HIM Briefings

It’s the end of the year, and many of us have been on the fast track to EHRs and EDMS installation, so we pause this month for a little levity and to honor all those working so hard behind the scenes. Happy holidays to all the brave health information professionals continuing to blaze the paths of progress in automated medical record documentation!

We went to medical school. We studied, and many of us learned about pathogenesis of diseases. We were encouraged by our attendings and throttled by our chief residents to be able to spout off the causes of conditions. It wasn’t enough to name the condition; we had to know the myriad possible etiologies. Being quizzed made us sharp. We started to learn patterns and became better diagnosticians because we could digest the complexities of a patient while we did the history and physical. And we knew, even before lab tests came back, what was going on with the patient and how it got there.

Present-on-admission (POA) indicators, hospital-acquired conditions (HAC), and never events have been around for a while. However, they still seem to cause compliance conundrums, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.

It should come as no surprise that medical record documentation made the list for top standards noncompliance for the first half of 2010. Our old favorites just won’t go away.

MRB recently asked several advisory board members for crucial tips that new HIM managers and directors should know as they learn their way around their job and department.

The Office of the National Coordinator of Health Information Technology (ONC) approved the Chicago-based Certification Commission for Health Information Technology (CCHIT) and the Drummond Group, Inc. (DGI) of Austin, TX, as the first official certifiers of EHR technology in late summer 2010. In late September, ONC also approved InfoGard Laboratories, Inc., in San Luis Obispo, CA. Now that ONC has named at least three authorized testing and certification bodies (ATCB), healthcare vendors can seek certification for their EHR systems and technologies, and providers can begin to look for certified products in the marketplace. Providers must use certified EHR technology to qualify for meaningful use incentive payments.

HHS released a notice of proposed rulemaking in July modifying the HIPAA Privacy, Security, and Enforcement Rules under the HITECH Act.

Use this Q&A to test staff members’ knowledge of HIPAA privacy.

In the past year or so, many hospitals have seen a dramatic rise in external audit activity from a multitude of contractors.