health information management technology- an applied approach, 4th edition.pdf

i

Health Information Management Technology

An Applied Approach

Fourth Edition

Nanette B. Sayles, EdD, RHIA, CHPS, CCS, CPHIMS, FAHIMA

Editor

AHIMA_HIT2012_ch00fm.indd 1 9/24/12 5:13 PM

Copyright 2013 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher.

ISBN: 978-1-58426-352-7AHIMA Product No.: AB103112

AHIMA Staff:Jessica Block, MA, Assistant EditorClaire Blondeau, MBA, Managing EditorJune E. Bronnert, RHIA, CCS, CCS-PJill S. Clark, MBA, RHIAAdrienne Cook, JD, Developmental EditorKathryn A. DeVault, RHIA, CCSAngela K. Dinh, MHA, RHIA, CHPSMelanie A. Endicott, MBA, RHIA, CCS, CCS-PKatie Greenock, MS, Editorial and Production CoordinatorKaren M. Kostick, RHIT, CCS, CCS-PJason O. Malley, Director, Creative Content DevelopmentDiana M. Warner, MS, RHIA, CHPSLou Ann Wiedemann, MS, RHIA

All information contained within this book, including websites and regulatory information, was current and valid as of the date of publication. However, web page addresses and the information on them may change or disappear at any time and for any number of reasons. The user is encouraged to perform his or her own general web searches to locate information associated with addresses that are no longer valid.

All products mentioned in this book are either trademarks of the companies referenced in this book, registered trademarks of the companies referenced in this book, or neither.

This book is sold, as is, without warranty of any kind, either express or implied. While every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information or instructions contained herein. It is further stated that the publisher and author are not responsible for any damage or loss to your data or your equipment that results directly or indirectly from your use of this book.

American Health Information Management Association233 North Michigan Avenue, 21st Floor

Chicago, Illinois 60601-5809ahima.org


iii

Contents

About the Editor and Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii

Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xli

Part 1 Healthcare Data Management

Chapter 1 Introduction to the HIMProfession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Nanette B. Sayles, EdD, RHIA, CCS, CHPS, CPHIMS, FAHIMA

Chapter 2 Purpose and Function of the Health Record . . . . . . . . . . . . . . . . . . . . . . 31Cheryl V. Homan, MBA, RHIA

Chapter 3 Content and Structure of the Health Record. . . . . . . . . . . . . . . . . . . . . . 67Bonnie J. Petterson, PhD, RHIA

Chapter 4 Healthcare Data Sets and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA

Chapter 5 Clinical Vocabularies and Classification Systems . . . . . . . . . . . . . . . . 179Karen S. Scott, MEd, RHIA, CCS-P, CPC

Chapter 6 Reimbursement Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227Anita C. Hazelwood, MLS, RHIA, FAHIMACarol A. Venable, MPH, RHIA, FAHIMA

Chapter 7 Health Information Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315Lisa A. Cerrato, MS, RHIA and Jane Roberts, MS, RHIA

Part 2 Health Statistics, Biomedical Research, and Quality Management

Chapter 8 Secondary Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431Marcia Sharp, EdD, RHIA

Chapter 9 Healthcare Statistics and Productivity . . . . . . . . . . . . . . . . . . . . . . . . . 469Loretta A. Horton, MEd, RHIA

Chapter 10 Clinical Quality Performance Improvement and Management . . . . . . 559Chris R. Elliott, MS, RHIA


iv Contents

Part 3 Health Services Organization and Delivery

Chapter 11 Healthcare Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637Donald W. Kellogg, PhD, RHIA, CPEHR

Chapter 12 Ethical Issues in Health Information Management. . . . . . . . . . . . . . . . 715Laurinda B. Harman, PhD, RHIA, FAHIMA

Appendix A: Ethical Standards for Clinical Documentation Improvement (CDI) Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765

Chapter 13 Legal Issues in Health Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . 771Laurie A. Rinehart-Thompson, JD, RHIA, CHP

Part 4 Information Technology and Systems

Chapter 14 Fundamentals of Electronic Information Systems . . . . . . . . . . . . . . . . 845Martin J. Smith, MEd, RHIT, CCA

Chapter 15 Introduction to Electronic Health Information Systems . . . . . . . . . . . . 905Nanette B. Sayles, EdD, RHIA, CCS, CHPS, CPHIMS,FAHIMA

Chapter 16 Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 947Margret K. Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS

Chapter 17 Information Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021Sheila Carlon, PhD, RHIA, FAHIMA, CHPS

Part 5 Organizational Resources

Chapter 18 Principles of Organization and Work Planning. . . . . . . . . . . . . . . . . . 1073Donald W. Kellogg, PhD, RHIA, CPEHR

Chapter 19 Envisioning the Future of the Health Information Management Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, 2011President of AHIMA

Appendix A Sample HIM Position Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . 1155

Appendix B Sample Notice of Health Information Practices . . . . . . . . . . . . . . . . . 1157

Appendix C Check Your Understanding Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1177

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1259


v

Detailed Table of Contents

About the Editor and Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii

Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xli

Part 1 Healthcare Data Management

Chapter 1 Introduction to the HIMProfession . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Early History of Health Information Management. . . . . . . . . . . . . . . . . . 6

Hospital Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Organization of the Association of Record Librarians. . . . . . . . . . . . 7Approval of Formal Education and Certification Programs. . . . . . . . 7

Evolution of Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Traditional Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Information-Oriented Management Practice . . . . . . . . . . . . . . . . . . 10Visioning the Future of HIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10From Traditional Roles to New Opportunities . . . . . . . . . . . . . . . . . 12

Todays Professional Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Structure and Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Health Information Management Specialty Professional Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Healthcare Information and Management Systems Society . . . . . . 24Association for Healthcare Documentation Integrity. . . . . . . . . . . . 25American Academy of Professional Coders. . . . . . . . . . . . . . . . . . . 25National Cancer Registrars Association . . . . . . . . . . . . . . . . . . . . . . 25

American Recovery and Reinvestment Act of 2009Community College Consortia to Educate Health Information Technology Professionals . . . . . . . . . . . . . . . . . . . . 25

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29


vi Detailed Table of Contents

Chapter 2 Purpose and Function of the Health Record . . . . . . . . . . . . . . . . . . . 31

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Purposes of the Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Primary Purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Secondary Purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Users of the Health Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Individual Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Institutional Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Functions of the Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Storage of Patient Care Documentation . . . . . . . . . . . . . . . . . . . . . . 47Guidance in Clinical Problem Solving. . . . . . . . . . . . . . . . . . . . . . . 60

Real-World Case #1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Real-World Case #2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Chapter 3 Content and Structure of the Health Record . . . . . . . . . . . . . . . . . . . 67

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Documentation Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Types of Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Standards Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Acute Care Health Record Documentation . . . . . . . . . . . . . . . . . . . . . . 77Basic Acute Care Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Clinical Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Administrative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Consents, Authorizations, and Acknowledgments . . . . . . . . . . . . . 102

Specialized Health Record Documentation . . . . . . . . . . . . . . . . . . . . . 106Emergency Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . 106Ambulatory Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . 107Ambulatory Surgical Care Documentation . . . . . . . . . . . . . . . . . . 110Long-term Care Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 111Home Healthcare Documentation . . . . . . . . . . . . . . . . . . . . . . . . . 113Hospice Care Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114Behavioral Healthcare Documentation . . . . . . . . . . . . . . . . . . . . . 114Rehabilitation Services Documentation . . . . . . . . . . . . . . . . . . . . . 116Documentation of Services Provided in Correctional

Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117End-stage Renal Disease Service Documentation . . . . . . . . . . . . . 117


Detailed Table of Contents vii

Principles and Practices of Health Record Documentation . . . . . . . . . 119Basic Documentation Principles . . . . . . . . . . . . . . . . . . . . . . . . . . 119Clinical Documentation Improvement . . . . . . . . . . . . . . . . . . . . . . 120

Format of the Health Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Paper-Based Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128Hybrid Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130Personal Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Chapter 4 Healthcare Data Sets and Standards . . . . . . . . . . . . . . . . . . . . . . . . . 139

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140History of Healthcare Data Collection . . . . . . . . . . . . . . . . . . . . . . 141Data Sets in the Electronic Environment . . . . . . . . . . . . . . . . . . . . 142Developing Standardized Data Sets and Standards . . . . . . . . . . . . 142

Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Data Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Definition of Data Set. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Importance and Use of Data Sets . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Types of Data Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146Data Sets Required or Recommended by the Federal

Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146Data Sets for Interoperable Electronic Information Exchange . . . 156

Standards for Electronic Data and Electronic DataInterchange . . . . . 159Definition of Data Standard for Electronic Data Exchange . . . . . . 160Data Needs in an Electronic Environment . . . . . . . . . . . . . . . . . . . 160Benefits of Data Exchange Standards . . . . . . . . . . . . . . . . . . . . . . 161American Recovery and Reinvestment Act . . . . . . . . . . . . . . . . . . 162Standards Development, Coordination, Testing, and

Harmonization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Types of Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Emerging Health Information Standards . . . . . . . . . . . . . . . . . . . . . . . 172Extensible Markup Language (XML) . . . . . . . . . . . . . . . . . . . . . . 172Metadata Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Role of HIM Professional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177


viii Detailed Table of Contents

Chapter 5 Clinical Vocabularies and Classification Systems . . . . . . . . . . . . . . 179

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180History and Importance of Clinical Vocabularies . . . . . . . . . . . . . . . . . 181Clinical Vocabularies, Classifications, and Nomenclatures . . . . . . . . . 181

International Classification of Diseases, Ninth Revision, Clinical Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

International Classification of Diseases, Tenth Revision, Clinical Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

International Classification of Diseases, Tenth Revision, Procedure Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Implementation of ICD-10 in the United States. . . . . . . . . . . . . . . 194ICD-9-CM to ICD-10-CM Transition Issues . . . . . . . . . . . . . . . . . 195International Classification of Functioning,

Disability, and Health (ICF). . . . . . . . . . . . . . . . . . . . . . . . . . . . 196International Classification of Diseases for Oncology,

Third Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Healthcare Common Procedure Coding System . . . . . . . . . . . . . . 199Current Procedural Terminology, Version 4 . . . . . . . . . . . . . . . . . . 201Systematized Nomenclature of Medicine . . . . . . . . . . . . . . . . . . . 205Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, Text Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . 208Nursing Vocabularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

The Coding Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Standards of Ethical Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Elements of Coding Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213Coding Policies and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . 214Steps in the Coding Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214Quality Assessment for the Coding Process. . . . . . . . . . . . . . . . . . 215

Coding Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Encoders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Unifying Clinical Vocabularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221National Library of Medicine UMLS Project . . . . . . . . . . . . . . . . 221Development of the Nosologist Role . . . . . . . . . . . . . . . . . . . . . . . 222

Real-world Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226


Detailed Table of Contents ix

Chapter 6 Reimbursement Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231History of Healthcare Reimbursement in the UnitedStates . . . . . . . . . 231

Pre-Medicare/Medicaid Campaigns for National Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Medicare/Medicaid Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232Cost Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233Development of Prepaid Health Plans . . . . . . . . . . . . . . . . . . . . . . 233

Healthcare Reimbursement Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . 237Commercial Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237Not-for-Profit and For-Profit Healthcare Plans . . . . . . . . . . . . . . . 238Blue Cross and Blue Shield Plans . . . . . . . . . . . . . . . . . . . . . . . . . 238Government-Sponsored Healthcare Programs . . . . . . . . . . . . . . . . 239Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

Healthcare Reimbursement Methodologies . . . . . . . . . . . . . . . . . . . . . 260Fee-for-Service Reimbursement Methodologies . . . . . . . . . . . . . . 261Episode-of-Care Reimbursement Methodologies . . . . . . . . . . . . . 262Capitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263Global Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263Prospective Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Medicare Prospective Payment Systems. . . . . . . . . . . . . . . . . . . . . . . . 266Medicare Acute Inpatient Prospective Payment System (IPPS) . . . 266Resource-Based Relative Value Scale (RBRVS) System. . . . . . . . 271Skilled Nursing Facility Prospective Payment System . . . . . . . . . 273Outpatient Prospective Payment System . . . . . . . . . . . . . . . . . . . . 274Ambulatory Surgery Center Prospective Payment

System (ASCPPS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Home Health Prospective Payment System (HH PPS) . . . . . . . . . 278Ambulance Fee Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280Inpatient Rehabilitation Facility (IRF) Prospective

Payment System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281Long-Term Care Hospital (LTCH) Prospective

Payment System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282Inpatient Psychiatric Facilities (IPFs) Prospective

Payment System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284Processing of Reimbursement Claims . . . . . . . . . . . . . . . . . . . . . . . . . 288

Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288Submission of Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288


x Detailed Table of Contents

Explanation of Benefits and Medicare Summary Notice Remittance Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

National Correct Coding Initiative (NCCI) . . . . . . . . . . . . . . . . . . 289Electronic Data Interchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Reimbursement Support Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Management of the Fee Schedules. . . . . . . . . . . . . . . . . . . . . . . . . 295Management of the Chargemaster . . . . . . . . . . . . . . . . . . . . . . . . . 297Maintenance of the Chargemaster . . . . . . . . . . . . . . . . . . . . . . . . . 299Management of the Revenue Cycle . . . . . . . . . . . . . . . . . . . . . . . . 300Management of Documentation and Coding Quality . . . . . . . . . . 301

Coding and Corporate Compliance. . . . . . . . . . . . . . . . . . . . . . . . . . . . 302History of Fraud and Abuse and Corporate Compliance

in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302Elements of Corporate Compliance . . . . . . . . . . . . . . . . . . . . . . . . 304Relationship between Coding Practice and Compliance . . . . . . . . 305

Recovery Audit Contractor Program . . . . . . . . . . . . . . . . . . . . . . . . . . 309Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

Streamlining the Revenue Cycle Management Process . . . . . . . . . 311Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Mapping the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312Ready for RCM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

Chapter 7 Health Information Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318HIM Functions and Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318Master Patient Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322

Maintenance of Master Patient Index. . . . . . . . . . . . . . . . . . . . . . . 324Patient Identity in a Health Information

Exchange Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326Identification Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

HIM Functions in a Paper-Based Environment . . . . . . . . . . . . . . . . . . 331Record Storage and Retrieval Functions . . . . . . . . . . . . . . . . . . . . 331Record Processing of Paper-Based Records. . . . . . . . . . . . . . . . . . 349Authorization and Access Control for Paper-Based Records. . . . . 354Forms Design, Development, and Control for Paper-Based

Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354Quality Control Functions in Paper-Based Systems . . . . . . . . . . . 357


Detailed Table of Contents xi

HIM Functions in a Hybrid Environment . . . . . . . . . . . . . . . . . . . . . . . 360Storage, Retrieval, and Retention of Hybrid Records . . . . . . . . . . 361Authorization and Access Control for Hybrid Records . . . . . . . . . 366Quality Control Functions for Hybrid Records . . . . . . . . . . . . . . . 366Issues and Challenges with Hybrid Records . . . . . . . . . . . . . . . . . 367

HIM Functions in an Electronic Environment . . . . . . . . . . . . . . . . . . . 372Transition Functions to an EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . 374Record Filing and Tracking of EHRs. . . . . . . . . . . . . . . . . . . . . . . 375Record Processing of EHRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375Version Control of EHRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376Management of Free Text in EHRs . . . . . . . . . . . . . . . . . . . . . . . . 376Management and Integration of Digital Dictation,

Transcription, and Voice Recognition . . . . . . . . . . . . . . . . . . . . 377Reconciliation Processes for EHRs . . . . . . . . . . . . . . . . . . . . . . . . 377Managing Other Electronic Documentation . . . . . . . . . . . . . . . . . 379Handling Materials from Other Facilities . . . . . . . . . . . . . . . . . . . 380Search, Retrieval, and Manipulation Functions of EHRs. . . . . . . . 380Access Control for EHRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381Handling Amendments and Corrections in EHRs . . . . . . . . . . . . . 382Purge and Destruction of EHRs . . . . . . . . . . . . . . . . . . . . . . . . . . . 383Quality Control Functions for EHRs . . . . . . . . . . . . . . . . . . . . . . . 384

Medical Transcription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388Management of Medical Transcription . . . . . . . . . . . . . . . . . . . . . 388Quality Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

Release of Information (ROI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389ROI Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390

Legal Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391Tracking and Reporting of Disclosures . . . . . . . . . . . . . . . . . . . . . . . . 393Clinical Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Quality Control in Clinical Coding . . . . . . . . . . . . . . . . . . . . . . . . 396Revenue Cycle Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396Other HIM Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397

Data Reporting and Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . 397Maintenance of Indexes and Registries . . . . . . . . . . . . . . . . . . . . . 397Birth Certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399

HIM Interdepartmental Relationships . . . . . . . . . . . . . . . . . . . . . . . . . 399Patient Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399Billing Department. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401Patient Care Departments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401


xii Detailed Table of Contents

Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402Participation on Medical Staff and Organizational

Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402Managing Documentation Requirements. . . . . . . . . . . . . . . . . . . . 403Virtual HIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

Accreditation and Licensing Documentation Requirements . . . . . . . . 403Monitoring of Accreditation, Licensure, and Standards

Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405Management and Supervisory Processes . . . . . . . . . . . . . . . . . . . . . . . 406

Policy and Procedure Development . . . . . . . . . . . . . . . . . . . . . . . . 407Future Directions in Health Information Management

Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418The Planning Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419Implementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

Part 2 Health Statistics, Biomedical Research, and Quality Management

Chapter 8 Secondary Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433Differences between Primary and Secondary DataSources

and Databases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433Purposes and Users of Secondary Data Sources. . . . . . . . . . . . . . . . . . 434

Internal Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435External Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435

Types of Secondary Data Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436Facility-Specific Indexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437Healthcare Databases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450

Processing and Maintenance of Secondary Databases . . . . . . . . . . . . . 460Manual versus Automated Methods of Data Collection . . . . . . . . 460Vendor Systems versus Facility-Specific Systems . . . . . . . . . . . . . 461


Detailed Table of Contents xiii

Data Stewardship Issues Associated with Secondary Data Collection and Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461

Data Quality Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466

Chapter 9 Healthcare Statistics and Productivity . . . . . . . . . . . . . . . . . . . . . . . 469

Introduction to Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471Discrete versus Continuous Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473Common Statistical Measures Used in Healthcare. . . . . . . . . . . . . . . . 474

Ratios, Proportions, and Rates: Three Common Examples of Ratio-Level Data Worth Knowing . . . . . . . . . . . . . . . . . . . . . . . 474

Statistical Data Used in Healthcare Facilities. . . . . . . . . . . . . . . . . . . . 478Acute Care Statistical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478Administrative Statistical Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . 478Inpatient Census Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480Inpatient Bed Occupancy Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483Bed Turnover Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484Length of Stay Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

Patient Care and Clinical Statistical Data . . . . . . . . . . . . . . . . . . . . . . . 488Hospital Death (Mortality) Rates . . . . . . . . . . . . . . . . . . . . . . . . . . 488Autopsy Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493Hospital Infection Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497Consultation Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498

Case-Mix Statistical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499Ambulatory Care Statistical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502Public Health Statistics and Epidemiological Information. . . . . . . . . . 504

National Vital Statistics System . . . . . . . . . . . . . . . . . . . . . . . . . . . 504Population-Based Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506National Notifiable Diseases Surveillance System . . . . . . . . . . . . 517

Presentation of Statistical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520Charts and Graphs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522Spreadsheets and Statistical Packages . . . . . . . . . . . . . . . . . . . . . . 533

Descriptive Statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536Measures of Central TendencyThe Center of a

Variables Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536Measures of VariabilitySpread of a Variables Values . . . . . . . . 540Normal Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544


xiv Detailed Table of Contents

Health Information Management Statistics . . . . . . . . . . . . . . . . . . 546Productivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546Staffing Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547How to Analyze Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549

Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550Real-World Case Discussion Questions . . . . . . . . . . . . . . . . . . . . . . . . 550Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557

Chapter 10 Clinical Quality Performance Improvement and Management . . . 559

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562Performance Measurement and Quality Improvement . . . . . . . . . . . . . 563

Definition of Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563Performance Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565Quality Dimensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568Contemporary Approach to PI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568The Focus Is on the Customer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569

Fundamental Principles of Continuous PerformanceImprovement. . . 571The Problem Is Usually the System . . . . . . . . . . . . . . . . . . . . . . . . 572Variation Is Constant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573Data Must Support PI Activities and Decisions . . . . . . . . . . . . . . . 574Support Must Come from the Top Down . . . . . . . . . . . . . . . . . . . . 574The Organization Must Have a Shared Vision . . . . . . . . . . . . . . . . 574Staff and Management Must Be Involved in the Process. . . . . . . . 575Setting Goals Is Crucial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575Effective Communication Is Important . . . . . . . . . . . . . . . . . . . . . 575Success Should Be Celebrated . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576

Formal Performance Improvement Activities. . . . . . . . . . . . . . . . . . . . 576Performance Improvement Tools and Techniques . . . . . . . . . . . . . 578

Team-Based Performance Improvement Processes . . . . . . . . . . . . . . . 583Establishing Ground Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584Stating the Teams Purpose or Mission . . . . . . . . . . . . . . . . . . . . . 584Identifying Customers and Their Requirements . . . . . . . . . . . . . . 584Documenting Current Processes and Identifying Barriers . . . . . . . 585Collecting Current Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . 585Analyzing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588Process Redesign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592Recommendations for Process Change . . . . . . . . . . . . . . . . . . . . . 594


Detailed Table of Contents xv

Managing Quality and Performance Improvement. . . . . . . . . . . . . . . . 596Organizational Components of Performance Improvement. . . . . . 597Standards of Organizational Quality in Healthcare . . . . . . . . . . . . 599Utilization Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

Recent Clinical Quality Management Initiatives . . . . . . . . . . . . . . . . . 623Accountable Care Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . 624Six Sigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625Virtuoso Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627ISO 9000 Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627

Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632

Part 3 Health Services Organization and Delivery

Chapter 11 Healthcare Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639History of Western Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640

North Americas First Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . 640Standardization of Medical Practice . . . . . . . . . . . . . . . . . . . . . . . 640Standardization of Nursing Practice. . . . . . . . . . . . . . . . . . . . . . . . 643Standardization of Hospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . 644

Professionalization of the Allied Health Professions . . . . . . . . . . . . . . 646Modern Healthcare Delivery in the United States . . . . . . . . . . . . . . . . 649

Effects of the Great Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . 650Postwar Efforts toward Improving Healthcare Access. . . . . . . . . . 651Influence of Federal Legislation. . . . . . . . . . . . . . . . . . . . . . . . . . . 651

Professional and Trade Associations Related toHealthcare. . . . . . . . . 664American Medical Association (AMA) . . . . . . . . . . . . . . . . . . . . . 664American Hospital Association (AHA) . . . . . . . . . . . . . . . . . . . . . 665The Joint Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665Blue Cross and Blue Shield Association . . . . . . . . . . . . . . . . . . . . 667American College of Healthcare Executives . . . . . . . . . . . . . . . . . 667American Nurses Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667American Health Information Management Association. . . . . . . . 668


xvi Detailed Table of Contents

Certification Commission for Health Information Technology (CCHIT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 668

Other Healthcare-Related Associations . . . . . . . . . . . . . . . . . . . . . 669Organization and Operation of Modern Hospitals . . . . . . . . . . . . . . . . 671

Rise and Fall in Numbers of Hospitals. . . . . . . . . . . . . . . . . . . . . . 671Types of Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672Organization of Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . 674

Forces Affecting Healthcare Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . 682Growth of Subacute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682Development of Peer Review and Quality Improvement

Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682Growth of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683Efforts at Healthcare Reengineering . . . . . . . . . . . . . . . . . . . . . . . 684Emphasis on Patient-Focused Care . . . . . . . . . . . . . . . . . . . . . . . . 684Evidence-Based Best Practices and Outcomes . . . . . . . . . . . . . . . 685Development of Integrated Healthcare Delivery Systems . . . . . . . 686Licensure, Certification, and Accreditation of Healthcare

Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687Other Types of Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 690

Integrated Delivery Network/System . . . . . . . . . . . . . . . . . . . . . . . 690Ambulatory Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695

Reimbursement of Healthcare Expenditures . . . . . . . . . . . . . . . . . . . . 700Evolution of Third-Party Reimbursement . . . . . . . . . . . . . . . . . . . 700Government-Sponsored Reimbursement Systems . . . . . . . . . . . . . 700Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703Consumer-Driven Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703Healthcare Reform Initiatives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704

Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706Evolution from e-Health Task Force to e-HIM Task Force . . . . . . 706Vision for e-Health Information Management . . . . . . . . . . . . . . . . 707From HIM to e-HIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707Career Opportunities for e-HIM professionals. . . . . . . . . . . . . . . . 708Roles, Resources, and Competencies in e-HIM. . . . . . . . . . . . . . . 709Future of e-HIM and Where You Might Work . . . . . . . . . . . . . . . . 709

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714


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Chapter 12 Ethical Issues in Health Information Management . . . . . . . . . . . . . 715

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717Moral Values and Ethical Competencies . . . . . . . . . . . . . . . . . . . . . . . 717Ethical Foundations in Health Information Management. . . . . . . . . . . 719

Protection of Privacy, Maintenance of Confidentiality, and Assurance of Data Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719

Professional Code of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721Professional Values and Obligations . . . . . . . . . . . . . . . . . . . . . . . 724

Ethical Responsibilities of the HIM Professional. . . . . . . . . . . . . . . . . 736Ethical Issues Related to Medical Identity Theft . . . . . . . . . . . . . . . . . 737

The Patients Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739The HIM Professionals Perspective . . . . . . . . . . . . . . . . . . . . . . . 739Ethical Issues Related to Documentation and Privacy . . . . . . . . . . 742Ethical Issues Related to Release of Information. . . . . . . . . . . . . . 743

Ethical Decision-Making Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745Important Health Information Ethical Problems . . . . . . . . . . . . . . . . . 748

Ethical Issues Related to Coding . . . . . . . . . . . . . . . . . . . . . . . . . . 748Ethical Issues Related to Quality Management, Decision

Support, Public Health, Managed Care, and Clinical Care . . . . 749Ethical Issues Related to Sensitive Health Information . . . . . . . . . 750Ethical Issues Related to Research. . . . . . . . . . . . . . . . . . . . . . . . . 752Ethical Issues Related to Electronic Health Record Systems . . . . 753Roles of Manager, Entrepreneur, and Advocate. . . . . . . . . . . . . . . 757

Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 758Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 764Appendix A: Ethical Standards for Clinical

Documentation Improvement (CDI) Professionals . . . . . . . . . . 765Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765Ethical Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765How to Interpret the Ethical Standards. . . . . . . . . . . . . . . . . . . . . . . . . 766Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770

Chapter 13 Legal Issues in Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . 771

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773Overview of Legal Issues in Health Information Management . . . . . . 774

Compilation and Maintenance of Health Records . . . . . . . . . . . . . 774


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Ownership and Control of Health Records, Including Use and Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775

Use of Health Records and Health Information in Judicial Proceedings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776

Introduction to the US Legal System . . . . . . . . . . . . . . . . . . . . . . . . . . 777The Source and Making of Laws . . . . . . . . . . . . . . . . . . . . . . . . . . 778The Handling of Legal Disputes . . . . . . . . . . . . . . . . . . . . . . . . . . 779Legal Proceedings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781

Professional Liability and the PhysicianPatient Relationship . . . . . . 782Form and Content of the Health Record. . . . . . . . . . . . . . . . . . . . . . . . 785Legal Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 787Retention of the Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788

AHIMA Retention Recommendations . . . . . . . . . . . . . . . . . . . . . . 789The HIPAA Privacy Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791

HIPAA Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791Historical Context of the HIPAA Privacy Rule . . . . . . . . . . . . . . . 791American Recovery and Reinvestment Act of 2009 . . . . . . . . . . . 793Applicability of the Privacy Rule . . . . . . . . . . . . . . . . . . . . . . . . . . 793Other Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 797Individual Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800HIPAA Privacy Rule Documents . . . . . . . . . . . . . . . . . . . . . . . . . . 808Uses and Disclosures of Health Information . . . . . . . . . . . . . . . . . 813Breach Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826HIPAA Requirements Related to Marketing and Fundraising . . . . 827HIPAA Privacy Rule Administrative Requirements. . . . . . . . . . . . 828Enforcement of Federal Privacy Legislation and Rules . . . . . . . . . 830

Medical Identity Theft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 831Definition of Medical Identity Theft . . . . . . . . . . . . . . . . . . . . . . . 831Implications of Medical Identity Theft . . . . . . . . . . . . . . . . . . . . . 831Fair and Accurate Credit Transactions Act (FACTA). . . . . . . . . . . 832Meeting the Red Flags Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833

Medical Staff Appointments and Privileges . . . . . . . . . . . . . . . . . . . . . 834Labor Laws and Unionized Personnel . . . . . . . . . . . . . . . . . . . . . . . . . 835Americans with Disabilities Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 836Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 838Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839


Detailed Table of Contents xix

Part 4 Information Technology andSystems

Chapter 14 Fundamentals of Electronic Information Systems . . . . . . . . . . . . . . 845

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847Basic Concepts of an Information System . . . . . . . . . . . . . . . . . . . . . . 849

Information System Components. . . . . . . . . . . . . . . . . . . . . . . . . . 850Information System Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850Types of Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851Development of Information Systems . . . . . . . . . . . . . . . . . . . . . . 857Cloud Computing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863Turnkey Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863Information Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870Computer Programming Languages and Software . . . . . . . . . . . . 875

Databases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879Database Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879Database Purpose and Activities . . . . . . . . . . . . . . . . . . . . . . . . . . 879Relational Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880Data Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 881Data Dictionary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882Techniques for Database Integrity . . . . . . . . . . . . . . . . . . . . . . . . . 885Database Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 886Data Warehouses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886Data Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887

Telecommunications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888Network Fundamentals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888Clients, Peers, and Servers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889Network Architectures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891Network Topologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892Data Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 893

Electronic Commerce in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . 895Management of Information Technology . . . . . . . . . . . . . . . . . . . . . . . 896Personal Productivity Software. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897

Database Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898Spreadsheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898Presentation Software. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 898Project Management Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899Groupware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899


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Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899Developing and Implementing Telehealth Program:

The VAs Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902

Chapter 15 Introduction to Electronic Health Information Systems . . . . . . . . . 905

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 907Evolution of Information Systems in Healthcare . . . . . . . . . . . . . . . . . 908

Development of Clinical Systems . . . . . . . . . . . . . . . . . . . . . . . . . 909Electronic Health Record Systems. . . . . . . . . . . . . . . . . . . . . . . . . 909

Electronic Healthcare Information Applications . . . . . . . . . . . . . . . . . 910Clinical Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912

Multimedia and Telematics Systems . . . . . . . . . . . . . . . . . . . . . . . 918Toward an Electronic Health Record System . . . . . . . . . . . . . . . . . . . . 919Administrative Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 921

Financial Information Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . 921Human Resource Management Systems . . . . . . . . . . . . . . . . . . . . 922Materials Management Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . 922Facilities Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 922Management Information Systems. . . . . . . . . . . . . . . . . . . . . . . . . 922Strategic Decision Support System . . . . . . . . . . . . . . . . . . . . . . . . 923Executive Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . 924

Research and Data Analytics Systems . . . . . . . . . . . . . . . . . . . . . . . . . 924Data Warehouses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 924Data Mart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925Data Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925Online Analytical Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926

Overview of Electronic Clinical Information Applications in Nonacute Care Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 927

Ambulatory Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929Home Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930

Healthcare Information Resources Management . . . . . . . . . . . . . . . . . 931Organizational Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932Enterprise Content and Records Management Department . . . . . . 936


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Roles of HIM Professionals in Electronic Health Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937

Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938Data Collection and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938Data Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 938Data Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939Electronic System Design and Development . . . . . . . . . . . . . . . . . 939Other HIM Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 945

Chapter 16 Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 947

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 950Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 951The EHR System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 952

EHR Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 953HIT Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954

EHR System Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955Source Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955Core EHR Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959Analytics and Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 967Specialty Systems and Automated Medical Devices . . . . . . . . . . . 968Supporting Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969Connectivity Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 969

Evolution of the Electronic Health Record. . . . . . . . . . . . . . . . . . . . . . 971Evolution of EHRs in Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . 972Evolution of EHR in Physician Practices. . . . . . . . . . . . . . . . . . . . 974Evolution of EHR in Other Care Settings . . . . . . . . . . . . . . . . . . . 975Implementation versus Adoption versus Optimization . . . . . . . . . 976Challenges to Implementation and Adoption . . . . . . . . . . . . . . . . . 977

Initiatives and Framework for the Electronic HealthRecord . . . . . . . . 982Governmental Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 982Meaningful Use Incentives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 987Initiatives Directed toward Consumers . . . . . . . . . . . . . . . . . . . . . 988

Technologies That Support Electronic HealthRecords . . . . . . . . . . . . 992Databases and Data Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 992Hardware Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 999


xxii Detailed Table of Contents

Acquisition of Electronic Health Record Systems . . . . . . . . . . . . . . . 1003Readiness Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003Strategic and Tactical Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005

Information Management in an Electronic Environment . . . . . . . . . . 1009Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010

Future Directions in Information Technology . . . . . . . . . . . . . . . . . . 1012Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1017

Chapter 17 Information Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1022Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024Confidentiality, Privacy, and Security. . . . . . . . . . . . . . . . . . . . . . . . . 1024

Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1024

Elements of a Security Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026Protecting the Privacy of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026Ensuring the Integrity of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026Ensuring the Availability of Data . . . . . . . . . . . . . . . . . . . . . . . . . 1027

Data Security Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1029Threats Caused by People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030Threats Caused by Environmental and Hardware or

Software Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030Strategies for Minimizing Security Threats . . . . . . . . . . . . . . . . . 1032Components of a Security Program . . . . . . . . . . . . . . . . . . . . . . . 1033

Coordinated Security Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1045Data Security Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047

Breaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047Managing Organizational Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . 1049

HIPAA Security Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1049American Recovery and Reinvestment Act of 2009 . . . . . . . . . . 1050HIPAA Security Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051

Forensics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1062Enforcement and Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1063

External Enforcement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1063Internal Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064


Detailed Table of Contents xxiii

Roles and Responsibilities of the Health InformationTechnician . . . . . . . . . . . . . . . . . . . . . . . . 1065

Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1066Unauthorized Access/Disclosure from an EHR . . . . . . . . . . . . . . 1066

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1069

Part 5 Organizational Resources

Chapter 18 Principles of Organization and Work Planning . . . . . . . . . . . . . . . 1073

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1075Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1076Principles of Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1076Nature of Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077

Management Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1079Roles of Teams and Committees . . . . . . . . . . . . . . . . . . . . . . . . . 1082

Organizational Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083Organizational Charts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083Mission, Vision, and Values Statements . . . . . . . . . . . . . . . . . . . . 1086Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1088Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1088

Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1090Leadership Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1091Recruitment, Orientation, and Training . . . . . . . . . . . . . . . . . . . . 1095Staff Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099Delegation of Authority and Empowerment. . . . . . . . . . . . . . . . . 1100Performance Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101Conflict Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103Employee Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1106

Fundamentals of Work Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1110Strategic Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111Operational Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113Expense Budgets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1114Supply Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1117Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1118Work Analysis and Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1123


xxiv Detailed Table of Contents

Performance and Quality Improvement for HIMFunctions. . . . . . . . 1129A Model for Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . 1129Change Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134Real-World Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1138

Chapter 19 Envisioning the Future of the Health Information Management Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139The e-HIM Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1140

Changing Times: HIM and ICD-10-CM/PCS . . . . . . . . . . . . . . . 1142Changing Times: HIM and Patient-Centered Care. . . . . . . . . . . . 1143

Employment Outlook for HIM Professionals . . . . . . . . . . . . . . . . . . . 1144HIM Expertise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1145Vision of the HIM Professional in the C-suite . . . . . . . . . . . . . . . 1148

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1149References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151

Appendices, Glossary, and Index

Appendix A Sample HIM Position Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . 1153

Appendix B Sample Notice of Health Information Practices . . . . . . . . . . . . . . . . . 1157

Appendix C Check Your Understanding Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1177

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1259


xxv

Nanette B . Sayles, EdD, RHIA, CCS, CHP, CPHIMS, FAHIMA, an associate profes-sor in the Health Information Management Program at East Central College in Union, Missouri, has a BS in medical record administration, an MS in health information manage-ment, a masters in public administration, and a doctorate of education in adult education. Dr. Sayles has more than 10 years of experience as a health information management prac-titioner with experience in hospitals, a consulting firm, and a computer vendor. She was the 2005 American Health Information Management Association Triumph Educator award winner. She has held numerous volunteer roles for the American Health Information Man-agement Association (AHIMA), the Georgia Health Information Management Associa-tion (GHIMA), the Alabama Association of Health Information Management (AAHIM), Middle Georgia Health Information Management Association (MGHIMA), and Birming-ham Regional Health Information Management Association (BRHIMA). These positions include: AHIMA Educational Strategies Committee, AHIMA co-chair RHIA Workgroup, GHIMA director, and president of MGHIMA. Dr. Sayles has published two books: Pro-fessional Review Guide for the CHP, CHS, and CHPS Examinations and Case Studies for Health Information Management. She is an editor for two chapters in the PRG Profes-sional Review Guide for the RHIA and RHIT Examinations.

Margret K . Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS, is presi-dent of Margret\A Consulting, LLC, in Schaumburg, Illinois, a consulting firm specializ-ing in computer-based patient records and associated HIM standards and regulations, such as HIPAA. She has more than 30 years of experience in national and international HIM. A leading authority on electronic health record (EHR) strategies for healthcare organiza-tions, she has extensive experience in EHR selection and project management, and she formed and served as executive director of the Computer-based Patient Record Institute (CPRI). Other positions held include associate executive director of AHIMA, associate professor at the University of Illinois, and director of medical record services at the Illi-nois Eye and Ear Infirmary. She is a much sought-after speaker, has published extensively, and has earned several professional service awards. Amatayakul also serves as an adjunct faculty member of the College of St. Scholastica and the University of Illinois at Chicago.

Sheila Carlon, PhD, RHIA, FAHIMA, CHPS, has served as the director of the Division of Health Services Administration at Regis University in Denver for twelve years. Prior to that she was the HIM program director at Dakota State University in Madison, South Dakota. Her industry experience includes consulting with Deloitte & Touche, HIM man-agement at Stanford Hospital and Dominican Hospital in California, practice management in California and additional HIM experience in various hospitals in Colorado. She has a PhD in organization development from the Fielding Graduate Institute, an MS in health services from San Jose State University, and bachelors degrees in health care management

About the Editor and Authors


xxvi About the Editor and Authors

and broadcast journalism and communications. She has served as chair of Education Strat-egy Committee for AHIMA, is on the CAHIIM Panel of Reviewers, and is a reviewer for Perspectives in HIM, and received the Educators Award in 2006. She is a frequent speaker on health information management and technology at the local, national, and international levels and is involved in international implementation of HIT in several countries.

Bonnie S . Cassidy, MPA, RHIA, FAHIMA, FHIMSS, was the 2011 President of AHIMA, serving as the Chairman of the AHIMA Board of Directors, and continues to serve on the Board as the 2012 Past President Director. Bonnie previously served on the AHIMA Board as a Director from 2006 to 2008. Bonnie is the Vice President of HIM Innovation for QuadraMed and previously served as the Vice President of HIM Product Management for QuadraMed. Bonnie is an AHIMA Academy ICD-10-CM/PCS Certifi-cate Holder and Ambassador.

Prior to joining QuadraMed, Bonnie served as an executive with the Certification Commission for Healthcare Information Technology (CCHIT). Bonnie is an experienced healthcare consultant and advisor, having worked for the national management consulting firms of Price Waterhouse and Ernst & Young, and she was an HIM administrator at two major teaching hospitals, including the Cleveland Clinic Foundation.

Bonnie was the president of the Ohio Health Information Management Association (OHIMA) and was honored to receive the OHIMA Distinguished Member Award. Ms. Cassidy is the recipient of three AHIMA awards: Legacy Award, Volunteer Excellence Award, and Professional Achievement Award.

Lisa A . Cerrato, MS, RHIA, is the program coordinator of the health information man-agement technology department at Columbus State Community College (CSCC), in Columbus, Ohio. She received a BS in health information management administration from The Ohio State University. Upon graduation, Lisa became the director of the medical records department at Meridia Huron Hospital, part of the Cleveland Clinic Health System in Cleveland. She then earned an MS in allied health education. Lisa is now a full-time faculty member at CSCC. She led the development of CSCCs online courses and certifi-cate programs in medical coding and medical transcription.

Chris Elliott, MS, RHIA, holds a masters degree in information systems and has pursued significant graduate study in medical informatics at the University of Utah. He recently retired as director of health information services and privacy officer designee at San Fran-cisco General Hospital Medical Center after 40 years of public service in hospitals and health profession education settings.

Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, is a medical informaticist with Lan-guage and Computing, Inc. In this position, she supports the ontology, modeling, sales, and product development activities related to the creation and implementation of natural language-processing applications where clinical terminology and classification systems are utilized. Kathy has a comprehensive background in the field of clinical terminologies


About the Editor and Authors xxvii

and classification, with more than 30 years of experience in the health information man-agement (HIM) field. Prior to joining L&C, she was director of practice leadership with AHIMA in Chicago. Kathy has served as senior nosologist for a health information ser-vices company and worked in various HIM roles, including vice president of product development, education specialist, director of medical records, quality assurance coordi-nator, and manager of a Centers for Disease Control and Prevention research team. Kathy has developed classification, grouping, and reimbursement systems products for health-care providers; conducted seminars; and provided consulting assessments throughout the United States as well as in Canada, Australia, the United Kingdom, Ireland, and Bulgaria. In addition, she has authored numerous articles and created online continuing education courses on clinical terminologies. As adjunct faculty at the College of St. Scholastica, she teaches the graduate-level course, Clinical Vocabularies and Classification Systems. In addition, she is actively involved as a volunteer in the HIM profession at the international, national, state, and local levels. Kathy holds a masters degree in HIM from the College of St. Scholastica.

Laurinda B . Harman, PhD, RHIA, FAHIMA, Associate Professor Emeritus, Depart-ment of Health Information Management in the College of Health Professions and Social Work at Temple University in Philadelphia, has been an HIM professional and educator for over 40 years. She has directed HIM baccalaureate programs at Temple University, George Washington University in Washington, DC, and The Ohio State University in Columbus. Dr. Harman was a faculty member in the health information technology program at North-ern Virginia Community College and served as director of education and human resource development for the Department of Health Care Sciences at George Washington Univer-sity. She edited Ethical Challenges in the Management of Health Information in 2001, the 2nd edition was published in 2006 and the 3rd edition is in progress. She contributed chapters to Health Informatics Research: Practices and Innovative Approaches; Health Information Management: Concepts, Principles, and Practice; and Health Information Technology: An Applied Approach for the American Health Information Management Association. Dr. Harman is on the editorial board of Perspectives in Health Informa-tion Management, has contributed articles to the Journal of American Health Informa-tion Management Association and has delivered presentations at international, national, state and local association meetings on topics related to HIM and ethics. She received a BSin biology with a concentration in medical record administration from Daemen Col-lege inBuffalo, New York, an MS in education at Virginia Polytechnic and State Univer-sity in Blacksburg, Virginia, and a PhD in human and organizational systems at Fielding Graduate University in Santa Barbara, California. Dr. Harman received the AHIMA 2001 Triumph Legacy Award for Ethical Challenges in the Management of Health Information, the 2011 Triumph Legacy Educator Award, and the 2011 Dorland Peoples Ethicist Award for her textbook and its contribution to helping healthcare professionals deal with ever-increasing ethical health information issues.


xxviii About the Editor and Authors

Anita C . Hazelwood, MLS, RHIA, FAHIMA, is a professor in the Health Informa-tion Management Department at the University of Louisiana at Lafayette and has been a credentialed registered health information administrator (RHIA) for more than 30 years. Anita has actively consulted in hospitals, nursing homes, physicians offices, clinics, facil-ities for the mentally retarded, and in other educational institutions. She has conducted numerous ICD-9-CM and CPT coding workshops throughout Louisiana for hospitals and physicians offices and has written numerous articles and coauthored chapters in several HIM textbooks. Anita has coauthored two books titled ICD-9-CM Coding and Reimburse-ment for Physicians Services and ICD-10-CM Preview for which she won AHIMAs Leg-acy Award in 2003. Anita has been a member of AHIMA for 32 years and has served on various committees and boards. Anita is a member of the Louisiana Health Information Management Association (LHIMA) and was selected as its 1997 Distinguished Member. She has served throughout the years as president, president-elect, treasurer, strategy man-ager, and board member and has directed numerous committees and projects.

Cheryl V . Homan, MBA, RHIA, is administrative director of information systems and biomedical engineering for the Lima Memorial Health System, located in Lima, Ohio. She also serves as adjunct faculty for the Health Management Program at The Ohio State University at Lima. She received her MBA from Ashland University in Ashland, Ohio, and her BS in allied health professions from The Ohio State University. She has been an HIM professional for more than 30 years, served on AHIMAs Board of Directors from 1997 to 1999, and is a former president of the Ohio Health Information Management Association.

Loretta A . Horton, MEd, RHIA, FAHIMA, received a medical record technician certifi-cate from Research Hospital and Medical Center and a bachelors degree in psychology from Rockhurst College, both in Kansas City, Missouri; a post-baccalaureate certificate in health information administration from Stephens College in Columbia, Missouri; and a masters in education with an emphasis in curriculum and instruction from Wichita State University in Wichita, Kansas. She also has completed graduate work in sociology at the University of Nebraska in Omaha. Currently, Loretta is cochair of the Allied Health Department and coordinator of the Health Information Technology Program at Hutchinson Community College in Hutchinson, Kansas. Previously, she worked in a variety of health information settings, including acute care and mental health, and she has consulted with long-term care, mental retardation, home health, hospice, and prison systems. She is an AHIMA fellow.

Donald W . Kellogg, PhD, RHIA, CPEHR, is an assistant professor at University of Saint Mary in Leavenworth, Kansas, and is the coordinator of the bachelor of health science pro-gram as well as a faculty member in the health information technology program. He earned a bachelors degree in health information management at the University of Kansas Medical Center and his doctorate