technology also expounded on the opportunities for increased
consumer engagement:
The increasing number of smart phones, mobile applications
and remote monitoring devices, coupled with providers deployment of electronic health records (EHRs), patient portals,
and secure messaging, offers innovative ways to connect patients and providers and to strengthen peoples engagement in
their health and care. Over 30% of Americans online are eager
to use their smart phones or tablets for health management or
services and over 60% say they would like to communicate with
their providers electronically.8
All of this innovative technologyand the desire to use it

creates new opportunities for care providers and patients to collaborate in managing patient-generated data to enhance care
and improve outcomes.
Records Management for PGHD

Providers may use PGHD to assist the patient in managing some
of their own health needs. PGHD has the potential to reduce the
need for office visits, emergency room visits, or inpatient treatment. HIM professionals can assist providers by developing
guidelines and procedures to evaluate whether to incorporate
PGHD into the patient records and help promote the benefits of
PGHD for patient care.
Technology, education, health literacy, financial limitations,
patient age, and a number of other elements need to be factored
into the general acceptance and willingness of patients and clinicians to collect and use PGHD.
in making certain that all informationPGHD includedsupports the strategic goals of the organization.
Recommendations for Working with PGHD

It is broadly accepted that reforming the US healthcare system
requires engaging patients and their caregivers. While effective
PGHD management will require new technology and policies
and procedures that support its inclusion in the care delivery
model, using PGHD is an important strategy for building a
partnership that will connect patients and caregivers with their
healthcare team.
Recommendations for working with PGHD include:
1. Create a strategic information governance framework that
best meets clinician and patient needs for reliable collection,
dissemination, and use of PGHD. Planning for PGHD should
be part of an overall information governance initiative.
2. Develop policies and procedures that assist in determining when PGHD coming from an unverified source should
be incorporated into the EHR. Considerations should include the intended use and reliability of the PGHD technology that is being used to collect PGHD and incorporate
it into the existing EHR system.
3. Work with information technology leadership and EHR
vendors to design a system that meets consumer and clinician needs. Consider technology solutions that allow for
segregating PGHD in the EHR in such a manner that it is
clearly designated as having been patient-generated. This
would help illuminate for the providers the unverified nature of the data, yet still allow flexibility for the use of the
data to promote consumer engagement and allow for better clinician decision making.
The culture of the US healthcare system is rapidly changing
as consumer demands for PGHD increase. HIM professionals
must be ready and willing to assist in ensuring that those demands can be successfully met.
PGHDs Role in the EHR and Information Governance
Notes
Any information that is filed, maintained, or incorporated into

the patients health record, including PGHD, becomes a part of
the legal health record. These records are therefore subject to all
applicable state and federal regulations concerning privacy, security, use, maintenance, and disclosure. Legal implications as
well as risk and liability issues must be considered when making
decisions related to the inclusion of PGHD in the EHR.
A framework of organizational policies and solid information
governance practices can help to successfully engage providers
while continuing to ensure the privacy, security, availability,
and appropriate use of PGHD.
With PGHD, as with all forms of information in healthcare,
there is a need to ensure the data are accurate, timely, reliable,
valid, and complete. An information governance program helps
support the core goal of collecting PGHD, which is the safe and
effective delivery of patient care. As with other healthcare information needs, the industry needs safe and reliable ways to
manage PGHD. An information governance program can assist
1. HealthIT.gov. Patient Generated Health Data. www.healthit.gov/policy-researchers-implementers/patient-generated-health-data.

2. Johnson, Bev et al. Partnering with Patients and Families
to Design a Patient- and Family-Centered Health Care System. April 2008. www.ipfcc.org/pdf/PartneringwithPatientsandFamilies.pdf.
3. Pew Research Internet Project. Health Fact Sheet. www.
pewinternet.org/fact-sheets/health-fact-sheet/.
4. AHIMA. Fundamentals of the Legal Health Record and Designated Record Set. Journal of AHIMA 82, no. 2 (February
2011): expanded online version. http://library.ahima.org/
xpedio/groups/public/documents/ahima/bok1_048604.
hcsp?dDocName=bok1_048604.
5. HealthIT.gov. Patient Generated Health Data Fact Sheet.
March 2014. www.healthit.gov/sites/default/files/patient_
generated_data_factsheet.pdf.
6. Health Level Seven. HL7 Implementation Guide for CDA
Practice Brief
R2: Patient Generated Document Header Template, Release 1. www.hl7.org/implement/standards/product_brief.

cfm?product_id=316.
7. eHealth Initiative. Consumer eHealth: The Policy and Technology to Empower Patients and Families. October 2014. www.google.com/url?sa=t&rct=
j&q=&esrc=s&source=web&cd=1&ved=0CB4QFjA A
&url=http%3A%2F%2Fw w w.ehidc.org%2Fresourcecenter%2Fpublications%2Fdoc_download%2F464-webinar-materials-policy-workgroup-consumer-ehealththe-policy-and-technology-to-empower-patients-andfamilies&ei=kQphVJb4J4afyQTQzoCwCg&usg=AFQjCN
EvvBmzrVaQcKsOGddrQQ6UF61Twg.
8. Deering, Mary Jo. Issue Brief: Patient-Generated Health
Data and Health IT. December 20, 2013. http://healthit.
gov/sites/default/files/pghd_brief_final122013.pdf.
References
41% of Most Wired Hospitals Accept Patient-Generated Data
through Their Patient Portal. Trustee 67, no. 2 (February
2014): 32.
Dolan, Pamela Lewis. Patient-Generated Data Likely to Grow
as Meaningful Use Moves Forward. January 9, 2014. http://
exclusive.multibriefs.com/content/patient-generated-datalikely-to-grow-in-prominence-as-meaningful-use-moves.
Gordon, Lynne Thomas. Information Governance for the
Healthcare Industry: Now is the Time. iHealthBeat.
February 3, 2014. www.ihealthbeat.org/perspectives/2014/
information-governance-for-the-health-care-industrynow-is-the-time.
Gregg, Helen. MU3 Expected to Have Increased PatientGenerated Data Requirements. December 31, 2013. www.
beckershospitalrev iew.com/healthcare-informationtechnolog y/mu3-expected-to-have-increased-patientgenerated-data-requirements.html.
Halamka, John. Patient Generated Data Goes Mainstream.
Life as a Healthcare CIO. July 23, 2014. http://geekdoctor.
blogspot.com/2014/07/pat ient-generated-data-goesmainstream.html.
Institute for Healthcare Improvement. IHI Triple Aim Initiative.
www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx.
National Learning Consortium. Frequently Asked Questions
about the Patient Portal. August 2012. www.google.com/
url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CC
cQFjAB&url=http%3A%2F%2Fwww.healthit.gov%2Fsites
%2Fdefault%2Ffiles%2Fmeasure-tools%2Fnlc-faqs-aboutpatient-portal.docx&ei=i3A1VNH-FIz9yQTtnIJI&usg=AFQ
jCNF2WyKDGqMmWwgoUZIoljiNZVbN5w&bvm=bv.7694
3099,d.aWw.
Nelson, Scott. Patient Generated Health DataIts Coming
Faster Than You Think. Logic PD Insights. June 16, 2014.
www.logicpdinsights.com/patient-generated-health-data/.
Perna, Gabriel. Top Ten Tech Trends: Patient-Generated
Health Data. Transforming Patient-Generated Data into
Decision Support. Healthcare Informatics. February
17, 2014. www.healthcare-informatics.com/article/top-
ten-tech-trends-transforming-patient-generated-datadecision-support.
Rudansky, Alex Kane. How Patient Generated Data Changes
Healthcare. InformationWeek. September 10, 2013. www.
informationweek.com/healthcare/patient/how-patientgenerated-data-changes-healt/240161051.
Sujansky and Associates. A Standards-Based Model for
the Sharing of Patient-Generated Health Information
With Electronic Health Records. July 18, 2013. www.
projecthealthdesign.org/media/file/Standard-ModelF o r- C o l l e c t i n g -A n d - R e p o r t i n g - P G H I _ S u j a n s k y_
Assoc_2013-07-18.pdf.
Taylor, Lisa Brooks. Preparing for Patient-Generated Documents:
Initiatives Call for Incorporating Patient-Generated Data in the
EHR. Journal of AHIMA 84, no. 5 (May 2013): 46-47.
Van Doornik, William. Meaningful Use of Patient-Generated Data
in EHRs. Journal of AHIMA 84, no. 10 (October 2013): 30-35.
Prepared By
Lucia Aschettino, HITPRO-CP
Kevin Baldwin, MPH, CPHIMS
Beth Friedman, BSHA, RHIT
Reginald Grady, RHIA
Leah Grebner, MS, RHIA, CCS, FAHIMA
Margaret E. Hennings, MBA, RHIA
Lesley Kadlec, MA, RHIA
Annessa Kirby
Melanie Meyer, MHA, RHIT, CCS
Rosann M. ODell, DHSc, MS, RHIA, CDIP
Sandra Pearson, MHA, RHIA
Jill Roberson, MBA, RHIA, CHPS, CCS
Vera Rulon, MS, RHIT, FAHIMA
Bryanna Schoeffel, RHIA
Alisha Smith, RHIA
Anne Tegen, MHA, RHIA, HRM
Lydia Washington, MS, RHIA, CPHIMS
Acknowledgments
Cecilia Backman, MBA, RHIA, CPHQ, FHIMSS
Linda Bailey-Woods, RHIA
Susan Clark, RHIT, CHTS-IM, CHTS-PW
Marlisa Coloso, RHIA, CCS
Julie Dooling, RHIA, CHDA
Katherine Downing, MA, RHIA, CHPS, PMP
Margaret Hennings, MBA, RHIA
Michelle Lakins-Waller, MBA, RHIA, RN, BSN
Cathy Munn, MPH, RHIA, CPHQ
Kelli Provost, RHIT
Angela Rose, MHA, RHIA, CHPS, FAHIMA
Heidi Shaffer, RHIA
Alicia Smith, RHIA
Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR, FAHIMA
Coding Notes
Hospital Discharge Status

Codes: Risks and Rewards
By William E. Haik, MD, FCCP, CDIP
IT IS A well known fact that ICD-9-CM diagnosis and procedure

codes impact hospital reimbursement and compliance. But
there is an additional code that often flies under the radarthe
discharge status code. Inaccurate discharge status code assignments for Medicare post-acute care transfers can lead to underreimbursement, as well as compliance issues.
In 1998, Medicare enacted the post-acute care transfer (PACT)
payment methodology in response to prospectively paid hospitals attempts to reduce the cost of care by early transfer of patients to post-acute care facilities such as skilled nursing facilities and home health agencies. Because of this, the Centers for
Medicare and Medicaid Services (CMS) concluded Medicare
was overpaying for inpatient care as it was paying the acute
care hospital the full DRG reimbursement, as well as a separate
payment for the post-acute care transfer facility or agency within the same healthcare encounter.
Initially, only 10 DRGs (or approximately nine percent of
Medicare discharges) were selected for the PACT policy. However, due to its financial success, for fiscal year 2015 the DRG list
was expanded to 273 MS-DRGs (or approximately 65 percent
of Medicare discharges). The discharge status codes impacted
by the PACT policy are listed in Table 1 on page 59 and the discharge status codes not impacted by the PACT policy are listed
in Table 2, also on page 59.
PACT Payment Methodology

Hospitals are reimbursed a per diem payment under the PACT
methodology (see Table 3 on page 60). The per diem payment
is determined by dividing the full DRG reimbursement by the
DRG specific geometric mean length of stay (GMLOS). The first

hospital day receives double the per diem payment followed by
the per diem payment for the remainder of the hospital length
of stay (up to the full DRG reimbursement). If the DRG is a special-pay DRG, the hospital receives 50 percent of the expected
DRG payment on the first hospital day followed by the per diem
payment for the remainder of the hospital length of stay (up to
the full DRG payment).
Challenges with Discharge Status Codes

The two most common reasons for incorrect discharge status
code assignments are lack of communication between the hospital and the transferring facility, and incomplete understanding of the discharge status codes by hospital personnel. Adding
to this problem is the absence of Medicare edits in the common
working file that detect incorrect discharge status codes resulting in underpayment to the hospital. Ironically, there are only
CMS edits for overpayment.
Most discharge status code reporting errors occur with transfers to skilled nursing facilities (code 03) and home health agencies (code 06).
Skilled Nursing Facility Transfers

Several different scenarios resulting in suboptimal hospital payment often occur when a patient is transferred to a skilled nursing facility (SNF):
1. A patient is admitted to the SNF for skilled care. After evaluation, however, skilled care is not required and the patient
receives non-skilled long-term care only. If the hospital had
Coding Notes
Table 1: Inpatient Discharge Status Codes

Impacted by PACT Policy
Table 2: Inpatient Discharge Status Codes

Not Impacted by PACT Policy
02 (All DRGs) Hospital
82 Planned re-admission
01 Home
03 SNF
04 ICF
05 Cancer/childrens
hospital
06 With condition code -42 HHA

unrelated Dx
06 HHA
62 IRF
06 With condition code -43 HHA

> 3 days
63 LTCH
65 Psych
known the patient didnt require skilled care on admission

to the SNF, discharge status code 04 would have been assigned, resulting in the full hospital DRG reimbursement.
2. The SNF may have multiple levels of care and the patient is
admitted to an assisted living facility (04).
3. The patient may elect hospice (50, 51) on arrival at the SNF
which is exempt from the PACT policy.
4. Hospitals are often unaware of the certification status of
nursing home facilities such as Medicaid-certified only (64)
or federal healthcare facility (VA) nursing homes (43), both
of which are exempt from the PACT payment methodology.
Ironically, skilled nursing facility transfers also represent a
compliance risk. This occurs when the hospital or a consulting vendor incorrectly assumes the patient did not receive
skilled nursing care because there is no charge for skilled
care in the Medicare eligibility file. Medicare patients often
receive skilled care, but due to various reasons may not be
Medicare-eligible for skilled nursing care benefitsfor example, if the patient did not have a qualifying hospital stay.
Therefore, when patients receive skilled nursing care paid by
means other than Medicare, there is no evidence of skilled
nursing care in the Medicare eligibility file as no payment is
provided by Medicare. This results in the full DRG payment
being incorrectly paid by Medicare.
The rule regarding assignment of discharge status code
03 (skilled nursing facility) is discussed in the IPPS Final
Notice that appeared July 31, 1998 in the Federal Register,
when the original PACT policy was finalized. It is also delineated in the revised definition of discharge status code
03 in the National Uniform Bill Committee Specifications
Manual of July 2009.
Home Health Agency (HHA) Transfers

Home health agency transfers represent another problem area
where multiple instances of incorrect discharge status code assignment may occur, such as:
1. The patient either refuses care or does not meet criteria for
07 AMA
43 VA
50 Hospice, home
51 Hospice, facility
61 Swing bed
64 Medicaid only
66 CAH
69 Alternative disaster care site

70 Other
home healthcare. Discharge status code 01 (home) is assigned, resulting in full DRG reimbursement.
2. The patient may elect hospice care (50), which supersedes
the home health discharge status code.
3. Hospitals may also confuse discharges with physical therapy, infusion therapy, or DME supplies as a home health
transfer even when a patient is not under the care of a
home health agency. When this occurs, discharge status
code 06 (home health care) is incorrectly assigned rather
than the correct code 01 (home).
4. Frequently, the patient does not receive home health services within three days of the hospital discharge and condition
code -43 (Continuing care not provided within prescribed
post-discharge window) is appended to the discharge status
code 06, resulting in the full DRG reimbursement.
5. Home healthcare is unrelated to the reason for hospitalization and condition code -42 (Continuing care not related (i.e. condition or diagnosis) to inpatient admission)
is appended to the discharge status code 06 resulting in
the full DRG reimbursement. The assignment of condition code -42 often requires an evaluation by a clinician
and also escapes the Medicare payment edits, making it
highly scrutinized by CMS.
Addressing Discharge Status Code Challenges

A hospital may address the problem of inaccurate discharge status codes by developing an internal action plan or consulting
with an outside vendor.
Coding Notes
Table 3: Example of Hospital Reimbursement

via Per Diem Payment Under PACT
MS-DRG 064 Payment
GMLOS 6 Days
MS-DRG: 064: Cerebral infarction w MCC
RW 1.6212 GMLOS 6.0 days
Blended Rate: $5,644
Full DRG payment: $9,150
Per diem payment: $1,525
Day 1: $1,525 + $1,525 ($3,050)
Day 2: $1,525 ($4,575)
Day 3: $1,525 ($6,100)
Day 4: $1,525 ($7,625)
Day 5: $1,525 ($9,150)
Internal Action Plan

Involve case managers, discharge planners, Medicare billers,
and coders to develop an internal auditing and monitoring
protocol for Transfer DRGs concentrating on at least discharge
status codes 03 and 06. The protocol should focus on the Transfer DRGs with a hospital length of stay of at least 1.1 days less
than the DRG-specific GMLOS. This action plan will also involve
communicating with the transfer facilities to determine the actual care provided.
The impact of internal audit efforts can be demonstrated by
monitoring the positive trend of the following discharge status
code ratios, attempting to increase the ratio value:
01/06
06-42/06
06-43/06
04/03
External Audit
Another way to improve the accuracy of discharge status code
assignments is through an external audit. Choosing a vendor
can be difficult, and bigger is not always better.
The following questions should be asked of perspective vendors:
1. Does the vendor identify errors based on Medicare eligibility file analysis only, or does the vendor also contact
the appropriate transfer facilities to determine the level
of care? If a Medicare-certified SNF is not contacted for
confirmation before submitting discharge status code
04, then the hospital could be subject to potential billing
fraud if the Medicare patient received skilled care. If it is
assumed a patient did not receive home health services
due to absence of home health services in the Medicare
eligibility file, the hospital may expose themselves to a
billing error as home health agencies have up to one year
to submit a bill.
2.
Does the vendor provide an educational component
to their audit? If the vendor only provides a list of accounts to be rebilled with the revised discharge status
code, then the hospital will always be dependent on the
external vendor as there is no explanation as to how or
why the discharge status code errors occurred. An educational exit review should be provided and include all
interested parties, such as case managers, discharge
planners, Medicare billers, and health information coders, to understand how to avoid future discharge status
code reporting errors.
3. How often and under what circumstances is condition
code -42 appended to discharge status code 06 (home
health agency)? The failure to make a clinical determination as to whether the home health services are related to the hospitalization could result in potential loss
of revenue.
The discharge status code assignment and the resultant
post-acute care transfer payment methodology is a seductively simple system which is filled with financial opportunities as well as compliance risks. These problems can be addressed through education and communication among the
involved parties.
William E. Haik (william.haik@drgreview.com) is director at DRG Review, Inc.
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Coding Notes

By Patty Buttner, RHIA, CDIP, CCS
ON JANUARY 1, 2015, the updates to the American Medical Associations Current Procedural Terminology (CPT) went into effect. The updates include 276 new codes, including three new
Category II codes and 39 new Category III codes. There are a
total of 129 revised codes and 137 deleted codes. This article will
highlight the majority of the new CPT codes for 2015. Appendix
B of the CPT Manual contains a summary of all additions, deletions, and revisions.
Evaluation and Management Updates

Three new codes have been added to the Evaluation and Management (E/M) section for calendar year (CY) 2015. These are in
the Care Management and Advance Care planning subsections.
Care Management Services is new this year with extensive
notes. This subcategory is for the management and support services provided by clinical staff, under the direction of a physician, to patients at home, in a domiciliary, or in assisted living.
Chronic Care Management Services is a new category under
the subsection of Care Management Services. Code 99490 will
be utilized to capture chronic care management services for the
establishment, implementation, revision, or monitoring of the
care plan for patients with at least two chronic conditions, expected to last at least 12 months, and may place the patient at
risk of death, exacerbation, or functional decline. This code is
reported if, during the calendar month, at least 20 minutes of
clinical staff time is spent on care management activities.
Advance Care Planning is a new subsection in the E/M section. Two codes were placed in this subsection. The codes are
used to report face-to-face discussion of advance directives:
99497, advanced care planning for the first 30 minutes

99498, an add-on code assigned for each additional 30 minutes
E/M Guidelines for Social History has been expanded and will
now include a bullet for Military History.
Changes for Surgery Section

New Surgery codes were added to the following subsections:
Musculoskeletal System, Cardiovascular System, Digestive System, Urinary System, Eye and Ocular Adnexa.
Additional changes noted in the CPT Surgical Package Definition appear in the Surgical Guidelines to include the new language or other qualified health care professional who performs
the surgery in the descriptor of provider of services.
Musculoskeletal System Subsection Changes

Three new codes20604, 20606, 20611were added to the Arthrocentesis category for use when ultrasound guidance with
permanent recording and reporting are utilized.
New notes and codes were added to describe and define percutaneous vertebroplasty and percutaneous vertebral augmentation. Percutaneous vertebroplasty codes describe procedures
on one vertebral body either unilaterally or bilaterally based
on region, cervicothoracic (22510), and lumbosacral (22511).
A new add-on code, 22512, was created for percutaneous vertebroplasty and is assigned for each additional vertebral body.
Percutaneous vertebral augmentation codes are also selected
according to region: thoracic (22513), lumbar (22514), and the
add-on code (22515).
Coding Notes
Cardiovascular System Subsection Changes
Nervous System Subsection Changes
The 2014 subheading of Pacemaker or Pacing Cardioverter-Defrillator was replaced by Pacemaker and Implantable Defibrillator. There are extensive new and revised notes which include
updated definitions as well as additions to the table for Pacemaker and Implantable Defibrillator code selections.
A new code has been added for the insertion of an implantable defibrillator system, 33270, and one for electrode insertion,
33271. Two new codes were added for the removal (33272) and
repositioning (33273) of the electrodes.
New coding notes pertaining to transcatheter mitral valve repair (TMVR) were added for the subheading Mitral Valve. These
notes pertain exclusively to the two new codes added for TMVR,
33418, and add-on code for additional prosthesis during the
same session, 33419.
Twenty-five new codes were added to the new subheading of
Extracorporeal Membrane Oxygenation (ECMO) or Extracorporeal Life Support Services (ECLS). These procedures provide
cardiac and/or respiratory support to the heart and lungs. The
codes represent the services directly related to the cannulation,
initiation, management, and discontinuation of the ECMO/
ECLS (33946-33989).
The Spine and Spinal Cord subheading, Injection, Drainage, or

Aspiration Category includes the addition of four new codes:
62302, Myelography via lumbar injection, coded according to the spinal region, cervical
62303, Thoracic
62304, Lumbosacral
62305, Two or more regions
Digestive System Subsection Changes

New notes were added to Endoscopy, Small Intestine, including
a note advising, When bleeding occurs as the result of an endoscopic procedure the control of the bleeding is not reported
separately during the same operative session.
A new subheading for Endoscopy, Stomal was added this year.
New notes provide guidance on coding when the intended procedure is unable to be completed. These notes also address the
correct code assignment when reporting colonoscopy through
a stoma. Ten new codes were added in this area: 44381, 44384,
44401-44408. They include codes for balloon dilation, placements of stents, ablation of tumors, mucosal resection, injection
procedures, and decompression all conducted through a stoma.
Under the Endoscopy subheading additional notes and clarification was added for coding the extent of the procedure. A
valuable new tool has been added in the form of a colonoscopy
decision tree. Eight new codes were included this year. Two of
the new codes replaced deleted codes.
Several of the new codes replaced deleted codes and added
the terms includes pre- and post-dilations and guide wire passage, when performed. There are new codes for band ligations
as well (45350, 45398).
Two new anoscopy codes46601, 46607were added to capture the use of high-resolution magnification (HRA).
Finishing up the new codes added in the Surgery Section, Digestive System Subsection in the Subheading of Other Procedures is a new code to represent Ablation of one or more liver
tumor(s) by percutaneous cryoablation, 47383.
Urinary System Subsection Changes

Two new codes were added in the Vesical Neck and Prostate
subheading. Cystourethroscopy with insertion of transprostatic
implant single, 52441, and each additional, 52442.
Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System, Introduction/Injection Category includes four
new codes to capture Transversus abdominis plane blocks, unilateral (64486-64487) or bilateral (64488-64489).
Eye and Ocular Adnexa Subsection Changes

Anterior Sclera subheading, Aqueous Shunt Category includes
a new code for aqueous shunt to extraocular plate reservoir,
66179, and a revision code, 66184.
Changes for Radiology Section

Under the Breast, Mammography subsection there are three new
codes to represent digital tomosynthesisunilateral (77061) and
bilateral (77062)along with an add-on screening code, 77063.
Two new codes are listed in the Bone/Joint Studies subheading:
dual-energy X-ray absorptiometry for axial skeleton, 77085, and
vertebral fracture assessment, 77086.
Medical Radiation Physics, Dosimetry, Treatment Devices,
and Special Services include the addition of five new codes:
Teletherapy isodose plan, simple (77306) and complex (77307),
and three Brachytherapy isodose plan codes, simple (77316),
intermediate (77317), and complex (77318).
Extensive new notes for radiation treatment delivery offer definitions and point the user to the Radiation Management and
Treatment Table.
Changes for Pathology and Laboratory Section

The Pathology and Laboratory section has a significant amount
of new codes and changes. There are new and revised notes for
Drug Assay testing, Presumptive Drug Class Screening, Definitive Drug testing, and Genomic Sequencing Procedures and
Other Molecular Multanalyte Assays. The new codes are too
numerous to list out separately. Extensive notes and examples
are provided for new codes for drug screening (80300-80301).
Definitive Drug testing codes are reported with codes 8032080377. Genomic Sequencing Procedures and Other Molecular
Multianalyte Assays are coded with codes 81410-81471. The Microbiology subheading includes three new codes for gastrointestinal pathogen testing:
87505, three to five targets
87506, six to 11 targets
87507, 12 to 25 targets
There is one new code, 87806, for HIV-1 antigen(s) with HIV1 and 2 antibodies. The Immunohistochemistry add-on code,
88341, is new as well as a code for each multiplex antibody stain
procedure, 88344. In situ hydridization has six new codes. There
Coding Notes
is a new code for Cryopreservation of mature oocyte(s), 89337,

which is the last of the new codes for this section.
Changes for Medicine Section

Five new codes were added to the cardiovascular subsection.
Two are in the Implantable and Wearable Cardiac Device Evaluations subheading, which describe the services for cardiac
device evaluations to assess device therapy and cardiovascular physiologic data. The new codes are Programming device
evaluation of an implantable subcutaneous lead defibrillator
system, 93260, and Interrogation device evaluation and analysis of an implantable subcutaneous lead defibrillator system,
93261. Echocardiography, transesophageal codes have an added code, 93355, this year to capture when used for guidance of
transcatheter intracardiac or great vessel(s) structural interventions. Electrophysiologic evaluation of subcutaneous implantable defibrillator, 93644, is new this year along with a code for
Bioimpedance spectroscopy, extracellular fluid analysis, 93702.
Other Services and Procedures have two new codes for the initiation of hypothermia in the critically ill neonate, 99184, and
application of topical fluoride varnish, 99188.

HIM Domain Area: Clinical Data Management
ArticleCPT Updates for CY 2015
New Category II Codes

There is a new code for Esophageal biopsy report with a statement about dysplasia (present, absent, or indefinite, and if
present, contains appropriate grading), 3126F. The two other
new codes are Adenoma(s) or other neoplasm detected during
screening colonoscopy, 3775F, and not detected during screening colonoscopy, 3776F.
New Category III codes

There are 16 new codes in the Subcutaneous Implantable Defibrillator System subheading (0340T-3058T). Adaptive Behavior
Assessments and Treatment subsections include 21 new codes
(0359T-0380T).
Reference
American Medical Association. Current Procedural
Terminology (CPT) 2015. Chicago, IL: American Medical
Association, 2014.
Patty Buttner (patty.buttner@ahima.org) is a director of HIM practice excellence at AHIMA.

LONGER BE ACCEPTED
1. Care Management Services are utilized:

a. for hospital inpatient case manager services

b. for patients at home, in a domiciliary, or in assisted living

c. for patients in a rehabilitation facility

d. for patients attending outpatient therapy services
2. S
elect the most appropriate code(s) assigned for a face-to-face
discussion regarding advance directives attending by a physician
and the patient for 1 hour 15 minutes.

a. 99490

b. 99498

c. 99497

d. both b and c
3. There are now arthocentesis codes to assign when ultrasound
guidance and recording are utilized.

a. true

b. false
4. When bleeding occurs as the result of an endoscopic procedure
the control of bleeding may be reported during the same
operative session.

a. true

b. false
5. Select the appropriate code for the ablation of one or more liver
tumors by percutaneous cyroablation.

a. 47380

b. 47382

c. 47383

d. 47370
6. Select the appropriate code for myelography via a lumbar injection,

including radiological supervision and interpretation: thoracic.

a. 62302

b. 62303

c. 62305

d. 62310
7. Select the appropriate code for bilateral digital breast
tomosynthesis

a. 77059

b. 77061

c. 77062

d. 77051
8. The code for HIV-1 antigen(s) with HIV-1 and HIV-2 antibodies is:

a. 87806

b. 87800

c. 87903

d. 87536
9. The new code for programming device evaluation of an
implantable subcutaneous lead defibrillator system is:

a. 93260

b. 93261

c. 93644

d. 93701
10. The category II code for adenoma(s) or other neoplasm detected
during a screening colonoscopy is:

a. 3126F

b. 3775F

c. 3776F

d. 3058T
Ad Space
HOUSE
65
AHIMA invites all health information professionals to

join the celebration and be recognized during the 26th
annual Health Information Professionals (HIP) Week,
March 2228, 2015.
HIP Week coincides with AHIMAs Hill Day, when
AHIMA members converge on Capitol Hill to advance
HIM. This is a great opportunity for professionals to
showcase the benefits of their profession, and work
collectively to deliver quality healthcare through
reliable information. Help spread our message of
awareness and pride by participating in HIP Week!
To get your free planning kit, visit ahima.org/hipweek.
MX10470
Calendar
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
WEBINAR:
WEBINAR:
ICD-10-CM
Coding for
Inpatient Rehab
Facilities
ICD-10-CM
Coding:
Symptoms,
Signs, Abnormal
Clinical and
Laboratory
Findings
10
WEBINAR:
Deep Dive:
Concepts, Root
Operations and
Body Systems
in ICD-10-PCS
Sections 1-5
15
THURSDAY
16
11
12
FRIDAY
SATURDAY
13
14
20
21
27
28
Advanced ICD-10-PCS Skills Workshop,

Atlanta, GA
WEBINAR:
How A Mock
Audit Can
Identify Gaps in
Preparedness
17
18
19
WEBINAR:
Preparing Your
Organization for
Round Two: Tips
for Surviving
Privacy and
Security Desk
Audits
22
23
24
25
26
WEBINAR:
CDI and ICD-10

Documentation
Tips
AHIMA Annual Convention

2016 Baltimore, MD
October 15-20
A Look Ahead
Upcoming AHIMA Institutes, Seminars, Workshops,

and Webinars
Keep Informed
Resources and News from AHIMA

February is Information Governance Month
MARCH
3
Webinar: The Top 20 ICD-10 Documentation Issues

that Cause DRG Changes
4-6
Advanced ICD-10-PCS Skills Workshop, Morrisville

(Raleigh), NC
16-17
CDIP Exam Prep Workshop, Chicago, IL
17
Webinar: Federal Health Information Model:

Supporting Effective, Secure Health Information
Exchange
18-20
CSA Meeting: Tennessee, Gatlinburg, TN
19
Webinar: Using CDI Programs to Improve Quality

Reporting
23-24
Webinar: Using CDI Programs to Improve Quality

Reporting
23-25
CSA Meeting: Ohio, Columbus, OH
26
Webinar: How to Recognize and Combat Medicare

Billing Fraud
30-April 1
AHIMA Coder Academy for ICD-10-CM/PCS,

Las Vegas, NV
31-April 1
Certified Health Data Analyst (CHDA) Exam Prep

Workshop, Las Vegas, NV
31
Webinar: Coding and Clinical Documentation

Improvement with a Technology Backbone
UPCOMING INSTITUTES, SEMINARS,

WORKSHOPS, AND WEBINARS
April 8-10
Advanced ICD-10-PCS Skills Workshop, San

Diego, CA
April 9
Webinar: Oncology Service Coding with ICD-10CM/PCS
April 21
Webinar: An Introduction to Logical Observation

Identifiers Names and Codes (LOINC)
April 22-24
AHIMA Coder Academy for ICD-10-CM/PCS,

Denver, CO
April 22-24
CDI Academy, Denver, CO
April 29May 1
Webinar: Using Healthcare Statistics in ACOs

Model Building and Risk/Payment Infrastructures
May 12
Webinar: Clinical Documentation Improvement

Stepping Beyond Fee for Service
May 14-15
Faculty Development Regional Meeting,

Tacoma, WA
May 21
Webinar: Patient Engagement vs. Patient

EducationWhats the Difference?
Check www.ahima.org/events for the latest schedule of

institutes, seminars, and workshops.
Information governance is a strategic imperative for

the future of healthcare and is critical to meeting
the Triple Aim of quality care, population health,
and lowering the per capita cost of healthcare. For
HIM professionals specifically, information governance is vital to ensuring the trustworthiness of information in healthcare.
Throughout the month AHIMA will be unveiling
new infographics, launching a new webpage for information governance on ahima.org, and presenting
a webinar as part of its annual Information Governance Month. AHIMA will also host a twitter chat on
February 20 at 12 p.m. CT with the hashtag #IGNow.
Learn more about the importance of information
governance in healthcare at ahima.org/infogov.
AHIMA Launches Online HIPAA Privacy and

Security Course
HIPAA is vast and complex, and is one of the most
difficult regulations to understand. AHIMA and
Teach Privacy have collaborated to produce a new
three-part online course series that makes HIPAA
easy to comprehend. The course series points out
HIPAAs key components, shows how the various
parts of the regulation work together, explains the
regulation in easy-to-comprehend terms, and discusses how HIPAA applies to various situations.
Participants can take all three online courses by
purchasing the bundle at a cost savings, or take
them one at a time as their schedule allows. Each
course in the series has an access period of eight
weeks to allow users to complete the course at
their own pace, offers one CEU, and requires no
course pre-requisite or materials other than the
course itself.
More information is available at www.ahima.org/
education/onlineed/Programs/hipaa.
AHIMA Introduces Online Tool

ResourceConnect
AHIMA is committed to providing the healthcare
community the opportunity to connect, and in
keeping with that goal is introducing a new online
resource. ResourceConnect is a comprehensive
online resource dedicated to providing professional
resources to AHIMA members and the healthcare
industry. The resource is publicly available at resourceconnect.ahima.org. Users can:
Search for products and services
Find resources and professional content, such
as white papers and videos
Connect with solutions that meet practice or
organization requirements
AHIMA Volunteer Leaders
AHIMA BOARD OF DIRECTORS

President/Chair
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
President/Chair-elect
Melissa M. Martin, RHIA, CCS, CHTS-IM
Chief Privacy Officer and Director of Health
Information Management, West Virginia
University Hospitals
Morgantown, WV
(304) 598-4109 x73716
melissa.martin@ahima.org
Past President/Chair
Angela C. Kennedy, EdD, MBA, RHIA
Head and Professor, LA Tech University
Ruston, LA
(318) 257-2854
angela.kennedy@ahima.org
Speaker of the House of Delegates
Laura W. Pait, RHIA, CDIP, CCS
Pfafftown, NC
lwpait@aol.com
CEO, AHIMA
Lynne Thomas Gordon, MBA, RHIA, CAE,
FACHE, FAHIMA
Chicago, IL
(312) 233-1165
lynne.thomasgordon@ahima.org
TERM ENDS 2015DIRECTORS
Treasurer
Susan J. Carey, RHIT, PMP
System Director, HIM, Norton Healthcare
Louisville, KY
(502) 629-8913
susan.carey@nortonhealthcare.org
Dana C. McWay, JD, RHIA
Court Executive/Clerk of Court, US Bankruptcy
Court for the Eastern District of Missouri
(314) 244-4600
danahimlaw@aol.com
Cindy Zak, MS, RHIA, PMP, FAHIMA
Executive Director Corporate HIM and Patient
Access, Yale New Haven Health System
Woodbridge, CT
(203) 688-5466
cindy.zak@ynhh.org

Zinethia L. Clemmons, MBA, MHA, RHIA, PMP
Senior Health Information Privacy Specialist,
Department of Health and Human Services/OCR
Washington, DC
(202) 495-0533
zinethia.clemmons@hhs.gov
Secretary
Ginna E. Evans, MBA, RHIA, FAHIMA
Business Analyst, Revenue Cycle Development,
Emory Healthcare
Avondale Estates, GA
(404) 778-7960
ginna.evans@emoryhealthcare.org
Colleen A. Goethals, MS, RHIA, FAHIMA
HIM Consultant, Cardone Record Services, Inc.
Belvidere, IL
(815) 378-2632
cgoethals@mmrainc.com
Dwan A. Thomas-Flowers, MBA, RHIA, CCS

HIM Consultant
Jacksonville, FL
(904) 220-2486
HIMprofexcel@bellsouth.net
Susan E. White, PhD, RHIA, CHDA
Associate Professor, Clinical HRS HIM and
Systems Division, School of Health and
Rehabilitation Sciences, Ohio State University
(614) 247-2495
Columbus, OH
white.2@osu.edu
Advisor to the Board
David S. Muntz, CHCIO, FCHIME, LCHIME,
FHIMSS
Senior Vice President/CIO, GetWellNetwork
Bethesda, MD
(240) 482-3192
david.muntz@getwellnetwork.com

Barbara J. Manor, MA, RHIA
Vice President of HIM, SCL Health
Aurora, CO
(303) 403-7511
barbara.manor@sclhs.net
2015 CHAIRS OF AHIMA VOLUNTEER GROUPS

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

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

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

Judith A. Gizinski, RHIA, MPH
(321) 757-5226
judy.gizinski@health-first.org
Fellowship Committee
Mona Y. Calhoun, MEd, MS, RHIA, FAHIMA
(301) 352-0304
mcalhoun@coppin.edu
Professional Ethics Committee

Rose T. Dunn, MBA, CPA, RHIA, CHPS, FAHIMA,
FACHE
(314) 209-7800
Rose.Dunn@FirstClassSolutions.com
Virtual Lab Strategic Advisory Committee

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

Kimberly D. Theodos, JD, MS, RHIA
(318) 257-2854
ktheodos@latech.edu
2015 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
Kay Merriweather, RHIA, CHDA, CDIP, CCS,
CCS-P, CPC-H
(404) 849-0459
wdmerr@earthlink.net
Council for Excellence in Education

Ellen Karl, MBA, RHIA, CHDA, FAHIMA
(646) 344-7324
ellen.karl@cuny.edu
Envisioning Collaborative
(336) 946-1750
lpait@novanthealth.org
House Leadership
Elizabeth A. Delahoussaye, RHIA, CHPS
(865) 659-5059
edelahoussaye@iodincorporated.com
Judi G. Hofman, CHPS, BCRT, CAP, CHSS,

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

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

Speaker of the House of Delegates
(336) 946-1750
lpait@novanthealth.org
Speaker-elect of the House of Delegates

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

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

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

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

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

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

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

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

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

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ICD-10-CM/PCS
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AHIMA Thanks Its Loyalty Program Members
In Record Time, Inc.................................inside front cover
EXECUTIVE LEVEL
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MedData, Inc.......................................... inside back cover
MRO................................................................................ 25
DIRECTOR LEVEL
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Rasmussen College........................................................ 61
MANAGER LEVEL
St. Josephs College of Maine........................................53
University of Cincinnati................................................... 23
Health Language
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AHIMA Career Center

For classified advertising information, call Emily Leahy: 410-584-1961 | e-mail: eleahy@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 Emily Leahy at 410-584-1961 for pricing and options, or
leave her an email at eleahy@NetworkMediaPartners.com.
Upcoming Issues:
March
Electronic Health Records
April
Privacy and Security
Exclusively Specializing
in HIM for
almost 25 years!
We assist both
job seekers and employers
in the following specialties:
Executive Level | Consultants
Coders | Auditors | CDI
Directors | Managers | Vendors
Contact us in confidence:
Doug Ellie or
Perry Ellie, MA, RHIA, Fellow AHIMA
Careers@HIMjobs.com
800-248-6989
May
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for 2015!
Contact Emily Leahy at
410-584-1961 to reserve your space.
Custom Packages available to fit your
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Advertise in
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Journal
Journal of
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AHIMA February
February 15/71
15 / 71
AHIMA Career Center
HELP
InSPiRe better Health
JOIN OUR TEAM OF CODERS AND TRAINERS
Every day, our employees are here to care for patients from
moment one. We are a leading health care organization
with a network of seven hospitals, physician ofces and
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The benefts of joining our team include:
An attractive compensation package.
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Opportunities to work from any location; quality
training provided.
Comprehensive health care, life insurance, paid
time of.
To learn more, contact Casey Morris at 540-983-4150
or CHMorris@carilionclinic.org. Job details and an
application are at www.CarilionClinic.org/Careers.
Equal Opportunity Employer: Minorities/Females/Protected
Veterans/Individuals with Disabilities.
Inspiring better health.
QualCode, Inc. is looking for a PartTime Coding and Data Quality Manager
(New York Office)
Responsible for management and oversight of all coding and

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72/Journal
15
72
/ Journal of AHIMA February 1
5
QualCode delivering quality-focused people, responses and

results.
Journal
Journal of
of AHIMA
AHIMA February
February 15/73
15 / 73
2014
ICD-10-PCS
This comprehensive text is devoted to learning and
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Updated to include the 2014 ICD-10-PCS

Coding Guidelines
Online student workbook and additional resources
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About the Authors:
AHIMA PRESS 233 N. Michigan Ave., 21st Fl. Chicago, IL 60601

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Lynn M. Kuehn, MS, RHIA, CCS-P, FAHIMA

Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA
9 781584 260745
Authors
Lynn M. Kuehn, MS, RHIA, CCS-P, FAHIMA
Therese M. Jorwic, MPH, RHIA, CCS,
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Prod. No. AC201113 | ISBN: 9781584260745
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Includes Online Assessments

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STRATeGIeS FoR
Darice Grzybowski, MA, RHIA, FAHIMA
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Strategies for Electronic Document and Health

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KEY FEATURES
An Applied Approach
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AHIMA is the premier association of health information management (HIM) professionals. AHIMAs more than 67,000 members are
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ICD-9-CM Code Book, 2015
ICD-10-PCS
Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA, is an assistant professor in health information management
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Lynn M. Kuehn, MS, RHIA, CCS-P, FAHIMA, and Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA
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EDUCATION &
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CONTENTS
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February 2015 / EDUCATION & PROFESSIONAL DEVELOPMENT GUIDE
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SEE OUR DISPLAY AD ON PAGE 23.
83
HE TENSION BETWEEN DATA PRIVACY and consumers demand for their health information will
become more strained in 2015, a new report predicts. As the number of privacy breaches in the healthcare sector has grown in recent years, so too has the desire of consumers to be one click away from
their personal health information, according to a report published by PricewaterhouseCoopers Health
Research Institute (HRI).
For the time being, consumers value privacy over convenience. n the November 2014 HRI survey titled
Top Health Industry Issues of 2015, 65 percent of respondents said data security trumped convenient access to imaging and test results, doctors notes, diagnoses, and prescriptions. The only scenario in which this
wasnt the case was with an individuals
itness information.
However, consumers have good reason
to worry about the safety of their health information. One persons record can be worth up to $1,300 on the black market. And in the summer of 2014 alone, more than five
million consumers had information that was compromised, according to HRI.
ackers and cyber criminals are upping the ante, too. For example, at the Clay County
ospital in
the small rural community of Flora, IL, hospital officials received an e-mail saying that
unless a
substantial payment was made, cyber criminals would leak patient records onto the Internet. The e-mail was
received in November 2014. While the theft of health information is common, reports of ransom are rare, and
its difficult to know if rates of it are increasing, Modern Healthcare reported.
What is more important to you, data security or convenience in the following instances?
MEDICAL TEST AND
IMAGING RESULTS:
DOCTORS NOTES
AND DIAGNOSIS:
29%
27%
71%
73%
DRUG PRESCRIPTION
INFORMATION:
DIET AND
EXERCISE RESULTS:
35%
65%
68%
32%
data security
convenience
W56.02XA
Struck by dolphin, initial encounter
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FEBRUARY 2015

HIM RUSHES TO BRIDGE EDUCATIONAL AND

Match Made in HIM Heaven

AHIMAs Mentor Match program partners HIM leaders with

Education and Professional Development Guide

The latest special advertising section from the Journal highlights

Contents February 2015

Mind the Gap

HIM rushes to bridge

Vol. 86, no. 2

Retirees dont just have to sew to pass the time

Dissecting the Details

Optimizing PHI Disclosure Management in

HIM After Retirement

Word from Washington

AHIMA Career Center

Contents February 2015

Navigating Privacy and Security

By Anna Orlova, PhD, and Harold Lehmann, MD, PhD

e-HIM Best Practices

The Sound Record

By Diane Dolezel, MSCS, RHIA

By Galina Datskovsky, PhD; Ron Hedges, JD;

AHIMA members may earn continuing

Hospital Discharge Status Codes:

CPT Updates for CY 2015

Including Patient-Generated Health

4/Journal of AHIMA February 15

Dissecting the Details

Optimizing PHI Disclosure Management in the Age of

CPT Updates for CY 2015

Contents February 2015

Video: Match Made in HIM Heaven

AHIMAs Mentor Match program partners HIM

Projects Help Students Prepare for e-HIM

Share and Connect with AHIMA

6/Journal of AHIMA February 15

For the treatment of toxic plasma methotrexate

Voraxaze New Technology Add-on Payment (NTAP) Extended

Receive up to an additional 50% payment on your MS-DRG submission.*

Injection or infusion of glucarpidase

Call 1-866-369-9290 or email Voraxaze@thepinnaclehealthgroup.com with questions

Selected Safety Information

Please see brief summary of prescribing information on adjacent page.

BTG International Inc.

rates in the clinical trials of other drugs and

specifed for 1 patient. Doses ranged from

This incidence includes the following terms: fushing,

One of these reactions was classifed as Grade 3

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

Meeting Evolving Workforce Requirements

NEW TECHNOLOGY, AN evolving regulatory environment, financial pressures,

Vice President of Patient Experience

HealthPort best practices are used to

You will have peace of mind with:

Unlimited capacity to handle

For more information, visit

Bulletin Board whats happening in healthcare

Report: Expect More Healthcare Data Cyber Breaches in 2015

data breach headlines in 2015.

ART DIRECTOR Graham Simpson