Many hospitals and health systems include computer-assisted coding (CAC) systems as a strategic tool in their plan for ICD-10. CAC software is considered an antidote to the significant decrease in coder productivity anticipated with ICD-10.
In September 2014, CMS and the Office for the National Coordinator (ONC) released a final rule that offers enhanced flexibility for eligible professionals, eligible hospitals, and critical access hospitals using certified EHR technology (CEHRT) and working toward meaningful use attestation (https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-21021.pdf). The final rule regulations became effective October 1, 2014.
RC.01.01.01, Content of the Medical Record, did not top the list of the survey findings for hospitals in the first half of 2014, according to the September 2014 issue of Joint Commission Perspectives. Nor was it on the list for critical access hospitals at all! However, 49% of hospitals surveyed received a requirement for improvement for this standard, primarily in the EPs related to timing and dating entries. This indicates hospitals are still using a lot of paper records. That said, the downward swing is encouraging as more and more hospitals fully implement the EMR.
MRB asked HIM and release of information (ROI) professionals about their ROI practices for its first quarterly benchmarking survey of 2015. (The survey was completed in October 2014.) Half of survey respondents are HIM directors or managers (52%). Other respondents identified themselves as non-managerial HIM staff members (18%) or ROI directors or managers (4%). The majority of respondents (65%) work in hospitals.
More than ever before, HIM is being recognized as an enterprise profession important to ambulatory, acute, and postacute settings. A good example of the transformation is HIM's involvement in CMS' risk adjustment and Hierarchical Condition Category coding system.
While it can be challenging to define your organization's legal health record (LHR), one health system in Denver is proving that collaboration and perseverance can lead to an effective LHR and EHR.
Perhaps it's because I reside in Chicago?home of both Oprah Winfrey and the American Health Information Management Association?but lately I have been thinking about "aha moments" for HIM professionals.
I have recently heard questions and discussion about the use of abbreviations within the medical record. With that in mind, this quarter's Joint Commission column will outline the requirements for abbreviations and provide guidance regarding the pros and cons of expanding the limited "do-not-use" list
