The new template was designed by a former ED physician. Front-line emergency departments facing an onslaught of patients suspected of contracting the novel coronavirus that causes COVID-19 now have a new tool designed to help them quickly diagnose patients. The new tool is a documentation template that can be programmed…

The rule does not set requirements for the privacy and security of the apps and the data they contain.  The Office of the National Coordinator for Health Information Technology (ONC) and Centers for Medicare & Medicaid Services (CMS) final interoperability rules were released last week, about a year after the…

This is the second in a series of five articles on the search for reliable health information. EDITOR’S NOTE: This article is focused on that component of the health information domain related to the acquisition of data.    This is the most involved article of the set, because it represents the…

Privacy is the right of an individual to keep oneself and one’s information concealed from unauthorized access and view by others. As the world moves to electronic health records, albeit at varying stages, health data is being used for a wider range of purposes, including improving population health, disease surveillance,…

CORRECTION: This story has been corrected. There was no Meaningful Use Act. The American Reinvestment & Recovery Act (ARRA) was enacted on Feb. 17, 2009. ARRA included many measures to modernize our nation's infrastructure, one of which was the “Health Information Technology for Economic and Clinical Health (HITECH) Act”. We apologize for the…

EDITOR’S NOTE:  Dr. Erica Remer reported this story live during the January 14 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. When I do my Case Western Reserve University documentation course, I sometimes joke about the future, when we won’t need to document because the…

There is a disconnect between what the doctor may have ordered and what the EHR read or translated. In my capacity as a healthcare consultant and auditor, I review patient records from all over the country – actually, the world, with the ever-growing popularity of offshore companies now performing coding…

Data for clinical and business intelligence can uncover significant opportunities within clinical documentation improvement. In my previous article, I discussed the process of how transformational change occurs, through transparency resulting from strategic connectivity across the healthcare system. To expand on this theory, let's examine the current state of clinical documentation…

Four areas where HIM professionals impact collections. I met with a coding manager recently who shared that her annual pay increase would be partially based on collections. Of course, we both looked at each other and said “why?!” But then I reflected on it and said, “why not?”  We know…