Health Information Management Technology

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Health
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Management
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Technology
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An Applied Approach
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Sixth Edition
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Copyright ©2020 by the American Health Information Management Association. All rights reserved.
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Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced, stored
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in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or
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otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue, 21st Floor,
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Chicago, Illinois 60601-5809 (http://www.ahima.org/reprint).
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ISBN: 978-1-58426-720-1
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AHIMA Product No.: AB103118
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AHIMA Staff:
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Megan Grennan, Managing Editor
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Kimberly Wilson, Production Development Editor

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James Pinnick, Vice President, Content and Product Development

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Rachel Schratz, MA, Assistant Editor

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Cover image: sollia ©Shutterstock

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

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The websites listed in this book were current and valid as of the date of publication. However, webpage
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addresses and the information on them may change at any time. The user is encouraged to perform his or
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her own general web searches to locate any site addresses listed here that are no longer valid.
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CPT® is a registered trademark of the American Medical Association. All other copyrights and trademarks
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mentioned in this book are the possession of their respective owners. AHIMA makes no claim of ownership
by mentioning products that contain such marks.
Microsoft and Excel are registered trademarks of Microsoft Corporation. All other trademarks are the
property of their respective owners. This is an independent publication of the American Health Information
Management Association, and is neither affiliated with, nor an authorized sponsor of Microsoft Corporation.
AHIMA makes no claim of ownership by mentioning products that contain such marks.
For more information, including updates, about AHIMA Press publications, visit http://www.ahima.org
/education/press.
American Health Information Management Association

233 North Michigan Avenue, 21st Floor
Chicago, Illinois 60601-5809
ahima.org
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Health
Information
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An Applied Approach
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Sixth Edition
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Volume Editors
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Nanette B. Sayles, EdD, RHIA, CCS, CDIP, CHDA, CHPS, CPHI, CPHIMS, FAHIMA
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Leslie L. Gordon, MS, RHIA, FAHIMA

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Brief Table of Contents
About the Volume Editors and Chapter Authors xxvi

Preface xxxii
Student and Instructor Online Resources xxxv
Acknowledgments xxxvi
Foreword xxxvii
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Part I Foundational Concepts 1
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Chapter 1 Health Information Management Profession 3
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Chapter 2 Healthcare Delivery Systems 21
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Kelly Miller, MA, RHIA
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Chapter 3 Health Information Functions, Purpose, and Users 63
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Part II Data Content, Structures and Standards 91

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Chapter 4 Health Record Content and Documentation 93

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Megan R. Brickner, MSA, RHIA

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Chapter 5 Clinical Terminologies, Classifications, and Code Systems 123

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Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA

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Chapter 6 Data Management 153

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Danika E. Brinda, PhD, RHIA, CHPS, HCISPP

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Chapter 7 Secondary Data Sources 197

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Marcia Y. Sharp, EdD, MBA, RHIA

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Part III Information Protection: Access, Disclosure and Archival,

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Privacy and Security 221

Chapter 8 Health Law 223
Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA
Chapter 9 Data Privacy and Confidentiality 247
Chapter 10 Data Security 285
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vi Brief Table of Contents
Part IV Informatics, Analytics, and Data Use 319

Chapter 11 Health Information Systems 321
Margret K. Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS
Chapter 12 Healthcare Information 363
Hertencia Bowe, EdD, MSA, RHIA, FAHIMA
Lynette M. Williamson, EdD, RHIA, CCS, CPC, FAHIMA
Chapter 13 Research and Data Analysis 391
Chapter 14 Healthcare Statistics 429
Marjorie H. McNeill, PhD, RHIA, CCS, FAHIMA
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Part V Revenue Cycle Management and Compliance 471
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Chapter 15 Revenue Management and Reimbursement 473
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Morley L. Gordon, RHIT
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Chapter 16 Fraud and Abuse Compliance 499
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Darline A. Foltz, RHIA, CHPS, CPC
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Karen M. Lankisch, PhD, MHI, RHIA, CHDA, CPC, CPPM
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Part VI Leadership 525
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Chapter 17 Management 527

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Chapter 18 Performance Improvement 549

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Darcy Carter, DHSc, MHA, RHIA

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Miland N. Palmer, MPH, RHIA

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Chapter 19 Leadership 583

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Chapter 20 Human Resources Management 607

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Valerie S. Prater, MBA, RHIT, FAHIMA

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Chapter 21 Ethical Issues in Health Information Management 655

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Misty Hamilton, MBA, RHIT

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Appendix A Check Your Understanding Answer Key 679

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Appendix B Glossary 715

Index 765
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Table of Contents
About the Volume Editors and Chapter Authors xxvi

Preface xxxii
Student and Instructor Online Resources xxxv
Acknowledgments xxxvi
Foreword xxxvii
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Part I Foundational Concepts 1
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Health Information Management Profession 3
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Chapter 1
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Early History of Health Information Management 4
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Hospital Standardization 4
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Organization of the Association of Record Librarians 4
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Approval of Formal Education and Certification Programs 5
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Evolution of Practice io 5
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Traditional Practice 6
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Information-Oriented Management Practice 6

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The Future of HIM 7

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Today’s Professional Organization 8

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AHIMA Mission and Vision 9

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AHIMA Membership 9
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AHIMA Structure and Operation 10

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Association Leadership 10
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Engage10
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National Committees 10
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House of Delegates 12
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State and Local Associations 12

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Staff Structure 13
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Accreditation of Educational Programs 13

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Certification and Registration Program 13

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Fellowship Program 14
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AHIMA Support of Training and Education 14

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AHIMA Career Map 15

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AHIMA Foundation 16
Commission on Accreditation for Health Informatics and Information
Management Education 16
Health Information Management Specialty Professional Organizations 16
Healthcare Information and Management Systems Society 17
Association for Healthcare Documentation Integrity 17
American Academy of Professional Coders 17
National Cancer Registrars Association 17
Real-World Case 1.1 18
References 19
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viii Table of Contents

Healthcare Providers 22
Medical Practice 22
Physician Assistants 26
Nursing Practice 27
Allied Health Professions 27
Organization and Operation of Modern Hospitals 31
Types of Hospitals 33
Functionality 33
Location 33
Number of Beds 33
Specialization 33
Types of Ownership 34
Safety Net Hospitals 34
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Critical Access Hospitals 34
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Organization of Hospital Services 35
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Board of Directors 35
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Medical Staff 35
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Administrative Staff 36
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Patient Care Services 36
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Diagnostic Services 37
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Rehabilitation Services 37
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Ancillary Support Services 37
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Other Types of Healthcare Services 39
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Managed Care Organizations
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Accountable Care Organizations 40

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Ambulatory Care 40
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Private Medical Practice 41

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Medical Home 41
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Hospital-Based Ambulatory Care Services 41

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Community-Based Ambulatory Care Services 41

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Public Health Services 42

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Home Healthcare Services 42

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Voluntary Agencies 43
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Subacute Care 44
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Long-Term Care 44
Long-Term Care in the Continuum of Care 44
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Delivery of Long-Term Care Services 44

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Biomedical and Technological Advances in Medicine 45

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Telehealth 45
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Electronic Health Records and Health Data 46

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Artificial Intelligence 46
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Policy Making and Healthcare Delivery 48

Healthy People 2020 48
The National Institutes of Health 50
National Academy of Medicine Reports 51
Centers for Disease Control and Prevention 51
Local, State, and Federal Policies 52
Patient-Centered Outcomes Research Institute 52
Modern Healthcare Delivery in the United States 54
Social Security Act of 1935 54
Public Law 89–97 of 1965 54
Public Law 92–603 of 1972 55
Utilization Review Act of 1977 55
Peer Review Improvement Act of 1982 55
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Table of Contents ix
Tax Equity and Fiscal Responsibility Act of 1982 56

Public Law 98–21 of 1983 56
Health Insurance Portability and Accountability Act of 1996 56
American Recovery and Reinvestment Act of 2009 56
Patient Protection and Affordable Care Act of 2010 57
Real World Case 2.1 58
References 59

Purposes of the Health Record 64
Primary Purposes 64
Secondary Purposes 65
Formats of the Health Record 65
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Users of the Health Record 66
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Individual Users 66
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Institutional Users 67
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Overview of HIM Functions 68
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Medical Transcription and Voice Recognition 69
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Disclosure of Health Information 69
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Clinical Coding and Reimbursement 70
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Record Storage and Retrieval Functions 70
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Master Patient Index 70
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Record Storage and Retrieval Functions in a Paper Environment 72
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Record Storage and Retrieval in an Electronic Environment 81
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Identification Systems 84
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Paper Health Record – Serial Numbering System 84

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Paper Health Record – Unit Numbering System 85

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Paper Health Record – Serial-Unit Numbering System 85

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Paper Health Record – Alphabetic Filing System 85

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Electronic Health Record 85

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Statistics and Research 85

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Registries 85
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Birth and Death Certificates 85

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HIM Interdepartmental Relationships 86

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Virtual HIM 86
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HIM Information Systems 87

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Chart Tracking 87
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Coding 87
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Registries 87
Billing 87
Quality Improvement 87
Electronic Health Records 87
Personal Health Records 88
References 89
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x Table of Contents
Part II Data Content, Structures and Standards 91

Role of Documentation 95
Documentation Standards 95
Standards 95
Medical Staff Bylaws 96
Accreditation 97
Joint Commission 99
State Statutes 100
Legal Health Record 100
General Documentation Guidelines 101
Documentation by Settings 103
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Inpatient Health Record 103
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Medical and Surgical 104
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Ambulatory Surgery Record 110
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Ancillary Departments 110
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Physician Office Record 111
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Long-Term Care 111
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Rehabilitation 112
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Behavioral Health 113
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Home Health 113
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Federal and State Initiatives on Documentation 115
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Health Information Media 116

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Paper Health Record Documentation 116

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Electronic Health Record Documentation 117

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Web-Based Document Imaging 117

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Healthcare Providers in Documentation 118

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Physicians 118
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Nurses 118
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Allied Health Professionals 118

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HIM and Documentation 119

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HIM Roles 120

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Clinical Terminologies, Classifications, and Code Systems 123

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History and Importance of Clinical Terminologies, Classifications, and Code Systems 124
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Clinical Terminologies 126

SNOMED Clinical Terms 127
SNOMED CT Purpose and Use 127
SNOMED CT Content and Structure 127
Current Procedural Terminology 129
CPT Purpose and Use 129
CPT Content and Structure 131
Nursing Terminologies 131
Nursing Terminologies Purpose and Use 131
Nursing Terminologies Content and Structure 132
Classifications 133
International Classification of Diseases, Tenth Revision, Clinical Modification 133
ICD-10-CM Purpose and Use 133
ICD-10-CM Content and Structure 134
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Table of Contents xi
ICD-10-Procedure Coding System 134

ICD-10-PCS Purpose and Use 135
ICD-10-PCS Content and Structure 135
International Classification of Diseases 11th Revision 136
ICD-11 Foundation Component and ICD-11-MMS Purpose and Use 137
ICD-11 Foundation Component and ICD-11-MMS Content and Structure 137
International Classification of Functioning, Disability, and Health 138
ICF Purpose and Use 138
ICF Content and Structure 138
International Classification of Diseases for Oncology, Third Edition 139
ICD-O-3 Purpose and Use 139
ICD-O-3 Content and Structure 139
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 140
DSM-5 Purpose and Use 140
DSM-5 Content and Structure 140
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Code Systems 141
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Logical Observation Identifiers, Names, and Codes 141
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LOINC Purpose and Use 141
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LOINC Content and Structure 142
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Healthcare Common Procedure Coding System Level II 142
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HCPCS Purpose and Use 142
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HCPCS Content and Structure 143
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RxNorm 143
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RxNorm Purpose and Use 144
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RxNorm Content and Structure io 144
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Clinical Terminologies, Classifications, and Code Systems Found in Health
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Data and Information Sets 145

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Outcomes and Assessment Information Set 145

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Healthcare Effectiveness Data and Information Set 146

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Uniform Hospital Discharge Data Set 146

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Common Clinical Data Set 146

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Database of Clinical Terminologies, Classifications, and Code Systems 147

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References 149
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Data Sources 154

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Data Management 155

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Data Elements 155

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Data Sets 156

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Databases 159
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Indices 162
Data Mapping 163
Data Warehousing 164
Information Governance 166
Valued Strategic Asset 167
Business Intelligence 167
Situation, Background, Assessment, Recommendation (SBAR) 167
Enterprise Information Management 168
Information Governance Principles for Healthcare 168
AHIMA’s Information Governance Adoption Model Competencies 169
Data Governance 171
Data Stewardship 171
Data Integrity 172
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xii Table of Contents
Data Sharing 173

Data Interchange Standards 174
Information and Data Strategy Methods and Techniques 174
Data Visualization and Presentation 176
Critical Thinking Skills 176
Data Quality 177
AHIMA’s Data Quality Management Model 178
Accuracy 179
Accessibility 179
Comprehensiveness 179
Consistency 179
Currency 179
Definition 179
Granularity 179
Precision 180
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Relevancy 180
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Timeliness 180
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Data Collection Tools 180
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Screen Design 180
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Forms Design 181
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Clinical Documentation Integrity 183
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CDI Tools 185
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Data Management and Bylaws 189
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Provider Contracts with Healthcare Organizations 190
Hospital Bylaws
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Data Management and Technology 190
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HIM Roles 191

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References 193
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Secondary Data Sources 197

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Differences between Primary and Secondary Data Sources 198

Purposes and Users of Secondary Data Sources 199
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Internal Users 199

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External Users 199

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Types of Secondary Data Sources 200

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Facility-Specific Indexes 200

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Disease and Operation Indexes 200

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Physician Index 201

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Registries 201
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Cancer Registries 202

Trauma Registries 204
Birth Defects Registries 206
Diabetes Registries 206
Implant Registries 207
Transplant Registries 208
Immunization Registries 208
Other Registries 211
Healthcare Databases 211
National and State Administrative Databases 211
National, State, and County Public Health Databases 212
HIM Roles 215
References 218
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Table of Contents xiii
Part III Information Protection: Access, Disclosure

and Archival, Privacy and Security 221
Basic Legal Concepts 224
Types and Sources of Laws 224
Constitutions 225
Statutes 225
Administrative Law 226
Judicial Decisions 226
Legal Process 226
Initiation of Lawsuit 226
Discovery 227
E-Discovery 227
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Trial 228
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Evidence 229
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Causes of Action in Professional Liability 229
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Patient Rights Regarding Healthcare Decisions 231
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Advance Directives 231
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Overview of Legal Issues in Health Information Management 234
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Creation and Maintenance of Health Records 234
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Ownership and Control of Health Records, Including Use and Disclosure 234
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Use and Disclosure Under State and Federal Law 235
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Use of Health Records in Judicial Proceedings 236
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Legal Health Record 236

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Importance of the Legal Health Record 236

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Content of the Legal Health Record 237

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Retention of the Legal Health Record 237

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AHIMA Retention Recommendations 238

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Destruction 238
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Medical Staff Credentialing 239

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Licensure 240
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Certification 240
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Accreditation 240
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HIM Roles 241

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References 244
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Use and Disclosure 248

State Laws—Privacy 248
HIPAA Privacy Rule and ARRA 249
HIPAA and ARRA Overview 249
Office of the National Coordinator for Health Information Technology (ONC) 249
Applicability of the Privacy Rule 250
Covered Entities 250
Business Associates 250
Workforce Members 251
Protected Health Information 251
Deidentified Information 252
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xiv Table of Contents
Other Basic Concepts 252

Individual 252
Personal Representative 253
Designated Record Set 253
Minimum Necessary 253
Treatment, Payment, and Operations 253
Individual Rights 254
Right of Access 254
Right to Request Amendment of PHI 255
Right to Request Accounting of Disclosures 256
Right to Request Restrictions of PHI 258
Right to Request Confidential Communications 258
Right to Complain of Privacy Rule Violations 258
HIPAA Privacy Rule Documents 260
Notice of Privacy Practices 260
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Consent to Use or Disclose PHI 262
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Authorization 263
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Uses and Disclosures of Health Information: Authorization and Patient
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Right of Access 263
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Patient Has Opportunity to Agree or Object 264
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Patient Does Not Have Opportunity to Agree or Object 265
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Breach Notification 270
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Definition of Breach 270
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Notification Requirements 271
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Requirements Related to Commercial Uses: Marketing, Sale of Information,
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and Fundraising 271

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HIPAA Privacy Rule Administrative Requirements 272

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Designation of Privacy Officer 272

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Standards for Policies and Procedures 273

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Privacy Training 273

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Enforcement of Federal Privacy Legislation and Rules 273

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Penalties 273
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Legal Action by State Attorneys General 274

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Audits 274
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The Disclosure of Health Information Function 274

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Disclosure of Health Information Quality Control 275

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Authorizations 276
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Valid Authorization 276

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Who Can Authorize Release 277

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Medical Identity Theft 277

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Patient Verification 278

Fair and Accurate Credit Transactions Act (FACTA) 278
Patient Advocacy 279
Compliance 279
HIM Roles 279
References 282

Ensuring the Integrity of Data 286
Ensuring the Availability of Data 287
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Table of Contents xv
Data Security Threats 288

Threats Caused by People 288
Social Engineering 289
Threats Caused by Environmental and Hardware or Software Factors 290
Strategies for Minimizing Security Threats 291
Components of a Security Program 294
Employee Awareness 295
Risk Management Program 296
Risk Analysis 296
Incident Detection 296
Incident Response Plan and Procedures 297
Access Safeguards 297
Identification 298
Authentication 298
Authorization 299
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Physical Safeguards 299
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Administrative Safeguards 300
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Software Application Safeguards 301
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Network Safeguards 301
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Firewalls 301
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Cryptographic Technologies 301
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Web Security Protocols 303
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Intrusion Detection Systems 303
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Disaster Planning and Recovery 303
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Risk Analysis io 303
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Disaster Planning 303
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Disaster Recovery 304

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Data Quality Control Processes 304

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Coordinated Security Program 306

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HIPAA Security Provisions 306

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General Rules 307

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Administrative Safeguards 308

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Physical Safeguards 309

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Technical Safeguards 310

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Organizational Requirements 311

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Policies and Procedures and Documentation Requirements 312

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American Recovery and Reinvestment Act of 2009 Provisions 313

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Forensics 313
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HIM Roles 315

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References 316
Part IV Informatics, Analytics, and Data Use 319

Health Information Systems 323
Current State of Health Information Systems 325
Scope of Health Information Systems 327
Source Systems 327
Administrative and Financial Applications 327
Clinical Departmental Applications 331
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xvi Table of Contents
Specialty Clinical Systems 332

“Smart” Peripherals 332
Core Clinical EHR Systems 333
Results Management 333
Point of Care Documentation 333
Medication Management 335
Clinical Decision Support 338
Analytics and Reporting 339
Supporting Infrastructure 342
Connectivity Systems 344
Telehealth and Newer Forms of Healthcare Delivery 345
Patient-Exchanged Health Information 345
Health Information Exchange 347
Systems Development Life Cycle 349
Identify Needs 350
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Specify Requirements 351
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Design or Acquire 351
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Develop and Implement 354
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Maintain 355
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Monitor Results 355
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HIM Roles 356
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References 359
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Role of Data Analytics in Healthcare Information 365

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Introduction to Analytics 365

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Analytics Tools 366

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Data Visualization 366

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Dashboard 367
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Data Capture Tools 367

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Data Mining 369

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HIM Professionals and Analytics 369

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Strategic Uses of Healthcare Information 370

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Decision Support 370

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Quality Measurement 371

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Clinical Research 372

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Consumers and Healthcare Information 372

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Introduction to Consumer Health Informatics 373

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Health Literacy 373

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Telehealth 374
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Information Access and Navigational Tools 376

Mobile Devices 376
Patient Portals 377
Social Media 377
Personal Health Records 378
Information in Personal Health Records 378
Models of Personal Health Records 378
Patient Safety 379
Health Information Exchange 380
Impact of HIE 380
Interoperability 381
Forms of Health Information Exchange 381
Benefits of Health Information Exchange 381
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Table of Contents xvii
Users of Health Information Exchange 382

eHealth Exchange 382
Challenges with Sharing Healthcare Information 382
Patient Identity 383
Data Standards 383
HIM Roles 386
References 387

Presentation of Statistical Data 392
Tables 393
Charts and Graphs 394
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Bar Charts 394
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Pareto Charts 397
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Pie Charts 397
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Line Graphs 398
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Histograms 398
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Frequency Polygons 398
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Scatter Charts 399
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Bubble Charts 401
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Stem and Leaf Plots 402
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Box-and-Whisker Plots 403
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Statistical Packages and Presentation Software io 403
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Descriptive Statistics 405
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Frequency and Percentile 406

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Measures of Central Tendency 406

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Mean 406
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Median 407
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Mode 407
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Measures of Variability 407

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Range 407
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Variance 407
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Standard Deviation 407

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Normal Distribution 408

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Inferential Statistics 410

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t-tests 410
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Chi-square Tests 411

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Regression Equations 411

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Analysis of Variance 411

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How to Analyze Information 413

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Quality, Safety, and Effectiveness of Healthcare 413

Structure and Use of Health Information and Healthcare Outcomes 414
Individual Data 414
Comparative Data 414
Aggregate Data 415
Research Methodologies 416
Quantitative Studies 416
Descriptive Studies 416
Correlational Studies 416
Retrospective Studies 417
Prospective Studies 417
Experimental Studies 419
Quasi-Experimental Studies 419
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xviii Table of Contents
Qualitative Research 420

Grounded Theory 420
Ethnography 420
Mixed-Methods Approach 421
Randomization 421
Institutional Review Board 422
Healthcare Research Organizations 423
Centers for Disease Control and Prevention 423
World Health Organization 423
Agency for Healthcare Research and Quality 424
Ethics in Research 424
HIM Roles 425
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References 427
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Discrete versus Continuous Data 431
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Common Statistical Measures Used in Healthcare 432
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Three Common Examples of Ratio-Level Data: Ratios, Proportions, and Rates 433
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Ratio 433
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Proportion 433
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Rate 433
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Acute-Care Statistical Data 435
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Administrative Statistical Data 435

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Inpatient Census Data 436

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Inpatient Bed Occupancy Rate 438

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Bed Turnover Rate 439

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Length of Stay Data 440

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Patient Care and Clinical Statistical Data 443

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Hospital Death (Mortality) Rates 443

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Gross Death Rate 443

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Net Death Rate 443

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Newborn Death Rate 443

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Fetal Death Rate 444

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Maternal Death Rate 444

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Autopsy Rates 446

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Gross Autopsy Rates 446

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Net Autopsy Rates

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446
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Hospital Autopsy Rates 447

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Newborn Autopsy Rates 447

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Fetal Autopsy Rates 448

Healthcare-Associated Infection Rates 449
Healthcare-Associated Infection Rates 449
Postoperative Infection Rates 450
Consultation Rates 451
Case-Mix Statistical Data 451
Ambulatory Care Statistical Data 454
Public Health Statistics and Epidemiological Information 455
National Vital Statistics System 456
Population-Based Statistics 460
Birth Rates and Measures of Infant Mortality 460
Other Death (Mortality) Rates 462
Measures of Morbidity 464
National Notifiable Diseases Surveillance System 466
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Table of Contents xix
HIM Roles 468

References 469
Part V Revenue Cylce Management and Compliance 471

Healthcare Insurance 474
Revenue Cycle Management 475
Patient Registration 475
Documentation, Coding, and Charge Capture 476
Healthcare Claims Processing 477
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Working the Accounts Receivable 478
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Healthcare Insurers 479
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Commercial Insurance 479
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Private Healthcare Insurance 480
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Employer-Based Coverage 480
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Employer-Based Self-Insurance Plans 480
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Not-for-Profit and For-Profit Healthcare Plans 480
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Managed Care 481
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Health Maintenance Organizations 481
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Preferred Provider Organizations io 482
Point-of-Service Plans 482
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Exclusive Provider Organizations 482

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Government-Sponsored Healthcare Plans 482

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Medicare 483
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Medicaid 484
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The Medicare–Medicaid Relationship 484

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TRICARE 485
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Veterans Health Administration 485

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Civilian Health and Medical Program of the Department of Veterans Affairs 485
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Indian Health Services 486

e
Workers’ Compensation 487

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New Trends 488

20
Health Insurance Marketplace or Exchange 488

20
Consumer-Directed Health Plans 488

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Hospital-Acquired Conditions and Present on Admission Indicator Reporting 489

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Medicare Access and CHIP Reauthorization Act 489

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yr
Patient Protection and the Affordable Care Act 490

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Utilization Management 490

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Case Management 490

Healthcare Reimbursement Methodologies 491
Fee-for-Service Reimbursement 491
Value-Based Purchasing 491
Traditional Fee-for-Service Reimbursement 491
Managed Fee-for-Service Reimbursement 492
Episode-of-Care Reimbursement Methodologies 492
Capitation 492
Global Payment 492
Prospective Payment 492
Medicare Acute Inpatient Prospective Payment System 493
Medicare Severity Diagnosis-Related Groups 493
Resource-Based Relative Value Scale System 494
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xx Table of Contents
Skilled Nursing Facility Prospective Payment System 494

Outpatient Prospective Payment System 494
Ambulatory Surgery Center Prospective Payment System 494
Home Health Prospective Payment System 494
Ambulance Fee Schedule 495
HIM Roles 495
References 496

Federal Regulations and Initiatives 502
Office of the Inspector General 502
False Claims Act 504
n.
Whistleblower Protection Act 504
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Anti-Kickback Statute 504
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The Stark Law 504
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Balanced Budget Act of 1997 and the Exclusions Program 505
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Health Insurance Portability and Accountability Act 505
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Health Care Fraud Prevention and Enforcement Action Team 506
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Recovery Audit Contractor 506
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Quality Improvement Organization 508
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Merit-Based Incentive Payment System 509
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Compliance Program
io 511
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Fraud and Abuse Prevention Strategies 512

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Audits 513
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Types of Audits 513

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Preparing for and Conducting Audits 515

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External Audits 517

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Denials and Appeals 517

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Coding and Fraud and Abuse 518

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Coding Compliance 518

Queries 519
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Computer-Assisted Coding 519

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Clinical Documentation Integrity 521

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Information Systems and CDI 521

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Clinical Documentation Integrity Monitoring and Metrics 521

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HIM Roles 522

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References 522
Part VI Leadership 525

Management 528
Organizational Behavior 530
Organizational Structure 530
Management Levels 531
Organizational Tools 531
Organizational Chart 531
Mission, Vision, and Values Statements 531
Policies and Procedures 532
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Table of Contents xxi
Strategic and Operational Planning 534

Developing Strategic and Operational Plans 535
Information Management Strategic Plan 535
Strategic Information Systems Planning 535
Work Analysis, Change Management, and Project Management 536
Work Analysis and Design 536
Change Management 537
Project Management 538
Project Management Life Cycle 538
Project Management Tools 538
Project Management Professional 539
Financial Management 540
Accounting 541
Budgets 541
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Supply management 542
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Staffing 542
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Management of Resources and Allocation 542
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Management of Vendors and Contracts 543
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Enterprise Information Management 543
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Management of Mergers 543
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Management of Corporate Compliance and Patient Safety 544
an
Risk Management and Risk Analysis
M
544
n
Customer Satisfaction io 545
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HIM Roles 546
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In

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References 547
ea
H

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ic
Performance Measurement and Quality Improvement 550

er
Traditional Performance Improvement Process 551

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Sentinel Events 553

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Quality Dimensions of Performance Improvement 553

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Contemporary Approach to Process Improvement 554

20
Fundamental Principles of Continuous Performance Improvement 555

20
The Problem Is Usually the System 556

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Variation Is Constant 556

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Data Must Support Performance Improvement Activities

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and Decisions 557

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Support Must Come from the Top Down 557

The Organization Must Have a Shared Vision 557
Staff and Management Must Be Involved in the Process 557
Setting Goals Is Critical 558
Effective Communication Is Important 558
Success Should Be Celebrated 558
Formal Performance Improvement Activities 558
Checksheets 559
Data Abstracts 559
Time Ladders 559
Statistics-Based Modeling Techniques 560
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xxii Table of Contents
Team-Based Performance Improvement 562

Identifying Customers and Their Requirements 562
Documenting Current Processes and Identifying Barriers 562
Benchmarking 562
Collecting Current Process Data 563
Flow Chart Current Process 563
Brainstorm Problem Areas 563
Cause-and-Effect Diagram 565
Force-Field Analysis 565
Analyzing Process Data 566
Process Redesign 566
Recommendations for Process Change 566
Managing Quality and Performance Improvement 568
Organizational Components of PI 568
Standards of Organizational Quality in Healthcare 569
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Clinical Practice Guidelines and Protocols 569
ia
Accreditation Standards 569
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Government Regulations and Licensure Requirements 571
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Utilization Management 572
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Risk Management 572
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Risk Identification and Analysis 572
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Loss Prevention and Reduction 573
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Claims Management 573
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Patient Advocacy 573
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Accreditation Requirements for Risk Management in Acute-Care Hospitals
io 573
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Clinical Quality Management Initiatives 576
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Accountable Care Organizations 577

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Robust Process Improvement Methodologies 577

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Lean 577
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Six Sigma 578

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Lean Six Sigma 578

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High Reliability Organizations 578

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ISO 9001 Certification 578

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Medication Reconciliation 579

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HIM Roles 579

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by

20
References 581
20
©
Leadership 583
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Chapter 19
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Leadership Theories 584

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Trait Theory 585

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Behavior Theory 585

Contingency Theory 585
Power and Influence Theory 586
Leadership Styles 587
Patterns of Leadership 588
Transformational and Transactional Leadership 589
Change Management 590
Methods of Change Management 590
Kotter’s Eight-Step Method to Leading Change 590
Lewin’s Change Management Model 590
Bridge’s Transitional Model of Change 591
Mergers 592
Electronic Record Systems 592
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Table of Contents xxiii
Leadership 592
Leadership Competencies 592
Emotional Intelligence 593
Leading Others 593
Critical-Thinking Skills 593
C-Suite 594
Chief Executive Officer 594
Chief Information Officer 594
Chief Financial Officer 594
Team Leadership 595
Team Charter 596
Team Purpose 596
Team Selection 596
Team and Member Participation 597
n.
Team Norms 598
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Team Meetings 598
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Scheduling of Meetings 598
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Conducting Effective Meetings 598
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Consensus Building 599
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Communication 599
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Business-Related Partnerships 601
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Internal Business Partnerships 602
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External Business Partnerships 602
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Leadership Roles 602 io
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m
HIM Roles 603

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fo

In

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References 605
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Human Resources Management 607

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Chapter 20
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Human Resources Management 608

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Roles and Responsibilities 609

Employment Law and Ethics
e
609
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Ethical Principles 610

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Fair Labor Standards Act of 1938 610

20
Equal Pay Act of 1963 610

20
Title VII of the Civil Rights Act of 1964 611

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ht
Harassment 612
ig
Pregnancy Discrimination Act of 1978 612

yr
Age Discrimination in Employment Act of 1967 612

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C
Occupational Safety and Health Act of 1970 612

Americans with Disabilities Act of 1990 613
Civil Rights Act of 1991 613
Family and Medical Leave Act of 1993 613
Genetic Nondiscrimination Act of 2008 614
Major Labor Laws 614
Workforce Planning and Job Analysis 616
Workforce Planning 617
Job Analysis 617
Job Description and Job Specifications 618
Recruitment and Selection 621
Recruitment 621
Selection 621
Testing 622
Interviewing 623
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xxiv Table of Contents
Staffing 625
Organizing Work 625
Scheduling Work 626
Measuring and Improving Performance 627
Performance Management 628
Performance Measurement 628
Developing Standards 628
Measuring Performance 629
Performance Appraisal 630
Performance Appraisal Methods 631
Employee Engagement and Retention 635
Employee Engagement 635
Reducing Turnover 635
Employee Relations and Fair Treatment 636
n.
Communication Strategies 636
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Conflict Management 636
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Disciplinary Action 637
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Handling Grievances 637
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Dismissal 638
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Labor Relations 639
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Union Organization 640
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Supervising in a Union Environment 640
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Training and Development 642
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New Employee Orientation 643
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Employee Training and Development 643

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Planning and Implementation 644

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Delivery Methods 645

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Career Development 647

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Employer Role 648

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an
Employee Role 648

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Return on Investment: Training and Development 649

er
HIM Roles 650

Am

e
th

by
References 651
20
20
Chapter 21 Ethical Issues in Health Information Management 655

©
Moral Values and Ethical Principles 656

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Cultural Competence in the Healthcare Environment 658

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Cultural Disparities in US Healthcare 658

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Healthcare Professionals and Cultural Competence 659

Healthcare Organization Cultural Competence Awareness 660
Training Programs 662
Regulations for Cultural Awareness 662
Ethical Foundations of Health Information Management 663
Professional Code of Ethics for the Health Information Management Professional 664
Professional Values and Obligations 664
Ethical Issues Related to Medical Identity Theft 666
Ethical Decision Making 668
Breach of Healthcare Ethics 669
Important Health Information Ethical Problems 670
Ethical Issues Related to Documentation and Privacy 670
Ethical Issues Related to Disclosure of Health Information 670
Ethical Issues Related to Coding 671
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Table of Contents xxv
Ethical Issues Related to Quality Management, Decision Support, and Public Health 672
Ethical Issues Related to Managed Care 672
Ethical Issues Related to Sensitive Health Information 673
Ethical Issues Related to Research 673
Ethical Issues Related to Electronic Health Record Systems 674
HIM Roles 675
References 676
Appendix A Check Your Understanding Answer Key 679

Appendix B Glossary 715
Index 765
n.
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20
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AB103118_FM.indd 25 2/11/2020 1:38:52 PM

About the Volume Editors and
Chapter Authors
Volume Editors
Nanette B. Sayles, EdD, RHIA, CCS, CDIP, CHDA, CHPS, CPHI, CPHIMS,
FAHIMA, is a professor in the health information management program at East
n.
Central College in Union, MC. She has a BS in medical record administration, an MS
tio
ia
in health information management, a master’s degree in public administration,
oc
and a doctorate of education in adult education. Dr. Sayles has more than 10
ss
tA
years of experience as a health information management practitioner with
en
experience in hospitals, a consulting firm, and a computer vendor. She was the
em
2005 American Health Information Management Association Triumph Educator
ag
an
award recipient. She has held numerous volunteer roles for the American
M
Health Information Management Association (AHIMA), the Georgia Health
n
io
Information Management Association (GHIMA), the Alabama Association of
at
m
Health Information Management (AAHIM), Middle Georgia Health Information

r
fo
Management Association (MGHIMA), and Birmingham Regional Health

In
lth
Information Management Association (BRHIMA). These positions include:

ea
AHIMA Educational Strategies Committee, AHIMA co-chair RHIA Workgroup,

H
an
GHIMA director, and president of MGHIMA. Dr. Sayles is the author of Professional
ic
Review Guide for the CHP, CHS, and CHPS Examinations and Case Studies for Health
er
Am
Information Management. She is an editor for two chapters in the PRG Professional
e
Review Guide for the RHIA and RHIT examinations.

th
by
20
Leslie L. Gordon, MS, RHIA, FAHIMA, is the director of performance

20
improvement for the Southeast Alaska Regional Health Consortium. She earned
©
a BA and an MS from the College of St. Scholastica. She taught at the University
ht
ig
of Alaska Southeast for many years. Before teaching she worked as a coder, reim-
yr
op
bursement manager, and data analyst at a hospital in Sitka, Alaska. Ms. Gordon is
C
an active member of the Alaska CSA (AKHIMA) and has served in several posi-
tions on the AKHIMA Board. She is a Fellow of AHIMA and currently serves on
the Council of Accreditation of Health Informatics and Information Management
Education (CAHIIM) Health Information Management Accreditation Council
(HIMAC).
xxvi
AB103118_FM.indd 26 2/11/2020 1:38:53 PM

About the Volume Editors and Chapter Authors xxvii
Paradigm Education Solutions in 2015-2019. Other

Chapter Authors volunteer experiences include being a member of
Margret K. Amatayakul, MBA, RHIA, CHPS, the AHIMA Council for Excellence in Education
CPEHR, FHIMSS, is president of Margret\A Con- (CEE) HIMR Strategic Oversight Committee,
sulting, LLC, in West Linn, Oregon, a consult- the AHIMA Commission on Certification for
ing firm specializing in electronic health records Health Informatics and Information Management
(EHRs) and health information, including imple- (CCHIIM), the Registered Health Information
menting standards and regulations. She has been Technician Construction Committee and several
a leading authority on health IT strategies for over AHIMA CEE workgroups. Dr. Bowe has also
40 years. She has extensive national and interna- served as a CAHIIM accreditation peer reviewer.
tional experience in EHR optimization and workflow
redesign, HIPAA privacy, security, and transac- Megan R. Brickner, MSA, RHIA, serves as the
n.
tions/code sets, and adoption of value-based care. director of compliance programs and privacy of-
tio
She helped form and served as executive direc- ficer for the Kettering Health Network in Dayton,
ia
oc
tor of the Computer-based Patient Record Insti- Ohio. She is responsible for daily and strategic
ss
operations of the Kettering Health Network’s
tA
tute (CPRI), was associate executive director of
en
AHIMA, associate professor at the University of information security and privacy program, titled
em
Illinois at Chicago, and director of medical record PROTECT. Her PROTECT Program was highlight-
ag
services at the Illinois Eye and Ear Infirmary. She ed at the 2012 Annual Ohio Hospital Association
an
M
holds a clinical associate professorship at the Uni- Meeting as a program of best practice and at
n
versity of Illinois at Chicago, and she is serves as io
the 2016 Ohio Health Information Management
at
adjunct faculty at the College of St. Scholastica. She Association’s 36th Annual Meeting and Trade
m r
fo
is a highly sought-after speaker, has published ex- Show. Most recently, her privacy program was
In
tensively, serves on several boards, and has earned highlighted as an industry best practice in the cus-
lth
ea
numerous professional service awards. tomer success story published by the FairWarning
H
company in 2019. Ms. Brickner has over 20 years

an
ic
Hertencia Bowe, EdD, MSA, RHIA, FAHIMA, of experience in the area of healthcare compliance.
er
Am
is an assistant professor at Fisher College in She holds a bachelor’s in healthcare administra-

the undergraduate health information manage- tion and health information management as
e
th
ment. Dr. Bowe is also the principal consultant at well as a master’s in healthcare administration.
by
Bowe Academic Consulting, LCC. In this role, she Ms. Brickner is a registered health information
20
20
coaches academic programs challenged by ap- administrator (RHIA) and has served as an adjunct
©
plying professional competencies and navigating faculty member for the health information manage-
ht
ig
accreditation standards. Dr. Bowe has extensive ment department at Sinclair Community College
yr
op
experience in teaching and developing health in- in Dayton for over 15 years.
C
formation management (HIM) curricula and has

a depth of knowledge in academic programmatic Danika E. Brinda, PhD, RHIA, CHPS, HCISPP,
accreditation solutions. She has held numerous ap- is an associate professor in the health informatics
pointed and volunteer positions with the American and information management department at the
Health Information Management Association College of St. Scholastica. She teaches a variety
(AHIMA), the Commission on Accreditation of of courses in the health information management
Health Information and Informatics Management and health informatics programs related to legal
(CAHIIM), and the Florida HIM Association issues in healthcare, HIPAA privacy and security,
(FHIMA). She served on the 2017-2018 CAHIM compliance, EHRs in healthcare, and research.
Board while chairing its HIM Accreditation Dr. Brinda is the CEO of TriPoint Healthcare Solutions
Council. Dr. Bowe has served as a health in- and Planet HIPAA, which focus on helping organi-
formation technology advisory board member for zations understand, operationalize, and implement
AB103118_FM.indd 27 2/11/2020 1:38:53 PM

xxviii About the Volume Editors and Chapter Authors
the complex healthcare privacy and security regu- and product development activities related to
lations. She enjoys making privacy and security the creation and implementation of natural lan-
regulations fun and understandable to all organi- guage-processing applications where clinical ter-
zations and specialties in healthcare. Dr. Brinda is minology and classification systems are utilized.
a well-known speaker in healthcare privacy and Ms. Giannangelo has a comprehensive background
security. She is a 2010 recipient of the AHIMA in the field of clinical terminologies and classifica-
Rising Star Triumph Award. tion, with over 30 years of experience in the health
information management (HIM) field. Prior to
Darcy Carter, DHSc, MHA, RHIA, earned her joining L&C, she was director of practice leader-
doctorate degree in health science with an em- ship with AHIMA. She has served as senior no-
phasis in leadership and organizational behavior sologist for a health information services company
and her master’s degree in healthcare administra- and worked in various HIM roles, including vice
n.
tion. She is currently assistant professor and MHA president of product development, education spe-
tio
program director at Weber State University where cialist, director of medical records, quality assur-
ia
oc
she teaches courses in coding, reimbursement, ance coordinator, and manager of a Centers for
ss
tA
and database management. Dr. Carter is coauthor Disease Control and Prevention research team.
en
of Quality and Performance Improvement in Health- Ms. Giannangelo has developed classification,
em
care: Theory, Practice, and Management published by grouping, and reimbursement systems products
ag
AHIMA. for healthcare providers; conducted seminars;
an
M
and provided consulting assessments throughout
n
Darline Foltz, RHIA, CHPS, CPC, is assistant io
the United States as well as in Canada, Australia,
at
professor-educator in the online health information Ireland, Bulgaria, and the United Kingdom. She
m
r
fo
systems technology program at the University has authored numerous articles and created online
In
of Cincinnati Clermont College. She is currently continuing education courses on clinical termi-
lth
ea
pursuing her master’s degree in educational stud- nologies. As an adjunct faculty at the College
H
ies from the University of Cincinnati. Ms. Foltz has of St. Scholastica, she teaches a graduate course
an
ic
a bachelor’s degree in health information manage- in clinical vocabularies and classification systems.
er
Am
ment (HIM) from The Ohio State University and She is an active volunteer in the HIM profession at
a bachelor’s degree in information systems from the international, national, state, and local levels.
e
th
the University of Cincinnati. Prior to joining UC Ms. Giannangelo holds a master’s degree in HIM
by
Clermont, Ms. Foltz spent her career in many fac- from the College of St. Scholastica.
20
20
ets of HIM including owning her own consulting

©
business; director of HIM at Deaconess Hospital, Morley L. Gordon, RHIT, is a clinical infor-
ht
ig
Cincinnati; director of HIM at the Drake Center; matics specialist for Home Health and Hospice
yr
op
and director of IS and telecommunications at Dea- at Evergreen Health Hospital in Kirkland,

C
coness Hospital, Cincinnati. Ms. Foltz has been a Washington. Prior to that role, she was the di-
consultant for long-term and acute-care hospitals, rector of health information management (HIM)
nursing homes, dialysis clinics, physician offices, at a long-term care facility in Central Washington.
mental health agencies, drug and alcohol rehab She graduated from the Western Governors
centers, and rehab hospitals and she is the co- University with her bachelor’s degree in health
author of the textbook, Exploring the Electronic informatics. She also studied health informa-
Health Records. tion technology at the University of Alaska. She
credits her mom, Leslie Gordon, with introduc-
Kathy Giannangelo, MA, RHIA, CCS, ing her to the field of health information man-
CPHIMS, FAHIMA, is a medical informaticist with agement and for recommending that she pursue
Language and Computing, Inc (L&C). In this posi a career in HIM. Ms. Gordon is grateful for the
tion, she supports the ontology, modeling, sales, opportunities that she is afforded because of it.
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About the Volume Editors and Chapter Authors xxix
Misty Hamilton, MBA, RHIT, is a professor and egree in medical record administration from the
d
director of health information management tech- Medical College of Georgia, a master’s degree in
nology at Zane State College for the past 13 years. health education from Florida State University,
She teaches courses in introduction to health infor and PhD in educational leadership from Florida
mation management, legal aspects in health care, A&M University. Dr. McNeill has over 30 years of
clinical classification I, II, and III, health care qual- experience as a health information management
ity improvement, and management of health in- educator, rising to the academic rank of profes-
formation services. Ms. Hamilton is also a member sor. She is the former director of the division of
of the Ohio Educator’s Day Committee as well as health informatics and information management.
the curricula workgroup through AHIMA. Dr. McNeill has several educational publications
to her credit, including research articles in Per-
Karen M. Lankisch, PhD, MHI, RHIA, CHDA, spectives in Health Information Management, Jour-
n.
CPC, CPPM, holds a bachelor’s degree in busi- nal of Allied Health, and the Journal of the American
tio
ness, a master’s degree in health informatics, a Health Information Management Association. She is
ia
oc
master’s degree in education, and a doctorate an active member and has served in leadership
ss
degree in education. Dr. Lankisch has has over roles of the Northwest Florida Health Informa-
tA
en
10 years of experience in the health information tion Management Association, Florida Health
em
management. Dr. Lankisch is a registered health Information Management Association, and
ag
information administrator (RHIA), a certified American Health Information Management As-
an
M
data analyst (CHDA), and an active member of sociation (AHIMA). Dr. McNeill is the recipient
the American Health Information Management n
io
of the Florida Health Information Management
at
Association (AHIMA). She holds certified pro- Association 2008 Distinguished Service Award,
m r
fo
fessional coder (CPC) and a certified physician the 2010 Literary Award, and the 2015 Educator
In
practice management (CPPM) credentials through Award. Dr. McNeill is the recipient of the 2015
lth
ea
the American Association of Professional Coders American Health Information Management As-
H
(CPC). Dr. Lankisch has worked in higher educa- sociation Educator Triumph Award. She is also a
an
ic
tion for over 20 years. Dr. Lankisch is a Quality Fellow of AHIMA.

er
Am
Matters Master Peer Review and has completed

reviews both nationally and internationally. Kelly Miller, MA, RHIA, is an assistant profes
e
th
Dr. Lankisch has served on the panel of reviewers sor and program coordinator for the health in-
by
for the Commission on Accreditation for Health formation management (HIM) program at Regis
20
20
Informatics and Information Management Edu- University. She is currently pursuing her doctor-
©
cation (CAHIIM) since 2016. Dr. Lankisch is a co- ate in health administration with a focus in health
ht
ig
author of two textbooks and a contributing co-author care quality analytics. She has worked in various
yr
op
of a health-related textbook for health information HIM roles including assistant director at an acute
C
technology. In 2013, she received the University care hospital, director of records management for
of Cincinnati Faculty Award for Innovative Use of a large hospital network and HIM director at a
Technology in the Classroom. In 2016, Dr. Lankisch Specialty Hospital. In these roles, she oversaw all
was selected as a member of the Academy of Fel- HIM operations including a system-wide records
lows of Teaching and Learning at the University of retention/destruction project, scanning and ar-
Cincinnati. In 2018, she received the UC Clermont chiving of medical records and an EHR implemen-
Faculty Mentoring Award. tation. Ms. Miller served as a member of AHIMA’s
Council for Excellence in Education from 2015-
Marjorie H. McNeill, PhD, RHIA, CCS, 2018. In this role she chaired the curriculum work-
FAHIMA, serves as the interim associate dean group. She has served in numerous roles within
of the School of allied health sciences at Florida the Colorado HIM Association; including director,
A&M University. Dr. McNeill earned her bachelor’s education committee chair and delegate. She is a
AB103118_FM.indd 29 2/11/2020 1:38:53 PM

xxx About the Volume Editors and Chapter Authors
recipient of CHIMA’s Distinguished Member and Laurie A. Rinehart-Thompson, JD, RHIA, CHP,
Outstanding Volunteer award. FAHIMA, is professor and director of the health
information management (HIM) and systems pro-
Miland N. Palmer, MPH, RHIA, earned his gram at The Ohio State University. She earned a
master’s degree in public health from the Univer- bachelor’s degree in medical record administra-
sity of Utah and is currently pursuing his PhD tion and a Juris Doctor degree, both from The Ohio
in public health. Mr. Palmer is a full-time faculty State University. In addition to education, her pro-
member at Weber State University in the health fessional experiences include behavioral health,
administrative services department where he home health, and acute care. She has served as
teaches courses in health administration, health an expert witness in civil litigation regarding the
information management, healthcare data govern- privacy and confidentiality of health information/
ance, epidemiology, and biostatistics. Mr. Palm- HIPAA compliance. She has served on numerous
n.
er has over 10 years experience in public health, AHIMA committees and is a member of AHIMA’s
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health administration, and health information Council for Excellence in Education. She is a mem-
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management, spending time at the Utah Depart- ber of the board of directors of the Ohio Health
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ment of Health and the Department of Veterans Information Management Association (OHIMA).
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Affairs Salt Lake City Healthcare System. She is a recipient of the AHIMA Triumph Award
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and the OHIMA Distinguished Member Award.
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Valerie S. Prater, MBA, RHIT, FAHIMA, is a A speaker on the HIPAA Privacy Rule, she is a co-
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retired clinical assistant professor in the HIM editor and coauthor of AHIMA’s Fundamentals of
program, department of biomedical and health n
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Law for Health Informatics and Information Manage-
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information sciences, College of Applied Health ment, the author of AHIMA’s Introduction to Health
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Sciences, University of Illinois at Chicago (UIC), Information Privacy and Security, and a contributing
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where she continues to teach as an adjunct instruc- author in Health Information Technology: An Applied
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tor. Ms. Prater has been recognized by students Approach (AHIMA), Documentation for Health Re-
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and peers at UIC for her commitment as an cords (AHIMA), Documentation for Medical Practices
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educator, including being the recipient of the (AHIMA), and Ethical Health Informatics: Challeng-
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University’s Silver Circle Award and the Educator es and Opportunities (Jones & Bartlett Learning).
of the Year for the College of Applied Health She has been published in the Journal of AHIMA
e
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Sciences. She serves on the Health Information and in AHIMA’s Perspectives in Health Information
by
Management Council of the Commission on Ac- Management.

20
20
creditation for Health Informatics and Informa-

©
tion Management Education (CAHIIM) and is a Marcia Y. Sharp, EdD, MBA, RHIA, is associate
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member of Society for Human Resource Manage- professor and program director at the University
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ment (SHRM). Ms. Prater has extensive experi- of Tennessee Health Science Center in the depart-
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ence developing curricula for health information ment of health informatics and information man-
programs at UIC and in her previous positions agement. She teaches leadership, information
as program director, DeVry University, Corporate technology, and healthcare information systems.
Academics, and as adjunct faculty for the Uni- Prior to teaching, Dr. Sharp served in leadership
versity of Connecticut. Prior to entering educa- roles in health information management for over
tion, Ms. Prater held healthcare management 15 years. She is a former human resources director
positions with responsibilities encompassing and a retired member of the US Navy Reserve.
operations, strategic planning, quality manage- Previously, Dr. Sharp served as member of
ment, business development, and HIM. She has AHIMA’s Council for Excellence in Education.
delivered numerous presentations to national Additionally, she served on the CEE’s faculty
professional groups, including AHIMA’s Assembly development workgroup and as a delegate for
on Education. the Tennessee Health Information Management
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About the Volume Editors and Chapter Authors xxxi
ssociation. Currently, Dr. Sharp is a reviewer for

A Previously, she served as program director for
AHIMA’s Perspectives in Health Information Man- the medical coding specialist certificate program
agement. She holds a PhD in higher and adult ed- at Santa Barbara City College. Dr. Williamson has
ucation from the University of Memphis, an MBA served in various volunteer capacities including
from Webster University, and a bachelor’s degree the Registered Health Information Technician
in health information management from the Uni- Exam Construction Committee, peer reviewer for
versity of Tennessee. CAHIIM, CAHIIM board member, and most re-
cently a member of CAHIIM’s Health Information
Lynette M. Williamson, EdD, RHIA, CCS, CPC, Management Accreditation Council. In 2011,
FAHIMA, is a full-time assistant professor-educator Dr. Williamson was awarded fellowship from
in the health information management (HIM) de- AHIMA. In 2017, she received the merit scholarship
partment at the University of Hawai’i-West O’ahu. for leadership from AHIMA. Currently, she serves on
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She teaches a variety of courses related to HIM, the Commission on Certification for Health Infor-
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medical coding, and healthcare administration. matics and Information Management (CCHIM).
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Preface
Health information management (HIM) profes- essential for every entry-level HIT practitioner.
sionals play an integral role on the healthcare Although the primary audience for this book is
team. They serve the healthcare industry and the students enrolled in two-year HIT programs, stu-
public by using best practices in managing health- dents in other HIM disciplines and allied health
care information to support quality healthcare programs will find its content highly valuable and
n.
delivery. Whether stored on paper or in electronic useful.
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file format, reliable health information is crucial The fundamental organization of the book is
oc
to quality healthcare. One of the primary goals of built on the curricular content of the HIM associ-
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the HIM professional and profession is to enhance ate degree entry-level competencies. Each of the
en
the individual patient care through timely and rel- content areas is represented in this textbook ex-
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evant information. cept those relating to the biomedical sciences and
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The American Health Information Manage-
an
to technical aspects of classification systems such
M
ment Association (AHIMA) represents more than as the International Classification of Diseases. To
n
103,000 health information professionals who
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provide maximum flexibility for instructional de-
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work throughout the healthcare industry. AHIMA livery, the content of each chapter is designed to
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has a long history of commitment to HIM educa- stand on its own, providing maximum coverage
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tion. Among other contributions, AHIMA has de- of specific domains and competencies. Because
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veloped and maintained a rigorous accreditation of the interdependency of content areas that sup-
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process for academic programs, continuously de- port knowledge and skills for performing many of
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veloped up-to-date curriculum models, supported the competencies, this approach has necessitated
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faculty development, and continued to research some duplication of material throughout the text.
e
and study the needs and future directions of HIM In these cases, the predominant content is cov-
th
education. ered in depth and is supplemented by a high-level

by
20
This textbook is specifically developed for as- overview of other supporting knowledge. Where
20
sociate degree programs in health information appropriate, students are referred to other chap-
©
technology (HIT) and serves as an outgrowth of ters for additional information or detail to round
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AHIMA’s ongoing commitment to provide valu- out necessary knowledge.

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able resources for the education and training of The organizing framework for content of the
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new HIM professionals. Its subject matter is based text is arranged in order by the six domains con-
on AHIMA’s HIM associate degree program entry- tained in the HIM Associate Degree Entry-Level
level competencies and AHIMA’s registered health Competencies. These domains are: Data Content
information technician (RHIT) certification exam- Structure and Standards; Information Protection:
ination content domains. AHIMA made a signif- Access, Disclosure, Archival, Privacy, and Securi-
icant change to the entry-level competencies in ty; Informatics, Analytics, and Data Use; Revenue
2018 and this curriculum change created the need Management; Compliance; and Leadership. This
for modifications to this edition. This edition fol- organization does not presuppose a pedagogical
lows the prescribed curricular content found in the progression of presenting basic foundations and
HIM associate degree entry-level competencies then progressing to advanced concepts. Therefore,
and covers the information and topics considered given its student population, mission and goals,
xxxii
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Preface xxxiii
and other variables, each academic program must information; the healthcare delivery system; and
assess the appropriate sequence of presentation of how health information is managed. Chapter 1,
the chapters within its curriculum. Additional in- Health Information Management Profession, intro-
formation and models of chapter sequencing can duces the concept of HIM. The discussion focus-
be found in the instructor’s manual. es on the history of the HIM profession and the
The book’s underlying structure is to translate evolution of the roles and functions of HIM pro-
basic theory into practice. A review of the cogni- fessionals over the years. Particular emphasis is
tive and competency levels of the entry-level com- placed on HIM future roles and their relationship
petencies reveals that HIT programs are applied to the movement toward an electronic health record
in nature. Outcome expectations are that students (EHR). Chapter 2, Healthcare Delivery Systems, intro-
understand theory at a basic level with a major em- duces the history, organization, financing, and deliv-
phasis on skill building to perform day-to-day op- ery of health services in the United States. Chapter
n.
erational tasks in health information management. 3, Health Information Functions, Purpose, and Users,
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Therefore, the pedagogical tools used throughout introduces the function and purpose of the health
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the book focus on translating basic theory into prac- record function as well as who uses the record.
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tice. To accomplish this, each chapter contains the
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following features to reinforce comprehension: Part II, Data Content Structure and Standards
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Part II reflects Domain I of the 2018 AHIMA com-
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Check Your Understanding This active learn- petencies and explores the content related to diag-
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ing review feature includes multiple-choice, nostic and procedural classification and terminol-
matching, and true-and-false questions. These re- n
ogies, health record documentation requirements,
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view quizzes appear throughout each chapter to data accuracy and integrity, data integration and
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reinforce concepts covered in the sections the stu- interoperability, and the needs for data, informa-
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dents have just read. Students are asked to pause tion standards, and data management policies and
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and review these concepts to ensure they under- procedures. Chapter 4, Health Record Content and
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stand the key concepts before moving ahead. Documentation, introduces students to standards
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for the content of the health record and require-

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Real-World Cases Two real-world cases appear ments for documentation. Chapter 5, Clinical Termi-
at the end of each chapter. These cases present two nologies, Classifications, and Code Systems, provides an
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actual situations faced by HIM professionals. The introduction to clinical vocabularies and classifica-
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cases are designed to help students develop the tion systems. Its purpose is to introduce the char-
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critical skills they need to be successful. acteristics of prominent systems and help students
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understand how they are used throughout the

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This text is divided into six parts that correspond with healthcare system. Chapter 6, Data Management, is
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the domains from the 2018 AHIMA Associate Degree

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an essential part of the day-to-day operations of

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Entry-Level Competencies. Where appropriate, chap- a healthcare organization. It includes understand-

ter content has been expanded in this new edition to ing data sources and where they exist, how they are
prepare students for transitional and changing roles transmitted, and where they are stored. Chapter 7,
in an electronic health information environment. All Secondary Data Sources, explains the uses of the
chapters have been updated to reflect current trends, health record beyond patient care, such as registries
practices, standards, and legal issues. and administrative functions.
Part I, Foundational Concepts These chapters Part III, Information Protection: Access, Disclo-
provide a vital foundational base to the under- sure and Archival, Privacy and Security This
standing of HIM in general. This part concentrates part contains healthcare law including theory of
on the roles of the health information manager; all healthcare law excluding what is covered by
the content, function, structure, and uses of health compliance, privacy, security, and confidentiality

AB103118_FM.indd 33 2/11/2020 1:38:53 PM

xxxiv Preface
policies and procedures, in addition to the infra- as well as revenue cycle regulations and activities
structure and education of staff on information related to revenue management and compliance.
protection methods, risk assessment, access, and Chapter 15, Revenue Cycle and Reimbursement,
disclosure management and falls under Domain explores the billing and payment methodologies.
II of the 2018 AHIMA competencies. Chapter 8, Chapter 16, Fraud and Abuse Compliance, addresses
Health Law, discusses legal issues associated with federal laws that mandates all healthcare organi-
health information and includes an overview of zations comply with standards of quality care and
sources of law and legal system. Chapter 9, Data Pri- proper billing practices.
vacy and Confidentiality, are defined in terms of the
legal rights of patients and the responsibility of Part VI, Leadership This part covers leadership
healthcare organizations to protect those rights. models, theories and skills, change management,
Chapter 10, Data Security, examines the concept of workflow analysis, design tools and techniques,
n.
data security, which encompasses measures and human resources management training and de-
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tools to safeguard data and the information sys- velopment strategic planning, financial manage-
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tems on which they reside from unauthorized ment, ethics and project management and reflects
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access, use, disclosure, disruption, modification, Domain VI of the 2018 AHIMA competencies. In
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or destruction. Chapter 17, Management, explores the process of
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planning, controlling, leading, and organizing
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Part IV, Informatics, Analytics and Data the activities of a healthcare organization Chap-
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Use Part IV addresses the creation and use of ter 18, Performance Improvement, is the continuous
business health intelligence, including the review of n
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study and adaptation of a healthcare organiza-
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selection implementation, use and management of tion’s functions and processes to increase the like-
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technology solutions, system and data architecture, lihood of achieving desired outcomes. Chapter
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interface consideration, information management 19, Leadership, leadership theories and styles are
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planning, data modeling systems, testing technol- explored and the impact of change management
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ogy, benefit realization analytics and decision sup- on processes, people, and systems. Chapter 20,
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port, data visualization techniques, trend analysis Human Resources Management and Professional De-
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administrative reports, statistics, data quality and velopment, help students understand the laws and
covers Domain III of the 2018 AHIMA competen- regulations related to human resource management
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cies. Chapter 11, Health Information Systems, defines and the need for employee training and develop-
by
the scope of health information technology and ment. Chapter 21, Ethical Issues in Health Information
20
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how it has evolved into its current state in health- Management, discusses the ethical issues asso-
©
care settings. The systems development life cycle ciated with health information management and
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is explored in terms of management of health IT. presents the concepts of stewardship and the HIM
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Chapter 12, Healthcare Information, discusses the professional’s core ethical obligations.
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importance of healthcare information to the health- A complete glossary of HIM terms is provided
care industry and the strategic uses of that in- at the end of the book. Boldface type is used in the
formation. Chapter 13, Research and Data Analysis, text chapters to indicate the first substantial refer-
provides methods to analyze and present health- ence to each glossary term. The bolded terms in a
care data and information in an understandable chapter are listed at the beginning of the chapter
and useful fashion. Chapter 14, Healthcare Sta- and are identified as key terms.
tistics, discusses common statistical measures and An answer key, glossary, and a detailed content
types of data used by organization in different index complete the book.
healthcare settings. AHIMA provides supplemental materials for ed-
ucators who use this book in their classes. Instructor
Part V, Revenue Cycle and Compliance This part materials for this book include lesson plans, lesson
reflects Domains IV and V of the 2018 AHIMA com- slides, RHIT competency map, test bank, and other
petencies and includes healthcare reimbursement, useful resources.
AB103118_FM.indd 34 2/11/2020 1:38:53 PM

Student and Instructor Online
Resources
For Students the instructor materials, please contact AHIMA

Visit http://www.ahimapress.org/sayles7201/ and Customer Relations at (800) 335-5535 or submit
register your unique student access code that is pro- a customer support request at https://my.ahima
vided on the inside front cover of this text to down- .org/messages.
laod the following valuable study and practice
n.
resources: Information about a new optional digital
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adaptive learning tool to strengthen comprehension AHIMA’s new responsive adaptive learning tool
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of key concepts; student workbook with real-world for health information management programs
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cases and case discussion questions, application ex-
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ercises, and review quizzes; and AHIMA’s Code of What is Adaptive Learning?
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Ethics, and AHIMA’s Standards of Ethical Coding. AHIMA Press has partnered with adaptive learning
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systems leader, Area9 Lyceum, to bring this power-
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ful technology to health information management
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For Instructors
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academic programs. This adaptive learning tool
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Instructor materials for this textbook are provided automatically customizes instructional content
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only to approved educators. In addition to the stu- based on need. Students receive incremental as-
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dent resources, instructors can access the following sistance in areas where they struggle, facilitating
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educator resources: instructor’s manual, presenta- both mastery and confidence.

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tion slides, new adaptive learning tool, course cur- Technology will never replace a student’s hard
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riculum map, and a test bank instructor’s manual work nor an experienced educator’s training and
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and PowerPoint slides. Please visit http://www intuition. But innovation can improve how we
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.ahima.org/publications/educators.aspx for further approach and deliver education. Learn more at

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instruction. If you have any questions regarding ahima.org/adapt.

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Acknowledgments
Many health information management profes- Elizabeth D. Bowman, MPA, RHIA

sionals contributed to the development of the Sheila Carlon, PhD, RHIA, CHPS, FAHIMA
sixth edition of this landmark textbook. The vol- Bonnie S. Cassidy, MPA, RHIA, FHIMSS, FAHIMA
ume editors and AHIMA press extend their sin- Lisa A. Cerrato, MS, RHIA
cere thank you to Merida L. Johns, PhD, RHIA, Michelle L. Dougherty, RHIA, CHP
n.
for pioneering this textbook through the first three Chris Elliott, MS, RHIA
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editions. We thank all the chapter authors for shar- Sandra R. Fuller, MA, RHIA
oc
ing their expertise and time revising this text with Michelle A. Green, MPS, RHIA, CMA, CHP
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the most up-to-date content and the best examples Laurinda B. Harman, PhD, RHIA, FAHIMA
en
and resources. Anita C. Hazelwood, MLS, RHIA, FAHIMA
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No publication is ever complete without the dil- Terrill Herzig, MSHI
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igent efforts of the subject expert reviewers. Their Beth M. Hjort, RHIA
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careful reviews and insightful suggestions have Joan Hicks, MSHI, RHIA
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helped us ensure the quality and integrity of this Cheryl V. Homan, MBA, RHIA
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edition. We also want to thank the following review- Merida L. Johns, PhD, RHIA
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ers for their time and critical technical review to Kathleen M. LaTour, MA, RHIA, FAHIMA
In
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this endeavor: Joan Ludwig, RHIA

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Carol E. Osborn, PhD, RHIA

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Nora Blankenbecler, MBA, RHIA

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Dana D. Carcamo, RHIA, CCS Bonnie Petterson, PhD, RHIA

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Harry B. Rhodes, MBA, RHIA

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Valerie D. Brock, RHIA, RHIT, CPC, CDIP, CPAR

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Angela Campbell, RHIA, CHEP Jane Roberts, MS, RHIA

e
Karen S. Scott, MEd, RHIA, CCS-P, CPC

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We also want to acknowledge the following

by
Martin Smith, MEd, RHIT, CCA

chapter authors who contributed to past editions
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Carol A. Venable, MPH, RHIA, FAHIMA

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of this text: Karen A. Wager, DBA, RHIA

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Frances Wickham Lee, DBA, RHIA

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Sandra Bailey, RHIA

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Susan B. Willner, RHIA

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Cathleen A. Barnes, RHIA, CCS

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Mary Jo Bowie, MS, RHIA Andrea Weatherby White, PhD, RHIA

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Foreword
Health Information Management Technology: An Ap- learning, and augmented reality. Every decade
plied Approach continues as the foundational text for brings with it changes in learning and changes
the education and training of health information in the demands placed on it by the workforce. As
management (HIM) students. For the sixth edition, technology continues to evolve, so do the skills re-
the volume editors, Nanette B. Sayles and Leslie L. quired to manage healthcare information. None-
n.
Gordon, have updated the competency coverage for theless, healthcare information will always need
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the data management, data security, and fraud and people to handle it and employers will need
oc
abuse compliance topics. They have also expanded people in place to analyze the information and
ss
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on ethical issues in the health information manage- manage the systems. It is the Health Information
en
ment profession. professional that is needed to ensure that the in-
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The healthcare ecosystem continues to evolve. formation is rich in accuracy and reliable.
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Healthcare delivery, practice, regulation, laws, and It is expected that the next decade will bring
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employment have and continue to change. These both predictable and unpredictable changes in all
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changes have required innovation from all corners areas of healthcare management. However, we re-
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of healthcare, but information remains the most main securely grounded knowing that this book
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important component of quality healthcare. This is anchored in solid facts, principles, and direc-
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text will help prepare the next generation of HIM tives to help ensure your success as you progress
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professionals handling vitally important health- through your career.

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care information, ensuring that quality informa- In closing, I wish you the best that life has to
ic
tion is passed on to students seeking to learn new offer, and I hope this book helps you in your HIM
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knowledge or update their skills. goals, whether you are just starting your career
e
There are several trends happening now in the or you are a seasoned veteran using this book as
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professional development arena that will have an reference.

20
impact on the health information sector: profes-

20
sionalized learning paths, micro-learning/stackable Amy Mosser

©
learning, collaborative leaning, peer-to-peer Chief Operating Officer

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xxxvii
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AB103118_FM.indd 38
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PART
Foundational M
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Concepts
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AB103118_Ch01.indd 1 2/11/2020 12:15:41 PM

AB103118_Ch01.indd 2
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2/11/2020 12:15:41 PM
Chapter
1
Health Information
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Management Profession
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Learning Objectives n
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•• Summarize the development of the health •• Describe the purpose and structure of the American
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information management (HIM) profession from its Health Information Management Association (AHIMA)
In
beginnings to the present •• Explain AHIMA’s certification processes

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•• Discuss how professional practice must evolve •• Discuss the accreditation process of the Commission
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to accommodate changes in the healthcare on Accreditation for Health Informatics and

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environment Information Management Education

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•• Identify the roles of HIM professionals •• Identify the appropriate professional organizations
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for the various specializations of HIM

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Key Terms
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Accreditation Association of Record Librarians of Continuing education units (CEUs)

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Active membership North America (ARLNA) Council for Excellence in Education

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AHIMA Foundation Board of directors (CEE)

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American Academy of Professional Certification Credential

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Coders (AAPC) Chief executive officer Data analytics

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American Association of Medical Code of ethics Data use

Record Librarians (AAMRL) Commission on Accreditation Emeritus membership
American College of Surgeons for Health Informatics and Engage
(ACS) Information Management Fellowship program
American Health Information Education (CAHIIM) Global membership
Management Association Commission on Certification Group membership
(AHIMA) for Health Informatics and Health information management
American Medical Record Information Management (HIM)
Association (AMRA) (CCHIIM) Healthcare Information and
Association for Healthcare Component state associations Management Systems Society
Documentation Integrity (AHDI) (CSAs) (HIMSS)
AB103118_Ch01.indd 3 2/11/2020 12:15:42 PM

4 Part 1 Foundational Concepts
Hospital Standardization Program New graduate membership Registered Health Information

House of Delegates New to AHIMA membership Technician (RHIT)
Informatics Premier membership Registration
Information governance Registered Health Information Student membership
National Cancer Registrars Administrator (RHIA)
Association (NCRA)
This chapter introduces the history of the health more important now than it was when the Asso-
information management (HIM) profession and ciation of Record Librarians of North America
offers insights into the current and future roles (ARLNA) was created in 1928 due to the complex-
and functions of those who manage health in- ity of today’s information- and technology-driven
formation. The role of HIM professionals is even healthcare environment.
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Early History of Health Information Management
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The commitment, wisdom, and efforts of Surgeons (ACS). The purpose of the resulting
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of HIM pioneers are reflected in what we see to- Hospital Standardization Program was to raise
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day as the HIM profession. Four distinct steps the standards of surgery by establishing mini-
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influenced development of the HIM profession. mum quality standards for hospitals. The ASC
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These steps include the hospital standardization realized one of the most important items in the
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movement, the organization of record librarians, care of every patient was a complete and accurate
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the approval of formal educational processes, report of the care and treatment provided during
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and an educational curriculum for medical record hospitalization. The health record should contain
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(now known as health information) librarians. test results, identification information, diagnoses,
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treatment, and more (Huffman 1941).

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Hospital Standardization It was not long before hospitals realized that to

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comply with the hospital standards, new health

Before 1918, the creation and management of hos-
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record processes had to be implemented. In

pital health records were the sole responsibilities
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addition, staff had to be hired to ensure the new

of the attending physician. Physicians of that time
20
processes were appropriately carried out. Further-

20
often disliked doing paperwork. Unless the physi-

more, hospitals recognized health records must be
©
cian was interested in medical research, the medical

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maintained and filed in an orderly manner. Cross-

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records in the early 20th century were “practically

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indexes of diseases, operations, and physicians

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worthless and consisted principally of nurse’s

must be compiled. Thus, the job position of health
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notes” (Huffman 1941, 101).

record clerk was established.
Health records of that time did not contain
graphical records or laboratory reports. Because
there was no general management of health record Organization of the Association of
processes, hospitals made no effort to ensure miss- Record Librarians
ing or incomplete portions of the health records In 1928, 35 members of the Club of Record Clerks
were completed. Furthermore, no standardized met at the Hospital Standardization Conference
vocabulary was used to document why the patient in Boston. Near the close of the meeting, the As-
was admitted to the hospital or the final diagnosis sociation of Record Librarians of North America
upon discharge. (ARLNA) was formed. During its first year the
In 1918, the hospital standardization move- association had a charter membership of 58 indi-
ment was inaugurated by the American College viduals. Members were admitted from 25 of the
AB103118_Ch01.indd 4 2/11/2020 12:15:42 PM

48 states, the District of Columbia, and Canada or individual complies with applicable standards.
(Huffman 1985). ARLNA was the original name of In the case of CAHIIM, it is academic educational
the American Health Information Management programs.
Association (AHIMA), which is discussed later in The Board of Registration, a certification board,
this chapter. was instituted in 1933 and developed the base-
line by which to measure qualified health record
Approval of Formal Education and librarians. “Certification is a credential earned by
Certification Programs demonstrating specific skills or knowledge usu-
Early HIM professionals understood that for an ally tied to an occupation, technology, or industry.
occupation to be recognized as a profession there Certifications are usually offered by a professional
must be preliminary training. They also under- organization or a company that specializes in a
stood such training needed to be distinguished particular field or technology” (CareerOneStop
n.
from mere skill. This training needed to be intellec- 2018). The Board of Registration developed the eli-
tio
tual in character, involving knowledge and learn- gibility criteria for registration and developed and
ia
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ing. Therefore, work began on the formulation of administered a national qualifying examination.
ss
a prescribed course of study as early as 1929. In Registration is the act of enrolling; in this case,
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en
1932, the association adopted the first formal cur- enrolling in AHIMA’s certifications (this process is
em
riculum for HIM education. discussed later in this chapter). Today, AHIMA’s
ag
The first schools for medical record librarians Commission on Certification for Health Infor-
an
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were surveyed and approved by ARLNA in 1934. matics and Information Management (CCHIIM)
By 1941, 10 schools had been approved to provide n
functions as the Board of Registration. CCHIIM’s
io
at
training for medical record librarians. This formal role and function are discussed later in this chapter.
m r
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approval process of academic programs was the The professional membership of the association
In
precursor to the current accreditation program of HIM professionals grew over the subsequent
lth
ea
managed by the Commission on Accreditation decades. Although the name of the association
H
for Health Informatics and Information Man- changed several times, the fundamental elements
an
ic
agement Education (CAHIIM). Accreditation is of the profession—formal training requirements

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a determination by an accrediting body that an and certification by examination—have remained

eligible organization, network, program, group, the same.
e
th
by
20
20
Evolution of Practice
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The various names given to the health participate in continuing education activities to
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record association and its associated credentials maintain the credential thereafter. The health rec-
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reveal a lot about the evolution of the profession ord association was known as ARLNA until Ca-
and its practice. A credential is a formal agreement nadian members formed their own organization
granting an individual permission to practice in a in 1944. At that time, the name of the professional
profession, usually conferred by a national profes- organization was changed to the American Asso-
sional organization dedicated to a specific area of ciation of Medical Record Librarians (AAMRL).
healthcare practice; or the accordance of permis- In 1970, the professional organization changed its
sion by a healthcare organization to a licensed, name again to eliminate the term librarian. The
independent practitioner (physician, nurse practi- professional organization’s name became the
tioner, or other professional) to practice in a spe- American Medical Record Association (AMRA).
cific area of specialty within that organization. It The professional organization underwent another
usually requires an applicant to pass an examina- name change in 1991 to become American Health
tion to obtain the credential initially and then to Information Management Association (AHIMA).
AB103118_Ch01.indd 5 2/11/2020 12:15:42 PM

The changes in the professional organization’s Table 1.1 HIM profession’s job setting
name in 1970 and 1991 reflected the changing na-
Setting Roles
ture of the roles and functions of the association’s
Acute-care hospital HIM director
professional membership. In 1970, the term admin- Cancer registrar
istrator mirrored the work performed by members Discharge analyst
Systems analyst
more accurately than the term librarian. Similarly, Privacy officer
in 1991, association leaders believed that the man- Compliance
agement of information, rather than the manage- Integrated healthcare delivery HIM director
ment of records, would be the primary function of sytem Privacy officer
Coder
the profession in the future. Compliance officer
In 1999, AHIMA’s House of Delegates (HOD) Other provider setting (such HIM director
approved a credential name change. Registered as long-term care and Privacy officer
n.
Record Administrator (RRA) became Registered psychiatric) Coder
tio
Compliance officer
Health Information Administrator (RHIA), and
ia
Vendor Sales
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Accredited Record Technician (ART) became Reg-
ss
Systems analyst
istered Health Information Technician (RHIT).
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Consultant
en
Systems implementation
These certifications are discussed later in this
em
Trainer
chapter. This section will address the traditional
ag
Insurance companies Claims coordinator
practice of HIM, the current information-oriented
an
Auditor
M
management practice, as well as the future of HIM. Privacy officer
n
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Consulting Consultant
at
Traditional Practice Educational institution Professor
m
r
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The original practice of HIM emphasized the need Law firm HIM director
In
Government agency Reimbursement specialist

lth
to ensure that complete and accurate health re-

Data manager
ea
cords were compiled and maintained for every pa- Data mapper
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tient. Accurate records were needed to support the

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Pharmaceutical companies Research assistant

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care and treatment provided to the patient as well

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Source: ©AHIMA.
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as to conduct various types of clinical research.

Traditional practices of HIM involved planning,
e
th
developing, and implementing systems designed

Information-Oriented Management
by
Practice
20
to control, monitor, and track the quantity of rec-

20
ord content and the flow, storage, and retrieval of The traditional model of practice roles is not ap-
©
health records. In other words, activities centered propriate for today’s information-intensive and
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primarily on the health record or reports within automated healthcare environment. The tradi-
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the record as a physical unit rather than on the tional model of practice is department focused
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data elements that make up the information with- with an emphasis on tasks. These tasks include
in the health record. the processing and tracking of records rather than
In 1928, very few standards “addressed issues processing and tracking information.
relating to determination of the completion, sig- In today’s information age, information crosses
nificance, organization, timeliness, or accuracy of departmental boundaries and is broadly dissemi-
information contained in the medical record or its nated throughout the organization and beyond.
usefulness to decision support” (Johns 1991, 57). Because of the focus on information, information
Traditionally, HIM professionals worked in a governance is crucial. Information governance
hospital HIM department. Today, HIM profession- is “an organization-wide framework for manag-
als are found in many settings and in many roles. ing information throughout its lifecycle and for
Some of the more common settings and some HIM supporting the organization’s strategy, opera-
roles are listed in table 1.1. tions, regulatory, legal, risk, and environmental
AB103118_Ch01.indd 6 2/11/2020 12:15:42 PM

requirements” (IG Advisors 2018). In other The Future of HIM

words, the information must be managed to en-
Research shows the HIM profession is contin-
sure the needs of the organization are met. See
uing to evolve from the traditional HIM roles
chapter 6, Data Management, for more on informa-
to roles focused on information. Many of these
tion governance.
changes result from the conversion to the elec-
Information grows out of data manipulation
tronic health record (EHR), but other factors
using data from a variety of shared data sources,
including regulations, new technologies, and
both internal and external to the healthcare or-
engaged consumers also influence the changes
ganization. For the HIM professional to manage
(The Caviart Group 2015). The EHR is an elec-
this information, informatics skills, data analytics
tronic record of health-related information
skills, and data use skills are required (Dooling
about an individual that conforms to nation-
et al. 2016). Informatics is a field of study that fo-
ally recognized interoperability standards and
n.
cuses on the use of technology to improve access
tio
can be created, managed, and consulted by au-
to, and utilization of, information. Informatics
ia
thorized clinicians and staff across more than
oc
uses software applications, databases, managing
ss
one healthcare organization. The EHR has dra-
processes, and more (Dooling et al. 2016). To learn
tA
matically increased the amount of information
en
more about informatics, refer to chapter 13, Re-
available and the ability to manipulate and in-
em
search and Data Analysis. Data analytics is the sci-
ag
terpret information. With a paper health record,
ence of examining raw data with the purpose of
an
collecting and analyzing data is very resource
M
drawing conclusions about that information. For
intensive so there are many limitations. Data
example, the data may be analyzed to determine n
io
analytics and informatics, discussed earlier in
at
what services increase revenue for the healthcare
m
the chapter, will be important in the future for

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organization and which ones incur a loss. Data

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managing the increased data and information

analytics includes healthcare statistics, research
lth
created by the EHR and other changes, such as

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methods, and interpretation. Data use is the abil-

changes in regulations and in technology. The
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ity to use technology to collect, store, analyze, and

an
2015 Work Force Study, a research study on the

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manage information, including the ability to use

er
roles and opportunities for HIM professions,

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data visualization methods (Dooling et al. 2016).

identified the top 10 skills required by HIM
For example, a graph or chart may be created to
e
th
professionals both today and into the future

show the trends of inpatient admissions over time.
by
(The Caviart Group 2015). Table 1.2 shows these

Information on graphs and charts is found in chap-
20
skills in order of importance.

20
ter 13, Research and Data Analysis.

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Table 1.2 Comparison of the most important present and future HIM skills
op
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Today’s most important skills Future’s most important skills

1. Medical record coding 1. Electronic health record (EHR) management
2. Managing information privacy and security 2. Managing information privacy and security
3. Analytical thinking 3. Analytical thinking
4. Ensuring data integrity 4. Critical thinking
5. Critical thinking 5. Ensuring data integrity
6. Clinical documentation integrity 6. Problem solving
7. Electronic health record (EHR) management 7. Communication (written, spoken, or presentation)
8. Communication (written, spoken, or presentation) 8. Clinical documentation integrity
9. Problem solving 9. Leadership
10. Developing and promoting HIM standards 10. Analyzing big data
Source: Adapted from The Caviart Group 2015.
AB103118_Ch01.indd 7 2/11/2020 12:15:42 PM

Check Your Understanding 1.1

Answer the following questions.
1. The hospital standardization movement was initiated by the:
a. American Health Information Management Association
b. American College of Surgeons
c. Record Librarians of North America
d. American College of Physicians
2. The healthcare organization wants to examine raw data to make conclusions about the future of the healthcare
organization. This is known as:
a. Data use
b. Data analytics
n.
tio
c. Informatics
ia
d. Information governance
oc
ss
3. The HIM profession is changing due to:
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a. Changes in technology
en
em
b. Demands of physicians
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c. Changes in medical staff bylaws
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d. Changes at AHIMA
M
4. The new model of HIM practice is:
n
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at
a. Information focused
m
b. Record focused
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c. Department focused
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d. Traditional focused
ea
5. A formal agreement granting an individual permission to practice in a profession is known as:

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a. Registration
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er
b. Certification
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c. Informatics
e
d. Information governance
th
by
6. The organization that accredits HIM education programs is:

20
a. Joint Commission
20
b. CAHIIM
©
c. AHIMA
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d. CCHIIM
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Today’s Professional Organization

AHIMA is a membership organization AHIMA strives to foster the professional de-
representing more than 103,000 health informa- velopment of its members through education,
tion professionals. These professionals serve the certification, and lifelong learning. AHIMA also
healthcare industry and the public by managing, advocates for the HIM profession by working with
analyzing, and utilizing information vital for pa- legislators, stakeholders, and others to address is-
tient care and making it accessible to healthcare sues related to HIM. The intent of this advocacy
providers when and where it is needed. is to promote the development of high-quality
AB103118_Ch01.indd 8 2/11/2020 12:15:42 PM

information that benefits the public, healthcare nonmembers (certificants), and students enrolled
consumers, healthcare providers, and other users in a formal certificate- or degree-granting pro-
of clinical data. The organization has certification grams directly relevant to AHIMA’s purpose to
programs that set high standards to ensure the act in an ethical manner and comply with all laws,
minimum qualifications of the individuals who regulations, and standards governing the prac-
practice as health information managers and tech- tice of HIM. Just as professionals, members, cer-
nicians. In addition, AHIMA supports numerous tificants, and students are expected to continually
continuing education (CE) programs to help its update their knowledge base and skills through
credentialed members and others maintain their CE and lifelong learning, HIM professionals and
knowledge base and skills. managers are expected to promote high standards
As previously described, AHIMA’s name has of HIM practice, education, and research. Addi-
changed several times over the years to reflect tionally, they are expected to promote and protect
n.
changes in the organization and the profession. the confidentiality and security of health records
tio
The sections that follow discuss the mission, mem- and health information.
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bership, and organizational structure of AHIMA.
ss
AHIMA Membership
tA
AHIMA Mission and Vision
en
To accommodate the diversity in AHIMA member-
em
Before studying AHIMA’s structure, it is impor- ship, the organization has established the following
ag
seven membership categories: active member-
an
tant to understand why the organization exists
M
and what contributions it makes to its members ship, premier membership, student membership,
n
and the healthcare system in general. The mission
io
new graduate membership, emeritus member-
at
m
of an organization explains what the organization ship, global membership, and group membership
r
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is and what it does. In other words, it describes (AHIMA 2019b).

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Active membership is open to all individuals

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the organization’s distinctive purpose. A vision is

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a futuristic view of where the organization is go- who are interested in AHIMA’s purpose and will-
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ing to abide by the code of ethics. Active members

an
ing. Figure 1.1 shows AHIMA’s current mission

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and vision. in good standing are entitled to all membership

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All organizations have values but these values privileges including the right to vote and to serve
in the House of Delegates (discussed later in this
e
may or may not be written. The values provide

th
chapter). Active membership provides HIM pro-

by
guidance to the organization when making deci-

fessionals the opportunity to participate in the
20
sions and establishing a culture (Tutorialspoint nd).

20
To accomplish its mission, AHIMA expects its organization and to offer input to the current and
©
members to follow a code of professional ethics future practices of the profession.

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(a complete discussion of ethical principles and Premier membership provides all the benefits
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AHIMA’s Code of Ethics is provided in chapter 21, described in active membership plus additional
C
Ethical Issues in Health Information Management.) A benefits such as unlimited recertification and
code of ethics is a statement of ethical principles additional discounts.
regarding business practices and profession- Student membership includes any student who
al behavior. The AHIMA Code of Ethics r equires does not have an AHIMA credential, has not previ-
members of AHIMA, CCHIIM, credentialed ously been an active member of AHIMA, and who
is formally enrolled in a Professional Certificate
Approval Program or an Approved Committee for
Figure 1.1 AHIMA’s mission and vision
Certificate Program, or in a CAHIIM-accredited
Mission Vision HIM program. The student membership category
Empowering people A world where trusted information
to impact health transforms health and healthcare by gives entry-level professionals an opportunity to
connecting people, systems, and ideas participate on a national level in promoting sound
Source: AHIMA 2019a. HIM practices. Student members can serve on
AB103118_Ch01.indd 9 2/11/2020 12:15:42 PM

committees and subcommittees in designated stu- maintain fiscal oversight, and act as trustees of the
dent positions with a voice, but they do not have organization (AHIMA 2019c). The business and af-
a vote. fairs of AHIMA are managed by or under the direc-
New graduate membership is for student mem- tion of the Board of Directors. Its members include
bers who are recent graduates of accredited associ- the president/chair, the president/chair-elect, the
ate, bachelor’s, and master’s degree programs as past president/chair, speaker of the House of Del-
well as AHIMA-approved coding programs. This egates, nine elected directors, the chief executive
membership level allows the students to continue officer of the organization, and the advisor to the
their membership at a reduced rate for one year. board. Except for the chief executive officer and the
This membership level has all membership rights advisor, who are selected by the board of directors,
including voting. all members of the board of directors are elected by
Emeritus membership allows AHIMA mem- the membership and serve three-year terms of of-
n.
bers who are 65 years or older to be a member at a fice; members must be active members of the associ-
tio
reduced rate. This membership level has all mem- ation. The p resident/chair must be a certificant and
ia
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bership rights including the right to vote. the majority of the directors must also be certificants.
ss
Global membership is for people who are inter- In addition to the board of directors, CCHIIM
tA
en
ested in HIM but live outside of the United States. is elected by the membership. CCHIIM is an
em
Group membership allows multiple indi- AHIMA commission that is dedicated to assuring
ag
viduals from an organization to join at one time. the competency of professionals practicing HIIM.
an
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Student and business groups are eligible for this It is a standing commission of AHIMA that is em-
membership type. n
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powered with the responsibility and authority re-
at
New to AHIMA membership offers those who lated to certification and recertification of HIIM
r m
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have never been a member of AHIMA a discount- professionals (AHIMA 2019c).

In
ed rate for two years. This membership receives the

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ea
same benefits as the Active Member (AHIMA 2019b). Engage

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Engage is a community website managed by

an
AHIMA Structure and Operation

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AHIMA for members to communicate on HIM

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Every organization needs a management structure topics. Engage has communities open to all HIM
to operate effectively and efficiently. AHIMA is
e
professionals and some specific for AHIMA mem-

th
made up of two components—volunteer and staff. bers only. Engage provides the following benefits:
by
The volunteer structure establishes the organiza-

20
Opportunities for members to contact

20
●●
tion’s mission and goals, develops policy, and pro-
other members to gain knowledge, share
©
vides oversight for the organization’s operations.

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information, and learn best practices

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Figure 1.2 shows AHIMA’s volunteer structure. The

yr
Opportunities to identify members with

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staff component of the organization carries out the ●●

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operational tasks necessary to support the organiza- similar interests and backgrounds
tion’s mission and goals. The staff works within the ●● Gives members the ability to share and
policies established by the volunteer component. retrieve resources (AHIMA 2019d)
Association Leadership National Committees

As a nonprofit membership association, AHIMA AHIMA’s president/chair oversees the appoint-
depends on the participation and direction of ment of members of the association’s national
volunteer leaders from the HIM community.
committees, practice councils, and workgroups.
AHIMA’s members elect those who serve in the These groups support the mission of the organi-
governing bodies of the organization. zation and work on specific projects as designated
The AHIMA board of directors governs the by the president/chair and the board of directors.
association. They set the organizational strategy,
Examples of the national committees include the
AB103118_Ch01.indd 10 2/11/2020 12:15:42 PM

Figure 1.2 AHIMA’s volunteer structure
AB103118_Ch01.indd 11
MEMBERSHIP
BOARD OF DIRECTORS COMPONENT STATE ASSOCIATIONS (CSAs) AHIMA FOUNDATION
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HOUSE OF DELEGATES PRESIDENT/CHAIR-ELECT CCHIIM AHIMA GRACE AWARD COMMITTEE CEE COUNCIL
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AHIMA TRIUMPH AWARD COMMITTEE CEE MEMBERS
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© DIRECTOR (3) COMMISSIONERS
SPEAKER-ELECT
CONFERENCE PROGRAM COMMITTEE CEE WORKGROUPS
20
20
ENVISIONING COLLABORATIVE ADVOCACY AND POLICY COUNCIL CONFERENCE SUBCOMMITTEE:
CLINICAL CODING PROGRAM TRACK
by
CDI, QUALITY AND REVENUE MANAGEMENT ASSEMBLY ON EDUCATION
HOD TASK FORCE
th
PRACTICE COUNCIL e CONFERENCE SUBCOMMITTEE: PROGRAM WORKGROUP
CLINICAL DOCUMENTATION INTEGRITY
CLINICAL TERMINOLOGY AND CLASSIFICATION PROGRAM TRACK GRADUATE RESOURCE
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HOUSE LEADERSHIP
PRACTICE COUNCIL er ALLIANCE WORKGROUP
CONFERENCE SUBCOMMITTEE:
DATA USE, GOVERNANCE, AND EHR STRUCTURE PROFESSIONAL CERTIFICATE
ic
PRIVACY AND SECURITY PROGRAM TRACK
PRACTICE COUNCIL APPROVAL PROGRAM (PCAP)
an
REVIEW TEAM
HEALTH INFORMATION TECHNOLOGIES AND INNOVATION H FELLOWSHIP COMMITTEE
PRACTICE COUNCIL
STUDENT ADVISORY WORKGROUP
ea
LEADERSHIP AND PROFESSIONAL DEVELOPMENT
NOMINATING COMMITTEE
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PRACTICE COUNCIL
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LONG TERM POST-ACUTE CARE (LTPAC)
fo
PROFESSIONAL ETHICS COMMITTEE
PRACTICE COUNCIL r m
PRIVACY AND SECURITY
at
PRACTICE COUNCIL io
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en
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ss
Elected Appointed
oc
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n.
Source: AHIMA 2019b.
2/11/2020 12:15:44 PM
Conference Program Committee, the Fellowship address topics that are important to the profession.
Committee, and the Professional Ethics Commit- These task forces change over time as the needs of
tee. Practice councils are established as thought the profession change.
leadership groups to develop HIM content for a The House of Delegates is responsible for estab-
specific topic. Examples of practice councils include lishing the position of AHIMA on issues related to
clinical classification and terminology, clinical docu- HIM and taking action on a number of topics, in-
mentation integrity, and privacy and security. Prac- cluding the following:
tice councils and committees are created to meet a
( a) “The standards governing the health
specific need and may continue for years. In addi-
information management profession, including:
tion, AHIMA addresses challenges by establishing
• AHIMA Code of Ethics
workgroups for short-term projects and then dis-
• Standing rules of the House of
banding them. An example of a workgroup is the
Delegates
n.
LGBTQ (lesbian, gay, bisexual, transgender and
tio
• Development of positions and best
queer equality) Volunteer Workgroup.
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practices in health information
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ss
management
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House of Delegates (b) Election of six (6) members of the AHIMA
en
The House of Delegates governs the profession
em
Nominating Committee in accordance with
of health information management by providing
ag
the process set forth in the AHIMA Policy and
an
a forum for membership and professional issues Procedure Manual.
M
and to establish and maintain professional stan-
n
(c) Any other matters put before the House of
io
dards of the membership. For this reason, it is
at
Delegates by the AHIMA Board of Directors
m
an important component of the volunteer struc-

r
for final consideration and action” (AHIMA

fo
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ture (AHIMA 2019c). The House works virtually 2019d, 14).

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year-round with one annual face-to-face busi-

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ness meeting held in conjunction with AHIMA’s Figure 1.3 shows the formal governance struc-
H
an
conference. ture of AHIMA.

ic
er
Each component state association, defined later

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in this chapter, elects or appoints representatives State and Local Associations

e
to the House of Delegates to serve for a specified In addition to its national volunteer organization,
th
by
term of office. For this reason, the House of Del- AHIMA supports a system of component orga-
20
egates is similar to the legislative branch of the nizations in every state, plus Washington, DC,
20
US government. Under the House are two teams: and Puerto Rico. Component state associations
©
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House Leadership and Envisioning Collaborative. (CSAs) are professional associations that support
ig
The teams are made up of one delegate from each the mission and views of AHIMA in their state
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state. The Envisioning Collaborative serves as a (AHIMA 2019d). CSAs provide their members
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“think tank.” It is composed of delegates, subject with professional education, networking, and
matter experts, and industry leaders. Their role is representation.
to bring forward an exchange of viewpoints, inno- Many states also have local or regional organi-
vation, and ideas. The outcomes of these discus- zations. For newly credentialed professionals, the
sions are the development of strategies used to state and local organizations are ideal avenues for
advance the profession (AHIMA 2019d). becoming involved with volunteer work within
The House Leadership team ensures effective the professional organization. Most HIM profes-
House operations through alignment with strat- sionals who serve in the House of Delegates or
egy and fosters the overall delegate experience serve on AHIMA’s Board of Directors began their
and provides oversight of task force progression. volunteerism by serving at the local, regional, and
Ad hoc task forces are created under the House to state associations.
AB103118_Ch01.indd 12 2/11/2020 12:15:44 PM

Figure 1.3 Governance structure of AHIMA
Board of
directors
(13 board
members)
Triage
(president, speaker,
CEO)
House of
delegates
(239 delegates
Informs 2018–19)
strategy
n.
SBARs
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House leadership
Practice Envisioning
ia
(52 delegates)
collaborative
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councils -Operations and direction
ss
(52 delegates & SMEs) -Task force development*
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-Project management and
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follow-up
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HoD Task HoD Task HoD Task
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Force* Force* Force*
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Source: AHIMA 2019. io
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m
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Staff Structure developed and maintained a rigorous accredi-

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The AHIMA headquarters is located in Chicago, tation process for academic programs, continu-
ea
Illinois. The chief executive officer (CEO) is giv- ously developed up-to-date curriculum models,
H
and supported educational programs in a variety

an
en the authority and responsibility to operate

ic
AHIMA in all its activities, subject to the policies of ways. Accreditation is discussed in more detail
er
Am
and directions of the Board of Directors. The CEO later in this chapter.
e
undertakes his or her duties in accordance with a

th
by
job description approved by the Board (AHIMA

Certification and Registration Program
20
2019d). The CEO is responsible for overseeing

20
day-to-day operations. A team of executives, man- As the field of HIM became more complex, the
©
agers, and staff support the CEO. These executives association recognized the need to regulate its
ht
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include a chief knowledge officer and chief oper- credentialing program. In 2008, CCHIIM was es-
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ating officer. Examples of the staff departments tablished. CCHIIM is dedicated to ensuring the
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include, among others, member services, profes- competency of HIM professionals. CCHIIM serves
sional practice services, AHIMA Press, marketing, the public by establishing, implementing, and en-
and policy and government relations. forcing standards and procedures for certification
and recertification of HIM professionals. CCHI-
IM provides strategic oversight of all AHIMA
Accreditation of Educational Programs certification programs. This standing commission
AHIMA has a long tradition of commitment to of AHIMA is empowered with the sole and inde-
HIM education. As discussed previously, the first pendent authority in all matters pertaining to both
prescribed educational curriculum for the train- the initial certification and ongoing recertification
ing of health record professionals was proposed (certification maintenance) of HIM professionals.
in 1929. The first educational programs were ac- Today, AHIMA’s certification program encom-
credited in 1934. Since then, the association has passes several credentials, including the following:
AB103118_Ch01.indd 13 2/11/2020 12:15:45 PM

●● Registered Health Information Technician Fellowship is open to any individual who is an

(RHIT) active or Emeritus member of AHIMA and who
●● Registered Health Information meets the eligibility requirements. Fellows must
Administrator (RHIA) have a minimum of 10 years full-time professional
experience in HIM or a related field, a minimum
●● Certified Coding Associate (CCA)
of 10 years continuous AHIMA membership at
●● Certified Coding Specialist (CCS) the time they submit their application (excluding
●● Certified Coding Specialist—Physician- years as a student member), hold a minimum of
based (CCS-P) a master’s degree, hold an active CCHIIM cre-
●● Certified in Healthcare Privacy and Security dential and provide evidence of sustained and
(CHPS) substantial professional achievement that demon-
●● Certified Health Data Analyst (CHDA) strates professional growth and use of innovative
n.
and creative solutions. AHIMA members who de-
tio
●● Clinical Documentation Improvement
sire to apply for fellowship but do not yet meet
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Practitioner (CDIP)
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the eligibility requirements may apply for can-
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Each of these credentials has specific eligibility didacy. Candidacy is a period of time where the
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requirements and a certification examination. To HIM professional, who is not currently eligible,
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achieve certification from CCHIIM, individuals works toward the recognition. Once conferred,
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must meet the eligibility requirements for certifi- fellowship is a lifetime recognition as long as the
an
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cation and successfully complete the certification individual remains an AHIMA member and com-
examination. n
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plies with AHIMA’s Code of Ethics. At the time
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Because the HIM profession is constantly of this writing, 200 members have been awarded
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changing, certified individuals must demonstrate fellowship status.

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they are continuing to maintain their knowledge

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and skill base. Therefore, to maintain their certi- AHIMA Support of Training and Education
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fication, individuals who hold any of AHIMA’s AHIMA supports training and education in a
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credentials must complete a designated set of number of ways including educational webinars
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continuing education units (CEUs). Activities and face-to-face meetings for HIM profession-
that qualify for CEUs include participation in als. AHIMA has also created self-assessments
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workshops and seminars, taking college courses, for HIM professionals to evaluate their skills in
by
participating in independent study activities, comparison to the skills required for current HIM
20
20
and engaging in self-assessment activities. The practices.

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CCHIIM website provides information on the AHIMA provides HIM educational programs
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most recent requirements for maintenance of with a number of resources. For example, the
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certification. Virtual Lab provides HIM educational pro-

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grams access to a number of information sys-

Fellowship Program tems, such as the EHR and data visioning, that
AHIMA’s fellowship program is a program of students will see in practice. AHIMA publishes
earned recognition for AHIMA members who HIM textbooks and creates entry-level com-
have made significant and sustained contributions petencies used in HIM educational programs.
to the HIM profession through meritorious serv- AHIMA also provides courses in a number of
ice, excellence in professional practice, education, topics related to HIM.
and advancement of the profession through inno- AHIMA created the Council for Excellence in
vation and knowledge sharing (AHIMA 2019e). Education (CEE) to bring together representatives
Individuals who earn fellowship use the designa- of the HIM education stakeholders, including in-
tion Fellow of the American Health Information dustry representatives, to address issues related
Management Association (FAHIMA). to the future of the profession and HIM education.
AB103118_Ch01.indd 14 2/11/2020 12:15:45 PM

Figure 1.4 Career Map
AND REVENUE CY
ODING CLE
C
M
AS
TE
R
AD
VA
NC
ED
CE
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ID
ATION GOVERNAN
EN
TR
n.
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INFORMATICS
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HIM
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CAREERS
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INF
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In
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Current Transitio
Transition
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DATA A LYTICS
Emerging NA Promotion
Promotio
ic
er
Source: AHIMA 2019g.

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e
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The CEE works to “ensure that education is posi- AHIMA Career Map
by
tioned as the cornerstone of health information AHIMA created the interactive Career Map. This
20
20
professions through communication, collaboration, Career Map provides a synopsis of current and
©
innovation, and research” (AHIMA 2019f). The

emerging HIM careers (roles) in four categories:
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CEE board is elected by the AHIMA membership

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Coding and Revenue Cycle, Data Analytics, In-

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for a three-year term.

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formatics, and Information Governance. These

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The CEE has a number of workgroups to c onduct roles are categorized into four tiers: entry, mid,
the work of the council. These workgroups in- advanced, and master level. The Career Map
clude curricula, educational programming, grad- shows common paths a HIM professional might
uate resources, student advisory, and workforce take as he or she moves from entry-level roles
(AHIMA 2019f). These workgroups help strength- to master-level roles. This path may jump from
en members by identifying the future needs of the category to category. For example, the Informat-
profession and then setting the college curriculum ics mid-level of implementation support analyst
required to ensure future HIM professionals have can jump to the Information Governance ad-
those skills. They also assist educators by helping vanced role of HIM manager (AHIMA nd). The
educators keep skills current and by assisting with Career Map is shown in figure 1.4. To access
establishing standards for professional practice the Career Map, visit http://www.ahima.org/
experiences. careermap.
AB103118_Ch01.indd 15 2/11/2020 12:15:48 PM

AHIMA Foundation in research, workforce development, scholarships,

Founded in 1962, AHIMA Foundation is a sep- and competency-based education for the HIM
arate entity from AHIMA but supports AHIMA professional. One of the ways that it supports
in a multitude of ways. AHIMA Foundation sup- workforce development is through an apprentice-
ports people (including HIM professionals, HIM ship program that allows recent HIM graduates to
students, and others), research, and resources that obtain real-world experience. Its role is to envision
enhance the HIM profession. the future direction and needs of the field and to
The HIM profession is based on the belief that respond with strategies, information, planning,
high-quality healthcare requires high-quality infor- and programs that will keep the HIM profession
mation. AHIMA Foundation provides leadership on the cutting edge.
n.
Commission on Accreditation for Health Informatics
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and Information Management Education
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In 2004, AHIMA’s House of Delegates voted to es- in programs placed in candidacy status are eligible
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tablish an independent accreditation commission, to join AHIMA as student members. The steps of
ag
Commission on Accreditation for Health Infor- the accreditation process are the following:
an
matics and Information Management Education
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1. The college program prepares a
n
(CAHIIM), with sole and independent authority in io
self-assessment document that helps the
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all matters pertaining to accreditation of educational
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college identify its strengths and weaknesses.

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programs in health informatics and information

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2. Accreditation site visitors visit the campus

In
management. CAHIIM serves the public interest by

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to review documents and interview faculty,

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establishing quality standards for the educational

students, and administration.
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preparation of future HIM professionals. When a

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program is accredited by CAHIIM, it means it has 3. A final determination is made as to the

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voluntarily undergone a rigorous review process ability of the college program to meet the
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and has been determined to meet or exceed the accreditation standards for curriculum,
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facility, resources, and other requirements.

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accreditation standards established by CAHIIM.

by
CAHIIM accreditation recognizes and publicizes The accreditation of educational programs is im-
20
best practices for HIM education programs. portant because only those individuals who grad-
20
©
CAHIIM reviews formal applications from col- uate from an approved program may sit for the
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lege programs that apply for candidacy status, national credentialing examinations for the RHIT
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which is a preliminary approval process. After a and RHIA. At the time this chapter was written, an
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successful review of the application documenta- exception has been made that allows RHITs who
tion, a program may be deemed a candidate for ac- have a bachelor’s degree in any subject to qualify
creditation for up to two years. Students enrolled to sit for the RHIA exam.
Health Information Management Specialty

Professional Organizations
Health information management professionals fre- transcription, information governance, privacy
quently specialize in an area of the HIM p
rofession. and security, standards, and information systems.
Examples of these specialties include clinical docu- A number of specialty organizations support these
mentation integrity, coding, tumor registry, medical areas.
AB103118_Ch01.indd 16 2/11/2020 12:15:48 PM

Healthcare Information and standards and style, clinical medicine, and health
Management Systems Society information technology (AHDI 2018b).
Healthcare Information and Management Sys- American Academy of Professional

tems Society (HIMSS) is a not-for-profit organ-
Coders
ization that supports “the information of health
through the application of information and The American Academy of Professional Coders
technology” (HIMSS 2018a). The HIMSS sponsors (AAPC) educates and certifies medical coders,
exams for health information and information sys- billers, medical auditors, revenue cycle managers,
tems professionals—the certified professional in and other administrative specialties. The AAPC
Healthcare Information and Management Systems sponsors certifications in these specialty areas.
(CPHIMS) certification and Certified Associate Some of the certifications include the following:
Professional in Healthcare Information and Man- Certified Professional Coder (CPC)
n.
●●
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agement Systems (CAHIMS). The CPHIMS exam
Certified Professional Medical Auditor (CPMA)
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●●
covers topics such as healthcare environment, tech-
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Certified Professional Compliance Officer
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nology environment, system analysis, system de- ●●
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sign, system selection and implementation, privacy (CPCO)
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Certified Inpatient Coder (CIC)
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and security, and administration (HIMSS 2018b). ●●
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The CAHIMS certification covers administration, ●● Certified Outpatient Coder (COC)
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healthcare information and systems management, Certified Risk Adjustment Coder (CRC)
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●●
organization environment, and the technology/
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●●
io Certified Documentation Expert Outpatient
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organizational environment (HIMSS 2018c).
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(CDEO)
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Association for Healthcare Certified Physician Practice Manager (CPPM)

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●●
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Documentation Integrity (AAPC 2018)

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The Association for Healthcare Documentation

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Integrity (AHDI) is a professional organization National Cancer Registrars Association

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er
dedicated to the capture of health data and doc- The National Cancer Registrars Association
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umentation (AHDI 2018a). AHDI sponsors the (NCRA) represents cancer registrar professionals.
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Registered Healthcare Documentation Specialist Their mission is to “serve as the premier educa-
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(RHDS) and Certified Healthcare Documentation tion, credentialing, and advocacy resource for can-
20
20
Specialist (CHDS) credentials. The RHDS is the cer data professionals” (NCRA 2018). The NCRA
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entry-level certification sponsored by AHDI. The sponsors the Certified Tumor Registrar (CTR)
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CHDS determines if the candidate is qualified to certification. This exam includes information on
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be a transcriptionist in a multidisciplinary envi- registry organization and operations, abstracting,

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ronment. Both certification exams address basic coding, follow-up, data analysis, and interpreta-
transcription concepts including transcription tion as well as coding and staging.

1. Our college has applied to become accredited by CAHIIM and we have completed the initial steps. Identify the name
of the initial stage of accreditation that we are in.
a. Certification
b. Candidacy
c. Fellowship
d. Credentialing
AB103118_Ch01.indd 17 2/11/2020 12:15:48 PM

2. I would like to consult with other HIM professionals on what to do in a situation. I should utilize:
a. Engage
b. Fellowship
c. House of Delegates
d. CEE
3. I would like to propose a change to the HIM profession. I should go to:
a. Board of Directors
b. House of Delegates
c. CCHIIM
d. CAHIIM
4. I would like to apply for AHIMA Fellowship. I have been a member of AHIMA for eight continuous years of HIM
experience. I have a master’s degree and I have worked in a number of volunteer roles for AHIMA. Determine if I am
eligible for the designation. If not, determine why.
n.
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a. I am currently eligible for AHIMA Fellowship.
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b. I am not eligible for AHIMA Fellowship because I need a minimum of 10 years of HIM experience.
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c. I am not eligible for AHIMA Fellowship because I need to publish in journals as well as volunteer for AHIMA.
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d. I am not eligible for AHIMA Fellowship because I must have a doctorate degree.
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5. I need to decide which CCHIIM credential to apply for. I am graduating with an associate degree in health information
em
management from a CAHIIM-accredited program. The best credential for me to take is:
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a. Registered Healthcare Documentation Specialist
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b. Registered Health Information Technician
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c. Certified Professional in Healthcare Information and Management Systems
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d. Certified Professional Coder

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Real-World Case 1.1

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The electronic health record (EHR) is centralized their HIM functions, enabling them to
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causing many changes in both the health informa- standardize the HIM functions and to share staff
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th
tion management (HIM) profession and the struc- among the healthcare organizations. The HIM
by
ture of the HIM department. Because of the EHR, staff at the central location can perform most of
20
20
many functions of the HIM department can be the functions of the HIM department. There may
©
performed remotely. Some HIM staff such as cod- be some staff at the healthcare organization to at-
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ers and transcriptionists are now working from tend committee meetings, take authorization for
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home. The file areas where the paper records are release of information from patients, and perform
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housed are disappearing as more and more of the other functions that require staff on site. Whether
health records are electronic. These changes en- employees work from home or at a centralized lo-
able the healthcare organization to use the space cation, the privacy and security of patient infor-
previously occupied by the HIM staff and the file mation must always be ensured at all the locations
areas to be used for other purposes. Some health- and employee productivity must meet the stan-
care o
rganizations with multiple locations have dards established by the organization.
Real-World Case 1.2

One of the strengths of the HIM pro- al’s career path to evolve over time. Kathryn has
fession is the opportunity for the HIM profession- a registered health information technician (RHIT)
AB103118_Ch01.indd 18 2/11/2020 12:15:49 PM

credential. She began her HIM career immediately vendor. In both roles, she traveled around the coun-
after college working in utilization review. After a try working with clients. Kathryn quickly tired of
year or two, she transitioned to HIM department the travel and decided to change the focus of her ca-
management and worked at hospitals ranging in reer path once again. Now, she is a HIM educator and
size from 60 beds to 900+ beds. After 15 years of writes HIM textbooks on the side. While Kathryn has
working in hospitals she was ready for a change, earned both a master’s degree and a doctorate de-
so she left the hospital and worked first in a HIM gree, it was her HIM degree and skills that allowed
consulting firm and then for an information system her to move from one career path to another.
References
n.
American Academy of Professional Coders. 2018. American Health Information Management
tio
ia
Medical Billing and Coding Certification. http:// Association. 2019f. CEE Workgroups. http://ahima.
oc
www.aapc.com/certification. org/education/academic-affairs/council-for-
ss
excellence.
tA
American Health Information Management
en
Association. 2017. Pocket Glossary of Health American Health Information Management
em
Information Management and Technology, 5th ed. Association. 2019g. Career Map. https://my.ahima.
ag
Chicago: AHIMA. org/careermap.
an
M
American Health Information Management American Health Information Management
n
Association. 2019a. Who We Are. https://www.ahima. Association. 2019g. What is the CEE. http://www.
io
at
org/about/aboutahima. ahima.org/education/academic-affairs/council-for-
m
excellence.
r
fo

In
Association. 2019b. About the Commission. http:// Association for Healthcare Documentation Integrity.
lth
www.ahima.org/certification/cchiim. 2018a. About AHDI. https://www.ahdionline.org

ea
/page/about.
H

an
Association. 2019b. AHIMA Membership. http:// Association for Healthcare Documentation Integrity.
ic
er
www.ahima.org/membership. 2018b. https://cdn.ymaws.com/ahdionline.site-ym.

Am
American Health Information Management com/resource/resmgr/Credentialing-Downloads

e
Association. 2019c. AHIMA House of Delegates Policy /CredentialingCandidateGuide.pdf.

th
by
and Procedure Management. http://bok.ahima.org/ CareerOneStop. 2018. Earning a certification can help
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PdfView?oid=302856 you enter or advance in many careers. https://www.

20
American Health Information Management careeronestop.org/FindTraining/Types/certifications.

©
Association. 2019d. Bylaws of American Health aspx.

ht
ig
Information Management Association. http://bok. The Caviart Group. 2015. A Workforce Study of
yr
ahima.org/PdfView?oid=302856. the Future Direction and Skill Set for HIM

op
Professionals. http://bok.ahima.org/
C

Association. 2019d. How to Guide. https://engage. PdfView?oid=300801.
ahima.org/helpfaqs1/tutorials. Dooling, J.A., S.H. Houser, R. Mikaelian, C.P. Smith.
American Health Information Management 2016. Transitioning to a Data-Driven Informatics-
Association. 2019e. Fellowship Program. http:// Oriented Department. Journal of AHIMA 87(10):
www.ahima.org/about/recognition?tabid= 58-62.
fellowship. Healthcare Information Management Systems Society.
American Health Information Management 2018a. About HIMSS. http://www.himss.org
Association. 2019e. House of Delegates. http://www. /aboutHIMSS/.
ahima.org/about/governance?tabid=hod. Healthcare Information Management Systems
American Health Information Management Association. Society. 2018b. CPHIMS Candidate Handbook.
2019e. Volunteer organization. http://www.ahima. https://www.himss.org/health-it-certification/
org/volunteers. cphims/handbook.
AB103118_Ch01.indd 19 2/11/2020 12:15:49 PM

Healthcare Information Management Systems Society. Johns, M.L. 1991. Information management: A
2018c. CAHIMS Candidate Handbook. https://www. shifting paradigm for medical record professionals?
himss.org/health-it-certification/cahims/handbook. Journal of the American Medical Record Association
Huffman, E.K. 1985. Medical Record Management, 8th 62(8):55–63.
ed. Berwyn, IL: Physicians’ Record Company. National Cancer Registrars Association. 2018.
Huffman, E.K. 1941. Requirements and advantages Membership. http://www.ncra-usa.org/
of registration for health record librarians. Bulletin of Membership.
the American Association of Medical Record Librarians. Tutorialspoint. nd. Mission, Vision and Values.
IG Advisors. 2018. Information Governance Glossary. https://www.tutorialspoint.com/management_
http://www.ahima.org/topics/infogovernance/ principles/management_principles_mission_vision_
ig-glossary. values.htm.
n.
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ss
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In
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Am
e
th
by
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20
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AB103118_Ch01.indd 20 2/11/2020 12:15:49 PM

Chapter
2
Healthcare Delivery
n.
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Systems
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en
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Kelly Miller, MA, RHIA
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Learning Objectives
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•• Differentiate the roles of various healthcare •• Examine the influence of artificial intelligence in the
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providers throughout the healthcare delivery system delivery of healthcare

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•• Determine the basic organization and operation •• Identify the various policy making influences in the
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of various types of hospitals and other healthcare delivery of healthcare

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organizations and services •• Examine healthcare delivery in the United States

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•• Examine the use and functions of telehealth services

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in healthcare
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e
Key Terms
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by
Accountable care organizations Chief operating officer (COO) Medical home

20
(ACOs) Clinical privileges Medical staff bylaws

20
Allied health professional Continuum of care Medical staff classification

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Ambulatory care Critical access hospital (CAH) Medicare

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American Recovery and Extended care facility Patient Protection and Affordable
yr
Reinvestment Act (ARRA) Health Information Technology for Care Act (ACA)
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Artificial intelligence (AI) Economic and Clinical Health Peer review organization (PRO)
Average length of stay (ALOS) (HITECH) Act Quality improvement organization
Big data Home healthcare (QIO)
Case management Hospice Safety net hospital (SNH)
Centers for Disease Control and Hospital Skilled nursing facility (SNF)
Prevention (CDC) Hospitalist Social determinants of health (SDOH)
Chief executive officer (CEO) Integrated delivery network (IDN) Subacute care
Chief financial officer (CFO) Integrated delivery system (IDS) Telehealth
Chief information officer (CIO) Managed care organization (MCO) Utilization review (UR)
Chief nursing officer (CNO) Medicaid Utilization Review Act
21
AB103118_Ch02.indd 21 2/6/2020 4:52:52 PM

A broad array of healthcare services is available in for health information management profession-
the United States today, from simple preventive als to have a comprehensive understanding
measures such as vaccinations to complex life- of healthcare delivery. This chapter discusses
saving procedures such as heart transplants. An healthcare delivery in the United States and
individual’s contact with the healthcare d elivery how political, societal, and other factors have
system often begins before he or she is born, with influenced its development. Well-known leg-
family planning and prenatal care, and continues islation affecting healthcare and healthcare in-
through the end of life, when long-term care or formation systems in the United States is exam-
hospice care may be needed. ined. D ifferent healthcare providers and types
Health information is a vital component of of delivery facilities and the services they pro-
the healthcare system. Therefore, it is crucial vide are explained.
n.
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Healthcare Providers
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The US healthcare system employs an es- Optometrist (OD—Doctor of Optometry)
tA
●●
timated 16 million workers in the roles of health prac- focuses on vision and visual systems and is
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titioners, practitioner support, technologists, techni- trained to prescribe and fit lenses to improve
ag
cians, and support roles (BLS 2017a). Physicians, vision.
an
nurses, and other clinical providers deliver healthcare Osteopath (DO—Doctor of Osteopathic
M
●●
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services in a variety of healthcare settings. Those care Medicine) not only focuses on
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settings include ambulatory, acute care, rehabilita- manipulation of muscles and bones
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tive, psychiatric, long-term care, hospice, home care,

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but also incorporates the diagnosis and

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assisted living centers, industrial medical clinics, and treatment of diseases.

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public health clinics. In other words, wherever peo-

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●● Podiatrist (DPM—Doctor of Podiatric

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ple need access to the healthcare system, there are

Medicine) focuses on the treatment of
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healthcare professionals providing that care.

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disorders of the foot, ankle, and lower

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Medical Practice extremities.

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There are many providers included under the term All states require physicians be licensed to prac-
by
medical practice, all of which are referred to as “doc- tice. Licensure requires graduating from a medical
20
tor.” It should be noted that doctor is an educational school with a Doctor of Medicine (MD) or a Doc-
20
tor of Osteopathy (DO), successful completion of

©
degree, not a profession. Some of the most common

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healthcare practitioners are the following: a licensing examination, and completion of a su-
ig
yr
pervised residency program. Residencies are paid,

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●● Chiropractor (DC—Doctor of Chiropractic)

on-the-job training that may last two to six years.
C
focuses on the diagnosis, treatment,

Both MDs and DOs utilize acceptable treatment
and prevention of disorders of the
practices, including prescribing medications or
neuromusculoskeletal system.
performing surgeries.
●● Dentist (DDS or DMD—Doctor of Dental The main difference between a DO and MD is
Surgery or Doctor of Medicine in Dentistry) in the philosophy and approach to medical treat-
focuses on the diagnosis, prevention, and ment. The DO practices osteopathic medicine,
treatment of diseases and conditions of the which places an emphasis on the muscular sys-
oral cavity. tem, stresses preventive medicine, and takes a ho-
●● Medical (MD—Doctor of Medicine) focuses listic approach to patient care (Shi and Singh 2019).
on the diagnosis, treatment, and education MDs practice allopathic medicine, which uti-
of any human disease or condition. lizes medical treatment as an active intervention
AB103118_Ch02.indd 22 2/6/2020 4:52:52 PM

to counteract and neutralize the effects of disease primary care physicians. Non–primary care phy-
(Shi and Singh 2019). MDs may utilize preventive sicians are specialists. Specialists must obtain ad-
medicine combined with allopathic medicine. A ditional certification in their specialty. Medical
2016 census of active licensed physicians in the specialties are divided into six major categories: 1)
US identified 953,695 allopathic and osteopathic subspecialties of internal medicine 2) broad medi-
physicians serving a population of 323 million cal specialties 3) obstetrics and gynecology 4) sur-
people. More than 90 percent of actively licensed gery, 5) hospital-based radiology anesthesiology,
physicians are MDs, compared to DOs (Young and (6) psychiatry (Shi and Singh 2019). Some of
et al. 2016) the medical specialties and subspecialties are de-
Physicians can be categorized as generalists or fined in figure 2.1. Some subspecialties can be in-
specialists. A generalist is trained in family med- cluded in more than one specialty category. For
icine, general practice, general internal medicine, example, there is a subspecialty of pediatrics for
n.
and general pediatrics. Generalists are considered most specialties.
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Figure 2.1 Medical specialties and subspecialties
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Medical Specialties and Subspecialties
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Allergy and Immunology Diagnoses and manages disorders involving immune conditions such as asthma,
n
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anaphylaxis, rhinitis, and eczema as well as adverse reactions to drugs, food, and
at
insects. In addition, they diagnose and manage immune deficiency diseases and
m
problems related autoimmune diseases, organ transplantation, or malignancies of the

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immune system.
In
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Anesthesiology Provides anesthesia for patients undergoing surgical, obstetric, diagnostic, or therapeutic
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procedures while monitoring the patient’s condition and supporting vital organ functions.
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Anesthesiologists also provide resuscitation and medical management for patients with critical
an
illnesses and severe injuries.

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Pediatric Provides anesthesia for neonates, infants, children, and adolescents undergoing surgical,
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diagnostic, or therapeutic procedures as well as appropriate pre- and post-operative care,

advanced life support, and acute pain management.
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Colon and Rectal Surgery Diagnoses and treats various diseases of the small intestine, colon, rectum, anal
by
canal, and perianal area including the organs and tissues related to primary intestinal
20
diseases.
20
Dermatology Provides diagnosis and medical/surgical management of diseases of the skin, hair and nails, and
©
mucous membranes.
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Dermatopathology Diagnoses and monitors diseases of the skin, including infectious, immunologic, degenerative,
yr
and neoplastic diseases

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C
Emergency Medicine Focuses on the immediate decision-making and action necessary to prevent death or any further
disability both in the pre-hospital setting by directing emergency medical technicians and in the
emergency department.
Family Medicine Delivers a range of acute, chronic, and preventive medical care services to individuals of all
ages, families, and communities. In addition to diagnosing and treating illness, these personal
physicians manage chronic illness and provide preventive care, including routine checkups, health
risk assessments, immunization and screening tests, and personalized counseling on maintaining
a healthy lifestyle.
Geriatric Medicine Includes special knowledge of the aging process and special skills in the diagnostic, therapeutic,
preventive, and rehabilitative aspects of illness in the elderly.
ospice and Palliative
H Provides care to prevent and relieve the suffering experienced by patients with life-limiting
Medicine illnesses.
continued
AB103118_Ch02.indd 23 2/6/2020 4:52:52 PM

Figure 2.1 Medical specialties and subspecialties (continued)

Internal Medicine Provides long-term, comprehensive care in the office and in the hospital, managing both common
and complex illnesses of adolescents, adults, and the elderly. Internists are trained in the
diagnosis and treatment of cancer, infections, and diseases affecting the heart, blood, kidneys,
joints, and the digestive, respiratory, and vascular systems. They are also trained in the essentials
of primary care internal medicine.
Cardiovascular Disease Specializes in diseases of the heart and blood vessels and manages complex cardiac conditions,
such as heart attacks and life-threatening, abnormal heartbeat rhythms.
Critical Care Medicine Specializes in the diagnosis, treatment, and support of critically ill and injured patients, particularly
trauma victims and patients with multiple organ dysfunction.
Neurocritical Care Provides comprehensive multisystem care of the critically ill patient with neurological diseases
and conditions.
Endocrinology, Diabetes, Specializes in the diagnosis and management of disorders of hormones and their actions,
and Metabolism metabolic disorders, and neoplasia of the endocrine glands.
n.
Gastroenterology Specializes in diagnosis and treatment of diseases of the digestive organs including the stomach,
tio
bowels, liver, and gallbladder.
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Hematology Specializes in diseases of the blood, spleen, and lymph.
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Infectious Disease Provides care for infectious diseases of all types and in all organ systems. Infectious disease
tA
specialists may also have expertise in preventive medicine and travel medicine.
en
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Interventional Cardiology Uses specialized imaging and other diagnostic techniques to evaluate blood flow and pressure in
the coronary arteries and chambers of the heart, and uses technical procedures and medications
ag
to treat abnormalities that impair the function of the cardiovascular system.
an
M
Medical Oncology Diagnoses and treats all types of cancer and other benign and malignant tumors.
n
Nephrology io
Treats disorders of the kidney, high blood pressure, fluid and mineral balance, and dialysis of body
at
wastes when the kidneys do not function.
m
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Pulmonary Disease Treats diseases of the lungs and airways. Diagnoses and treats cancer, pneumonia, pleurisy,
fo
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asthma, occupational and environmental diseases, bronchitis, sleep disorders, emphysema, and
lth
other complex disorders of the lungs.

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Rheumatology Treats diseases of joints, muscle, bones, and tendons. Diagnoses and treats arthritis, back pain,
H
muscle strains, common athletic injuries, and collagen diseases.

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Medical Genetics and Specializes in medicine that involves the interaction between genes and health. Medical
er
Genomics geneticists are trained to evaluate, diagnose, manage, treat, and counsel individuals of all ages
Am
with hereditary disorders. These specialists use modern cytogenetic, molecular, genomic, and
e
biochemical genetic testing to assist in specialized diagnostic evaluations, implement needed

th
therapeutic interventions, and provide genetic counseling and prevention through prenatal and
by
preimplantation diagnosis.
20
Neurological Surgery Treats adult and pediatric patients for pain or pathological processes that may modify the function
20
or activity of the central nervous system, the peripheral nervous system, the autonomic nervous
©
system, the supporting structures of these systems, and their vascular supply.
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Neurology Evaluates and treats all types of diseases or impaired functions of the brain, spinal cord,
yr
peripheral nerves, muscles, and autonomic nervous system, as well as the blood vessels that
op
relate to these structures.

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Brain Injury Medicine Focuses on the prevention, evaluation, treatment, and rehabilitation of individuals with acquired
brain injury.
Clinical Neurophysiology Evaluates and treats central, peripheral, and autonomic nervous system disorders
using a combination of clinical evaluation and electrophysiologic testing such as
electroencephalography (EEG), electromyography (EMG), and nerve conduction studies
(NCS). Practitioners may be neurologists, pediatric neurologists, or psychiatrists.
Epilepsy Evaluates and treats adults and children with recurrent seizure activity and seizure disorders.
Neurologists and pediatric neurologists provide epilepsy care.
Obstetrics and Gynecology Focuses on the health of women before, during, and after childbearing years, diagnosing and
treating conditions of the reproductive system and associated disorders.
continued
AB103118_Ch02.indd 24 2/6/2020 4:52:52 PM

Figure 2.1 Medical specialties and subspecialties (continued)

Complex Family Planning Diagnoses and treats women with medically and surgically complex conditions.
Maternal–Fetal Medicine Focuses on patients with complications of pregnancy and the effects on both the mother and the
fetus.
Reproductive Endocrinology Concentrates on hormonal functioning as it pertains to reproduction as well as the issue of
and Infertility infertility. These specialists also are trained to evaluate and treat hormonal dysfunctions in females
outside of infertility.
Ophthalmology Prescribes eyeglasses and contact lenses, dispenses medications, diagnoses and treats eye
conditions and diseases, and performs surgeries. Ophthalmologists are the only physicians
medically trained to manage the complete range of eye and vision care.
Orthopaedic Surgery Focuses on the preservation, investigation, and restoration of the form and function of the
extremities, spine, and associated structures by medical, surgical, and physical means.
Otolaryngology – Head and Provides medical and surgical therapy for the prevention of diseases, allergies, neoplasms,
Neck Surgery deformities, disorders, and injuries of the ears, nose, sinuses, throat, respiratory, and upper
n.
alimentary systems, face, jaws, and the other head and neck systems.
tio
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Pain Medicine Provides care for patients with acute, chronic, or cancer pain in both inpatient and outpatient
oc
settings while coordinating patient care needs with other specialists.
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Pathology Deals with the causes and nature of disease and contributes to diagnosis, prognosis, and
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treatment through knowledge gained by the laboratory application of the biological, chemical, and
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physical sciences.
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Pediatrics Focuses on the physical, emotional, and social health of children from birth to young adulthood.
ag
Pediatric care encompasses a broad spectrum of health services ranging from preventive
an
healthcare to the diagnosis and treatment of acute and chronic diseases.
M
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Adolescent Medicine Focuses on the unique physical, psychological, and social characteristics of adolescents, and
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their healthcare problems and needs.
m
Physical Medicine and Evaluates and treats patients with physical or cognitive impairments and disabilities that
r
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Rehabilitation result from musculoskeletal conditions (such as neck or back pain, or sports or work injuries),
In
neurological conditions (such as stroke, brain injury, or spinal cord injury), or other medical
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conditions. Also called a physiatrist.

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Plastic Surgery Deals with the repair, reconstruction, or replacement of physical defects of form or function
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involving the skin, musculoskeletal system, craniomaxillofacial structures, hand, extremities,

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breast and trunk, and external genitalia or cosmetic enhancement of these areas of the body.
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Cosmetic surgery is an essential component of plastic surgery

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Preventive Medicine Focuses on the health of individuals and defined populations to protect, promote, and maintain
e
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health and well-being and to prevent disease, disability, and premature death.
by
Addiction Medicine Concerned with the prevention, evaluation, diagnosis, and treatment of persons with the disease
20
of addiction, of those with substance-related health conditions, and of people who show
20
unhealthy use of substances including nicotine, alcohol, prescription medications, and other licit
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and illicit drugs.

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Clinical Informatics Collaborates with other healthcare and information technology professionals to analyze, design,
ig
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implement, and evaluate information and communication systems that enhance individual
op
and population health outcomes, improve patient care, and strengthen the clinician–patient
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relationship.
Medical Toxicology Specializes in the prevention, evaluation, treatment, and monitoring of injury and illness from
exposures to drugs and chemicals, as well as biological and radiological agents.
Psychiatry Evaluates and treats mental, addictive, and emotional disorders such as schizophrenia and other
psychotic disorders, mood disorders, anxiety disorders, substance-related disorders, sexual and
gender-identity disorders, and adjustment disorders.
Radiology Utilizes imaging methodologies to diagnose and manage patients and provide therapeutic options.
Diagnostic Utilizes x-rays, radionuclides, ultrasound, and electromagnetic radiation to diagnose and treat
disease.
Interventional Radiology and Combines competence in imaging, image-guided minimally invasive procedures, and
Diagnostic Radiology peri-procedural patient care to diagnose and treat benign and malignant conditions of the
thorax, abdomen, pelvis, and extremities.
continued
AB103118_Ch02.indd 25 2/6/2020 4:52:52 PM

Figure 2.1 Medical specialties and subspecialties (concluded)

Radiation Oncology Uses ionizing radiation and other modalities to treat malignant and some benign diseases.
Neuroradiology Diagnoses and treats disorders of the brain, sinuses, spine, spinal cord, neck, and the central
nervous system, such as aging and degenerative diseases, seizure disorders, cancer, stroke,
cerebrovascular diseases, and trauma.
Nuclear Radiology Uses the administration of trace amounts of radioactive substances (radionuclides) to provide
images and information for making a diagnosis.
Sleep Medicine Diagnoses and manages clinical conditions that occur during sleep, that disturb sleep, or that
are affected by disturbances in the wake-sleep cycle. Includes the analysis and interpretation of
comprehensive polysomnography, and practitioners are well versed in emerging research and
management of a sleep laboratory.
Sports Medicine Focuses on the prevention, diagnosis, and treatment of injuries related to participating in sports or
exercise.
Surgery (General) Provides diagnosis and care of patients with diseases and disorders affecting the abdomen,
n.
digestive tract, endocrine system, breast, skin, and blood vessels. General surgeons are skilled
tio
in the use of minimally invasive techniques and endoscopies. Common conditions treated by
ia
general surgeons include hernias, gallstones, appendicitis, breast tumors, thyroid disorders,
oc
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pancreatitis, bowel obstructions, colon inflammation, and colon cancer.
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Thoracic Surgery Encompasses the operative, perioperative, and surgical critical care of patients with acquired and
en
congenital pathological conditions within the chest.
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Congenital Cardiac Surgery Refers to the procedures that are performed to repair the many types of heart defects that may be
ag
present at birth and can occasionally go undiagnosed into adulthood.
an
Urology Focuses on diagnosing and treating disorders of the urinary tracts of males and females, and on
M
the reproductive system of males. Manages nonsurgical problems such as urinary tract infections,
n
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as well as surgical problems such as the correction of congenital abnormalities.
at
m
Female Pelvic Medicine and Provides consultation and comprehensive management of women with complex benign pelvic
r
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Reconstructive Surgery conditions, lower urinary tract disorders, and pelvic floor dysfunction.
In
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Source: Adapted from American Board of Medical Specialties (ABMS).2019. ABMS Guide to Medical Specialties. https://www.abms.org/media/194925/abms-
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guide-to-medical-specialties-2019.pdf
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Another specific role for physicians is that of a primary care physicians can devote more time
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hospitalist. A hospitalist is a physician who spe- to their office practices. There are approx-
by
cializes in the care of inpatient hospital patients imately 50,000 hospitalists practicing in 75
20
20
(Shi and Singh 2019). Typically, hospitalists do percent of US Hospitals (Wachter and Goldman
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not have a relationship with the patient prior to 2016).

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providing care during the hospitalization. In the

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Physician Assistants
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traditional inpatient model, the patient’s pri-

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mary care physician would oversee their care. Some physicians and healthcare facilities employ
In the hospitalist model, the hospitalist over- physician assistants (PAs) to help carry out clin-
sees the patient’s care until discharge; then the ical responsibilities. PAs practice medicine with
patient returns to the care of their primary care teams of physicians, surgeons, and other health-
physician. care workers to examine, diagnose, and treat pa-
Hospitalists were first utilized to provide care tients. They work in a variety of clinical settings.
for unassigned patients on general medicine A PA is licensed to provide care and perform med-
floors and to cover for community-based pri- ical procedures only under the supervision of a
mary care physicians. As hospitals began to fo- physician. In most states PAs have the authority
cus on managed care, hospitalists were viewed to prescribe medications. Employment of PAs is
as a means for hospitals to gain greater efficiency projected to grow 37 percent from 2016 to 2026
(Furci and Furci 2017). With the use of hospitalists, (BLS 2018).
AB103118_Ch02.indd 26 2/6/2020 4:52:52 PM

Nursing Practice certified by the Council on Certification/Council

on Recertification of Nurse Anesthetists. Nurse
Nurses represent the largest number of healthcare
practitioners also receive advanced training at the
professionals with four million registered nurses
master’s level that qualifies them to provide pri-
(RNs) (ANA 2019). Nurses are the primary care-
mary care services to patients. They are certified
givers for sick and injured patients. They use their
by several organizations (for example, the National
judgment to integrate objective data with subjec-
Board of Pediatric Nurse Practitioners) to practice
tive observation of the patient’s biological, phys-
in the area of their specialty.
ical, and behavioral needs. Nurses work in a va-
The need for RNs is expected to rise over the
riety of health settings, from providing critical
next decade. Hospitals in the US report continued
care to vaccinations in a physician practice. The
vacancies for RNs. The Bureau of Labor Statistics
American Nurses Association (2019) provides the
estimates that between the years 2016 and 2026
following four key responsibilities of registered
n.
approximately 438,100 more RNs will be needed
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nurses (ABMS 2019):
over the projected supply (BLS 2017b).
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1. Perform physical exams and health histories
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Allied Health Professions
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before making critical decisions
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2. Provide health promotion, counseling, and After World War I, many roles previously as-
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education sumed by nurses and nonclinical personnel began
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to change. With the advent of modern diagnostic
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3. Administer medications and other
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personalized interventions and therapeutic technology in the mid-20th cen-
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tury, the complex skills needed by ancillary med-
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4. Coordinate care in collaboration with a wide
m
ical personnel fostered the growth of specialized

array of healthcare professionals
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training programs and professional accreditation

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Most RNs have either a two-year associate de- and licensure.

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gree or a four-year bachelor of science degree from According to the Association of Schools of Al-
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a state-approved nursing school, though some lied Health Professions (ASAHP), allied health en-
an
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schools offer a master’s degree that allows the compasses a broad group of health professionals
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graduate to sit for the licensure examination. Nurse who use scientific principles and evidence-based
practitioners, researchers, educators, and adminis- practice for the diagnosis, evaluation, and treat-
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trators generally have a four-year degree in nursing ment of acute and chronic diseases; promote dis-
by
and additional postgraduate education in nursing. ease prevention and wellness for optimum health;
20
20
The postgraduate degree may be a master of science and apply administration and management skills
©
or a doctorate in nursing. Nurses who graduate from to support healthcare systems in a variety of set-
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nonacademic training programs are called licensed tings. The Health Professions Education Extension
yr
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practical nurses (LPNs) or licensed vocational nurses Amendment of 1992, which amended the Public
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(LVNs). Non-degreed nursing personnel work under Health Service Act, describes allied health profes-
the direct supervision of RNs. Nurses must be li- sionals as health professionals (other than regis-
censed in the state in which they are working. They tered nurses, physicians, and physician assistants)
may be licensed in more than one state through who have received a certificate, an associate de-
examination or endorsement of a license issued by gree, a bachelor degree, a master degree, a doctor-
another state. ate, or postdoctoral training in a healthcare-related
Today’s RNs are highly trained clinical profes- science. Such individuals share responsibility for
sionals. Many nurses specialize in specific areas of the delivery of healthcare services with clinicians
practice such as surgery, psychiatry, or intensive (physicians, nurses, and physician assistants).
care. Nurse-midwives complete advanced train- Allied health plays an essential role in the de-
ing and are certified by the American College of livery of healthcare. It is estimated that as much as
Nurse-Midwives. Similarly, nurse-anesthetists are 60 percent of the US healthcare workforce can be
AB103118_Ch02.indd 27 2/6/2020 4:52:52 PM

classified as allied health (ASAHP 2018). Profes- Laboratory technicians are allied health
sions that fall in the category of allied health are professionals trained to operate laboratory
the non-nurse, non-physician healthcare providers. equipment and perform laboratory tests
The formal education requirements for these pro- under the supervision of a pathologist.
fessions range from certifications through post- ●● Diagnostic medical sonography or imaging
secondary education to postgraduate degrees. technology. Originally referred to as x-ray
Technicians and assistants such as a physical technology and then radiologic technology,
therapist assistant, dental assistant, or laboratory this field is now referred to as diagnostic
technician typically receive less than two years imaging. The field continues to expand to
postsecondary education and must work under include nuclear medicine, radiation therapy,
the supervision of a therapist or technologist. and echocardiography. Physician specialists
Therapists such as a physical or speech therapist (radiologists) and technologists including
n.
receive more advanced training. radiation therapists, cardiosonographers
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The following list briefly describes some of the
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(ultrasound technologists), and magnetic
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major occupations usually considered to be allied resonance imaging technologists provide
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health professions:
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these services. Nuclear medicine involves
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the use of ionizing radiation and small
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●● Audiology. Audiology is the branch of science amounts of short-lived radioactive tracers to
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that studies hearing, balance, and related
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treat disease, specifically neoplastic disease
disorders. Audiologists treat those with
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(that is, nonmalignant tumors and malignant
hearing loss and proactively prevent related
n
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cancers). Radiation therapy uses high-energy
at
damage. According to the American Speech-
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x-rays, cobalt, electrons, and other sources

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Language-Hearing Association, audiologists of radiation to treat human disease. In

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provide comprehensive diagnostic and

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current practice, radiation therapy is used

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treatment or rehabilitative services for auditory alone or in combination with surgery or

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and related impairments. These services are

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chemotherapy (drugs) to treat many types of

provided to all individuals regardless of age,
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cancer. In addition to external beam therapy,

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socioeconomic status, ethnicity, or cultural

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radioactive implants (as well as therapy

backgrounds (ASHA 2016).
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performed with heat—hyperthermia) are

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Clinical laboratory science. Originally referred

by
●● available.
to as medical laboratory technology, this
20
●● Dietetics and nutrition. Dietitians (also clinical

20
field is now known as clinical laboratory nutritionists) are trained in nutrition. They
©
science. Clinical laboratory technicians

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are responsible for providing nutritional care

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perform a wide array of tests on body fluids, to individuals and for overseeing nutrition
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tissues, and cells to assist in the detection, and food services in a variety of settings,
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diagnosis, and treatment of diseases and ranging from hospitals to schools.

illnesses. The clinical laboratory is divided
●● Emergency medical technology. Emergency
into two sections—anatomic pathology and
medical technicians (EMTs) and paramedics
clinical pathology. Anatomic pathology
provide a wide range of services on an
deals with human tissues and provides
emergency basis for cases of traumatic
surgical pathology, autopsy, and cytology
injury and other emergency situations and
services. Clinical pathology deals mainly
in the transport of emergency patients to a
with the analysis of body fluids—principally
healthcare organization.
blood, but also urine, gastric contents, and
cerebrospinal fluid. Physicians who specialize ●● Health information management. Health
in performing and interpreting the results information management (HIM)
of pathology tests are called pathologists. professionals. Registered Health Information
AB103118_Ch02.indd 28 2/6/2020 4:52:52 PM

Administrators (RHIAs) and Registered standard for pharmacists. The current

Health Information Technicians (RHITs) standard is a PharmD, which requires
are the credentials for HIM professions. six years of postsecondary education.
They are responsible for ensuring the The scope of practice for a pharmacist is
availability, accuracy, and protection of the expanding into specialty areas such as
clinical information that is needed to deliver pharmacotherapy. Pharmacotherapists work
healthcare services and to make appropriate closely with physicians and specialize in drug
healthcare-related decisions. therapy. Pharmacists take an active role in
●● Occupational therapy. Occupational therapists pharmaceutical care of patients by assisting
(OTs) use work and play activities to prescribers in appropriate drug choices,
improve patients’ independent functioning, by effecting distribution of medications to
enhance their development, and prevent patients, and by assuming direct responsibility
n.
or decrease their level of disability. to collaborate with other healthcare providers
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and the patient to achieve a desired
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Occupational therapy activities may involve
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the adaptation of tasks or the environment therapeutic outcome (Shi and Sing 2019).
ss
tA
to achieve maximum independence and ●● Physical therapy. Physical therapists (PTs),
en
to enhance the patient’s quality of life and who work under the direction of a physician,
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improve his or her activities of daily living evaluate and treat patients to improve
ag
an
(ADL). An occupational therapist may functional mobility, reduce pain, maintain
M
treat developmental deficits, birth defects, cardiopulmonary function, and limit
n
io disability. PTs treat movement dysfunction
learning disabilities, traumatic injuries,
at
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burns, neurological conditions, orthopedic resulting from accidents, trauma, stroke,

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conditions, mental deficiencies, and fractures, multiple sclerosis, cerebral palsy,

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psychiatric disorders. Working under the arthritis, and heart and respiratory illness.
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direction of physicians, occupational therapy Treatment modalities include therapeutic

H
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is made available in acute-care hospitals, exercise, therapeutic massage, biofeedback,

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clinics, and rehabilitation centers. and applications of heat, low-energy lasers,

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●● Optometry. Optometry is a health profession cold, water, electricity, and ultrasound.

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Respiratory therapy. Respiratory therapists

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that is focused on the eyes and related ●●

by
structures, as well as vision, visual systems, (RTs) evaluate, treat, and care for patients
20
and vision information processing in with acute or chronic lung disorders. They
20
humans. Optometrists provide treatments work under the direction of qualified

©
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such as contact lenses and corrective and physicians and provide services such
ig
as emergency care for stroke, heart

yr
low-vision devices and are authorized to use

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diagnostic and therapeutic pharmaceutical failure, and shock. In addition, they treat
C
agents to treat anterior segment disease, patients with emphysema and asthma.
glaucoma, and ocular hypertension. As Respiratory treatments include the
primary eye care practitioners, optometrists administration of oxygen and inhalants
often are the first ones to detect such such as bronchodilators and setting up and
potentially serious conditions as diabetes, monitoring ventilator equipment.
hypertension, and arteriosclerosis. ●● Speech-language pathology. Speech-language
●● Pharmacy. Traditionally the role of a pathologists and audiologists identify,
pharmacist was to dispense medications assess, and provide treatment for individuals
and to provide consultation on the proper with speech, language, or hearing problems.
selection and use of medications. Prior ●● Surgical technologist. Surgical technologists
to 2005, the bachelor’s degree was the provide surgical care to patients in a variety
AB103118_Ch02.indd 29 2/6/2020 4:52:52 PM

Figure 2.2 Largest occupations in healthcare and the social assistance industry
Registered nurses 2,585,920
Personal care aides 2,115,970
Nursing assistants 1,340,690
Home health aides 765,790

Occupation
Medical assistants 638,490
Licensed practical and licensed vocational nurses 607,960
Medical secretaries 546,510
n.
Receptionists and information clerks 495,640
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Office clerks, general 356,960
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Childcare workers 332,200
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0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000
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Employment
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Source: BLS 2017c.
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of settings; the majority are hospital operating The occupations in the healthcare industry with
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rooms. Surgical technologists work under the largest number of employees include RNs and
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medical supervision to facilitate the safe personal care aides. Figure 2.2 shows the number
ea
and effective conduct of invasive surgical of employees by field in healthcare and the social
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an
procedures (Kickman and Kovner 2015). assistance industry.

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th
by

20
20

©
ht
1. Which of the following is a physician specializing in the care of inpatient hospital patients?
ig
yr
a. Hospitalist
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b. Internist
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c. Critical care specialist

d. Hospice physician
2. Which healthcare professional is licensed to practice medicine with physician supervision?
a. Diagnostic medical sonographer
b. Health information manager
c. Clinical laboratory technician
d. Physician assistant
3. Which service diagnoses and treats patients who have acute or chronic lung disorders?
a. Occupational therapy
b. Physical therapy
c. Respiratory therapy
d. Clinical laboratory services
AB103118_Ch02.indd 30 2/6/2020 4:52:53 PM

4. Which healthcare provider utilizes ultrasound, computed tomography, or magnetic resonance imaging?
a. Nuclear medicine technologist
b. Orthodontist
c. Podiatrist
d. Radiologic technologist
5. Which of the following is a surgical specialty?
a. Internal medicine
b. Oncology
c. Neurology
d. Orthopedics
6. Which of the following statements is true about registered nurses (RNs)?
a. RNs only provide clinical services within a healthcare entity.
b. RNs are required to have a license in the state in which they practice.
n.
tio
c. RNs are graduates of nonacademic training programs.
ia
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d. RNs must have a bachelor’s degree from an approved nursing school.
ss
7. Which of the following perform a wide array of tests on body fluids, tissues, and cells to assist in the detection,
tA
iagnosis, and treatment of diseases and illnesses?
d
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a. Clinical laboratory scientists
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b. Sonographers
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c. Licensed practical nurses
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d. Surgical technologists
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8. True or false: HIM professionals are responsible for ensuring the availability, accuracy, and protection of clinical
m
information.
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9. True or false: Audiologists provide comprehensive diagnostic and treatment and rehabilitative services for auditory,
lth
vestibular, and related impairments.

ea
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10. True or false: Physical therapists and occupational therapists are the only members of the rehabilitation service team
an
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Organization and Operation of Modern Hospitals

by
20
20
During the 1990s, hospitals in the United inpatient care to long-term care. The continuum
©
States faced growing pressure to contain costs, im- of care places an emphasis on treating individual
ht
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prove quality, and demonstrate how they contrib- patients at the level of care required by their course
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uted to the health of the communities they served. of treatment and extends from their primary care
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Hospitals responded to these pressures in various providers to specialists and ancillary providers. In
ways. Some hospitals merged with other hospitals 2014, the American Hospital Association released
and healthcare facilities, or they were bought out. “Your Hospital’s Path to the Second Curve: Integra-
Other hospitals created integrated delivery systems tion and Transformation.” This paper discusses the
(IDSs). These are healthcare systems that combine shift in the healthcare field from the “first curve,”
the financial and clinical aspects of healthcare and where hospitals operate in a volume-based envi-
use a group of healthcare providers, selected on ronment to the “second curve” where they build
the basis of quality and cost management criteria, value-based care systems (AHA 2014). Hospitals
to furnish comprehensive health services across and care systems need to redesign how care is de-
the continuum of care. The IDSs were created to livered to eliminate inefficiencies within the system
provide a full range of healthcare services along that will lead to better, integrated care, and lower
the continuum of care, from ambulatory care to total cost of care. The establishment of IDSs, the
AB103118_Ch02.indd 31 2/6/2020 4:52:54 PM

greater use of teams, and leveraging the skills and employ nearly 6 million people and are one of the
capabilities of all providers in different settings top sources of private-sector jobs (AHA 2018b). In
within the IDS is a step towards achieving patient- 2017, healthcare expenditures in the United States
centered care and the second curve environment. were approximately $3.5 trillion, which represent-
Others have concentrated on improving the care ed 17.9 percent of the total American economy
they provide by focusing on patients as customers. (CMS 2018a). According to Centers for Medicare
Many hospitals responded to local competition by and Medicaid Services (CMS) projections, national
quickly entering into affiliations and other risk- health spending is projected to grow an average
sharing agreements with acute- and nonacute- rate of 5.5 percent each year and reach $5.7 trillion
care providers, physicians’ groups, and managed by 2026 (CMS 2018b). Figure 2.3 shows the national
care organizations (MCOs)—a type of healthcare health expenditures in 2017 were $3.5 trillion
organization that delivers medical care and man- dollars, with 45 percent going toward hospital
n.
ages all aspects of patient care or the payment for care.
tio
care by limiting providers of care, discounting The term hospital can be applied to any health-
ia
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payments to providers of care, or limiting access care facility that does the following:
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to care.
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Has an organized medical staff
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●●
While most hospitals are integrated into their
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communities through ties with area physicians ●● Provides permanent inpatient beds
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and other healthcare providers, clinics and out- Offers around-the-clock nursing services
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●●
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patient facilities, and other practitioners, almost ●● Provides diagnostic and therapeutic services
half the nation’s hospitals also are tied to larger n
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organizational entities such as multihospital and Most hospitals provide acute-care services to in-
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patients. Acute care is the short-term care provided

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integrated healthcare systems (IHCSs), integrated

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delivery networks (IDNs), and alliances. An IDN to diagnose or treat an illness or injury. The individ-
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uals who receive acute-care services in hospitals are

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comprises a group of hospitals, physicians, other

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providers, insurers, or community agencies that considered inpatients. Inpatients receive room-and-
an
board services in addition to continuous nursing

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work together to deliver health services. In 2015,

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services. Generally, patients who spend more than

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55 percent of all hospitals in the US belonged to an

IDN (AHA 2015). 24 hours in a hospital are considered inpatients.
e
th
By the end of 2010, healthcare organizations Hospitals that have an average length of stay
by
faced the challenges of a stressed economy. Hospi- (ALOS) of 25 days or less are considered acute-care
20
20
tal reimbursement payments continued to shrink

©
as a result of higher unemployment and more Figure 2.3 National health expenditures in 2017
ht
ig
uninsured individuals throughout the nation. At National Health Expeditures 2017,

yr
op
that time, hospitals reached out for opportuni- $3.5 trillion

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ties to control costs, streamline operations, imple- Health Spending by Type of Service or
ment efficient information technologies, engage in Product
Hospital care
quality initiatives, and pursue joint ventures and 7%
consolidation. Today, hospitals are a dominant 7% Physician and clinical
services
player in the healthcare system and have a signif-
icant impact on the US economy. According to the 14% Retail prescription
45% drugs
American Hospital Association (AHA), in 2016
hospitals treated 143 million people in their emer- Nursing care and
home health
gency departments, provided 605 million outpa- 27%
tient visits, performed over 27 million surgeries, Other
and delivered nearly 4 million infants. In addition

to providing vital healthcare services, hospitals Source: Adapted from CMS 2018a.
AB103118_Ch02.indd 32 2/6/2020 4:52:55 PM

hospitals. Hospitals that have ALOSs longer than Functionality

25 days are considered long-term acute-care fa- This refers to how the hospitals function within
cilities. Long-term care is discussed in detail lat- the communities they serve. They could be gen-
er in this chapter. The ALOS is the mean length eral, teaching, acute care, long term, community,
of stay for hospital inpatients discharged during and research or trauma centers.
a given period of time. With recent advances in
surgical technology, anesthesia, and pharmacol- Location
ogy, the ALOS in an acute-care hospital is much Hospitals can be classified by their location. Ru-
shorter today than it was only a few years ago. ral hospitals may have limited access to advanced
In addition, many diagnostic and therapeutic pro- equipment or specialized procedures. Urban hos-
cedures that once required inpatient care now can pitals serve larger metropolitan areas and often of-
be performed on an outpatient basis. fer a wide degree of versatility when it comes to
n.
For example, before the development of lapa- treatment options.
tio
roscopic surgical techniques, a patient might be
ia
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hospitalized for 10 days after a routine appendec- Number of Beds
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tomy (surgical removal of the appendix). Today,
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A hospital’s number of beds refers to the beds that
en
a patient undergoing a laparoscopic appendec-
are equipped and staffed for patient care. The term
em
tomy might spend only a few hours in the hospi-
ag
bed capacity sometimes is used to reflect the maxi-
tal’s outpatient surgery department and go home
an
mum number of inpatients for which the hospital
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the same day. The influence of managed care and
can care. Licensed beds are the number of beds that
the emphasis on cost control in the Medicare or n
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the state has authorized the hospital to have availa-
at
Medicaid programs also have resulted in shorter
m
ble for patients and staffed beds refers to the number

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hospital stays. More information on healthcare

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of beds for which the hospital has nursing staff to

statistics can be found in chapter 14, Healthcare
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cover patient treatment. A hospital is usually con-

ea
Statistics.
sidered small if it has fewer than 100 beds. Most US
H
In large acute-care hospitals, hundreds of cli-

an
hospitals fall into this category. Some large, urban

ic
nicians, administrators, managers, and support

er
hospitals may have more than 500 beds. The num-

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staff must work closely to provide effective and

ber of beds is usually broken down by adult and
efficient diagnostic and therapeutic services. Most
e
th
pediatric beds. The number of maternity beds and

hospitals provide services to both inpatients and
by
other special categories may be listed separately.

outpatients. A hospital outpatient is a patient who
20
Hospitals also can be categorized according to the

20
receives hospital services without being admitted

number of outpatient visits per year.
©
for inpatient (overnight) hospital care. Outpatient

ht
ig
care is considered ambulatory care. (Ambulatory Specialization

yr
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care is discussed later in this chapter.)

A hospital may specialize in certain types of services
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and treatment of specific illnesses. The following are

Types of Hospitals examples:
There are many types of hospitals providing care ●● Rehabilitation hospitals generally provide
within the US healthcare system. The five major cri- long-term care services to patients
teria used to classify hospital types are the following: recuperating from debilitating or chronic
illnesses and injuries such as strokes, head
1. Functionality
and spine injuries, and gunshot wounds.
2. Location Patients often stay in rehabilitation hospitals
3. Number of beds for several months.
4. Specialization ●● Psychiatric hospitals provide inpatient care
5. Types of ownership for patients with mental and developmental
AB103118_Ch02.indd 33 2/6/2020 4:52:55 PM

disorders. In the past, the ALOS for especially those residents who are unable to
psychiatric inpatients was longer than it is pay for their care.
today. Rather than months or years, most ●● Proprietary hospitals may be owned by
patients now spend only a few days or private foundations, partnerships, or
weeks per stay. However, many patients investor-owned corporations. Large
require repeated hospitalization for chronic corporations may own a number of for-
psychiatric illnesses. profit hospitals, and the stocks of several
●● General hospitals provide a wide range large US hospital chains are traded
of medical and surgical services to publicly.
diagnose and treat most illnesses and ●● Voluntary hospitals are not-for-profit hospitals
injuries. owned by universities, churches, charities,
●● Specialty hospitals provide diagnostic and religious orders, unions, and other not-for-
n.
therapeutic services for a limited range profit entities. They often provide free care
tio
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of conditions such as burns, cancer, to patients who otherwise would not have
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access to healthcare services.
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tuberculosis, obstetrics, or gynecology.
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Long-term acute-care hospitals (LTACHs) Hospitals also can be classified based on their
en
●●
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specialize in the treatment of patients with ownership and profitability status. Not-for-profit
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serious medical conditions that require care healthcare facilities use excess funds to improve
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on an ongoing basis. These patients do not their services and to finance educational programs
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require intensive care or extensive diagnostic and community services. For-profit healthcare or-
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procedures but require more care than they ganizations are privately owned. Excess funds are
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can receive in a rehabilitation center, skilled paid back to the managers, owners, and investors
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nursing facility, or home. in the form of bonuses and dividends.

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Safety Net Hospitals

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Types of Ownership A safety net hospital (SNH) is defined as a hospi-

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The most common ownership types for hospitals tal with the highest number of inpatient stays paid
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and other kinds of healthcare organizations in the by Medicaid. Uninsured safety net organizations
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United States include the following: play a major role in providing services to medi-
by
Government-owned hospitals which are cally and socially vulnerable populations. When
20
●●
compared with non-SNHs, SNHs are more likely
20
operated by a specific branch of federal,

©
state, or local government as not-for- to be teaching hospitals, have a large number of

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inpatient beds, and just over 27 percent are locat-

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profit organizations. (Government-owned

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ed in large central metropolitan areas (Sutton et al.

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hospitals sometimes are called public

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hospitals.) They are supported, at least in 2016).

part, by tax dollars. Examples of federally
owned and operated hospitals include Critical Access Hospitals
those operated by the Department of As part of the Balanced Budget Act of 1997 (dis-
Veterans Affairs (VA) to serve retired cussed later in this chapter), CMS was authorized to
military personnel. The Department of allow certain healthcare organizations the designa-
Defense operates facilities for active military tion of critical access hospital (CAH). By meeting
personnel and their dependents. Many certain requirements these hospitals are allowed a
states own and operate psychiatric hospitals. separate payment system that allows reimburse-
County and city governments often operate ment for Medicare patients at 101 percent of rea-
public (municipal) hospitals to serve the sonable costs and are not subject to the inpatient
healthcare needs of their communities, prospective payment system (IPPS) or the hospital
AB103118_Ch02.indd 34 2/6/2020 4:52:55 PM

outpatient prospective payment system (OPPS). fundamental principles or beliefs). Chapter 17,
The criteria to qualify as a CAH are as follows (see Management, covers mission, vision, and values in
chapter 15, Revenue Management and Reimbursement more detail.
for more details on IPPS and OPPS): The board of directors’ other responsibilities in-
clude the following:
●● Be located in a state that accepted a grant
under the Medicare Rural Hospital Flexibility ●● Establishing bylaws in accordance with
Program, which helps states to strengthen the organization’s legal and licensing
their rural healthcare infrastructure requirements
●● Be located in a rural area ●● Selecting qualified administrators
●● Furnish 24-hour emergency care services ●● Approving the organization and makeup of
7 days a week the clinical staff
n.
●● Maintain no more than 25 inpatient beds Monitoring the quality of care
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●●
that may also be used as swing beds
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Board members are elected or appointed to
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(hospital beds that can be either acute-care
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serve a specific term (for example, five years).
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or skilled nursing facility beds)
Boards may elect officers, commonly a chairman,
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Have an annual length of stay of 96 hours or
em
●●
vice-chairman, president, secretary, and treasurer.
less per patient for acute-care services
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The size of the board varies. Individual board
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●● Be located more than a 35-mile distance from members are called directors, board members, or
M
any other hospital
n
trustees. Individuals serve on one or more standing
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Be certified as a CAH prior to January 1, committees such as the executive committee, joint
m
●●
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2006 (CMS 2014) conference committee, finance committee, strategic

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planning committee, and building committee.

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Organization of Hospital Services The makeup of the board depends on the type
ea
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The organizational structure of every hospital is of hospital and the form of ownership. For exam-
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ple, the board of a community hospital is likely to

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designed to meet its specific needs. For example,

er
most acute-care hospitals are comprised of a pro- include local business leaders, representatives of
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fessional medical staff and hospital administrative community organizations, and other people inter-
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services, which include an executive administrative ested in the welfare of the community. The board
by
staff, medical and surgical services, patient care of a teaching hospital, on the other hand, is likely
20
to include medical school alumni and university

20
(nursing) services, diagnostic and laboratory serv-

administrators, among others.
©
ices, and support services (for example, nutritional

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services, environmental safety, and HIM services). Increased competition among healthcare provid-
ig
yr
Hospitals are overseen by a board of directors. ers and limits on managed care and Medicare or
op
Medicaid reimbursement have made the govern-

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Board of Directors ing of hospitals especially difficult in the past two

decades. In the future, boards of directors will con-
The board of directors (also known as the gov-
tinue to face strict accountability in terms of cost
erning board or board of trustees) has primary re-
containment, performance management, and inte-
sponsibility for setting the overall direction of the
gration of services to maintain fiscal stability and
hospital. The board works with the chief executive
to ensure the delivery of high-quality patient care.
officer (CEO) and the leaders of the organization’s
medical staff to develop the hospital’s strategic
direction as well as its mission (statement of the Medical Staff
hospital’s purpose and the customers it serves), The medical staff consists of physicians who have
vision (description of the hospital’s ideal future), received extensive training in various medical dis-
and values (descriptive list of the organization’s ciplines (internal medicine, pediatrics, cardiology,
AB103118_Ch02.indd 35 2/6/2020 4:52:55 PM

gynecology and obstetrics, orthopedics, surgery, bylaws are considered legally binding. The med-
and so on). The medical staff’s primary objective ical staff and the hospital’s governing body must
is to provide high-quality patient care to the pa- vote to approve any changes to the bylaws.
tients who come to the hospital. The physicians
on the hospital’s medical staff diagnose illnesses Administrative Staff
and develop patient-centered treatment regimens. The CEO or chief administrator is the leader of the
Moreover, they may serve on the hospital’s gov- administrative staff. The CEO implements the pol-
erning board, where they provide critical insight icies and strategic direction set by the hospital’s
relevant to strategic and operational planning and board of directors. The CEO is also responsible
policy making. for building an effective executive management
The medical staff is the aggregate of physicians team and coordinating the hospital’s services.
who have been granted permission to provide Today, healthcare organizations commonly des-
n.
clinical services in the hospital. This permission ignate the following roles as the executive man-
tio
is called clinical privileges. An individual phys- agement team: chief financial officer (CFO), the
ia
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ician’s privileges are limited to a specific scope of senior manager responsible for the fiscal manage-
ss
practice. For example, an internal medicine phy-
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ment of an organization; a chief operating officer
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sician would be permitted to diagnose and treat a (COO), the executive responsible for high-level,
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patient with pneumonia, but not to perform a sur- day-to-day operations; and a chief information
ag
gical procedure. Traditionally, most members of officer (CIO), the senior manager responsible for
an
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the medical staff have not been employees of the the management of the information resources.
hospital, although this is changing as many hospi- n
io
The executive management team is responsible
at
tals are purchasing physician practices.
m
for managing the hospital’s finances and ensuring

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Medical staff classification refers to the orga- the hospital complies with the federal, state, and
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nization of physicians according to clinical as-

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local rules, standards, and laws that govern the

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signment. Depending on the size of the hospital delivery of healthcare services. Depending on the
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and on the credentials and clinical privileges of size of the hospital, the CEO’s staff may include
an
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its physicians, the medical staff may be separated healthcare administrators with job titles such as
er
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into departments such as medicine, surgery, ob- vice president, associate administrator, depart-
stetrics, pediatrics, and other specialty services.
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ment director or manager, or administrative as-

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Typical medical staff classifications include active, sistant. Department-level administrators manage
by
provisional, honorary, consulting, courtesy, and

20
and coordinate the activities of the highly special-

20
medical resident assignments. ized and multidisciplinary units that perform clin-
©
Officers of the medical staff usually include a ical, administrative, and support services in the
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president or chief of staff, a vice president or chief hospital.

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of staff elect, and a secretary. These officers are Healthcare administrators may hold advanced
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authorized by a vote of the entire active medical degrees in healthcare administration, nursing,
staff. The president presides over all regular meet- public health, or business management. A grow-
ings of the medical staff and is an ex officio mem- ing number of hospitals are hiring physician exec-
ber of all medical staff committees. The secretary utives to lead their executive management teams.
keeps the minutes from the meetings and ensures
they are accurate and complete. The secretary also Patient Care Services
handles correspondence appropriately. Most direct patient care delivered in hospitals is
The medical staff operates according to a pre- provided by professional nurses. Modern nursing
determined set of policies called the medical staff requires a diverse skill set, advanced clinical com-
bylaws. The bylaws state the specific qualifica- petencies, and postgraduate education. In almost
tions a physician must demonstrate before he or every hospital, patient care services constitute the
she can practice medicine in the hospital. The largest clinical department in terms of staffing,
AB103118_Ch02.indd 36 2/6/2020 4:52:55 PM

budget, specialized services offered, and clinical Rehabilitation Services

expertise required. Rehabilitation services are dedicated to eliminat-
Nurses are responsible for providing continuing the patient’s disability or alleviating it as fully
ous, around-the-clock treatment and support for as possible. The goal is to improve the cognitive,
hospital inpatients. The quantity and quality of social, and physical abilities of patients impaired
nursing care available to patients is influenced by by chronic disease or injury. Rehabilitation serv-
a number of factors, including the nursing staff’s ices can be provided within the acute-care setting
educational preparation and specialization, ex- or in specialty hospitals dedicated to providing
perience, and skill level. The level of patient care many forms of rehabilitation to patients to facili-
staffing also is a critical component of quality. tate their return to work or home. The rehabilita-
Traditionally, physicians alone determined the tion team may include physicians, nurses, occupa-
type of treatment each patient would receive. tional therapists, physical therapists, respiratory
n.
However, today’s nurses are playing a wider role therapists, speech therapists, social workers, and
tio
in treatment planning and case management. They
ia
other healthcare personnel.
oc
perform an ongoing, concurrent review to ensure
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the necessity and effectiveness of the clinical
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Ancillary Support Services
en
services being provided to patients. Their respon-
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The ancillary units of the hospital provide vital
sibilities include performing patient assessments, cre-
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clinical and administrative support services to pa-
ating care plans, evaluating the appropriateness of
an
tients, medical staff, visitors, and employees.
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treatment, and evaluating the effectiveness of care.
The clinical support units provide the following
At the same time, they provide technical care and n
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services:
offer personal care that recognizes the concerns
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and emotional needs of patients and their families. Pharmaceutical services (provided by
In
●●
An RN who is qualified by advanced education registered pharmacists and pharmacy

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and clinical and management experience usually technologists)

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administers patient care services. Although the

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●● Food and nutrition services (managed by

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title may vary, this role is usually referred to as registered dietitians who develop general
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the chief nursing officer (CNO) or vice president and special-diet menus and nutritional plans
of nursing or patient care. The CNO is a member
e
for individual patients)

th
of the hospital’s executive management team and

by
●● Health information services (managed by

usually reports directly to the CEO.
20
RHIAs and RHITs)

20
Social work and social services (provided by

©
Diagnostic Services ●●
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licensed social workers and licensed clinical

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The services provided to patients in hospitals go

yr
social workers)
op
beyond the clinical services provided directly by

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the medical and nursing staff. Many diagnostic ●● Patient advocacy services (provided by
and therapeutic services involve the work of allied several types of healthcare professionals,
health professionals. Allied health professionals most commonly registered nurses and
receive specialized education and training, and licensed social workers)
their qualifications are registered or certified by a ●● Environmental (housekeeping) services
number of specialty organizations. ●● Purchasing, central supply, and materials
Diagnostic and therapeutic services are critical management services
to the success of every patient care delivery sys-
●● Engineering and plant operations (maintenance)
tem. Diagnostic services include clinical labora-
tory, radiology, and nuclear medicine. Therapeutic In addition to clinical support services, hospi-
services include clinical laboratory services, radi- tals need administrative support services to op-
ology, and radiation therapy. erate effectively. Administrative support services
AB103118_Ch02.indd 37 2/6/2020 4:52:55 PM

Figure 2.4 Hospital structure – example organizational chart

Board of
directors or
trustees
Chief
Chief of executive
medical staff officer
Chief Chief
Chief finanical Chief nursing
Medical staff information operating
officer officer
officer officer
Health
Business Plant
information Nursing units
office management operations
n.
tio
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Revenue cycle Information Labor and Human
ss
management systems delivery resources
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en
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Materials Patient Ambulatory Environmental
management registration surgery services
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Source: ©AHIMA.
n
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at
provide business management and clerical serv- Public relations
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●●
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ices in several key areas, including the following: Fund development

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●●
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Marketing
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●●
●● Admissions and central registration
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Figure 2.4 is an example of a healthcare organi-

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●● Claims and billing (business office)

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zational chart showing the reporting structure for

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●● Accounting
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departments within the organization. The board

●● Information services of directors has the ultimate responsibility for the
e
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Human resources organization.

by
●●
20
20
©

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1. The emphasis on treating individual patients at the level of care required by their treatment across all healthcare serv-
ices refers to:
a. Managed care
b. Continuum of care
c. Primary care
d. Palliative care
2. Who has the primary responsibility to guide the direction of the hospital?
a. Board of directors
b. Chief executive officer
c. Medical staff
d. Chief operating officer
AB103118_Ch02.indd 38 2/6/2020 4:52:56 PM

3. Which of the following is an example of a federally run hospital?
a. Veterans Administration
b. Psychiatric
c. Not-for-profit
d. Community
4. This type of hospital has the majority of its inpatient visits paid for through Medicaid.
a. Safety net hospital
b. Critical access hospital
c. Proprietary hospital
d. General hospital
5. Dr. Smith has been granted permission by community hospital to perform cardiac catheterizations. This permission
is called:
a. Clinical privileges
n.
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b. Clinical assignment
ia
c. Clinical classification
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d. Case management
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6. True or false: Acute-care hospitals provide short-term care to diagnose or treat an illness.
en
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7. True or false: Case management is the ongoing, concurrent review to ensure the necessity and effectiveness of
ag
clinical services provided to patients.
an
8. True or false: Pharmaceutical services are considered part of the clinical support services.
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9. True or false: Critical access hospitals specialize in the treatment of patients with serious medical conditions that
at
require care on an ongoing basis.
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Other Types of Healthcare Services

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er
Healthcare delivery is more than hos- Managed care delivery systems also attempt to
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pital-related care. It can be viewed as a continuum manage cost and quality by doing the following:
e
th
of services that cuts across care settings, including

Implementing various forms of financial
by
●●
ambulatory, acute, subacute, long-term, and resi-
20
incentives for providers

dential care, among others.
20
Promoting healthy lifestyles

©
●●
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Managed Care Organizations Identifying risk factors and illnesses early in

ig
●●
yr
the disease process

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Managed care is a generic term for a healthcare

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reimbursement system that manages cost, qual- ●● Providing patient education

ity, and access to services. Most managed care There are three basic types of managed care
plans do not provide healthcare directly. In- plans. The following are the three types of man-
stead, they enter into service contracts with the aged care plans:
physicians, hospitals, and other healthcare provid-
ers who provide medical services to enrollees in 1. Health maintenance organizations (HMOs),
the plans. which provide healthcare within a closed
Managed care systems control costs primar- network
ily by presetting payment amounts and restrict- 2. Preferred provider organizations (PPOs),
ing patient access to healthcare services through which provide reduced costs if the plan
precertification and utilization review processes. member stays within the network but will
(Managed care is discussed in more detail in chap- contribute at a reduced cost if the member
ter 15, Revenue Management and Reimbursement.) goes outside the network
AB103118_Ch02.indd 39 2/6/2020 4:52:56 PM

3. Point of service (POS), which allows patients Ambulatory Care

to choose between an HMO or PPO each time
Ambulatory care is defined as the preventive or
they have a medical encounter (NIH 2015).
corrective healthcare provided in a practitioner’s
office, a clinic, or a hospital on a nonresident (out-
Accountable Care Organizations
patient) basis. The term usually implies that pa-
The Patient Protection and Affordable Care Act tients go to locations outside their homes to obtain
of 2010 has had a significant impact on physi- healthcare services and return the same day.
cians and hospitals, namely in the establishment Ambulatory care encompasses all the health
of accountable care organizations (ACOs). An services provided to individual patients who are
ACO generally describes groups of providers not residents in a healthcare facility. Such services
who are willing and able to take responsibility include the educational services provided by
for improving the overall health status, care ef- community health clinics and public health
n.
ficiency, and healthcare experience for a defined
tio
departments. Primary care, emergency care, and
ia
population (DeVore and Champion 2011). The ambulatory specialty care (which includes ambu-
oc
law allows CMS to create ACOs by developing
ss
latory surgery) all may be considered ambulatory
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voluntary partnerships between hospitals and care. Ambulatory care services are provided in a
en
physicians to coordinate and deliver quality care variety of settings, including urgent care centers,
em
to patients and allow the participating organiza-
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school-based clinics, public health clinics, and
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tions to share the savings that would result from neighborhood and community health centers.
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improvement of care for those Medicare popula- Current medical practice emphasizes perform-
n
tions. CMS has established three primary ACO
io
ing healthcare services in the least costly set-
at
m
programs whereby participating ACOs would ting possible. This change in thinking has led
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assume the accountability for improving qual-

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to decreased utilization of emergency services,

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ity care while reducing costs for a defined Med- increased utilization of nonemergency ambula-
ea
icare patient population. The beneficiaries will tory facilities, decreased hospital admissions, and
H
an
be assigned to the ACO based on utilization of shorter hospital stays. The need to reduce the cost
ic
primary care services provided by primary care

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of healthcare also has led primary care physicians

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physicians. The following are the three ACO to treat conditions they once would have referred
e
models:
th
to specialists.
by
1. Medicare Shared Savings program that Physicians who provide ambulatory care ser-
20
gives Medicare fee-for-service providers an vices fall into two categories—physicians working
20
opportunity to become an ACO in private practice and physicians working for am-
©
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2. Advance Payment ACO model designed as a bulatory care organizations. Physicians in private
ig
yr
supplementary incentive program for selected practice are self-employed. They may work solo,
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in partnership, and in group practices set up as

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participants
for-profit organizations.
3. Pioneer ACO model created for early
Alternatively, physicians who work for ambu-
adopters of coordinate care, though CMS is no
latory care organizations are employees of those
longer accepting applications for this model
organizations. Ambulatory care organizations in-
CMS has outlined a series of 33 quality measures clude HMOs, hospital-based ambulatory clinics,
in four categories (patient or caregiver experience; walk-in and emergency clinics, hospital-owned
care coordination or patient safety; preventative group practices and health promotion centers,
health; and at-risk population) to assess the quality freestanding surgery centers, freestanding urgent
of care furnished by the ACO (RTI International care centers, freestanding emergency care centers,
2015). As of 2018, there are 561 ACOs with 10.5 health department clinics, neighborhood clinics,
million beneficiaries (CMS 2018c). home care agencies, community mental health
AB103118_Ch02.indd 40 2/6/2020 4:52:56 PM

centers, school and workplace health services, and assess patients with problems that may either lead
prison health services. to an inpatient admission or require equipment or
Ambulatory care organizations also employ diagnostic imaging facilities not available in a pri-
other healthcare providers, including nurses, labo- vate office or nursing home. Emergency services
ratory technicians, podiatrists, chiropractors, physi- function as a major source of unscheduled admis-
cal therapists, radiology technicians, psychologists, sions to the hospital.
and social workers.
Outpatient Surgical Services Generally, the
Private Medical Practice term ambulatory surgery refers to any surgical pro-
Private medical practices are physician-owned en- cedure that does not require an overnight stay in a
tities that provide primary care or medical or sur- hospital. It can be performed in the outpatient sur-
gical specialty care services in a freestanding office gery department of a hospital and in a freestand-
n.
setting. The physicians have medical privileges at ing ambulatory surgery center.
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local hospitals and surgical centers but are not em-
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ployees of the other healthcare entities. Outpatient Diagnostic and Therapeutic Services
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Outpatient diagnostic and therapeutic services
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Medical Home are provided in a hospital or one of its satellite
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The medical home is a model of primary care phy- facilities. Diagnostic services are those services
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sician practices that is patient-centered, compre- performed by a physician to identify the disease
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hensive, team-based, coordinated, accessible, and or condition from which the patient is suffering.
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focused on quality and safety. This has become a io
Therapeutic services are those services performed
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by a physician to treat the disease or condition that
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model for how primary care should be delivered.

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It is sometimes referred to as a patient-centered has been identified.

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Hospital outpatients fall into different classifi-

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medical home (PCPCC 2019). Many hospitals

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have established medical home programs to pro- cations according to the types of services they re-
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vide the patient with a direct relationship with the ceive and the location of the service. For example,
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provider responsible for providing their care. Be- emergency outpatients are treated in the hospital’s
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tween 2012 and 2016, the percentage of hospitals emergency or trauma care department for condi-
tions that require immediate care. Clinic outpa-
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with a medical home grew from 18 percent to 28

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percent (AHA 2018). tients are treated in one of the hospital’s clinical
by
departments on an ambulatory basis. Referral out-

20
20
Hospital-Based Ambulatory Care Services patients receive special diagnostic or therapeutic

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In addition to providing inpatient services, many services in the hospital on an ambulatory basis,
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acute-care hospitals provide various ambulatory but responsibility for their care remains with the
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care services such as the following. referring physician.

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Emergency Services and Trauma Care More Observation Services An observation patient
than 90 percent of community hospitals in the visit is a type of outpatient visit. While they may
US provide emergency services. Hospital-based be in the same units as inpatients, they are consid-
emergency departments provide specialized care ered an outpatient visit. Observation services are
for victims of traumatic accidents and life-threat- used when physicians need to determine if the pa-
ening illnesses. In urban areas, many also provide tient is sick enough to need inpatient treatment.
walk-in services for patients with minor illnesses
and injuries who do not have access to regular pri- Community-Based Ambulatory Care Services
mary care physicians. Community-based ambulatory care services are
Many physicians on the hospital staff also use those services provided in freestanding facilities
the emergency care department as a setting to that are not owned by or affiliated with a hospital.
AB103118_Ch02.indd 41 2/6/2020 4:52:56 PM

Such facilities can range in size from a small medi- and laws. The Department of Health and Human
cal practice with a single physician to a large clinic Services (HHS) is the principal federal agency that
with an organized medical staff. ensures health and provides essential human
Among the organizations that provide ambu- services. HHS has eleven operating divisions, in-
latory care services are specialized treatment fa- cluding eight agencies in the US Public Health
cilities. Examples of these community-based am- Services and three human services agencies. These
bulatory care services facilities include birthing operating divisions are responsible for a wide
centers, cancer treatment centers, renal dialysis variety of health and human services, including
centers, and rehabilitation centers. prevention and conducting research for the nation.
HHS coordinates closely with state and local gov-
Freestanding Ambulatory Care Centers Free- ernment agencies and many HHS-funded serv-
standing ambulatory care centers provide emer- ices are provided by these agencies as well as by
n.
gency services and urgent care for walk-in patients. private-sector and nonprofit organizations.
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Urgent care centers provide diagnostic and thera- Two units in the Office of the Secretary of HHS
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peutic care for patients with minor illnesses and in- are important to public health—the Office of the
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juries. They do not serve seriously ill patients, and Surgeon General of the United States and the
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most do not accept patients arriving by ambulance. Office of Disease Prevention and Health Promot-
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Two groups of patients find these centers attrac- ion (ODPHP). The surgeon general is appointed
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tive. The first group consists of patients seeking by the president of the United States and provides
an
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the convenience and access of emergency services leadership and authoritative, science-based rec-
without the delays and high costs associated with n
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ommendations about the public’s health. He or
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using hospital services for nonurgent problems. she has responsibility for the public health serv-
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The second group consists of patients whose in- ice (PHS) workforce and the ODPHP provides an
In
surance treats urgent care centers preferentially analysis and leadership role for health promot-
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compared with physicians’ offices. ion and disease prevention. Figure 2.5 shows the
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As they have increased in number and become agencies that exist within HHS.
an
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familiar to more patients, many freestanding am-

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Home Healthcare Services

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bulatory care centers now offer a combination of

walk-in and appointment services. Home healthcare is the fastest-growing sector
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to offer services for recipients. Home healthcare

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Freestanding Ambulatory Surgery Centers Free- is limited part-time or intermittent skilled nurs-
20
20
standing ambulatory surgery centers generally pro- ing care and home health aide services, physical
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vide surgical procedures that take anywhere from 5 therapy, occupational therapy, speech-language
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to 90 minutes to perform and require less than a four- therapy, medical social services, durable medi-
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hour recovery period. Patients must schedule their cal equipment, supplies and other services (CMS
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surgeries in advance and be prepared to return home 2017a). The primary reason for this is increased
on the same day. Patients who experience surgical economic pressure from third-party payers who
complications are sent to an inpatient facility for care. want patients released from the hospital more
Most ambulatory surgery centers are for-profit en- quickly than they were in the past. Moreover, pa-
tities. Individual physicians, MCOs, or entrepreneurs tients generally prefer to be cared for in their own
may own them. Generally, ambulatory care centers homes. In fact, most patients prefer home care, no
can provide surgical services at lower cost than hos- matter how complex their medical problems.
pitals can because their overhead expenses are lower. In 1989, Medicare rules for home care services
were clarified to make it easier for Medicare ben-
Public Health Services eficiaries to receive them. Patients are eligible
The states have constitutional authority to imple- to receive home health services from a qualified
ment public health measures, and many of them Medicare provider when they are homebound,
are assisted by a wide variety of federal programs under the care of a specified physician who will
AB103118_Ch02.indd 42 2/6/2020 4:52:56 PM

Figure 2.5 Department of Health and Human Services agencies
Administration for Children and ACF promotes the economic and social well-being of families, children, individuals, and
Families (ACF) communities.
Administration for Community ACL increases access to community support and resources for the unique needs of older
Living (ACL) Americans and people with disabilities.
Agency for Healthcare Research AHRQ’s mission is to produce evidence to make healthcare safer, higher quality, more
and Quality (AHRQ) accessible, equitable, and affordable, and to work within HHS and with other partners to
make sure that the evidence is understood and used.
Agency for Toxic Substances and ATSDR prevents exposure to toxic substances and the adverse health effects and diminished
Disease Registry (ATSDR) quality of life associated with exposure to hazardous substances from waste sites, unplanned
releases, and other sources of environmental pollution.
Centers for Disease Control and CDC, part of the US Public Health Service (PHS) protects the public health of the nation
Prevention (CDC) by providing leadership and direction in the prevention and control of diseases and other
n.
preventable conditions, and responding to public health emergencies.
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Centers for Medicare & Medicaid CMS combines the oversight of the Medicare program, the federal portion of the Medicaid
ia
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Services (CMS) program and State Children’s Health Insurance Program, the Health Insurance Marketplace,
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and related quality assurance activities.
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Food and Drug Administration FDA, part of the PHS ensures food is safe, pure, and wholesome; human and animal drugs,
en
(FDA) biological products, and medical devices are safe and effective; and electronic products that
em
emit radiation are safe.
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Health Resources and Services HRSA, part of the PHS provides healthcare to people who are geographically isolated or
an
Administration (HRSA) economically or medically vulnerable.
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Indian Health Service (IHS) IHS, part of the PHS provides American Indians and Alaskan Natives with comprehensive
n
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health services by developing and managing programs to meet their health needs.
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National Institutes of Health (NIH) NIH, part of the PHS, supports biomedical and behavioral research within the US and abroad,
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conducts research in its own laboratories and clinics, trains promising young researchers, and
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promotes collecting and sharing medical knowledge.

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Substance Abuse and Mental SAMHSA, part of the PHS, improves access and reduces barriers to high-quality, effective
H
Health Services Administration programs and services for individuals who suffer from or are at risk for addictive and mental
an
(SAMHSA) disorders, as well as for their families and communities.

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Source: Adapted from HHS 2019.

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establish a home health plan, and when they need planning counseling. Funds to operate such agen-
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physical or occupational therapy, speech therapy, cies come from a variety of sources, including local
20
20
or intermittent skilled nursing care. or state health departments, private grants, and
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Skilled nursing care is defined as technical pro- funds from different federal bureaus.
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cedures, such as tube feedings and catheter care, One common example of a voluntary agency
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and skilled nursing observations. Intermittent is is the community health center. Sometimes called
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defined as up to 28 hours per week for nursing neighborhood health centers, community health
care and 35 hours per week for home health aide centers offer comprehensive, primary healthcare
care. Many hospitals have formed their own home services to patients who otherwise would not have
healthcare agencies to increase revenues and at access to them. Often patients pay for these services
the same time to enable them to discharge patients on a sliding scale based on income or according to
from the hospital earlier. a flat rate, discounted fee schedule supplemented
by public funding.
Voluntary Agencies Some voluntary agencies offer specialized services
Voluntary agencies provide healthcare and health- such as counseling for battered and abused women.
care planning services, usually at the local level Typically, these are set up within local communities.
and to low-income patients. Their services range An example of a voluntary agency that offers serv-
from giving free immunizations to offering family ices on a much larger scale is the Red Cross.
AB103118_Ch02.indd 43 2/6/2020 4:52:56 PM

Subacute Care Long-Term Care in the Continuum of Care

Patients needing ongoing rehabilitative care or The availability of long-term care is one of the most
treatment using advanced technology sometimes important health issues in the United States today.
are eligible to receive subacute care. Subacute There are two principal reasons for this. First, people
care offers patients access to constant nursing care are living longer today than they did in the past as a
while recovering at home. In the past, patients result of advances in medicine and healthcare prac-
could receive comprehensive rehabilitative care tices. The number of people who survive previously
only while in the hospital. Today, however, the fatal conditions is growing, and more and more peo-
availability of subacute-care services allows pa- ple with chronic medical problems can live reasona-
tients to optimize their functional gain in a famil- bly normal lives. Second, there was an explosion in
iar and more comfortable environment. In essence, the birthrate after World War II. Children born dur-
subacute care in most IDNs emphasizes patient ing that period (1946 to 1964), the “baby-boomer”
n.
generation, are today in their late 1950s to 1970s.
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independence. The patient is given an individual-
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ized care plan developed by a highly trained team These factors combined mean that the need for long-
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term care will only increase in the years to come.
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of healthcare professionals. Patients considered
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appropriate for subacute care are those recovering As discussed earlier, healthcare is now viewed
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from stroke, cardiac surgery, serious injury, ampu- as a continuum of care. In the case of long-term
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care, the patient’s continuum of care may have
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tation, joint replacement, or chronic wounds.
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begun with a primary provider in a hospital and
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then continued with home care and eventually
Long-Term Care
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care in a skilled nursing facility. The patient’s care
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In general, long-term care is the healthcare rendered
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is coordinated from one care setting to the next.

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in a non-acute-care facility to patients who require Moreover, the roles of the different care providers
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inpatient nursing and related services for more

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along the patient’s continuum of care are continu-

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than 30 consecutive days. Skilled nursing facilities, ing to evolve. Health information managers play
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nursing homes, and rehabilitation hospitals are the

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a key part in providing consultation services to

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principal facilities that provide long-term care. Reha- long-term care facilities with regard to develop-
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bilitation hospitals provide recuperative services for ing systems to manage information from a diverse
patients who have suffered strokes and traumatic
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number of healthcare providers.

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injuries as well as other serious illnesses. Specialized

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long-term care facilities serve patients with chronic Delivery of Long-Term Care Services
20
20
respiratory disease, permanent cognitive impair- Long-term care services are delivered in a variety
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ment, and other incapacitating conditions. of settings, including skilled nursing facilities or
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Long-term care encompasses a range of health, nursing homes, residential care facilities, hospice
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personal care, social, and housing services pro- programs, and adult day-care programs.
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vided to people of all ages with health conditions

that limit their ability to carry out normal daily ac- Skilled Nursing Facilities or Nursing Homes The
tivities without assistance. People who need long- most important providers of formal, long-term
term care have many different types of physical care services are nursing homes, or skilled nursing
and mental disabilities. Moreover, their need for facilities (SNFs), which provide medical, nursing,
the mix and intensity of long-term care services or rehabilitative care, in some cases, around the
can change over time. clock. Most SNFs have residents over the age 65
Long-term care is mainly rehabilitative and sup- and provide care for those who can no longer live
portive rather than curative. Moreover, healthcare independently.
workers other than physicians can provide long- Many SNFs are owned by for-profit organiza-
term care in the home or in residential or institutions. However, SNFs also may be owned by not-
tional settings. for-profit groups as well as local, state, and federal
AB103118_Ch02.indd 44 2/6/2020 4:52:57 PM

governments. In recent years, there has been a de- is palliative; focusing on pain relief, comfort, and
cline in the total number of nursing homes in the US, enhanced quality of life for the terminally ill.
but an increase in the number of nursing home beds. In the hospice approach, the family is the unit of
Nursing homes are no longer the only option for treatment. An interdisciplinary team provides med-
patients needing long-term care. Various factors ical, nursing, psychological, therapeutic, pharma-
play a role in determining which type of long-term cological, and spiritual support during the final
care facility is best for a particular patient, includ- stages of illness, at the time of death, and during
ing cost, access to services, and individual needs. bereavement. The main goals are to control pain,
maintain independence, and minimize the stress
Residential Care Facilities New living environ- and trauma of death.
ments that are more homelike and less institutional Hospice services have gained acceptance as an
are the focus of much attention in the current long- alternative to hospital care for the terminally ill.
n.
term care market. Residential care facilities now The number of hospices is likely to continue to
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play a growing role in the continuum of long-term grow because this philosophy of care for people at
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care services. Having affordable and appropriate the end of life has become a model for the nation.
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housing available for elderly and disabled people
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can reduce the level of need for institutional long- Adult Day-Care Programs Adult day-care pro-
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term care services in the community. Institutional- grams offer a wide range of health and social
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ization can be postponed or prevented when the services to elderly persons during the daytime
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elderly and disabled live in safe, accessible settings hours. Adult day-care services are usually tar-
where assistance with daily activities is available. n
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geted to elderly members of families in which the
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regular caregivers work during the day. Many
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Hospice Programs Hospice care is provided elderly people who live alone also benefit from
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mainly in the home to patients who are diagnosed leaving their homes every day to participate in
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with a terminal illness with a limited life expec- programs designed to keep them active. The goals
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tancy of six months or less. Hospice is based on of adult day-care programs are to delay the need
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a philosophy of palliative care imported from for institutionalization and to provide respite for
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England and Canada that holds that during the caregivers.

course of terminal illness, the patient should be Data on adult day-care programs are still limited,
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able to live life as fully and as comfortably as pos- but there were about 5,000 programs in 2015 pro-
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sible, but without artificial or mechanical efforts to viding services to 260,000 participants in a variety
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20
prolong life. Hospice care is not focused on cure. It of programs (NADSA 2019).
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Biomedical and Technological Advances in Medicine

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Advances in technology in the health- as the use of electronic information and tele-
care industry have made it possible for care to be communications technologies to support
delivered to patients closer to their home or even in and promote long-d istance clinical health-
their home. The sections that follow will explore and care, patient and professional h ealth-related
describe the benefits of telehealth technologies and education, public health, and health admin-
electronic health records and health data and the ef- istration. Technologies include videocon-
fects they have made on the delivery of healthcare. ferencing, the internet, store-and-forward
imaging, streaming media, and terrestrial and
Telehealth wireless communications (ONCHIT 2019).
The Health Resources and Services Admin- Figure 2.6 shows the types of telehealth
istration (HRSA) of HHS defines telehealth applications.
AB103118_Ch02.indd 45 2/6/2020 4:52:57 PM

Figure 2.6 Types of telehealth applications
Live (synchronous) A two-way audiovisual link between a patient and a care

video conferencing provider
Store-and-forward
Transmission of a recorded health history to a health
(asynchronous) practitioner, usually a specialist
video conferencing
Remote patient The use of connected electronic tools to record personal

health and medical data in one location for review by a
monitoring (RPM)
provider in another location, usually at a different time
Mobile health Healthcare and public health information provided
n.
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(mHealth) through mobile devices
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Source: Adapted from ONCHIT 2019.
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Electronic Health Records collection and evaluation of data in a central-
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and Health Data ized system can identify a viral or bacterial in-
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fection to give insights into how widespread an
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Electronic health records (EHRs) and the ability to
outbreak is.
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record, capture, and manipulate health data have
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Ninety-six percent of hospitals in the United
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had a tremendous impact on the delivery of health-

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States have a federally tested and certified EHR

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care. Big data refers to large amounts of data that

program (Reisman 2017). The next challenge for the
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are collected from sources and then processed and

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use of EHRs is ensuring interoperability. Interoper-

used for analytics. Collected and analyzed health
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ability refers to more than the exchange of informa-

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data have multiple benefits including the following:

tion; it requires that the data exchanged are usable.
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This means that the receiving system must be able

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●● Reducing healthcare costs

to interpret the data. With the variety of govern-
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Predicting epidemics
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●●
ment certified EHR products in use, each one has its
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●● Avoiding preventable deaths own clinical terminologies, technical specifications,

20
Improving quality of life

20
●● and functional capabilities. This makes it very dif-

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●● Reducing healthcare waste ficult to create one standard interoperability format

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to share data.
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Improving efficiency and quality of care

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Developing new drugs and treatments

●●
Artificial Intelligence
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(Banova, 2018)
The increasing availability of healthcare data and
The American Recovery and Reinvestment Act rapid development of big data analytic methods
of 2009, the Patient Protection and Affordable have made possible the recent successful appli-
Care Act, and other quality-of-care programs rep- cations of artificial intelligence (AI) in health-
resent the movement from a volume-based deliv- care. AI is the ability of a computer program or
ery model to a data-driven, value-based approach. machine to think and learn. AI uses sophisticated
Data collected from EHRs is utilized to measure algorithms to learn trends or features from large
outcomes performance that is directly tied to re- volumes of health data to make judgments. It can
imbursement. In addition, data collected from be equipped with learning and self-correcting
EHRs is utilized by clinical researchers to develop abilities to improve accuracy based on feedback.
new treatments for common health problems. The AI is not meant to replace the physician, but to
AB103118_Ch02.indd 46 2/6/2020 4:52:58 PM

assist the physician in making better clinical de- machine-readable structured data that can be ana-
cisions or replace human judgment in functional lyzed by ML techniques.
areas of healthcare such as radiology (Jiang et al. One of the most common uses of AI in health-
2017). care has been the use of speech recognition. It is
Before AI systems can be successfully utilized, also being used in radiology to assist in the diag-
they have to be trained through data that are gen- nostic process by analyzing images such as MRIs,
erated from clinical activities so they can learn the x-rays, and CT scans and providing feedback on
group of subjects and associations. There are two what it detects. AI is being utilized in medical
major categories of AI: machine learning (ML) monitoring devices to transform them into smart
and natural language processing (NLP). Machine medical devices. Traditional medical devices mon-
learning analyzes structured data such as imag- itor and record data to be reviewed by a clinician
ing and genetic results, then attempts to cluster at a later time. Smart medical devices can analyze
n.
the patient’s traits or infer the probability of the and respond to the recorded data. For example, an
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disease outcomes (Jiang et al. 2017). NLP meth- insulin pump utilizing AI can predict how much
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ods extract information from unstructured data insulin the patient will need and when they will
ss
such as clinical notes to supplement the struc- need it rather than just responding to spikes in
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tured data. NLP focuses on turning the text into blood sugar.
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1. The healthcare organization provides healthcare services to low-income patients in the local community at a:
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a. Freestanding ambulatory care center

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b. Private medical practice

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c. Subacute care

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d. Voluntary agency

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2. My daughter fell and cut herself tonight. Though it is not an emergency, I believe she needs stitches and she should
20
see healthcare practitioner tonight for treatment. Which type of setting would I most likely access?
20
a. Hospital emergency department

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b. Community-based ambulatory care services

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c. Private medical practice

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d. Freestanding ambulatory care center

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3. Most patients in long-term care facilities require inpatient nursing and related services for more than how many
consecutive days?
a. 14
b. 30
c. 60
d. 100
4. Which healthcare organization offers palliative care for end-of-life care so that the patient may live life as fully and as
comfortably as possible?
a. Hospice
b. Adult day-care
c. Skilled nursing facility
d. Nursing home
AB103118_Ch02.indd 47 2/6/2020 4:52:58 PM

5. The ability of a computer to think and learn is:
a. Artificial intelligence
b. Big data
c. Interoperability
d. Telehealth
Match the descriptions with the terms.

6. _____ Managed care
7. _____ Freestanding ambulatory care centers
8. _____ Human Genome Project
9. _____ Subacute care
10. _____ Continuum of care
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a. A 13-year-long international effort with three principal goals: (1) to determine the sequence of the three billion DNA
ia
subunits, (2) to identify all human genes, and (3) to enable genes to be used in further biological study
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b. Provides emergency services and urgent care for walk-in patients
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c. Care that offers patients access to constant nursing care while recovering at home
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d. Care provided by different caregivers at several different levels of the healthcare system
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e. Manages cost, quality, and access to services
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Policy Making and Healthcare Delivery

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The American healthcare system is a Healthy People 2020 sets out a plan to improve the
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patchwork of independent and governmental en- nation’s health with a vision of “a society in which
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tities that provide healthcare services to those in all people live long, healthy lives” (Healthy Peo-
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need. Institutions ranging from not-for-profits, ple 2015). Healthy People provides users with ac-
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for-profits, and governmental agencies provide cess to data on changes in the health status of the
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not only services but also policy on how Ameri- US population and informs of each new decade’s
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cans are to receive and pay for their healthcare. goals and objectives. Communities may adopt the
20
The government’s role in healthcare services Healthy People goals and objectives and may al-
20
is extensive from the federal level down to the ter them to set the priorities for their region and
©
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county and local levels. By setting policies on how population groups. Since it was launched, Healthy
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healthcare is provided, delivered, and reimbursed, People has noted significant achievements in re-
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government agencies have a significant impact on ducing causes of death such as heart disease and
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our healthcare delivery system. cancer; reducing infant and maternal mortality;
The following sections list five ways that reducing risk factors like tobacco smoking, hyper-
healthcare policies affect the American people. tension, and elevated cholesterol; and increasing
All the policies are dedicated to providing the childhood vaccinations (Healthy People 2019a).
best services in a system that is constrained by Healthy People 2020 is the third initiative (start-
increasing costs generally at the expense of access ing with Healthy People 2000) since its inception
and quality. 30 years ago. The overall goals of Healthy People
2020 are to do the following:
Healthy People 2020 ●● Attain high-quality, longer lives free of
Launched in December 2010 by the Office of Dis- preventable disease, disability, injury, and
ease Prevention and Heath Promotion of HHS, premature death
AB103118_Ch02.indd 48 2/6/2020 4:52:58 PM

●● Achieve health equity, eliminate disparities, Figure 2.7 Healthy People 2020 five key social
and improve the health of all groups determinants of health
●● Create social and physical environments that
promote good health for all
●● Promote quality of life, healthy Economic
stability
development, and healthy behaviors across
all life stages (Healthy People 2015)
One topic area of Healthy People 2020 is social Neighborhood
determinants of health. Social determinants of and built Education
health (SDOH) are conditions such as environ- environment
ment and age that impact a wide range of health, SDOH

functioning, and quality-of-life outcomes and
n.
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risks. Examples of social determinants include:
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Availability of resources to meet daily needs
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●●
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Access to educational, economic, and job Health and Social and
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●●
health community
opportunities
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care context
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●● Availability of community-based resources
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Exposure to crime, violence, and social
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●● Source: Adapted from Healthy People 2019b.
disorder
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●● Socioeconomic conditions 2030 initiative has been developed. HHS solic-

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Language and literacy ited comments on the proposed framework and

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Access to mass media and emerging these comments were used to finalize the frame-
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●●
technologies work. The Healthy People 2030 framework was

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Culture (Healthy People 2019b) approved by the HHS Secretary in June 2018. The
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●●
overarching goals of the framework include the
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Healthy People 2020 established a place-based following:

organizing framework reflecting five determinants
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areas of SDOH. This framework reflects the impor- ●● Attain healthy, thriving lives and well-being,
by
tance of the relationship between how population free of preventable disease, disability, injury,
20
and premature death

20
groups experience “place” and the impact of “place”

©
on health. This includes both social and physical de- ●● Eliminate health disparities, achieve health
ht
ig
terminants. The five key determinants are economic equity, and attain health literacy to improve
yr
op
stability, education, social and community context, the health and well-being of all
C
health and healthcare, and neighborhood and built ●● Create social, physical, and economic
environment (Healthy People 2019b). Figure 2.7 environments that promote attaining full
shows the five key social determinants of health, potential for health and well-being for all
including economic stability, education, social ●● Promote healthy development, healthy
and community context, health and healthcare and behaviors and well-being across all life stages
neighborhood and built environment.
●● Engage leadership, key constituents, and the
Healthy People 2020 also recognizes that health
public across multiple sectors to take action
information technology and health communi-
and design policies that improve the health
cation are integral parts of the implementation
and well-being of all (Healthy People 2019a)
process of the initiative.
The next phase of Healthy People is Healthy The ultimate goal of Healthy People 2020 is
People 2030. The framework for the Healthy People to develop a feasible, public health information
AB103118_Ch02.indd 49 2/6/2020 4:52:59 PM

technology infrastructure in conjunction with the Joseph Lister was the first to apply Pasteur’s research
national health information network. to the treatment of infected wounds. His discovery
was called the antiseptic principle, which helped
The National Institutes of Health reduce the mortality rate in Lister’s own hospital.
At the end of the 19th century, German physicist
The National Institutes of Health (NIH), part of
Wilhelm Rontgen was studying the effects of pass-
HHS, is the nation’s medical research agency. The
ing an electrical current through gases at low pres-
mission of the NIH is to seek fundamental knowl-
sure. While doing this, he accidentally discovered
edge about the nature and behavior of living sys-
x-rays (The Scientist 2011).
tems and the application of that knowledge to en-
Diagnostic radiology and radiation therapy
hance health, lengthen life, and reduce illness and
have undergone huge advances in the past 50
disability (NIH 2017). To support their mission,
years. In 1971 an imaging modality called com-
the NIH invests over $30 billion in taxpayer dol-
n.
puted tomography (CT) was first invented. The
lars in biomedical research.
tio
first CT scanners were used to create images of
ia
The goals of the agency are to do the following:
oc
the skull. Whole-body scanners were introduced
ss
Foster fundamental creative discoveries, in 1974. In the 1980s, another powerful diagnos-
tA
●●
en
innovative research strategies, and their tic tool was added—magnetic resonance imaging
em
applications as a basis for ultimately (MRI). An MRI is a noninvasive technique that
ag
protecting and improving health uses magnetic and radio-frequency fields to record
an
M
●● Develop, maintain, and renew scientific images of soft tissues.
n
Surgical advances have been remarkable as
human and physical resources that will io
at
well. Cardiac bypass surgery and joint replace-
m
ensure the nation’s capability to prevent

r
fo
disease ment surgery were developed in the 1970s. Organs

In
are now successfully transplanted, and artificial

lth
●● Expand the knowledge base in medical and

ea
associated sciences to enhance the nation’s organs are being tested. New surgical techniques
H
have included the use of lasers in ophthalmology,

an
economic well-being and ensure a continued

ic
high return on the public investment in gynecology, and urology. Microsurgery is now a
er
Am
research common tool in the reconstruction of damaged

nerves and blood vessels.
e
th
●● Exemplify and promote the highest level

The future of surgery could include physicians
by
of scientific integrity, public accountability,

using advanced robots, virtual reality, augmented
20
and social responsibility in the conduct of

20
reality, and 3D printing and simulations in preop-

science
©
erative planning and education (The Medical Fu-

ht
ig
Surgical procedures were performed before the turist 2017).

yr
op
development of anesthesia, requiring surgeons to Today, it is human genetics and progress to-
C
work quickly on conscious patients to minimize ward sequencing the human genome that promise
the risk and pain. The availability of anesthesia to change the healthcare paradigm. New research
made it possible for surgeons to develop more ad- on cellular and molecular changes underlying dis-
vanced surgical techniques. Ether, nitrous oxide, ease processes will necessitate new approaches to
and chloroform were used as anesthetics by the diagnosis and treatment.
middle of the 19th century. By the 1860s, the phy- The current paradigm for treating disease is
sicians who treated the casualties of the American to meet with the patient, diagnose the patient’s
Civil War on both sides had access to anesthetic symptoms, and prescribe therapy to treat them.
and painkilling drugs. The hope is that genetic medicine will enable the
During the late 1800s, significant improvements provider to identify gene patterns that underlie
in healthcare were being made. In 1885, Louis the process of cellular dysfunction that leads to
Pasteur developed a vaccine that prevented rabies. injury before even meeting with the patient. Thus,
AB103118_Ch02.indd 50 2/6/2020 4:52:59 PM

diseases will be diagnosed much earlier, enabling ●● Crossing the Quality Chasm (2001) identified
physicians to provide treatment to stop or slow gaps in the delivery of patient care services
the disease process. resulting from a complex medical system as
The study of cell-based technologies is controver- well as the rapid advancement in medical
sial. Cell-based technologies include the following: knowledge (IOM 2001).
●● Tissue engineering, which involves the ●● Envisioning a National Health Care Quality
use of biomaterials to develop new tissue Report (2001) addressed the collection,
and even whole organs with or without measurement, and analysis of quality data
transplanting cells (Hurtado et al. 2001).
●● Human embryonic stem cells or adult ●● Leadership by Example (2002) addressed the
stem cells used for transplantation and in duplication and contrasting approaches
regenerative medicine to performance measures by the six major
n.
governmental healthcare programs that serve
tio
Gene therapy or cell transplantation
ia
●●
nearly 100 million Americans (IOM 2002).
oc
ss
The National Human Genome Research Insti- Priority Areas for National Action (2003)
tA
●●
tute (NHGRI) was established in 1989 to carry out recognized priorities from earlier reports and
en
the role of the NIH in the International Human
em
suggested a framework for action (IOM 2003).
Genome Project (HGP). The HGP began in 1990 to
ag
Health IT and Patient Safety (2012) stated that the
an
●●
map the human genome. Since the completion of
improvement in safety of health IT is essential
M
the human genome sequence in 2003, the NHGRI
n
and can help improve healthcare providers’
io
expanded its role to apply genome technologies to
at
performance, improve communication
m
the study of specific diseases (NHGRI 2018). In fall

r
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between patients and providers, and enhance

In
2020, NHGRI will launch its newest strategic plan

patient safety (IOM 2012).
lth
aimed at accelerating scientific and medical break-

ea
throughs. Through its strategic plan, the NHGRI ●● Human Genome Editing: Science, Ethics and
H
Governance (2017) considered important

an
will prioritize discussions in emerging areas of

ic
questions about the human application of

er
genomics that are not well defined and that are

Am
not specific to particular diseases or physiological genome editing.

e
systems. These include broadly applicable areas Optimizing Strategies for Clinical Decision
th
●●
by
such as genomic technology development; using Support (2017) identified the need for a
20
genomic information in patient care; and the ethi- continuously learning health system driven
20
cal, legal, and social implications of genomics. by the seamless and rapid generation,
©
processing, and practical application of

ht
ig
National Academy of Medicine the best available evidence for clinical

yr
op
Reports decision-making.
C
The National Academy of Medicine (NAM), for- ●● Procuring Interoperability: Achieving High-
merly known as the Institute of Medicine, was es- Quality, Connected, and Person-Centered Care
tablished in 1970 as a nongovernmental agency to (2018) identified data exchanges determined
provide unbiased advice to decision makers and to be critical to achieving interoperability and
the public. NAM has written over 1,000 reports identified the key characteristics of information
since 1970. A selection of quintessential publica- exchange involved in health and healthcare.
tions dealing with the public’s health include the
following publications: Centers for Disease Control and
●● To Error is Human (1999) reported that as Prevention
many as 98,000 people die each year from Founded in 1946, the Centers for Disease Con-
preventable medical errors (IOM 1999). trol and Prevention (CDC) is the leading federal
AB103118_Ch02.indd 51 2/6/2020 4:52:59 PM

agency charged with protecting the public health Program [SCHIP], Veterans Health Administra-
and safety through the control and prevention of tion [VHA], TRICARE, and Indian Health Serv-
disease, injury, and disability. The CDC leads the ice [IHS]). All three branches of government have
nation in the following services: input on the cost, access, and quality of care pro-
vided to Americans through these federal agencies
●● Detecting and responding to diseases and
as well as the various policy-making institutions
conditions (attention deficit hyperactivity
that provide carefully considered input to the de-
disorder, sexually transmitted diseases,
cision makers.
cancer, heart disease, diabetes, flu)
Unfortunately, the American healthcare sys-
●● Promoting healthy living (adolescents tem was not developed from a master plan but
and school health, food safety, tobacco is instead a patchwork quilt of measures passed
and alcohol use, overweight and obesity, not from thought as to how they would affect the
vaccines and immunizations)
n.
whole, but rather based on ideology. Much atten-
tio
Providing information for travelers’ health tion today is focused on the cost of healthcare of-
ia
●●
oc
(destinations, travel notices, find a clinic) ten at the expense of patient access and the quality
ss
of care provided.
tA
●● Educating for emergency preparedness
en
(natural disasters and severe weather, recent
em
outbreaks and incidents, bioterrorism, Patient-Centered Outcomes Research
ag
chemical emergencies, radiation Institute
an
M
emergencies, mass casualties) The Patient-Centered Outcomes Research Insti-
n
io
tute (PCORI) was created in 2010 from the pas-
at
The CDC headquarters is in Atlanta, GA and
m
sage of the Patient Protection and Affordable

r
there are 10 additional locations in the United

fo
Care Act (ACA) as a nonprofit, nongovernmental

In
States. With over 14,000 employees, the CDC

lth
collects, analyzes, and creates national statisti- organization mandated to improve the quality
ea
and applicability of evidence available to help

H
cal databases and publishes papers on important

an
health issues (CDC 2019). all stakeholders (patients, caregivers, clinicians,

ic
employers, insurers, and policy makers) to make

er
Am
knowledgeable healthcare choices. While PCORI

Local, State, and Federal Policies
e
is not the first organization focusing on patient-

th
All levels of government create policies affecting

by
centered care, it is the largest single research

the nation’s healthcare. At the local and commun-
20
funder that has comparative effectiveness re-

20
ity level, leaders decide where public funds will search (CER) as its main focus and incorporates
©
finance community health centers and municipal patients and other stakeholders throughout the
ht
ig
hospitals, which provide care regardless of the pa- process more consistently and intensively than
yr
op
tient’s ability to pay. others have before. In its strategic plan, PCORI
C
At the state level, decisions on access, eligi- has outlined the following three overarching
bility, and level of treatments for Medicaid re- goals:
cipients, where state and federal dollars will be
spent on items like tobacco cessation and gam- 1. Substantially increase the quantity, quality,
bling addiction centers (for those states with and timeliness of useful, trustworthy
casinos), and how to provide services to people information available to support health
with special needs, as well as funding for men- decisions
tal health facilities are a large component of most 2. Speed the implementation and use of patient-
state budgets. centered outcomes research (PCOR) evidence.
At the federal level, six agencies provide health- 3. Influence clinical and healthcare research
care to over 100 million Americans (Medicare, funded by others to be more patient centered
Medicaid, State Children’s Health Insurance (PCORI 2017)
AB103118_Ch02.indd 52 2/6/2020 4:52:59 PM


1. According to the publication To Error Is Human, how many patients die each year from preventable medical mistakes?
a. 10,000
b. 46,000
c. 72,000
d. 98,000
2. To “create social and physical environments that promote good health for all” is a goal of:
a. CDC
b. Healthy People 2020
n.
c. PCORI
tio
d. VHA
ia
oc
3. Identify a nonprofit, nongovernmental organization from the following.
ss
tA
a. SCHIP
en
b. CDC
em
c. National Academy of Medicine
ag
d. Healthy People 2020
an
M
4. The federal agency that monitors healthy precautions for international travelers is the:
n
a. CDC io
at
b. VHA
m
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fo
c. IHS
In
d. PCORI
lth
ea
5. A report from the National Academy of Medicine addressing the duplication and contrasting approaches to perfor-
H
mance measures by the six major governmental healthcare programs that serve nearly 100 million Americans is:
an
a. To Error is Human

ic
er
b. Leadership by Example

Am
c. Envisioning a National Health Care Quality Report

e
th
d. Priority Areas for National Action

by
6. True or false: The National Academy of Medicine is the largest single research funder hospitals and care systems use
20
to redesign how care is delivered, to eliminate inefficiencies within the system that will lead to better, integrated care,
20
and lower total cost of care.

©
ht
7. True or false: Healthcare policy is only formulated at the federal level.

ig
yr
8. True or false: Hospitals and care systems need to redesign how patient care is delivered so inefficiencies can be
op
eliminated within the system.

C
9. True or false: The organization that collects, analyzes, and creates national statistical databases and publishes papers
on important health issues is the CDC.
10. True or false: Social determinants of health are environmental issues that impact a wide range of health, functioning,
and quality-of-life outcomes and risks.
AB103118_Ch02.indd 53 2/6/2020 4:52:59 PM

Modern Healthcare Delivery in the United States

Until World War II, most healthcare Although old-age pension and unemployment
was provided in the home. Quality in healthcare insurance bills were introduced into Congress
services was considered a product of appropriate soon after his election, Roosevelt refused to give
medical practice and oversight by physicians and them his strong support. Instead, he created a pro-
surgeons. Even the minimum standards used to gram of his own and appointed a Committee on
evaluate the performance of hospitals were based Economic Security to study the issue comprehen-
on factors directly related to the composition and sively and report to Congress in January 1935.
skills of the hospital medical staff. Sentiment in favor of health insurance was strong
The 20th century was a period of tremendous among members of the Committee on Economic
change in American society. Advances in medical Security. However, many members of the commit-
n.
science promised better outcomes and increased tee were convinced that adding a health insurance
tio
the demand for healthcare services. But medical amendment would spell defeat for the entire Social
ia
oc
care has never been free. Even in the best economic Security legislation. Ultimately, the Social Security
ss
tA
times, many Americans have been unable to take bill included only one reference to health insurance
en
full advantage of what medicine has to offer be- as a subject that the new Social Security Board might
em
cause they cannot afford it. study. The Social Security Act was passed in 1935.
ag
Concern over access to healthcare was especially
an
M
evident during the Great Depression of the 1930s.
During the Depression, America’s leaders were Public Law 89–97 of 1965
n
io
at
m
forced to consider how the poor and disadvantaged In 1965, passage of a number of amendments to
r
fo
could receive the care they needed. Before the the Social Security Act brought Medicare and
In
Medicaid into existence. The two programs have

lth
Depression, medical care for the poor and elderly

ea
had been handled as a function of social welfare greatly changed how healthcare organizations are
H
agencies. However, during the 1930s, few people reimbursed. Recent attempts to curtail Medicare
an
ic
were able to pay for medical care. The problem of and Medicaid spending continue to affect health-
er
Am
how to pay for the healthcare needs of millions of care organizations.

Medicare (Title XVIII of the Social Security Act)
e
Americans became a public and governmental con-

th
cern. Working Americans turned to prepaid health is a federal program that provides healthcare ben-
by
efits for people age 65 and older who are covered

20
plans to help them pay for healthcare, but the

20
unemployed and the unemployable needed help by Social Security. The program was inaugurated
©
from a different source. on July 1, 1966. Over the years, amendments have
ht
ig
During the 20th century, Congress passed many extended coverage to individuals who are not cov-
yr
op
pieces of legislation that had a significant impact on ered by Social Security but are willing to pay a pre-
C
the delivery of healthcare services in the United States. mium for coverage, to the disabled, and to those
suffering from end-stage renal disease (ESRD).
The companion program, Medicaid (Title XIX
Social Security Act of 1935 of the Social Security Act), was established at the
The Great Depression revived the dormant social same time to support medical and hospital care
reform movement in the United States as well as for persons classified as medically indigent. Origi-
more radical currents in American politics. The nally targeting recipients of public assistance (pri-
Depression also brought to power the Democratic marily single-parent families and the aged, blind,
administration of Franklin D. Roosevelt, which and disabled), Medicaid has expanded to addi-
was more willing than any previous administration tional groups so that it now targets poor children,
to involve the federal government in the manage- the disabled, pregnant women, and very poor
ment of economic and social welfare. adults, including those age 65 and older.
AB103118_Ch02.indd 54 2/6/2020 4:52:59 PM

Today, Medicaid is a federally mandated pro- Utilization review (UR) is the process of de-
gram that provides healthcare benefits to low- termining whether the medical care provided to
income people and their children. Medicaid pro- a specific patient is necessary according to pre-
grams are administered and partially paid for by established objective screening criteria at time
individual states. Medicaid is an umbrella for 50 frames specified in the organization’s utilization
different state programs designed specifically to management plan. UR was a mandatory compo-
serve the poor. Beginning in January 1967, Med- nent of the original Medicare legislation. Medicare
icaid provided federal funds to states on a cost- required hospitals and extended care facilities,
sharing basis to ensure welfare recipients would which are facilities licensed by applicable state or
be guaranteed medical services. Coverage of four local law to offer room and board, skilled nursing
types of care was required: inpatient and outpa- by a full-time RN, intermediate care, or a combi-
tient services, other laboratory and x-ray services, nation of levels on a 24-hour basis over a long per-
n.
physician services, and nursing facility care for iod of time. Extended care facilities are required
tio
persons over 21 years of age. to establish a plan for UR as well as a permanent
ia
oc
Many enhancements have been made in the utilization review committee. The goal of the UR
ss
years since Medicaid was enacted. Services now process is to ensure the services provided to Medi-
tA
en
include family planning and 31 other optional care beneficiaries are medically necessary.
em
services such as prescription drugs and dental
ag
services. With few exceptions, recipients of cash
an
Utilization Review Act of 1977
M
assistance are automatically eligible for Medi-
caid. Medicaid also pays the Medicare premium, n
In 1977, the Utilization Review Act made it a re-
io
at
deductible, and coinsurance costs for some low- quirement for hospitals to conduct continued-
m r
fo
income Medicare beneficiaries. More information stay reviews for Medicare and Medicaid patients.
In
on Medicaid can be found in chapter 15, Revenue Continued-stay reviews determine whether it is
lth
ea
Management and Reimbursement. medically necessary for a patient to remain hos-

H
Medicaid spending has also increased 13.9 per- pitalized. This legislation also included fraud and
an
ic
cent over that time period. The increase in spend- abuse regulations. More information on fraud and
er
Am
ing is attributed to the growth in enrollment, in- abuse can be found in chapter 16, Fraud and Abuse
creased provider rates, increased prescription Compliance.
e
th
costs, and other costs spread out over the health-

by
care system (Kaiser Family Foundation 2015).

20
Peer Review Improvement

20
This represented a peak in enrollment. Since 2015,

Act of 1982
©
enrollment growth has slowed, in part, to the ta-

ht
ig
pering of ACA enrollment growth (Kaiser Family In 1982, the Peer Review Improvement Act rede-
yr
op
Foundation 2019). signed the PSRO program and renamed the agen-
C
cies peer review organizations (PROs). At that

time, hospitals began to review the medical ne-
Public Law 92–603 of 1972 cessity and appropriateness of certain admissions
To curtail Medicare and Medicaid spending, addi- even before patients were admitted. PROs were
tional amendments to the Social Security Act were given a new name in 2002 and now are called qual-
instituted in 1972. Public Law 92–603 required con- ity improvement organizations (QIOs). They cur-
current review for Medicare and Medicaid patients. rently emphasize quality improvement processes.
It also established the professional standards re- Each state and territory, as well as the District of
view organization (PSRO) program to implement Columbia, now has its own QIO. The mission of
concurrent review. PSROs performed professional the QIOs is to ensure the quality, efficiency, and
review and evaluated patient care services for ne- cost-effectiveness of the healthcare services pro-
cessity, quality, and cost-effectiveness. vided to Medicare beneficiaries in its locale.
AB103118_Ch02.indd 55 2/6/2020 4:52:59 PM

Tax Equity and Fiscal Responsibility identifiers for providers, health plans, and employ-
Act of 1982 ers. A portion of HIPAA addressed the security
and privacy of health information by establishing
In 1982, Congress passed the Tax Equity and Fis-
privacy standards to protect health information
cal Responsibility Act (TEFRA). TEFRA required
and security standards for electronic healthcare in-
extensive changes in the Medicare program. Its
formation. HIPAA privacy and security standards
purpose was to control the rising cost of provid-
are covered in chapter 9, Data Privacy and Confi-
ing healthcare services to Medicare beneficiaries.
dentiality, and chapter 10, Data Security. Another
Before this legislation was passed, healthcare serv-
provision of HIPAA was the creation of the Health-
ices provided to Medicare beneficiaries were reim-
care Integrity and Protection Data Bank (HIPDB)
bursed on a retrospective, or fee-based, payment
to combat fraud and abuse in health insurance and
system. TEFRA required the gradual implemen-
healthcare delivery. A purpose of the HIPDB is to
tation of a prospective payment system (PPS) for
n.
inform federal and state agencies about potential
tio
Medicare reimbursement.
quality problems with clinicians, suppliers, and
ia
In a retrospective payment system, a service is
oc
providers of healthcare services. The American
ss
provided, a claim for payment for the service is
Recovery and Reinvestment Act (ARRA) includes
tA
made, and the healthcare provider is reimbursed
en
important changes in HIPAA privacy and security
em
for the cost of delivering the service. In a PPS, a
standards that are also discussed in chapters 9
ag
predetermined level of reimbursement is estab-
and 10.
an
lished before the service is provided. More in-
M
formation on PPSs can be found in chapter 15, Rev- American Recovery and Reinvestment
n
io
at
enue Management and Reimbursement. Act of 2009
m
r
fo
The American Recovery and Reinvestment Act

Public Law 98–21 of 1983
In
of 2009 (ARRA) is considered one of the major

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The PPS for acute hospital care (inpatient) services

ea
health information technology laws that provided

H
was implemented on October 1, 1983, according stimulus funds to the US economy in the midst of
an
to Public Law 98–21. Under the inpatient PPS, re-

ic
a major economic downturn. A substantial portion

er
imbursement for hospital care provided to Medi-

Am
of the bill, Title XIII of the Act entitled the Health

care patients is based on diagnosis-related groups Information Technology for Economic and Clin-
e
th
(DRGs). Each case is assigned to a DRG based on ical Health (HITECH) Act, allocated funds for
by
the patient’s diagnosis at the time of discharge. implementation of a nationwide health information
20
For example, under the inpatient PPS, all cases of

20
exchange and implementation of electronic health

©
viral pneumonia would be reimbursed at the same records. The bill provides for investment of bil-
ht
predetermined level of reimbursement no matter

ig
lions of dollars in health information technology

yr
how long the patients stayed in the hospital or

op
and incentives to encourage physicians and hos-

C
how many services they received. PPSs for other pitals to use information technology; $19.2 billion
healthcare services provided to Medicare ben- was dedicated to implementing and supporting
eficiaries have been gradually implemented since health information technology. ARRA requires
1983. the government to take a leadership role in devel-
oping standards for exchange of health informa-
Health Insurance Portability and tion nationwide, strengthens federal privacy and
Accountability Act of 1996 security standards, and established the Office of
The Health Insurance Portability and Accountabil- the National Coordinator for Health Information
ity Act of 1996 (HIPAA) addresses issues related Technology (ONC) as a permanent office (Rode
to the portability of health insurance after leaving 2009). Four major components of the bill include:
employment, establishment of national standards meaningful use (that providers are using certi-
for electronic healthcare transactions, and national fied EHRs to improve patient outcomes); EHR
AB103118_Ch02.indd 56 2/6/2020 4:52:59 PM

standards and certifications; regional extension higher premiums based on health status
centers (used to assist providers with selection and gender
and implementation of EHRs); and breach notifi- ●● The requirement that most individuals have
cation guidance. Though challenged in court, the health insurance beginning in 2014 with tax
US Supreme Court upheld the law in a 6–3 deci- penalties for those without insurance
sion. Meaningful use was changed in 2018 to the ●● The penalties to employers that do not offer
Promoting Interoperability incentive program. affordable coverage to their employees,
EHR incentive programs are discussed in chapter with exceptions for small employers (Kaiser
16, Fraud and Abuse Compliance. Family Foundation 2012)
Since the ACA became law, the number of unin-
Patient Protection and Affordable sured individuals in the United States has declined
Care Act of 2010 from 49 million in 2010 to 29 million in 2015
n.
tio
The Patient Protection and Affordable Care Act (JAMA 2016). The law’s major coverage provisions
ia
oc
(ACA) was signed into law on March 23, 2010, and combined with financial assistance for low- and
ss
is the most significant healthcare reform legisla- moderate-income individuals to purchase their
tA
tion of the first decade of the 21st century. The Kai- coverage and generous federal support for states
en
em
ser Family Foundation summarizes the following that expand their Medicaid programs to cover
ag
major provisions of the ACA: more low-income adults have all contributed to
an
the gains in health coverage. The law’s provision
M
The Medicaid expansion to 138 percent of
n
●●
allowing young adults to stay on a parent’s plan
io
the federal poverty level ($15,415 for an
at
until age 26 years has also played a contributing
m
individual and $31,809 for a family of four in

r
role, covering an estimated 2.3 million people after

fo
2012) for individuals under age 65

In
it took effect in late 2010 (JAMA 2016).

lth
The creation of health insurance exchanges Since 2017, a number of proposals have been
ea
●●
through which individuals who do not

H
presented to repeal and replace the ACA. One in-

an
have access to public coverage or affordable cludes the repeal of a 2.3 percent excise tax on the
ic
er
employer coverage will be able to purchase sale of certain medical devices by manufacturers.
Am
insurance with premium and cost-sharing This tax was passed on to purchasers of devices,
e
th
credits available to some people to make mainly hospitals and physicians, which filtered
by
coverage more affordable down to consumers. An executive order signed by

20
New regulations on all health plans President Trump on January 20, 2017, authorized
20
●●
that will prevent health insurers from the Secretary of the Department of Health and
©
ht
denying coverage to people for any reason, Human Services to repeal this tax at his discretion
ig
yr
including health status, and from charging (Shi and Singh 2019).
op
C

1. Identify the law that created the HITECH Act.
a. Health Insurance Portability and Accountability Act
b. American Recovery and Reinvestment Act
c. Consolidated Omnibus Budget Reconciliation Act
d. Healthcare Quality Improvement Act
AB103118_Ch02.indd 57 2/6/2020 4:52:59 PM

2. Until World War II, most healthcare was provided:

a. In a government clinic
b. At a physician’s office
c. At home
d. In a hospital
3. A HIM student has asked you why Medicare reimburses healthcare providers through prospective payment systems.
Identify the piece of legislation that answers the student.
a. Peer Review Improvement Act of 1982
b. Consolidated Budget Reconciliation Act of 1986
c. Tax Equity and Fiscal Responsibility Act of 1982
d. Omnibus Budget Reconciliation Act of 1986
4. Identify the legislation that authorized the creation of the Office of National Coordinator for Health Information
Technology.
n.
tio
a. PPACA
ia
b. HIPAA
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c. ARRA
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d. TEFRA
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5. Medicaid is a:
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a. Federal program targeted principally for those age 65 and older
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b. Federally mandated healthcare program for low-income people
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c. Healthcare program limited to those under age 65
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d. Healthcare program for low-income persons regardless of age that is totally financed and operated by the states
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Match the description with the appropriate legislation.

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6. _____ Tax Equity and Fiscal Responsibility Act of 1982

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7. _____ Social Security Act of 1935

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8. _____ Public Law 92–603 of 1972

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9. _____ Patient Protection and Affordable Care Act of 2010

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10. _____ Utilization Review Act of 1977

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a. Required that hospitals conduct continued-stay reviews for Medicare and Medicaid patients
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b. Required concurrent review of Medicare and Medicaid patients

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c. Provided an individual mandate to have minimum acceptable coverage or pay a tax penalty
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d. Gave the states funds on a matching basis for maternal and infant care, rehabilitation of crippled children, general
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public health work, and aid for dependent children under age 16
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e. Required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement
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Real World Case 2.1

Steve is a 35-year-old, single male who employees, including him. Though he was dev-
lived in a one-bedroom apartment in a safe neigh- astated about losing his job, Steve was grateful
borhood. Steve worked as a maintenance techni- that he had some savings that he could use for
cian for a local mill. Steve’s job provided health rent and other bills, in addition to the unem-
insurance and he rarely needed to use it. Steve ployment checks he would receive for a few
smoked half a pack of cigarettes each day and months. For the next six months, Steve searched
drank socially a few times a month. aggressively for a job but was unable to find
One afternoon, Steve’s company notified him one. With his savings depleted, he was not able
that it was laying off more than one hundred to make ends meet, and he was evicted from his
AB103118_Ch02.indd 58 2/6/2020 4:52:59 PM

apartment. His self-esteem plummeted and he his backpack. A bystander called 911 and he was
became depressed. taken to the same emergency department where
Steve stayed with various family members and he had sought treatment for the shin injury. Again,
friends and was able to pick up some odd jobs to the providers didn’t screen him for homelessness,
make some money. However, his drinking and an- and he was discharged back to “home.”
ger got worse and his hosts asked him to leave. A few days later, an outreach team from a lo-
When he ran out of people to call, he started sleep- cal nonprofit organization introduced themselves
ing at the park. One night when Steve was drunk, he to Steve and asked if he was ok. He did not en-
fell and cut his shin. The injury became red and filled gage in conversation with them. They offered him
with pus. Steve was embarrassed about his situation a sandwich, a drink, and a blanket, which he took
and didn’t want anyone to see him. But when he de- without making eye contact. The outreach team
veloped a fever and pain, he decided to walk to the visited him over the next several days and noticed
n.
nearest emergency department. He saw a provider his shortness of breath and the cut on his leg.
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who diagnosed him with cellulitis, a common but After a couple of weeks, Steve began to trust
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potentially serious bacterial skin infection, and gave the outreach team and agreed to go to the orga-
ss
him a copy of the patient instructions that read “dis- nization’s medical clinic. The clinic provided pri-
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charge to home” and a prescription for antibiotics. mary care and behavioral health services through
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Steve could not afford the entire prescription, but he scheduled and walk-in appointments. Steve said
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was able to purchase half the tablets. the providers there treated him like a real person.
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Steve began staying at a shelter. Each morn- He was able to have regular appointments with
ing he had to leave the shelter by 6 am, and he n
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a therapist and began working on his depression
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walked the streets during the day and panhandled and substance abuse. A year later, his health has
m r
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for money to buy alcohol. One day two men improved. He is sober and working with a case
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jumped Steve, kicked him repeatedly, and stole manager to find housing.
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Real-World Case 2.2

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A municipal medical center in a city of but ran into a problem with patient identification
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100,000 residents decided that they needed to di- for health record purposes. The issue was that the
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versify if they were going to survive the ups and same patient may have been or was going to be in
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20
downs of the economy. The board of directors met multiple facilities within the new enterprise. How-
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with the chief of the medical staff to determine the ever, at each of the present facilities (physician of-
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best course of action. They mutually decided to fice, medical center, and nursing home), the same
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emphasize a cradle-to-grave approach by acquiring patient would have different health record num-
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a few select physician practices and a local nursing bers. A plan for an enterprise health record num-
home, starting a home health agency, and creating ber was needed. The medical center administration
a hospice unit within the medical center. The board decided to bring in the health information manage-
then decided to link all new acquisitions to the med- ment director of the medical center to provide ex-
ical center’s existing electronic health record (EHR) pertise and experience in resolving the problem.
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American Hospital Association. 2018b. Hospitals and-Systems/Statistics-Trends-and-Reports/

are Economic Drivers in Their Communities. NationalHealthExpendData/Downloads/
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American Nurses Association. 2019. What is Nursing?
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Banova, B. 2018. The Impact of Technology on Department of Health and Human Services. 2019.
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National Health Expenditures 2017 Highlights. Institute of Medicine. 2003. Priority Areas for National
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nationalacademies.org/reports/2003/priority-areas- The National Human Genome Research Institute.

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government-roles-in-improving-health-care-quality.aspx. National Institutes of Health. 2015. Managed
Institute of Medicine. 1999. To Error is Human: Care. Medline Plus. https://www.nlm.nih.gov/
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electronic data usable and interoperable. P&T: A
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Q. Dong, H. Shen, and Y. Wang. 2017. Stroke Vascular
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Rode, D. 2009. Recovery and privacy: Why a law about
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Kaiser Family Foundation. 2019. Medicaid Enrollment of AHIMA 80(5):42–44.

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& Spending Growth: FY 2018 & 2019. https://www.

RTI International. 2015. Accountable Care
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Organization 2015: Program Analysis Quality

spending-growth-fy-2018-2019/.
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and Spending Growth: FY 2015 and 2016. http:// gov/medicare/medicare-fee-for-service-payment/

kff.org/medicaid/issue-brief/medicaid-enrollment- sharedsavingsprogram/downloads/ry2015-narrative-
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the-scientist.com/foundations/the-first-x-ray-1895-42279.
Affordable Care Act. https://www.kff.org/health-
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costs/issue-brief/summary-of-coverage-provisions-in-
America: A Systems Approach. 7th ed. Burlington, MA:
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Jones & Bartlett Learning.

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Kickman, J.R. and A.R. Kovner. 2015. Jonas and Kovner’s

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Sutton, J.P., R.E.Washington, K.R. Fingar, and

Healthcare Delivery in the United States, 11th ed. New
A. Elixhauser. 2016. Characteristics of Safety-Net
York: Springer.
Hospitals, 2014. https://www.hcup-us.ahrq.gov/
The Medical Futurist. 2017. The Technological reports/statbriefs/sb213-Safety-Net-Hospitals-
Future of Surgery. https://medicalfuturist.com/the- 2014.pdf.
technological-future-of-surgery.
Young, A., Chaudhry, H., Pei, X, Arnhart, K., Dugan,
National Academy on Medicine. 2018. Procuring M., and Snyder, G. 2016. A Census of Activity
Interoperability: Achieving High-Quality, Licensed Physicians in the United States, 2016.
Connected, and Person-Centered Care. https:// https://www.fsmb.org/siteassets/advocacy/
nam.edu/wp-content/uploads/2018/10/Procuring- publications/2016census.pdf.
Interoperability_web.pdf. Wachter, R. M. and L. Goldman. 2016. Zero to 50,000 -
National Adult Day Services Association. 2019. The 20th Anniversary of the Hospitalist. The New
https://www.nadsa.org/research/. England Journal of Medicine 375(11):1009–11.
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AB103118_Ch02.indd 62
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2/6/2020 4:53:00 PM
Chapter
3
Health Information
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Functions, Purpose,
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and Users
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Learning Objectives
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•• Identify the purposes of the health record •• Justify the use of the virtual health information
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•• Describe the different users of the health record and management (HIM) department
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how they use it •• Educate others in the paper-based and electronic

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•• Utilize the master patient index health records processes

•• Determine the appropriate format for the healthcare •• Justify the need for the use of information systems
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organization in the HIM department

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•• Justify the need to work with other departments in •• Explain the health information management
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a healthcare organization information systems

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Key Terms
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Abstracting Computer-assisted coding (CAC) Duplicate health record

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Addendum Concurrent review Electronic health record (EHR)

Aggregate data Correction Encoder
Alphabetic filing system Data Enterprise master patient
Alphanumeric filing system Data mining index (EMPI)
Amendment Deficiency slip Free-text data
Analysis Delinquent record Grouper
Assembly Demographics Guidelines
Audit trail Deterministic algorithm Health record
Centralized unit filing system Disclosure of health information Hybrid health record
Clinical coding Document management system Index
Clinical decision support (CDC) (DMS) Information
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AB103118_Ch03.indd 63 2/11/2020 12:18:31 PM

Input mask Patient account number Secondary purpose

Knowledge Primary purpose Serial numbering system
Loose material Probabilistic algorithm Serial-unit numbering system
Master patient index (MPI) Qualitative analysis Standard
Microfilm Quantitative analysis Statistics
Natural language processing (NLP) Record reconciliation Straight numeric filing system
Numeric filing system Registry Terminal-digit filing system
Outguide Requisition Turnaround time
Overlap Research Unit numbering system
Overlay Retrospective review Version control
Paper health record Rules-based algorithm Voice recognition technology
The health record contains information relating to Hospital A discharged 560 patients last month.
n.
the physical or mental health or condition of an Information is data that have been turned into
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individual, as made by or on behalf of a health something meaningful such as Hospital A dis-
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professional in connection with the care ascribed charged 560 patients last month, which was up 10
ss
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that individual. In other words, the health record percent from the prior month and 20 percent from
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contains the who, what, where, when, why, and this time last year. Knowledge is the information,
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how of patient care and is used for many reasons understanding, and experience that give individ-
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and by many people. When discussing these us- uals the power to make informed decisions. For
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ages and users, it is important to understand the example, investigation identified that the increase
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difference between three terms—data, information, io
in patients was primarily due to an increase in ob-
at
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and knowledge. The terms data and information are stetrics patients. This increase in obstetrics patients
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often used interchangeably but they are distinctly is why the healthcare organization decided to in-
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different. Data are raw facts and figures such as vestigate ways to improve its obstetric services.
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Purposes of the Health Record

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The uses of a health record can be di- provided by physicians, nurses, and
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vided into primary and secondary purposes. The allied health professionals such as
by
primary purposes are those for which the health physical therapists and dietitians.
20
20
record is developed and used—patient care. The This documentation serves as a

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secondary purposes are those where the health communication tool between these
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record is used for healthcare purposes not directly healthcare professionals, as discussed
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related to patient care. in chapter 2, Healthcare Delivery Systems,

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and may contain treatments and the

patient’s response to the treatment.
Primary Purposes
For more information on health record
The primary purposes of the health record are documentation, see chapter 4, Health Record
related to providing care to the patient. Patient Content and Documentation.
care includes the direct care provided and the ●● Management of patient care. The health record
day-to-day business of the healthcare organiza-
is an important part of managing patient
tion. These usages can be categorized in the fol-
care services performed at the healthcare
lowing ways:
organization. The health record is used to
●● Patient care. One of the most important develop patient care standards; conduct
uses of the health record for patient care research at the local, state, and national
is the documentation of the care levels; and evaluate the quality of care
AB103118_Ch03.indd 64 2/11/2020 12:18:32 PM

rovided. For more on quality, see chapter

p alpractice and other lawsuits, to monitor
m
18, Performance Improvement. compliance with laws and regulations,
●● Administrative purposes. The health record is and to adhere to accreditation standards.
used for administrative purposes including Information from the health record is also
billing for services provided, making decisions used at the national level to determine
about the future of the healthcare organization, where funding will be allocated, as well as
monitoring the fiscal health of the the direction the healthcare industry should
organization, and scheduling staffing. Many take. For additional information on how the
administrative purposes are discussed in record is used for legal purposes, see chapter
detail in chapter 13, Research and Data Analysis, 8, Health Law, chapter 9, Data Privacy and
chapter 14, Healthcare Statistics, chapter 15, Confidentiality, and chapter 10, Data Security.
Revenue Management and Reimbursement, and ●● Public health and research. Data in the
n.
chapter 18. health record are aggregated and turned into
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information that is used at the national level
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Secondary Purposes to establish best practices of patient care,
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Healthcare is a sophisticated industry and in- conduct research on new medications and
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formation from the health record is used for many technologies, and study patient outcomes.
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New diseases are continuously identified
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purposes not related specifically to patient care.
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These secondary purposes include the following: while current ones evolve, sometimes
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making them resistant to traditional
Education of healthcare professionals. Health n
●● io treatment. The information from the health
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records are used by medical, nursing, and
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record is used to determine what traditional

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other allied health professionals including and nontraditional treatments are effective
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health information management (HIM) to

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for these new diseases and conditions.

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teach present and future healthcare providers Registries are covered in chapter 7, Secondary
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how to document care provided, and how

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Data Sources. Local health departments use

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to manage the healthcare information. See health information to identify outbreaks in

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chapter 20, Human Resources Management, for diseases early so the source of the disease can
more on training.
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be managed, and epidemics can be managed

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by
●● Legal, accreditation, and policy development. or prevented. For additional information

20
The health record is used to protect the regarding public health and research usage,
20
healthcare organization from medical see chapter 14, Healthcare Statistics.

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Formats of the Health Record

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To understand how the health record created, managed, and consulted by authorized
is used, it is important to understand the three clinicians and staff across more than one health-
types of health records: paper, electronic, and hy- care organization. The hybrid health record, also
brid. The paper health record is completely avail- known as hybrid record, is a combination of the
able in paper media. Some portions of it may have paper health record and the EHR. In the hybrid
been created electronically, like lab results, but health record, some documents are stored in the
the lab results are printed and filed in the paper paper health record while others are stored in the
health record. The electronic health record (EHR) EHR. The electronic documents may or may not
is a digital record of an individual’s health-related be printed and stored in the paper health record.
information that conforms to nationally recog-
These three types of health records are discussed
nized interoperability standards and that can be in more detail later in this chapter.
AB103118_Ch03.indd 65 2/11/2020 12:18:32 PM

Users of the Health Record

Healthcare providers are the primary staff gathers information for the patient care
users of the health record; however, others use the managers to use.
health record to manage the healthcare organiza- ●● Coding and billing staff. Documentation in the
tion and the healthcare industry. Some users of health record is the basis for reimbursement, or
the health record access and use the health record payment, for the care provided. The coding staff
directly while others use data or information that at the healthcare organization must read the
has been aggregated from multiple health records. entire health record and assign the appropriate
Aggregate data are data that have been extracted diagnoses and procedure codes for treatment
from individual health records and combined to received during the encounter. The billing staff
form deidentified information about groups of obtains the codes from the coders and submits
n.
patients that can be compared and analyzed. For the bill to the insurance company. (Chapter 15,
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example, aggregate data can be used to determine
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Revenue Management and Reimbursement, covers
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survival rates for various kinds of cancer or to de- reimbursement in more detail.)
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termine if a new drug is safe. Deidentification is ●● Patients. Patients are informed consumers
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the removal of all data elements that can identify
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of their healthcare. As informed consumers,
the patient.
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patients may obtain access to and be
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informed about their health record by
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Individual Users obtaining a copy of their health record,
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Individual users are those who depend on the
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accessing a patient portal, or maintaining
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health record to complete their jobs. The way the a personal health record. Personal health
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health record is used varies by individual user. records are discussed later in this chapter.
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For example, nurses use physician orders to know (Chapter 9, Data Privacy and Confidentiality,
ea
how to care for the patient. The following are

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covers patient rights and the health record in

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descriptions of these individual users: more detail.)

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Patient care providers. Patient care providers Employers. Employers may use health
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●● ●●
include physicians, nurses, and other allied records when processing health insurance
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health professionals who rely on informa- claims and in managing wellness programs.
by
tion from the health record to make deci- Employers may also use the health record
20
to determine when employees are well

20
sions about the care provided to the patient

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and for documentation of care. Allied health enough to return to work after an injury or
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professionals include respiratory therapists, illness, although this is generally limited

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nutritionists, physical therapists, and many to a note from the physician giving his or
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more. (Chapter 2, Healthcare Delivery Systems, her approval. When an employee claims
covers allied health professionals in more disability due to a work-related incident, it
detail.) is the information found in the health record
●● Patient care managers and support staff. that supports or refutes the claim.
Patient care managers evaluate the services ●● Lawyers. Lawyers may need access to
provided by their employees. As care is support a client (the patient) for life
documented in the health record, it becomes insurance claims and lawsuits such as those
a key resource in their evaluation of the related to motor vehicle crashes, disability,
quality of care provided. The managers and such. The lawyer must obtain consent
look for patterns and trends to recommend from the patient to access the patient’s health
changes to the process to improve outcomes information. To protect themselves from
and efficiency of the care provided. Support medical malpractice and other lawsuits,
AB103118_Ch03.indd 66 2/11/2020 12:18:32 PM

healthcare organizations may grant lawyers through an insurance program. These

access to patient records. insurance programs include commercial
●● Law enforcement officials. Law enforcement insurance, managed care organizations,
officials need access to health record government insurance programs,
documentation to investigate gunshot accountable care organizations, as well as
wounds and other injuries resulting from a self-insured employers. The health record
crime. They also may access documentation is used to justify the care provided and
for information that will help protect the therefore the reimbursement. For additional
security of the country. information, refer to chapter 15, Revenue
Management and Reimbursement.
●● Healthcare researchers and clinical investigators.
Healthcare researchers use health records ●● Medical review organizations. Medical review
to study the safety and efficacy of drugs or organizations evaluate the quality and
n.
the value of care provided. The researcher’s appropriateness of the care provided to the
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aggregate data and information based on patient. Medicare hires organizations known
oc
as quality improvement organizations to
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these findings are used to approve new
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treatments and to stop unsafe treatments. determine if the care provided to the patient
en
How the health record is used in research was medically necessary. See chapter 18,
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is covered in more detail in chapter 14, Performance Improvement, for more information
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an
Healthcare Statistics. on quality improvement organizations.
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Research organizations. Research
n
●● Government policy makers. The health record ●●
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organizations conduct medical research and
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may be used to develop and evaluate current
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include state disease registries such as the

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and future laws, regulations, and standards

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related to healthcare. The data collected cancer registry, research centers, and others
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can help determine best practices, gaps in who explore diseases and their treatment.
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current legislation, and other issues that ●● Educational organizations. Colleges and
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need to be addressed to improve care and universities train healthcare professionals.

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prevent fraud. The students in these programs use the

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health records as case studies as a part of the

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th
Institutional Users educational program.

by
Accreditation organizations. To be granted

20
●●
Institutional users are organizations that need ac-
20
and maintain accreditation, a healthcare

cess to health records to accomplish their mission. In-
©
organization must show compliance with

stitutional users include healthcare organizations,
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the accrediting body standards. This

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third-party payers, medical review organizations,

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frequently requires review of the health

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research organizations, educational organizations,

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record to determine compliance with

accreditation organizations, government licensing
documentation and patient care standards.
agencies, and policy-making bodies.
For example, the accreditation organization
●● Healthcare organizations. Healthcare organiza- may require the history and physical (refer
tions—including hospitals, physician offices, to chapter 4, Health Record Content and
home health agencies, and others—use the Documentation) to be completed within 24
health record to provide care, submit claims hours of admission. To learn more about
for reimbursement, and evaluate the quality accreditation, see chapter 8, Health Law.
of care provided. ●● Government licensing agencies. Government
●● Third-party payers. Third-party payers agencies at the local, state, and federal level
are organizations responsible for the review the health record to ensure compliance
reimbursement of healthcare services with state licensing requirements and to verify
AB103118_Ch03.indd 67 2/11/2020 12:18:32 PM

compliance with standards that enable the databases and other sources are analyzed
healthcare organization to receive federal and utilized for decision-making related
funding. A more detailed discussion on licensing to healthcare programs. For example, the
is also included in chapter 8, Health Law. Centers for Medicare and Medicaid Services
●● Policy-making bodies. The data submitted (CMS) utilize a wide range of data to revise
for healthcare claims to governmental reimbursement systems each year.
n.
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1. Identify an example of a primary purpose of the health record.
ss
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a. Education
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b. Policy making
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c. Research
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d. Patient care
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2. Identify the institutional user that utilizes health record data to make decisions regarding healthcare programs.
a. Educational organization
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b. Policy-making body
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c. Research organization

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d. Third-party payer

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3. The entire health record at our healthcare organization is accessible online. We utilize a(n):
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a. Paper health record

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b. Personal health record

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c. EHR
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d. Hybrid health record

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4. Identify a type of individual user.

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a. Policy-making body

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b. Government licensing agency

20
c. Patient
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d. Accreditation organization

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5. Deidentified data are used for:

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a. Education of healthcare professionals

b. Public health and research
c. Investigating gunshot wounds
d. Patient care
Overview of HIM Functions

The HIM department performs many the quality, security, and availability of the health
functions to support patient care and the health- record. Some functions are performed in the HIM
care organization. The functions focus on ensuring department, while others may be in their own
AB103118_Ch03.indd 68 2/11/2020 12:18:32 PM

epartment or outsourced. Outsourcing is the hiring

d to ensure that proper formatting was used, there
of an individual or a company external to an organ- were no typographical or other errors, and it was
ization to perform a function either on-site or off- transcribed in a timely manner. The date dictated
site. Typical HIM functions include the following: and the date transcribed should be recorded on
the document. The expected turnaround time is
●● Medical transcription and voice recognition
determined by the healthcare organization and
●● Disclosure of health information may vary by document. For example, a radiology
●● Clinical coding and reimbursement report may be transcribed within 24 hours and a
●● Record storage and retrieval (paper and discharge summary within three days of dictation.
electronic) Today, healthcare organizations may use speech
●● Statistics and research recognition to go directly from dictation to a typed
document. There are two strategies to be considered
●● Master patient index
n.
with speech recognition. Front-end speech recog-
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●● Record storage and retrieval (paper and nition occurs when physicians review and edit the
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electronic) document directly upon dictation and then can sign
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Record processing it immediately. The document is available quickly
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●●
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●● Registries (cancer, trauma, birth defects, with this strategy. The other strategy is back-end
em
and more) speech recognition. In this strategy, the transcription-
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ists become editors, making corrections to the docu-
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●● Birth and death certificate completion
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ment rather than typing it. Because they review and
The HIM department operates in conjunction with n
io
edit the document after dictation, the physician can-
at
other departments to support and enhance their serv- not sign the document until a later time. The advan-
mr
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ices including patient care, information governance, tage is that the physician can focus on patient care
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quality management, billing, and patient registration. rather than correcting any issues in the document.
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Medical Transcription and Voice Disclosure of Health Information

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Recognition
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One of the responsibilities of the HIM department

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Medical transcription, the process of deciphering is disclosure of health information. Disclosure of

and typing medical dictation, may be a part of the health information is the process of disclosing
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HIM department or it may be a separate central- patient-identifiable information from the health
by
ized department where all transcription services record to another party. The HIM department re-
20
20
are performed. Transcription services may also be ceives a request for access to patient information,
©
outsourced to another company. In that case, there ensures that the request is appropriate for release,
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should be a liaison between the HIM department and then submits the information for use in pa-
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and the transcription company. This liaison would tient care, insurance claims, legal claims, or oth-
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work with physicians, monitor turnaround time, er purpose. Disclosure of health information can
monitor the quality of the work, and more. Com- be performed internally or can be outsourced to
monly transcribed reports include history and a disclosure of health information company. For
physical, discharge summary, pathology reports, more information on disclosure of health informa-
procedure reports (such as colonoscopy and car- tion and privacy requirements, see chapter 9, Data
diac catheterization), and radiology reports. See Privacy and Confidentiality.
chapter 4, Health Record Content and Documenta- The disclosure of health information supervisor
tion, for a description of these reports. is responsible for ensuring policies and procedures
The transcription manager is responsible for are followed, requests are processed in a timely
monitoring the quality of the documents and manner, and the staff meets their productivity re-
services performed. The transcription supervisor quirements. Quality control for the disclosure of
should review a sample of the documents typed health information function includes ensuring the
AB103118_Ch03.indd 69 2/11/2020 12:18:32 PM

health records are available first and foremost for Record Storage and Retrieval
patient care. It also includes ensuring the request- Functions
ed documents and only the requested documents
A healthcare organization cannot move quickly
are released or disclosed.
from a paper-based record to an electronic record.
The supervisor is responsible for ensuring turn-
The transition to the EHR can take years and often
around times are met. Turnaround time is the time
involves a hybrid record—part of the health record
between receipt of request and when the infor-
on paper and part of it electronic. During this time,
mation is sent to the requester. The disclosure of
some functions will be handled as described in the
health information system discussed later in this
paper-based record environment while others may
chapter can report this statistic.
be handled electronically. As the percentage of the
The disclosure of health information staff is
record digitized increases, more of the functions will
responsible for documenting to whom informa-
be as described in the electronic record environment.
n.
tion is released, when it was released, and spe-
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A common information system that is used dur-
cifically what was released. This is known as
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ing this transition period is the document manage-
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an Accounting of Disclosure Log. This includes
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ment system (DMS). The DMS scans the paper rec-
specific document(s) and the dates of service.
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ord and stores it digitally. The user has the benefits
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A copy of the formal request for copies of pa-
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of immediate access but unfortunately the user is
tient information must be retained by the HIM
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not able to manipulate the data as the document is
department.
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stored as a picture, not data. One of the advantages
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Clinical Coding and Reimbursement of a DMS is the ability to control the workflow elec-
n
io
at
tronically. The workflow is not limited to the HIM de-
m
Clinical coding, or assigning codes to represent

partment but can be automatically routed to other
r
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diagnoses and procedures, is a key responsibil-

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users throughout the healthcare organization.

ity of the HIM department. Several coding sys-
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During the period of transition to an EHR, it is

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tems can be used. During the coding process,

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difficult to identify the legal health record as some

data are abstracted into the information system.
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of it is paper, some is electronic (and may be in a

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Abstracting can be either the process of extract-

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multitude of information systems), and some docu-

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ing information from a document to create a brief

ments are created electronically but may be printed
summary of a patient’s illness, treatment, and
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and stored in the paper health record. (Chapter 4,

outcome, or the process of extracting elements
by
Health Record Content and Documentation, covers the

of data from a source document or database and
20
legal health record in more detail.) This period is

20
entering them into an automated system. The

also challenging as the HIM department must man-
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amount of data abstracted for coding purposes

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age both the paper and the electronic documents.

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varies by healthcare organization but includes

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data such as date of surgery, surgeon, and dis-

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position of patient upon discharge (went home, Master Patient Index

transferred to another hospital, and so forth). The master patient index (MPI) is the permanent
The codes are included on the bill and are used record of all patients treated at a healthcare or-
to determine reimbursement that the healthcare ganization. It is used by the HIM department to
organization will receive. The coding supervisor look up patient demographics, dates of care, the
must ensure the quality of code assignment and patient’s health record number, and other data.
the timeliness of the coding process. If the cod- Demographics, also known as demographic data,
ing process gets behind, the encounters cannot are basic information about the patient such as
be billed, thus ensuring that reimbursement for their name, address, date of birth, and insurance
patient care is delayed. For more information on information. The MPI is an important element of
coding, refer to chapter 15, Revenue Management a numeric filing system (discussed later in this
and Reimbursement. chapter) as it allows the user to look up the patient
AB103118_Ch03.indd 70 2/11/2020 12:18:32 PM

health record number so the record can be locat- ●● Admission or visit number
ed. When a healthcare enterprise has more than ●● Admission, encounter, or visit data
one healthcare organization (such as hospital ●● Discharge or departure date
and ambulatory clinic) and the patient is seen
at two or more places, the enterprise master
●● Encounter service type
patient index (EMPI) links the patient’s in-
●● Encounter primary physician
formation at the different healthcare facilities. ●● Patient disposition (AHIMA 2010)
The recommended core data elements for the
EMPI are the following: Before computerization, the MPI was maintained
on index cards; now the MPI is generally electronic,
●● Internal patient identification which allows for alphabetic and phonetic search capa-
●● Person name bilities, as well as the ability to search numerous data
Date of birth elements such as patient name, health record number,
n.
●●
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Gender and billing number. A phonetic search retrieves names
ia
●●
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that sound the same; for example, Burgur, Burger, Ber-
Race
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●●
ger, and Burgher. Figure 3.1 provides an example of
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●● Ethnicity an input screen for an electronic MPI system.
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●● Address The health record number is created by the
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●● Telephone number MPI and the numbers are issued in sequential nu-
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meric order. For example, Ms. Smith is admitted
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●● Alias, previous, or maiden names
n
to the healthcare organization at 4:00 p.m. and is
io
●● Social security number
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issued the health record number of 156876. When
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●● Facility identification
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Ms. Jones, the next new patient, is admitted at

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●● Universal patient identifier 4:06 p.m., she is issued the health record number
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Account or visit number of 156877.

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●●
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Figure 3.1 Input screen for an electronic MPI system

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by
20
20
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Source: MEDITECH Registration. Used with permission from MEDITECH Practice.
AB103118_Ch03.indd 71 2/11/2020 12:18:32 PM

Unfortunately, there are data quality issues that more common reasons for this is an error in select-
result from improper issuance of health record ing the correct patient by the hospital staff.
numbers. Typographical errors, outdated demo- A third issue is an overlap, or when a patient
graphic information, and other data quality issues has more than one health record number at dif-
are always present in the MPI. For example, pa- ferent locations within an enterprise or healthcare
tients change their name, identify themselves by organization. This frequently becomes an issue
their nickname, move, or change phone numbers. when healthcare organizations merge or create an
Some errors occur through data entry; for example, EMPI.
entering the birthday of January 1, instead of Janu- A healthcare organization must work to protect
ary 11. The erroneous information is then shared the integrity of the data in the MPI. Most errors are
with other information systems, exacerbating the human. The clerk may transpose numbers, make
problem. It takes a lot of time to identify and cor- typographical errors or use poor search strategies
n.
rect the erroneous information. Some of the more that fail to find the patient in the information sys-
tio
common problems include duplicates, overlays, tem, or the patient may give inaccurate information.
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oc
and overlaps. All healthcare organizations must have process-
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When the patient is registered in the admissions es in place to maintain and correct the MPI against
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en
department, previous MPI information may not the quality issues of duplicates, overlays, and
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be retrieved if the clerk does not conduct a thor- overlaps on a continuous basis. Algorithms are
ag
ough search for the patient or if the patient gives used to match patients so the patient information
an
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a different name. For example, the patient may can be merged. There are three types of matching
give her new married name rather than her maid- n
io
algorithms typically found in the MPI. The first,
at
en name. The patient may also give a nickname, a deterministic algorithm, requires exact matches
m
r
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such as Bob, rather than his legal name, Robert. in data elements such as the patient name, date of
In
This results in a duplicate health record number birth, and social security number. The second, a
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ea
being issued. A duplicate health record results probabilistic algorithm, uses mathematical prob-
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when the patient has two or more health record abilities to determine the possibility that two pa-
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ic
numbers issued. The patient’s health informa- tients are the same. The third, a rules-based algo-
er
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tion becomes fragmented with some information rithm, assigns weights to specific data elements
under the first number and the remainder under and uses those weights to compare one record to
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th
the second number. When this happens, duplicate another (AHIMA 2010).
by
laboratory testing may occur, causing unnecessary This clean-up process is ongoing. There should
20
20
expenses, poor decisions such as misdiagnoses or be a formal process to help prevent and identify
©
unnecessary tests, and the healthcare organiza- potential duplicates. Staff should be educated on
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tion’s increased legal risk with the potential for the impact of errors in the MPI. When duplicates,
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medical malpractice. overlays, and overlaps are identified, the depart-

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Another problem with the question of the qual- ment managers need to be notified so they can ad-
ity of the MPI is an overlay. With an overlay, a dress the problem with the staff making the errors.
patient is erroneously assigned another person’s
health record number. When this happens, patient Record Storage and Retrieval Functions
information from both patients becomes commin- in a Paper Environment
gled and care providers may make medical deci- While the EHR is becoming more prevalent, the
sions based on erroneous information, increasing existing paper records have not disappeared.
the legal risks to the healthcare organization and While HIM professionals operate in the EHR envi-
quality of care risks to the patient. For example, ronment, the paper records must still be managed.
a patient with the name Jeffery Johnson, date of The following sections address the HIM process-
birth January 1, 1962, may be mistaken for Jeffery es for the creation, storage, and maintenance of
Johnson, date of birth January 1, 1957. One of the paper-based records.
AB103118_Ch03.indd 72 2/11/2020 12:18:32 PM

The HIM department is responsible for the stor- it difficult to manage. Management
age and retrieval of the paper-based record. Poli- problems include the higher number of
cies and procedures should be in place to ensure department staff in one section of the
access to the health records for authorized users file room and the space required by the
but to prevent access for unauthorized users. In health records may exceed the amount
a paper-based record, the documentation is typi- available.
cally stored alphabetically or numerically in a spe- The terminal-digit filing system may
cial file folder. Healthcare organizations may also sound backward, but it is typically con-
file their paper-based records off-site, on micro- sidered the most efficient of the numeric
film, or digitally as scanned documents. filing systems in part because it distrib-
In a paper-based record filing system, the folders utes health records evenly throughout
containing the health records are stored in shelving the filing units. It is also effective for
n.
units or in filing cabinets based on the health record healthcare facilities with a heavy rec-
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number or patient name. The filing systems used
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ord volume. The health records are filed
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are the following alphabetic filing systems, numeric by the last two digits, called the ter-
ss
filing systems, and alphanumeric filing systems.
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minal digits, then the middle two digits,
en
known as the secondary unit. The health
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●● Alphabetic Filing System In the alpha-
records are then filed by the first two or
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betic filing system, health records are filed
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three numbers, known as the tertiary
in alphabetic order. This system works well
M
units. See figure 3.3 for an example.
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with a small volume of health records such io
Alphanumeric Filing System As the name
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as in a physician practice. Employees are ●●
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alphanumeric filing system indicates, both

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comfortable with it and the filing system is

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easy to create and use. A disadvantage is alphabetic and numeric characters are used
lth
that there is no unique identifier as patients to sort health records in this system. The
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first two letters of the patient’s last name are

H
can have the same name. Another problem is

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the alphabetic filing system does not expand followed by a unique numeric identifier such
ic
er
evenly. Statistically almost half of the files as SA2567. This filing system is appropriate
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fall under the letters B, C, H, M, S, and W. for small healthcare facilities. Like numeric
e
systems, alphanumeric filing systems require

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Figure 3.2 contains rules for alphabetic filing.

by
an MPI.
Numeric Filing Systems In a numeric filing
20
●●
20
system, the health records are filed by the Paper health records are frequently filed in a cen-
©
health record number. The MPI is consulted tralized unit filing system. In a centralized unit
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to identify the health record number and filing system, any patient encounters are filed to-
ig
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then the number is used to locate the health gether in a single location. For example, a patient
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record. This may seem like more work than may be seen in radiology for a mammogram and
the alphabetic system but there are many in the laboratory for a urinalysis. These test results
advantages to the numeric filing system. will be filed together. This type of filing system is
The most common types of numeric filing usually associated with the unit numbering sys-
systems are the following: tem; the unique identifiers can be alphabetic, al-
The straight numeric filing system files phanumeric, or numeric depending on the needs
the records in straight numeric order of the healthcare organization.
based on the health record number. This
filing system is easy to teach to new em- Storage Systems for Paper-Based Records Sev-
ployees; however, the most active area eral options are available for storing paper records
in the files is the higher numbers, which including filing cabinets, shelving units, micro-
are the most current files, making film, off-site storage, and image-based storage.
AB103118_Ch03.indd 73 2/11/2020 12:18:32 PM

Figure 3.2 Rules for alphabetic filing

1. File each record alphabetically by the last name, followed by the first name and middle
initial. For example:
Brown, Michelle L.
Brown, Michelle S.
Brown, Robert A.
When patients have identical last and first names and middle initials, order the records by
date of birth, filing the record with the earliest birthdate first.
2. Last names beginning with a prefix or containing an apostrophe are filed in strict
alphabetical order, ignoring any apostrophes or spaces. For example, the name D’Angelo would
be filed as Dangelo.
3. Names beginning with the abbreviation St., such as St. Clair, are filed as S-a-i-n-t.
n.
4. In hyphenated names such as Burchfield-Sayles, the hyphenation is ignored, and the record
tio
is filed as Burchfieldsayles.
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5. If a name is given as an initial, the rule is “file nothing before something.”
ss
For example, Smith, J would be filed before Smith, Jane.
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6. Mac and Mc can be filed either way but there should be a policy stating whether Mac or
em
Mc will be used.
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Source: Huffman 1994.
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Figure 3.3 Terminal-digit filing system example io
shelving units move and the aisles open and close
at
as needed. The units are on tracks, which allow the
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Health record number 12–34–56

units to be moved to open up the aisle.
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Files of patients who have not been at the health-

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Tertiary Middle Terminal

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digits digits digits care organization for a specified period, such as two
H
12 34 56
years, may be purged or removed from the active fil-
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Source: ©AHIMA.
ing area. The time period and frequency of purging
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depends on the space available, patient readmission

The storage choice for health records depends on rate, and the need for access to the health record. For
e
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the needs and storage capacity of the healthcare more information on retention and destruction, see
by
chapter 9, Data Privacy and Confidentiality.

20
organization.
20
Vertical and lateral filing cabinets, open shelves, or An important role of the HIM professional is to
©
compressible filing units can all be used for storage of determine the space requirements needed to store
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records. Vertical and lateral filing cabinets are seen in the paper health record by evaluating the volume
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most office settings and usually contain two or four indicators such as number of discharges, size of
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drawers. These small filing cabinets are only appro- records, and the capacity of the storage units. For
priate for low-volume storage as it is challenging to example, the space needed can be estimated with
quickly access health records from the drawers. the following information:
Typically, an HIM department uses open shelving
Shelving unit shelf width = 36 inches
units that resemble bookcases and can store large
volumes of files that are easy to view and access. Number of shelves per unit = 8 shelves
Multiple shelves separated by aisles large enough Average record thickness = ½ inch
for a person to walk through to access the files can Average annual inpatient discharges = 10,200
be used. A common variation is compressible fil-
ing units, where there is not an aisle between each The following demonstrates how these statistics
shelving unit but instead one or two aisles while are used to estimate the number of shelving units
the rest of the units are collapsed together. These to store one year of health records.
AB103118_Ch03.indd 74 2/11/2020 12:18:35 PM

1. Determine the linear inch capacity of each photographic process that reduces an original paper
shelving unit. document into a small static image on film. Micro-
36 inches per shelf x 8 shelves per unit = 288 film has been used for decades by healthcare facili-
inches per shelving unit ties and works well for inactive or infrequently used
2. Determine the linear filing inches needed health records. A photo image is taken of each page
for the volume of records. of the health record and stored as a small negative.
10,200 average annual inpatient discharges A microfilm viewer is required to read the image.
x ½ inch average record thickness = 5,100 The following are the different formats:
inches required to store one year of inpatient ●● Roll microfilm. The microfilm images are
discharge records stored on a long roll of film. Each roll can
3. Determine the number of shelving units store thousands of images for hundreds of
required by dividing the required filing space patients. The major problem with this format
n.
by the shelving unit linear inch capacity. is that patient encounters can be stored on
tio
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5,100/288 = 17.7 = 18 shelving units multiple rolls, making retrieval difficult.
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ss
●● Jacket microfilm. A roll of microfilm is cut
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Since it is impossible to purchase a part of a
and inserted into four-by-six-inch jackets
en
shelving unit, the number of shelving units required
em
with sleeves. Multiple jackets containing all
should always be rounded up to a whole number.
ag
episodes of care that have been microfilmed
This example only included inpatient discharges
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can be filed together to maintain the unit-
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for simplicity; however, outpatient health records
record. The same type of filing systems that
n
would also have to be considered. io
at
apply to paper records can be used.
m
In vertical and lateral filing cabinets, open

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Microfiche. This format is a copy of the jacket

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●●
shelves, or compressible filing units, file folders
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are used to hold paper health records. File fold- microfilm. Microfiche is the same size as the
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microfilm jacket. Some facilities use micro-

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ers used for health records are usually purchased

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in one of two standard weights or thicknesses—11 fiche rather than allow the original jacket
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microfilm outside of the HIM department

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points and 14 points—although the weight may

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(for example, microfiche would be sent to

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be as much as 20 points. The higher the points,

the more durable the file folder. The amount of fil- the nursing unit for patient care).
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ing and retrieval activity will impact the decision. Inactive records can be stored off-site and copied
by
Typically, side tabs are used for health records, on microfilm. The healthcare organization would
20
20
but top tabs may be used in lateral shelving units. define when a health record becomes inactive. The
©
Two-pronged record fasteners should be placed at off-site location may be under the control of the
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the top or sides of the file folder to hold the health healthcare organization or a commercial company
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record forms in place. that stores and retrieves the organization’s health
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File folders should be color coded for easy fil- records for a fee. The healthcare organization must
ing and retrieval. For example, the tab on the file meet privacy and security regulations in terms of
folder has a label that displays a single digit of storage of health records. The vendor must be able
the health record number in a specific color. This to protect the health records from fire, pests, bur-
makes it easy to identify misfiled records. For ex- glary, and other hazards. The commercial vendor
ample, a yellow label would stand out in a row of must be able to return the records to the healthcare
green and red. Typically, the file folders are pur- organization within a predetermined time. The
chased with the color-coding already applied, but health records can be faxed, scanned, and emailed,
labels can be applied manually. or hand-delivered to the healthcare organization.
Paper health records require a great deal of space. Image-based storage is used when the document
One way to reduce the amount of space required is scanned and storing it digitally on hard drives,
is to microfilm the health record, which is a CD, or another storage media. The file formats
AB103118_Ch03.indd 75 2/11/2020 12:18:35 PM

also vary but are typically picture file formats help ensure the accessibility and completeness of
such as .tif or .jpg. The advantage of image-based the health record. When the quality of the health
storage over microfilm is that each document can record is not maintained, patient care suffers due to
be indexed or identified by patient or document missing, inaccurate, or incomplete information and
type. The image itself cannot be searched but the it also impacts billing, research, and other purposes.
indexed information is used to retrieve patient in- Record processing includes the following processes:
formation. Retrieval of the images with a few key-
strokes is a much quicker method than microfilm ●● Admission and Discharge Record Recon-
retrieval. ciliation for Paper-Based Records When a
patient is admitted to the healthcare organ-
Retrieval and Tracking Systems for Paper-Based ization, a search of the MPI is performed
Records? Health records must be accessible to to identify if the patient has been at the
healthcare organization before. If so, then
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authorized users. A common way of tracking the
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location of a health record is the outguide. The out- the paper health record(s) from the previous
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guide identifies where the health record is located encounters will be made available for patient
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and when it was removed. It is generally made care. Once the patient is discharged from the
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healthcare organization, the health record is
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of colored vinyl with two plastic pockets and it is
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placed in the shelving unit where the health rec- taken to the HIM department for processing.
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ord should be. The outguide is approximately the The first task is to ensure all health records
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have been received. This process is known as
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size of the health record. The larger plastic pocket
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can hold documentation that needs to be filed in record reconciliation.
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the health record, known as loose material, which Record Assembly Function for Paper-
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includes dictated reports, reports not filed on the Based Records Assembly is the process of
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nursing unit, and such. The small pocket can be ensuring each page in the health record is
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used to hold a slip of paper that tells where the rec- organized in a standardized format, which
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ord has been moved to and when it was checked out. varies by healthcare organization. During
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Traditionally, when a patient care area or other the assembly process each page should be
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department in the healthcare organization needs reviewed to ensure all the pages belong to
a health record, they submit a requisition, or re- the same patient and same encounter.
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quest, for the health record. The requisition tells

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●● Analysis for Paper-Based Records Analysis,

the HIM department the name, health record
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or review, of the health record is performed

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number, date of request, name of requester, and by HIM department personnel to determine
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where the health record needs to be delivered. The the completeness of the health record. Two
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requisition can be handwritten or be generated by types of analysis should be performed—

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an information system. qualitative and quantitative.

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Today, automated systems frequently create the

Qualitative analysis is monitoring the quality
requisition and replace the outguide. In an automat-
ed chart tracking system, the computer keeps upof the documentation. This is a collaborative effort
among the HIM department, risk management,
with the location of the health record by “checking
healthcare providers, and others. While the physi-
out” the health record to the nursing unit or other
cians must review the quality of physician documen-
location. Because of this, an outguide is not needed
tation, nurses review nurse documentation, and
to record the location of the health record but may
so forth, HIM professionals can review legibility,
still be used to hold the documents to be filed.
timeliness of documentation, use of approved ab-
Record Processing of Paper-Based Records breviations, and other documentation standards.
Record processing ensures health records are Quantitative analysis is a review of the health
organized and meet standards. These functions record to determine if there are any missing r eports,
AB103118_Ch03.indd 76 2/11/2020 12:18:35 PM

forms, or signatures. This analysis can be performed a missing document or asking the physician or
by concurrent review—in an ongoing manner other healthcare provider to either sign or com-
while the patient is still in the healthcare organiza- plete a document. The specific analysis performed
tion. It can also be reviewed after discharge from depends on the medical staff bylaws, rules, and
the healthcare organization, known as retrospective regulations, as well as state licensing and accredi-
review. The review involves the following: tation requirements.
●● All forms and reports contain correct patient
identification (name, health record number, Monitoring Completion of Paper-Based Records
encounter number, and date of service) Physicians and other practitioners are notified
when they have incomplete health records requir-
●● All forms and reports are present
ing their attention. They usually come to the HIM
●● Reports requiring signatures are signed
department to complete the necessary documen-
n.
The healthcare organization would base their re- tation in the health record. The health records are
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view on accreditation standards, state licensure, and then reanalyzed to ensure everything has been
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other standards. When a document or signature is completed. If no deficiencies are identified, the de-
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missing, a deficiency slip is created. The deficiency ficiency slip is removed, and the health record is
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slip identifies the pertinent document and what filed away in the permanent file. If a health record
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needs to be done (dictated, completed, and signed), remains incomplete for a specified number of days
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and is often created by a computer system. An ex- as defined in the medical staff rules and regula-
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ample of a deficiency slip is shown in figure 3.4. tions, the record is considered a delinquent record.
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When a deficiency is identified in the health rec- io
The specific number of days varies by healthcare
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organization but is generally 15 to 30 days.
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ord, it must be corrected. This may require locating

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Figure 3.4 Sample deficiency slip

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Physician/Practitioner’s Name:
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Health Record Number:

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Patient’s Name:
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Discharge Date:
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Analyzed by:
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Date:
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Signatures required Dictation required Missing reports

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History History History

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Physical Physical Physical

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Consultation Consultation Consultation

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Operative report Operative report Operative report

Discharge summary Discharge summary Discharge summary
Radiology report
Other Other Pathology report
Progress notes
Other
Source: Cerrato and Roberts 2012.
AB103118_Ch03.indd 77 2/11/2020 12:18:36 PM

Handling Corrections and Addendums in Paper- ●● For clinical forms, patient identification
Based Records Occasionally, health records must information (name, health record number,
be corrected, amended, or deleted. There are a num- billing number, physician name and number,
ber of reasons for this. Information may be written date of birth, admission date, and room
in the wrong patient’s health record, information number) should appear on every page.
may have been omitted, or an error may have been ●● For clinical forms, a signature line should
made in documentation. Policies must be in place to appear at the bottom and there should be no
ensure the integrity of the health record. question about what has been authenticated.
Corrections to the health record should be made If initials are used, space also should be
by drawing a single line through the erroneous in- provided for the full name and title so that
formation and writing the word “error” above the each set of initials is identified.
mistake. The practitioner should sign, date, and ●● Data-entry methodology should be
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time the correction. An addendum is additional considered when the information is to be
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information provided in the health record. The ad-
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keyed into a computer. The order of the form
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dendum should be dated the day it was written—
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should mirror the data-entry order to ensure
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not the date it is referencing. It should be signed, the information is entered consistently.
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and the time of entry should be recorded. An
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●● Optical character reader codes and bar codes
amendment is a clarification made to healthcare
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should be printed in the upper left-hand
documentation after the original document has
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corner of the form when imaging the health
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been signed. It should be dated, timed, and signed.
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record is a possibility.
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A standard of 8.5 by 11 inches is the best size
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Forms Design, Development, and Control for
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for a document.
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Paper-Based Records Forms should be de-

Form colors should be black ink on white
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signed using appropriate form design principles
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that will enhance the documentation on the form. paper. If color coding is desired, a strip of
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color along one margin is the best option.

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The form must meet the needs of the end user,

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Documents that contain punched holes

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which means it should be easy to use and include ●●

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all necessary data. should have a margin of at least 3/4 inch.

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The purpose of the form should be identified All other margins should be at least 3/8-inch
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before development of the form begins to ensure wide.

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the appropriate data are included; and the form ●● Vertical and horizontal lines assist the user
20
should not duplicate one that is already in use. in completing and reviewing the form. Bold
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Users should be involved in development of the lines should be used to draw the reader’s
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form to ensure their needs are met. Effective form

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eye to an important field.

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design principles include the following. Sufficient space should be provided to

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●●
●● All forms should contain a unique identify- complete the entry (for example, 1/16
ing number for positive identification and inch for typed letters and 1/3 inch for
inventory control. handwritten entries).
●● Each form should include original and ●● Titles for boxes and fields should be located
revised dates for the tracking and purging of in the top left-hand corner of the box or field.
obsolete forms. ●● Paper ranging from 20 to 24 pounds in
●● Each form should have a concise title that weight is recommended for use in copiers,
clearly identifies the form’s purpose. scanners, and fax machines.
●● The healthcare organization’s name and logo ●● Type size should be no smaller than 9 points
should appear on each page of the form, for lowercase letters and 10 points for upper-
preferably in the same location on each. case letters (AHIMA 1997).
AB103118_Ch03.indd 78 2/11/2020 12:18:36 PM

When a document management system is used, ●● Establishing a testing and evaluation plan.
form design is critical as the color in both the paper New and revised forms should be tested
and the ink can negatively impact the quality of prior to their implementation to ensure data
the image and should be eliminated or reduced. elements are not missing and that there is
Forms that will be scanned should have a bar code enough space to write.
imprinted on them allowing the automatic index- ●● Checking the quality of new forms. A process
ing into the health record. should be in place to guarantee that the
Every healthcare organization should have a clini- printed forms were printed correctly.
cal forms committee to establish standards for design ●● Systematizing storage, inventory, and
and to approve new and revised forms. The commit-
distribution. There must be a process to store
tee should also have oversight of computer screens
and distribute the forms where and when
and other data capture tools. The committee should
they are needed.
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be comprised of users of health information and
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include representatives from the following areas:
●● Establishing a forms database. An electronic
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database should be used to store and
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●● HIM facilitate updating forms.
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Medical staff
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●● Nursing staff Quality Control Functions in Paper-Based Systems:
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There must be processes in place to safeguard the
Purchasing
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●●
quality of analysis and forms design. Each func-
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●● Information services
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tion should have its own acceptable level of per-
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Performance improvement
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●●
formance and monitoring should be performed to
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Support or ancillary departments confirm the standards are met. If not, corrective ac-
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Forms vendor representatives tions should be taken. See chapter 18, Performance
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●●
Improvement, for more on quality improvement.

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Representatives from the area that will use the

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Several components of storage and retrieval are

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form should attend the committee meeting to monitored. Managers monitor misfiles, timeliness
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explain the form and the need for it.

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of storage and retrieval to calculate filing accuracy,

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Without oversight the number of forms can be- and timeliness rates. Examples of standards include
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come overwhelming to manage and there can be

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the following:
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duplication. A forms control program includes the

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following: ●● An average of 50 health records will be filed

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in an hour
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●● Establishing standards. Written standards and

Records for the emergency department will
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●●
guidelines should ensure that effective forms
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be retrieved within 10 minutes of the request

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design principles, as previously discussed, are

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Loose materials will be filed in either the

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used. These standards should be recorded in a ●●
forms manual. Standards are fixed rules that health record or the outguide pocket within
must be followed. A guideline provides gen- 24 hours of receipt in the HIM department
eral direction about the design of the form. To complete health records in a paper media,
●● Establishing a number and tracking system. As the physician must come to the HIM department
stated earlier, a unique number should be to dictate, sign, or otherwise complete the health
assigned to each form. There should be a record. If health records are unavailable to the
master form index and a copy of all forms physician when he or she tries to complete the
should be maintained. The master form health record, the completion of the health record
index should include the title, number, is delayed. The manager monitors the number of
origination date, revision dates, purpose, health records not available to physicians, usually
and legal requirements. weekly.
AB103118_Ch03.indd 79 2/11/2020 12:18:36 PM


1. Identify the microfilm format that is inefficient when retrieving multiple admissions for a patient.
a. Roll
b. Jacket
c. Microfiche
d. Both roll and jacket
2. The decision was made to choose a filing system that distributes health records evenly throughout the filing system.
This is known as:
a. Alphanumeric
n.
b. Alphabetic
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c. Straight numeric
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d. Terminal digit
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3. _____ is used to assign weights to potential duplicate health records.
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a. Rules-based algorithm
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b. Deterministic algorithm
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c. Probabilistic algorithm
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d. Overlays
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4. Form design standards should include: n
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a. Using color to separate the various sections
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b. Using colored paper

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c. Using 8 1/2 by 13-inch paper

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d. Assigning a unique identifier

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5. Differentiate between qualitative analysis and quantitative analysis.

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a. Qualitative analysis looks at the quality of documentation and quantitative analysis looks for the presence of
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documents or signatures.
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b. Quantitative analysis looks at the quality of documentation and qualitative analysis looks for the presence of
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c. Qualitative analysis looks at the documentation standards and quantitative analysis looks for the presence of
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d. Quantitative analysis looks for duplicates, overlays, and overlaps; qualitative analysis looks for the presence of
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6. The forms design committee:

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a. Provides oversight for the development, review, and control of forms and computer screens
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b. Is responsible for the EHR implementation and maintenance

c. Is always a subcommittee of the quality improvement committee
d. Is an optional function for the HIM department
7. In a paper-based system, individual health records are organized in a standardized order in which of the following
processes?
a. Retrieval
b. Assembly
c. Analysis
d. Reordering
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8. Extracting data from a health record and entering it into an information system is known as:
a. Assembly
b. Indexing
c. Abstracting
d. Coding
9. Two patients were given the same health record number. This is an example of a(n):
a. Overlap
b. Overlay
c. Duplicate
d. Purge
10. The physician did not complete the health record in the time frame required by the medical staff rules and regulations.
These records are known as:
a. Suspended
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b. Delinquent
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c. Loose
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d. Default
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Record Storage and Retrieval in an Electronic documents, they may receive papers from the
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patient or other sources. These loose reports are
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The functions of the HIM department have changed scanned and indexed for inclusion in the EHR. In-
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dramatically with the introduction of the EHR. dexing is the linking of patient name, health rec-
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The EHR is an electronic record of health-related ord number, document type, and other identifying
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information on an individual that conforms to na- information to the scanned document.

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tionally recognized interoperability standards and Record completion in the EHR is performed via
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computer so healthcare professionals can com-

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that can be created, managed, and consulted by

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plete them from any accessible location. An elec-

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authorized clinicians and staff across more than one

healthcare organization. Because of the changes, the tronic work queue, or workflow, allows the health
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paper health record is gradually being eliminated. record to be routed to all healthcare profession-
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als who have deficiencies so that they can access,

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Record Filing and Tracking of EHRs Filing of complete, and authenticate the health record. The
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health records is significantly reduced or even work queue is also used to route the health rec-
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ord to HIM for processing. With a document man-

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eliminated in the EHR environment. As more

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agement system, one function does not have to be

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data are captured directly into the EHR, there is

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no need for paper or the storage of paper-based completed before the next one, so the health rec-
records. The EHR can track who has access to a ord is available for all functions. For example, the
record through the audit trail. An audit trail is a health record does not have to be analyzed before
chronological set of computerized records that it is coded. Also, if coding cannot be performed for
provides evidence of information system activity some reason, workflow will reroute the health rec-
(log-ins and log-outs, file accesses) used to deter- ord to coding once the problem has been resolved.
mine security violations. Audit logs are covered in
more detail in chapter 10, Data Security. Version Control of EHRs The health record may
have multiple versions of the same document; for
Record Processing of EHRs In the EHR, the as- example, a signed and unsigned copy of a docu-
sembly process is eliminated; however, even if ment. Additional versions are also created when
the healthcare organization does not use paper addendums, corrections, or amendments are made
AB103118_Ch03.indd 81 2/11/2020 12:18:36 PM

to original documents. To address the issues that Management and Integration of Digital Dicta-
result from having multiple versions of the same tion, Transcription, and Voice Recognition A
document, policies and procedures addressing common method to capture dictation in the EHR
version control must be developed. Version con- is digital dictation. The physician or other health-
trol identifies which version(s) of the documents care provider dictates a health report and the tran-
is available to the user. All versions must be main- scriptionist types what is said into an electronic,
tained but access to all except the current version or digital, format. These reports are electronically
should be controlled so that there is no confusion transmitted into the EHR where the physician can
about which version is correct. sign the document.
With voice recognition technology, also called
Management of Free Text in EHRs Free-text data continuous speech recognition or continuous speech
are the unstructured narrative data that are the re- technology, a computer captures the dictation and
n.
sult of a person typing data into an information sys- converts what is said directly into text and no tran-
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tem. Free-text data are undefined, unlimited, and scriptionist is needed. The transcriptionist becomes
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unstructured, meaning that the typist can type any- an editor and therefore focuses on data quality. More
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thing into the field or document. The amount of free-
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specifically, natural language processing (NLP) is a
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text data in the EHR should be limited because the technology that converts human language (struc-
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ability to manipulate data is diminished with its use. tured or unstructured) into data that can be trans-
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For example, terms used in structured data are con- lated then manipulated by computer systems. It is
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sistent, whereas synonyms may be used in free-text the software used for speech recognition.
data, making it more difficult to retrieve. The pre- n
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ferred data type is structured text where you point Reconciliation Processes for EHRs As in the
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and click or otherwise select the data. For example, paper-record environment, the HIM professional
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you would have two choices with the data element must verify that there is a complete health rec-
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gender: male and female. The user simply points and ord for every episode of care, including both in-
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clicks the appropriate choice rather than typing it in. patients and outpatients. HIM professionals also
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In the EHR, the user can copy and paste free text need to verify documents sent to the EHR from a
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from one patient or patient encounter to another. transcription system and other information sys-
This practice is dangerous as inaccurate informa- tems arrive in the EHR as expected. For example,
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tion can easily be copied. Specific risks to documen- all patients admitted to the hospital should have
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tation integrity of using copy functionality include an EHR created for that admission.
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the following:
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Inaccurate or outdated information Managing Other Electronic Documentation

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Many documentation sources not previously

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●● Redundant information, which makes it

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stored in the paper health record are included in

difficult to identify the current information
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the electronic health record. Examples of these

●● Inability to identify the author or intent of documentation sources include email, voicemail,
documentation audio, monitoring strips, images (radiology, pa-
●● Inability to identify when the documentation thology), video (heart catheterization), and moni-
was first created toring (fetal, electrocardiogram).
●● Propagation of false information Email is being used in healthcare to share pa-
●● Internally inconsistent progress notes tient information. Policies and procedures need to
be in place to address privacy and security as well
●● Unnecessarily lengthy progress notes
as the creation, storage, and maintenance of the
(AHIMA 2014, 4)
messages. The email management system should
Policies and procedures need to be in place to allow emails containing patient information to be
reduce some of the risks. stored in the EHR.
AB103118_Ch03.indd 82 2/11/2020 12:18:36 PM

Voicemail containing patient information can made the change along with the date and time the
also be included in the EHR. The message should change was made. If the change impacts data sent
include the provider and patient identification, to other information systems, then the change must
date and time of message, and the date and time be made in the other information systems as well.
of message into the EHR.
Quality Control Functions for EHRs Data are
Handling Materials from Other Healthcare Organ- collected in several ways: scanning, data entry, bar
izations When materials are received from other codes, and transfer of data from other information
healthcare organizations such as paper health re- systems. The information system should have meas-
cords or diagnostic images, they should be handled ures in place to control the data entered into the EHR.
per organizational policy; these typically are added For example, when entering fields such as the social
to the health records. Some states have laws that ad- security number (SSN), an input mask should be
n.
dress these external health records. If state law does used. An input mask shows the format in which the
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not address health records from other healthcare data will be displayed. Entering the SSN, the user
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facilities, then the healthcare organization attorney should be able to input the number 123456789 and
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should be consulted regarding whether to include it will appear in the system as 123-45-6789. This pre-
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them in the health record (AHIMA 2011). vents one user from entering the SSN as 123456789
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and the other as 123-45-6789. A drop-down box that
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Search, Retrieval, and Manipulation Functions of is pre-populated with acceptable entries is another
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EHRs One of the advantages of the EHR is the abil- way of controlling what is entered. For example, a
ity to search, retrieve, and manipulate health data n
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drop-down box can be used for states as there are
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quickly and easily. This information can be used for a finite number of states as choices. A checkbox can
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patient care, research, and monitoring patient care. be used for yes or no type entries. Radio buttons al-
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In the paper health record, each patient record had low the user to select from a small number of choices
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to be reviewed individually and data abstracted such as male and female in the gender field.
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into a database or another data collection tool. In Best practices for designing or evaluating the
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the EHR, data mining can be performed. Data min- entry screens are as follows. All these features help
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ing is the process of extracting and analyzing large ensure the quality of documentation and therefore
volumes of data from a database for the purpose of the quality of patient care.
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identifying hidden and sometimes subtle relation-

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ships or patterns and using those relationships to General guidelines

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predict behaviors. Data mining could be used to de-

Clear navigational buttons that direct the
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termine why one physician’s outcomes are better or
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user to the next step in the documentation

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which medication is the most effective.

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process and buttons to move from one

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screen to another
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Handling Amendments and Corrections in EHRs

Policies and procedures need to be in place to ad-
●● Clear labeling of buttons and data fields
dress amendments and corrections in the EHR. ●● Limited use of abbreviations on buttons and
Once a document is authenticated, the document data fields
should be locked to prevent changes. If an amend- ●● Consistent location on the screen of
ment, addendum, or deletion needs to be made, the navigation buttons
document would then need to be unlocked for edit- ●● Built-in alerts to notify the user of possible errors
ing. Not everyone should have the ability to unlock
●● Availability of references at the appropriate
the documents; the organizational policies should
data field
state who has the rights to unlock the d ocument
(Brown et al. 2012). The EHR should retain the pre- ●● Prompt for more information where appropriate
vious version of the document and identify who ●● Checks for warning signs or errors
AB103118_Ch03.indd 83 2/11/2020 12:18:36 PM

Navigation design On-screen list boxes

Drop-down list boxes
●● Ensure all controls are clear and placed in an
intuitive location on the screen Combo boxes
●● Use neutral colors and limit highlighting, Data validation
flashing, and so forth to reduce eye fatigue ●● Perform a completeness check to
●● Limit choices and label commands ensure all the required data have been
●● Provide undo buttons to make mistakes easy entered
to override ●● Perform a format check to ensure the data
●● Use consistent grammar and terminology are the right type (numeric, alphabetic, and
●● Provide a confirmation message for any so on)
critical function (such as deleting a file) Perform a range check to ensure the numeric
n.
●●
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Identify required fields data are in the correct range such as
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appropriate range for temperature
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Input design
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●● Perform a consistency check to ensure the
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●● Simplify data collection combinations of data are correct
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Sequence data input to follow workflow Perform a database check to compare data
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●● ●●
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●● Provide a title for each screen against a database or file to ensure data are
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correct as entered
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●● Minimize keystrokes by using pop-up menus io
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Use text-specific boxes to enter text
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Output design
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Use number-specific boxes to enter numbers

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●●
●● Minimize the number of clicks needed to
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●● Use a selection box to allow the user to select reach data or a specific screen
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a value from a predefined list:

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●● Combine data into a single, organized

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Check boxes (used for multiple selections) menu to eliminate layers of screens
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Radio buttons (used for single selections) (Williams 2006)

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Identification Systems
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Identification systems link the patient serial-unit numbering systems, and alphabetic filing
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to the health record. The health record number is a systems. In the EHR, identifiers such as the health
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key data element in the MPI as it is a unique identi- record number, patient name, and more are used.
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fier for the patient. It is used to look up the patient’s

health record number. The health record number is Paper Health Record – Serial
typically assigned during the patient’s initial reg- Numbering System
istration encounter at the healthcare organization. In the serial numbering system, a patient is issued
The social security number should not be used for a unique numeric identifier for every encounter at
the health record due to confidentiality concerns. the healthcare organization. If a patient is admitted
There are several ways to identify records in a to the healthcare organization five times, he or she
paper-based health record system. These include will have five different health record numbers. The
numeric, alphabetic, and alphanumeric systems. For documentation for each of the encounters is filed in
numeric systems to work, the health record number the health record for that encounter so the informa-
must be accessed in the MPI before the health record tion is filed separately, and all health records must
can be retrieved. The identification systems are be retrieved to view the complete health informa-
serial numbering systems, unit numbering systems, tion. The serial numbering system is inefficient and
AB103118_Ch03.indd 84 2/11/2020 12:18:36 PM

more costly because of the extra costs to manage the person in the EHR, so it is important to double-
folders as well as to purchase the folders. check to ensure the correct person is retrieved.
Paper Health Record – Unit Statistics and Research

Numbering System Statistics is a branch of mathematics concerned with
The unit numbering system is commonly used in collecting, organizing, summarizing, and analyzing
large healthcare organizations because it does not data. Traditionally statistics utilized by HIM related
have many of the inefficiencies of the serial num- to patient volume including the number of admis-
bering system. The patient is issued a health rec- sions, number of discharges, and length of stay as
ord number at the first encounter and that number manual data collection was time consuming. With
is used for all subsequent encounters. This system the implementation of the EHR, a healthcare organ-
consolidates all the information on the patient in ization can easily generate a wide range of statistics.
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one location and is therefore more efficient than These statistics can be used to manage the business
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the serial numbering system. of the healthcare organization as well as to evaluate
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and improve the quality of the care provided.
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Paper Health Record – Serial-Unit Research is an inquiry process aimed at discover-
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Numbering System ing new information about a subject or revising old
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information. Research utilizes statistics and other
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The serial-unit numbering system is a combina-
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tion of the serial and unit numbering systems. The methods to evaluate new medical treatments, new
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patient is issued a new health record number with drugs, best practices, and so forth. HIM profession-
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als can assist in research through data collection,
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each encounter, but all the documentation is moved
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from the last number to the new number. It would generating statistics, and data analysis. For more on
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statistics and research, refer to chapter 13, Research

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have many of the same advantages and disadvan-

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tages as the serial and unit numbering systems. and Data Analysis, and chapter 14, Healthcare Statistics.
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Paper Health Record – Alphabetic Registries

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Filing System A registry is a collection of care information re-

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The alphabetic filing system is typically used by lated to a specific disease, condition, or procedure
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small clinics and physician offices. The folders are that makes health record information available
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filed alphabetically by the patient’s last name. If for analysis and comparison. Common registries
20
include cancer, trauma, birth defects, and organ

20
there is more than one person with the same last

transplant. These registries collect data, and gen-
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name, then the first and middle initial are used.

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The disadvantage of this system is that more than erate reports, among other functions. For example,
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one person may have the same or similar name. the cancer registry evaluates life expectancy, num-
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bers of cases, and much more. Chapter 7, Secondary

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Electronic Health Record Data Sources, discusses registries in more detail.

The unit numbering system is the most common
system used in the EHR. The advantage of the Birth and Death Certificates
EHR is that identifiers other than the health record Today, information systems are used to collect and
number—such as the patient name and patient
share the data in birth and death certificates. Some,
account number—can be used to retrieve the but not all, HIM departments are involved in collect-
information. The patient account number is a num- ing and reporting that data. The birth certificate data
ber assigned by a healthcare organization for bill- collected include data about the birth, the pregnancy,
ing purposes that is unique to a particular episode of the parents, and more. Death certificates collect data
care; a new account number is assigned each time on the patient, the time of death, the cause of death,
the patient receives care or services at the health- and more. Chapter 14, Healthcare Statistics, discusses
care organization. It is easy to select the wrong birth and death certifications, in more detail.
AB103118_Ch03.indd 85 2/11/2020 12:18:36 PM

HIM Interdepartmental Relationships

The HIM department cannot manage in- encounters. In a paper-based environment,
formation in isolation. The HIM department must the records are delivered by the HIM staff or
work with many departments to ensure they have picked up by the patient care areas and then
the information that they need to perform their the records are returned once they are no
jobs. These departments include the following: longer needed. The departments may send
loose reports to the HIM department for
●● Patient registration. The health record filing if the health record has already been
typically begins in patient registration returned.
with the capture of patient demographic ●● Information systems. The interaction between
information. This information is entered
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the HIM department and the information
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into the MPI as discussed earlier. The health systems department will continue to
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record is assigned to new patients during increase as the EHR becomes more and
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the patient registration process. The HIM
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more important to the organization. The
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department works with patient registration HIM staff works with the information
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to ensure the quality of the data collected systems staff to plan, implement, and
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and to correct duplicate and other issues maintain information systems that
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with the MPI.
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impact the health record and other
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●● Billing department (also known as patient io
systems related to HIM. The information
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financial services). The billing department systems department also assists the HIM
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uses the codes assigned and data abstracted department with technical issues related to
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by the coders as part of the billing process. computers, printers, and other hardware.
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Because of this, the billing department For more information, see chapter 11, Health
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cannot perform their responsibilities until Information Systems.

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the HIM department completes theirs. The Quality management. The quality
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●●
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two departments must work together to management department depends on the

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ensure that all the information required for health record to complete their functions.
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billing is available.
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They need health records for committee

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●● Patient care departments. The HIM meetings, audits, and outcome monitoring.
20
department works closely with nursing HIM staff may collect some of the data
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units, the emergency department, and other needed, provide the records, generate
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patient care areas to ensure they have access statistics, write reports, mine data, or assist
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to the patient’s health records from previous in other ways.

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Virtual HIM
Much of the work of the HIM de- include coding and transcription, but others can
partment can be performed remotely due to the be performed remotely as well. The manager
implementation of the EHR. Some healthcare must ensure the employees are able to work in-
corporations have centralized their HIM services dependently so that productivity standards can
into a single location. Many healthcare facilities still be met. Chapter 1, Health Information Manage-
have employees who work at home. Common ment Profession, discusses the future of the HIM
functions that can be performed from home profession in more detail.
AB103118_Ch03.indd 86 2/11/2020 12:18:36 PM

HIM Information Systems

The HIM department cannot perform the diagnostic-related group or another group-
the functions of the department efficiently without ing. (See chapter 15, Revenue Management and Re-
the use of information systems. These information imbursement, for specifics on diagnostic-related
systems assist in health record processing, provide groups.) Some healthcare organizations are now
access to patient information, and more. Some of using computer-assisted coding (CAC), which
these information systems are becoming more and uses EHR data to assign the codes. With comput-
more important with the implementation of the er-assisted coding, the HIM professional monitors
EHR while others will be phased out completely the quality of the codes assigned by the informa-
as the EHR makes them obsolete. The information tion system rather than assigning the code.
systems include disclosure of health information,
Registries
n.
chart tracking, coding, registries, billing, quality
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improvement, and electronic health record.
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As stated earlier in this chapter, registry is a da-
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tabase on specific diseases and procedures; for
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Disclosure of Health Information
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example, cancer and transplant registries are com-
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The systems that track the disclosure of health mon ones. In the registry, data regarding the diag-
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information track requests for information from nosis, procedure, or other concept is captured and
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patients, insurance companies, and other request- can be used for research, patient care, and quality
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ers. HIM staff enters basic information from the monitoring. The data captured and functionality
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request such as the patient name, health record varies by the type of registry. Chapter 7, Secondary
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number, and who is requesting the health record. Data Sources, discusses registries in more detail.
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Once the patient information is released, the staff

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Billing
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records what information is released and the date.

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The information system can bill requesters for the

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The HIM department may or may not directly

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copies of records, when appropriate. It can moni- use the billing system. The encoder and grouper
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tor productivity, turnaround time, and more.

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may submit the codes and other data directly to

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the billing system or it may be entered manually

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Chart Tracking
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by the coder. The HIM department does not create

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This information system currently tracks the lo- the bill but rather provides information that is in-
20
cation of the health record but will eventually cluded on the bill.
20
©
become obsolete when paper health records are

Quality Improvement
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eliminated. The chart tracking information sys-

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tem records who checked it out, where it went, Quality improvement systems go by many dif-
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and how long it has been checked out. It also referent names and perform a number of functions.
cords when the health record returns to the HIM Characteristically, they are repositories of data
department. that are used to monitor trends, generate statistics,
monitor outcomes, and improve the quality of the
Coding documentation in the EHR. The data may be col-
lected from the EHR or be manually entered by
Coders use two specialty information systems—
HIM professionals.
encoders and groupers. An encoder assigns the
diagnosis and procedure codes. The encoder as-
sists in the coding process as it reminds coders Electronic Health Records
to check for important diagnoses and procedures The EHR utilizes several information systems to
and provides easy access to coding resources. The capture patient information. These source systems
grouper uses the codes assigned to determine supply the EHR with demographic information,
AB103118_Ch03.indd 87 2/11/2020 12:18:36 PM

test results, dictated reports, and more. The EHR an individual for himself or herself; a tool that in-
also has clinical decision support (CDS), which dividuals can use to collect, track, and share past
assists physicians and other users when making and current information about their health or the
decisions regarding medications, diagnoses, and health of someone in their care. The PHR pro-
such based on the information entered into the vides a way for a patient to be involved in his or
EHR. The EHR contains alerts and reminders to her healthcare. It is not the same as an EHR, but
notify the user of medication allergies, tests that rather is a subset of the information that is avail-
should be performed, immunizations due, and so able to and controlled by the patient. The patient
forth. Benefits of the EHR include reduction in ad- can add information to the PHR, such as over-the-
ministrative costs and improvement in quality of counter medications and self-administered blood
care. The healthcare organization becomes more glucose test results. The PHR is especially useful
efficient with the improved accessibility to health for patients with complex, chronic conditions. The
n.
information. healthcare provider or the insurance company
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may provide the PHR, or the patient may pur-
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Personal Health Records chase or subscribe to it from a commercial vendor.
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Refer to chapter 12, Healthcare Information, for ad-
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A personal health record (PHR) is an electronic or
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paper health record maintained and updated by ditional details.
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1. Identify the type of health record that is controlled by patients.

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a. Electronic health record

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b. Health record in any format

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c. Personal health record

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d. Certified health record

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2. Explain how amendments to the EHR are handled.

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a. Amendments are automatically appended to the original note. No additional signature is required.
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b. Amendments must be entered by the same person as the original note.
20
20
c. Amendments cannot be entered after 24 hours of the event.

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d. The amendment must have a separate signature, date, and time.
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3. Version control of documents in the EHR requires:

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a. The deletion of old versions and the retention of the most recent
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b. Policies and procedures to control which version(s) is displayed

c. Signed and unsigned documents not to be considered two versions
d. Previous versions to be accessible to administration only
4. The decision was made to not allow copying and pasting. Justification for this decision includes:
a. Reduction in the time required to document
b. Information system may not save data
c. Copying outdated information
d. The ease in identifying the author of the documentation
5. When I key in 10101963, the computer displays it as 10/10/1963. What enables this?
a. Toolkit
b. Input mask
c. Checkbox
d. Radio button
AB103118_Ch03.indd 88 2/11/2020 12:18:37 PM

Real-World Case 3.1

General Hospital knew they had issues be assigned while the cleanup process was going
with duplicate health records and needed to clean on. Once the training was complete, the consulting
up the master patient index (MPI) before the im- firm began cleaning up the MPI. The consultants re-
plementation date for the electronic health record viewed the potential duplicate health records and
(EHR) to get the best results. A consulting firm was merged the health records where appropriate. They
hired, and a review of the data confirmed this prob- ensured the health records were merged in other in-
lem when they identified over 3,000 potential dupli- formation systems used throughout the healthcare
cate health records issued over the past five years. organization. They provided documentation to Gen-
The hospital started the MPI cleanup process by eral Hospital showing which health records were
educating their patient registration staff on proper and were not duplicates based on their review. They
n.
search strategies, questions to ask the patient, the also provided statistics on which admission clerks
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importance of a unit health record, and other related created duplicate health records, and the depart-
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topics. This education was an important first step so ments (admissions, emergency department, outpa-
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that additional duplicate health records would not tient services and others) that created the duplicates.
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Real-World Case 3.2
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Yale New Haven Health received the New Haven Health was able to make significant
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2018 Grace Award from AHIMA. They received improvements such as reducing the errors in the
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this prestigious award for their efforts to improve MPI to less than two percent. They also central-
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the documentation in the health record, reducing ized their staff. HIM professionals were leaders
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errors in the MPI, and analyzing data from the in these initiatives. Their efforts allowed them to
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EHR. They were able to get patients involved in make good business decisions due to their empha-
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the management of their health information. Yale sis on the quality of data (AHIMA 2018).
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References
by
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20

©
Association. 2018. Grace W. Meyers Award. http:// Association. 1997. Practice brief: Developing
ht
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www.ahima.org/about/recognition. information capture tools. Journal of AHIMA 68(3):

yr
op
American Health Information Management supplement.

C
Association. 2014. Appropriate Use of the Copy and Brown, L., P. Komara, D. Warner, and L.A.
Paste Functionality in Electronic Health Records. Wiedemann. 2012. Amendments in the Electronic
http://bok.ahima.org/PdfView?oid=300306. Health Record Toolkit. http://bok.ahima.org/
American Health Information Management PdfView?oid=105672.
Association. 2017. Pocket Glossary of Health Information Cerrato, L.A. and J. Roberts. 2012. Health
Management and Technology, 5th ed. Chicago: AHIMA. Information Functions. Chapter 7 in Health
American Health Information Management Information Management Technology: An Applied
Association. 2011. Fundamentals of the legal health Approach, 4th ed. Edited by N.B. Sayles. Chicago:
record and designated record set. Journal of AHIMA AHIMA.
82(2):44–49. Huffman, E.K. 1994. Health Information Management.
American Health Information Management Berwyn, IL: Physician Record Co.
Association. 2010. Fundamentals for building a Williams, A. 2006. Design for better data: How
master patient index/enterprise master patient index software and users interact on screen matters to data
(updated). Journal of AHIMA. http://bok.ahima.org/ quality. Journal of AHIMA 77(2):56–60.
doc?oid=106227#.XSCh_Y8pCUk.
AB103118_Ch03.indd 89 2/11/2020 12:18:37 PM

AB103118_Ch03.indd 90
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©
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2/11/2020 12:18:37 PM
n.
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PART
Data Content, M
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Structures and
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Standards
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91
AB103118_Ch04.indd 91 2/11/2020 12:24:09 PM

AB103118_Ch04.indd 92
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©
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20
by
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2/11/2020 12:24:09 PM
Chapter
4
Health Record Content
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and Documentation
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•• Define documentation standards. •• Compare the documentation content of health

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•• Describe how medical staff bylaws, accreditation records within different healthcare settings
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entities, and state and federal regulations influence •• Evaluate the potential advantages and
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the documentation practice standards of healthcare disadvantages of different health record media
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provider organizations •• Describe the roles that various healthcare

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•• Articulate how documentation standards drive patient professionals play in health record
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safety and quality within the healthcare industry documentation

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•• Describe how the definition of a legal health •• Evaluate documentation to determine if it meets the
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record has changed as healthcare providers have general documentation guidelines

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more widely adopted electronic health record •• Justify the need for HIM professionals to be
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technologies involved in health record documentation

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Key Terms
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Accreditation Authentication Commission on Accreditation of

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Accreditation Association for Auto-authentication Rehabilitation Facilities (CARF)

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Ambulatory Healthcare Autopsy report Conditions for Coverage (CfC)

(AAAHC) Care area assessments Conditions of Participation (CoP)
Accreditation organizations (CAAs) Consultation report
Administrative data Care plan Core measures
Ambulatory surgery center/ Centers for Medicare and Medicaid Data quality
ambulatory surgical center Services (CMS) Deemed status
(ASC) Certification Discharge summary
Ancillary services Clinical data Documentation
Anesthesia report Clinical observations Documentation standards
93
93
AB103118_Ch04.indd 93 2/11/2020 12:24:10 PM

94 Part II Data Content, Structures and Standards
Document imaging Medical staff privileges Recovery room report

Healthcare Facilities Accreditation Medicare Access and CHIP Resident assessment instrument
Program (HFAP) Reauthorization Act (RAI)
History and physical (H&P) (MACRA) Source-oriented health record
Hybrid record Minimum Data Set Subjective, objective, assessment,
Integrated health record Operative report plan (SOAP)
Joint Commission Pathology report Standard
Legal health record Patient Driven Payment Model Standing orders
Licensure Physical examination Statute
Medical history Physician orders Template
Medical staff Problem-oriented health record Transfer record
Medical staff bylaws Progress notes Universal chart order
n.
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The saying “If it wasn’t documented, it wasn’t and planning. Complete and accurate health rec-
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done (or didn’t happen)” succinctly conveys ord documentation drives high-quality patient
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the level of importance all healthcare providers care as well as appropriate coding and claims
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should place on health record documentation. submission, resulting in appropriate reimburse-
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Documentation is the recording of pertinent ment. Data quality applies not only to health rec-
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healthcare findings, interventions, and respons- ord (clinical) information but also to billing and
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es to treatment as a business record and form of claims data, administrative and business data,
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communication among caregivers. Documenta- and disease registry data. Documentation must
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tion takes various forms within the health record. be complete and accurate, support quality ini-
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Examples of health record documentation tiatives, and meet accreditation requirements.

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include progress notes, laboratory test results, ra- Chapter 6, Data Management, will address data
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diology imaging reports, and operative reports, quality in more depth.

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all of which provide a complete medical picture When health record documentation is lack-
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of the patient. The health record centralizes doc- ing in accuracy, reliability, and effectiveness,
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umentation regarding a patient’s healthcare visit it may fail to appropriately describe the care
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and treatment history in an official, permanent, and treatment of the patient. This lack of data
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and recorded format. For thousands of years, quality can impact the quality of care the pa-
20
individuals have been documenting stories and tient receives. Poor documentation impacts the
20
events in written form to share and reshare with assessment and evaluation of the patient and
©
future generations. Healthcare documentation is the communication among healthcare provid-

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no exception. The health record, specifically the ers, results in medical errors, and contributes
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documentation maintained within it, has histori- to poor patient outcomes. Poor documentation
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cally allowed and presently enables the patient’s also impacts the accuracy of medical coding
healthcare providers to make well-informed con- due to potential improper code assignment,
current treatment decisions for the patient and resulting in inaccurate diagnosis and proce-
establishes a healthcare history for the patient for dure codes. Inaccurate coding impacts billing,
future reference. reimbursement, and claims submission for the
It is important not only that there is docu- care and treatment provided to the patient. If
mentation within the health record but that the poor-quality documentation affects the accu-
documentation itself is appropriate, accurate, racy of coding, billing, and claims submission,
reliable, and readily accessible. Data quality is then state and federal regulatory compliance
the reliability and effectiveness of data for its and accreditation standards of the healthcare
intended uses in operations, decision-making, organization can also be in jeopardy.
AB103118_Ch04.indd 94 2/11/2020 12:24:10 PM

Role of Documentation
Health record documentation plays of the patient is the starting point for the revenue
a variety of roles within the clinical healthcare cycle, which facilitates the coding and billing of
setting. Documentation is a communication tool the care and treatment. When the documentation
between and among healthcare providers. It al- is of the appropriate quality, it serves as proof
lows for continuity in the care and treatment of of care and services and demonstrates that docu-
the patient from one healthcare provider to the mentation standards are met (or not met). The
next and creates a permanent health record for next section will discuss the principles, codes
all future care of the patient. The documentation and beliefs, and guidelines related to documen-
that is generated during the care and treatment tation standards.
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Documentation Standards
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A standard is a set of principles, codes, ocumentation in a paper-based health record.
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beliefs, guidelines, and regulations that have been This belief is incorrect. In general, the standards
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vetted and agreed upon by an individual or a that traditionally applied to paper-based docu-
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group of individuals who are regarded as an au- mentation hold true for documentation generated
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thority on a particular subject matter. Standards and maintained within the EHR. As healthcare
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must be based on generally accepted rules of the providers have come to realize the great benefits
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healthcare industry. Within the context of health- of EHR technologies as they relate to documenta-
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care, documentation standards describe those tion quality and overall patient safety, those same
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principles, codes, beliefs, guidelines, and regu- technologies have also presented some challeng-
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lations that guide health record documentation. es. One example is the use of a template. A tem-
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Documentation standards dictate how healthcare plate is a pattern used in EHRs to capture data in a
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providers should document the treatment and ser- structured manner and specify the information to
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vices (rendered to the patient) within the health be collected. For example, a birth record template
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record. The basis for healthcare-related documen- would require data such as date of birth, time of
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tation standards is to promote healthcare quality birth, APGAR scores, length, weight, and so forth.
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and safety, as well as provide for optimized conti- It helps the care provider ensure key information
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nuity of care for the patient. As the health record is not forgotten. It also certifies that the data are
©
and health record documentation have become captured in a specific order and format. Whether
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more computer based, documentation standards the patient’s health record is electronic or paper-
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have become even more important, not only from based, accurate and appropriate documentation
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a clinical documentation standpoint but also from is key to meeting compliance standards—namely,
an organizational standpoint. How health record those for medical necessity and the justification for
documentation is used within the electronic health treating the patient.
record (EHR) has become a focus of many health
information management (HIM) professionals. Standards
When the EHR first began replacing traditional Over the years, documentation standards have be-
paper-based health records, a common belief was come more detailed and focused on patient care
that the standards addressing the documentation quality, appropriate reimbursement, and the pre-
contained within the EHR (covered in chapter 11, vention of fraud and abuse from a regulatory per-
Health Information Technologies) were somehow spective. The Centers for Medicare and Medicaid
different from those standards addressing the
Services (CMS) defines fraud as the intentional
AB103118_Ch04.indd 95 2/11/2020 12:24:10 PM

deception or misrepresentation that an individ- approved by the healthcare organization’s board

ual knows, or should know, to be false or does not of directors. They play an important role in docu-
believe to be true, knowing the deception could mentation standard mandates and development.
result in some unauthorized benefit to himself or Accreditation organizations measure the compli-
some other person(s) and abuse describes practices ance of the healthcare organization with the stan-
that either directly or indirectly result in unneces- dards developed by the accreditation organization.
sary costs to the Medicare Program (CMS 2017). Licensure organizations are the legal authority or
Abuse includes any practice that is not consistent formal permission from the authorities to carry out
with the goals of providing patients with services certain activities that require such permission. For
that are medically necessary, meet professionally example, a hospital cannot treat patients without
recognized standards, and are priced fairly. (See being licensed by the state. Federal and state reg-
chapter 16, Fraud and Abuse Compliance, for more ulatory agencies mandate the content, specifically
n.
discussion on fraud and abuse.) The application the breadth and depth of these bylaws, as well as
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of the standards varies depending upon the con- the application of the bylaws. Medical staff bylaws
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tent of the health record; whether the record is an vary slightly from one healthcare organization to
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inpatient, ambulatory, behavioral health, or phy- another as a result of differences in state laws and
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sician office record; and from where the standards the needs of individual healthcare organizations.
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originate. Sources for standards include insurance Before addressing medical staff bylaws, it is im-
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companies and payers, government regulatory portant to understand the function and responsi-
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agencies, licensing boards, accrediting bodies, bility of a healthcare organization’s medical staff.
healthcare organization policies and procedures, n
A healthcare organization’s medical staff is
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and healthcare provider organization medical staff a group of physicians and nonphysicians such
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bylaws. as nurse practitioners and physician assistants

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With the healthcare industry focusing on pa- who have medical staff privileges. Medical staff
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tient care quality, appropriate reimbursement, personnel go through a process that ensures the
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and the prevention of fraud and abuse, the goal physician or other healthcare professional has the
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of documentation standards is to ensure what is education and qualifications required to perform

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documented in the health record is complete and services and procedures in a healthcare organiza-
accurately reflects the treatment provided to the tion. The result is a specific list of services and pro-
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patient. This provides an inherent level of accept- cedures (medical staff privileges) that the medical
by
able quality so other healthcare providers have a staff member may perform at a particular health-
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20
clear and accurate understanding of the patient’s care provider organization. The medical staff by-
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condition and how the patient is responding to laws govern the business conduct, rights, and
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treatment. In addition, documentation standards responsibilities of the medical staff; medical staff
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drive appropriate healthcare reimbursement members must abide by the bylaws to practice in
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through accurate code capture during the reve- the healthcare organization. It is through the pro-
nue cycle process, reducing the chances that inac- cess of granting medical staff privileges and en-
curate or fraudulent claims are processed and forcing the medical staff bylaws that the overall
sent to commercial or governmental payers for quality of care and treatment provided to patients
reimbursement. is governed (Adelman 2012). Credentialing is the
process of reviewing and validating the qualifica-
Medical Staff Bylaws tions (degrees, licenses, and other credentials) of
A healthcare organization’s medical staff bylaws physicians and other licensed independent practi-
are the standards that govern the practice of medi- tioners for granting medical staff privileges to pro-
cal staff members. These medicals staff bylaws are vide patient care services (AAFP 2019).
typically voted upon by the organized medical staff A number of accrediting, licensing, and regula-
and the medical staff executive committee and tory entities drive the configuration of the medical
AB103118_Ch04.indd 96 2/11/2020 12:24:10 PM

staff and the content and application of the med- past and present illnesses, family history, social
ical staff bylaws of a healthcare organization. The history, and review of body systems, and must
Centers for Medicare and Medicaid Services be documented in the health record prior to any
(CMS) is the federal agency within the Department surgery or procedure requiring the patient to re-
of Health and Human Services (HHS) known for ceive anesthesia. If, however, the physical exam is
its operational oversight of the Medicare and Med- completed within the 30 days of a surgery or pro-
icaid programs. The Joint Commission also plays cedure, an updated exam must be documented
an important regulatory role in a healthcare orga- within 24 hours of admission and prior to the sur-
nization’s medical staff makeup and the content of gery or procedure. This updated exam must in-
the medical staff bylaws by establishing standards clude any changes in the patient’s condition since
for the medical staff bylaws. The Joint Commis- the time of the first exam (42 CFR 482.22(c)).
sion is a common accreditation organization for
Accreditation
n.
hospitals and other healthcare organizations. (The
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Joint Commission is covered in more detail later in Accreditation is a voluntary process of institutional
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this chapter.) or organizational review in which a quasi-independent
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Content required in medical staff bylaws in-
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body created for this purpose periodically evalu-
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cludes the healthcare provider organization’s pro- ates the quality of the entity’s work against
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cesses for self-governance and general oversight pre-established written criteria. CMS CoPs and
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obligations, due process rights as they relate to Conditions for Coverage (CfCs) ensure patient
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potential disciplinary action, peer review policies care quality, safety, and improvement of clinical
and procedures, and medical staff appointment, n
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outcomes. CfCs are standards applied to health-
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privileging, and credentialing (CMS 2018). CMS
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care organizations that choose to participate in

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mandates the medical staff bylaws must do the federal government reimbursement programs
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following: such as Medicare and Medicaid (Ambulatory Sur-

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gery Center Association n.d.). For a healthcare

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●● Be approved by the governing body of the provider to participate in federal government re-
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medical staff
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imbursement programs, the healthcare provider

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Address the duties and privileges of each

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type of medical staff member the CoPs and CfCs.
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Describe the organization of the medical Auditing and monitoring are the main ways
by
●●
state and federal government measure a healthcare

20
staff
20
Describe the qualifications that must be provider’s compliance with the CoP and CfC stan-
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●●
met by any individual wishing to seek dards and criteria. Healthcare providers that are
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appointment to the medical staff (42 CFR accredited by an approved accreditation organiza-
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482.22(c)) tion are exempt from direct government auditing

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and monitoring. The accreditation organization

CMS dictates that medical staff bylaws must ad- must go through its own CMS review to receive
dress certain documentation requirements in the deemed status. Deemed status is an official des-
Medicare Conditions of Participation. The Med- ignation indicating that a healthcare organization
icare Conditions of Participation (CoP) are the complies with the Medicare Conditions of Par-
standards that a healthcare organization must ticipation (ASHE n.d.). It is through this deemed
meet to receive Medicare funding. One of the re- status that the accreditation organization is per-
quirements is that a medical history and physical mitted to evaluate other healthcare provider orga-
(H&P) be documented for every patient no more nizations for CoP and CfC compliance through its
than 30 days before or 24 hours after admission to accreditation process. Currently nine national ac-
the hospital. The H&P contains pertinent informa- creditation organizations have obtained deemed
tion about the patient, including chief complaint, status and are responsible for surveying healthcare
AB103118_Ch04.indd 97 2/11/2020 12:24:10 PM

providers who are currently participating in the hospitals. A doctor of osteopathic medicine as
Medicare and Medicaid programs (see table 4.1). well as a healthcare organization that identi-
Many healthcare providers seek accreditation be- fies as an osteopathic entity, maintain a different
cause it gives the healthcare organization an oppor- philosophical and clinical approach to caring for
tunity to measure its own compliance as well as see the patient compared to the conventional (allo-
what operational improvements it can make based pathic) approach to medicine. Due to these dif-
upon the findings of the accreditation organiza- ferences, these healthcare providers required a
tion. Patients also want to know that the healthcare slightly different accreditation survey process.
provider they entrust with their care complies with However, over time, HFAP began to evaluate all
quality and clinical outcome measures. Accredita- healthcare providers. Similar to other accredita-
tion enhances reputation among healthcare organization organizations, the requirements that health-
tions that take part in the process. In most cases the care providers must meet are based upon, for
n.
accreditation process is voluntary, but the healthcare the most part, the CoPs. Most of the surveyors
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organization must be accredited by an accreditation who perform the HFAP surveys are healthcare
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organization to participate in specific programs and professionals themselves and survey and sub-
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services. This is true for the Medicare and Medicaid sequently accredit acute-care facilities, critical
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programs. Because of the vast number of specialties access facilities, hospitals, ambulatory surgery
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within healthcare, there are a number of accreditation centers, clinical labs, behavioral health facilities,
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organizations that specialize in the surveying of par- and office-based surgery.
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ticular types of healthcare facilities. These include: The Commission on Accreditation of Reha-
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bilitation Facilities (CARF) was established in
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Healthcare Organizations Accreditation the 1960s as an independent, nonprofit accrediting
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Program
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organization to meet the survey needs of vari-

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Commission on Accreditation of ous rehabilitation-based healthcare providers.

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Rehabilitation Facilities These rehabilitation-based healthcare providers

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Accreditation Association for Ambulatory include independent and nonprofit providers,

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Healthcare aging services, behavioral health, and opioid

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●● Joint Commission treatment programs. CARF surveys the business

operations, clinical processes, and rehabilitation
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The Healthcare Facilities Accreditation Program program specialties, and subspecialties for compli-
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(HFAP) was initially created to evaluate osteopathic ance. As with all accreditation organizations, the
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Table 4.1 CMS-approved accrediting organizations

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Accreditation organization Program

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Accreditation Association for Ambulatory Health Care (AAAHC) Ambulatory surgery centers
Accreditation Commission for Health Care (ACHC) Home health, hospice
American Association for Accreditation of Ambulatory Surgery Ambulatory surgery centers, occupational therapy, rural health
Facilities (AAAASF) clinics
American Osteopathic Association/Healthcare Facilities Ambulatory surgery centers, critical access hospitals, hospital
Accreditation Program (HFAP)
Center for Improvement in Healthcare Quality (CIHQ) Hospital
Community Health Accreditation Program (CHAP) Home health, hospice
DNV GL Healthcare Critical access hospitals, hospital
The Compliance Team Rural health clinics
Joint Commission Ambulatory surgery centers, critical access hospitals, hospital,
home health, hospice, psychiatric hospital
Source: Adapted from Centers for Medicare and Medicaid Services, CMS 2018.
AB103118_Ch04.indd 98 2/11/2020 12:24:10 PM

standards and evaluation methods are regularly and obtain Joint Commission accreditation, spe-
reviewed and revised as necessary to meet the cific programs addressing specific disease process-
ever-changing regulatory standards environment es can also obtain accreditation through the Joint
in these areas of healthcare. CARF also assists Commission certification process (Joint Commis-
healthcare providers with establishing best prac- sion 2016a).
tices in these specialized areas of rehabilitation Certification is the process by which a duly
treatment. authorized body evaluates and recognizes an in-
The Accreditation Association for Ambu- dividual, institution, or educational program as
latory Healthcare (AAAHC) was established meeting predetermined requirements. The more
in the late 1970s. AAAHC surveys and subse- commonly known programs that often obtain cer-
quently accredits various ambulatory-based tification address asthma, diabetes, and heart fail-
healthcare providers such as surgery centers, im- ure (Joint Commission 2016b–d).
n.
aging centers, endoscopy centers, and women’s Compliance, quality, and patient safety have
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health centers. Because of the variety of ambula- become the focal points of the healthcare indus-
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tory specialties AAAHC accredits, the surveyor try’s clinical and operational practices. The Joint
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who is sent to survey for compliance typically Commission responded to this shift in focus by
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has expertise in the specialty that is being sur- moving from announced reviews that occurred
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veyed. For example, a surveyor who reviews an once every three years to unannounced reviews,
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ambulatory surgery center should have experi- coupled with changes to the review process itself.
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ence at an ambulatory surgery center. AAAHC’s The Joint Commission provides organizations
focus is on establishing, reviewing, and revising n
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that choose to obtain or maintain their accredita-
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standards as well as measuring performance and tion with an accreditation manual. The manual is
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providing education to those healthcare provid- comprised of chapters addressing various areas
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ers it surveys. The surveys evaluate the facility of clinical and operational practice, including but
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infrastructure and safety, as well as business not limited to:

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operations, clinical operations, and patient

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Environment of Care
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●●
documentation for compliance.
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Leadership
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●●
Joint Commission Provision of Care, Treatment, and Services

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The Joint Commission has already been intro-

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●● Life Safety
duced in this chapter. Although there are many
20
●● Information Management (Joint Commission

20
high-quality accreditation organizations in exist- 2016e)

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ence today, all with the common goals of patient

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safety and the delivery of high-quality healthcare The chapters in the Joint Commission accredi-
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to patients, the Joint Commission has been an tation manual contain specific standards and
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industry leader in the area of healthcare accredita- elements that describe in detail the continuous
tion. The Joint Commission also provides organi- compliance expectations for the healthcare orga-
zations it accredits with education and compliance nization. Each standard and element has a cor-
outreach services. responding explanation and scoring procedure
Over the years, the Joint Commission has ex- associated with it. For example, within the Infec-
panded its accreditation program offerings and tion Control chapter, the Joint Commission de-
currently provides accreditation for ambulatory scribes when a healthcare provider should wear a
healthcare, behavioral health, critical access hos- gown when caring for a patient (contact precau-
pitals, home care, hospital, laboratory, nursing tions). When contact precautions are initiated,
care centers, physician offices, and office-based the Joint Commission expects that such activity
surgery centers. In addition to the different types will be documented appropriately in the patient’s
of healthcare provider organizations that can seek health record.
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The Joint Commission emphasizes appropriate a strictly paper-based record to a more hybrid
and standardized health record documentation. record model, and then to a fully electronic for-
Those standards and elements address health rec- mat since the health record became scattered and
ord content, legibility and completeness, dating more information was available.
and timing of entries, order sets, abbreviations, The current definition of the legal health
history and physical component requirements, record is complicated. Each healthcare organ-
and informed consent, among many other stan- ization must define what its legal health rec-
dards and elements. ord contains. The legal health record is used
to ensure compliance with laws and regula-
State Statutes tions, healthcare policies, accreditation stan-
dards, and any other requirements (HIMSS
A statute is a piece of legislation written and ap-
n.d.). Healthcare organizations with an EHR
proved by a state or federal legislature and then
n.
must determine what to do with health records
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signed into law by the state’s governor, or the
that they receive from other healthcare provid-
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President of the United States. State statutes, as
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ers. At one time, it was standard practice for
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they relate to health record documentation, vary
a healthcare organization to incorporate an-
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by state in terms of what components of health
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other provider ’s health record into the legal
record documentation are regulated and to what
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health record and release that documentation
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degree it is regulated by law. In many instanc-
as part of the healthcare organization’s legal
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es, state statutes address the documentation
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health record. Today, the healthcare organiza-
requirements according to the type of health rec-
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tion should consult with legal counsel to as-
ord. For example, Ohio law addresses the spe-
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sist with making a decision about whether or
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cific documentation requirements for inpatient

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not to include another provider ’s records in

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psychiatric service providers. For example, the

the legal health record. Some state laws dictate
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Ohio Administrative Code describes how in-

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what can and cannot be included in the health-

volved a patient should be in involved his or
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care organization’s legal health record and, in

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her care plan and how the care plan should be

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many cases, the hospital’s attorney is in the

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documented.
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best position to decide whether to include or

exclude the records from other providers. For
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Legal Health Record the EHR to be a legal health record and meet
by
In the past, the terms health record and legal health the requirements, several concepts need to be
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20
record were used interchangeably, and the subtle considered. These concepts include how doc-
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nuances of these two terms provided little im- umentation is actually created and signed by
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pact to the operations of a healthcare provider. healthcare providers; how the documentation
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The legal health record is the documents and is managed and preserved; how the documen-
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data elements that a healthcare provider may tation impacts and interacts with the revenue
include in response to legally permissible re- cycle functions of billing and claims submis-
quests for patient information. Identifying the sion; and how the documentation is displayed
legal health record was simple when health re- both electronically to the user as well as in hard
cords were primarily paper-based and included copy form, should the data be printed (HIMSS
the contents of the paper health record in addi- 2011). Once a healthcare organization defines
tion to diagnostic radiographic films or x-rays. its legal health record, necessary policies and
During this time, the health record and the legal procedures should be developed to formalize
health record were one and the same. The legal the healthcare organization’s approach to de-
health record became complicated when elec- fining the health record. See chapter 8, Health
tronic health record technology was adopted and Law, for more information about the legal
healthcare provider organizations moved from health record.
AB103118_Ch04.indd 100 2/11/2020 12:24:11 PM


1. Complete this statement: The patient’s medical history can be completed within ___________ of admission to the
hospital.
a. 3 days
b. 30 days
c. 60 days
d. 10 days
2. Justify the need for documentation standards.
a. To ensure physicians have access to the health record information they need to care for the patient
b. To ensure the healthcare provider organization is reimbursed appropriately by payers
n.
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c. To ensure CMS does not find reason to fine the healthcare provider organization
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d. To ensure what is documented in the health record is complete and accurately reflects the treatment provided to
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the patient
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3. A new hospital is town wants to accept Medicare patients. To receive Medicare funding, the hospital must meet:
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a. The medical bylaws of the healthcare provider organization
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b. The Medicare Conditions of Participation
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c. The accreditation organization
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d. The plan
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4. The fact that ABC hospital is accredited by an accreditation organization that allows the hospital to also meet the
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Medicare Conditions of Participation is known as:

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a. Deemed status
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b. Certification
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c. Bylaws
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d. State statute
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5. Dr. Smith admits patients to ABC hospital. There he is able to perform general surgery, order tests, and perform other
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services. This is known as:

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a. Certification
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b. Licensure
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c. Statutes
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d. Medical staff privileges

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General Documentation Guidelines

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General documentation guidelines ap- the content and the format of the health
ply to all categories of health records. These guidelines record. The policies should be based on all
address the uniformity, accuracy, completeness, applicable accreditation standards, federal
legibility, authenticity, timeliness, frequency, and and state regulations, payer requirements,
format of health record entries. The American Health and professional practice standards.
Information Management Association (AHIMA) ●● The health record should be organized
developed the following general documentation systematically to facilitate data retrieval and
guidelines: compilation.
●● Every healthcare organization should have ●● Only individuals (physicians, nurses,
policies that ensure the uniformity of both physical therapists, and more) authorized by
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the healthcare organization’s policies should From a governmental regulatory perspective, CMS
be allowed to enter documentation in the and federal regulations also address what would
health record. be considered general documentation guidelines
●● Organizational policy and medical staff rules and further explain what this guidance means.
and regulations should specify who may ●● All health record entries must be legible.
receive and transcribe verbal physician’s orders. Orders, progress notes, nursing notes, or
●● Health record entries should be documented other entries in the health record that are not
at the time the services described are legible may be misread or misinterpreted
rendered. and may lead to medical errors or other
●● The authors of all entries should be clearly adverse patient events.
identified in the health record. ●● All entries in the health record must be
complete. A health record is considered
n.
●● Only abbreviations and symbols approved
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by the organization and medical staff rules complete if it contains enough information
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and regulations should be used in the health to identify the patient; support the diagnosis
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record. or condition; justify the care, treatment,
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and services; document the course and
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All entries in the health record should be
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●●
results of care, treatment, and services; and
permanent (written in permanent ink).
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promote continuity of care among healthcare
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●● Errors in paper-based records should providers.
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be corrected according to the following
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The time and date of each entry (orders,
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process: Draw a single line in ink through
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reports, notes) must be accurately
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the incorrect entry. Then print the word

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documented. Timing establishes when

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“error” at the top of the entry along with

an order was given, when an activity
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a legal signature or initials, the date, time,

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happened, or when an activity is to occur.

and reason for change, and the title and
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Entries must be timed and dated for patient

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discipline of the individual making the

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safety and quality of care. Timed and dated

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correction. The correct information is then

entries establish a baseline for future actions
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added to the entry. Errors must never be

or assessments and establishes a timeline of
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obliterated. The original entry should

events.
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remain legible, and the corrections should

20
be entered in chronological order. Any late ●● There must be a method to establish the
20
entries should be labeled as such. identity of the author of each entry.

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There must be a method to require that each

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Any corrections or information added to
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●●
author takes a specific action to verify that
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the health record by the patient should be

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the entry being authenticated is his or her

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inserted as an addendum (a separate note).

entry or that he or she is responsible for
No changes should be made in the original
the entry and the entry is accurate (42 CFR
entries in the record. Any information added
482.24(c)(1)).
to the health record by the patient should
be clearly identified as a patient addendum Authentication is the process of identifying
(Smith 2001, 56). the source of health record entries by attaching a
●● When errors in the EHR are corrected, handwritten signature, the author’s initials, or an
the erroneous information should not electronic signature. CMS defines what authenti-
be displayed; however, there should be cation methods are to be used for health record en-
a method to view the previous version tries such as written signatures, initials, computer
of the document with the original data key, or other code; the requirements a healthcare
(Wiedemann 2010). provider needs to have in place; and controls to
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prevent any changes from being made to the authentication. For example, a physician dictates
health record after the entries have been authenti- an operation, the operative report is transcribed,
cated (42 CFR 482.24(c)(1)). but the physician never accesses the report to re-
Auto-authentication is a procedure that allows view it for accuracy and completeness. The EHR
dictated reports to be considered automatically system is set up to show the physician signed the
signed unless the HIM department is notified of operative report even though he or she never re-
needed revisions within a certain time limit or a viewed the document. Auto-authentication does
process by which the failure of an author to re- not meet standards for appropriate timing, dating,
view and affirmatively approve or disapprove and signing-off of documentation by healthcare
an entry within a specified time period results in providers and therefore should not be used.
n.
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1. True or false: Only individuals authorized by the healthcare organization’s policies should be allowed to enter
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documentation in the health record.
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2. True or false: Auto-authentication is the preferred method of authentication.
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3. Each entry in the health record should be:
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a. Signed only
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b. Signed and dated

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c. Reviewed by the patient

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d. Reviewed by another physician

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4. True or false: When an error is made, the erroneous information can be obliterated.
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5. True or false: Health record entries should be documented at the time the services they describe are rendered.
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Documentation by Settings
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20
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Despite different settings in which separate health records. Whether the health record
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healthcare can be provided—hospitals, ambula- is paper-based, electronic, or hybrid, there are dis-
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tory surgery centers, physician offices, long-term tinct differences in the documentation found in the
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care facilities—health records contain two distinct health record. Inpatient, emergency department,
types of information: clinical and administrative ambulatory, ambulatory surgery, ancillary, phy-
(defined later in the chapter). A healthcare organi- sician office, long-term care, rehabilitation, and
zation must maintain a health record on every pa- behavioral health settings are discussed in more
tient whom they treat. Hospitals frequently use a detail in the section that follows.
centralized health record. Having all patient care
records stored together enables physicians and Inpatient Health Record
other healthcare providers to see the documen- The inpatient health record is generated when a
tation of all the care provided to the patient by patient is provided with room, board, and contin-
others. In a centralized health record, the inpa- uous general nursing care in an area of an acute-
tient and outpatient health record documentation care healthcare organization, such as a hospital,
is maintained in one health record rather than in where the patient generally stays overnight at that
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healthcare organization. The documents typically medical history, physical exam, diagnostic and
found in an inpatient health record include but are therapeutic procedure orders, clinical observa-
not limited to history and physical (H&P), con- tions, diagnostic and procedure reports, surgical
sultation reports, physician’s orders and progress procedure documentation, consultation report,
notes, nursing assessments and progress notes, as discharge summary, and patient instructions and
well as a discharge summary. Over the years, there transfer record.
has been a dramatic shift in the delivery of health-
care treatment and services. Many services such Medical History The medical history portion of
as surgery, infusions, and other diagnostic proce- clinical data addresses the patient’s current com-
dures that once required a patient to stay overnight plaints and symptoms and describes his or her past
in the hospital can be performed on an outpatient medical, personal, and family history. In inpatient
basis. Only the most severely ill patients and the care, the medical history is the responsibility of the
n.
most invasive procedures require an overnight attending physician. The history generally focuses
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stay and therefore the inpatient health record is on the body systems involved in the patient’s cur-
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the most complex. A discussion of the three major rent illness. Table 4.2 shows the information that is
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health records categories within the inpatient care usually included in a medical history.
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services continuum (medical and surgical, obstet- Note that the chief complaint is a component of
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ric, and newborn) follows. the medical history that is told to the healthcare
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provider by the patient and in the patient’s own
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Medical and Surgical words. Examples of a chief complaint include
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The medical and surgical health record is found in io
vomiting, headache, and abdominal pain.
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a variety of settings including inpatient care units,

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long-term care facilities, home health, surgical cen- Physical Examination The physical examination
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represents the physician’s assessment of the pa-

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ters, and ambulatory care units. Medical and surgi-

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cal health record documentation pertains to adult tient’s current health status after evaluating the pa-
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patients with various acute and active disease pro- tient’s physical condition. The physician performs
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cesses or injuries. The medical and surgical health the physical examination to ensure appropriate
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record contains documentation originating from treatment and services are ordered for the patient.
Table 4.3 lists the components of the physical ex-
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physicians, nurses, diagnostic procedures, as well

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as from the dietary, pharmacy, social services, and amination documentation. Together the medical
by
history and physical examination are commonly

20
other departments. The categories of information

20
found in the medical and surgical record include referred to as the history and physical (H&P).
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clinical data, administrative data, and consents, CMS guidance and regulations, Joint Commis-
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authorizations, and acknowledgments. Consents sion standards, and healthcare organization poli-
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and authorizations are discussed in chapter 8. An cies and procedures will dictate when the medical
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acknowledgment is a document that the patient’ history and physical exam must be completed by
or the patient’s authorized personal representative the physician. There are also documentation stan-
sign, confirming the receipt of important information. dards that address when a previously completed
H&P can be utilized when a patient is admitted to
Clinical Data Clinical data is the information the hospital (discussed later in this chapter).
that reflects the treatment and services provided
to the patient as well as how the patient responded Diagnostic and Therapeutic Procedure Orders
to such treatment and services; it is also the ba- There are many diagnostic and therapeutic order
sis for the reimbursement of the treatment and types. Diagnostic orders include orders for x-rays,
service rendered to the patient. The clinical data CT, MRI, lab tests, and more for the purpose of di-
portion of the acute-care record constitutes the agnosing a patient’s symptoms of illness. Ther-
largest p
ortion of the health record and consists of apeutic orders are orders for treatment that either
nine separate and distinct parts. These parts are: prevent or address illness by way of medication
AB103118_Ch04.indd 104 2/11/2020 12:24:11 PM

Table 4.2 Information included in a complete medical history

Components of the history Complaints and symptoms
Chief complaint Nature and duration of the symptoms that caused the patient to seek medical attention as stated
in his or her own words
Present illness Detailed chronological description of the development of the patient’s illness, from the
appearance of the first symptom to the present situation
Past medical history Summary of childhood and adult illnesses and conditions, such as infectious diseases,
pregnancies, allergies and drug sensitivities, accidents, operations, hospitalizations, and current
medications
Social and personal history Marital status; dietary, sleep, and exercise patterns; use of coffee, tobacco, alcohol, and other
drugs; occupation; home environment; daily routine
Family medical history Diseases among relatives in which heredity or contact might play a role such as allergies, cancer,
and infectious, psychiatric, metabolic, endocrine, cardiovascular, and renal diseases; health
status or cause of and age at death for immediate relatives
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Review of systems Systemic inventory designed to uncover current or past subjective symptoms that includes the
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following types of data:
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• General: Usual weight, recent weight changes, fever, weakness, fatigue
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• Skin: Rashes, eruptions, dryness, cyanosis, jaundice; changes in skin, hair, or nails
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• Head: Headache (duration, severity, character, location)
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Eyes: Glasses or contact lenses, last eye examination, glaucoma, cataracts, eyestrain, pain,
•
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diplopia, redness, lacrimation, inflammation, blurring
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• Ears: Hearing, discharge, tinnitus, dizziness, pain
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• Nose: Head colds, epistaxis, discharges, obstruction, postnasal drip, sinus pain
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Mouth and throat: Condition of teeth and gums, last dental examination, soreness, redness,
•
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hoarseness, difficulty in swallowing

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Respiratory system: Chest pain, wheezing, cough, dyspnea, sputum (color and quantity),
•
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hemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last chest x-ray
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Neurological system: Fainting, blackouts, seizures, paralysis, tingling, tremors, memory loss
•
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Musculoskeletal system: Joint pain or stiffness, arthritis, gout, backache, muscle pain,
•
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cramps, swelling, redness, limitation in motor activity

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Cardiovascular system: Chest pain, rheumatic fever, tachycardia, palpitation, high blood
•
pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis
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Gastrointestinal system: Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding,

•
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change in bowel habits, diarrhea, constipation, indigestion, food intolerance, flatus,

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hemorrhoids, jaundice
20
Urinary system: Frequent or painful urination, nocturia, pyuria, hematuria, incontinence,

•
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urinary infections
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Genitoreproductive system: Male—venereal disease, sores, discharge from penis,

•
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hernias, testicular pain, or masses; female—age at menarche, frequency and duration

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of menstruation, dysmenorrhea, menorrhagia, symptoms of menopause, contraception,

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pregnancies, deliveries, abortions, last Pap smear

Endocrine system: Thyroid disease; heat or cold intolerance; excessive sweating, thirst,
•
hunger, or urination
Hematologic system: Anemia, easy bruising or bleeding, past transfusions
•
Psychiatric disorders: Insomnia, headache, nightmares, personality disorders, anxiety
•
disorders, mood disorders
Source: Petterson 2013, 79.
administration, surgery, or counseling. Physician patient. For example, the physician might order a
orders are the instructions the physician gives to nurse to take the patient’s temperature every two
other healthcare professionals who perform di- hours. Admission and discharge orders should be
agnostic tests and treatments, administer medica- found for every patient unless the patient leaves
tions, and provide specific services to a particular the healthcare organizations against medical advice
AB103118_Ch04.indd 105 2/11/2020 12:24:11 PM

Table 4.3 Information documented in the report of a physical examination

Report components Content
General condition Apparent state of health, signs of distress, posture, weight, height, skin color, dress and personal
hygiene, facial expression, manner, mood, state of awareness, speech
Vital signs Pulse, respiration, blood pressure, temperature
Skin Color, vascularity, lesions, edema, moisture, temperature, texture, thickness, mobility and
turgor, nails
Head Hair, scalp, skull, face
Eyes Visual acuity and fields; position and alignment of the eyes, eyebrows, eyelids; lacrimal apparatus;
conjunctivae; sclerae; corneas; irises; size, shape, equality, reaction to light, and accommodation
of pupils; extraocular movements; ophthalmoscopic exam
Ears Auricles, canals, tympanic membranes, hearing, discharge
Nose and sinuses Airways, mucosa, septum, sinus tenderness, discharge, bleeding, smell
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Mouth Breath, lips, teeth, gums, tongue, salivary ducts
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Throat Tonsils, pharynx, palate, uvula, postnasal drip
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Neck Stiffness, thyroid, trachea, vessels, lymph nodes, salivary glands
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Thorax, anterior and posterior Shape, symmetry, respiration
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Breasts Masses, tenderness, discharge from nipples
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Lungs Fremitus, breath sounds, adventitious sounds, friction, spoken voice, whispered voice
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Heart Location and quality of apical impulse, trill, pulsation, rhythm, sounds, murmurs, friction rub,
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jugular venous pressure and pulse, carotid artery pulse
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Abdomen io
Contour, peristalsis, scars, rigidity, tenderness, spasm, masses, fluid, hernia, bowel sounds and
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bruits, palpable organs
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Male genitourinary organs Scars, lesions, discharge, penis, scrotum, epididymis, varicocele, hydrocele
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Female reproductive organs External genitalia, Skene’s glands and Bartholin’s glands, vagina, cervix, uterus, adnexa
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Rectum Fissure, fistula, hemorrhoids, sphincter tone, masses, prostate, seminal vesicles, feces
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Musculoskeletal system Spine and extremities, deformities, swelling, redness, tenderness, range of motion
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Lymphatics Palpable cervical, axillary, inguinal nodes; location, size, consistency; mobility and tenderness
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Blood vessels Pulses, color, temperature, vessel walls, veins

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Neurological system Cranial nerves, coordination, reflexes, biceps, triceps, patellar, Achilles, abdominal, cremasteric,
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Babinski, Romberg, gait, sensory, vibratory

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Diagnosis(es)
20
Source: Petterson 2013, 80.

20
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(AMA), but other orders will vary from patient to are scheduled for an appendectomy would in-
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patient. All orders must be legible and include the clude all the orders commonly needed to get the
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date and the physician’s signature. In electronic patient ready for surgery. The physician can then
systems, signatures are attached via an authentica- add orders that are specific to a patient; for exam-
tion process discussed in chapter 10, Data Security. ple, a patient who is scheduled for an appendec-
Standing orders are orders the medical staff tomy and who is also diabetic will have different
or an individual physician established as routine standing orders than a patient with no underly-
care for a specific diagnosis or procedure. Standing ing disease process. Like other physician orders,
orders authorize other healthcare providers (such the standing orders must be signed, verified, and
as nurses) to begin treating the patient b efore the dated.
physician examines the patient. Standing orders Physicians may communicate orders verbal-
are commonly used for disease processes and in- ly or via telephone when the hospital’s medical
juries requiring prompt attention. For example, a staff rules allow. State law and medical staff rules
standing order to all the physician’s patients who specify which practitioners can accept and execute
AB103118_Ch04.indd 106 2/11/2020 12:24:11 PM

erbal and telephone orders (for example, only

v r esponsible for a major procedure must document
registered nurses). How the orders are to be both pre- and post-surgical patient evaluations.
signed as well as the time period allowed for au- In the case of a death, the attending physician
thentication also may be specified. Currently, there should add a summary statement to the patient’s
is technology that allows orders to be sent via mo- health record to document the circumstances sur-
bile devices, such as smart phones and tablets, and rounding the patient’s death. The statement can
healthcare organizations are beginning to explore take the form of a final progress note or a separate
the possibility of using this technology. report. The statement should indicate the reason
for the patient’s admission, his or her diagnosis
Clinical Observations In acute-care hospitals, and course in the hospital, and a description of the
the documentation of clinical observations is events that led to his or her death.
usually provided in a progress note. Clinical ob- Just as physician documentation begins with the
n.
servations are the comments of physicians, nurs- H&P, nurses and allied health professionals may
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es, and other caregivers that create a chronologi- begin their care with assessments focused on un-
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cal report of the patient’s condition and response derstanding the patient’s condition from the per-
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to treatment during his or her hospital stay. Prog- spective of their specialized body of knowledge.
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ress notes serve to justify further acute-care treat- Often a care plan— a summary of the patient’s
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ment in healthcare organizations. In addition, the problems from the nurse or other professional’s
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progress notes document the appropriateness perspective with a detailed plan for interven-
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and coordination of the services provided. The tions—may follow the assessment. In addition,
patient’s condition determines the frequency of n
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nurses are responsible for specific patient admis-
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the notes. sion and discharge notes and for documenting the
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The rules and regulations of the hospital’s med- patient’s condition at regular intervals through-
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ical staff specify which healthcare providers can out the patient’s stay. If a patient should die while
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enter progress notes in the health record. Typically, hospitalized, nursing notes regarding the circum-
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the patient’s attending physician, consulting phy- stances leading to and of death are important for
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sicians who have medical staff privileges, house quality and patient health outcomes improve-
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medical staff, nurses, nutritionists, social workers, ment, risk management activities, and, in some
and clinical therapists (such as physical therapists) cases, payer reimbursement considerations.
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are authorized to enter progress notes. Depending In certain situations, when the patient has died,
by
on the health record format used by the hospital, an autopsy may be requested or required and a
20
20
each discipline may maintain a separate section of subsequent autopsy report, a description of the
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the health record or the observations of all the pro- examination of a patient’s body after he or she has
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viders may be combined in the same chronologi- died, is completed. Also called necropsies, autopsies
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cal or integrated health record. Guidelines for the are usually conducted when there is some ques-
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frequency of notations may also be found in the tion about the cause of death or when information
medical staff rules and regulations. is needed for educational or legal purposes. The
Special types of notes are frequently found in purpose of the autopsy is to determine or confirm
a health record. For example, prior to the admin- the cause of death or to provide more information
istration of any medication other than local anes- about the course of the patient’s disease.
thesia, the anesthesiologist visits the patient and The autopsy report is completed by a patholo-
documents important factors about the patient’s gist and becomes part of the patient’s health rec-
condition that may have an impact on the anesthe- ord. The autopsy report content and the format of
sia chosen or its route of administration. Allergies the content is standardized and governed by the
and drug reactions are noted. A post-anesthesia National Association of Medical Examiners. Every
note that describes the patient’s recovery from autopsy report contains the diagnosis, toxicology,
the anesthetic is required. Similarly, the surgeon opinion, circumstances of death, identification of
AB103118_Ch04.indd 107 2/11/2020 12:24:11 PM

the decedent, general description of clothing and ●● Pathological examinations of tissue samples
personal effects, evidence of medical intervention, and tissues or organs removed during
external examination, external evidence of in- surgical procedures
jury, internal examination, and samples obtained. ●● Imaging procedures of the patient’s body
Because reports from tissue examination or labo- and specific organs (radiology, scans,
ratory testing can take weeks or even months, a ultrasounds, MRIs, PETs)
preliminary report including preliminary diagno-
●● Monitors and tracings of body functions
ses is often documented until findings are received
and the final report is completed. The authoriza- The results of most laboratory procedures are gen-
tion for the autopsy, signed by the patient’s next erated electronically by automated testing equip-
of kin or by law enforcement authorities, must be ment. In contrast, the results of monitors, imaging,
obtained prior to the autopsy and should become and pathology procedures require interpretation by
n.
part of the record. specially trained physicians such as cardiologists,
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Nursing professionals also maintain chronolog- radiologists, and pathologists. These physicians
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ical records of the patient’s vital signs (blood pres- document their findings in reports that then become
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sure, heart rate, respiration rate, and temperature) part of the patient’s permanent record, along with
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and documentation of medications ordered and copies or samples of the tracing, images, and scans.
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administered. Other chronological monitors such
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as measures of a patient’s fluid input and out- Surgical Procedure Documentation Any surgi-
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put may be ordered and recorded depending on cal procedure requires special documentation. Pre-
the patient’s diagnosis. Sometimes these records n
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operative notes are made by the anesthesiologist
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are referred to as flow records because they show
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and surgeon prior to the procedure, and nurses re-

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trends over time, or the data may be represented port preoperative patient preparations. The entire
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in graphic form for ease of communication. Spe- procedure itself is then recorded, along with an
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cial interventions such as the use of restraints also

anesthesia record, an operative report, and a post-
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require documentation. For example, restraint in- anesthesia or recovery room report. When tissue
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formation must include the type of restraint used, is removed for evaluation, a pathology report also
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time frame used, and regular vital sign monitors must be present.
and descriptions of the patient’s physical condi- The anesthesia report notes any preoperative
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tion while restrained. medication and the response to it, the dosage of
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After an initial assessment, documentation by the anesthesia administered and the route of ad-
20
20
other allied health professionals varies by spe- ministration, the duration of administration, the
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cialty. Each healthcare organization will define the

patient’s vital signs while under anesthesia, and
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appropriate content and frequency of documenta- any blood products administered to the patient
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tion based on specific regulations and standards during the procedure, and other preoperative in-
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and the profession’s practice guidelines. For ex- formation. The anesthesiologist or nurse anesthe-
ample, respiratory therapy treatments may be tist is responsible for this documentation.
documented via progress notes and social work The operative report describes in detail the sur-
interventions may appear as dictated reports. gical procedures performed on the patient. The
content of the operative report is found in table 4.4.
The operative report should be written or dic-
Diagnostic and Therapeutic Procedure Reports
tated by the surgeon immediately after surgery
The results of all diagnostic and therapeutic pro-
and become part of the health record as soon as
cedures become part of the patient’s health record.
possible. When there is a delay in dictation or tran-
Diagnostic procedures include the following:
scription, a progress note describing the surgery
●● Laboratory tests performed on blood, urine, should be entered into the patient’s health record.
and other body fluids Reports of non-surgical other procedures or treatments
AB103118_Ch04.indd 108 2/11/2020 12:24:11 PM

Table 4.4 Content of the operative report Some healthcare organizations allow consulta-
tion requests by telephone and provide the consultant
• Patient’s preoperative and postoperative diagnosis
with selected information from the patient’s
• Descriptions of the procedure(s) performed
health record. The consultant then dictates his or
• Descriptions of all normal and abnormal findings
her findings and returns them to the requesting
• Description of the patient’s medical condition before, during,
and after the surgical procedure physician.
• Estimated blood loss
• Descriptions of any specimens removed Discharge Summary The discharge summary is
• Descriptions of any unique or unusual events during the a concise account of the patient’s illness, course of
surgical procedure
treatment, response to treatment, and condition at
• Names of the surgeons and their assistants
the time of patient discharge (official release) from
• Date and duration of the surgical procedure
the hospital. The summary also includes instruc-
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Source: ©AHIMA.
tions for follow-up care to be given to the patient
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or to his or her caregiver at the time of discharge.
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will require documentation as well. These may
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Because the summary provides an overview of the
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include administration of blood transfusions, che- entire medical encounter, it is used for a variety of
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motherapy documentation, and more. purposes, including the following:
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Immediately after the procedure, the patient
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is evaluated for a period of time in a special unit Ensures the continuity of future care by
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●●
providing information to the patient’s
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called a recovery room. Monitoring is important
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attending physician, referring physician, and
to ensure the patient sufficiently recovers from the io
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anesthesia and is stable enough to be moved to an- any consulting physicians
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other location. The recovery room report includes Provides information to support the
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●●
the post-anesthesia note (if not found elsewhere), activities of the medical staff review
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nurses’ notes regarding the patient’s condition committee

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and surgical site, vital signs, intravenous fluids,

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●● Provides concise information that can be

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and other medical monitoring. used to answer information requests from

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A pathology report is dictated by a pathologist authorized individuals or entities

after examination of tissue received for evaluation.
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This report usually includes descriptions of the The discharge summary is the responsibility of
by
tissue from a gross or macroscopic (with the eye) and must be signed by the attending physician. If
20
the patient’s stay is not complicated and lasts less

20
level and representative cells at the microscopic

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level along with interpretive findings. Sometimes than 48 hours or involves an uncomplicated deliv-
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ery of a normal newborn, a discharge note in place

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an initial tissue evaluation occurs while the sur-

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of a full summary is often acceptable.

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gery is in progress to give the surgeon information

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important to the remainder of the operation. A full

written pathology report would follow. Patient Instructions and Transfer Records It is
vital that the patient be given clear and concise
Consultation Reports The consultation report instructions upon discharge, so the recovery prog-
documents the clinical opinion of a physician oth- ress begun in the hospital continues. Ideally, pa-
er than the primary or attending physician. The tient instructions are communicated verbally and
consultation is usually requested by the primary in writing. The healthcare professional who de-
or attending physician, but occasionally may be livers the instructions to the patient or caregiver
the request of the patient or the patient’s family. should sign the health record to indicate that he
The consultation report is based on the consult- or she has issued them. In addition, the person
ing physician’s examination of the patient and a receiving the instructions should sign to verify
review of the patient’s health record. that he or she has received and understands them.
AB103118_Ch04.indd 109 2/11/2020 12:24:11 PM

A copy of these instructions should be filed in the ●● Patient’s marital status

health record. ●● Patient’s religious affiliation (if patient has
When someone other than the patient assumes one and chooses to disclose it)
responsibility for the patient’s aftercare, the record
●● Race (often this is optional)
should indicate the instructions were given to the
responsible party. Documentation of patient edu- ●● Next of kin information
cation may be accomplished by using formats that ●● Healthcare power of attorney or advance
prompt the person providing instruction to cover directives (if the patient has these
important information. documents) (refer to chapter 8 for specifics)
When a patient is being transferred from the ●● If the patient wants to be a private or
acute setting to another healthcare organization, a confidential patient under HIPAA, where
transfer record may be initiated. This documenta- the patient opts-out of the healthcare
n.
tion is also called a referral form. A brief review of organization’s directory (discussed in
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the patient’s acute stay along with current status, chapter 9, Data Privacy and Confidentiality)
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discharge and transfer orders, and any additional
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Figure 4.1 is an example of demographics in an EHR.
instructions will be noted. Social service and nurs-
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ing personnel often complete portions of the transfer
Ambulatory Surgery Record
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record.
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Ambulatory facilities that perform surgery are
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Administrative Data Administrative data are called ambulatory surgery centers (ASC). Patients
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coded information contained in secondary records who have surgery in an ASC still must have a his-
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(such as billing records) describing patient identi- tory and physical prior to surgery present within
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fication and insurance. Patient registration infor- the health record. The patient must have signed the
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mation would be considered administrative data appropriate consent documentation prior to the
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as would patient account information. procedure. Much like an inpatient health record
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containing a surgery component, an ambulatory

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Patient Registration Information Patient regis- surgery record must contain operative reports and
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tration information includes those data elements notes, diagnostic and therapeutic documentation,
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obtained during the patient registration process. consultations, and discharge notes at the conclusion
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Most of the patient registration process usually of the treatment.

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takes place before the physician examines or be- Ambulatory surgery centers will also perform
20
gins treating the patient. During the registration, discharge follow-up phone calls, where a nurse will
20
process, demographic data are collected. Demo-

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call the patient within 24 to 48 hours postdischarge

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graphic data are data that identify the patient and to check on the patient. The nurse will assess pain
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includes the following: levels and address any immediate or future needs of
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●● Patient’s full name (including any aliases the patient related to the treatment. This conversa-
the patient uses; for example, Bob instead of tion must be documented in the health record. The
Robert) Joint Commission and the American Association
for Accreditation of Ambulatory Surgery Facilities
●● Patient’s health record number if the patient
(AAAASF) have requirements applicable to the am-
was not seen at the healthcare organization
bulatory surgery center setting. CMS’s Conditions
before. as well as a patient’s account number
for Coverage for ambulatory surgical centers govern
for this specific visit
those that seek Medicare reimbursement.
●● Patient’s address
●● Patient’s contact phone number Ancillary Departments
●● Patient’s date of birth Ancillary departments are the departments that
●● Patient’s gender provide treatment and services that support the
AB103118_Ch04.indd 110 2/11/2020 12:24:11 PM

Figure 4.1 Demographics in an EHR
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Source: ©drchrono. Used with permission.
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patient’s overall care plan. Ancillary departments that is EHR-based, is often in an integrated health
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perform ancillary services—tests and procedures record format.

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sometimes ordered by a physician—and these serv- The physician office record content consists of
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ices assist the physician with diagnosing and treat- the following:
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ing the patient. Ancillary departments also consist

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●● Medical history
of departments that play an indirect patient care role
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but are necessary for the overall management of pa- ●● Family history
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tient care. These departments include pharmacy, nu- ●● Social history

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trition, HIM, social services, and patient advocacy Vital signs

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●●
and patient relations. Many ancillary departmental

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●● Chief complaint
services must be documented within the patient
20
Progress notes
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●●
health record according to the governing standards
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and regulations within a specific department. Allergies

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●●
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Medication list
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●●
Physician Office Record

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●● History of present illness

Routine healthcare treatment commonly occurs ●● Review of systems
within the physician office setting. Routine serv-
●● Assessment and diagnosis
ices include preventative services such as yearly
physicals and blood tests, in addition to diagnosis ●● Plan of treatment
and treatment of minor illnesses and injuries. In The next section will discuss the regulations
many instances, hospital-based health records can that govern long-term care.
feed into the physician office record if the hospital
and physician office records are electronic and in- Long-Term Care
formation can be exchanged from one health rec- Long-term care is provided in a variety of healthcare
ord system to another. Much like a paper-based organizations, including skilled nursing facilities
physician office record, the physician office record (SNFs) or units; subacute-care facilities; nursing
AB103118_Ch04.indd 111 2/11/2020 12:24:12 PM

facilities (NFs) (nursing homes, long-term care fa- resident. The physician visits the resident in the
cilities); and assisted-living facilities. healthcare organizations on a 30- or 60-day sched-
The regulations that govern long-term care ule unless the resident’s condition requires more
facilities vary among these settings. Most SNFs frequent visits. At each visit, the physician reviews
and NFs are governed by both federal and state the plan of care and physician orders and makes
regulations, including the Medicare CoP. Assisted- changes as necessary. Between visits, the physi-
living facilities are usually governed only by state cian is contacted when nursing personnel identify
regulations. Most long-term care providers do not changes in the resident’s condition.
participate in voluntary accreditation programs, The following list identifies the most common
although the Joint Commission does have long- components of long-term care records:
term care facility standards.
●● Registration forms, including resident
Because the stay for a patient or resident in long-
identification data
n.
term settings can be lengthy, health records are
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based on ongoing assessments and reassessments ●● Personal property list, including furniture
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of the patient’s (or resident’s) needs. An interdisci- and electronics
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plinary team develops a plan of care for each patient History and physical and hospital records
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●●
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upon admission to the healthcare organization, and ●● Advance directives, bill of rights, and other
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the plan is updated regularly over the patient’s stay. legal records
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The team includes the patient’s physician and rep-
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●● Clinical assessments
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resentatives from nursing services, nutritional serv-
RAI and care plan
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●●
ices, social services, and other specialty areas (such io
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as physical therapy), as appropriate. Physician orders
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●●
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Assessments are a key component of the Patient Physician’s progress notes and consultations
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●●
Driven Payment Model (PDPM) used by Medicare

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●● Nursing notes
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for Skilled Nursing Facility reimbursement. The

Rehabilitation therapy notes (physical,
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●●
Minimum Data Set, Version 3 (MDS 3.0) Resident
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occupational, and speech therapy)

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Assessment Instrument is used to group patients

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Social services, nutritional services, and

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into a payment category. The MDS 3.0 includes di- ●●
agnosis, therapeutic services such as physical ther- activities documentation

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apy, data about the patient’s level of functioning and Medication and records of monitors,
by
●●
more. This means that health record documentation including administration of restraints
20
20
is crucial to the PDPM documentation and, there- ●● Laboratory, radiology, and special reports
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fore, reimbursement. For more on the PDPM, refer to Discharge or transfer documentation
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●●
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chapter 15. Revenue Management and Reimbursement.

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When paper-based records are found in a long-

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Some of the data elements collected by the MDS

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3.0 are used for the three assessments required by the term setting, a process called record thinning may
PDPM. These assessments are the 5-Day Assessment occur at intervals during the patient’s stay. Records
(mandatory), Interim Payment Assessment (op- of patients whose stay extends to months or years
tional), and the Discharge Assessment (mandatory). become cumbersome to handle. Selected material
The 5-Day Assessment and the Discharge Assess- may be removed and filed elsewhere according to
ment will be performed on all Medicare SNF patients. the healthcare organization’s guidelines. Any ma-
The Interim Payment Assessment is performed when terial removed must remain accessible when needed
there is a significant change in the patient’s situation. for patient care and service evaluation.
The physician’s role in a long-term care facility is
not as visible as it is in other care settings. The phy- Rehabilitation
sician develops a plan of treatment that includes The focus of services in physical medicine and reha-
the medications and treatments to be given to the bilitation settings is increasing a patient’s ability to
AB103118_Ch04.indd 112 2/11/2020 12:24:12 PM

function independently within the parameters of the ●● Correspondence related to the patient
individual’s illness or disability. The documentation ●● Release forms
requirements for rehabilitation facilities vary based
●● Discharge summary
on the type of rehabilitation services provided.
Inpatient rehabilitation hospitals and units with- ●● Follow-up reports (CARF 2016)
in hospitals are reimbursed by Medicare under
a prospective payment system. A Patient Driven
Behavioral Health
Payment Model is completed on Medicare pa- Behavioral health records contain much of the same
tients shortly after admission and upon discharge. content as a nonbehavioral health record such as
Based on the patient’s condition, services, diag- discharge summary, H&P, or physician orders. Be-
nosis, and medical condition, a payment level is havioral health records contain a treatment plan
determined for the inpatient rehabilitation stay. that often includes family and caregiver input and
information as well as assessments geared toward
n.
Comprehensive outpatient rehabilitation facilities
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have separate Medicare guidelines. For more in- the transition to outpatient, nonacute treatment.
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formation on the PAI, refer to chapter 15, Revenue CMS requires that the social workers assigned to
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Management and Reimbursement. a patient assess and document the family or home
tA
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Many rehabilitation facilities are accredited environment and community services that are
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through the Commission on Accreditation of Re- compatible with the patient’s needs. The behav-
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habilitation Facilities (CARF), although the Joint ioral health record also contains a psychiatric eval-
an
uation that is performed by a healthcare provider
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Commission or American Osteopathic Association
(AOA) also can be chosen. CARF requires a facil- n
appropriately trained to do such an evaluation
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ity to maintain a single case record for any patient and that evaluation consists of a patient history,
m r
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it admits. The documentation standard for the current mental status, and cognitive function.
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health record includes the following requirements:

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Home Health
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●● Patient identification data Home health records contain documentation reflect-

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●● Pertinent history, including functional ing care and treatment provided to patients in the
er
history
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home setting. Home care itself takes many forms

from very basic assistance that allows a patient to
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Diagnosis of disability and functional

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●●
diagnosis remain independent and live in his or her home,

by
to short-term rehabilitation care, or comprehensive

20
●● Rehabilitation problems, goals, and

20
prognosis management of a chronic illness. The care provided

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in the home setting as well as the skill level of the

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Reports of assessments and program plans

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●●
healthcare professional providing the care is indi-
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Reports from referring sources and service

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●●
vidualized based upon the needs of the patient.
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referrals The documentation that reflects the care and

●● Reports from outside consultations treatment in the home setting must be accurate and
and laboratory, radiology, orthotic, and complete to ensure appropriate and quality care is
prosthetic services provided to the patient, resulting in better patient
●● Designation of a manager for the patient’s outcomes. Quality home care documentation also
program drives appropriate coding, claims, and reimburse-
●● Evidence of the patient’s or family’s ment for the treatment and care provided to the
participation in decision-making patient. Typically, the home health documentation
itself includes an individualized treatment plan,
●● Evaluation reports from each service
general health assessment, problem list, treatment
●● Reports of staff conferences goals, interventions and outcomes, and communi-
●● Progress reports cations with other healthcare providers.
AB103118_Ch04.indd 113 2/11/2020 12:24:12 PM


1. True or false: The level and complexity of care a home care patient needs do not determine the skill level of the
individual providing the care to the patient.
2. A summary of the patient’s health record is found in the:
a. Progress notes
b. Discharge summary
c. Care plan
d. Physical examination
3. A patient’s gender, phone number, address, next of kin, and insurance policyholder information would be considered
what kind of data?
n.
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a. Clinical data
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b. Authorization data
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c. Administrative data
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d. Consent data
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4. The health record being reviewed documents the information from the family. The type of health record being
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reviewed is:
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a. Behavioral health records
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b. Ambulatory surgery health records
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c. Emergency department health records io
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d. Obstetric health record

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5. Recommend a method of facilitating documentation of orders for routine procedures and other common situations.
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a. Physician’s office records

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b. Emergency care records

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c. Standing orders
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d. Order sets
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6. True or false: Many services such as surgery, infusions, and other diagnostic procedures that once required an
overnight hospital stay for the patient no longer require that level of care.
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7. The assessment used by a rehabilitation center is known as:

by
20
a. Care plan
20
b. OASIS
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c. MDS
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d. PAI
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8. Critique each statement to determine the true statement about behavioral health records.
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a. Behavioral health records are completely different from other health records.
b. Behavioral health records are similar to other health records
c. Behavioral health records do not record the input of family members
d. Behavioral health records do not record the input of social workers.
9. The type of health record that records a nurse calling a patient 24 to 48 hours after they leave the healthcare setting.
a. Behavioral health
b. Ancillary services
c. Ambulatory surgery center
d. Long term care facility
AB103118_Ch04.indd 114 2/11/2020 12:24:13 PM

10. When a patient goes into labor and subsequently delivers a newborn, what documentation will be found in the Labor
and Delivery record?
a. Apgar scores
b. Fetal monitoring strips
c. Obstetrical risks
d. Medical history
11. A patient’s registration forms, personal property list, RAI, care plan, and discharge or transfer documentation would be
found most frequently in which type of health record?
a. Rehabilitative care
b. Ambulatory care
c. Behavioral health
d. Long-term care
n.
12. The physician spoke to a patient about the risks and benefits of a treatment or procedure. This is known as:
tio
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a. Consultation
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b. Clinical evaluation
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c. Implied consent
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d. Informed consent
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13. An attending physician requests the advice of a second physician who then reviews the health record and examines
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the patient. The second physician records his or her evaluation documentation known as a(n):
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a. Consultation
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b. Progress note io
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c. Operative report
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d. Discharge summary
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Federal and State Initiatives on Documentation

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As healthcare costs have steadily and, in For example, Medicare may hold a percentage of
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many cases, dramatically increased over the years, reimbursement until the healthcare provider meets
by
the government, on state and federal levels, has fo-

20
the quality standards. Clinical documentation

20
cused its attention on alternative reimbursement plays a key role in demonstrating if a healthcare
©
and payment models. It has developed initiatives provider is meeting or exceeding these perfor-
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for the healthcare sector to follow with the goals of mance measures.
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improving the quality of care provided and in- There are several federal and state initiatives re-
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creasing efficiencies with an increased value of lated to quality and content of health record doc-
the care provided to patients. The alternative umentation. Two initiatives, however, are more
reimbursement and payment models, called pay- commonly found across the entire healthcare con-
for-performance or value-based care, prioritize tinuum. These initiatives are the Medicare Access
quality and efficiency rather than quantity. Health- and CHIP Reauthorization Act (MACRA) and
care providers such as hospitals and physicians are core measures. Both MACRA and core measures
financially incentivized to put measures into place emphasize the quality and efficiency aspects of the
to continuously improve the quality and efficiency treatment physicians and other healthcare provid-
of the care they provide, resulting in better patient ers provide to patients more than the quantity of
outcomes. Pay-for-performance programs have the treatment provided.
performance measures that healthcare providers MACRA was signed into law in 2015 by then
must meet or exceed to receive financial payment. President Barack Obama. Like other pay-for-
AB103118_Ch04.indd 115 2/11/2020 12:24:13 PM

performance initiatives, MACRA financially rewards have been proven to improve overall patient out-
healthcare providers for treatment. By meeting spe- comes during treatment of these conditions. The
cific measures, the documentation generated by the goal of the core measures is to reduce patient ad-
treatment of Medicare beneficiaries demonstrates verse events and complications. The documen-
(or not) that the treatment provided was high- tation of the treatment must reflect adherence to
quality, efficient, and a good value for the patient. the core measures. Healthcare providers typically
Moreover, greater emphasis is being placed on the report core measures monthly or quarterly to the
patient outcomes over time. Healthcare providers Joint Commission, CMS, or other agency. The doc-
are and will continue to be evaluated for patient umentation of the adherence to and subsequent
outcomes and general management of specific con- reporting of the core measures demonstrates how
ditions within the Medicare patient population. frequently the healthcare provider follows the
Core measures are national treatment standards standards related to specific healthcare conditions.
n.
for specific healthcare conditions that were devel- This reporting reflects, in part, the level of quality
tio
oped and continue to be developed and updated treatment and care the healthcare provider pro-
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based on scientific clinical findings. Core measures vides to his or her patient population.
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Health Information Media
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Over the years, healthcare documenta- first. Reverse chronological order is kept while the
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tion media has transformed from a paper-based io
patient is being treated. Many times post patient
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health record that sat on a shelf to an EHR that discharge, the health record is kept in its source
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can be shared. Many of the same rules, standards, orientation, but the documentation in each source
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and quality measures that held true for the paper- section is rearranged and placed in chronological
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based health record hold true now for the EHR. order. Other times, the health record post patient
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Healthcare documentation integrity is paramount discharge is kept in reverse chronological order;

an
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regardless of its form. In many respects, the rules, this is called universal chart order.
er
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standards, and quality measures and indicators In an integrated health record, the documen-
e
are available through EHR software enhance- tation is placed in chronological order regardless
th
ments that can leverage technology against what of source. This means that the lab results, nurses’
by
20
was once a manual process. Leveraging EHR notes, physician orders, and physician progress
20
features and technical capabilities in conjunction notes are placed in the order in which they oc-
©
with strong and concise policies and procedures curred. The order of the health record is determined
ht
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can ensure the integrity and accuracy of health by when the documentation was entered into the
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record documentation (AHIMA 2013). health record, when the service or treatment was
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rendered, or when a test result was processed.

Paper Health Record Documentation The subjective, objective, assessment, plan
Some healthcare organizations still utilize the pa- (SOAP) method is used to construct physician
per-based health records. The paper-based health progress notes. Physicians use the acronym SOAP
record can take the source-orientated health to remember what elements of documentation
record format in which the documentation is or- must be included in a progress note. The SOAP
ganized by source or originating department. methodology came from the problem-oriented
For instance, all nursing notes are together, and health record developed by Lawrence Reed in
all the physician progress notes are grouped to- the 1970s, which defines and documents clinical
gether. With each source, the health record docu- problems individually (AAPC 2015). The prob-
mentation is placed in reverse chronological order, lem-oriented health record consists of a problem
where the most current or recent documentation is list, the history and physical examination and
AB103118_Ch04.indd 116 2/11/2020 12:24:13 PM

initial lab findings (the database), the initial plan discussed and rendered treatment to the patient.
(tests, procedures), and progress notes. The HIM The healthcare provider did not document what
professional must be able to read and understand occurred until after seeing the patient. Today,
the documentation structure to locate information EHRs allow point-of-care documentation to take
needed for coding, audits, and other usages. place—the healthcare provider can log into the
As EHR technologies have advanced, the pa- EHR in the exam or treatment room and document
per-based health record is considered antiquated in the patient’s health record during the exam or
by many. There are numerous shortcomings to the treatment. This change in the way healthcare doc-
paper-based health record, notably the inability umentation is captured has impacted treatment
to share needed health information with multiple workflow in some of the most meaningful ways.
healthcare providers at one time (access and avail- See chapter 11, Health Information Systems, for
ability), as well as the lack of controls that can be additional information on the EHR.
n.
placed in and around the paper-based health rec-
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ord in terms of data security. See chapter 10, Data Web-Based Document Imaging
ia
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Security, for more detail on data security. Document imaging is the process by which pa-
ss
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per-based documentation is captured, digitized,
Electronic Health Record
en
stored, and made available for retrieval by the end
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Documentation user (AIIM 2019). Although many healthcare pro-
ag
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Computer-based health record documentation via vider organizations have an EHR, there remains
M
EHRs has been in existence for 50 years. Over time, a good deal of paper-based documentation that
n
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as EHR systems became more sophisticated, the must be integrated and included in the patient’s
at
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way healthcare providers document the treatment EHR. Current EHR systems contain documenta-
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and services they render to the patient also dra- tion-imaging and document-management tech-
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matically changed. Before EHR adoption, health- nologies that provide for the capture, digitization,
ea
care providers would carry paper-based health integration, storage, and retrieval of paper-based
H
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records into the patient’s room to reference as they health record documentation.
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20
20

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1. The originating department organizes the paper-based health record. This is an example of:
ht
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a. Problem-oriented health record

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b. SOAP methodology
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c. Universal chart order

d. Source-oriented health record
2. The S in SOAP is:
a. Superior
b. Subjective
c. Simple
d. Sample
3. As the government has shifted its focus towards quality, alternative reimbursement and payment models have
developed. An example is:
a. Bundled payments
b. Managed care
c. Pay-for-performance
d. Fee-for-service
AB103118_Ch04.indd 117 2/11/2020 12:24:13 PM

4. The healthcare organization needs to incorporate paper-based health records into the patient’s EHR. It should use:
a. Database management
b. Document imaging
c. Text processing
d. Vocabulary standards
5. True or false: Pay-for-performance initiatives focus on treatment quality, efficiency, and value rather than the quantity
of treatment provided.
Healthcare Providers in Documentation
n.
Authenticated, accurate, legible, com- govern physician documentation. Those laws fall
tio
ia
plete, and timely documentation is paramount to into the general category of fraud and abuse laws,
oc
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patient safety, quality of care provided to patients, but the False Claims Act and Anti-Kickback Stat-
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and appropriate reimbursement. Healthcare pro- ute have significant documentation compliance
en
viders have an obligation to document appropri- jurisdiction for physicians.
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ately, reflecting a true picture of the treatment and
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Nurses
an
services rendered to the patient. Not only does the
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health record documentation itself need to be of Nurses play an important role in the day-to-day
n
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the highest quality, the health record also must be
at
caregiving of a patient, and they are an important
m
organized and available to the healthcare provid-

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member of the patient care team. As with physi-

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ers who need it to care for the patient. Physicians, cians, the way a nurse documents in the health
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nurses, allied health professionals, and HIM pro- record is based on the environment. Inpatient
ea
fessionals all play vital roles in meeting the doc-

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health record documentation looks slightly differ-

an
umentation standards from a healthcare organi- ent from documentation in the operating room or
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zation’s policy and procedural perspective and in a long-term care facility. The elements or com-
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meeting regulatory requirements applicable to ponents that the nurse captures in the documen-
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health record documentation.

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tation also varies depending upon licensing and

by
regulatory requirements, as well as the healthcare

20
Physicians organization’s internal policies and procedures.

20
However, the same rules apply to nursing docu-

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Patients place a significant level of trust in their

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mentation as to physician documentation. Legible,

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physicians. Patients rely on their physicians to

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complete, and timely entries are required. In addi-

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make sound medical decisions about them and

tion, though the documentation of a physician is
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document them accordingly. Payers and the gov-

both subjective and objective, nursing documenta-
ernment also trust physicians to document appro-
tion should only be objective in nature. In terms
priately in the health record so quality care can be
of the legal environment, nursing documentation
rendered and appropriate reimbursement issued
standards tend to be more restrictive than physi-
by the payer. The information a physician docu-
cian documentation standards because physicians,
ments in the health record impacts the patient first
not nurses, diagnose patients.
and foremost. All physicians caring for the patient
and payers connected to the physicians need to co-
ordinate their care and documentation. See chap- Allied Health Professionals
ter 16, Fraud and Abuse Compliance, for information Some allied health professionals work more inde-
on regulatory laws that directly and indirectly pendently than others when providing treatment
AB103118_Ch04.indd 118 2/11/2020 12:24:13 PM

and services to the patient. Many follow a treat- (assistant) and therapist or technologist. In both
ment plan developed by the patient’s physician. categories of practice, allied health profession-
In this case, the allied health professional docu- als may have to meet certification and licensing
ments the treatment and the patient’s response to requirements in addition to the standard docu-
the treatment. mentation practices of an organization. Chapter 2,
The allied health professional usually falls into Healthcare Delivery Systems, discusses allied health
one of two categories of practice—technician professionals in more detail.
HIM and Documentation
n.
tio
While HIM professionals do not docu- HIM professionals manage many aspects of the
ia
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ment in the health record, the documentation in health record and its content. This includes the
ss
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the health record is important to them for coding, following activities:
en
claim generation, data quality monitoring, disclo-
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sure of health information, and such. Complete, ●● Scanning paper-based health record
ag
accurate, and available health record informa- documentation into the EHR
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Organizing the content in the health
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tion is essential for quality care and patient safety. ●●
n
record
Other healthcare providers, the government, and io
at
payers expect the health record documentation to
m
●● Analyzing the documentation

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accurately reflect the treatment and services pro- for deficiencies like physician
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vided to the patient. This level of documentation

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signatures
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is needed to ensure the patient receives the best Coding the health record documentation for
H
●●
quality healthcare available and that the appropri-
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appropriate reimbursement
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ate reimbursement is received for the treatment

er
●● Controlling the access and disclosure of

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and services provided. HIM professionals are of-

the health record and its content across a
ten in charge of ensuring that physician documen-
e
th
healthcare organization
tation is complete and accurate and that the health
by
record documentation is organized and readily Within an EHR environment, HIM profes-
20
20
accessible when needed for patient care. AHIMA sionals are viewed as the experts to develop
©
defines information governance as “an organiza- workflows and infrastructure around the
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tion-wide framework for managing information EHR. As EHR technology proliferates, tra-
yr
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throughout its life cycle and supporting the orga- ditional HIM job roles continue to be more
C
nization’s strategy, operations, regulatory, legal, information technology (IT) focused. Contin-
risk, and environmental requirements” (AHIMA uing to learn and expand knowledge within
2014, 70). The governance or management of health the computer technology field and continuing
record information is a fundamental component to learn the many ways IT can be leveraged
of the overall information governance model. In- to improve the EHR infrastructure to support
formation governance applies to many categories information governance is paramount. HIM
of data, including health record information. HIM professionals and the roles they play will con-
professionals play vital and different roles in the tinue to evolve—as they will be involved in
overall governance of health record information. clinical documentation integrity (CDI), forms
For information on data governance, see chapter 6, design, screen design, data quality, and so
Data Management. much more.
AB103118_Ch04.indd 119 2/11/2020 12:24:13 PM


1. Documentation should be authenticated, accurate, legible, complete, and:
a. Based solely on clinical care
b. Based solely on reimbursement
c. Electronic
d. Timely
2. True or false: HIM professionals use the health record for coding.
3. True or false: HIM professionals are experts in the development of workflows related to the EHR.
4. Nursing documentation within the health record is:
n.
a. Subjective
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b. Objective
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c. Both subjective and objective
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d. Electronic
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5. True or false: HIM professionals document in the health record.
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HIM Roles
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Health information management roles coordinator works with physicians to ensure the
In
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within healthcare have drastically changed over documentation is completed and contains enough
ea
the past 10 to 15 years as the EHR has evolved. information to assign diagnosis and procedure
H
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As more and more healthcare entities have tran- codes. For example, the documentation should
ic
sitioned from paper-based records to electronic- identify whether the right or left radius was
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based records, traditional HIM roles have been fractured.

e
impacted. HIM professionals have readily adapt- Another role related to documentation is the an-
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ed to this impact and have taken more of a tech- alyst role. The analyst is responsible for ensuring
by
20
nical focus in response. An important role for the presence of key documents as defined by the
20
HIM professionals is the clinical documentation healthcare organization and that the health record
©
integrity coordinator. The clinical documentation entries are authenticated and dated.
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Real-World Case 4.1

The hospital clinical documentation im- documenting these conditions later in the patients’
provement (CDI) specialist reports to you, the HIM stays, making it appear that the patients have
manager of Anywhere hospital, that the hospital acquired these conditions from the hospital. The
has been receiving reimbursement penalties. The hospital is being financially penalized because
physician documentation is not appropriately iden- these conditions are considered to be preventable
tifying specific conditions that CMS has identified if the hospital follows national treatment standards
as hospital-acquired conditions (HACs). In most and guidelines.
cases, these conditions are present in patients Anywhere hospital has a robust EHR. Many
before they are admitted. However, physicians are documentation improvement initiatives have been
AB103118_Ch04.indd 120 2/11/2020 12:24:13 PM

leveraged by the technological capabilities of the and documenting these conditions would dem-
EHR. As the HIM manager, you wonder if some- onstrate that the hospital is following the national
thing could be done from a technology standpoint treatment standards and guidelines and the patients
that could assist physicians with identifying, upon are not acquiring these conditions in the hospital.
admission, those conditions that are causing the re- You assemble a multidisciplinary team consist-
imbursement issue, and appropriately documenting ing of physicians, revenue cycle representatives,
the conditions. Physicians appropriately capturing HIM, and information systems representation.
Real-World Case 4.2

You are a HIM professional working in utilized the copy and paste functionality inappro-
n.
Anywhere hospital’s HIM department. You have priately and accidentally copied health record in-
tio
been asked to review physician documentation formation from the health record of a 25-year-old
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within the hospital’s new EHR system, imple- female and pasted that information into the health
ss
mented six months ago. The goal of the review record of a 65-year-old male.
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is to catch any documentation issues early and This type of error could have patient safety
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work with the appropriate hospital leadership to concerns, as well as billing and claims issues, and
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fix those issues. the use of this functionality could open up the
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As you review the documentation in the EHR, facility to potential claims of fraud and abuse by
you notice that physicians are utilizing the copy n
the payer. You take this concern to your leader-
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and paste functionality available in the EHR, ship and a multidisciplinary group of hospital
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which allows them to select health record docu- employees including HIM professionals, nurses,
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mentation from one source or section of the EHR physicians, and billing and revenue cycle employ-
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and replicate it in another source or section of the ees to discuss and fix the problem. There are mixed
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EHR. In one instance the health record identifies opinions about the copy and paste functionality.
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a patient as a 65-year-old male (as identified dur- Some individuals feel this feature is a time-saver
er
ing the registration process), but in the progress

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and a productivity booster while others believe

notes the patient is described as a 25-year-old fe- it only opens the hospital up to additional CMS
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male who has given birth. Clearly, the physician scrutiny.

by
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20
©
References
ht
ig
yr
op
Adelman, T. 2012. Fundamentals of health law. American Health Information Management

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Fundamentals of Hospital Medical Staff Issues: Minimizing Association. 2017. Pocket Glossary of Health
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and_Time_Lines. B. Sayles. Chicago: AHIMA.

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Smith, C.M. 2001. Practice Brief: Documentation

lth
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H
/Content/files/LegalEMR_Flyer3.pdf.
an
Wiedemann, L.A. 2010. Deleting errors in the EHR.

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Am
HIMSS Knowledge Resources Task Force. 2011. The 42 CFR 482.22(c): Medical staff bylaws. 2015 (April 1).
e
th
Legal Electronic Health Record. Chicago: HIMSS. 42 CFR 482.24(c)(1): Interpretive guidelines. 2009 (June 5).
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Chapter
5
Clinical Terminologies,
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Classifications, and
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Code Systems
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Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
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Learning Objectives
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•• Identify the importance of clinical terminologies, •• Identify code systems for laboratory and clinical
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classifications, and code systems to observations; professional services, procedures, and

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healthcare supplies; and drugs

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•• Examine the content of SNOMED CT, Current •• Differentiate among clinical terminologies,
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Procedural Terminology, and terminologies used in classifications, and code systems found in health
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nursing practice data and information sets

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•• Analyze the different classification systems and •• Justify the need to have a database of clinical
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their purposes terminologies, classifications, and code systems

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Key Terms
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Axioms Functioning Nomenclature

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Classification Granular level Preferred term (PT)

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Clinical terminology Health information exchange (HIE) Reference terminology

Code set International Classification of RxNorm concept unique identifier
Code system Diseases 11th Revision for (RXCUI)
Common Clinical Data Set (CCDS) Mortality and Morbidity Semantic interoperability
Concepts Statistics (ICD-11-MMS) SNOMED CT identifier (SCTID)
Data set International Classification of Stem codes
Derived classification Functioning, Disability, and Unified Medical Language System
Disability Health (ICF) (UMLS)
Extension codes Linearization Vocabulary
Fully specified name (FSN) Morbidity
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Health information management (HIM) profession- Table 5.1 General definitions

als play a crucial role in capturing and organizing
Label Definition
clinical data. With the adoption of electronic health
Vocabulary/ A set of terms specific to a domain
records (EHRs), organizing clinical data may in- Terminology
volve several labels. For example, the Office of the Nomenclature A system of names that follows
National Coordinator for Health Information Tech- pre-established conventions
nology (ONC) uses vocabulary (a list of collection Classification A mono-hierarchical method of organizing
related terms together
of clinical words or phrases with their meanings),
Code An identifier
terminology, or code set to describe standards to
Code set An accumulation of numeric or alphanumeric
support interoperability (ONC 2018a). Vocabulary codes
is a list or collection of clinical words or phrases Code system An accumulation of terms and codes for
with their meanings. Standards organizations may exchanging or storing information
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also use the label nomenclature (a recognized sys- Source: © AHIMA.
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tem of terms that follows pre-established naming
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conventions), classification (a clinical vocabulary, healthcare industry to encode clinical data in a
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terminology, or nomenclature that lists words or
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standardized manner. Clinical terminologies are
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phrases with their meanings), or code system (an sets of standardized terms and their synonyms
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accumulation of terms and codes for exchanging that record patient findings, circumstances,
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or storing information). See table 5.1 for general events, and interventions with sufficient detail to
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definitions of each label. Nomenclature is a recog- support clinical care, decision support, outcomes
nized system of terms that follows pre-established n
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research, and quality improvement. They contain
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naming conventions. Classification is a clinical vo- terms and codes just as a code system does. As this
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cabulary, terminology, or nomenclature that lists chapter will explain, certain clinical terminologies
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words or phrases with their meanings and facili- are more appropriate for the collection of clinical
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tates mapping standardized terms to broader clas- data at a granular level (data consisting of small
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sifications or administrative, regulatory, oversight, components or details at the lowest level) such
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and fiscal requirements. A code is an identifier of as SNOMED CT. Others are best utilized for the
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data. A code set is any set of codes used to encode aggregation of clinical data for secondary data

data elements, such as tables of terms, medical con- purposes; for example, ICD-10-CM.
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cepts, medical diagnostic or procedure codes, and In addition, terminologies, classifications, and
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includes the descriptors of the codes. A code sys- code systems are a key type of data managed by
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tem is the accumulation of terms and codes for the the data governance function. Understanding
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exchange or storing of information. their purpose and use is necessary to succeed in

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This chapter discusses clinical terminologies, managing the usability of the data employed by
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classifications, and code systems used in the the healthcare organization.

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History and Importance of Clinical Terminologies,

Classifications, and Code Systems
Clinical terminologies, classifications, and code expanded to reporting diagnoses and procedures
systems exist to name and arrange medical content on claims for reimbursement. Today, the elec-
so it can be used for patient care, measuring patient tronic health record (EHR) can capture the detail
outcomes, research, and administrative activities of diagnostic studies, history and physical exami-
such as reimbursement. What started as a way to nations, visit notes, ancillary department informa-
identify causes of death for statistical purposes, tion, nursing notes, vital signs, outcome measures,
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Figure 5.1 What lies beneath?
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Source: Shulman and Stepro 2015. Used with permission.

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and any other clinically relevant observations while others are for aggregation. Table 5.2 lists ex-
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about the patient. Figure 5.1 illustrates a compari- amples of data uses and their data requirements.
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son of claims data and EHR data and the vast dif- As the table shows, granular data is needed when
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ference in clinical content. the details are key to use whereas aggregate data
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Investigating the reasons for collecting data il- suits when the combination of data provides in-
lustrates the importance of clinical terminologies, formation about related entities that is sufficient.
classifications, and code systems. If data granular- Additionally, primary and secondary data uses
ity, or detail, is the goal, then clinical terminolo- are relevant to understanding clinical terminolo-
gies are the best option. On the other hand, if the gies, classifications, and code systems. A terminol-
objective is aggregate data, then classifications ogy that allows for the collection of clinical data
are the better choice. Aggregate data is data ex- at a granular level is needed for primary data use
tracted from individual health records and may be such as for clinical decision support. One that ag-
combined to form deidentified information about gregates the data will work for secondary data
groups of patients that can be compared and ana- use. An example of secondary data use is the iden-
lyzed. With regards to code systems, some are for tification of diagnoses and procedures for the pur-
the collection of clinical data at a granular level pose of billing and payment. For more information
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Table 5.2 Examples of data uses and the requirements

Clinical terminologies,
Data use Requirement classifications, or code systems
To facilitate electronic data collection at the point of care with terms Granular data Clinical terminologies, code systems
familiar to the user
To allow many different sites and different providers the ability to send and Granular data Clinical terminologies, code systems
receive medical data in an understandable and usable manner, thereby
speeding care delivery and reducing duplicate testing and duplicate
prescribing
To allow the computer to manipulate standardized data and find Granular data Clinical terminologies, code systems
information relevant to individual patients for the purpose of producing
automatic reminders or alerts
To allow the computer to manipulate standardized data and find Granular data Clinical terminologies, code systems
information relevant to individual patients for the purpose of producing
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automatic reminders or alerts
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To allow collection and reporting of basic health statistics Aggregate data Classification systems, code systems
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To provide data that are used in designing payment systems and Aggregate data Classification systems, code systems
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determining the correct payment for healthcare services
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To provide data that are used in monitoring public health and risks Aggregate data Classification systems, code systems
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To provide data to consumers on costs and outcomes of treatment Aggregate data Classification systems, code systems
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options
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Source: Giannangelo 2015.
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on primary and secondary data, see chapter 7, building blocks. They support system interopera-
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Secondary Data Sources. bility by providing the mutual understanding of

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The determination of which clinical terminolo- the meaning of data exchanged between informa-
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gies, classifications, and code systems are used as tion systems.

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the standard is primarily driven by regulation. Congress creates legislation authorizing the es-
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Standards are critical for creating an interoperable tablishment of standards through regulatory agen-
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health information technology (IT) environment cies. For example, the Electronic Health Record
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(ONC n.d.). An interoperable health IT environ- Standards and Certification Criteria Rule defines the
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ment is one in which seamless health information standards that must be used for EHR technology to
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exchange is possible across different EHR systems be certified by the authorized Certification Bodies.
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and the information is understood and shared with Included in this rule are the content standards for
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those in need of it at the time it is needed. Clini- representing electronic health information such as
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cal terminologies, classifications, and code system SNOMED CT for problems and RxNorm for clinical
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standards are one of the ONC’s interoperability drugs, which will be discussed later in this chapter.
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Clinical Terminologies
A clinical terminology is a set of stan- information exchange. Semantic interoperability
dardized terms and codes for the healthcare indus- is the mutual understanding of the meaning of data
try for use in encoding clinical data. Examples of exchanged between information systems. Health
clinical terminologies include SNOMED CT, Cur- information exchange is when health informa-
rent Procedural Terminology, and various nursing tion is electronically traded between providers
terminologies. Clinical terminologies form the ba- and others with the same level of interoperability.
sis of coded data and provide the data structure Clinical terminologies may also be reference ter-
required for semantic interoperability and health minologies. A reference terminology in the health
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information technology (HIT) domain is “a termi- measures, and registries (Helwig 2013). For more
nology designed to provide common semantics information on registries, see chapter 7, Secondary
for diverse implementations” (CIMI 2013). Data Sources. Quality measures are discussed in
chapter 18, Performance Improvement.
SNOMED Clinical Terms SNOMED CT is also one of several standards
SNOMED Clinical Terms, or SNOMED CT, is the chosen for the entry of structured data in certified
most comprehensive, multilingual clinical health- EHR systems (ONC 2015). This includes patient
care terminology in the world (SNOMED Inter- problems, encounter diagnosis, procedures, fam-
national 2017a). There is no book of SNOMED ily health history, and smoking status. The Na-
CT codes and no coding professional assigns a tional Library of Medicine (NLM) produces the
SNOMED CT identifier. The terminology instead Clinical Observations Recording and Encoding
is implemented in software applications where (CORE) problem list subset of SNOMED CT. This
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healthcare providers record clinical information subset includes SNOMED CT concepts commonly
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using identifiers that refer to concepts that are used for encoding clinical information at a sum-
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formally defined as part of the terminology dur- mary level, such as the problem list.
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ing the process of care (SNOMED International
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2017b). It allows for the collection of clinical data SNOMED CT Content and Structure
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at a granular level. For example, at the point of SNOMED CT is made up of three main compo-
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care a physician using an EHR uses a drop-down nents—concepts, descriptions, and relationships.
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list to view the clinical terms relevant to their prac- Each component is assigned a unique, numeric,
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tice and the patient’s problem. While not seen by io
and machine-readable SNOMED CT identifier
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the physician, the clinical terms have SNOMED (SCTID). The SCTID identifier is a unique in-
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CT identifiers attached to them. By selecting the teger that includes an item identifier, a partition
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clinical term, the identifier is captured and thereby identifier, and a check-digit. It may also include a
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provides the primary source of information about namespace identifier when the component origi-
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the patient. nates in an extension. SNOMED International is-

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sues a namespace identifier to an organization

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SNOMED CT Purpose and Use

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with the responsibility of creating, distributing,

SNOMED CT’s overall purpose is to standard- and maintaining a SNOMED CT extension. An
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ize clinical phrases, making it easier to produce extension occurs when the SNOMED CT Interna-
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accurate electronic health information. Doing so en- tional release does not contain content needed at
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ables automatic interpretation and sharing of clin- the national, local, or organizational level.
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ical information. Semantic interoperability is also The SCTID is nonsemantic; therefore, no mean-
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possible. (Semantic interoperability is discussed ing is inferable from the numerical value of the
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in more detail in chapter 11, Health Information identifier or from the sequence of digits. Figure 5.2
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Systems.) provides an example of the SCTID for the concept

With the consistent, reliable, and comprehen- nosocomial pneumonia found in the international
sive capture of clinical phrases with SNOMED CT, edition and Figure 5.3 shows the SCTID for disor-
its uses and benefits are many. der of right lower extremity found in the US na-
With the SNOMED CT encoded data sent se- tional extension. The partition identifier of 00 and
curely during the transfer of care to other pro- 10 indicates the nature of the component identi-
viders or to patients, the barriers to the electronic fied is a concept.
exchange are reduced resulting in improved qual- Concepts are a unique unit of knowledge or
ity of the information. SNOMED CT coded data thought created by a unique combination of char-
combined with other encoded data, such as med- acteristics. SNOMED CT defines a concept as “a
ication and lab results, have a number of uses in- clinical idea to which a unique concept identifier
cluding clinical decision support, clinical quality has been assigned” (SNOMED International 2018).
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Figure 5.2 SCTID for the concept nosocomial pneumonia SNOMED CT International Edition 20180731
release
Item identifier Partition identifier
SCTID 425464 00 7
Check-digit
Source: © AHIMA.
Figure 5.3 SCTID for the concept disorder of right lower extremity US national extension 20180901 r elease
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Extension item identifier Partition identifier
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SCTID 45142 1000124 10 2
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Namespace identifier Check-digit
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Source: © AHIMA.
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Examples of clinical concepts are diagnoses (for ex- Associated morphology: inflammation
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ample, coronary arteriosclerosis) and procedures and consolidation

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(for example, coronary artery bypass grafting). Finding site: lung structure
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A concept has only a single meaning even though
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more than one term may be associated with a con- An example of a primitive concept is unsolved
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cept. The SNOMED CT concept definition is a set of lobar pneumonia. Its characteristics are:
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one or more axioms, or true statements, that serve as Unsolved lobar pneumonia is a lobar
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a starting point for further reasoning and arguments pneumonia
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(SNOMED International 2017a). The axioms may ei-

Unsolved lobar pneumonia is an unsolved
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ther partially or sufficiently specify the SNOMED
pneumonia
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CT concept’s meaning. When the defining char-

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acteristics are enough to define the concept in the ●● Unsolved lobar pneumonia has the
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following attributes:
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context of its hierarchy, it is sufficiently defined. In

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Associated morphology: inflammation

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the case of a concept that does not have the required

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characteristics to distinguish it from similar con- and consolidation

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cepts, it is partially defined; that is, it is a primitive Finding site: structure of lobe of lung
concept. The concept nosocomial pneumonia is suf-
Descriptions are human-readable representa-
ficiently defined by the following characteristics:
tions of concepts. A SNOMED CT concept may
●● Nosocomial pneumonia is a healthcare- have multiple descriptions. Each is designated a
associated infectious disease description type: a fully specified name or a syn-
onym. In SNOMED CT the fully specified name
●● Nosocomial pneumonia is an infective
(FSN) is the unique text assigned to a concept
pneumonia
that completely describes it, and the synonym
●● Nosocomial pneumonia has the following is an alternative way to describe the meaning
attributes: of the concept in a specific language or dialect.
Pathological process: infectious process More than one synonym may exist. One of the
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synonyms is noted as the preferred term and is target concepts of inflammation (associated mor-
the description or name assigned to a concept phology) and hand joint structure (finding site).
that is used most commonly in a clinical record
or in literature for a specific language or dialect. Current Procedural Terminology
In the example of transient cerebral ischemia, the The American Medical Association (AMA) owns
fully specified name is transient ischemic attack the copyrights to Current Procedural Terminology
(disorder). The term enclosed in parentheses (CPT). According to the AMA, “CPT is the most
at the end is called the semantic tag. It allows widely accepted nomenclature for the reporting
differentiation among concept domains such as of physician procedures and services under gov-
ulcer (disorder) from ulcer (morphologic abnor- ernment and private health insurance programs”
mality). Examples of synonyms for transient is- (AMA 2018). The CPT Editorial Panel in consulta-
chemic attack (disorder) are transient cerebral tion with medical specialty societies represented
n.
ischemia, temporary cerebral vascular dysfunc- by the CPT Advisory Committee is responsible for
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tion, and transient ischemic attack. In the case of maintaining the terminology.
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transient ischemic attack (disorder) the preferred CPT identifies the services rendered rather than
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term is transient cerebral ischemia for the English
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the diagnosis on the claim. The International Clas-
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language, US dialect. sification of Diseases (ICD), which identifies the
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Relationships are a type of connection between diagnosis, is discussed later in this chapter. CPT
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two concepts; for example, a source concept and ICD form units of information about a patient
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and a destination concept. These relationships visit in that the diagnosis represented by ICD sup-
between SNOMED CT concepts define them. n
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ports the medical necessity of the service repre-
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Structured according to logic-based representa-
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sented by CPT.
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tion of meanings, they form the poly-hierarchical CPT is published annually as a print and
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structure of SNOMED CT. At the top of the e-book. It is also available in software applications
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h ierarchy is the root concept. D escended from such as physician practice management systems.
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the root concept are specific domain hierarchies. Assignment of the CPT code is most often the
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For example, coronary arteriosclerosis belongs to responsibility of a professional coder based on

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the clinical finding domain hierarchy while coro- the healthcare provider’s documentation of the
nary artery bypass grafting belongs to the proce- medical services or procedures provided.
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dure domain hierarchy. Figure 5.4 shows how

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the concept arthritis of the knee belongs only to CPT Purpose and Use
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the clinical finding domain hierarchy. The purpose of CPT is to provide a uniform lan-
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Values of a range of relevant attributes make up guage that allows for accurate descriptions of med-
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the defining characteristics of a concept (SNOMED ical, surgical, and diagnostic services. It is designed
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International 2018). Defining characteristics in- to communicate consistent information about med-
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clude the “is a” relationship and defining attri- ical services and procedures among physicians,
bute relationships. The “is a” relationship type clinical staff, patients, accreditation o
rganizations,
indicates the source concept is a subtype of the and payers for administrative, financial, and ana-
destination concept. For example, figure 5.4 lytical purposes.
shows the “is a” relationship type indicating ar- Despite being copyrighted by the AMA, the
thritis of knee is a subtype of arthropathy of knee Health Insurance Portability and Accountabil-
joint. The defining attribute relationship is not ity Act (HIPAA) mandates the use of the CPT in
found in all domain hierarchies. For example, the healthcare data electronic transactions. HIPAA
defining attribute relationships for rheumatoid named CPT (including codes and modifiers) as
arthritis of hand joint, associated morphology the procedure code set for all but hospital inpa-
and finding site, are used to associate the source tient procedures. CPT codes are the five-character
concept rheumatoid arthritis of hand joint to the identifiers that represent the service or procedure
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Figure 5.4 SNOMED CT design
SNOMED CT DESIGN
ROOT Concepts Hierarchies Attributes Identifiers Descriptions Relationships
CONCEPT
SNOMED CT Heart failure (disorder)

SNOMED CT HIERARCHIES 84114007 Weak heart
Concepts are organized into top-level
hierarchies Cardiac failure
HF – Heart failure
• Body structure Is a
• Clinical finding Myocardial failure
• Environment or geographical Low granularity
location
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Finding by site
• Event
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• Linkage concept
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Is a
• Observable entity
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• Organism Musculoskeletal finding
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RELATIONSHIPS
• Pharmaceutical/biologic product
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• Physical force Is a Is a relationships connect
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• Physical object concepts in a hierarchy
Joint finding
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• Procedure
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• Qualifier value Is a Arthropathy Is a Joint finding
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• Record artifact
Arthropathy
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• Situation with explicit context
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• Social context
• Special concept
Is a io Attribute relationships connect concepts
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Arthropathy of knee in different hierarchies
• Specimen
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• Staging and scales

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Associated
Is a Appendicitis Inflammation
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• Substance morphology
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Arthritis of knee
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High granularity
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SNOMED CT DEVELOPMENT AND RELEASES

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IHTSDO Members Reference Sets Implementation Users Purposes

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Member country YY
• Development
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National Release Center

• Maintance • Clinical
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• Education documentation
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SNOMED CT ‘YY
• Distribution National’ Edition • Semantic
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Release: month/year
• Releases
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Member country XX interoperability

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• Decision support
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SNOMED CT international
SNOMED
‘SNOMED CTCTinternational
Core’ • Data retrieval
‘SNOMED CTinternational
Core’
SNOMED
Release:
Release:
SNOMED
CT
month/year
month/year
‘SNOMED CT
CTinternational
Core’
SNOMED CT ‘XX
National’ Edition
• Analytics
....
‘SNOMED
Release: CT Core’
month/year Release: month/year • Statistics
Release: month/year
• Information
Member country ZZ management
• Etc.
SNOMED CT ‘ZZ
National’ Edition
Release: month/year
Source: SNOMED International 2017b. Used with permission.
the individual receives from a healthcare provider. Thus, physicians and hospitals must use CPT to
Two-character modifiers indicate the service or report medical and procedure services performed
procedure performed has been altered by some by physicians and other healthcare professionals
circumstance but not changed in its definition. to public as well as private insurers.
AB103118_Ch05.indd 130 2/6/2020 4:54:41 PM

CPT Content and Structure e vidence base as contributing to quality patient care.
CPT includes codes, descriptions, and guidelines They represent clinical findings or services where
and covers the breadth of health services physi- there is strong evidence of contribution to health out-
cians provide. Descriptions for evaluation and comes and high-quality care. The Level II codes are
management services such as a new patient of- alphanumeric, consisting of four numbers followed
fice visit, anesthetic services, surgical procedures, by the letter F. The following is an example of a
radiology services, pathology and laboratory tests, Category II CPT service along with its identifier:
and medical care are all found in CPT. The Centers 1065F Ischemic stroke symptom onset of less
for Medicare and Medicaid Services (CMS) catego- than 3 hours prior to arrival
rizes CPT as Level I of the Health Care Common
Procedure Coding System (HCPCS) discussed Category III CPT is for emerging technologies,
later in this chapter. services, and procedures. They are considered
n.
CPT is divided into categories: Category I, Cat- temporary and they may or may not eventually be
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moved to Category I. Category III codes are alpha-
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egory II, and Category III. Category I is the major
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terminology. It contains a description along with numeric, consisting of four numbers followed by
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the letter T. The following is an example of a Cat-
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a five-digit code for each service or procedure.
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Two-digit modifiers are available to qualify the egory III CPT procedure along with its identifier:
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service or procedure. For example, the modifier 50
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0345T Transcatheter mitral valve repair
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is used to indicate a bilateral procedure. Criteria for percutaneous approach via the coronary sinus
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inclusion in Category I include the US Food and
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Drug Administration has approved the service or
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CPT also includes an introduction, an index, and
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appendices. Within the introduction are section
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procedure, many providers in different locations

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perform it, and it is clinically effective. numbers and their sequences and instructions for
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use of CPT. The index is used to locate a code or

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Category I CPT includes the following six main

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sections: code range and is organized by main and modi-

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fying terms. Appendices provide information to

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1. Evaluation and Management (E/M)

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supplement the main portion of CPT. For example,

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2. Anesthesia Appendix A, Modifiers, describes all the modifiers

available for use with a CPT code.
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3. Surgery
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4. Radiology
Nursing Terminologies
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5. Pathology and Laboratory

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Just as the field of nursing covers a wide range

6. Medicine
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of services, so do the terminologies available to

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The following are examples of Category I CPT identify those services. The choice of terminology
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services along with their identifiers: depends on the nursing care documented. In ad-
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dition, some are location specific. For example, the

33511 Coronary artery bypass, vein only: 2 Nursing Outcomes Classification (NOC) may be
coronary arteries used to represent the outcomes of nursing inter-
71046 Radiologic examination, chest; 2 views ventions in all settings and the Omaha System is
82951 Glucose; tolerance test (GTT), 3 used in the home health setting.
specimens (includes glucose)
Nursing Terminologies Purpose and Use
90839 Psychotherapy for crisis; first 60 minutes
Nursing terms provide an effective basis for use
Category II CPT is used for performance measure- in contemporary data systems (Warren 2015, 218).
ment. This category was created to support data col- The American Nursing Association (ANA) has
lection about the quality of care rendered by coding specific criteria nursing terminologies must meet
certain services and test results that support nationally to be approved. This includes support of all or
established performance measures and have an part of the nursing process such as assessment and
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iagnosis. Several organizations, including univer-

d Table 5.3 Content coverage of ANA-recognized
sities and associations, are responsible for nursing nursing terminologies
terminology development and maintenance.
ANA-recognized
The purpose of nursing terminologies is to rep- nursing terminology Content coverage
resent clinical information generated and used by NANDA International Thirteen domains:
nursing staff (Warren 2015, 207). Nursing termi- 1. Health promotion
2. Nutrition
nologies are designed to communicate consistent 3. Elimination/exchange
information about nursing services for a variety of 4. Activity/rest
reasons including directing patient care, measuring 5. Perception/cognition
6. Self-perception
progress of treatment, as well as for administrative 7. Role relationship
functions, education, and analytical purposes. 8. Sexuality
9. Coping/stress tolerance
Although there is no mandate to use nursing
10. Life principles
n.
terminologies, the ANA’s board of directors pub- 11. Safety/protection
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lished a position statement regarding the inclu- 12. Comfort
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13. Growth/development
sion of recognized terminologies within EHRs as
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Nursing Interventions Seven domains:
well as other HIT applications. The ANA indicated
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Classification (NIC) 1. Physiological: Basic
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support for the following recommendations: 2. Physiological: Complex
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3. Behavioral
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●● Plan implementation of terminologies 4. Safety
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5. Family
Obtain consensus on which terminology to use
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●●
6. Health system
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●● Make education and guidance available to io 7. Community
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assist with choosing the terminology Nursing Outcomes Seven domains:
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Classification (NOC) 1. Functional health

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Use SNOMED CT and LOINC for problems 2. Physiologic health

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●●
3. Psychosocial health
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and care plans when exchanging data

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4. Health knowledge and behavior

among settings
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5. Perceived health

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●● An exchange between providers using the 6. Family health

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7. Community health

same terminology requires no conversion to
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Clinical Care Classification Two taxonomies:

SNOMED CT or LOINC (CCC) 1. CCC of nursing diagnoses and
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outcomes
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●● A clinical data repository involving multiple

2. CCC of nursing interventions
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terminologies draws from national recognized and actions

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terminologies of ICD-10, CPT, RxNorm,

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Omaha System Three components:

SNOMED CT, and LOINC (ANA 2018) 1. Assessment
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2. Intervention
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3. Outcomes
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Nursing Terminologies Content and Structure

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International Classification Multiaxial representation with

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for Nursing Practice (ICNP) seven axes:

Each nursing terminology covers content specific to 1. Focus
its use. Table 5.3 lists the content coverage of some 2. Judgment
of the ANA-recognized nursing terminologies. 3. Means
4. Action
The structure also varies among terminolo- 5. Time
gies. For example, each nursing intervention in 6. Location
the Nursing Interventions Classification (NIC) 7. Client
includes a label name, definition, unique number Source: Matney 2019, TK.
(code), set of activities to carry out the intervention,

and background readings, whereas each nursing a target outcome rating, a place to identify the
outcome in the Nursing Outcomes Classification source of the data, a scale to measure patient sta-
(NOC) includes a definition, list of indicators tus, and a short list of references used in develop-
for evaluating patient status in relation to o utcome, ing the outcome (Matney 2019, TK).
AB103118_Ch05.indd 132 2/6/2020 4:54:41 PM


1. True or false: Category I CPT includes E/M, anesthesia, surgery, radiology, pathology and laboratory, and medicine.
2. True or false: The three main core components of SNOMED CT are the SNOMED CT identifier, concepts, and
descriptions.
3. True or false: The SNOMED CT preferred term includes the semantic tag.
4. True or false: Nursing terminologies are used for reimbursement of nursing care for Medicare patients.
5. True or false: If data granularity is the goal of colleting the data, clinical terminologies are the best choice.
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Classifications
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Classifications are key to secondary always occurs; the April update occurs when it is
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data use because they aggregate clinical data for necessary for improving the timelessness of data
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healthcare statistics, design payment systems, collection. Twice a year the ICD-10 Coordination
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and determine the correct payment for healthcare and Maintenance (C&M) Committee holds public
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services. They also provide data that are used in meetings to review proposals for ICD-10-CM revi-
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monitoring public health risks. Information can be sions. Representatives from NCHS are members
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obtained from data encoded with a classification of this committee and, based on their advice, the
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to improve clinical, financial, and administrative director of NCHS makes the final decisions on
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performance. Some of these classification systems ICD-10-CM revisions.

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are discussed in the following sections. Assignment of the ICD-10-CM code is most of-
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ten the responsibility of a professional coder based

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International Classification of on the healthcare provider’s documentation of the

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Diseases, Tenth Revision, Clinical patient’s diagnosis.

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Modification
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The National Center for Health Statistics (NCHS) ICD-10-CM Purpose and Use
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is the governmental body responsible for the The purpose of ICD-10-CM is to provide a clas-
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maintenance of ICD-10-CM. It originates from sification of diseases for morbidity. Morbidity is

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the World Health Organization’s International Sta- the state of being diseased including illness, injury,
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tistical Classification of Diseases and Related Health or deviation from normal health. It is intended to
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Problems, Tenth Revision (ICD-10). However,

classify diagnoses established by physicians at the
ICD-10-CM greatly expands the classification, re- conclusion of a patient encounter.
sulting in greater specificity and clinical detail. ICD-10-CM has many uses. All of those identified
ICD-10-CM identifies the diagnosis established previously for classifications apply to ICD-10-CM.
by the provider. An example is the ICD-10-CM One use is mandated by HIPAA, which specifies the
code and the CPT code result (diagnosis of pause of national standards for electronic healthcare
tient and procedure performed) in a package of transactions. ICD-10-CM (including the official
information about a patient visit performed in the ICD-10-CM guidelines for coding and reporting)
physician’s office. This bundle is an example of ag- is named as the standard for diseases, injuries,
gregate data that can be used for many purposes. impairments, other health-related problems, their
ICD-10-CM can be updated twice a year, in manifestations, and causes of injury, disease,
October and April, by NCHS. The October update impairment, or other health-related problems.
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Thus, healthcare providers must report diagnoses in the index is organized by main and modifying
to public as well as private insurers using ICD-10-CM. terms. Main terms represent the condition of the
patient and modifying terms further explain the
ICD-10-CM Content and Structure condition. For example, failure is the main term
ICD-10-CM contains three to seven-character codes and congestive heart the modifying terms for the
and descriptions for patient conditions. This in- diagnosis of congestive heart failure.
cludes symptoms, syndromes, diseases, and other
reasons for patients requiring healthcare services. ICD-10-Procedure Coding System
Instructions, referred to as conventions, are also a The Centers for Medicare and Medicaid Services
part of the classification. These are general rules to (CMS) is the federal agency responsible for the
apply when using ICD-10-CM. ICD-10-Procedure Coding System (ICD-10-PCS). It
ICD-10-CM is divided into 21 chapters. Many was developed through a contract with 3M Health In-
n.
are based on a body system; others are for certain formation Systems and is being maintained by CMS.
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types of conditions such as pregnancy. Within each Like CPT ICD-10-PCS identifies the procedure
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chapter are blocks of conditions related in some performed by the provider. However, ICD-10-PCS
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manner, such as a single disease entity, categories,
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was created as the companion to ICD-10-CM and
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subcategories and, when appropriate, subclassifi- not as a replacement for CPT. A diagnosis coded in
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cations. Figure 5.5 displays the blocks for Chapter 4, ICD-10-CM code combined with a procedure cod-
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Endocrine, Nutritional, and Metabolic Diseases, ed in ICD-10-PCS would be used by a hospital to
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category E11, subcategory E11.2, and subclassifi- explain the reason for a patient being admitted and
cation E11.21. n
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discharged for care and the inpatient procedures
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Another component of ICD-10-CM is the alpha-
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performed during the stay. The aggregated data are

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betic index. There are two major sections to the al- used to determine hospital payment under the in-
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phabetic index—the Index to Diseases and Injuries patient prospective payment system discussed in
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and the Index to External Causes. Two tables—one chapter 15, Revenue Management and Reimbursement.
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for neoplasm and the other for drugs and chem- Updates are possible for ICD-10-PCS twice a
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icals—are also included in the index. All content year on April 1 and October 1. The April update is
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Figure 5.5 Chapter 4, Endocrine, Nutritional, and Metabolic Diseases blocks, category, subcategory,
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and subclassification
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Blocks
E00-E07 Disorders of thyroid gland
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E08-E13 Diabetes mellitus

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E15-E16 Other disorders of glucose regulation and pancreatic internal secretion

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E20-E35 Disorders of other endocrine glands

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E36-E36 Intraoperative complications of endocrine system

E40-E46 Malnutrition
E50-E64 Other nutritional deficiencies
E65-E68 Overweight, obesity and other hyperalimentation
E70-E88 Metabolic disorders
E89-E89 Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified
Category E11
E11 Type 2 diabetes mellitus
Subcategory E11.2
E11.2 Type 2 diabetes mellitus with kidney complications
Subclassification E11.21
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
Source: NCHS 2018.
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available to address new technologies whereas the ●● Extracorporeal or systemic therapies

October 1st update happens yearly. CMS repre- ●● Osteopathic
sentatives on the ICD-10 Coordination and Main-
●● Other procedures
tenance (C&M) Committee provide advice to the
administrator of CMS who makes the final deci- ●● Chiropractic
sions on ICD-10-PCS revisions. CMS makes data Ancillary sections
files for software vendors and publishers to produce ●● Imaging
online and print ICD-10-PCS products available
●● Nuclear medicine
on their website.
Upon discharge of the patient from the hospital, ●● Radiation therapy
a professional coder assigns the ICD-10-PCS code ●● Physical rehabilitation and diagnostic
based on the physician documentation. audiology
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Mental health
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●●
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ICD-10-PCS Purpose and Use Substance abuse treatment
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●●
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The purpose of ICD-10-PCS is to provide a sys- New technology
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●●
tem for classifying procedures performed on hos-
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ICD-10-PCS is made up of a number of parts in-
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pital inpatients. It provides a unique code for all
cluding tables, an index, and definitions. The ta-
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substantially different procedures, both currently
bles are arranged in alphanumeric order and are
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known and those that may be identified at some
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formatted as a grid that lays out the valid combi-
future date in time.
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nations of character values for a procedure code.
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Uses for ICD-10-PCS include those identified
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There are two parts to the table. The upper portion

for classifications in general. Just as HIPAA man-
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lists the first three characters and their definition,

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dates ICD-10-CM, there is also a requirement for

and the lower portion contains columns for the
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ICD-10-PCS. ICD-10-PCS (including the official

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remaining four characters. Each column lists the

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ICD-10-PCS guidelines for coding and reporting)

possible options for completing the seven-character
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is the standard for preventive, diagnostic, thera-

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code. Figure 5.6 shows an ICD-10-PCS table.

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peutic, or other management procedures or other

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ICD-10-PCS has an alphabetic index organized

actions taken for diseases, injuries, and impair-
by two types of main terms. One type is based on
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ments on hospital inpatients reported by hospitals.

common procedure names such as cholecystectomy
by
Hospitals are required to use ICD-10-PCS to report

and the other type on the value of the third character
20
procedures to public as well as private insurers.

20
of the seven-character ICD-10-PCS code. The mean-

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ing of the third character varies depending on the

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ICD-10-PCS Content and Structure

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section. For example, the third character value for

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ICD-10-PCS contains seven-character codes and

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the medical and surgical procedure section is root

descriptions for procedures. Most of ICD-10-
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operation or the objective of the procedure. Resec-

PCS describes medical and surgical procedures. tion, as shown in table 5.4, is one of the root opera-
The other sections are divided into the following tions and is listed as a main term in the index.
groups: Another part of ICD-10-PCS is the definitions.
Medical and surgical-related sections Arranged in section order, definitions are tied to
●● Obstetrics the values of characters 3 through 7 of the seven-
●● Placement character code. Explanations and examples may
also be included with the definitions to aid in under-
●● Administration
standing how the character value is to be applied.
●● Measurement and monitoring To illustrate, the definitions and any associated ex-
●● Extracorporeal or systemic assistance and planation and examples for the third through fifth
performance characters are shown for T, 0, and 0 in table 5.4.
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Figure 5.6 Example of an ICD-10-PCS table
OFT
Section 0 Medical And Surgical
Body System F Hepatobiliary System and Pancreas
Operation T Resection: Cutting out or off, without replacement, all of a body part
Body Part Approach Device Qualifier
0 Liver 0 Open Z No Device Z No Qualifier
1 Liver, Right Lobe 4 Percutaneous Endoscopic
2 Liver, Left Lobe
4 Gallbladder
G Pancreas
5 Hepatic Duct, Right 0 Open Z No Device Z No Qualifier
6 Hepatic Duct, Left 4 Percutaneous Endoscopic
8 Cystic Duct
9 Common Bile Duct 7 Via Natural or Artificial
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C Ampulla of Vater Opening
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D Pancreatic Duct 8 Via Natural or Artificial
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F Pancreatic Duct,
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Opening Endoscopic
Accessory
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Source: CMS 2018.
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Table 5.4 Example of ICD-10-PCS characters
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Character 3 - Operation T Resection
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ICD-10-PCS Value Definition io
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Resection Definition: Cutting out or off, without replacement, all of a body part
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Includes/examples: Total nephrectomy, total lobectomy of lung

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Character 4 - Body Part O Liver

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ICD-10-PCS Value Definition

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Liver Includes: Quadrate lobe

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Character 5 - Approach O Open

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ICD-10-PCS Value Definition

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Open Definition: Cutting through the skin or mucous membrane and any other
body layers necessary to expose the site of the procedure
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by
Source: CMS 2018. Created from publicly available data from the Centers for Medicare and Medicaid Services.
20
20
(other and unspecified) are generated. For exam-

International Classification of
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ple, the International Classification of Diseases

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Diseases 11th Revision

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11th Revision for Mortality and Morbidity Statis-

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The foundation component of the International tics (ICD-11-MMS) is a linearization of the ICD-11
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Classification of Diseases 11th Revision (ICD-11) is foundation component. ICD-11-MMS will replace
a network of knowledge placed into a database. the World Health Organization (WHO)’s ICD-10.
It is from the foundation component that a line- NCHS has not yet decided if a US specific lineari-
arization and country-specific modifications are zation will be created as a possible replacement for
built. A linearization is a subset of the foundation ICD-10-CM.
component; once created the subset becomes the The establishment of a collaborative open de-
Tabular list. The Tabular list is built for a use case, velopment and maintenance process results in
such as reporting mortality and morbidity or pri- the ICD development version being continuously
mary care. The entities selected from the founda- updated. However, WHO plans to produce an an-
tion become categories that are jointly exhaustive nual official release for international mortality and
and mutually exclusive of each other. Each cate- morbidity use. The first version of ICD-11-MMS
gory has a single parent and residual categories was made available on June 18, 2018, and is meant
AB103118_Ch05.indd 136 2/6/2020 4:54:42 PM

to be used in preparation for implementation. The ICD-11 Foundation Component and ICD-11-MMS
WHO member states agreed to adopt the eleventh Content and Structure
revision of ICD-11 at their world assembly in May ICD-11-MMS has 26 chapters, one supplemental
of 2019 with reporting using ICD-11 to come into section, and an extension code chapter. Many of
effect on January 1, 2022 (WHO 2019). the 26 chapters are the same as in ICD-10. How-
The advancements in the information technol- ever, new content expands the classification into
ogy field and WHO’s intent with ICD-11 to make areas not covered in the past. For the first time
better use of the digital world may mean the proc- WHO includes ancient Chinese Medicine disor-
ess for ICD-11 code assignment evolves as well. ders and patterns, which allows for the recording
Technology advancements occurring in areas such of epidemiological data about these conditions.
as artificial intelligence (AI), specifically natural The supplementary section for functioning assess-
language processing and machine learning, may ment is available as well. There are also new chap-
n.
result in the initial assignment of the ICD-11 code ters for sleep-wake disorders, conditions related to
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“automatically” based on the healthcare provid-
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sexual health, and extension codes.
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er’s documentation of the patient’s condition by The ICD-11 foundation component includes a
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the time ICD-11 is implemented. An OptumIQ
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uniform resource identifier (URI). This identifier is
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survey of healthcare senior executives on AI con- a unique character string for each entity. For exam-
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cluded three-quarters of healthcare facilities are ple, the foundation URI for combined diastolic and
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actively implementing or have plans to execute an
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systolic hypertension is http://id.who.int/icd/
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AI strategy (Optum 2018). entity/1917449952. The foundation component al-
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lows for an entity to be classified in more than one
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ICD-11 Foundation Component and ICD-11-MMS
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place, that is an entity may have more than one

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Purpose and Use parent. In the case of influenza, certain infectious

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WHO embarked on the revision of ICD-11 in 2000

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or parasitic diseases, lung infections, and infec-

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with the goal to produce a classification that re- tions due to influenza virus are its parents.
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flects scientific and medical advances, can be in-

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ICD-11-MMS contains stem codes and extension

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tegrated with electronic health applications and codes. A stem code is a standalone code and can
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information systems, and makes it significantly be a single entity or a combination of clinical detail
easier for healthcare organizations to implement.
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(WHO 2018b). An extension code starts with a X,

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Accessibility and ease of use were important con- adds detail to the stem code, and must be used with
by
siderations as was instituting a collaborative open

20
it. Combinations of stem codes or a stem code and

20
development and maintenance process. In addi- extension code(s) result in a string of codes. WHO
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tion, WHO wanted to improve links to terminolo- requires a forward slash (/) or an ampersand (&)
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gies such as SNOMED CT and derived and related and a syntax showing what codes belong together.
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classifications such as the International Classifi- Code CA40.0Y&XN9YS is the string for Pneumo-
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cation of Functioning, Disability, and Health and nia due to Legionella pneumophila where the stem
International Classification of Diseases for Oncol- code CA40.0Y identifies pneumonia due to other
ogy, both of which are discussed the following specified bacteria and the extension code XN9YS
section. identifies Legionella pneumophila. The amper-
While ICD’s primary purpose is to classify dis- sand (&) combines the two. Code BD54/5A11 is
eases and injuries, the ICD-11 foundation compo- an example of two stem codes. This string is for di-
nent’s entities also include external causes, signs, abetic foot ulcer (BD54) where the cause of the foot
symptoms, abnormal findings, complaints, and ulcer is type 2 diabetes (5A11). A forward slash (/)
social factors found in a wide range of health separates two stem codes.
records. ICD use includes mortality, morbidity,
A code has a minimum of four characters. The
epidemiology, case mix, quality and safety, and first character, either a number or letter, signifies the
primary care (WHO 2018a). chapter number. To not confuse an ICD-11-MMS
AB103118_Ch05.indd 137 2/6/2020 4:54:42 PM

code with one in ICD-10, the second character is a WHO updates ICF once a year in October. While
letter. The third character is a number to prohibit the application of the ICF concepts and framework
the spelling of “undesirable words.” For any char- in clinical practice is the responsibility of health
acter where a letter is an option, the letters “O” professionals such as physical therapists, the indi-
and “I” are not allowed to avoid confusion with vidual or the individual’s advocate is an integral
the numbers “0” and “1.” Some examples of ICD- part of the assessment.
11-MMS codes and descriptions are MC18 Ocular
pain, BA40.0 Unstable angina, and NC72.20 Frac- ICF Purpose and Use
ture of neck of femur, subcapital. WHO specifies four primary ICF purposes:
Conventions are also a part of ICD-11-MMS.
These include instructions such as code also or 1. To provide a scientific basis for understanding
use additional code. The ICD-11-MMS Reference and studying health and health-related states,
outcomes, and determinants
n.
Guide contains information on the conventions
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and instructions on how to apply them. Another 2. To establish a common language for
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component of ICD-11-MMS is the alphabetic in- describing health and health-related states
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dex, a list of clinical terms (including synonyms or to improve communication between
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different users, such as healthcare workers,
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phrases) used to locate the codes or code combina-
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tions for conditions. researchers, policy makers and the public,
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including people with disabilities
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3. To permit comparison of data across countries,
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healthcare disciplines, services, and time
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Functioning, Disability, and Health
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4. To provide a systematic coding scheme for

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International Classification of Functioning, Dis- health information systems (WHO 2018d)

In
ability, and Health (ICF) is one of the three refer-

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ICF has a variety of uses including clinical prac-

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ence classifications approved by the WHO Family

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tice, for population-based census or survey data,

of International Classification (WHO-FIC) Net-
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in educational systems, policy making, and ad-

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work. A WHO reference classification is a product

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vocacy. Although considered during clinical data

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of international agreements, is broadly accepted

content standards discussions, the US has no
for international reporting on health, and may be
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federal mandate that requires ICF be used.

used as a model for the development or revision
by
of other classifications (Madden et al. 2012). Ac-

20
20
cording to WHO, “ICF is the WHO framework for ICF Content and Structure
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measuring health and disability at both individual ICF is both a model and a classification. The ICF
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and population levels” (WHO 2018c). model is a nonlinear, systemic, biopsychosocial

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ICD is also a WHO-FIC Network reference clas- model consisting of multiple components includ-
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sification. ICD classifies heath conditions, whereas ing Health Condition, Body Functions and
ICF classifies states of functioning, disability, and Structures, Activities and Participation, Contex-
health. For example, a patient with a spinal cord tual Factors (that is, Environmental and Personal
injury with moderate impairment with control Factors), and Umbrella Terms. Functioning is the
of voluntary movement would be represented umbrella term for Body Functions, Body Struc-
with an ICD code for condition of the patient, spi- tures, Activities and Participation. It denotes the
nal cord injury, and an ICF code for the level of positive or neutral aspects of the interaction be-
functioning, moderate impairment with control tween the health condition and contextual factors;
of voluntary movement. ICF provides a standard for example, completing the daily routine. Disabil-
language, terms, and concepts and an organized ity is the umbrella term for impairments, activity
data structure for health and disability informa- limitations, and participation restrictions. It denotes
tion (WHO 2013). the negative aspects of the interaction between an
AB103118_Ch05.indd 138 2/6/2020 4:54:42 PM

individual and that individual’s contextual fac- ICD-O-3 was published in 2000 with correc-
tors. An example is a person with a panic disor- tions added in 2001 and 2003. WHO produced
der has anxiety, which limits their ability to go out an additional update—ICD-O-3.1—in 2011. Both
alone, leading to no social relationships. ICD-O-3 and ICD-O-3.1 are searchable online
As a classification, ICF includes four code through WHO’s International Agency for Research
components—Body Structures, Body Functions, on Cancer web page.
Activities and Participation, and Environmental
Factors. The ICF model component health condi- ICD-O-3 Purpose and Use
tion is described by ICD-10. The purpose of ICD-O-3 is to classify diseases for
The first level of classification is the chapter and oncology, a branch of medicine that focuses on tu-
branches are the tiered levels of the classification mors. Data collected via ICD-O-3 is reported to state,
(Porter 2019, 305). An example of this structure is national, and North American cancer registries.
n.
shown as follows. The ICD-O-3 data have uses including the
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following:
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●● Body Structures (code component)
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7 Chapter 7 Structures related to move-
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Planning and evaluating the patient’s case
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●●
ment (chapter = first-level classification)
management
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730 Structure of the upper extremity
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(first branch = second-level ●● Administrative information for facility
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planners, cancer committees, and
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classification)
practitioners
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7301 Structure of forearm (second
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branch = third-level classification) ●●
io Developing and evaluating cancer control
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73010 Bones of forearm (third programs

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branch = fourth level of Cancer research (NCI n.d.)

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●●
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classification) (WHO 2017)

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ICD-O-3 Content and Structure

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ICD-O-3 is a dual classification. It contains a set of

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Diseases for Oncology, Third Edition

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codes for topography and morphology of tumors.

International Classification of Diseases for Oncology, The site of origin of the neoplasm is captured by
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Third Edition (ICD-O-3) is a derived classification the topography code. This code is the same four-
by
of the WHO Family of International Classifica- character category as in the malignant neoplasm
20
20
tions and is based on ICD. A derived classifica- section of the second chapter of ICD-10. The ex-
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tion is one based on a reference classification such ceptions are those categories that relate to second-
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as ICD or ICF by adopting the reference classi- ary neoplasms and to specified morphological
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fication structure and categories and providing types of tumors. In addition, ICD-O-3 includes a
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additional detail or through rearrangement or topography for specific types of tumors such as
aggregation of items from one or more reference reticuloendothelial tumors.
classifications. With very few histological types available in
Tumor or cancer registries regard ICD-O-3 as ICD-10, ICD-O-3 provides greater detail of the
their system for classifying the topography and histological classification. The morphology code
morphology of neoplasms. Topography refers to describes the characteristics of the tumor itself, in-
the anatomical site of a neoplasm’s origin and mor- cluding cell type and biologic activity. For exam-
phology refers to the structure and form. Specifi- ple, code M8170/3 is a hepatocellular carcinoma
cally, morphology pertains to cell type or histology where the first four digits indicate the histological
and the neoplasm’s biological activity or behavior. term (hepatocellular), and the fifth digit after the
The common source for the clinical content to be slash is the behavior code (malignant). A separate
classified with ICD-O-3 is the pathology report. single digit indicates the histological grading or
AB103118_Ch05.indd 139 2/6/2020 4:54:42 PM

Figure 5.7 Example of the structure of a complete needed to address advances in the science of men-
ICD-O-3 code tal disorders. Changes are posted when approved
on the APA website. Accessible via a link, the
documents list updates to reflect changes or
Topography code Morphology code
corrections, and other information relevant to
C22.0 M8170/31 mental health. The clinician is responsible for di-
agnosing the mental disorder using DSM-5, while
most o ften a professional coder is responsible for
Histologic term (hepatocellular) Histologic grading or assigning the ICD-10-CM code based on the docu-
differentiation mentation of the patient’s diagnosis.
Behavior code (malignant)
Source: ©AHIMA
DSM-5 Purpose and Use
n.
DSM-5 fills the need for “a clear and concise
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description of each mental disorder” (APA 2013, 5).
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differentiation. Figure 5.7 shows the structure of a
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complete ICD-O-3 code. It standardizes the clinician’s diagnostic process
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There are five main sections of ICD-O-3 are the for patients with mental disorders.
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following: By including the ICD-10-CM codes, the clinician
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can document mental health disorders for adminis-
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1. Instructions for Use
trative requirements such as requesting payment for
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2. Topography-Numerical List
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psychiatric services or to report public health statistics.
3. Morphology-Numerical List n
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DSM-5 may be used to conduct clinical assess-
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4. Alphabetic Index ments and to develop a comprehensive treatment

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5. Differences in Morphology Codes between plan. It is also used as a standard language for
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the second and third editions. communicating between healthcare providers

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about mental disorders for a variety of purposes

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The Alphabetic Index is used for searching for such as research. Although DSM-5 has forensic
an
a noun or adjective to locate the code for topogra-

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use, the APA warns there are risks and limitations

er
phy identified with a leading C and morphology

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to using it in this setting, as a clinical diagnosis of a

identified with a leading M.
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DSM-5 mental disorder does not necessarily meet

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legal criteria for the presence of a mental disorder.

by
Diagnostic and Statistical Manual of

20
It also does not determine a status such as compe-

Mental Disorders, Fifth Edition
20
tency or criminal responsibility.

©
The American Psychiatric Association (APA) de-

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veloped the Diagnostic and Statistical Manual of DSM-5 Content and Structure
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Mental Disorders (DSM). As the standard medical DSM-5 contains three sections, an Appendix, and
C
classification for mental disorders, the fifth edition an Index. The first section, DSM-5 Basics, provides
provides a reliable source of clinical criteria for men- an introduction along with instructions on how to
tal health and medical professionals when estab- use the manual. The APA’s statement regarding
lishing a diagnosis. For example, contained within forensic use is also a part of this section. Section
DSM-5 are diagnostic criteria for depressive, anxi- II, Diagnostic Criteria and Codes, contains the di-
ety, feeding and eating, and personality disorders. agnostic criteria, descriptive text, and ICD-10-CM
A clinician with the appropriate clinical train- codes.
ing and experience uses DSM-5 to identify mental Section III, Emerging Measures and Models,
disorders. ICD-10-CM codes are incorporated into provides supplemental content that is not required
the classification. for clinical use but could be helpful to the clini-
APA updates the ICD-10-CM codes for DSM-5 cian. Included in this section are proposed mental
diagnoses yearly and issues other revisions as disorders, which require further research.
AB103118_Ch05.indd 140 2/6/2020 4:54:43 PM


Match each classification with what it classifies.
1. ________ ICD-10-CM
2. ________ ICD-10-PCS
3. ________ ICF
4. ________ ICD-O-3
5. ________ ICD-11-MMS
a. External causes
b. States of disability
c. Inpatient procedures
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d. Chinese Medicine disorders
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Code Systems
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Code system is a very broad term. Given The LOINC Committee, a group of experts organ-
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its definition at the beginning of this chapter, some ized by the Regenstrief Institute to study available
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of the terminologies and classifications previ- standards, determined no code system available
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ously covered could also be called code systems. was granular enough for observation identifiers.
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Thus, a code system may have characteristics of Thus, LOINC was created to fill this gap.
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a terminology or a classification. Depending on Regenstrief Institute updates LOINC twice a

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the system, it may be used at the point of care or year in June and December. No book of LOINC
ic
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for secondary data use. Common healthcare code codes is produced. Regenstrief Institute releases
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systems are addressed in the following sections. a number of file formats on its website for down-
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loading. Regenstrief Institute also provides sev-

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Logical Observation Identifiers, eral tools for the industry. For example, it offers
20
Names, and Codes a web-based LOINC search application used to

20
©
LOINC is “a is a common language (set of iden- explore LOINC and a more extensive resource,
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Regenstrief LOINC Mapping Assistant (RELMA).

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tifiers, names, and codes) for identifying health

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The purpose of RELMA is to assist in the mapping

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measurements, observations, and documents”

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(Regenstrief Institute n.d.). An observation is a of local terms to the universal LOINC codes.
measurement, test, or simple assertion and ob-
servation identifiers are the universal identifiers LOINC Purpose and Use
(names and codes) for the observation. An obser- The purpose of LOINC is to standardize names
vation may be a test ordered or reported, a survey and codes for the identification of laboratory
question, or a clinical document. LOINC provides and clinical variables. Settings where LOINC is
names and codes for identifying laboratory and used include clinical institutions to health sys-
clinical variables. For example, the LOINC code tems, information technology vendors, research
24356-8 and its long text name, Urinalysis complete projects, government agencies, and interna-
panel—Urine, describes what was observed. Re- tional e-Health projects (McDonald et al. 2018).
genstrief Institute is the organization responsible Professional societies and insurance companies
for the development and maintenance of LOINC. also use LOINC.
AB103118_Ch05.indd 141 2/6/2020 4:54:43 PM

LOINC facilitates the exchange of data between For example, a 12-hour creatinine clearance test
diverse electronic systems including the clini- breaks down into the following parts:
cal laboratory information management and the
●● Component/analyte: creatinine renal
EHR. This clinical data can then be used for clini-
clearance
cal care and research. Another use is in outcomes
management where the clinical data are examined ●● Kind of property: Volume rate (VRat)
to study the outcome and improve care. ●● Time: 12 hours
LOINC is also one of several standards chosen ●● System: Urine and serum/plasma
for the entry of structured data in certified EHR ●● Scale: Quantitative
systems (ONC 2015). This includes using LOINC
in a number of situations such as reporting clini- This test can be described formally with the
cal lab test results and vital signs per the Common following syntax:
Creatinine renal clearance:VRat:12H:
n.
Clinical Data Set discussed later in this chapter.
tio
Other requirements include exchanging patient Ur+Ser/Plas:Qn
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summaries at transitions of care, using and ex- In LOINC, each lab test is assigned a unique
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changing social, psychological, and behavioral permanent code. The code identifies the test re-
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data, and reporting results to cancer registries and sults in electronic reports in clinical laboratory in-
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public health agencies for electronic quality meas- formation management and EHR systems, thereby
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ure reporting, patient assessment instruments re- facilitating data exchange for use in clinical care,
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quality measurement, and research. The code for a
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quired in post-acute care settings (Vreeman 2019).
Having a structured format for laboratory test in- n
12-hour creatinine clearance test is 2163-4.
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formation in certified EHRs enables the exchange
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Healthcare Common Procedure

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of data for use in clinical care and research.

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Coding System Level II

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LOINC Content and Structure HCPCS consists of two code systems: Level I and
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There are two major groups of LOINC content—

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Level II. Level I includes CPT, discussed previ-

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laboratory and clinical. The laboratory piece in- ously. HCPCS Level II standardizes the reporting
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cludes just as the name suggests: laboratory tests of professional services, procedures, products, and
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such as chemistry, urinalysis, serology, and toxicol- supplies. CMS publishes and maintains HCPCS
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ogy. For the clinical piece LOINC, the scope is broad.

by
Level II. One section within HCPCS Level II, the

20
Names and codes are available for observations like Dental Codes, or D codes, are a separate category
20
vital signs, obstetric ultrasound, radiology studies, and are published by the American Dental Associ-
©
respiratory therapy, nursing, clinical documents, ation, not CMS.

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and patient assessment instruments to name a few. CMS requires physicians to use HCPCS Level II
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The fully specified name of an observation is to report services provided to Medicare and Med-
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consists of the following five or six main parts: icaid patients. Hospitals must report ambulatory
surgery services, radiology, and other diagnostic
1. Component analyte
services using HCPCS Level II.
2. Kind of property
CMS updates HCPCS Level II quarterly on
3. Time aspect January 1, April 1, July 1, and October 1. A pro-
4. System fessional coder assigns the HCPCS Level II code
5. Scale based on the physician documentation.
6. Method (only used when different
methodologies significantly change the HCPCS Purpose and Use
interpretation of the results) (McDonald The primary purpose of HCPCS Level II is to
et al. 2018) meet the operational needs of Medicare and
AB103118_Ch05.indd 142 2/6/2020 4:54:43 PM

Medicaid reimbursement programs. Thus, as ●● H Codes: Alcohol and Drug Abuse

expected, HCPCS Level II is required for re- Treatment Services
imbursement of ambulatory services provided ●● J Codes: Drugs Administered Other than by
in healthcare settings. This includes physician Oral Method
and hospital outpatient reimbursement. Other
●● K Codes: (Temporary Codes)
uses of the code system include benchmarking,
trending, planning, and measurement of quality ●● L Codes: Orthotic and Prosthetic Procedures
of care. and Devices
HIPAA mandates HCPCS Level II as the ●● M Codes: Medical Services
standardized coding system for describing and ●● P Codes: Pathology and Laboratory
identifying healthcare equipment and supplies Services
in healthcare transactions that are not identified ●● Q Codes: (Temporary)
n.
by the HCPCS Level I, CPT codes. Thus, health-
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●● R Codes: Diagnostic Radiology Services
care providers must report these services to
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public as well as private insurers, using HCPCS ●● S Codes: Temporary National Codes
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Level II. (Non-Medicare)
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●● T Codes: Temporary National Codes
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HCPCS Content and Structure V Codes: Vision and Hearing Services
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●●
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Level II of HCPCS contains products, supplies,
The index for Level II codes lists terms alpha-
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and services. Included in HCPCS Level II are
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betically. Drugs are not included in the index but
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ambulance services, drugs, and durable medical
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are found in their own table.
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equipment, prosthetics, orthotics, and supplies.

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Modifiers are used with HCPCS Level II codes

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RxNorm
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to explain various circumstances of procedures

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and services. Modifiers are also used to enhance RxNorm is both a standardized nomenclature
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for clinical drugs and a semantic interoperabil-

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a code narrative to describe the circumstances of

ity tool. The NLM, an institute of the National
ic
each procedure or service and how it applies to an

er
Institutes of Medicine, is responsible for the

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individual patient. In some situations, insurers in-

maintenance of RxNorm. The nomenclature is
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struct providers and suppliers to add a modifier

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recognized as a standard for exchanging clinical

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to provide additional information regarding the

drug information.
20
service or item identified by the HCPCS Level II

20
code. RxNorm normalizes names and unique identi-

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HCPCS Level II is divided into the following fiers for clinical drugs and links its names to the
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varying names of drugs present in many different

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chapters:
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vocabularies within the Unified Medical Language

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C
●● A Codes: Transportation Services System (UMLS) Metathesaurus (NLM 2018a). A

including Ambulance, Medical and normalized name in RxNorm is the ingredient,
Surgical Supplies, Radiopharmaceuticals, strength, and dose form for a drug.
and Miscellaneous RxNorm is updated weekly and there is a
●● B Codes: External and Parental Therapy monthly full release update. The package includes
●● C Codes: Outpatient Prospective Payment the standardized nomenclature for clinical drugs
System (Temporary) and a tool for supporting semantic interopera-
tion between drug terminologies and pharmacy
●● D Codes: Dental Procedures
knowledge base systems (Meredith 2019, 237-238).
●● E Codes: Durable Medical Equipment NLM also provides several tools for the industry
●● G Codes: Procedures/Professional Services including a web-based RxNorm browser applica-
(Temporary) tion called RxNav.
AB103118_Ch05.indd 143 2/6/2020 4:54:43 PM

RxNorm Purpose and Use called the promoting interoperability program)

RxNorm’s purpose is to allow computer systems (ONC 2015). RxNorm is also the standard for
to efficiently and unambiguously communicate medication and medication allergy reporting per
drug-related information between hospitals, phar- the Common Clinical Data Set discussed later in
macies, and other organizations (NLM 2018b). Its this chapter. The Merit-Based Incentive Payment
objective is to normalize names of generic and System e-prescribing measure lists RxNorm as the
branded drugs and attach a unique identifier to standard for medications.
that name.
Common RxNorm uses include the following: RxNorm Content and Structure
●● Support interoperability during The drug name and all of its synonyms represent a
e-prescribing and formulary management single concept, which is assigned an RxNorm con-
Communication between hospital, cept unique identifier (RXCUI). Figure 5.8 shows
n.
●●
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pharmacy, and other organizations’ the RxNorm graph for an amoxicillin 400 mg
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chewable tablet. This display shows a text string
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computer systems, for order entry and
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analytics and for managing a medication list search using the classic view. At the top after the
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description is the RxCUI, 308188. On the left is the
en
●● Development of an allergy value set to
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ingredient (amoxicillin), ingredient plus strength
support effective and interoperable health
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(amoxicillin 400 mg), and ingredient plus strength
information exchange (Meredith 2019,
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plus dose form (amoxicillin 400 mg chewable tab-
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237-238)
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let). The combination of ingredient plus strength
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RxNorm has been named as the standard for a plus dose form is known as a semantic clinical
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number of governmental programs. This includes drug term type. At the bottom are windows dis-
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medications for the entry of structured data in certi- playing the clinical dose form group (bottom left)
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fied EHR systems under the Meaningful Use (now and dose form group (bottom middle).
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Figure 5.8 RxNorm graph for amoxicillin 400 mg chewable tablet

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20
20
©
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Source: NLM 2019. Created from publicly available data from the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of
Health and Human Services.
AB103118_Ch05.indd 144 2/6/2020 4:54:45 PM


1. The standard for clinical lab observations is __________.
2. The RxNorm semantic clinical drug term type contains information on which of the following?
a. Manufactured drug
b. Route
c. Ingredients
d. Packaged product
3. True or false: HCPCS Level II is standard for supplies under HIPAA.
4. True or false: LOINC is standard for drugs under the promoting interoperability program.
n.
5. Which type of HCPCS Level II code is not published by CMS?
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a. Dental Procedures
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b. Durable Medical Equipment
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c. Vision and Hearing Services
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d. Drugs Administered Other than by Oral Method
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Clinical Terminologies, Classifications, and Code

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Systems Found in Health Data and Information Sets

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There are many reasons for forming a data set, a a ccreditation, and exchanging clinical information
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list of recommended data elements with uniform (Giannangelo 2007). Some of these data sets are
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definitions. One reason might be to collect statisti- listed as follows.

cal data for reporting to national and state registries
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(discussed in more detail in chapter 7, Secondary Outcomes and Assessment

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Data Sources). Other purposes of data and informa- Information Set

20
20
tion sets are to gather data for clinical decision sup- The Outcomes and Assessment Information Set
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port and for computation and reporting of clinical (OASIS) is a standardized data set designed to
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quality measures (discussed in more detail in chap- provide the necessary data items to measure out-
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ter 18, Performance Improvement). Many of the data comes and patient risk factors of Medicare benefi-
C
elements contained in a data and information set ciaries who are receiving skilled services from a
are now captured electronically when data docu- Medicare-certified home health agency. According
mentation is done at the time of care. to CMS, “OASIS data items address sociodemo-
Data and information sets may come from graphic, environmental, support system, health
federal data reporting requirements, such as status, functional status, and health service utili-
Meaningful Use (now called the promoting in- zation characteristics of the patient” (CMS 2012).
teroperability program), and others from public OASIS has undergone several updates and re-
initiatives related to standardized performance finements. OASIS-D version is the version of the
measures. (Meaningful use is discussed in chapter OASIS data set that went into effect on January 1,
16, Fraud and Abuse Compliance.) Data sets may be 2019. It is the core data item set for collection on
formed for such activities as research, clinical trials, all adult home health patients whose skilled care
quality and safety improvement, reimbursement, is reimbursed by Medicare and Medicaid with the
AB103118_Ch05.indd 145 2/6/2020 4:54:45 PM

exception of patients receiving pre- or postnatal to encourage quality improvement or utilization

services only. Only a registered nurse (RN) or any adjustments.
of the therapies (physical therapist [PT], speech- Once the standardized HEDIS data elements
language pathologist/speech therapist [SLP/ST], from health records are gathered, these data are
occupational therapist [OT]) can conduct the com- combined with enrollment and claims data and
prehensive assessment and OASIS data collection analyzed according to HEDIS specifications. Health-
(CMS 2019). care purchasers and consumers can use the in-
A data collection instrument containing the formation to compare the performance of managed
data elements is used by those qualified to do so healthcare plans to help decide which plan to con-
at various times such as the start of care or upon tract with or enroll in.
discharge from home care services. Submission of
OASIS data is a CMS requirement if the agency Uniform Hospital Discharge Data Set
n.
participates in the Medicare program. The data are The Uniform Hospital Discharge Data Set (UHDDS)
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used in a variety of ways such as the assessment of is required by Department of Health and Human
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the patient’s ability to be discharged or transferred Services (HHS). This core set of data elements is
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from home care services or the creation of pa- collected by acute-care, short-term stay (usually
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tient case mix profile reports used by state survey less than 30 days) hospitals to report inpatient data
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staff in the certification process. The CMS Home elements in a standardized manner. It was devel-
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Health Compare website’s information on home oped through the National Committee on Vital and
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health agency process and improvement outcome Health Statistics (NCVHS).
measures is based on OASIS data submitted by n
The 837I, the institutional standard healthcare
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home health agencies to state repositories. Medi- claim format for electronic healthcare transactions,
mr
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care provides this information to anyone who may and Form CMS-1450, also known as the Uniform
In
have an interest in comparing home health agency Bill UB-04, for paper claims, are the instruments
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performance. for collecting UHDDS data elements. When diag-

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nosis-related groups (DRGs) were implemented,

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Healthcare Effectiveness Data and

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UHDDS definitions were incorporated into the in-

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Information Set
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patient prospective payment system (PPS) regula-

The Healthcare Effectiveness Data and Informa- tions. For additional information on DRGs and the
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tion Set (HEDIS), sponsored by the National Com- inpatient PPS, see chapter 15, Revenue Management
by
mittee for Quality Assurance (NCQA), is designed and Reimbursement.

20
20
to collect administrative, claims, and health record The UHDDS lists and defines a set of common
©
review data. HEDIS contains more than 90 stand- data elements for the purpose of facilitating the col-
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ard performance measures. Included are data lection of uniform and comparable health informa-
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related to patient outcomes and data about the tion from hospitals. Contained in the UHDDS’s
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treatment process. data dictionary are the definitions of the core data
NCQA collects the data from health plans, elements to be collected along with each data ele-
healthcare organizations, and government agen- ment’s guidelines for use. For example, the UHDDS
cies. HEDIS survey data and protocols standard- data element principal diagnosis is defined in the
ize data about specific health-related conditions data dictionary as the condition, after study, to be
or issues to evaluate and compare the success of chiefly responsible for occasioning the admission
various treatment plans. These data form the ba- of the patient to the hospital for care. This element
sis of performance improvement (PI) efforts for and its definition are used to determine a DRG.
health plans. HEDIS data also are important in the
creation of physician profiles for use in positively Common Clinical Data Set
shaping physician practice patterns by showing The Office of the National Coordinator for Health
comparative clinical performance information Information Technology (ONC) established a common
AB103118_Ch05.indd 146 2/6/2020 4:54:45 PM

Table 5.5 USCDI version 1 data classes

1. Patient name 2. Sex (birth sex)
3. Date of birth 4. Preferred language
5. Race 6. Ethnicity
7. Smoking status 8. Laboratory tests
9. Laboratory values/results 10. Vital signs
11. Problems 12. Medications
13. Medication allergies 14. Health concerns
15. Care team members 16. Assessment and plan of treatment
17. Immunizations 18. Procedures
19. Unique device identifier(s) for a patient’s implantable device(s) 20. Goals
21. Provenance 22. Clinical notes
n.
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Source: © AHIMA
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set of data types and elements and associated Former smoker. 8517006
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●●
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standards for use across several certification cri- ●● Never smoker. 266919005
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teria. The Common Clinical Data Set (CCDS)
Smoker, current status unknown. 77176002
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●●
is the combination of these common sets of data
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types and elements and associated standards used ●● Unknown if ever smoked. 266927001
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across several certification criteria. The CCDS is ●●io Heavy tobacco smoker. 428071000124103
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used across inpatient and ambulatory care set- Light tobacco smoker. 428061000124105
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●●
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tings. Some but not all data types or elements have

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a standard attached to them. An example of a data Released as a draft, the U.S. Core Data for In-
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teroperability (USCDI) in meant to help achieve

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element with a specified standard is smoking sta-

the goals in the 21st Century Cures Act. The USC-
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tus. It must be reported with one of the following

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SNOMED CT identifiers: DI takes the CCDS and adds clinical notes and
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provenance to the list of data classes. Table 5.5

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●● Current everyday smoker. 449868002 lists the draft USCDI data classes, which include
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●● Current some day smoker. 428041000124106 the CCDS.

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20
20
Database of Clinical Terminologies, Classifications,

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and Code Systems

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The number of clinical terminologies, classifica- and standards is the Unified Medical Language
tions, and code systems in healthcare has grown System (UMLS).
substantially over the past few decades and some Having access to terminologies, classifica-
that have been around for several years have un- tions, and code systems from a single source is
dergone revisions and updates expanding their made possible through the efforts of the NLM via
size. Although consolidation in some instances the UMLS. According to the NLM, “the UMLS
may occur in the future, requirements for use are integrates and distributes key terminology, classi-
not limited to just one. With so many available and fication and coding standards, and associated re-
some of them being quite large, a centralized loca- sources to promote creation of more effective and
tion is needed to maintain consistent terminology interoperable biomedical information systems
for implementation and use. One such centralized and services, including electronic health records”
location of health and biomedical terminologies (NLM 2016a).
AB103118_Ch05.indd 147 2/6/2020 4:54:45 PM

The UMLS is a multipurpose resource. It con- to the UMLS Knowledge Sources and the site to
tains the Metathesaurus, Semantic Network, and download the UMLS data files.
SPECIALIST Lexicon and Lexical Tools, which The uses of UMLS are the following:
make up the UMLS Knowledge Resources. In ad- ●● Linking health information, medical terms,
dition, the UMLS Terminology Services (UTS) pro- drug names, and billing codes across different
vides UMLS access. The Metathesaurus contains computer systems such as between the
the codes and terms from over 200 terminology, physician, pharmacy, and insurance company
classification, and coding standards. Those found
●● Coordinating patient care among different
include terminologies designed for use in EHR sys-
hospital departments
tems (for example, SNOMED CT), disease and pro-
cedure classifications used for statistical reporting ●● Searching engine retrieval
and billing (such as ICD-10-CM and HCPCS), and ●● Data mining
n.
code systems such as LOINC. The UTS is a set of ●● Reporting public health statistics
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web-based applications that serves as the gateway
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●● Researching terminology (NLM 2016b)
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1. True or false: Data elements specified in OASIS-D are collected on long-term care patients.
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2. True or false: The Common Clinical Data Set definitions are incorporated into the inpatient prospective payment
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system.
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3. LOINC would be found in the UMLS ____________.

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a. Value Set Authority Center

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b. SPECIALIST Lexicon
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c. Semantic Network
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d. Metathesaurus
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4. The ___________ is a core component of SNOMED CT.

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a. Identifier
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b. Hierarchy
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c. Concept
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d. Definition
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5. The ________ in SNOMED CT is the description assigned to a concept that is used most commonly in a clinical
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record or in literature for a specific language or dialect.

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a. Main term
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b. Preferred term
c. Customary term
d. Fully specified name
Real-World Case 5.1

The 2015 Edition EHR technology certi- of a patient in accordance with the standard
fication criteria state the following: specified.
Smoking status: Enable a user to electronically 45 CFR 170.315(a)(11). Coded to one of the fol-
record, change, and access the smoking status lowing SNOMED CT codes:
AB103118_Ch05.indd 148 2/6/2020 4:54:45 PM

● Current everyday smoker. 449868002 professional or admitted to the eligible hospi-

● Current some day smoker. 428041000124106 tal’s or critical care hospital’s inpatient or emer-
gency department during the EHR reporting
● Former smoker. 8517006
period have smoking status records as struc-
● Never smoker. 266919005 tured data.
● Smoker, current status unknown. 77176002 A quick reference for meeting the smoking
● Unknown if ever smoked. 266927001 status promoting interoperability requirement
● Heavy tobacco smoker. 428071000124103 is included in the American Academy of Family
Physicians (AAFP) Tobacco and Nicotine Cessa-
● Light tobacco smoker. 428061000124105
tion Toolkit. The AAFP supports the incorporation
Objective: Record smoking status for patients 13 of tobacco cessation into EHR templates (AAFP
years or older. 2015). The quick reference provides guidance on
n.
Measure: More than 85 percent of all unique what should be included in a tobacco cessation
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patients 13 years old or older seen by the eligible EHR template.
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Real-World Case 5.2
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Opioid use is a major concern for to curtail the national opioid public health crisis.
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healthcare professionals and organizations world- The accurate identification of opioid use disorder
n
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wide. Even governmental agencies are becoming is important to the success of the research that will
at
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involved. For example, the National Institutes of take place. DSM-5, ICD-10-CM, SNOMED CT, and
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Health launched the Helping to End Addiction in the future ICD-11-MMS are all possible ways to
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Long-term as a way to speed scientific solutions identify cases for research.

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References
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American Academy of Family Physicians. 2015. American Psychiatric Association. 2013. Diagnostic and
by
Integrating Tobacco Cessation into Electronic Health Statistical Manual of Mental Disorders, 5th ed. Arlington,
20
Records. https://www.aafp.org/dam/AAFP/ VA: APA.

20
documents/patient_care/tobacco/ehr-tobacco- Centers for Medicare and Medicaid Services. 2019.

©
cessation.pdf.
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OASIS-D Guidance Manual. https://www.cms.gov/

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American Health Information Management Medicare/Quality-Initiatives-Patient-Assessment-

yr
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Association. 2017. Pocket Glossary of Health Information Instruments/HomeHealthQualityInits

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Management and Technology, 5th ed. Chicago: /HHQIOASISUserManual.html.

AHIMA. Centers for Medicare and Medicaid Services. 2018.
American Medical Association. 2018. Current ICD-10-PCS. http://www.cms.gov/Medicare
Procedural Terminology, 4th ed. Chicago: AMA. /Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html.
American Nursing Association. 2018 (April 19). Centers for Medicare and Medicaid Services. 2012
Inclusion of Recognized Terminologies Supporting (August 21). Outcomes and Assessment Information
Nursing Practice within Electronic Health Records Set (OASIS): Data Set. https://www.cms.gov/
and Other Health Information Technology Solutions. Medicare/Quality-Initiatives-Patient-Assessment-
https://www.nursingworld.org/practice-policy/ Instruments/OASIS/DataSet.html.
nursing-excellence/official-position-statements/id/ Clinical Information Modeling Initiative. 2013.
Inclusion-of-Recognized-Terminologies-Supporting- Category: Reference Terminology. http://informatics.
Nursing-Practice-within-Electronic-Health- mayo.edu/CIMI/index.php/Category:Reference
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Code Sets, Clinical Terminologies, and Classification Information Technology. n.d. What is EHR
Systems, 4th ed. Chicago: AHIMA. interoperability and why is it important? https://
Giannangelo, K. 2007. Unraveling the data set, an www.healthit.gov/faq/what-ehr-interoperability-and-
e-HIM essential. Journal of AHIMA 78(2):60–61. why-it-important.
Helwig, A. 2013 (October 29). EHR Certification Office of the National Coordinator for Health
Criteria for SNOMED CT Will Help Doctors Transition Information Technology. 2018a. 2018 Interoperability
to ICD-10. http://www.healthit.gov/buzz-blog standards advisory. https://www.healthit.gov/isa/
/electronic-health-and-medical-records sites/isa/files/2018%20ISA%20Reference%20Edition.
/ehr-certification-criteria-snomed-ct-doctors- pdf.
transition-icd10/. Office of the National Coordinator for Health
Madden, R., C. Sykes, and T. B. Ustun. 2012. World Information Technology. 2018b. Draft U.S. Core Data
Health Organization Family of International for Interoperability (USCDI) and proposed expansion
process. https://www.healthit.gov/sites
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Classifications: Definition, scope and purpose.
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https://www.who.int/classifications/en/ /default/files/draft-uscdi.pdf.
ia
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FamilyDocument2007.pdf?ua=1. Office of the National Coordinator for Health
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Matney, S. 2019. Terminologies Used in Nursing Information Technology. 2015 (October 16). 2015
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Practice. Chapter 12 in Healthcare Code Sets, Clinical edition health information technology (Health IT)
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certification criteria, 2015 edition base electronic
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Terminologies, and Classification Systems, 4th ed. Edited
by K. Giannangelo. Chicago: AHIMA. health record (EHR) definition, and ONC health
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IT certification program modifications. Federal
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McDonald, C.J., S. Huff, J. Deckard, S. Armson, S. Register. https://www.federalregister.gov/
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Abhyankar, and D. Vreeman, eds. 2018. Logical
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articles/2015/10/16/2015-25597/2015-edition-health-
io
Observation Identifiers Names and Codes (LOINC)
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information-technology-health-it-certification-criteria-
m
Users’ Guide. https://loinc.org/downloads 2015-edition-base.

r
fo
/loinc/#users-guide.
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Optum. 2018. OptumIQ annual survey on AI in health

lth
Meredith, T. 2019. RxNorm. Chapter 8 in Healthcare Code care fact sheet. https://www.optum.com/content
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Sets, Clinical Terminologies, and Classification Systems, 4th /dam/optum3/optum/en/resources

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ed. Edited by K. Giannangelo. Chicago: AHIMA. /PDFs/OptumIQ_AI%20Survey%20Data%20Points_

an
ic
National Cancer Institute. n.d. SEER Training Media%20Fact%20Sheet.pdf.

er
Modules: Data Standards. http://training.seer.cancer.

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Porter, H.R. 2019. International Classification

gov/operations/standards/. of Functioning, Disability, and Health. Chapter
e
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National Center for Health Statistics. 2018. 11 in Healthcare Code Sets, Clinical Terminologies,
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ICD-10-CM. http://www.cdc.gov/nchs/icd/ and Classification Systems, 4th ed. Edited by K.

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icd10cm.htm. Giannangelo. Chicago: AHIMA.

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©
National Library of Medicine. 2019. RxNav, Regenstrief Institute. n.d. What LOINC is. https://
ht
Version 07-Jan-2019. https://mor.nlm.nih.gov loinc.org/get-started/what-loinc-is/.

ig
/RxNav/.
yr
Shulman, L. and N. Stepro. 2015 (June 3). What

op
National Library of Medicine. 2018a. RxNorm Lies Beneath. Arcadia Healthcare Solutions. http://
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Technical Documentation, Version 2018-1. https:// arcadiasolutions.com/lies-beneath/.

www.nlm.nih.gov/research/umls/rxnorm/docs SNOMED International. 2018 (July 26). SNOMED CT
/index.html. Editorial Guide. https://confluence.ihtsdotools.org
National Library of Medicine. 2018b. RxNorm /display/DOCEG/SNOMED+CT+Editorial+
Overview. https://www.nlm.nih.gov/research/umls Guide.
/rxnorm/overview.html. SNOMED International. 2017a (December 21).
National Library of Medicine. 2016a. Unified Medical SNOMED CT Glossary. https://confluence.
Language System. https://www.nlm.nih.gov/ ihtsdotools.org/display/DOCGLOSS/
research/umls/. SNOMED+Glossary.
National Library of Medicine. 2016b. UMLS Quick SNOMED International. 2017b (July 28). SNOMED CT
Start Guide. https://www.nlm.nih.gov Starter Guide. https://confluence.ihtsdotools.org
/research/umls/quickstart.html. /display/DOCSTART.
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Vreeman, D. 2019. Logical Observation Identifiers, and Health. http://www.who.int/classifications/

Names, and Codes. Chapter 10 in Healthcare Code icf/en/.
Sets, Clinical Terminologies, and Classification Systems, World Health Organization. 2019. World Health
4th ed. Edited by K. Giannangelo. Chicago: Assembly Update, 25, May 2019. https://www.who
AHIMA. .int/news-room/detail/25-05-2019-world-health
Warren, J. 2015. Terminologies Used in Nursing -assembly-update
Practice. Chapter 12 in Healthcare Code Sets, Clinical World Health Organization. 2018d.
Terminologies, and Classification Systems, 3rd ed. Edited ICF e-learning tool. https://www.icf-elearning
by K. Giannangelo. Chicago: AHIMA. .com/.
World Health Organization. 2019. International World Health Organization. 2017. ICF
Statistical Classification of Diseases and Related Browser. http://apps.who.int/classifications/
Health Problems (ICD-11). icfbrowser/.
World Health Organization. 2018a (December 18). World Health Organization. 2013. A Practical
n.
ICD-11-MMS Reference guide. https://icd.who.int/ Manual for using the International Classification
tio
icd11refguide/en/index.html. of Functioning, Disability and Health (ICF). http://
ia
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World Health Organization. 2018b. Classifications: The www.who.int/classifications/drafticfpracticalmanual.
ss
International Classification of Functioning, Disability pdf.
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AB103118_Ch05.indd 151 2/6/2020 4:54:45 PM

AB103118_Ch05.indd 152
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2/6/2020 4:54:45 PM
Chapter
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Data Management
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Danika E. Brinda, PhD, RHIA, CHPS, HCISPP
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• Identify the different sources where data are created, • Examine the purpose of clinical documentation
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stored, or transmitted integrity and how it relates to data

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• Distinguish among data elements, data sets, databases, quality

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indices, data mapping, and data warehousing • Identify the basics of clinical documentation
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• Distinguish among information governance, data integrity query processes

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governance, data stewardship, data integrity, data • Describe the reasons for establishing data quality
ic
er
sharing, and data interchange standards and data management requirements in provider
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• Explain the principles of information governance contracts, medical staff bylaws, and hospital
e
• Illustrate the impact of data quality on the bylaws

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healthcare organization as it relates to patient care,

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reimbursement, and healthcare operations

20
20
Key Terms
©
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Business intelligence (BI) Data management Data warehousing

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Bylaws Data mapping Database

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Clinical documentation Data mining Database life cycle

Clinical documentation Data quality (DBLC)
integrity (CDI) Data quality management Enterprise information
Critical thinking Data quality management management (EIM)
Data model Hospital bylaws
Data dictionary Data sets Index
Data element Data Steward Information
Data governance Data stewardship Information assets
Data integrity Data visualization Information
Data interchange standards Data warehouse governance (IG)
153
153
AB103118_Ch06.indd 153 2/11/2020 4:17:34 PM

Information Governance Principles Situation, background, assessment, Structured data

of Healthcare and recommendation (SBAR) System characterization
Interoperability Source data Target data
Object-oriented database (OODB) Standards Unstructured data
Query Standards development Use case
Relational database organization (SDO)
With the advancement of technology in the US IT, and HI that affect how data and documentation
healthcare system, most healthcare organizations combine to create a single business record for an
are inundated with data from multiple sources, organization. Effective oversight and management
which are stored and maintained in a variety of lo- of the data is an essential part of the day-to-day
cations. Data are representations of basic facts and operations of a healthcare organization. Knowing
n.
observations about people, processes, measure- and understanding how data are produced, why
tio
ments, and conditions. An example of data is 50 certain types and formats of data are produced,
ia
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patients were discharged yesterday. Healthcare- how data are stored and managed, and how data
ss
specific data focus on patients and include integrity is maintained become foundational steps
tA
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demographic, financial, and clinical data. Data to ensuring the data within healthcare organiza-
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management is the combined practices of HIM, tions are properly managed.
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Data Sources
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A foundational step to the manage- Other clinical documentation systems (home

In
●●
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ment of data within a healthcare organization is health, therapy, long-term care) (discussed in
ea
to understand the basic sources of data gener- chapter 11, Health Information Systems)
H
an
ated and stored by the healthcare organization. ●● Master patient index (discussed in chapter 3,
ic
Data includes both clinical and administrative

er
Health Information Functions, Purpose, and Users)

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elements. The data elements stored in the electronic ●● Other patient index (indices) (discussed in
e
health record are an example of clinical data.

th
chapter 7, Secondary Data Sources)

Administrative data includes the data elements
by
●● Databases (discussed later in this chapter)

20
required for billing and quality improvement.

20
The common data sources in healthcare: are the

●● Registries (discussed in chapter 7, Secondary
©
following: Data Sources)

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To manage the different aspects of data effec-

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●● Electronic health records (EHR)

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(discussed in chapter 11, Health Information tively, the healthcare organization should conduct
Systems) system characterization. System characterization
●● Practice management systems (discussed in is the process of creating an inventory of all sys-
chapter 11, Health Information Systems) tems that contain data, including documenting
where the data are stored, what types of data are
●● Lab information systems (discussed in
created or stored, how they are managed, with
chapter 11, Health Information Systems)
what hardware and software they interact, and
●● Radiology information systems (discussed in providing basic security measures for the systems
chapter 11, Health Information Systems) (Walsh 2013). This process helps identify all sources
●● Picture archival and communications (PACs) of data that exist within a healthcare organization,
(discussed in chapter 11, Health Information which supports effective oversight over all the data
Systems) created and maintained by an organization.
AB103118_Ch06.indd 154 2/11/2020 4:17:35 PM

Data Management
Managing the data that healthcare Data Elements
organizations create and produce is challeng-
The term data is actually the plural format of datum;
ing. Data can exist in an information system, on
however, it is more common to hear the term
a file on an employee’s computer or file server,
data element to describe one fact or measurement.
in an email, and in many other formats and loca-
A data element can be a single or individual fact
tions. Healthcare organizations are challenged
that represents the smallest unique subset of a
with how to properly manage all the data that
larger database. Data elements are sometimes
exist and how to effectively use and preserve
referred to as the raw facts and figures. Examples
that data.
of data elements include age, gender, blood pres-
n.
The process of data collection has evolved
sure, temperature, test results, and date of birth.
tio
over the years as healthcare organizations mi-
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Data elements create a measure for progress to be
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grate from paper-based recordkeeping systems
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determined and the future to be calculated and
to electronic health records (EHR). For additional
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planned for. Data elements are entered into differ-
en
information on EHRs, refer to chapter 11, Health
ent formats through the EHR and other support-
em
Information Systems. Additionally, healthcare
ing patient systems. Information is different from
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organizations are collecting more patient data
an
data in that it refers to data elements that have
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and using the data to support patient care and
been combined and then manipulated into some-
healthcare operations. The ability to properly n
io
thing meaningful regarding a patient or a group
at
collect, analyze, and utilize patient data is more
m
of patients. For example, a healthcare organization

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important now than ever before. Third-party

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can create a report on the data element’s most recent

payers, government agencies, accreditation or-
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A1C test result and diagnosis of a heart attack and

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ganizations, and others also use data to support

analyze and determine if there is a relationship
H
the healthcare delivery system and improve pa-

an
between the A1C test score and the heart attack

ic
tient care. One of the challenges for healthcare

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diagnosis. By taking the specific data elements of

systems that are managing data in an electronic
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the heart attack diagnosis and the most current

environment is the vast differences in the col-
e
A1C result, the healthcare organization can create

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lection of healthcare data throughout the orga-

by
best practices to enhance patient care based on the

nization’s electronic information systems, such
20
findings (Davoudi et al. 2015). For more on data

20
as EHRs, lab information systems, radiology

and information, see chapter 3, Health Information
©
information systems, and billing systems (dis-

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Functions, Purpose, and Users.

cussed in chapter 11, Health Information Systems).
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To help support and manage data elements

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Many methods, formats, and processes are used

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within an EHR, the use of a data dictionary is

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for the collection and storage of patient informa-

implemented to support standardized input and
tion, such as direct entry into an electronic sys-
understanding of all data elements. A data diction-
tem, scanning of documents, and uploading of
ary is a listing of all the data elements within a
transcribed documentation. Data management
specific information system that defines each indi-
is further complicated because data are collected
vidual data element, standard input of the data ele-
and stored in many locations in the healthcare
ment, and specific data length. The following are the
organization. Given the various methodologies
common data elements within a data dictionary:
that exist for data collection, understanding data
and data collection is important. Data manage-
●● Data field (such as date of birth)
ment focuses on understanding data elements,
data sets, databases, indices, data mapping, and ●● Definition
data warehousing. ●● Data type (date, text, number, and so forth)
AB103118_Ch06.indd 155 2/11/2020 4:17:35 PM

●● Format (such as MM-DD-YYYY) US healthcare industry was the Uniform Hospital

●● Field size (such as 10 digits for phone Discharge Data Set (UHDDS), implemented in the
number) mid-1970s. Created by NCHS, the National Center
for Health Services Research and Development,
●● Data values (such as M and F for gender)
and Johns Hopkins University, UHDDS collects
●● Data source (where data are collected) uniform data elements from the health records of
●● Data first entered (when the data element is every hospital inpatient (Brinda 2016). The main
first used) data elements defined in the UHDDS data set are
●● Why item is included (justification for collection listed in figure 6.1.
of the data element) (AHIMA 2017) Each of the data elements defined within the
Defining a data dictionary can help with accu- UHDDS has specific criteria for data collection.
racy of patient data and create support for data For example, the data of birth are defined as the
n.
comparison and data sharing (AHIMA 2016a). (Ad- month, day, and year of birth, with a recommen-
tio
dation to collect all four digits of the birth year.
ia
ditional information on the sharing of data is found
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in chapter 12, Healthcare Information.) Table 6.1 Another example is the definition of type of
ss
admission. There are two choices—unscheduled
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provides a sample of a data dictionary defining
en
the data elements in an EHR. or scheduled admission. Each of the types of ad-
em
Defining a data dictionary is a fundamental mission is defined in the data set for use of the
ag
UHDDS (Brinda 2016).
an
step to understanding data elements and their
M
meaning and usage. It also supports the creation Shortly after the UHDDS was created and imple-
n
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mented, the need to expand uniform data sets
of well-structured and defined data sets by creat-
at
across other healthcare settings became evident
m
ing standardized definitions of data elements to

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help ensure consistency of collection and use of the with the continuing movement from an inpatient,
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acute setting to outpatient care including surgical

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data. For example, the time of discharge could be

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the time the discharge order was written, the time centers and emergency care settings. A standard-
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ized data set for the ambulatory setting, known as

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the order was entered into the information system,

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or the time the patient actually left the unit. These the Uniform Ambulatory Care Data Set (UACDS),
er
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times could vary widely so it is important that the was created. With fewer data elements than the
UHDDS, the UACDS collects data specific to am-
e
data dictionary defines which time should be used.

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bulatory care settings with an intent to improve

by
data comparison across different settings of health-

20
Data Sets
20
care (see figure 6.2). After the success of the stand-

©
The concept of comparing data and the need for ardization of data elements with the UHDDS and
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standardization became a common theme for UACDS, the standardization of data sets across
yr
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healthcare organizations in the 1960s as a result healthcare settings commenced. Another key data
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of the work of the National Center for Health Sta- set is Data Elements for Emergency Department
tistics (NCHS) and the National Committee on Systems (DEEDS), which collects data for hospital-
Vital and Health Statistics (NCVHS). It became based emergency departments. The following are
evident that common structure and collection of other data sets that are defined within healthcare
data elements was needed to collect consistent settings:
data to allow for comparison across all healthcare
●● Minimum Data Set (MDS)—Long-term care
organizations. As a result, the concept of data sets
setting
was created. Data sets are a recommended list
of data elements that have defined and uniform ●● Outcomes and Assessment Information
definitions that are relevant for a particular use or Set (OASIS)—Home healthcare setting
are specific to a type of healthcare industry. One ●● Essential Medical Data Set (EMDS)—
of the first defined and used data sets across the Emergency care setting
AB103118_Ch06.indd 156 2/11/2020 4:17:35 PM

Table 6.1 Sample data dictionary
AB103118_Ch06.indd 157
DATE
DATA FIELD SOURCE FIRST WHY ITEM IS
FIELD NAME DEFINITION DATA TYPE FORMAT SIZE VALUES SYSTEM ENTERED INCLUDED
Admission ADMIT_ The date the patient is date mmddyyyy 8 Admission date Patient Census 2/23/2008 Allows analysis
Date DATE admitted to the facility as cannot precede of patients and
an inpatient Co birth date or 2007 services within a
py No hyphens or specific period that
rig slashes can be compared
ht with other periods
© or trended
2
Census CENSUS The number of inpatients numeric
02 x to xx 3 Any whole number Patient Census 2/23/2008 Provides analysis of
present in the facility at 0 from 0 to 999 budget variances,
any given time by aids future budgetary
th decisions, and allows
e quicker response to
negative trends
Am
e
Ethnicity PT_ETHNIC Patient’s ethnicity alphanumeric Ex;rletter
ic 2 E1 = Hispanic or Patient Census; 2/23/2008 Patient demographics
Must be reported must bean Latino Ethnicity Practice aid marketing and
according to official uppercase H E2 = Non- Hispanic Management planning future bud-
Office of Management
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or Latino Ethnicity gets and services
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and Budget categories
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Infant INFANT_PT A patient who has not alphanumeric Age in months fo 3 Must be > 0 Patient Census; 2/23/2008 Patient age affects
Patient reached 1 year of age at = xD to xxD OR rm AND < 1 year Practice types of services
the time of discharge xM to xxM at Management required and payer
io sources
n
Inpatient IP_DAY_ The number of inpatients numeric x to xx 3 Any a
M
whole number Patient Census 2/23/2008 Provides analysis of
Daily Cen- CENSUS present at census-taking to 999
from 0na budget variances,
sus time each day, plus any ge aids future budgetary
inpatients who were both m decisions, and allows
admitted and discharged quicker response to
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after the previous day’s negative trends
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census-taking time
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Medical MR_NUM The unique number alphanumeric xxxxxx: requires 6 000001 to 999999 Patient
ia Census; Provides analysis of
Record assigned to a patient’s leading zeros Practice
tio services, resource
Number medical record Management
n. utilization, and
The medical record is patient outcomes at
filed under this number the physician level
Patient PT_AGE Age of patient calculated numeric or Age in days = 3 Age must be > 0, Patient Census; 2/23/2008 Patient age impacts
Age by using most recent alphanumeric xD to xxD OR and < OR = 124 Practice the services utilized
birthday attained before Age in months = years; children less Management and payer sources
or on same day as xM to xxM OR than 1 year must
discharge be > 0 M AND <
Age in years = x
1 year
to xxx
continued
2/11/2020 4:17:35 PM
Table 6.1 Sample data dictionary (concluded )
DATE
AB103118_Ch06.indd 158
DATA FIELD SOURCE FIRST WHY ITEM IS
FIELD NAME DEFINITION DATA TYPE FORMAT SIZE VALUES SYSTEM ENTERED INCLUDED
Patient PT_SEX Patient sex alphanumeric letter; must be 1 M = Male Patient Census; 2/23/2008 Patient sex impacts
Sex uppercase F = Female Practice the services and
Management specialties utilized
U = Unknown
Patient Zip PT_ZIP_ C
Zip code of patient’s alphanumeric xxxxx-xxxx 11 00000 to 99999; Patient Census; 2/23/2008 Patient demograph-
Code CODE residence 00000 = Unknown Practice ics aid marketing
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yrig 99999 = Foreign Management and planning future
ht budgets/services
Pediatric PED_PT A patient who has not
© numeric Age in days = 3 Age must be > 0 AND Patient Census; 2/23/2008 Patient age impacts
Patient reached 18 years of age xD to xxD OR Practice the services utilized
20
< 18 years;
at the time of discharge and payer sources
20
Age in months = children less than 1 Management
xM to xxM OR year must be > 0 M
by
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e Age in years = x AND < 1 year
A to xxx
m
Source: AHIMA 2017.

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2/11/2020 4:17:35 PM
With the success of these data sets and the shift information entered into an EHR or maintained
toward the ability to share data that are consistent on a paper record. A database is a collection of
across the healthcare spectrum, the need for addi- data organized in such a way that its contents
tional standards to support standardized data sets can be easily accessed, managed, reported, and
continues to be a focus in the healthcare industry. updated. For proper management of data with-
in a healthcare organization it is important to
Databases understand what databases exist, the purpos-

Databases are commonly used throughout the es of the databases, the storage and backup of
healthcare industry to support and store patient the databases, and who accesses and uses the
Figure 6.1 UHDDS data elements
Data Element Definition/Descriptor
n.
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01. Personal identification The unique number assigned to each patient within a hospital that
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distinguishes the patient and his or her hospital record from all others
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in that institution.
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Month, day, and year of birth. Capture of the full four-digit year of birth is
02. Date of birth
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recommended.
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03. Sex Male or female
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M
04. Race and ethnicity 04a. Race
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American Indian/Eskimo/Aleut
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Asian or Pacific Islander
m
Black
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White
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Other race
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Unknown
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04b. Ethnicity
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Spanish origin/Hispanic
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Non-Spanish origin/Non-Hispanic
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Unknown
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05. Residence Full address of usual residence

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Zip code (nine digits, if available)

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Code for foreign residence

20
20
06. Hospital identification A unique institutional number across data collection systems. The
©
Medicare provider number is the preferred hospital identifier.

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07. Admission date Month, day, and year of admission

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08. Type of admission Scheduled: Arranged with admissions office at least 24 hours prior to
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admission
Unscheduled: All other admissions
09. Discharge date Month, day, and year of discharge
10. Physician identification The Medicare unique physician identification number (UPIN) is the
11. • Attending physician preferred method of identifying the attending physician and operating
• Operating physician physician(s) because it is uniform across all data systems.
12. Principal diagnosis The condition established after study to be chiefly responsible for
occasioning the admission of the patient to the hospital for care.
13. Other diagnoses All conditions that coexist at the time of admission or that develop
subsequently or that affect the treatment received and/or the length of
stay. Diagnoses that relate to an earlier episode and have no bearing
on the current hospital stay are to be excluded.
continued
AB103118_Ch06.indd 159 2/11/2020 4:17:36 PM

Figure 6.1 UHDDS data elements (concluded )
14. Qualifier for A qualifier is given for each diagnosis coded under “other diagnoses” to
other diagnoses indicate whether the onset of the diagnosis preceded or followed admis-
sion to the hospital. The option “uncertain” is permitted.
15. External The ICD-10-CM code for the external cause of an injury, poisoning, or
cause-of-injury code adverse effect. Hospitals should
complete this item whenever there is a diagnosis of an injury, poisoning,
or adverse effect.
16. Birth weight of neonate The specific birth weight of a newborn, preferably recorded in grams
17. Procedures and dates All significant procedures are to be reported. A significant procedure is
one that is:
n.
• Surgical in nature, or
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• Carries a procedural risk, or
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• Carries an anesthetic risk, or
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• Requires specialized training
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The date of each significant procedure must be reported. When more
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than one procedure is reported, the principal procedure must be
en
designated. The principal procedure is one that is performed for
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definitive treatment rather than one performed for diagnostic or
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exploratory purposes or was necessary to take care of a complication.
an
If there appear to be two procedures that are principal, then the one
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most closely related to the principal diagnosis should be selected as
the principal procedure. The UPIN must be reported for the person
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performing the principal procedure.
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• Discharged to home (excludes those patients referred to home

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18. Disposition
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of the patient health service)

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• Discharged to acute care hospital

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• Discharged to nursing facility

• Discharged home to be under the care of a home health service
H
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(including a hospice)
• Discharged to other healthcare facility
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• Left against medical advice

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• Alive, other; or alive, not stated

• Died
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th
by
19. Patient’s expected Primary source

source of payment Other sources
20
All categories for primary and other sources are:

20
• Blue Cross/Blue Shield

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• Other health insurance companies

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• Other liability insurance

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yr
• Medicare
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• Medicaid
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• Worker’s Compensation
• Self-insured employer plan
• Health maintenance organization (HMO)
• CHAMPUS
• CHAMPVA
• Other government payers
• Self-pay
• No charge (free, charity, special research, teaching)
• Other
20. Total charges All charges billed by the hospital for this hospitalization. Professional
charges for individual patient care by physicians are excluded.
Source: Brinda 2016.
atabases. Common databases found in health-

d Refer to chapter 7, Secondary Data Sources, for
care include Medicare Provider Analysis and specifics on these databases.
Review File, National Practitioner Data Bank, The database design and structure impacts how
and National Health Care Survey (Sharp 2016). it can be used. A poorly designed database will
AB103118_Ch06.indd 160 2/11/2020 4:17:37 PM

Figure 6.2 UACDS data elements
Provider identification, Provider identification: Include the full name of the provider as well as
address, type of practice the unique physician identification number (UPIN).
Address: The complete address of the provider’s office. In cases where
the provider has multiple offices, the location of the usual or principal
place of practice should be given.
Profession:
• Physician including specialty or field of practice
• Other (specify)
Place of encounter Specify the location of the encounter:

• Private office
• Clinic or health center
• Hospital outpatient department
n.
• Hospital emergency department
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• Other (specify)
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Reason for encounter Includes, but is not limited to, the patient’s complaints and symptoms
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reflecting his or her own perception of needs, provided verbally or in writ-
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ing by the patient at the point of entry into the healthcare system, or the
patient’s own words recorded by an intermediary or provider at that time.
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Diagnostic services Includes all diagnostic services of any type.
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Problem, diagnosis, Describes the provider’s level of understanding and the interpretation of
n
or assessment io
the patient’s reasons for the encounter and all conditions requiring treat-
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ment or management at the time of the encounter.
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Therapeutic services List by name all services done or ordered:

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• Medical (including drug therapy)

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• Surgical
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• Patient education
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Preventive services List by name all preventive services and procedures performed at the
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time of the encounter.

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Disposition The provider’s statement of the next step(s) in the care of the patient.
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At a minimum, the following classification is suggested:

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1. No follow-up planned
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2. Follow-up planned
20
• Return when necessary

20
• Return to the current provider at a specified time

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• Telephone follow-up
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• Returned to referring provider

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• Referred to other provider

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• Admit to hospital
• Other
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Source: Brinda 2016.
result in redundant collection of data and data 3. Implementation (developing database)

information errors. Understanding the database 4. Testing and evaluation (ensuring system
life cycle (DBLC) is an important step in the proper works as expected)
execution, implementation, and management of 5. Operation (using database)
databases within healthcare. The following are the
6. Database maintenance and evaluation
six basic steps in the database life cycle:
(updating and backing up database and
1. Initial study (determining need for database) ensuring that it still meets needs)
2. Design (identifying data fields, structure, Health information management (HIM) profes-
and so forth) sionals should be involved in all stages of the
AB103118_Ch06.indd 161 2/11/2020 4:17:38 PM

database life cycle as they have the knowledge allows a healthcare organization to query the
and skills needed to understand the essential steps database to retrieve an image for a specific person.
of data collection privacy and security, and data Another potential use is to produce a report based
integrity (Coronel and Morris 2015). on the date of the fetal heart monitor for retention
The two most common types of databases used and destruction of the images. When this type of
in healthcare are relational databases and object- database is used, the data are provided with the
oriented databases. A relational database stores additional ability to retrieve the file when the link
data in tables that are predefined and contain rows to the image is selected.
and columns of information. Typically, a relational
database is two-dimensional as it contains rows and Indices
columns. Relational databases are used frequently
An index is a report or list from a database that
in the healthcare industry because they are easy to
provides guidance, indication, or other references
n.
build, use, and query within the application. For
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to the data contained in the database. An index
example, a healthcare organization might choose to
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serves as a guide or indicator to locate something
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use a relational database to document the number of
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within a database or in other systems storing data.
health record deficiencies a physician has at the time
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For example, an index of a book will provide key
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of evaluation for reporting to the organization’s
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terms and where to find each term within a book;
board (Sharp 2016). Table 6.2 provides a sample of
ag
the reader is able to find more information and
a relational database for physician deficiency status.
an
detail regarding a specific topic. The indices used
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An object-oriented database (OODB) is designed
in healthcare identify where the desired informa-
to store different types of data including images, n
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at
tion can be found, making it easier to aggregate
audio files, documents, videos, and data elements.
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and analyze data. There are many types of indices

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OODBs are useful for storing fetal monitoring

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used within the healthcare industry. The following

strips, electrocardiograms, PACs, and more. The
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are the most common indices:

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OODB is dynamic because it provides the data as

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well as the object (image and document). Table Master patient index. A guide to locating
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●●
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6.3 provides an example of an OODB. Using an specific demographic information about

er
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OODB for the storage of fetal heart monitors a patient such as the patient name, health
e
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Table 6.2 Relational database: physician deficiency status

by
20
History and physical Discharge summary Deficiencies greater

20
Provider ID Total # of deficiencies deficiencies deficiencies than 30 days past due

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1285 14 2 5 3
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1965 2 1 1 0
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8914 35 13 15 25
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9462 6 3 2 2
3651 17 11 2 2
Source: ©AHIMA.
Table 6.3 Object-oriented database: fetal heart monitors (FHMs)

Patient ID FHM start date FHM end date FHM image
110011 6/30/15 7/1/15 Link to FHM image
123023 7/1/15 7/3/15 Link to FHM image
154623 7/2/15 7/2/15 Link to FHM image
948513 7/2/15 7/3/15 Link to FHM image
Source: ©AHIMA.
AB103118_Ch06.indd 162 2/11/2020 4:17:38 PM

r ecord number, date of birth, gender, and in this index include physician’s identification
dates of service. For more details, refer (code or name), health r ecord n umber,
to chapter 3, Health Information Functions, diagnosis, operations, dates of service,
Purpose, and Users. patient gender, patient age, and patient
●● Disease index. A listing of specific codes such outcome from encounter. A provider index
as International Classification of Diseases, Tenth can be used to produce information regarding
Revision, Clinical Modification (ICD-10-CM) the work of the provider within a healthcare
codes that link a disease or diagnosis to a organization, which can be useful for
patient. (ICD-10-CM is explained later in certification and credentialing purposes. For
this chapter.) Common data in a disease example, a healthcare organization may need
index would include diagnosis codes, to produce a report for administration detailing
health record number, gender, age, race, the treatment of patients and diagnoses
n.
attending physician, hospital service, patient and procedures performed in the past year
tio
by a specific provider (Sharp 2016). More
ia
outcomes, and dates of encounter. A disease
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index can be used to query a specific information on indexes is found in chapter 7
ss
Secondary Data Sources.
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diagnosis to determine other attributes of
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patients with the disease. For example, if Indices support daily operations for healthcare
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a healthcare organization wanted to know
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organizations and are tools used to gather specific
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the age range and gender of all patients information quickly.
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diagnosed with a myocardial infarction,
n
Data Mapping
the disease index could be queried to
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get a listing of patients with that specific Data mapping is a process that allows for connec-
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diagnosis code(s).
In
tions between two systems. For example, map-

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●● Operation or procedure index. A listing of ping two different coding systems to show the
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specific codes such as Current Procedural equivalent codes allows for data initially captured
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Terminology (CPT) for procedures or for one purpose to be translated and used for an-
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operations performed within the healthcare other purpose. For example, the ICD-10 code of
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organization. (CPT is explained later in E10.11, type 1 diabetes mellitus with ketoacidosis
e
this chapter.) An operation or procedure can be mapped to SNOMED-CT Code 371055001,

th
by
code would include information similar to type 1 diabetes mellitus with ketoacidosis. This al-
20
the disease index but would also include lows for comparison between two different cod-
20
the specific code numbers as well as the ing systems based on one code. One system in a
©
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operating physician. An operation or map is identified as the source while the other is
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procedure index can be used to query the target. Source data is the location from which
yr
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specific information regarding procedures the data originate, such as a database or a data set;
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or operations done within the facility. whereas target data is the location from which the
For example, if a healthcare organization data are mapped or to where the data are sent. A
wanted to know the age range of patients data map creates a process to evaluate the dispar-
who had an appendectomy in the past year, ity between the two systems and links the data be-
the operation or procedure index could ing collected together. Data mapping is conducted
be queried to generate a listing of patients to ensure the data exchange from one database to
based on the procedure code. another is done in a meaningful way and main-
●● Physician index. A listing of all physicians tains the integrity of the data (Maimone 2016).
within a healthcare organization with all the During the process of data mapping, each data
diagnosis and procedure codes linked to each map should have a defined purpose that specifies
provider within the index. The data collected why the data map is created and what purpose it
AB103118_Ch06.indd 163 2/11/2020 4:17:38 PM

serves. The purpose should describe why the data between ICD-10-CM codes and SNOMED CT codes,
map is needed, what it represents, and how it will both explained later in this chapter.
be used within the healthcare organization. For Data mapping can be a long and tedious task for
example, a healthcare organization may create a a healthcare organization; however, it is important
data map to show the relationship of the types of from a data management perspective. To properly
ambulatory services such as emergency department manage the data and ensure data integrity between
or ambulatory surgery and map them directly to systems, data maps serve as the tool to define the
the ambulatory services. meaning and history of data elements within sys-
Data mapping should be completed carefully to tems. Inaccurate data mapping can result in misin-
evaluate where the data come from and the rela- terpretation of data and inaccuracy of information
tionships of the source data to data in other sys- stored and maintained in systems. For example,
tems. The process helps to ensure the integrity if the ICD-10-CM code was mapped to the incor-
n.
of the data in all systems. When conducting data rect SNOMED CT code, data used and reported
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mapping within a healthcare organization, evalu- from the SNOMED system could show incorrect
ia
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ating the relationship of the data is fundamental to information regarding patients diagnosed with
ss
understanding the equivalence between the data. cholera, unspecified. Data map creators need to
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Equivalence of data is the relationship between understand the data to be mapped between sys-
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the source data and target data in regard to how tems and the reasons for the data mapping. One
ag
close or distant the data from the two systems are way of doing this is to create a use case. A use
an
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linked. The three common types of relationships case describes how the users will interact with the
are no match, approximate match, and exact match n
io
data map in a specific scenario. Some general data
at
(Maimone 2016). Table 6.4 shows the differences mapping steps are found in table 6.6.
m
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between the three types of relationships.

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When creating data maps, healthcare organiza- Data Warehousing

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tions should create a common format for the output Data warehousing is the process of collect-
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of the map to create consistency and ease the end using the data from different data sources within a
an
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er’s ability to interpret the data map. Table 6.5 is an healthcare organization and storing it in a single
er
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example of a data map that shows the r elationship database that can be used for decision-making.
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Table 6.4 Types of relationships used in mapping

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20
Example Terms Used (Terms

20
Type of Relationship Description May Vary by Category)

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No match A code (concept) exists in one coding system without a similar No match
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concept in the other coding system. No map

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No possible connection between source and target system. No code

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Approximate match A code (concept) that exists in one coding system may have a direct Approximate match
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relationship to the other coding system. Approximate map

Possible direct connection between source and target system. Approximate code
Related
Exact match A code (concept) exists in one coding system with a direct Exact match
relationship to the other coding system. Equivalent map
Direct connection between source and target system. Equivalent code
Equal
Source: Maimone 2016.
Table 6.5 Data map

ICD-10-CM code ICD-10-CM name Equivalence SNOMED CT code SNOMED CT name
A00.0 Cholera, unspecified Equal 63650001 Cholera
Source: © AHIMA.
AB103118_Ch06.indd 164 2/11/2020 4:17:38 PM

Table 6.6 AHIMA practice brief data mapping best practices: general data mapping steps
Develop a business case first. Questions to ask include:
• What is the reason for the project?
• What is the expected business benefit?
• What are the expected costs of the project?
• What are the expected risks?
Define a use case for how the content will be used within applications. Questions to ask include:
• Who will use the maps?
• Is the mapping between standard terminologies or between proprietary (local) terminologies?
• Are there delivery constraints or licensing issues?
• What systems will rely on the map as a data source?
Develop rules (heuristics) to be implemented within the project. Questions to ask when developing the rules include:
• What is the version of source and target schema to be used?
• What is included or excluded?
• How will the relationship between source and target be defined (such as are maps equivalent or related)?
n.
• What mapping methodologies will be utilized?
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• What procedures will be used for ensuring intercoder or interrater reliability (reproducibility) in the map development phase?
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• What parameters will be used to ensure usefulness? (For example, a map from the SNOMED CT concept “procedure on head”
ss
could be mapped to hundreds of CPT codes, making the map virtually useless.)
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• What tools will be used to develop and maintain the map?
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Plan a pilot phase to test the rules. Maps must be tested and deemed “fit for purpose,” meaning they are performing as desired.
em
This may be done using random samples of statistically significant size. Additional pilot phases may be needed until variance from
ag
the expected result are resolved. Reproducibility is a fundamental best practice when mapping.
an
Develop full content with periodic testing throughout the process. Organizations should perform a final quality assurance test
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for the maps and review those data items unable to be mapped to complete the mapping phase. Any modifications from the review
n
process should be retested to assure accuracy.
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Organizations should release the map results to software configuration management where software and content are integrated.
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They should then perform quality assurance testing on the content within the software application (done in a development
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environment). They can then deploy the content to the production environment, or go-live.
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Communicate with source and target system owners when issues are identified with the systems that require attention or
ea
additional documentation for clarity.

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Source: Maimone 2016.

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A data warehouse is a database that makes it pos- lab value or a diagnosis code. The following are the
sible to access data that exist in multiple databases advantages to the use of data warehouses:
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through a single query and reporting interface.

by
One consistent data storage area for

20
Data warehouses allow healthcare organiza- ●●

20
tions to obtain information needed to streamline reporting, forecasting, and analysis

©
processes and simplify access to the information Easier and timely access to data
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●●
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that is stored among different databases within Improved end-user productivity

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●●
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a healthcare system. If a user had to query each

Improved information services productivity
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●●
information system, the amount of time needed to
combine the data manually and then analyze the
●● Reduced costs
data would serve as a barrier to properly report- ●● Scalability
ing and analyzing the data. With the use of a data ●● Flexibility
warehouse, the data can be consolidated by pulling ●● Reliability (HIMSS 2009)
the data from multiple information systems into
a single database that allows for ease in reporting Since large amounts of data are being captured
and analysis of the information. electronically within healthcare organizations, data
Data mining is the processing of extracting from warehousing will become a foundational aspect of
a database or data warehouse information stored in healthcare operations due to its ability to gather
discrete, structured data format—that is, data that data from multiple databases, incorporate the
have a specific value. Examples of discrete data are a data, and then produce meaningful information.
AB103118_Ch06.indd 165 2/11/2020 4:17:39 PM


1. True or false: A data element is a single or individual fact that represents the smallest unique subset of larger data.
2. Critique each statement to determine the one that demonstrates the intent of a data set.
a. A clearly defined data dictionary for the electronic health record
b. A recommended list of data elements that support a specific healthcare industry
c. One element within an electronic health record
d. A database where data are compiled from many sources into one central location
3. The intent and purpose of the creation of a data dictionary is to:
a. Identify the data elements that you want to collect
n.
b. Create support for structured data collection
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c. Create use case
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d. Control security
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4. The two most commonly used databases in healthcare are:
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a. Relational and object-relational databases
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b. Object-relational and object-linking databases
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c. Relational and object-oriented databases
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d. Object-linking and object-oriented databases
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n
5. True or false: An index creates a definition for data elements within a database.
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6. True or false: There is usually only one source of data within a healthcare organization.
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In
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Information Governance
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Information assets are becoming an es- worthiness of a healthcare organization’s informa-

e
th
sential strategic and operational part of a healthcare tion. Having trustworthy information is essential
by
organization, requiring a rigorous process that will pro- to improving patient care and safety, reducing or
20
tect information from unauthorized access, use, dis- mitigating risks to the information, improving
20
closure, modification, and destruction. For example, operational efficiency, and achieving and main-
©
ht
prevent hackers from accessing health information taining a competitive advantage in healthcare
ig
yr
from outside the healthcare organization. Informa- (Fahy et al. 2018). The implementation of an IG
op
tion assets refer to the information collected during framework in a healthcare organization assists in
C
the day-to-day operations of a healthcare organi- the establishment of policies and procedures that
zation that has value within the healthcare organiza- govern the oversight, aligning it to the strategic
tion. An example is patient data collected to support vision of the organization. In addition, IG helps to
patient care for the healthcare organization. Without prioritize a healthcare organization’s investments,
patient data, the healthcare organization would not establishes the value of information assets, estab-
be able to support the continuity of patient care or lishes a process to protect information assets, and
the billing of services provided to the patient. creates accountability for managing information
Information governance (IG) is an “organization- over the entire healthcare spectrum (Dickey 2018).
wide framework for managing information through-
out its lifecycle and supporting the organization’s Valued Strategic Asset
strategy, operations, regulatory, legal, risk, and Information should be treated as a valued strate-
environmental requirements” (Dickey 2018, p. 38). gic asset. A valued strategic asset is a resource that
One of the main goals of IG is to provide trust- is used in a way that will improve the healthcare
AB103118_Ch06.indd 166 2/11/2020 4:17:39 PM

organization today and into the future. For ex- good decisions for the organization as well as the
ample, a healthcare organization needs informa- population it serves. One of the benefits of IG is
tion (financial projections, cost of services, and so the ability to support business intelligence. Busi-
forth) that can assist in the negotiation of contracts ness intelligence (BI)is the end product or goal
that can run for years. A successful IG initiative of knowledge management. In other words, it is
must have support from the healthcare organiza- what you can do with what you know about your
tion’s executive leadership and align directly to the healthcare organization, your community, and so
healthcare organization’s strategic plan. To ensure forth. With data being produced at a rapid rate, IG
the success of an IG initiative, it needs to be “driv- helps the healthcare organization manage and use
en from the board of directors and C-Suite level the information. Using the information to create
down to the rest of the organization while simul- and support business intelligence is an essential
taneously being driven up from the grassroots and component of IG. With an effective IG initiative,
n.
recognizing the needs of the end-users of data and reliable information will be available to support
tio
information” (Fahey et al. 2018, p 4). One of the the compliance efforts, benchmarks, and compari-
ia
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initial steps in the IG initiative is to secure an ex- sons of an organization in areas such as population
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ecutive sponsor at the C-Suite level of the organi- health, quality of care, public reporting, financial
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zation. Some common sponsors of an IG initiative performance, and regulatory compliance (Warner
em
are a Chief Financial Officer, Chief Data or Health 2013a). For example, the ability to analyze the top
ag
Information Officer, Chief Financial Officer, Chief trends in diagnoses in a healthcare organization
an
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Innovation Officer, Chief Strategy Officer, Chief will enable the organization to expand service lines
Medical and Information Officer, and Chief Execu- n
or enhance patient outcomes in a specific area.
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at
tive Officer. The executive sponsor will ensure the
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Situation, Background, Assessment,

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IG initiative has the appropriate resources such as

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budget, personnel, and tools; that the goals of the Recommendation (SBAR)
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IG initiative align with the healthcare organiza- As a healthcare organization begins to implement
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tion’s strategy; that the importance of the IG initia-

an
IG, the reason and intent of the process must be

ic
tive is communicated to the executive team as well effectively communicated within the organization.
er
Am
as the workforce; and that the appropriate controls The situation, background, assessment, and rec-
and accountability are established to meet the in-
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ommendation (SBAR) tool is an easy to use and

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tended goals of the IG initiative (Fahey et al. 2018).

by
understand tool that can help define the intent of

An IG framework can help a company with com-
20
the IG program and clearly articulate the entire pro-

20
peting strategic priorities. One of the main ways cess to gain organizational and executive support.
©
that an IG initiative can support the strategy of the SBAR uses four distinct components to describe
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healthcare organization is by aligning the needs the issues, provide background information, con-
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of the leadership with the organizational business duct a current state analysis, and define the rec-
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strategy and goals. It helps to create the valuation ommended steps to fix the issue (Glondys 2016;
of information and assign resources to the proper Kadlec 2015). Figure 6.3 describes each component
areas within an organization. This helps to avoid of the SBAR tool.
unnecessary costs with inappropriate assignment When using SBAR to support an IG initiative,
of resources to support the organization’s informa- it is important to be specific about the issue and
tion assets (Fahey et al. 2018). Aligning the IG ini- directly link it to the specific IG principle. If nec-
tiative with the healthcare o rganization’s strategic essary, include information such as accreditation
priorities with the support of an executive sponsor requirements and federal and state regulations to
is the foundation of a successful IG initiative. help support the background information. In addi-
tion, special considerations should be documented
Business Intelligence linking the specific issue to the organization’s stra-
An effective IG initiative will support the informa- tegic plan (Glondys 2016). Figure 6.4 demonstrates
tion that the healthcare organization needs to make SBAR linked to the IG principle of availability.
AB103118_Ch06.indd 167 2/11/2020 4:17:39 PM

Enterprise Information Management Information Governance Principles

Enterprise information management (EIM) is the for Healthcare
set of functions created by a healthcare organiza- In 2014, AHIMA established Information Gover-
tion to plan, organize, and coordinate the people, nance Principles of Healthcare (IGPHC), which
processes, technology, and content needed to man- were aligned with ARMA’s Generally Accepted
age information for the purposes of data quality, Recordkeeping (GARP) Principles. The IGPHC
patient safety, and ease of use (Johns 2015). As were intended to be comprehensive and broad to
part of the creation of an IG strategy, healthcare allow for scalability based on the healthcare or-
organizations should establish EIM policies and ganization’s type, size, role, mission, sophistica-
procedures to address the collaboration and inte- tion, legal environment, and resources. AHIMA
grative efforts used across the system to protect intended to offer a framework to help organiza-
the healthcare organization’s enterprise informa- tions leverage information as an asset, while en-
n.
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tion assets (Warner 2013b). suring compliance with legal requirements and
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Figure 6.3 Situation, Background, Assessment, and Recommendation
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The SBAR Elements
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S = Situation (a concise statement of the problem)
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B = Background (pertinent and brief information related to the situation)
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A = Assessment (analysis and consideration of options—what you found/think)
n
R = Recommendation (action requested/recommended—what you want) io
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Situation
m
This section of the SBAR process helps determine what is going on and why. In this section, the relevant parties identify the prob-
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lem and why it is a concern for the organization and then provide a brief description of it.
In
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Background
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The goal of the background section is to be able to identify and provide the reason for the problem.
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Assessment
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At this stage, the situation is analyzed to determine the most appropriate course of action. Include any data that have been gath-
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ered and spell out the pros and cons of each option being considered.
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Recommendation
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Possible solutions that could correct the situation at hand are considered. In this section, a recommendation is provided based on
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the data presented in the assessment section.

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20
Source: Glondys, 2016, 35.

20
©
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Figure 6.4 Example: the principle of availability

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Situation: New fields are being added to EHRs but are not communicated throughout the organization. Output (for release of
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information) does not include these data, resulting in incomplete information being released.
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Background: No control mechanism exists for altering new fields in the EHR. There is no documented standardized process for
changing and adding fields. It follows, then, that there is no education for this practice. There has been no audit of input-to-output
flow.
Assessment: Survey IT and clinical areas that frequently request template and data field changes. Audit critical content (that
is, core measures) that is not part of standard output. Identify examples of adverse impacts of incomplete data on clinical care
(resulting in legal action), coding (resulting in a loss of revenue), and reporting (resulting in low performance). List pros and cons for
each approach and identify any associated costs.
Recommendation: Formalize the process and approval procedures for changes to the EHR. Educate the workforce about the
approved process for EHR changes.
Special Considerations for IG
This example clearly shows the importance of organization-wide communication, collaboration, and commitment to govern the
quality of information. People, processes, and technology in every department should be involved in this effort. Everyone is a
stakeholder in information quality.
Source: Glondys, 2016.
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other duties and responsibilities. Whether used in standards, and organizational policies, and
whole or in part, the IGPHC were developed to maintains its information in the manner
inform an organization’s information governance and for the time prescribed by law or
strategy (Datskovsky et. al, 2015a). organizational policy (Datskovsky et. al,
The eight principles included: 2015b). (Compliance is defined in more detail
in chapters 9 Data Privacy and Confidentiality
●● Principle of accountability. This principle and 16 Fraud and Abuse Compliance.)
recommended that one person, preferably ●● Principle of availability. The principle states an
someone in senior leadership, oversee organization should maintain information in
and implement an IG program within an a manner that ensures timely, accurate, and
organization. This individual could help efficient retrieval. This applies to healthcare
approve policies and procedures to guide teams (patients, caregivers) as well as legal
n.
implementation of an IG program and and compliance authorities (Datskovsky
tio
remediate identified issues (Datskovsky
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et. al, 2015b).
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et. al, 2015a).
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●● Principle of retention. This helps organizations
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●● Principle of transparency. This stipulates that create processes for proper retention of
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documentation related to an organization’s information based on requirements from
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IG initiatives be available to its workforce regulations, accrediting organizations, and
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and other appropriate interested parties, company policy. According to the principle,
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according to the principle. Records “[t]he ability to properly and consistently
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demonstrating transparency of the
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retain all relevant information is especially
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information governance program should: important, as organizations create and store

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Document the principles and processes

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large quantities—most of it in electronic

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that govern the program; accurately and form.” (Datskovsky et. al, 2015c). (Chapter 8,
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completely record the activities undertaken to Health Law, contains more information
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implement the program; and be available to regarding retention of information within an

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interested parties (Datskovsky et. al, 2015a).

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organization.)
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●● Principle of integrity. According to the ●● Principle of disposition. This principle applies

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principles an (IG) program should be to all information in the custody of an

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arranged such that “the organization has organization and encourages them to “secure
20
a reasonable and suitable guarantee of and appropriate disposition for information

20
authenticity and reliability.” This includes no longer required to be maintained by

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elements such as appropriate workforce applicable laws and the organization’s

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training and adherence to the organization’s policies.” (Datskovsky et. al, 2015c).
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policies and procedures, as well as See chapter 8 for information regarding

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acceptable audit trails and admissibility of disposition of information.

records for litigation purposes.
●● Principle of protection. An IG program must
ensure the appropriate levels of protection AHIMA’s Information Governance
from breach, corruption, and loss are Adoption Model Competencies
provided for information that is private, AHIMA’s Information Governance Adoption
confidential, secret, classified, and essential Model (IGAM) consists of 10 competencies that
to business continuity. This facilitates the were intended to assist a healthcare organization
protection of sensitive healthcare information. in applying appropriate IG concepts. The adoption
●● Principle of compliance. Achieving compliance model permitted an organization to focus on those
through IG ensures healthcare entities areas of IG that it deemed important. This type of
comply with applicable laws, regulations, scalability promotes a natural progression of IG
AB103118_Ch06.indd 169 2/11/2020 4:17:39 PM

improvement in terms of expectations and, more 4. Data Governance

importantly, resources, according to AHIMA’s In- 5. IT Governance
formation Governance Toolkit 3.0 (AHIMA n.d.). 6. Analytics
The 10 key organization competencies promoted
7. Privacy and Security
by the IGAM included:
8. Regulatory and Legal
1. IG Structure 9. Awareness and Adherence
2. Strategic Alignment 10. IG Performance
3. Enterprise Information Management (EIM) Figure 6.5 summarizes the 10 IGAM Competencies
Figure 6.5 AHIMA’s 10 IGAM Competencies
n.
Creates the information governance program including executive sponsorship,
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IG STRUCTURE
IG committee, and policies and procedures to support the program.
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STRATEGIC Ensures the information goverance program strategy aligns with the
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ALIGNMENT organization’s strategy, mission, vision, and goals.
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PRIVACY
Protects information across all types of media, throughout the life cycle.
AND SECURITY
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LEGAL AND Verifies a proper, accurate, reliable, efficient response to regulatory audits,
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REGULATORY information requests, and eDiscovery.
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DATA Ensures usable and reliable data through comprehensive and proven data
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GOVERNANCE management practices.

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Strives for risk reduction through an integrated approach to technology selection,

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IT GOVERNANCE
evaluation, and use.
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Proves the value of information governance and contributes to a data-driven

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ANALYTICS decision-making culture in the organization through use of advanced tools and
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technologies.
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ENTERPRISE
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Guides practice for information through the information lifecycle across the
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INFORMATION
healthcare ecosystem.
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MANAGEMENT
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IG PERFORMANCE Measures the performance and impact of the IG program.

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Creates a path for trusted information and safe use of health IT throught
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AWARENESS
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consistent behavior with respect to information use, sharing, handling, access,

AND ADHERENCE
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storage, retention, and disposition.

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Source: Iron Mountain Advisory Services.

1. Which term is defined as principles and oversight to manage the information that is produced by the different systems
within a healthcare organization?
a. Information governance
b. Data governance
c. Data assets
d. Information assets
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2. Select the process that can help organizations evaluate the current state of best practices with data management,
gaps, and areas of opportunity based on risk, strategy, and operations of the organization.
a. Data governance
b. Information Governance Adoption Model
c. Enterprise information management
d. Business intelligence
3. Define the principle of integrity.
a. Create a process for ensuring that all the information complies with appropriate laws, regulations, standards, and
organizational policies
b. Create assurances that the data generated and maintained by an organization maintains authenticity and
reliability
c. Create protections to safeguard data and information from improper use and disclosure to avoid data breaches
d. Create a clear and open documentation process for the information governance strategy and activities within an
n.
organization
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4. True or false: An information governance initiative is a project within a healthcare organization led by middle level
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leadership.
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Data Governance
In
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Data governance is “enterprise au- are to establish policies and procedures on how
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thority that ensures control and accountability for data will be connected, who is responsible for the
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enterprise data through the establishment of de- data, how the data will be stored, and how the
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cision rights and data policies and standards that data will be distributed within the healthcare
are implemented and monitored through a formal organization.
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structure of assigned roles, responsibilities, and HIM professionals play a key role in the success
by
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accountabilities” (Johns 2015, 81). Data govern- of implementing information and data gover-
20
ance focuses on how healthcare organizations cre- nance programs in healthcare organizations. Their
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ate processes, policies, and procedures for keeping training provides them with an understanding
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information that is relevant to patient care and of healthcare’s clinical, financial, regulatory, and
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healthcare operations. The goal of data govern- technology environments, which allows them to
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ance is maintaining data accuracy and removing lead the information governance within an or-
unnecessary data from the health record. Com- ganization and be the liaison between executive
monly, data governance is confused with the term leadership and clinical leadership (AHIMA 2011;
information governance, even though there is a clear AHIMA 2014a).
distinction between the two terms. Data govern-
ance focuses on managing the data as they are cre- Data Stewardship
ated within an information system. Simply stated, Data stewardship is an important component of
data governance manages the data put into the dif- the data governance process. Data stewardship
ferent information systems used in healthcare and creates responsibility for data through principles
information governance manages the information and practices to “ensure the knowledgeable and
output from those systems. The core processes of appropriate use of data derived from individuals’
data governance within a healthcare organization personal health information” (Kanaan and Carr
AB103118_Ch06.indd 171 2/11/2020 4:17:40 PM

2009, 1). Data stewardship is important due to the The National Committee on Vital and Health
increase in availability of health data, the use of Statistics (NCVHS) recommends that the crea-
the health data within the healthcare industry, the tion of principles for data stewardship fall into
use of health information for population manage- four categories: (1) individual’s rights, (2) respon-
ment, and the legal and financial risks associated sibilities of the data steward, (3) needed security
with health data. Data stewardship is created to safeguards and controls, and (4) accountability,
establish common and essential practices and prin- enforcement, and remedies for data stewardship.
ciples for the management of health data. Benefits Individual rights should be analyzed to ensure the
of data stewardship are the following: following:
●● Improved patient safety ●● The individual has proper access to their
●● Increased efficiencies protected health information
The individual has a right to review and
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●● Decreased cost of care provided ●●
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amend their health information
Improved patient care and outcomes
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●●
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●● The individual is provided transparency of
Facilitated coordination of care
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●●
information allowing them to understand what
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●● Structured data collection
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information will exist and how it will be used
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●● Comprehensive data collection
●● The individual must provide consent and
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(Noreen 2017)
authorization for use and disclosure of
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Oversight and data stewardship are essential health information
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for proper management of information and data. ●●
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Adequate information and education are pro-
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This helps ensure the data and information meet vided regarding the rights and responsibilities
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the needs of the healthcare organization. One of the of health information (Kanaan and Carr 2009)
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emerging roles in healthcare is the data steward.

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The data steward’s responsibilities should be

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Data stewards are the people within an organiza-

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clearly defined to support adherence to the pri-

tion who are responsible for either a specific system
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vacy and security of health information including

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or a specific set of data within the organization

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requirements for uses and disclosures and guar-

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(Downing 2016). The data steward serves as the

antees for gaining access to what is needed to per-
subject matter expert for data governance for the
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form job responsibilities. Data security safeguards

healthcare organization, business unit, or data set
by
and controls should be established to define what

that they represent. For example, a heart clinic
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technical and nontechnical mechanisms are be-

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may have a data steward that oversees imaging

ing used to protect the confidentiality, integrity,
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and EKGs in the clinic, leads data quality initia-

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and accessibility of protected health information.

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tives to evaluate potential issues and risks, and

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Data stewardship should express accountability of

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leads the remediation process to ensure the accu-

appropriate use as well as sanctions in the event
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racy and integrity of the data. The data steward’s

of noncompliance to the requirements (Downing
roles are to establish policies, procedures, and pro-
2016). The goal is to create and build trust and
cessing for the system, data set, or business unit
transparency through the entire healthcare organi-
they support as they relate to data management.
zation as it pertains to the use of health data.
In an IG framework, the data steward acts as the li-
aison between the workforce (users of the systems
or data) and the information governance commit- Data Integrity
tee to help both sides create priorities, identify Many tools and functionalities of information
specific issues, and create plans for resolving the systems are available to assist with the quality,
identified issues. Other common job titles for the completeness, and timeliness of clinical docu-
data steward in healthcare are business analyst or mentation. While these tools and functionalities
data analyst (Downing 2016). of information systems create efficiencies in a
AB103118_Ch06.indd 172 2/11/2020 4:17:40 PM

healthcare organization, they have also been shown ●● Requiring periodic training
to create data integrity issues when not properly ●● Defining management responsibility
implemented and managed (AHIMA 2013; Vimal- (AHIMA 2013)
achandran et al. 2016). Data integrity is the assur-
Specific HIM department policies and proce-
ance that the data entered into an information
dures should also be established to address the ad-
system or maintained on paper are only accessed
ministrative documentation requirements, clinical
and amended by individuals with the authority
documentation requirements, entering information
to do so. Integrity of the documentation within
into the EHR, correcting and amending the health
the patient’s records includes information gov-
record, and time frames for correcting the health rec-
ernance, data governance, patient identification,
ord (Maimone 2016). HIM professionals need to be a
authorship validation, amendments and record
part of establishing proper integrity throughout the
corrections, and audits of documentation validity
health record as they are the custodians of the health
n.
for reimbursement (AHIMA 2013; Vimalachan-
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record. It is common practice that the HIM depart-
dran et al. 2016). A healthcare organization needs
ia
ment and HIM professionals ensure the health rec-
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to establish proper safeguards with the use of
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ord is complete and accurate, so it is available for the
technology, including policies and procedures to
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purposes of patient care and healthcare operations.
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help manage the integrity of the data in the health
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record. The Health Insurance Portability and
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Accountability Act (HIPAA) requires covered Data Sharing
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entities (defined in chapter 9, Data Privacy and Con- Electronic health information systems were imple-
fidentiality) to implement policies and procedures n
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mented to create a foundation for data sharing
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to protect electronic protected health information
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across healthcare organizations regardless of the

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from improper alteration or destruction and to information system(s) used. Data sharing allows
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establish security measures to ensure electronically information to be exchanged via electronic formats
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transmitted protected health information is not to help support and deliver quality healthcare.
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improperly modified (chapter 10, Data Security, Also known as health information exchange, data
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covers this topic in more detail). AHIMA recom- sharing is the electronic exchange of information
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mends healthcare organizations institute policies between providers’ electronic systems. Data shar-
and procedures for the management of data integ- ing, or health information exchange, has two basic
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rity. Some key topics to be included in data integ- components: (1) the ability of two or more infor-
by
rity policies are the documentation requirements, mation systems to communicate and exchange
20
20
identification of who can document and the scope patient information and (2) the ability of two or
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of that documentation, timeliness of documen- more information systems to effectively collect

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tation, and safeguards regarding changing and and use the information that has been exchanged
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deleting documentation. Guidelines a healthcare (Dean 2018). When implemented correctly, a proper
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organization establishes to reduce the likelihood data sharing process can assist with coordinating
of issues or damages to the patient data include patient information, analyzing patient informa-
the following: tion across multiple healthcare organizations, and
●● Committing to comply with laws and reducing unnecessary repeated tests to support
regulations in an ethical manner improvement in patient outcomes and patient sat-
isfaction. For example, if a CT scan is performed
●● Requiring accurate data
on a patient prior to referral to another healthcare
●● Holding individuals accountable for errors organization, the results of the CT scan can be
as per medical staff bylaws or rules and shared electronically to prevent the patient from
regulations having the same test replicated (Dean 2018). See
●● Identifying penalties for the falsification of chapter 12, Healthcare Information, for more infor-
information mation regarding health information exchange.
AB103118_Ch06.indd 173 2/11/2020 4:17:40 PM

Data Interchange Standards organization that oversees the creation of data

standards from a variety of business sectors,
To help support and drive interoperability and data
including healthcare. The following are some
sharing between healthcare organizations, stan-
common SDOs:
dards development organizations have created
standards for the sharing of information in elec- ●● Health Level 7 (HL7). An ANSI-accredited
tronic formats. Interoperability is the capability SDO, HL7 established the creation of
of two or more information systems and software standards to support the exchange of clinical
applications to communicate and exchange infor- information in multiple formats
mation. Standards development organizations ●● Institute of Electrical and Electronics Engineers
(SDOs) are private or government agencies that (IEEE). A national organization that
are involved in the creation and implementation creates and develops different standards
of healthcare standards. In this case, SDOs define for hospital information systems that
n.
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standards to support the process of electronic need communication between bedside
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exchange of data. Data interchange standards are
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instruments and clinical information
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developed in order to support and create structure systems (for example, cardiac monitoring
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with data exchanges to sustain interoperability. performed in the intensive care unit being
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The goal of the data interchange standards is to
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integrated with the EHR); IEEE currently has
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facilitate consistent, accurate, and reproducible standards that allow providers and hospitals
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capture of clinical data. Data interchange stan- to achieve interoperability between medical
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dards help support data integrity and safeguard
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instrumentation and a computer healthcare
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data quality when sharing between organizations.
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information system, and though used in
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Using data interchange standards for interoper-

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multiple types of systems, it is most often

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ability helps to do the following: used within acute-care settings

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●● Create a basis to enable the electronic ●● National Council for Prescription Drug
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exchange of data between two or more Programs (NCPDP). A committee within

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information systems or applications by the Designated and Standard Maintenance

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Organization focused on the development of

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creating consistent formats and sequences

of data that are applied during data standards regarding exchanging prescription
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transmission information and payment information;

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NCPDP created multiple standards

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●● Reflect the existing clinical and

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administrative data contained in both including a standardized data dictionary for

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paper and electronic information systems pharmacy data, standards for transactions
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of file submissions between pharmacies and

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to maintain patient data consistency in

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processors, standards for common billing

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growing EHRs
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unit language for submission of prescription

●● Transfer health data using appropriate
claims, and standards to communicate
business processes and necessary ethical and
formulary and benefit information to
regulatory demands and guidance
prescribers (Orlova et al. 2016).
●● Foster electronic transmission as a business
strategy to support patient care and better Information and Data Strategy
patient outcomes Methods and Techniques
●● Promote efficient information sharing among
With the implementation of data and information
individual computer systems and institutions
governance, healthcare organizations must evaluate
(AHIMA 2006; Murphy and Brandt 2001)
and implement strategies focused on the oversight
In the US, SDOs are managed by the American and management of the information and data in
National Standards Institute (ANSI). ANSI is the their healthcare organization. Information and data
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Figure 6.6 Characteristics of a successful information governance strategy
A successful IG strategy incorporates the following characteristics:

• Business-led and Business-driven: Accountability and responsibility for data and information rests with the business owners who
lead the departments or business units that create or generate the data and information, as opposed to IT
• Measurable: Clear goals and objectives and related metrics are established for performance improvements, reduction of risk, and
optimization of data and information
• Achievable: A realistic level of resources (funding, staffing, and so on) is provided to develop and sustain IG efforts
• Avoids complexity: Initial goals and objectives should be focused and targeted to specific issues or problem areas
• Communicable: Communications explain and educate employees and clinicians about their information management responsibilities
• Copes with uncertainty: Standardization of processes leads to a more consistent approach and response to threats that can help
the organization cope with ambiguity or uncertainties
• Flexible: Information management functions provide adequate controls but are designed to allow for flexibility where required to
carry out job duties
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Source: Washington 2015.
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strategies are the steps taken to manage the data the information system can pull data from
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and information. The information and data strate- one field to another to avoid re-entering
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gies should align to the healthcare organization’s information that has already been entered.
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overall strategy and support the broader business The intent of data standardization is to
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goals of the organization. The information and document the location of data collection and
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data strategies help to promote the collection of ensure standardized formats and meaning of
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quality healthcare data, support decision-making, the data.
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define proper use of information, and manage the Data quality. Data quality focuses on entering
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●●
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compliance risk of an organization (Washington

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data that is true, accurate, and relevant to

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2015). Figure 6.6 describes the characteristics of a patient care and business operation into
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successful information governance strategy. the information system. Data quality is

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Data strategy should be a clear, concise method discussed in detail later in this chapter.
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created to support proper collection and use of

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●● Metadata management. Refers to managing

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healthcare data within an organization that is ap-

and defining the metadata within the
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proved by executive leadership. A data strategy

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information system. Metadata refers to

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will clearly define the healthcare organization’s

the data that characterizes other data
20
data policies and procedures, roles and respon-

such as creation date of data, date sent,
20
sibilities for data governance, business rules for

date received, last accessed date, and last
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data governance, process for controlling data re-

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modification date. It is important to clearly

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dundancy, management of key master data, use of

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define what metadata will be collected and

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structured and unstructured data, storage for all

why it will be collected.
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healthcare data, and safeguards and protections of

the data. The strategy must define the following:
●● Data modeling. Refers to the creation of
documentation to justify business decisions
●● Data standardization and integration. Focus made based on the different data collection
on how the data is being entered into the and storage systems that are used within
information system, where the same data an organization. Creating data models
might exist in multiple areas, and how it and defining the use of data in relation to
is being integrated into other information business mission and vision allow for the
systems. For example, review where data of support of data standardization across the
birth is being entered into the information organization.
system and if it is always in the same format ●● Data ownership. Refers to the creation of
such as MM/DD/YYYY. Also, evaluate if business leaders, or owners, of specific
AB103118_Ch06.indd 175 2/11/2020 4:17:40 PM

areas of the data. For example, the Director type of information to be reported to support busi-
of Radiology can be assigned as the ness strategy. In other words, the focus should be on
business leader, or owner, of the radiology presenting data that will help the healthcare orga-
information system. Based on the business nization reach its goals. Additionally, the data may
need, the business owners are responsible provide information and detail that elicit negative
for creating business rules and definitions feedback. For example, if a healthcare organization
when collecting specific data to support is trying to determine if it wants to add an addi-
patient care and their business operations. tional cardiac catheterization room, it may choose
●● Data stewardship. Data stewardship is the to evaluate and create data presentations for indi-
evaluation of the data collection based on viduals within a specific geographic area who have
business need and strategy to ensure the been diagnosed with cardiac conditions. Graphs
data meets the requirements of patient care with data pertaining to emergency department vis-
n.
and organizational needs (AHIMA 2011; its would not be useful in evaluating the expansion
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Downing 2016). of a cardiac catheterization room. Understanding
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the data and properly managing it becomes an es-
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A clearly defined data strategy approved by
sential part of handling data assets appropriately.
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executive leadership is necessary to manage the
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most important healthcare assets—patient data.
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Critical Thinking Skills
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Data Visualization and Presentation
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Another key aspect in the management of data as-
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It is important to properly organize and visualize io
sets in the organization is critical thinking skills.
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data used for business purposes. Data visualiza- Critical thinking refers to the process of analyzing,
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tion creates a visual context for data to help people assessing, and reconstructing a situation to pro-
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better understand the data and the significance of vide enhanced solutions and outcomes to a prob-
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the data. Data visualization can take a large vol- lem (The Critical Thinking Community n.d.). It is
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ume of data and provide key aspects and insights estimated that in the coming years, new technol-
an
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to the data in a visual format (Meyer 2017). Many ogy advancement, including the use of technology
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tools such as graphs, charts, and tables exist to in healthcare, will occur every 30 seconds (Hum-
present data. It is easy to create different charts bert 2018). The skill of critical thinking is essential
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and graphs that provide information and detail in healthcare. Humbert (2018) stated: “A critical
by
regarding data, but it is important to present the thinker is able to deduce consequences from what
20
20
data in ways that are appropriate to the health- he knows, and he knows how to make use of in-
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care organization and the data being analyzed. formation to solve problems, and to seek relevant
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For example, to present the frequency of a specific sources of information to inform himself….Critical
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diagnosis by gender, a pie chart—meant to show thinking can help us acquire knowledge, improve
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the percentages of a total—would not be a good our theories, and strengthen arguments. We can
selection. A table could provide that information use critical thinking to enhance work processes
in a better format. Chapter 13, Research and Data and improve social institutions” (p. 56).
Analysis, provides specific information regarding The issues and challenges that face healthcare
data visualization and presentation methods. organizations and the healthcare industry continue
Another important aspect for the management to become more complex and require the effective
and presentation of data is that the data and infor- evaluation of data to help support the change in
mation need to be meaningful and useful to the the healthcare environment (Meyer 2017; Sharp et
organization. Presenting data that do not support al. 2013). Many individuals can effectively utilize
an initiative of the organization can be an unpro- critical thinking to analyze a situation and gener-
ductive use of company resources and time. It is ate solutions to an issue. During the critical think-
important to define a clear strategy regarding the ing process, it is common for data to be analyzed
AB103118_Ch06.indd 176 2/11/2020 4:17:40 PM

to effectively evaluate the current state and future care potentially needed. Based on this gathering
solution in addition to generating a solution to the and analysis of data, an enhanced decision on the
current issue. For example, a healthcare organiza- nature of care can be made to support the commu-
tion is currently evaluating a new line of service to nity and its care needs.
add to an outpatient clinic being built in a small With the implementation of EHRs, new roles
community where they currently only have family such as data analysts or EHR analysts are being
practice providers. Without critical thinking, an in- established for the oversight and management of
dividual may evaluate only common types of care data collection within a healthcare organization as
associated with family practice and add that new well as how information is used. While principles
line of service to the outpatient clinic. From a criti- of information governance have been established
cal thinking perspective, a healthcare organization by AHIMA and data governance is an essential com-
may evaluate common referrals to other clinics for ponent of daily operations, the ability to under-
n.
the patients seen and treated at the clinic. In addi- stand, evaluate, and apply the different principles
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tion, they may profile the community in which the becomes an essential part of a successful informa-
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clinic exists to understand the population and the tion and data governance program.
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Answer the following questions. io
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1. True or false: Information governance and data governance are the same concept and can be used interchangeably.
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2. Distinguish which of the following are components of AHIMA’s principles of information governance.
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a. Accountability and accessibility

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b. Integrity and safeguards

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c. Safeguards and accessibility

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d. Accountability and integrity

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3. True or false: Data stewardship is principles and practices established to ensure the knowledgeable and appropriate
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use of data derived from individuals’ personal health information.

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by
4. True or false: Data sharing is needed regardless of the information system used.
20
5. Identify which of the following describes what information assets are:

20
©
a. Information considered to add value to an organization

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b. Data entered into a patient’s health record by a provider

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yr
c. Clearly defined elements required to be documented in the health record

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d. Information collected by a healthcare organization that has value

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Data Quality
Data quality is the reliability and effec- aggregation), warehousing, and analysis” (Davoudi
tiveness of data for its intended uses in healthcare et al. 2015, 8). Data quality has always been a focus
operations, decision-making, planning, and patient for HIM professionals; with the implementation of
care. Data quality management is “business pro- the EHR, the need for more complete and accurate
cesses that ensure the integrity of an organization’s information is critical to support proper patient
data during collection, application (including care and corresponding reimbursement.
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Data quality serves as one of the most im- Quality Model is an important tool in ensuring the
portant elements of healthcare operations and quality of the data collected.
patient care. “All data must be accurate, timely,
relevant, valid, and complete to ensure the reli- AHIMA’s Data Quality Management
ability of the information” (Davoudi et al. 2015, 8). Model
This is because the data support patient care and AHIMA created the data quality management
patient safety, provide evidence for reimburse- model to support the need for true and accurate
ment and accreditation, and afford documenta- data. Data quality management is “the business
tion needed for quality initiatives and research process that ensures integrity of an organization’s
(AHIMA 2015). Without complete and accurate data during collection, application, warehousing,
data in a health record, a healthcare organization and analysis” (Davoudi 2015). Many areas such
is at risk for patient safety issues. For example, if as patient care, patient outcomes, reimbursement,
n.
a provider does not document what medications process improvement, and daily healthcare oper-
tio
were administered to a patient and the exact ations depend on detailed quality of information.
ia
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dosages, the patient may be prescribed a nother Core functions of enterprise information manage-
ss
medication that could have adverse effects when
tA
ment must be established to create the ability to
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combined with the first medication. In addition, collect high-quality data from the health record.
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there are risks such as having to return pay- The goal of EIM is to make sure that information
ag
ment if the documentation does not support the being used for business decisions and patient
an
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healthcare organization’s billing and reimburse- care is reliable and trustworthy. The data quality
ment request. For example, if a physician billed n
io
management model can help set up policies, pro-
at
that they performed a procedure, but the docu-
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cesses, and expectations to support EIM within an

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mentation does not support the procedure, the organization.

In
physician may have to return the money and The data quality management model defines
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rebill the services. four domains that link and support data quality.
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Clinical documentation is “any manual or The first domain is application, which is focused
an
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electronic notation (or recording) made by a phy- on understanding the purpose of data collec-
er
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sician or other healthcare clinician related to a tion. Since the amount of patient data collected
patient’s medical condition or treatment” (Hess through a patient encounter is immense, it is
e
th
2015). Clinical documentation is the foundation important to evaluate and understand why the
by
of every health record in that it supports the care data is being gathered and the purpose it serves
20
20
the patient received and the reimbursement that for the healthcare organization. The second do-
©
should be received for the care. Inaccurate infor- main is collection, which concentrates on how
ht
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mation and poor documentation negatively impact the data elements are being collected through-
yr
op
patient care and reimbursement, which can drive out the encounter. Understanding where data is
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up the cost of healthcare (AHIMA 2015), creating being entered and how it is being entered is an
a need for data quality and data quality manage- essential part of basic data quality management.
ment over healthcare data. This focus allows a healthcare organization to
Many accrediting organizations such as the understand if duplicate or redundant informa-
Joint Commission require evidence of clinical care tion is being collected. The third domain is ware-
based on the data that is documented in the health housing, which describes the processes as well as
record. If the accrediting organization has basic re- systems a healthcare organization uses to archive
quirements for documentation in the health record, data; it also includes understanding where the
and the healthcare organization does not meet data is being stored, and how it is being archived
those requirements, it runs the risk of losing ac- and managed. The last domain is analysis, which
creditation. Data quality is critical to both clinical centers on how the data collected throughout the
care and administrative processes. AHIMA’s Data patient encounter is transformed into meaningful
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data for use throughout the entire spectrum of element within an information system. For exam-
the healthcare setting (Davoudi 2015). ple, the EHR will require at a minimum the user’s
Ten characteristics of quality data defined with- name, date of birth, address, telephone number,
in the AHIMA data quality model are accuracy, and gender on a specific screen collecting patient
accessibility, comprehensiveness, consistency, cur- information. The information system can require
rency, definition, granularity, precision, relevancy, information to be entered into all these fields be-
and timeliness. Understanding and applying each fore the user is able to move to the next screen,
of these characteristics to the data quality man- which supports comprehensiveness. Training and
agement domains is an essential part of effec- education should be conducted across the health-
tive oversight and management of data quality care organization to ensure the staff members col-
(Davoudi 2015). lect all the required data elements in the health
record (Davoudi 2015).
n.
Accuracy
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Consistency
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Accuracy focuses on the data being free of errors.
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It is important that the data within the health Consistency means ensuring the patient data are
ss
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record are accurate across the entire health record reliable and the same across the entire patient
en
(that is, the data are valid with the appropriate test encounter. In other words, patient data within the
em
results and placed into the proper health record). health record should be the same and should not
ag
contradict other data also in the health record; for
an
An example of monitoring the health record for
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data accuracy is the analysis of patient notes in the example, a test result and diagnosis should be the
n
io
same throughout the health record (Davoudi 2015).
health record to ensure they support the diagno-
at
m
sis throughout the entire health record (Davoudi

r
fo
2015). For instance, the information in an operative Currency

In
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report should be compared to information in the The data within the health record need to be current
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discharge summary to confirm the operation per- and up to date. EHRs present information across a
H
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formed and findings are accurate (the same) in broad spectrum of care, including data that may be
ic
both documents.
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outdated. Specific procedures should be established

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for updating data elements used for each patient

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encounter, including the discontinuation of collect-

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Accessibility
by
Proper safeguards must be established and em- ed data elements that are no longer current. An ex-
20
ployed to ensure the data are available when needed ample of data currency is reviewing and updating
20
while implementing proper precautions and safe- patient medications at each patient encounter to
©
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guards to protect the information. An example of remove medications that are no longer being taken
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and add any new medications (Davoudi 2015).

yr
data accessibility is ensuring that nurses have

op
access to the health records of patients that they are

C
treating (Davoudi 2015). (See chapters 9, Data Priva- Definition

cy and Confidentiality, and 10, Data Security, for ad- All data elements should be clearly defined to
ditional information on access to health records.) guarantee that all individuals using and collecting
the data will understand the meaning of that data
Comprehensiveness element. An example of data definition is defining
Data comprehensiveness certifies that all required date of birth as the date the individual was born by
data elements that should be collected through- month, day, and four-digit year (Davoudi 2015).
out the health record are documented. One way
to ensure this is happening in the EHR is to use Granularity
required fields. Required fields allow for the infor- The data collected for patient care must be at the
mation system to force a response in a specific data appropriate level of detail. An example of data
AB103118_Ch06.indd 179 2/11/2020 4:17:40 PM

granularity is documenting the results of a lab test HIM professionals work in a variety of roles to
with the appropriate number of characters after a support and manage the quality of data, especial-
decimal point in the lab value (Davoudi 2015). ly as the implementation of the EHR continues.
Some common HIM roles include clinical data
Precision manager, health data analysis, terminology asset
Data should be precise and collected in their exact manager, clinical documentation integrity specialist,
form within the course of patient care; for example, data collection specialist, and EHR documenta-
documenting the exact measurement, such as the tion specialist (Davoudi 2015). The HIM profes-
height or temperature of the patient. When infor- sional understands the need for quality data
mation is entered precisely, there should be little to and can bring that knowledge and expertise into
no variability of the data (Davoudi 2015). many different areas of the healthcare delivery
system.
n.
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Relevancy Data Collection Tools
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Data relevancy is the extent to which the data
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The management of data quality depends on how
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elements being collected are useful for the pur-
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the data are collected during the patient encounter.
poses for which they are collected. If a healthcare
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With data created, stored, and maintained on pa-
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organization collects data that are not relevant
per as well as in electronic format, it is important
ag
in supporting patient care and administration,
to ensure the data collection tools—such as forms
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it adds additional, unnecessary information in
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and computer screens—used throughout a health-
n
the health record. For example, if a patient pres- io
care organization are effective and efficient. HIM
at
ents with pain during urination, data collection
m
professionals should be involved in the creation of

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should be focused around the symptoms, testing,

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data collection tools for both electronic and paper-

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and treatment. Collecting additional data or data

based tools.
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not relevant to support treatment, payment, and

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In addition to data collection tools, standardiza-

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healthcare operations adds superfluous data to the

tion of the collection of patient data is essential to
an
record. An example of relevancy is the creation of

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collect the proper information and reach data qual-

er
templates to collect the correct information during

Am
ity levels needed to support the enhancement of

an emergency department visit for a patient, as
patient care and the healthcare industry. The two
e
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this can help assemble accurate and relevant data

major ways to collect data elements are through
by
to support the visit and help prevent additional,

the use of electronic templates and paper-based
20
nonrelevant information from being collected

20
forms. Not all paper forms will convert easily to

(Davoudi 2015).
©
an electronic format, so it is important to evaluate

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each of the different screens to ensure the data cap-

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Timeliness
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ture is correct. There are standards for both screen

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Patient documentation should be entered promptly, design and paper forms to facilitate data collection.
ensuring up-to-date information is available with-
in specified and required time frames. Timeliness Screen Design
may vary throughout the health record depending Most EHRs come with prebuilt forms and tem-
on what the data are being used for and how the plates for use within the information system. For
data are supporting patient care. An example of example, a template would contain all the infor-
timeliness is specifying when notes such as dis- mation required for inclusion in the discharge
charge summaries or operative reports should be summary such as discharge diagnosis, discharge
entered in the information system. Healthcare or- medications, and follow-up. Usually, prebuilt
ganizations frequently require specific forms such forms and templates do not match the healthcare
as orders or admitting evaluations to be entered organization’s specific needs. One reason for this
within a defined period. is that a screen typically holds approximately a
AB103118_Ch06.indd 180 2/11/2020 4:17:41 PM

third of what is contained on a form. In addition, the user can choose. Radio buttons are used when
the prebuilt forms may not be constructed to col- there are few options, such as only male or female,
lect the information needed to support the health- from which the user should choose. Unstructured
care organization’s patient care and payment data, also known as free text, are data entered into
processes. The Department of Health and Human the information system with no format specified.
Services Office of National Coordinator for Health An example of unstructured data is a narrative
Information Technology (ONC) discusses the need discharge summary that does not follow a specific
to evaluate workflow and customize patient data format or use a template. Unstructured data can-
collection functions. They recommend the follow- not be interpreted by an information system and
ing for patient data collection functions: usually are not used in structured reports. When
choosing how to collect data within an EHR, it is
●● Create templates for common types of notes, important to evaluate and make decisions based
visits, and procedures
n.
on how data are reported.
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Configure patient data lists with multiple Since many healthcare organizations are unsure
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●●
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choices for diagnoses, medications, and of what data they need, especially as they transition
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orders to the EHR, it is important to have a standardizing
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●● Develop flow sheets for common vital signs committee or process to evaluate data collection
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and blood tests, allowing for trending across within information systems. This individual or
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group is responsible for assuring that quality data
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a period of time
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are entered into the information system and prop-
Confirm that the EHR being used meets
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●●
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er data reporting is obtained from the information
at
basic standards for interoperability and data
system. The documentation should be used to
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sharing across systems (HHS 2015).

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support decisions for future evaluation.

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In addition, analysts who are assisting with

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Forms Design
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building the EHR within the healthcare organiza-

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tion should meet with each department that enters Forms design is a major part of assuring data qual-
an
ity within a healthcare organization. Forms design

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data into the health record to evaluate current data

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is the oversight process in which paper forms are

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collection processes within the EHR and evaluate

additional forms or tools necessary to support created to make sure that they are easily under-
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current workflow. Some key elements when eval- stood and to collect the correct amount of informa-
by
uating forms design is deciding what should be in tion necessary. Forms design helps to make sure
20
20
structured data format and what should be in un- there is a consistent process to determine if a form
©
structured data format. Structured data are data is necessary and how it will be developed (Pyra-
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mid Solutions 2017). With any new creation of a

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that can be read and interpreted by an information

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form, the following questions should be asked:

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system. An example of structured data is a diag-

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nosis code entered in the proper format into the ●● What is the purpose of this form?
information system, such as an ICD-10-CM code ●● Can the data be collected in electronic format
format of XXX.XXXX. If the data element is in versus paper format?
the proper format and in the proper location, the
●● When will this form be used during the
information system will read and perform analysis
patient encounter and in which type of
on that data. Other methods to collect structured
patient encounters?
data include check boxes, drop-down boxes, and
radio buttons. Check boxes allow the user to select ●● Who will use this form within the healthcare
multiple values. For example, murmurs, gallops, organization?
and rubs can be chosen under the cardiac section ●● What will be done with the paper once it
of the physical exam. Drop-down boxes list the is created (scanned into system, stored in a
appropriate options, such as states, from which paper health record)?
AB103118_Ch06.indd 181 2/11/2020 4:17:41 PM

Answering these questions during the assess- anyone directly affected by the new form or com-
ment of a new form will help the form be appro- puter view should be invited to attend the forms
priate and direct whether it is created in paper committee meeting. For example, when a form
or electronic format. The disadvantage of paper is being redesigned for use in the intensive care
forms used to support patient care is that they unit, nurses and physicians from that clinical area
have to be entered into an EHR manually or by should be invited to give their input.
scanning the paper documents, which does not al- Forms control, tracking, and management are
low for reporting. In some cases, paper forms that important issues. At a minimum, an effective forms
do not collect patient information, such as produc- control program includes the following activities:
tivity forms or staff vacation requests, will not be
entered into the EHR, but may be entered into a ●● Establishing standards. Written standards
human resources management system. It is impor- and guidelines are essential to ensure the
n.
tant to evaluate each form to determine if it will appropriate design and production practices
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remain on paper or be entered into an electronic
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are followed. Standards are fixed rules that
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system. must be followed for every form (for exam-
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The following are the recommended steps for
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ple, where the form title should be located).
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controlling, tracking, and managing paper forms: A guideline, on the other hand, provides
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general direction about the design of a form
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●● Establishing data collection standards within
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the healthcare organization (for example, usual size of the font used).
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Establishing a numbering and tracking system.
n
●●
●● Establishing testing and evaluation process io
A unique numbering system should be
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Evaluating the quality of new paper and
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●●
developed to identify all organizational
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electronic forms
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forms. A master form index should be

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●● Systemizing storage, inventory, and established, and copies of all forms should
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distribution of forms be maintained for easy retrieval. At a

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●● Numbering, tracking, and using bar codes to minimum, information in the master form
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manage paper forms index should include form title, form

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●● Establishing a documentation system that number, origination date, revision dates,

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supports decisions that are made by the form purpose, and legal requirements.
th
by
forms committee Ideally, the tracking system should be

20
automated.
20
Proper and effective management of data collec-

Establishing a testing and evaluation plan.
©
●●
tion requires quality data regardless of the media
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No new or revised form should be put into

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type. HIM professionals play a vital role in this

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production or use without a field test and

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process to verify that proper data is being collect-

evaluation. Mechanisms should be in place
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ed in the best format and to confirm that forms are

to ensure appropriate testing of any new or
designed properly to ensure efficient processing of
revised form.
the information.
There is typically a clinical forms committee ●● Checking the quality of new forms. A mechanism
that manages both paper and electronic forms de- should be in place to check all newly printed
sign. The clinical forms committee should be com- forms prior to distribution. This should be a
prised of a multidisciplinary team and led by the quality check to confirm that the new form
HIM department. Some common recommended conforms to the original procurement order.
committee members are medical staff, nursing ●● Systematizing storage, inventory, and
staff, purchasing, information services, performance distribution. Processes should be in place to
improvement, support and ancillary departments, ensure the forms are stored appropriately.
EHR support, and forms vendor liaison. In addition, Paper forms should be stored in safe and
AB103118_Ch06.indd 182 2/11/2020 4:17:41 PM

environmentally appropriate environments. a forms database may be used to store and

Inventory should be maintained at a facilitate updating of forms. Such a database
cost-effective level, and distribution should can provide information on utilization rates,
be timely. obsolescence, and replacement of individual
●● Establishing a forms database. In an electronic forms or documentation templates (Barnett
system that supports document imaging, 1996; Pyramid Solutions 2017).

n.
1. True or false: Healthcare organizations do not need to evaluate the purpose of data collection for assuring data quality.
tio
ia
2. Identify which of the following are the four data quality management domains.
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a. Accessibility, accuracy, consistency, and precision
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b. Application, collection, warehousing, and relevancy
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c. Accessibility, collection, warehousing, and precision
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d. Application, collection, warehousing, and analysis
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3. Which of the following data quality characteristics means all data items are included in the information collected?
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a. Accuracy
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b. Consistency io
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c. Comprehensiveness
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d. Relevancy
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4. True or false: Data granularity is where the data collected is collected at a level of detail that meets the needs of the
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healthcare organization.
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5. Recommend a guideline for maintaining integrity in the health record.

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a. Removing the consequences for the falsification of information

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b. Requiring training that covers the falsification of information and information security only at hire
c. Assuring documentation that is being changed is permanently deleted from the record
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d. Prohibiting the entry of false information into any of the healthcare organization’s health records
by
20
20
©
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Clinical Documentation Integrity representation of healthcare services through com-

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plete and accurate patient documentation within

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Clinical documentation relates to the quality and

the record. The following are some basic goals of
integrity of patient data while supporting other
a CDI program:
functions such as timely coding and reimburse-
ment. Clinical documentation integrity (CDI) is
●● Obtain specific documentation that can be
defined as the process of reviewing medical in-
used to identify the patient’s severity of
formation to verify that documentation is clinical
illness
specific, is appropriate, and supports the medical
codes assigned (AHIMA 2016c). Historically, CDI ●● Identify and clarify missing, conflicting, or
programs were created to support reimbursement; nonspecific provider documentation related
however, with the implementation of EHRs and to diagnoses and procedures
the expanded uses of clinically coded data, CDI ●● Support accurate diagnostic and
programs have shifted to facilitate an accurate procedural coding, and Medicare Severity
AB103118_Ch06.indd 183 2/11/2020 4:17:41 PM

Diagnosis Related Group (MS-DRG) ●● Legibility – documentation should be easy to

assignment, leading to appropriate decipher and understand
reimbursement ●● Reliability – documentation should be
●● Promote health record completion during trustworthy
the patient’s course of care, which promotes ●● Precision – documentation should follow
patient safety strict medical terminology and be as
●● Improve communication between physicians accurate and exact as possible
and other members of the healthcare team ●● Completeness – documentation should
●● Provide awareness and education contain all details that are necessary
●● Improve documentation to reflect quality to support continuity of care between
and outcome scores caregivers and support billing and
Improve coding professionals’ clinical reimbursement
n.
●●
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knowledge (AHIMA 2016c) ●● Consistency – documentation should
ia
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be consistent throughout the entire
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CDI programs can help healthcare organiza- record
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tions enhance patient documentation, reduce er-
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●● Clarity – documentation should describe all
em
rors within the health record, and improve the
details regarding the patient’s medical care
ag
quality of the patient data entered in the system
to the highest level of specificity
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while supporting patient care and reimbursement
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●● Timeliness – documentation must be
for the organization. Figure 6.7 provides an exam-
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completed in a timely manner (Barnette
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ple of how CDI impacts the patient.
m
et al. 2017; Combs 2016b)

CDI programs should be established with the
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In
initial review of the health record to verify all nec- Another impact on CDI is the evaluation of
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essary components of the health record. The fol- present on admission (POA) reporting require-
ea
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lowing areas should be evaluated during the initial ments. POA refers to the conditions that are
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CDI review process: present in a patient at the time of ordering the

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Figure 6.7 How does CDI impact the patient?

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th
by
Example Scenario:
20
This is a 48 y/o male that has hypertensive end-stage renal disease (ESRD) and is on home peritoneal dialysis. He recently had
20
knee replacement surgery. Two days after being discharged home, he went into respiratory failure and was rushed back to the
©
hospital. It was determined he was in fluid overload secondary to a blockage in the peritoneal dialysis catheter from fibrin. This
ht
was treated with heparin and returned to normal function. He was discharged home with home health nursing and physical
ig
yr
therapy.
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After being discharged home, the wife and home health nurse noticed the patient’s oxygen level would continue to drop to
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the low 80s to upper 70s every time he fell asleep. The primary care physician was called and home oxygen was ordered
for a decrease in oxygen saturations. A sleep study was also scheduled. The patient then received a call from the home oxygen
vendor and was told his insurance would not cover home oxygen for his condition. He was told the only way it could be delivered
was if he paid for it out of pocket. It is now 5:00 pm on a Friday evening and the physician’s office is closed.
This would be of great concern to a patient in this situation. He knows he needs the oxygen but does he have the money to
pay for it? The patient is sick enough to need the oxygen but unfortunately the clinical documentation doesn’t have the specificity
needed to reflect the true condition of the patient. Home oxygen has a specific set of requirements under the National Coverage
Determinations (NCDs) for Medicare that must be met before the treatment will be approved. Some other payers also use these
criteria to support medical necessity of certain treatments.
It is important for providers to be aware of National Coverage Determinations and Local Coverage Determinations (LCDs). The
Centers for Medicare and Medicaid Services has a website where providers can look at the NCD and LCD requirements (https://
www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx). In the hospital, patients have case
managers who ensure these requirements are met before discharge. But this is not the case in many outpatient settings.
Source: Combs 2016a.
AB103118_Ch06.indd 184 2/11/2020 4:17:41 PM

inpatient admission. The goal of the POA report- the documentation supports the code assignments,
ing is to document which conditions are pres- understand the coded data in quality measures
ent in a patient at the time of admission into an and reporting, and know how documentation im-
acute-care facility versus the conditions that may pacts payment methodologies. The physician also
develop during the patient’s stay in the facility works closely with the HIM coding department
(AHIMA 2009; Garrett 2009). A condition acquired and CDI specialists to review health record doc-
during a hospital stay is referred to as a hospital- umentation, discuss clinical issues that may have
acquired condition (HAC). If a patient acquires a been identified during the health record reviews,
HAC that increases the cost of the patient care, it discuss clinical criteria for disease processes, assist
may not be paid under Medicare if it is considered in the development of appropriate, compliant, and
preventable. It is important for a CDI program to ethical provider queries, and review HACs and
evaluate these two requirements and make sure treatment complications (AHIMA 2016c).
n.
proper documentation is in place at the time of the
tio
inpatient admission order to prevent loss of reim- CDI Tools
ia
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bursement (AHIMA 2009; Garrett 2009). Chapter There are different ways to conduct the CDI review
ss
15, Revenue Management and Reimbursement, offers
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within a healthcare organization. CDI tools help
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more information regarding POA and HACs. manage and document the work of CDI profes-
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A CDI program usually has dedicated staff that sionals. A variety of tools can be used to help sup-
ag
may include HIM professionals, physicians, nurs- port CDI processes within an organization. One
an
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es, and other healthcare professionals. CDI pro- tool is computer-assisted coding (CAC). CAC
grams impact quality of care and finances within n
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is software that can search and evaluate clinical
at
a healthcare organization along with other key
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documentation to produce information regard-

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stakeholders such as case management, utilization ing potential areas for documentation integrity.
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review, medical staff, physician leadership, execu-

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Electronic documentation is passed through the

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tive leadership, patient financial services, revenue CAC software application, which analyzes the
H
cycle management, quality and risk management, information and produces a report of procedure
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ic
nursing, and compliance (AHIMA 2018). The CDI and diagnosis codes based on the electronic docu-
er
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program must have clear goals and strategies that mentation evaluated. The codes are then manually
align with the healthcare organization’s require-
e
evaluated for accuracy and completeness. The use

th
ment for clear and precise clinical documentation. of CAC software can speed up the coding process
by
There are several CDI tools that can be used to

20
as it allows for evaluation of electronic assigned

20
enhance the quality of documentation. Clinical codes rather than having an individual analyze
©
documentation specialists use these tools. the entire electronic record and manually assign
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One of the successes of a CDI program is to have codes. While CAC is mainly used for the coding
yr
op
a physician advisor who will not only participate of the health record for reimbursement purposes,
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with the CDI program but also has the clinical re- it can be used to automate part of the CDI pro-
spect of his or her peers. The CDI physician advi- cess as well as provide an electronic evaluation of
sor serves as a liaison between the CDI specialists, documentation (AHIMA 2018). Other CDI tools
the coding professionals, the quality department, include audits, tip sheets, educational materials,
and the providers at the organization, supporting and queries.
the needs of the CDI program (AHIMA 2016c). The
primary responsibilities of the CDI physician advi- Audits Audits are an essential part of a CDI pro-
sor are to educate physicians on clinical language gram. For more on audits refer to chapter 16, Fraud
and coding guidelines, help providers document and Abuse Compliance. Audits can help an organi-
and reflect the true severity of the patient’s illness, zation determine where there are areas that are
properly capture all the services and treatments missing proper documentation. Audits can also
performed by the healthcare organization, ensure help an organization create a plan on the type of
AB103118_Ch06.indd 185 2/11/2020 4:17:41 PM

health records and services to focus on for CDI that the patient had surgery on the right leg, but in
efforts (AHIMA 2018). A healthcare organization the progress notes there is information regarding
can select a specific number of health records from the surgical wound on the left leg, a query may be
the healthcare organization and perform an audit requested to confirm which leg was operated on.
to determine if the documentation in the health There are two formats of queries for CDI: electron-
records meets the expectation of the codes being ic query and paper query. Both queries contain the
billed to the insurance company. The findings from same demographic information such as the patient
the audit can provide the healthcare organization name, admission date or date of service, health
with specific details on what areas of the health- record number, account number, date query initi-
care organization may be at risk due to missing or ated, name and contact of the person who created
incomplete documentation. A successful CDI au- the query, and a statement of issues to be resolved
dit program will evaluate all areas of the health- (AHIMA 2018). For additional information on de-
n.
care organization to determine the areas that are mographic information, refer to chapter 3, Health
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most out of compliance. Additionally, a healthcare Information Functions, Purpose, and Users.
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organization may decide to increase the number of An electronic query is conducted through an
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audits in high-risk billing areas, such as the focus EHR and allows the healthcare provider to offer
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of any federal government billing audits (AHIMA more clarification or specific information regard-
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2018). For example, if the federal government’s ing the patient’s treatment and diagnosis. The typi-
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Medicare program is focusing on recovery audits cal process for an electronic query is usually the
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for inpatient psychiatry, a healthcare organization same format as for a written query, however, the
may want to increase the audits in that area to un- n
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information will be sent electronically and will al-
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cover any areas of concern. After audits are com- low the provider to respond electronically or add
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pleted, the CDI department can start working with an additional clarification note in the health record.
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departments and physicians to make sure proper A paper query uses a standardized physical docu-
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documentation exists to support the billing. ment to request clarification or further specify a di-
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agnosis. With the use of paper queries, the health

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Queries The most common tool used for CDI is record must be made available to the healthcare
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a query. A query is a communication tool for CDI provider to review and document the clarification
staff to communicate with providers to obtain clini- in it. Additionally, the response of the query will be
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cal clarification, provide a documentation alert, documented on paper and the coder or CDI profes-
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clarify documentation, or ask additional ques- sional will need access to the entire paper health
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tions regarding documentation. Traditionally, record after the query is completed. The paper
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queries have been used to support coding and query is retained by the healthcare organization
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reimbursement; however, queries are expanding and can be stored within the paper health record or
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to the process of CDI outside the coding depart- scanned into the EHR. Since the query will support
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ment. Queries may be used to help clarify a com- patient care and reimbursement, the healthcare or-
plex diagnosis within a health record that does ganization must create policies and procedures to
not have proper documentation or clarify proce- manage how the query response will be incorpo-
dures that may not be specific enough to support rated into the health record and if it will become
patient care or add a valid code. Queries are used part of the legal health record or designated record
to obtain appropriate reimbursement for the care set (AHIMA 2018b). For additional information on
and services provided to the patient, request more the legal health record, refer to chapter 8, Health
detail regarding the documentation that exists, Law. See chapter 9, Data Privacy and Confidentiality,
or clarify contradictory documentation. Contra- for information on the designated record set.
dictory information exists when two parts of a
patient’s health record provide conflicting infor- Rules for Writing Queries When writing queries,
mation. For example, if an operative report states regardless of the medium, healthcare organizations
AB103118_Ch06.indd 186 2/11/2020 4:17:41 PM

must ensure they are not leading physicians to doc- There are multiple types of data queries: fur-
ument a particular response, but rather requesting ther specificity of a diagnosis, inconsistency in
clarification or additional specification. Policies documentation, and missing clinical indicators.
and procedures should delineate who to query, Figure 6.8 provides examples of two different types
when to query, when not to query, the query for- of queries with leading and nonleading questions.
mat, and the management of the query response. The CDI process needs professional, objective
In general, a query should be created when health communication. CDI specialists must have strong
record documentation meets one of the following written and oral communication skills and have
criteria: “[it] is conflicting, imprecise, incomplete, basic knowledge of clinical coding guidelines
illegible, ambiguous, or inconsistent; describes as well as clinical knowledge and knowledge of
or is associated with clinical indicators without a documentation requirements. All communication,
definitive relationship to an underlying diagnosis; verbal or written, between the CDI professional
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includes clinical indicators, diagnostic evaluation, and the provider needs to be conducted in a
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and/or treatment not related to a specific con- professional manner. Most of the information and
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dition or procedure; provides a diagnosis with- detail that will be discussed and concluded based
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out underlying clinical validation; or is unclear on the findings from the CDI process or query
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for present on admission indicator assignment” process will need to be documented in the health
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(AHIMA 2016c). record and may become part of the health record.
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Figure 6.8 Examples of queries with leading and nonleading queries
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Example Open-Ended Query
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A patient is admitted with pneumonia. The admitting H&P examination reveals white blood count of 14,000; a r espiratory
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rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient is
In
administered an IV antibiotic and IV fluid resuscitation.

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Leading: The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the
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blood. Are you treating for sepsis?

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Nonleading: Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical
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indicators? In this patient admitted with pneumonia, the admitting H&P examination reveals the following:
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• WBC 14,000
• Respiratory rate 24
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• Temperature 102°F
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• Heart rate 120

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• Hypotension
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• Altered mental status

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• IV antibiotic administration
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• IV fluid resuscitation
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Please document the condition and the causative organism (if known) in the health record.
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Example Multiple-Choice Query

A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure.
A recent echocardiogram showed left ventricular ejection fraction (EF) of 25 percent. The patient’s home medications
include metoprolol XL, lisinopril, and furosemide.
Leading: Please document if you agree the patient has chronic diastolic heart failure.
Nonleading: It is noted in the impression of the H&P that this patient has chronic congestive heart failure and a recent
echocardiogram noted under the cardiac review of systems reveals an EF of 25 percent. Can the chronic heart failure be
further specified as:
• Chronic systolic heart failure _______________________
• Chronic diastolic heart failure
• Chronic systolic and diastolic heart failure
• Some other type of heart failure
• Undetermined __________________
Source: AHIMA 2016b, 2.
AB103118_Ch06.indd 187 2/11/2020 4:17:41 PM

Both providers and CDI professionals must ensure ●● Case mix index (CMI) impact by services
communication is professional and appropri- line
ate to support patient care and reimbursement ●● Reimbursement impact by queries (AHIMA
(AHIMA 2016c). 2016c)
Reporting To help support the need for and The most important part of leading a CDI pro-
successes of the CDI program, it is important to gram is to establish the reporting dashboard and
establish reporting tools with key performance process to make sure that leadership within the
indicators (KPIs) to provide to leadership and healthcare organization understands the need and
providers. Key performance indicators are mea- impact of the program. It allows providers to see
sures that can be used over time to determine if and understand the impact of appropriateness of
a structure, process, or outcome supports high- documentation on reimbursement and case mix
index (AHIMA 2016c). Figure 6.9 provides an
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quality performance measures against best practices.
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KPIs must align with an organization’s strategy example of a monthly query repost rate report.
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and must be measurable (Malmgren and Solberg
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2016). A best practice is to establish a dashboard
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Education One of the major goals of a CDI pro-
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that is updated on a consistent basis and reviewed gram is to provide education based on the find-
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for opportunities to expand on areas of concern. ings throughout the CDI process. CDI education
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Some common reporting areas for a CDI program
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programs should bring knowledge and informa-
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may include the following: tion back to the healthcare provider to enhance
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Discharges available/Discharges reviewed the quality and completeness of documentation
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●●
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for CDI to support the severity of illness. In addition, a

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CDI education program can be brought back

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●● Number of queries by provider and impact

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on diagnosis related group to the HIM coders to help support the accurate
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assignment of codes based on the documentation.

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●● Number of queries resulting in severity of

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A CDI education component provides u sable,

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illness changes
efficient, compliant, and meaningful documen-
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●● Provider response to queries and turnaround tation findings to help enhance the patient care
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time by provider workflow, collect complete and accurate data

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●● Outcomes of CDI queries by physician in a timelier fashion, and improve healthcare

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(agree or disagree with CDI specialist) reimbursement (AHIMA 2016c).

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©
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1. Identify the two types of queries used in clinical documentation integrity.
a. Manual and electronic
b. Paper and electronic
c. Manual and computer-assisted coding
d. Electronic and computer-assisted coding
2. True or false: The response from a query will never go into the health record as it is just communication between the
CDI professional and the provider.
3. Distinguish which of the following is a goal of a CDI program.
a. Identify the providers who are not performing properly
b. Ensure documentation is meeting minimum requirements of the medical staff bylaws
c. Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures
d. Analyze the records after the patient is discharged to document missing pieces of information
AB103118_Ch06.indd 188 2/11/2020 4:17:41 PM

Figure 6.9 Example of monthly query repost rate report
CHF Monthly Physician Response to Query Process Report

1st quarter 2nd quarter
# CHF
Mo. Queries # Answers % Response Mo. # CHF Queries # Answers % Response
JAN 150 92 61% APR 180 110 61%
FEB 89 61 69% MAY 160 104 65%
MAR 110 79 72% JUN 98 75 77%
3rd quarter 4th quarter
# CHF
Mo. Queries # Answers % Response Mo. # CHF Queries # Answers % Response
JUL 172 133 77% OCT 99 53 54%
n.
AUG 132 87 66% NOV 186 141 76%
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SEP 169 115 68% DEC 201 159 79%
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CHF Monthly Physician Query Response Rate
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90%
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80%
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Response Rate Percentage
70%
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60%
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50%
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40%
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30%
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20%
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10%
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0%
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January February March April May June July August September October November December
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Response Rate 61% 69% 72% 61% 65% 77% 77% 66% 68% 54% 76% 79%
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Source: AHIMA 2016c, p. 37.

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Data Management and Bylaws

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To help with the facilitation of the information documented in the health record sup-
collection and assurance of quality data within ports patient care as well as quality improvement
a healthcare organization, bylaws should be cre- initiatives and accreditation activities. Additionally,
ated. Bylaws are written documents that provide the bylaws should define the processes that align
details and information regarding the rules and with the organization’s data and information gov-
regulations established by a healthcare organiza- ernance strategy regarding the completeness and
tion to help support healthcare operations. Part of accuracy of health information within a health
the bylaws set the expectations of the medical staff record, including expectations of timeliness. Data
for documentation and timeliness of documenta- quality is a common area to analyze for the pur-
tion, which directly impacts an organization’s data poses of healthcare operations and creates a need
and information governance. Among the concerns for healthcare organizations to define minimum
with healthcare operations is ensuring that the standards of clinical documentation. The minimum
AB103118_Ch06.indd 189 2/11/2020 4:17:42 PM

clinical documentation requirements are most often a provider contract will state that all labs must be
defined in the bylaws of the healthcare organization. reviewed and signed within 24 hours of completion
By defining the expectations for documentation of the lab test. The contract will also include conse-
and data management in the bylaws, the health- quences if minimal requirements are not met, such
care organization can hold providers accountable as the cancellation of the contract in the event of a
if they are not meeting the expectations and im- breach.
pacting the information governance and data gov-
ernance processes. Additionally, the establishment Hospital Bylaws
of data collection and data quality requirements in Hospital bylaws are written documents that gov-
bylaws can help support and ensure proper doc- ern the staff members, both medical providers and
umentation as required by the healthcare organi- non-physician providers, who create data within
zation to support the data management processes. the health record for additional support of patient
n.
Another area commonly addressed in bylaws is care and reimbursement. Since medical provid-
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ensuring compliance with federal and state laws
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ers are not the sole authors of clinical documen-
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and regulations through provider contracts and tation, it is important for hospitals to define who
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hospital bylaws.
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can document within the record, the type of doc-
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umentation that can occur, and the timeliness and
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Provider Contracts with Healthcare completeness of that documentation. Common
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Organizations
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healthcare professionals who enter information
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In the ambulatory care setting, healthcare providers are nurses, ancillary support, therapists, social
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work, health unit coordinators, and other support
enter into a contract with a healthcare organization
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to provide patient care. The contracts delineate all staff given rights to document within the record.
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expectations of the provider as they care for patients As with the medical staff bylaws, clear and con-
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in a specific ambulatory care setting. When creating cise expectations of data entry and documenta-
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a provider contract, requirements for data quality tion should be established, and training provided
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should be established. These requirements should for all healthcare employees. The hospital bylaws
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include documentation and timeliness of docu- support data governance and data quality across
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mentation within the health record. For example, the spectrum of care.
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by
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Data Management and Technology

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Currently, most of the work support- to use technology to assist in the management of
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ing data management within healthcare happens the data.

in an electronic manner. This is due to the imple- There are many benefits to using technology in
mentation of EHRs and other electronic informa- a healthcare organization. Technology can be used
tion systems used to support patient care. Because to support data management and the implemen-
of the amount of data available in healthcare or- tation of information governance and data gov-
ganizations, data have become valuable assets. ernance. Technology can also be used to facilitate
While this causes some concern with the amount working across teams. With advances in technol-
of data collected by the healthcare organization, ogy and the increase in data created, the need for
it also allows healthcare organizations to use the new forms of data management through technol-
data to make decisions based on information de- ogy will continue to be a priority in healthcare
rived from the data. One of the powerful aspects to ensure standardization in the collection and
of having data in electronic format is the ability management of data.
AB103118_Ch06.indd 190 2/11/2020 4:17:42 PM

HIM Roles
Many different roles exist for HIM HIM professionals have always advocated for
professionals in data management. These roles clear, accurate, and complete documentation in the
may exist within a healthcare system, a physi- health record. HIM professionals fit perfectly in
cian clinic, an insurance company, or a vendor the CDI role as they understand medical coding in-
that supports a healthcare organization. HIM cluding guidelines, documentation requirements,
professionals can lead an organization’s IG ini- the need for complete and accurate information,
tiative as an Information Governance Program and billing and reimbursement requirements. The
Director, support the IG initiative as a data stew- clinical documentation specialist is a new role es-
ard or business analyst, support the information tablished to improve work processes related to
systems and data collection as a database admin- documentation by communicating with provid-
n.
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istrator, or take on the role of data analyst. HIM ers, improving clinical documentation design, and
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roles require the ability to gather information, ensuring accurate documentation to support code
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analyze the information, and transform data into assignment. The clinical documentation special-
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powerful information the healthcare organiza- ist must have a strong working relationship with
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tion can use for strategic, regulatory, quality, and the providers and feel comfortable requesting
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reimbursement purposes. additional information via query processes.
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1. True or false: When creating bylaws for the medical staff, expectations of data quality should be established and
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documented within the bylaws.

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2. True or false: Without proper definition and requirements of data quality and data collection, it is challenging for
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healthcare organizations to hold healthcare providers accountable for documentation.

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3. When creating requirements of documentation for hospital bylaws, which of the following should be evaluated?
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a. The personal preferences of the healthcare practitioner

20
b. The documentation needs based on accrediting bodies

20
c. Information taught in the local nursing programs

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d. The wants of the department chairs in a hospital

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4. True or false: When creating provider contracts, healthcare organizations should not define disciplinary actions in the
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event that the contract requirements are not met.

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Real-World Case 6.1

A large urban children’s hospital in Dal- were working in their own silos with little inter-
las, Texas, is leading in the delivery of care pro- departmental communication occurring, and the
vided to children from birth through age 18. individual business units had different policies, pro-
After implementing an electronic health record, the cedures, and processes for information governance
hospital identified operations in need of im- and data management. The hospital quickly realized
provement. It found that individual business units the need to standardize processes and create an
AB103118_Ch06.indd 191 2/11/2020 4:17:42 PM

effective information governance program to help The outcome of implementing an information

streamline and manage the vast amount of data be- governance program at the children’s hospital
ing collected across the organization. produced many benefits. The hospital was able
Using tools that are available through AHIMA’s to create a consistent process for training and
Information Governance Adoption Model (IGAM), educating all workforce members to support
the hospital evaluated the current state of informa- the transparency of data management to use
tion governance at the organization. This was done the information to its competitive advantage. It
through the evaluation and review of information- created a platform to have open and transpar-
related policies and procedures throughout the ent conversations throughout the healthcare
system. It also created the foundation necessary to organization, supporting the mission of the or-
implement a process to review, edit, and update all ganization. By streamlining all the policies and
those information policies and procedures to cre- procedures across the organization, the hospital
n.
ate a consistent and standardized process across all was able to break down department silos that
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business units of the organization. Most important, existed within the organization and implement
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it showed the need to educate workforce members an organization-wide culture supporting the
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on the importance of having a consistent format for information governance program. (Fahy and
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data collection across the entire organization. Hermann 2017.)
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Real-World Case 6.2 at
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A medium-sized hospital had been using The health record is coded and the codes are
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an electronic health record (EHR) for 12 months. sent to billing

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It was having great success in getting the provid-

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While it was a strong process and the provid-

ers to document within a timely fashion; however,
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ers did answer the questions, it caused a spike in

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many of the notes did not provide enough in-

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the amount of time it took to get the health record

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formation to code the record or key components to

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coded and billed, as providers usually came into

adequately code diagnoses and procedures were
the department once every 20 to 25 days. In some
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missing. The hospital had a process for physician

cases, providers would leave the coding que-
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query, as follows:
ries unanswered for up to 60 days. The average
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Electronically flag the record for physician

20
●●
turnaround time for a coding query was 28 days.
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query The hospital needed to accelerate the query pro-

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●● Create a paper query form for the provider cess and reduce the physicians’ frustrations with
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●● Send the electronic query to the HIM having to come to the HIM department.
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operations department to put in a physician New functionality within the EHR was used
completion folder to send an electronic query that automatically
●● HIM operations adds a deficiency to the assigned the deficiency and sent a note to the
patient health record to flag the provider provider’s inbox alerting them that there was a
that a coding query needs to be completed coding query. The new process had fewer steps
and involved fewer people; however, the physi-
●● The provider comes to the HIM department
cians were concerned that the additional time re-
to complete the query
quired to learn the new process and system was
●● The deficiency is removed, and the query is impacting time spent with their patients. With
scanned into the health record careful training and education, the new process
●● HIM operations notifies the coder via e-mail was implemented and reduced the steps, which
that the query was answered made the physician query process easier for coding,
AB103118_Ch06.indd 192 2/11/2020 4:17:43 PM

HIM operations, and the providers. The following electronically submitted to the physician
are the new process steps: and retained and the health record then
automatically flagged to complete coding
●● Electronically flag the record for physician ●● The health record is coded and sent to billing
query
●● Create the electronic physician query
With the change in the process, the HIM opera-
through predesigned templates and
tions department has little involvement unless it
assign the correct physician (this would
is supporting the physician in completing the
automatically assign the deficiency and send
query. The turnaround time for completion of cod-
the coding query to the inbox)
ing queries was reduced from 28 days to 15 days
●● The physician electronically completes the within the first 60 days of completion. The process
coding query through the EHR was a success and the hospital has significantly
n.
●● The electronic deficiency is automatically reduced the time it takes to code and bill all patient
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removed, and the coding query is encounters.
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References
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American Health Information Management EHR documentation (2013 update). Journal of AHIMA
M
Association. 2018. Clinical Documentation 84(8): 58–62 [extended web version]. http://library.
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Integrity Toolkit. https://my.ahima.org/store/ io
ahima.org/doc?oid=300257#.XDj-Z89KhTY.
at
product?id=63693.
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American Health Information Management Association. 2011. HIM functions in healthcare quality
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http://bok.ahima.org/PdfView?oid=302359. governance. Journal of AHIMA 82(8). http://library.

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American Health Information Management ahima.org/doc?oid=104977#.Vw581fkrK9I.

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XDiyrM9KhTY. SREs for quality reporting and reimbursement.

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AHIMA. http://library.ahima.org/doc?oid=301357#. 2006. Data standard time: Data content standardization

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Combs, T. 2016a. How do CDI programs impact the Healthcare Data Management. http://s3.amazonaws.
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and F. Whittaker. 2016. 2016 International Conference ahima.org/doc?oid=107796#.XGRBLM9KjSc.
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Chapter
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Secondary Data Sources
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Marcia Y. Sharp, EdD, MBA, RHIA
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• Distinguish between primary and secondary data follow-up, and pertinent laws and regulations
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and between patient-identifiable and aggregate data affecting registry operations

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• Differentiate between internal and external users of • Explain the terms associated with each type of
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secondary data secondary record or database

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• Compare the facility-specific indexes commonly • Discuss the agencies for approval, education, and
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found in hospitals certification for cancer, immunization, and trauma

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• Describe the registries used in hospitals according registries

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to purpose, methods of case definition and case • Distinguish between healthcare databases in terms
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finding, data collection methods, reporting and of purpose and content

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Key Terms
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Abbreviated Injury Scale (AIS) Collaborative Stage Data Set National Cancer Registrars
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Accession number Disease index Association (NCRA)

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Accession registry Disease registry National Center for Health

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Agency for Healthcare Research Facility-based registry Statistics (NCHS)

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and Quality (AHRQ) Health Services Research National Library of Medicine

Aggregate data Healthcare Cost and Utilization (NLM)
American College of Surgeons Project (HCUP) National Practitioner Data Bank
(ACS) Commission on Incident (NPDB)
Cancer Index North American Association
Case definition Injury Severity Score (ISS) of Central Cancer Registries
Case finding Medical Literature, Analysis, (NAACCR)
Centers for Disease Control and and Retrieval System Online Operation index
Prevention (CDC) (MEDLINE) Patient-identifiable data
Certified tumor registrar (CTR) Medicare Provider Analysis Physician index
Clinical trial and Review (MEDPAR) File Population-based registry
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Primary data source Secondary data source Unified Medical Language System
Protocol Stage of the neoplasm (UMLS)
Public health Traumatic injury Vital statistics
As a rich source of data about an individual pa- content of the database and ensuring compliance
tient, the health record’s primary purpose is in with the laws, regulations, and accreditation stan-
patient care and reimbursement for individual dards that affect its content and use. All data
encounters. (Chapter 3, Health Information Func- elements included in the database or registry must
tions, Purpose, and Users, discusses the purpose be defined in a data dictionary. A data dictionary
of the health record in more detail). It is difficult is a descriptive list of names, definitions, and
to see trends in a population of patients by look- attributes of data elements to be collected in an
ing at individual health records. For this purpose, information system or database (AHIMA 2014a).
n.
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data must be extracted from individual health re- For more on the data dictionary, see chapter 6,
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cords and entered into databases. These data may Data Management. The HIM professional serves
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be used in a facility-specific or population-based as a data steward to oversee the completeness
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registry for research and improvement of patient and accuracy of the data abstracted for inclusion
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care (explained later in this chapter). Data may be in the database or registry. “Data stewardship is a
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reported to the state and become part of state- and responsibility guided by principles and practices
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federal-level databases used to set health policy to ensure the knowledgeable and appropriate use
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and improve healthcare. With the electronic health of data derived from individuals’ personal health
n
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record (EHR), it is possible for data to be collected information” (NCVHS 2009, 1). Data stewardship
at
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once in the EHR and used many times (secondary and the role of the data steward are also discussed
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records) for a variety of purposes as outlined in in chapter 6.

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this chapter. This chapter explains the difference between

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The health information management (HIM) primary and secondary data and its users. It offers
H
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professional can play a variety of roles in manag- an in-depth look at the types of secondary data-
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ing secondary data and databases. The HIM pro- bases, including indexes and registries, and their
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fessional plays a key role in database setup. The functions. Finally, this chapter discusses how sec-
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HIM professional’s role includes determining the ondary databases are processed and maintained.
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Differences between Primary and Secondary

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Data Sources
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The health record is considered a primary data data, the patient is identified within the data either
source because it contains information about a pa- by name, address, date of birth, or social security
tient that has been documented by the profession- number or other government issued identifica-
als who provided care or services to that patient. tion. The health record consists entirely of patient-
A primary data source is an original data source identifiable data. In other words, every fact in the
where the data are documented or collected by the health record relates to a particular patient identi-
provider of care. Data derived from the primary fied by name. Secondary data also may be patient
health record, such as an index or a database, are identifiable. In some instances, data are entered
considered secondary data sources. These data into a database along with information such as the
are known as secondary data. patient’s name maintained in an identifiable form.
Data are categorized as either patient-identifiable Registries are an example of patient-identifiable
data or aggregate data. With patient-identifiable data in a secondary data source.
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Data are patient-identifiable if the identity of the More often, however, secondary data are con-
patient is linked via address, age, or another iden- sidered aggregate data. Aggregate data include
tifier. For example, if an individual can be identi- data on groups of people or patients without iden-
fied by using a combination of elements such as tifying any patient individually. Examples of
date of birth, zip code, gender, marital status, and aggregate data are statistics on the average length
phone number, this would be considered patient- of stay (ALOS) for patients discharged within a
identifiable data. particular diagnosis-related group (DRG).
Purposes and Users of Secondary Data Sources
n.
There are four major purposes for on previous malpractice or other adverse
tio
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collecting secondary data. They are the following: decisions against a physician. This information
oc
is used to evaluate the qualifications, skills,
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1. Quality, performance, and patient safety.
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and performance history of a physician.
Healthcare organizations, for example,
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collect core measure information from the In healthcare, the health record is a source for
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health record for the Centers for Medicare various types of data and serves many purposes.
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and Medicaid Services (CMS) to evaluate The various users of healthcare data are discussed
M
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the quality of care within the healthcare in the following sections.
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organization.
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Internal Users
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2. Research. Data taken from health records

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and entered into databases help researchers Internal users of secondary data are individuals
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determine the effectiveness of alternate treat- located within the healthcare organization. For
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ment methods. An example of this type of example, internal users include medical staff and
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secondary data use is a disease database that administrative and management staff. Second-
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cross-references an index of human diseases, ary data enable these users to identify patterns
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medications, signs, abnormal findings, and and trends that are helpful to inpatient care, long-
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more (Diseases Database 2019). Another range planning, budgeting, and benchmarking
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example is the secondary data collected from with other healthcare organizations.
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the Patient-Centered Outcomes Research

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External Users
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Institute (PCORI) used to help patients,

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families, and clinicians make better healthcare

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External users of patient data are individuals and

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choices (PCORI 2019).

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institutions outside the healthcare organization.

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3. Population health. Population health is an Examples of external users are state data banks
“interdisciplinary, customized approach that (discussed later in this chapter) and federal agen-
allows health departments to connect practice cies. States have laws mandating that cases of
to policy for change to happen locally” (CDC patients with diseases such as tuberculosis, sexu-
2019a). For example, states require information ally transmitted diseases, and other communicable
be reported to them on certain diseases so diseases be reported to the state department. The
the extent of the disease can be determined, federal government collects data from the states
and steps taken to prevent the spread of that on vital events such as births and deaths.
disease. The secondary data provided to external users are
4. Administrative. In credentialing physicians, generally aggregate data, not patient-identifiable
healthcare organizations are required to data. Thus, these data can be used as needed with-
access a national database for information out risking breaches of confidentiality.
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1. Identify an instance of patient-identifiable data.
a. The patient was born on March 10 and lives at 123 Main Street
b. The patient has both cancer and end-stage renal disease and has dialysis three
times a week.
c. There were 50 Medicare patients treated today.
d. Of all our patients 50 percent have commercial insurance.
2. Identify when an internal user might utilize secondary data.
a. State infectious disease reporting
b. Birth certificates
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c. Death certificates
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d. Benchmarking with other healthcare organizations
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3. Secondary data are used for multiple reasons including:
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a. Assisting researchers in determining effectiveness of treatments
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b. Assisting nurses in providing patient care
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c. Billing for services provided to the patient
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d. Coding diagnoses and procedures treated
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4. True or false: A patient health record is a secondary data source.
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5. True or false: A patient health record contains aggregate data.
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6. True or false: HIM supervisors and managers are internal users of secondary data.
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7. True or false: Secondary data may be used to improve the health of an entire human population.
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Types of Secondary Data Sources

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Secondary data sources consist of Disease and Operation Indexes

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facility-specific indexes; registries, either facility or The disease index is a listing in diagnosis code
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population based; or other healthcare databases. number order of patients discharged from the
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healthcare organization during a specific time

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Facility-Specific Indexes period. Each patient’s diagnoses are converted

The most long-standing secondary data sources from a verbal description to a numerical code, usu-
are those developed within healthcare orga- ally using the International Classification of Diseases,
nizations to meet their individual needs. These Tenth Revision, Clinical Modification (ICD-10-CM).
indexes enable health records to be located by The patient’s diagnosis codes are entered into
diagnosis, procedure, or physician. Prior to exten- the healthcare organization’s health information
sive computerization in healthcare, these indexes system as part of the discharge processing of the
were kept on cards. Today, most indexes are main- patient’s health record. The index always includes
tained as computerized reports based on data the patient’s health record number as well as the
from databases routinely developed in the health- diagnosis codes so health records can be retrieved
care organization. by diagnosis. Because each patient is listed with
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the health record number, which may be linked to may include, but are not limited to, Alzheimer’s
the patient’s name and other information, the dis- Prevention Registry, Colon Cancer Family Regis-
ease index is considered patient-identifiable data. try, National and State Cancer Registries, and Rare
The disease index also may include information Disease Registry. Registries are different from
such as the date of discharge and the attending indexes because they contain more extensive data.
physician’s name. Index reports are usually produced using data from
The operation index is similar to the disease in- the healthcare organization’s existing databases.
dex except that it is arranged in numerical order by Registries often require more extensive entry of
the patient’s procedure code(s) using International data from the health record. Each registry must
Classification of Diseases, Tenth Revision, Procedure define the cases that are to be included; this proc-
Coding System (ICD-10-PCS) or Current Procedural ess is called case definition. In a trauma registry,
Terminology (CPT) codes. For specifics on ICD- for example, the case definition might be all pa-
n.
10-PCS and CPT, refer to chapter 15, Revenue Man- tients admitted with a diagnosis that includes the
tio
agement and Reimbursement. The other information ICD-10-CM trauma diagnosis codes.
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listed in the operation index is generally the same After the cases to be included have been de-
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as that listed in the disease index except that the termined, the next step is usually case finding.
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surgeon may be listed in addition to, or instead of, Case finding is a method used to identify the
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the attending physician. For additional informa- patients who have been seen or treated in the
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tion on coding systems, see chapter 5, Clinical healthcare organization for the specific disease
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Terminologies, Classifications, and Code Systems. or condition of interest to the registry. After cas-
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es have been identified, extensive information is
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Physician Index abstracted from the patients’ health records into
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The physician index is a listing of cases organized the registry database or extracted from other
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by physician name or physician identification databases and automatically entered into the
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number. It also includes the patient’s health r ecord registry database.

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number and may include other information, such The sole purpose of some registries is to collect
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as date of discharge. The physician index enables data from health records and make them available
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users to retrieve information about a particular for users. Other registries take further steps to en-
physician, including the number of cases seen ter additional information in the registry database,
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during a specific time period. such as routine follow-up of patients at specified

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intervals. Follow-up information might include

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Registries
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rate and duration of survival and quality of life

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Disease registries are collections of secondary data over time. General terminology associated with
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related to patients with a specific diagnosis, condi- registries is defined in figure 7.1 and a list of major
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tion, or procedure. Examples of disease registries registries is displayed in table 7.1.

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Figure 7.1 Terminology associated with registries
Accession number: A number assigned to each case as it is entered in a cancer registry

Accession registry: A list of cases in a cancer registry in the order in which they were entered
Demographic information: Information used to identify an individual, such as name, address, gender, age, and
other information linked to a specific person
Facility-based registry: A registry that includes only cases from a particular type of healthcare facility, such as a
hospital or clinic
Incident: An occurrence in a medical facility that is inconsistent with accepted standards of care
Population-based registry: A type of registry that includes information from more than one facility in a specific
geopolitical area, such as a state or region
Source: ©AHIMA.
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Table 7.1 Major registries

Registry Definition
Cancer registry Tracks the incidence (new cases) of cancer
Trauma registry Tracks patients with traumatic injuries from the initial trauma treatment to death
Birth defects registry Collects information on newborns with birth defects
Diabetes registry Collects cases of patients with diabetes to assist in managing care as well as for research
Implant registry Tracks the performance of implants including complications, deaths, and defects resulting from implants, as
well as implant longevity
Transplant registry Maintains databases of cases of patients who need organ transplants
Immunization registry Collects information within a particular geographic area on children and their immunization status and
maintains a central source of information for a particular child’s immunization history, even when the child
has received immunizations from a variety of providers
Source: ©AHIMA.
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Cancer Registries in each state. According to the law, these regis-
ss
tries were mandated to collect data such as the
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According to the National Cancer Registrars
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Association (NCRA), the first hospital cancer
following:
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registry was founded in 1926 at Yale–New Hav- Demographic data about each case of cancer;
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●●
en Hospital (NCRA 2018a). It has long been rec-
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demographic data describing the individual,
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ognized that information is needed to improve including the patient’s name, age, gender,
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the diagnosis and treatment of cancer. Cancer io
race, ethnicity, and birthplace
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registries were developed as an organized meth-

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Information on the industrial or

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●●
od to collect these data. The data may be facility
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occupational history of the individuals with

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based (for example, within a hospital or clinic)

the cancers (to the extent such information is
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or population based (for example, from more

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available from the same health record)

than one healthcare organization within a state
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Administrative information, including date

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●●
or region).
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of diagnosis and source of information

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Facility-based registries include cases from a

particular type of healthcare organization such
●● Pathological data characterizing the cancer,
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as a hospital or clinic. The data from facility- including site, stage of the neoplasm (specifies
by
the amount of metastasis, if any), incidence,

20
based registries are used to provide information

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for the improved understanding of cancer, in- and type of treatment (Public Law
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cluding its causes and methods of diagnosis and 102-515 1992)

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treatment. The data collected also may provide

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comparisons in survival rates and quality of life Case Definition and Case Finding in Cancer
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for patients with different treatments and at dif- Registries As defined previously, case definition
ferent stages of cancer at the time of diagnosis. is the process of deciding which cases should be
Population-based registries include informa- entered in the registry. For example, in a cancer
tion from more than one healthcare organization registry all cancer cases except skin cancer might
in a specific geographical area such as a state or meet the definition for the cases to be included.
region. In population-based registries, the em- Information on malignant neoplasms, data on
phasis is on identifying trends and changes in benign and borderline brain or central nervous
the incidence (new cases) of cancer within the system tumors must be collected by the National
area covered by the registry. Program of Cancer Registries (CDC 2018a).
The Cancer Registries Amendment Act of In the facility-based cancer registry, the first step
1992 provided funding for a national program of is case finding. One way to find cases is through the
cancer registries with population-based registries discharge process in the HIM department. During
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the discharge procedure, coders or discharge an- The stage provides information on the size and
alysts can easily earmark cases of patients with extent of spread of the tumor throughout the body.
cancer for inclusion in the registry. Another case- There are currently several staging systems. The
finding method is using the facility-specific dis- American Joint Committee on Cancer (AJCC) has
ease indexes to identify patients with diagnoses of worked through its Collaborative Stage Task Force
cancer. Additional methods may include reviews with other organizations with staging systems to
of pathology reports and lists of patients receiv- develop a new standardized staging system—the
ing radiation therapy or other cancer treatments to Collaborative Stage Data Set. This staging system
determine cases that have not been found by other uses computer algorithms to describe how far a
methods. cancer has spread (Collaborative Stage Data Col-
Population-based registries usually depend on lection System 2019). After the initial information
hospitals, physician offices, radiation facilities, is collected at the patient’s first encounter, data in
n.
ambulatory surgery centers (ASCs), and pathology the registry are updated periodically through the
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laboratories to identify and report cases to the cen- follow-up process, which is discussed in the
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tral registry. The administrators of a population- section that follows.
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based registry have a responsibility to ensure all Frequently, the population-based registry only
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cases of cancer have been identified and reported collects information when the patient is diagnosed.
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to the central registry. Sometimes, however, it receives follow-up infor-
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mation from its local, state, or national entities.
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Data Collection for Cancer Registries Data col-
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These entities usually submit information to the
lection methods vary between facility-based and
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central registry electronically.
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population-based registries. When a case is first
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entered in the registry, it is assigned an accession Reporting and Follow-up for Cancer Registries
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number, a number unique to the patient. This Formal reporting of cancer registry data is done
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number consists of the first digits of the year the annually. The annual report includes aggregate
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patient was first seen at the healthcare organiza- data on the number of cases in the past year by site
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tion, and the remaining digits are assigned sequen-

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and type of cancer. It also may include informa-

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tially throughout the year. For example, the first

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tion on patients by gender, age, and ethnic group.

case in the year might be 21-0001. The 21 indicates Often a particular site or type of cancer is featured
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that the person was seen in the year 2021. An with more in-depth data provided.
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accession registry is a list of cases in a cancer Other reports are provided as needed. Data
20
20
registry in the order in which they were entered. from the cancer registry are frequently used in the
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An accession registry of all cases can be kept manually quality assessment process for a healthcare orga-
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or provided as a report by the database software.

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nization as well as in research. Data on survival

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This listing of patients in accession number order

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rates by site of cancer and methods of treatment,

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provides a way to ensure all the cases have been for instance, would be helpful in researching the
entered into the registry. most effective treatment for a type of cancer.
In a facility-based registry, data are initially Another activity of the cancer registry is patient
reviewed and collected from the patient’s health follow-up. On an annual basis, the registry attempts
record. In addition to demographic information, to obtain information about each patient in the
data in the registry about the patient include the registry, including whether they are still alive, sta-
following: tus of the cancer, and treatment received during
the period. Various methods are used to obtain
●● Type and site of the cancer
this information. For a facility-based registry, the
●● Diagnostic methodologies healthcare organization’s patient health records
●● Treatment methodologies may be checked for return hospitalizations or
●● Stage at the time of diagnosis visits for treatment. Additionally, the patient’s
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physician may be contacted to determine whether the completeness, timeliness, and quality of cancer
the patient is still living and to obtain information registry data from state registries through the
about the cancer. National Program of Cancer Registries (NPCR).
When patient status cannot be determined The NPCR was developed as a result of the Can-
through these methods, an attempt may be made cer Registries Amendment Act of 1992. The CDC
to contact the patient directly using information collects data from the NPCR state registries.
in the registry such as the patient’s address and
telephone number. In addition, contact informa- Education and Certification for Cancer Registrars
tion from the patient’s health record may be used Traditionally, cancer registrars have been trained
to request information from the patient’s relatives. through on-the-job training and professional
Other methods used include reading newspaper workshops and seminars. The National Cancer
obituaries for deaths and using the Internet Registrars Association (NCRA) has worked with
n.
to locate patients through sites such as the Social colleges to develop formal educational programs
tio
Security Death Index. The information obtained for cancer registrars. A cancer registrar may be-
ia
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through follow-up is important and allows the reg- come credentialed as a certified tumor registrar
ss
istry to develop statistics on survival rates for spe- (CTR) by passing an examination provided by
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cific cancers and different treatment methodologies. the National Board for Certification of Registrars
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Population-based registries do not always in- (NBCR). Eligibility requirements for the cer-
ag
clude follow-up information on the patients in tification examination include a combination of
an
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their databases. However, those who follow up experience and education (NCRA 2018b).
usually receive the information from the report- n
io
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ing entities such as hospitals, physician offices, Trauma Registries
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and other healthcare organizations providing Trauma registries maintain databases on patients
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follow-up care.
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with severe traumatic injuries. A traumatic injury

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is a wound or other injury caused by an external

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Standards and Approval Processes for Cancer physical force such as a motor vehicle crash, a gun-
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Registries Several organizations have developed shot wound, a stabbing, or a fall. Information in
er
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standards or approval processes for cancer pro- the trauma registry may be used for performance
grams. The American College of Surgeons (ACS)
e
improvement and research in the area of trauma

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Commission on Cancer has an approval process care. Trauma registries may be facility based or
by
for cancer programs. One of the requirements

20
may include data for a region or state.

20
of this process is the existence of a cancer regis-

©
try as part of the program. The ACS standards Case Definition and Case Finding for Trauma
ht
ig
are published in the Cancer Program Standards Registries The case definition for the trauma reg-
yr
op
(ACS 2019a). When the ACS surveys the cancer istry varies but frequently involves inclusion of cas-
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program, part of the survey process is a review of es with diagnoses from the trauma diagnosis codes
cancer registry activities. in the ICD-10-CM. To find cases with trauma diag-
The North American Association of Central noses, the trauma registrar can access the disease
Cancer Registries (NAACCR) has a certification indexes looking for cases with codes from this sec-
program for state population-based registries. tion of ICD-10-CM. In addition, the registrar may
Certification is based on the quality of data col- look at deaths in services with frequent trauma di-
lected and reported by the state registry. NAAC- agnoses—such as trauma, neurosurgery, orthope-
CR has developed standards for data quality and dics, and plastic surgery—to find additional cases.
format and works with other cancer organizations
to align their various standards sets. Data Collection for Trauma Registries After
The Centers for Disease Control and Preven- the cases have been identified, information is ab-
tion (CDC) also has national standards regarding stracted from the health records of the injured
AB103118_Ch07.indd 204 2/6/2020 4:55:53 PM

patients and entered into the trauma registry Reporting and Follow-up for Trauma Registries
database. The data elements collected in the ab- Reporting varies among trauma registries. An
stracting process vary from registry to registry. annual report is often developed to show the ac-
Abstracting can be either the process of extracting tivity of the trauma registry. Other reports may be
information from a document to create a brief generated as part of the performance improvement
summary of a patient’s illness, treatment, and process, such as self-extubation (patients removing
outcome, or extracting elements of data from a their own tubes) and delays in abdominal surgery
source document or database and entering them or patient complications. Some hospitals report data
into an automated system. Data elements in the to the National Trauma Data Bank (ACS 2019b).
abstracting process include the following: Trauma registries may or may not follow up
●● Demographic information on the patient on the patients entered in the registry. When a fol-
low-up is done, the emphasis is frequently on
●● Information on the injury
n.
the patient’s quality of life after a period of time.
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●● Care the patient received before Unlike cancer, where physician follow-up is cru-
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hospitalization (such as care at another cial to detect recurrence, many traumatic injuries
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transferring hospital or care from an
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do not require continued patient care over time.
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emergency medical technician who provided Thus, follow-up is often not given the emphasis it
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care at the scene of the crash or in transport receives in cancer registries.
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from the crash site to the hospital)
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●● Status of the patient at the time of admission Standards and Approval Process for Trauma
n
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Registries The ACS certifies levels I, II, III, IV,
Patient’s course in the hospital
at
●●
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Diagnosis and procedure codes and V trauma centers. As part of its requirements,
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●●
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the ACS states that the level I trauma center must

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●● Abbreviated Injury Scale

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have a trauma registry (ACS 2019c). As part of its

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●● Injury Severity Score certification requirements, the ACS states that the
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level I trauma center, the type of center receiving

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The Abbreviated Injury Scale (AIS) reflects

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the nature of the injury and its threat to life by the most serious cases and providing the highest
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each body system. It may be assigned manually level of trauma service, must have a trauma regis-
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by the registrar or generated as part of the data- try (ACS 2019c). See table 7.2 for a description of
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each trauma center level.

by
base from data entered by the registrar. The In-

20
jury Severity Score (ISS) is an overall severity

20
measurement calculated from the AIS scores for Education and Certification of Trauma Registrars
©
patients with multiple injuries (Agency for Clini- Trauma registrars may be registered health in-
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cal Innovation 2019). formation technicians (RHITs), registered health

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Table 7.2 Trauma center levels and definitions

Trauma center level Description
Level I Able to provide total care for every aspect of injury from prevention through rehabilitation
Level II Able to initiate definitive care for all injured patients
Level III Able to provide prompt assessment, resuscitation, surgery intensive care and stabilization of injured
patients, and emergency operations
Level IV Able to provide advanced trauma life support (ATLS) prior to transfer of patients to a higher-level trauma
center; provides evaluation, stabilization, and diagnostic capabilities for injured patients
Level V Able to provide initial evaluation, stabilization, and diagnostic capabilities, and prepares patients for
transfer to higher levels of care
Source: ATS 2018.
AB103118_Ch07.indd 205 2/6/2020 4:55:53 PM

information administrators (RHIAs), registered ●● Demographic information

nurses (RNs), licensed practical nurses (LPNs), ●● Codes for diagnoses
emergency medical technicians (EMTs), or other ●● Birth weight
health professionals. Training for trauma regis-
trars is through workshops and on-the-job train-
●● Status at birth, including live born, stillborn,
ing. The American Trauma Society (ATS) provides aborted
core and advanced workshops for trauma regis- ●● Autopsy
trars and a certification examination for trauma ●● Cytogenetics results
registrars who meet its education and experience ●● Whether the infant was a single birth or one
requirements through its Registrar Certification in a multiple birth
Board. Certified trauma registrars have earned ●● Mother’s use of alcohol, tobacco, or illicit
the certified specialist in trauma registry (CSTR)
drugs
n.
credential.
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●● Father’s use of drugs and alcohol
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Birth Defects Registries ●● Family history of birth defects
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Birth defects registries collect information on new-
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borns with birth defects. Often population based, Diabetes Registries
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these registries serve a variety of purposes. For Diabetes registries include cases of patients with
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example, birth defects registries provide infor-
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diabetes for the purpose of assistance in manag-
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mation on the incidence of birth defects to study ing care as well as for research. Patients whose dia-
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causes and prevention; monitor trends in birth de- io
betes is not kept under control frequently have
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fects; improve medical care for children with birth numerous complications. The diabetes registry

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defects; and target interventions for preventable can keep up with whether the patient has been
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birth defects.
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seen by a physician to prevent complications.

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Case Definition and Case Finding for Birth Defects

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Case Definition and Case Finding for Diabetes

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Registries Birth defects registries use a variety of

er
Registries There are two types of diabetes melli-

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criteria to determine which cases to include in the tus: type 1 and type 2 diabetes. Registries some-
registry. Some registries limit cases to those with
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times limit their cases by type of diabetes. In some

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defects found within the first year of life. Others

by
instances, there may be further definition by age.

include those children with a major defect that oc-
20
Some diabetes registries, for example, only include

20
curred in the first year of life and was discovered children with diabetes.
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within the first five years of life. Still other regis-

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Case finding includes the review of health re-

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tries include only children who were live born or cords of patients with diabetes. Other case-finding
yr
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stillborn babies with obvious birth defects. methods include review of the following:
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Cases may be detected in a variety of ways,

including review of disease indexes, labor and ●● Diagnostic codes
delivery logs, pathology and autopsy reports, ul- ●● Billing data
trasound reports, and cytogenetic reports. In addi- ●● Medication lists
tion to information from hospitals and physicians, ●● Physician identification
cases may be identified from rehabilitation centers
●● Health plans
and children’s hospitals and from vital records
such as birth, death, and fetal death certificates. Although facility-based registries for cancer and
trauma are usually hospital based, facility-based
Data Collection for Birth Defects Registries A diabetes registries are often found in physician
variety of information is abstracted for the birth offices or clinics. The office or clinic is the main
defects registry, including the following: location for diabetes care. Thus, data about the
AB103118_Ch07.indd 206 2/6/2020 4:55:53 PM

patient to be entered into the registry are availa- of implants including complications, deaths, and
ble at these sites rather than at the hospital. The defects resulting from implants, as well as implant
health records of diabetes patients treated in phy- longevity. In the recent past, the safety of implants
sician practices may be identified through diag- has been questioned. For example, there have
nosis code numbers for diabetes, billing data for been questions about the safety of silicone breast
diabetes-related services, medication lists for implants and temporomandibular joint implants.
patients on diabetic medications, or identification When such cases arise, it has often been difficult
of patients as the physician treats them. to ensure all the patients with the implants have
Health plans are interested in optimal care for been notified of safety concerns. A number of fed-
their enrollees because diabetes can have serious eral laws have been enacted to regulate medical de-
complications when not managed correctly. The vices, including implants. These devices were first
plans can provide information to the office or covered under Section 15 of the Food, Drug, and
n.
clinic on enrollees who are diabetics. Cosmetic Act. The Safe Medical Devices Act of 1990
tio
was passed (GPO 1990). It was amended through
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Data Collection for Diabetes Registries In addi- the Medical Device Amendments of 1992 (GPO
ss
tion to demographic information about the cases, 1992). These acts required a sample of healthcare
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other data collected may include laboratory val- organizations to report deaths and severe complica-
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ues such as glycated hemoglobin, also known as tions thought to be due to a device to the manufac-
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HbA1c. This test is used to determine the patient’s turer and the Food and Drug Administration (FDA)
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blood glucose for a period of approximately 60 days through its MedWatch reporting system. The Med-
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prior to the time of the test. Moreover, facility reg- Watch reporting system alerts health professionals
io
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istries may track patient visits to follow up with and the public of safety alerts and medical device
m r
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patients who have not been seen in the past year. recalls (FDA 2018). Implant registries may help en-
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sure compliance with legal reporting requirements

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Reporting and Follow-up for Diabetes Registries for device-related deaths and complications.
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A variety of reports can be developed from the

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diabetes registry. For facility-based registries, one Case Definition and Case Finding for Implant
er
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report might keep up with laboratory monitoring Registries Implant registries sometimes include
of the patient’s diabetes to allow intensive inter- all types of implants but often are restricted to a
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vention with patients whose diabetes is not well specific type of implant. Examples of specific types
by
controlled. Another report might concern patients of implants may be cochlear, silicone, or temporo-
20
20
who have not been tested within a year or have mandibular joint.
©
not had a primary care provider visit within a year.

ht
ig
Population-based diabetes registries might pro- Data Collection for Implant Registries Demo-
yr
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vide reporting on the incidence of diabetes for the graphic data on patients receiving implants are
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geographic area covered by the registry. Registry included in the registry. The FDA requires that
data also might be used to investigate risk factors all reportable events involving medical devices
for diabetes. include the following information: “User facility
Follow-up is aimed primarily at ensuring that report number; name and address of the device
the patient with diabetes is seen by the physician manufacturer; device brand name and common
at appropriate intervals to prevent complications. name; product model, catalog, serial, and lot num-
bers; brief description of the event reported to the
Implant Registries manufacturer or the FDA; where the report was
An implant is a material or substance inserted into submitted (for example, to the FDA, manufacturer,
the body, such as breast implants, heart valves, and or distributor)” (FDA 2018).
pacemakers. Implant registries have been devel- Thus, these data items should be included in the
oped for the purpose of tracking the performance implant registry to facilitate reporting.
AB103118_Ch07.indd 207 2/6/2020 4:55:53 PM

Transplant Registries Information on donors varies according to

Transplant registries may have varied purposes. whether the donor is living. For organs harvested
Some organ transplant registries maintain data- from patients who have died, the following infor-
bases of patients who need organs. When an organ mation is collected:
becomes available, allocation of the organ to the ●● Cause and circumstances of the death
patient is based on a prioritization method. In oth- ●● Organ procurement and consent process
er cases, the purpose of the registry is to provide a
database of potential donors for transplants us-
●● Medications the donor was taking
ing live donors, such as bone marrow transplants.
●● Other donor history
Post-transplant information also is kept on organ For a living donor, information includes the
recipients and donors. following:
Because transplant registries are used to try
n.
to match donor organs with recipients, they
●● Relationship of the donor to the recipient
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(if any)
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are often national or even international in scope.
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Examples of national registries include the UNet of Clinical information
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●●
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the United Network for Organ Sharing (UNOS) ●● Information on organ recovery
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and the registry of the National Marrow Donor
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●● Histocompatibility
Program (NMDP).
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Data collected in the transplant registry may
Reporting and Follow-up for Transplant Registries
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be used for research, policy analysis, and quality
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Reporting includes information on donors and re-
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control.
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cipients as well as survival rates, length of time on
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the waiting list for an organ, and death rates.

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Case Definition and Case Finding for Transplant

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Follow-up information is collected for recipients

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Registries A physician will identify patients need- as well as living donors. For living donors, the in-
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ing transplants. Information about the patient is

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formation collected might include complications

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provided to the registry. When an organ becomes of the procedure and length of stay in the hospital.
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available, the patient’s information is matched

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Follow-up on recipients includes information on

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with potential donors. For donor registries, do- status at the time of follow-up (for example, living,
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nors are solicited through community information

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expired, lost to follow-up), functional status, graft

by
efforts similar to those carried out by blood banks status, and treatment, such as immunosuppres-
20
to encourage blood donations. sive drugs. Follow-up is carried out at intervals

20
throughout the first year after the transplant and

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Data Collection for Transplant Registries The then annually after that.
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type of information collected varies according to

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the type of registry. Pre-transplant data about the

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Immunization Registries
recipient include the following:
There is a scheduled list of immunizations chil-
●● Demographic data dren are supposed to receive during the first six
●● Patient’s diagnosis years of life. These immunizations are so impor-
●● Patient’s status codes regarding medical tant that the federal government has set several
urgency objectives related to immunizations in Healthy
People 2020, a set of health goals for the nation.
●● Patient’s functional status
These include increasing the proportion of
●● Whether the patient is on life support children and adolescents that are fully immu-
●● Previous transplantations nized and increasing the proportion of children
●● Histocompatibility (compatibility of donor in population-based immunization registries
and recipient tissues) (HHS 2019).
AB103118_Ch07.indd 208 2/6/2020 4:55:53 PM

Immunization registries usually have the purpose ●● Mother’s name (first, middle, last, and
of increasing the number of infants and children maiden)
who receive the required immunizations at the ●● Vaccine product
proper intervals. To accomplish this goal, registries ●● Vaccine manufacturer
collect information within a specific geographic
area on children and their immunization status.
●● Vaccination expiration date
They help by maintaining a central source of in-
●● Vaccine lot number (CDC 2018b)
formation for a child’s immunization history, even Other elements may be included as needed by
when the child has received immunizations from the individual registry.
a variety of providers. This central location for
immunization data relieves parents of the re-
sponsibility of maintaining immunization records Reporting and Follow-up for Immunization
Registries Because the purpose of the immu-
n.
for their children. This helps to ensure there is
tio
immunization data on children. nization registry is to increase the number of
ia
children who receive immunizations in a timely
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ss
manner, reporting should emphasize immuni-
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Case Definition and Case Finding for Immuniza-
zation rates. Immunization registries also can
en
tion Registries All children in the population area
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served by the registry should be included in the provide automatic reporting of children’s immu-
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registry. Some registries limit their inclusion of nization to schools to check the immunization
an
status of their students.
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patients to only those seen at public clinics. Al-
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though children are usually targeted in immuniza- Follow-ups are done to remind parents when
io
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tion registries, some registries include information it is time for immunizations as well as to identify
m r
parents who fail to bring the child in for the immu-

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on adults for influenza and pneumonia vaccines.

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Children are often entered in the registry at birth. nization after a reminder. Reminders may include
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a letter, email, automatic reminder generated from

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Registry personnel may review birth and death cer-

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tificates and adoption records to determine which the EHR, or a telephone call. Autodialing systems
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may be used to call parents and deliver a prere-

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children to include and which children to exclude

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corded reminder. Moreover, registries must decide

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because they died after birth. In some cases, chil-

dren are entered electronically through a connec- how frequently to follow up with parents who
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tion with an electronic birth record system. do not bring their children in for immunization.
by
Maintaining up-to-date addresses and telephone

20
numbers is important for providing follow-up. In

20
Data Collection for Immunization Registries The some states, registries may allow parents to opt out
©
National Immunization Program at the CDC has

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of the registry if they prefer not to be reminded.

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worked with the National Vaccine Advisory

yr
op
Committee (NVAC) to develop a core set of immu-

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nization data elements to be included in all immu- Standards and Approval Processes for Immuni-
nization registries. These data elements include zation Registries The CDC provides funding
the following: for some population-based immunization regis-
tries. In recognition of the growing importance of
●● Patient name (first, middle, and last) an Immunization Information System (IIS) to the
●● Patient birth date broader health information technology landscape,
●● Patient gender the 2001 IIS Minimum Functional Standards have
●● Patient race been revised. The new standards are an attempt
to lay the framework for the development of IIS
●● Patient ethnicity
through 2018 (CDC 2018c). The new program goals
●● Patient birth order and standards include objectives from Healthy
●● Patient birth state and country People 2020 and are listed in figure 7.2.
AB103118_Ch07.indd 209 2/6/2020 4:55:53 PM

Figure 7.2 Functional Standards 2013 to 2018 for Healthy People 2020
1. Support the delivery of clinical immunization services at the point of immunization administration, regardless of setting.
1.1 The IIS provides individual immunization records accessible to authorized users at the point and time where immunization
services are being delivered.
1.2 The IIS has an automated function that determines vaccines due, past due, or coming due (“vaccine forecast”) in a manner
consistent with current ACIP recommendations. Any deficiency is visible to the clinical user each time an individual’s record
is viewed.
1.3 The IIS automatically identifies individuals due or past due for immunization(s), to enable the production of reminder and re-
call notifications from within the IIS itself or from interoperable systems.
1.4 When the IIS receives queries from other health information systems, it can generate an automatic response in accordance
with interoperability standards endorsed by CDC for message content and format and transport.
1.5 The IIS can receive submissions in accordance with interoperability standards endorsed by CDC for message content and
format and transport.
2. Support the activities and requirements for publicly purchased vaccine, including the Vaccines For Children (VFC) and state pur-
chase programs.
n.
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2.1 The IIS has a vaccine inventory function that tracks and decrements inventory at the provider site level according to VFC
ia
program requirements.
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2.2 The IIS vaccine inventory function is available to direct data entry users and can interoperate with EHR or other inventory
ss
systems.
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2.3 The IIS vaccine inventory function automatically decrements as vaccine doses are recorded.
en
2.4 Eligibility is tracked at the dose level for all doses administered.
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2.5 The IIS interfaces with the national vaccine ordering, inventory, and distribution system (currently VTrckS).
ag
2.6 The IIS can provide data and produce management reports for VFC and other public vaccine programs.
an
3. Maintain data quality (accurate, complete, timely data) on all immunization and demographic information in the IIS.
M
n
3.1 The IIS provides consolidated demographic and immunization records for persons of all ages in its geopolitical area, except
io
where prohibited by law, regulation, or policy.
at
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3.2 The IIS can regularly evaluate incoming and existing patient records to identify, prevent, and resolve duplicate and
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fragmented records.
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3.3 The IIS can regularly evaluate incoming and existing immunization information to identify, prevent, and resolve duplicate vac-
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cination events.
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3.4 The IIS can store all IIS Core Data Elements.
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3.5 The IIS can establish a record in a timely manner from sources such as Vital Records for each newborn child born and resid-
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ing at the date of birth in its geopolitical area.

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3.6 The IIS records and makes available all submitted vaccination and demographic information in a timely manner.
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3.7 The IIS documents active or inactive status of individuals at both the provider organization or site and geographic levels.
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4. Preserve the integrity, security, availability and privacy of all personally identifiable health and demographic data in the IIS.
th
by
4.1 The IIS program has written confidentiality and privacy practices and policies based on applicable law or regulation that pro-
tect all individuals whose data are contained in the system.
20
4.2 The IIS has user access controls and logging, including distinct credentials for each user, least-privilege access, and r outine
20
maintenance of access privileges.

©
4.3 The IIS is operated or hosted on secure hardware and software in accordance with industry standards for protected health
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information, including standards for security and encryption, uptime, and disaster recovery.
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5. Provide immunization information to all authorized stakeholders.

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5.1 The IIS can provide immunization data access to healthcare providers, public health, and other authorized stakeholders
(for example, schools, public programs, payers) according to law, regulation, or policy.
5.2 The IIS can generate predefined or ad hoc reports (for example, immunization coverage, vaccine usage, and other important
indicators by geographic, demographic, provider, or provider groups) for authorized users without assistance from IIS per-
sonnel.
5.3 With appropriate levels of authentication, IIS can provide copies of immunization records to individuals or parents and
guardians with custodial rights.
5.4 The IIS can produce an immunization record acceptable for official purposes (for example, school, childcare, camp).
6. Promote vaccine safety in public and private provider settings.

6.1 Provide the necessary reports and functionality to facilitate vaccine recalls when necessary, including the identification of
recipients by vaccine lot, manufacturer, provider, and time frame.
6.2 Facilitate reporting and/or investigation of adverse events following immunization.
Source: CDC 2018c.
AB103118_Ch07.indd 210 2/6/2020 4:55:53 PM

Other Registries r egistry. The NPI Registry enables users to search

Registries may be developed for any type of for a provider’s national plan and provider enu-
disease or condition. Other commonly kept
meration system information, including the na-
types of registries are cystic fibrosis, cardiac, and tional provider identification number. The NPI
registries for chronic disease management and number is a 10-digit unique identification num-
gastroenterology. ber assigned to healthcare providers in the US
A registry can be developed for administrative (CMS 2018). There is no charge to use the registry
purposes. The National Provider Identifier (NPI) and it is updated daily (National Plan and Pro-
Registry is an example of an administrative vider Enumeration System 2018).
Healthcare Databases
n.
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Databases are developed for a variety ●● Covered charges
ss
of purposes. For example, the federal government Charges broken down by specific type of
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●●
developed databases to carry out surveillance,
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service, such as operating room, physical
em
improvement, and prevention duties. HIM man- therapy, and pharmacy charges
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agers may provide information for these databases
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●● ICD diagnosis and procedure codes
through data abstraction or from data reported by
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●● Medicare severity diagnosis-related groups
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a healthcare organization to state and local entities. io (MS-DRGs)
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They also may use these data to perform research
m r
or work with other researchers on issues related to The MEDPAR file is frequently used for re-
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reimbursement and health status. search on topics such as charges for particular
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types of care and MS-DRGs. The limitation of the

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National and State Administrative MEDPAR data for research purposes is that the file
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Databases contains only Medicare patients (RPC Health Data

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er
Store 2019).
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Some databases are established for administra-

tive rather than disease-oriented reasons. For ex-
e
th
ample, a database may be developed for claims National Practitioner Data Bank The National
by
data submitted on Medicare claims. Other admin- Practitioner Data Bank (NPDB) was mandated
20
20
istrative databases assist in the credentialing and under the Health Care Quality Improvement Act
©
privileging of health practitioners. Some of these of 1986 to provide a database of medical malprac-
ht
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are discussed next. tice payments, adverse licensure actions, and cer-
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tain professional review actions (such as denial

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Medicare Provider Analysis and Review File of medical staff privileges) taken by healthcare
The Medicare Provider Analysis and Review organizations such as hospitals against physi-
(MEDPAR) File is made up of acute-care hospi- cians, dentists, suppliers, and other healthcare
tal and skilled nursing facility (SNF) claims data providers (NPDB 2018). The NPDB was devel-
for all Medicare claims. It consists of the following oped to alleviate the lack of information about
types of data: malpractice decisions, denial of medical staff
●● Demographic data on the patient privileges, and loss of medical license. Because
these data were not widely available, physi-
●● Data on the provider
cians whose license to practice was revoked in
●● Information on Medicare coverage for the
one state or healthcare organization could easily
claim move to another state or healthcare organization
●● Total charges and begin practicing again with the current state
AB103118_Ch07.indd 211 2/6/2020 4:55:53 PM

or healthcare organization being unaware of pre- In addition, consumers are becoming more actively
vious actions against the physician. involved in their healthcare. Publicly reported
Information in the NPDB is provided through data may be presented for consumer use through
a required reporting mechanism. Entities making various star ratings on different quality measures
malpractice payments, including insurance com- via organizations such as The Leapfrog Group,
panies, boards of medical examiners, and entities HealthGrades, or Hospital Compare. The Leapfrog
such as hospitals and professional societies, must Group and Hospital Compare allow users to select
report to the NPDB. The information reported various hospitals to compare data such as specific
includes information about the practitioner, the medical conditions, surgical procedures, or over-
reporting entity, and the judgment or settlement. all patient safety ratings. Based on the selections
Information about physicians and other healthcare made, data are compared to the hospitals selected
providers must be provided (NPDB 2018). Enti- as well as to state and national averages.
n.
ties such as private accrediting organizations and One of the duties of public health agencies is
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quality improvement organizations are required surveillance of the health status of the population
ia
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to report adverse actions to the data bank. In ad- within their jurisdiction. The databases developed
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dition, adverse licensure and other actions against by public health departments provide information
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any healthcare organization, not just physicians on the incidence and prevalence of diseases, pos-
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and dentists, must be reported. Adverse actions sible high-risk populations, survival statistics, and
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may include reporting incidents of license suspen- trends over time. Data for the databases may be col-
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sions or revocations. An incident is an occurrence lected using a variety of methods, including inter-
in a healthcare organization that is inconsistent n
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views, physical examinations of individuals, and
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with acceptable standards of care. It may also in- reviews of health records. Thus, the HIM man-
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clude issues related to professional competence, ager may have input in these databases through
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and malpractice payments. Monetary penalties data provided from health records. At the national
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may be assessed for failure to report. level, the National Center for Health Statistics
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The law requires healthcare organizations to (NCHS) has responsibility for these databases.
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query the NPDB as part of the credentialing pro- The NCHS provides statistical, accurate, relevant,
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cess when a physician initially applies for medical and timely data that help guide actions and poli-
staff privileges and every two years thereafter. cies to improve the health of the American people.
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The information or data obtained may be gathered

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State Administrative Data Banks States frequent- through surveys.

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20
ly have health-related administrative databases.

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For example, many states collect either Uniform National Health Care Survey One of the major
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national public health surveys is the National

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Hospital Discharge Data Set or UB-04/837 institu-

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Health Care Survey. To a large extent, it relies on

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tional data on patients discharged from hospitals

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located within their area. data from patients’ health records. It consists of a
number of parts, including the following:
National, State, and County Public Health ●● National Hospital Care Survey
Databases ●● National Hospital Ambulatory Medical Care
Public health is the area of healthcare dealing with Surgery
the health of populations in geographic areas such ●● National Ambulatory Medical Care Survey
as states or counties. Publicly reported healthcare ●● National Survey of Long-Term Care
data vary from quality and patient safety meas-
Providers
urement data to patient satisfaction results. The
aggregated data range from a local to national per Data in the National Hospital Care Survey is in-
spective, such as state-specific public health condi- formation on the utilization of healthcare provided
tions to national morbidity and mortality statistics. in inpatient settings, emergency departments, and
AB103118_Ch07.indd 212 2/6/2020 4:55:53 PM

outpatient departments. The survey collects data prevention measures can be taken to avoid large
from a nationally representative sample of entities outbreaks of these diseases. As mentioned previ-
and aims to provide hospital utilization statistics ously, state and local reporting systems connect
for the nation. with the CDC through NEDSS to evaluate trends
Data for the National Hospital Ambulatory in disease outbreaks. There also may be statewide
Medical Care Survey are collected on a represen- databases or registries that collect extensive infor-
tative sample of hospital-based and freestanding mation on particular diseases and conditions such
ambulatory surgery centers. Data include patient as birth defects, immunizations, and cancer.
demographic characteristics, source of payment,
and information on anesthesia given, diagnoses, Vital Statistics Vital statistics include data on
and surgical and nonsurgical procedures on births, deaths, fetal deaths, marriages, and divorc-
patient visits. es. Responsibility for the collection of vital statistics
n.
The National Study of Long-Term Care Provid- rests with the states. The states share the informa-
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ers collects data on the residential care community tion with the NCHS. The actual collection of the
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and adult day services sectors, and administra- information is carried out at the local level. For ex-
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tive data on the home health, nursing home, and ample, birth certificates are completed at the health-
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hospice sectors. care organization where the birth occurred and then
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Because of bioterrorism scares, the CDC devel- are sent to the state. The state serves as the official
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oped the National Electronic Disease Surveillance repository for the certificate and provides vital sta-
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System (NEDSS) that serves as a major part of the tistics information to the NCHS. From the vital sta-
Public Health Information Network (PHIN). This n
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tistics collected, states and the national g
overnment
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system provides a national surveillance system develop a variety of databases.
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by connecting the CDC with local and state pub- One vital statistics database at the national level
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lic health partners. It allows the CDC to monitor is the Linked Birth and Infant Death Data Set. In
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trends from disease reporting at the local and state this database, the data from birth certificates are
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levels to look for possible bioterrorism incidents. compared to death certificates for infants less than
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Another national public health database is the one year of age. This database provides data to
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National Health Interview Survey used to monitor conduct analyses for patterns of infant death. Oth-
the health status of the civilian, non-institutional- er national programs that use vital statistics data
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ized population of the US. The National Health include the National Mortality Followback Survey,
by
Interview Survey data are collected through per- the National Maternal and Infant Health Survey,
20
20
sonal household interviews. Interviewers from the the National Survey of Family Growth, and the
©
U.S. Census Bureau visit American homes to ask National Death Index (CDC 2018d). In some of
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about a broad range of health topics. The National these databases, such as the National Maternal
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Survey of Family Growth collects information on and Infant Health Survey and the National Mor-
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family life, marriage and divorce, pregnancy, in- tality Followback Survey, additional information
fertility, use of contraception, and men’s and wom- is collected on deaths originally identified through
en’s health. Information is collected from personal the vital statistics system.
interviews, from men and women between 15 and Similar databases based on vital statistics data
44 years of age. are found at the state level. Birth defects registries,
State and local public health departments devel- for example, frequently use vital records data with
op databases, as needed, to perform their duties information on the birth defect as part of their data
of health surveillance, disease prevention, and re- collection process. For additional information on
search. An example of state databases is infectious vital statistics, see chapter 14, Healthcare Statistics.
or notifiable disease databases. Each state has a list
of diseases that must be reported to the state—such Clinical Trials A clinical trial is a research project
as measles, and syphilis—so that containment and in which new treatments and tests are investigated
AB103118_Ch07.indd 213 2/6/2020 4:55:53 PM

to determine whether they are safe and effective. HCUP consists of a set of databases, including
The trial proceeds according to a protocol, which the following:
is the list of rules and procedures to be followed. ●● Nationwide inpatient sample (NIS): inpatient
Clinical trial databases have been developed to
database from a sample of hospitals
allow physicians and patients to find clinical trials.
A patient with cancer or AIDS, for example, might
●● State inpatient database (SID): hospital
be interested in participating in a clinical trial but discharge database
not know how to locate one applicable to their ●● Nationwide emergency department
type of disease. Clinical trial databases provide sample (NEDS): database on emergency
the data that enable patients and practitioners departments (EDs)
to determine what clinical trials are available and ●● State emergency department databases
applicable to the patient. (SEDD): database on hospital emergency
n.
The Food and Drug Administration Modern- departments (EDs)
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ization Act of 1997 mandated that a clinical trial Kids inpatient database (KID): database of
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●●
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database be developed. The National Library inpatient discharge data on children (AHRQ
ss
of Medicine (NLM) has developed the data-
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2018)
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base, available on the Internet for use by patients
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and practitioners. The NLM is a biomedical li- These databases are unique because they include
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brary that maintains and makes available a vast data on inpatients whose care is paid for by all
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types of payers, including Medicare, Medicaid,
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amount of print collections and produces elec-
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tronic information resources on a wide range of private insurance, self-paying, and uninsured
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topics (NLM 2019). patients. Data elements include demographic in-
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formation, diagnoses and procedures information,

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Health Services Research Databases Health admission and discharge status, payment sources,
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total charges, length of stay, and information on

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services research is research concerning healthcare

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delivery systems, including organization and de- the hospital or freestanding ambulatory surgery
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center. Researchers may use these databases to look

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livery and care effectiveness and efficiency. Within

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at issues such as those related to the costs of treating

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the federal government, the organization most in-

volved in health services research is the Agency particular diseases, the extent to which treatments
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for Healthcare Research and Quality (AHRQ). are used, and differences in outcomes and cost for
by
AHRQ looks at issues related to the efficiency and alternative treatments.

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effectiveness of the healthcare delivery system,

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disease protocols, and guidelines for improved National Library of Medicine The National Library
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disease outcomes. of Medicine (NLM) produces two databases of

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A major initiative for AHRQ has been the Health- special interest to the HIM manager—MEDLINE
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care Cost and Utilization Project (HCUP). HCUP and UMLS.

uses data collected at the state level from either Medical Literature, Analysis, and Retrieval
claims data or discharge-abstracted data, including System Online (MEDLINE) is the best-known
the UHDDS items reported by individual hospi- database from the NLM. It includes bibliographic
tals and, in some cases, by freestanding ambulato- listings for publications in the areas of medicine,
ry care centers. Which data are reported depends dentistry, nursing, pharmacy, allied health, and vet-
on the individual state. Data may be reported by erinary medicine. HIM managers use MEDLINE to
healthcare organizations to a state agency or to the locate articles on HIM issues as well as articles on
state hospital association, depending on state reg- medical topics necessary to carry out quality im-
ulations. The data then are reported from the state provement and medical research activities.
to AHRQ, where they become part of the HCUP The Unified Medical Language System (UMLS)
databases (AHRQ 2018). provides a way to integrate biomedical concepts
AB103118_Ch07.indd 214 2/6/2020 4:55:54 PM

from a variety of sources to show their relationships. Data for Performance Measurement The Joint
This process allows links to be made between dif- Commission, CMS, and some health plans require
ferent information systems for purposes such as the healthcare organizations to collect data on core
electronic health record. UMLS is of particular inter- performance measures. Core performance mea-
est to the HIM manager because of medical vocabu- sures are a set of national standardized processes
laries such as ICD-10-CM, CPT, and the Healthcare and best practices used to render and improve
Common Procedure Coding System (HCPCS). patient care. These measures are secondary
data because they are taken from patients’ health
Health Information Exchange Health informa- records. Whether a healthcare organization re-
tion exchange (HIE) initiatives were developed to ports such measures will be used as a basis for
move toward a longitudinal patient record with pay-for-performance systems. The goal is to link
complete information about the patient available at performance measures to provider payment (for
n.
the point of care. The data are patient-specific rath- example, helping the healthcare system move
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er than aggregate and are used primarily for patient away from paying providers based on quantity to
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care. Some researchers have looked at the amount a system based on the quality of care rendered).
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of data available through the HIEs as a possible
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Therefore, it is extremely important that the data
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source of data to aggregate for research. Aggre- accurately reflect the quality of care provided by
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gated data can be deidentified to add another layer the healthcare organization (see chapter 3, Health
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of protection for the patient’s identity. (Chapter 12, Information Functions, Purpose, and Users, for more
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Healthcare Information, covers HIEs in more detail.) information).
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HIM Roles
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Health information management pro- manager registry services, or trauma registry coor-
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fessionals are often involved in various roles using dinator or data analyst. Likewise, many HIM pro-
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secondary data. These roles may include gathering fessionals may work with healthcare databases.
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information from secondary data sources, analyz- Those job titles may include, but are not limited to,
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ing data from the data source, or assisting in main- database manager, database specialist, database
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taining the privacy and security of data sources. administrator, data abstractor, or HIM administra-
by
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Healthcare job titles for individuals working with tive assistant. As the healthcare environment con-
20
registries may vary from entity to entity. Most of tinues to rely on accurate and reliable information,
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the registry titles include, but are not limited to, HIM professionals may find themselves working
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cancer registry specialist, certified tumor registrar, in the world of healthcare secondary data in new
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HIM technician birth registry, registry coordinator, and emerging ways.

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1. Which of the following indexes would be used if a physician wanted to conduct a study on patients who have had a
C-section?
a. Physician index
b. Master patient index
c. Operation index
d. Disease index
AB103118_Ch07.indd 215 2/6/2020 4:55:54 PM

2. The healthcare organization would like to get approval for their cancer program.
They should contact the:
a. American College of Surgeon’s Commission on Cancer
b. Centers for Disease Control and Prevention
c. North American Association of Central Cancer Registries
d. National Committee on Vital Health Statistics
3. After several visits to the hospital, a 75-year-old female has just been diagnosed with cancer. What is the first thing
you would do to get this patient entered in the cancer registry?
a. Assign a patient number
b. Assign an accession number
c. Assign a financial record number
d. Assign a health number
4. Patient data such as name, age, and address are known as:
n.
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a. Primary data
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b. Secondary data
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c. Aggregate data
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d. Identification data
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5. What type of registry maintains a database on patients injured by external forces in events out
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of their control?
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a. Implant registry
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b. Birth defects registry
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c. Trauma registry io
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d. Transplant registry
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6. Why is the MEDPAR File limited in terms of being used for research purposes?
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a. It only provides demographic data about patients.

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b. It only contains Medicare patients.

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c. It uses ICD-10-CM diagnoses and procedure codes.

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d. It breaks charges down by specific type of service.

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7. Which of the following acts mandated establishment of the National Practitioner Data Bank?
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a. Health Care Quality Improvement Act of 1986

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b. Health Insurance Portability and Accountability Act of 1996

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c. Safe Medical Devices Act of 1990

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d. Food and Drug Administration Modernization Act of 1997

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8. I started work today on a clinical trial and need to familiarize myself with the rules and procedures
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to be followed. This information is called the:

yr
a. Protocol
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b. MEDPAR
c. UMLS
d. HCUP
9. An advantage of HCUP is that it:
a. Contains only Medicare data
b. Helps determine pay for performance
c. Contains data on all payer types
d. Contains bibliographic listings from medical journals
AB103118_Ch07.indd 216 2/6/2020 4:55:54 PM

Real-World Case 7.1

Remember, databases are used for a 2. Attackers Seeking Personal Data: Attackers
variety of reasons and contain large amounts of seek personal data to use in multiple ways
secondary data. One significant issue that health- such as sell electronic protected health
care professionals face is ensuring the data are information, blackmail individuals, or use
kept safe and secure. The digitization of healthit as a basis for future fraud like phishing or
care data has created many benefits, but it has scam calls.
also created challenges. A research report from 3. Attackers Taking Control of Medical Devices
IntSights, “Chronic (Cyber) Pain: Exposed and for Ransom: Attackers target medial IT equipment
Misconfigured Databases in the Healthcare Indus- to spread malware that exploits specific
try,” reveals how hackers are obtaining personally vulnerabilities and demands a ransom to
n.
identified information from exposed databases. release the infected devices (Ainhoren 2018).
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It is not only old or outdated databases that get
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breached, some newly established platforms are Many healthcare organizations are working dil-
ss
igently to protect themselves from cyber-attacks
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vulnerable due to misconfiguration or open ac-
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cess. The researchers found that hackers were able and threats. It is important to constantly evaluate
em
to access sensitive data in databases through such for gaps in the IT infrastructure and implement
ag
strategies such as assessing what needs to be
an
simple methods as Google searches (Landi 2018).
secured, mastering identity and mobile device

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Most cybercriminals usually attack for money,
n
management, testing and re-testing tools, detect-
io
but since hospitals don’t hold currency, these at-
at
ing and continuously monitoring threats, and
m
tackers target the industry for one of three reasons:

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training employees (Davis 2017).

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1. State-sponsored APTs Targeting Critical Infra- While secondary data such as databases makes
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structure: An attempt to infiltrate a network it a powerful tool for data collection, it is impor-
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to test tools and techniques to set the stage for tant for healthcare professionals to be aware of the
an
larger, future hacks, or to obtain information threats and challenges presented which include
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on a specific individual’s medical condition. privacy, security, data quality, and more.
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by
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Real-World Case 7.2

©
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As mentioned before, many databases percent among middle school students in the past
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are maintained at the state and national level for year. The recent increase is largely due to the pop-
C
public use. The National Youth Tobacco Survey ularity of one e-cigarette brand, which looks like a
(NYTS) serves this purpose and others. The NYTS USB flash drive (Boyles 2018).
is used to help provide researchers with informa- Vaping, the act of inhaling the vapors of
tion to explore in detail. It also is used as part of e-cigarettes, by US teenagers has reached epidemic
a public initiative (Healthy People 2020) for sur- levels, threatening to hook a new generation of
veillance of trends of adolescent tobacco use (CDC young people on nicotine. “We have never seen
2019b). Evidence of current topics of secondary use of any substance by America’s young peo-
data (in other words, databases) is all around us. ple rise this rapidly,” HHS Secretary Alex Azar
A recent report from CDC’s 2018 NYTS indicates explains. Vaping is ingrained in the high school
that the use of electronic cigarettes (e-cigarettes) is culture with kids using e-cigarettes in school bath-
on the rise. The use of e-cigarettes spiked almost rooms and even during class. Kids don’t realize
80 percent among high school students and 50 many e-cigarettes contain nicotine. Among younger
AB103118_Ch07.indd 217 2/6/2020 4:55:54 PM

students, candy-flavored e-cigarettes are the most NYTS was designed to provide national data on
popular, while fruit-flavored products are popular long-term, intermediate, and short-term indicators
with older students (Finnegan 2018). to serve as a baseline for data comparison toward
Numerous efforts are underway to prevent and meeting the Healthy People 2020 goal of reducing
reduce tobacco use among young people. The tobacco use among youth (CDC 2018d).
References
Agency for Clinical Innovation. 2019. Injury Scoring. tobacco/data_statistics/surveys/nyts/index.htm.
https://www.aci.health.nsw.gov.au/networks/itim/ Centers for Disease Control. 2018a. National Program
Data/injury-scoring/injury_severity_score. of Cancer Registries. https://www.cdc.gov/cancer/
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Agency for Healthcare Research and Quality. 2018. npcr/index.htm.
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Healthcare Cost and Utilization Project (HCUP). http://
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Centers for Disease Control. 2018b. Core Data
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www.ahrq.gov/research/data/hcup/index.html. Elements for IIS Functional Standards v4.0. https://
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Ainhoren, A. 2018. Exposed and Misconfigured www.cdc.gov/vaccines/programs/iis/core-data-
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Databases in the Healthcare Industry. https:// elements/iis-func-stds.html.
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intsights.com/resources/chronic-cyber-pain-exposed-
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Centers for Disease Control. 2018c. Immunization
misconfigured-databases-in-the-healthcare-industry.
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American College of Surgeons. 2019a. Commission on www.cdc.gov/vaccines/programs/iis/func-stds.
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Cancer. https://www.facs.org/quality-programs/cancer. html. io
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American College of Surgeons. 2019b. National Centers for Disease Control. 2018d. National
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Trauma Data Bank. https://www.facs.org/quality- Notifiable Disease Surveillance System. https://

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programs/trauma/tqp/center-programs/ntdb. wwwn.cdc.gov/nndss.
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American College of Surgeons. 2019c. The Committee Centers for Medicare and Medicaid Services.
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trauma/tqp/center-programs/vrc. (NPI). https://www.cms.gov/Regulations-

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Association. 2014a. Health Data Analysis Toolkit. NationalProvIdentStand/.
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DataAnalysis#.XjGlXGhKg2w. Collaborative Stage Transition Newsletter. https://

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American Health Information Management cancerstaging.org/cstage/about/Pages/default.aspx.

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Association. 2017. Pocket Glossary of Health Information Davis, J. 2017. Checklist: These 5 Steps Will Future-
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American Health Information Management Association.

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ahima.org/doc?oid=100307#.Vw_QDPkrLDc. program.
American Trauma Society. 2018. Trauma Center Levels Department of Health and Human Services. 2019.
Explained. https://www.amtrauma.org/page/ Healthy People 2020. http://www.healthypeople.
TraumaLevels. gov/2020/topics-objectives/topic/immunization-
and-infectious-diseases.
Boyles, S. 2018. CDC: 3.6 Million Teens Using
E-Cigarettes in 2018. https://www.medpagetoday. Diseases Database. 2019. What is in the Diseases
com/pulmonology/smoking/76396. Database? http://www.diseasesdatabase.com/
content.asp.
Centers for Disease Control. 2019a. Population Health
Training in Place Program. https://www.cdc.gov/ Finnegan, J. 2018. Surgeon General to Healthcare
pophealthtraining/whatis.html. Professionals: Ask Kids About E-cigarette Use.
https://www.fiercehealthcare.com/practices/
Centers for Disease Control. 2019b. National Youth surgeon-general-to-healthcare-professionals-ask-kids-
Tobacco Survey (NYTS). https://www.cdc.gov/. about-e-cig-use.
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Food and Drug Administration. 2018. Mandatory National Committee on Vital and Health
Reporting Requirements. http://www.fda.gov/ Statistics. 2009. Health Data Stewardship: What,
MedicalDevices/DeviceRegulationandGuidance/ Why, Who, How. https://bok.ahima.org/
PostmarketRequirements/ReportingAdverseEvents/ PdfView?oid=94786.
ucm2005737.htm#3. National Library of Medicine. 2019. About the
Food and Drug Administration. 2016. Reporting by National Library of Medicine. https://www.nlm.nih.
Health Professionals. http://www.fda.gov/Safety/ gov/about/index.html#.
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Amendments of 1992. http://www.gpo.gov/fdsys/ National Practitioner Data Bank. 2018. https://www.
pkg/STATUTE-106/pdf/STATUTE-106-Pg238.pdf. npdb.hrsa.gov/topNavigation/aboutUs.jsp.
Government Publishing Office. 1990. Safe Medical Office of the Surgeon General. 2018. https://e-
Devices Act of 1990. http://www.gpo.gov/fdsys/ cigarettes.surgeongeneral.gov/documents/
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pkg/STATUTE-104/pdf/STATUTE-104-Pg4511.pdf. surgeon-generals-advisory-on-e-cigarette-use-among-
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Landi, H. 2018. Report: 30 Percent of Healthcare youth-2018.pdf.
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Databases Exposed Online. https://www.healthcare- Patient-Centered Outcomes Research Institute. 2019.
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informatics.com/news-item/cybersecurity/report-30-
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About Us. https://www.pcori.org/about-us.
percent-healthcare-databases-exposed-online.
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Public Law 102-515. 1992. Cancer Registries
em
National Cancer Registrars Association. 2018a. History. Amendment Act. http://www.cdc.gov/cancer/npcr/
ag
http://www.ncra-usa.org/About/History. pdf/publaw.pdf.
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National Cancer Registrars Association. 2018b.
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RPC Health Data Store. 2019. MedPAR File. https://
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Education. http://www.ncra-usa.org/About/Become- io
healthdatastore.com/data/national-medicare-data/
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a-Cancer-Registrar. medpar-file/.
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AB103118_Ch07.indd 220
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PART
Information
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Protection: Access,
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Discloure and
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Archival, Privacy
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and Security
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AB103118_Ch08.indd 222
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2/11/2020 1:16:06 PM
Chapter
8
Health Law
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Learning Objectives
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•• Compare the types and sources of laws that govern •• Identify legal issues in health information
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the healthcare industry management, including factors that govern the
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•• Identify the steps in the legal process io
creation and maintenance of the health record
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•• Apply professional liability theories to situations of •• Analyze the content of the legal health record
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wrongdoing •• Apply legally sound health record retention and

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•• Articulate patient rights regarding healthcare destruction principles

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decisions, including the purpose and types of •• Identify the purpose of medical staff credentialing
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consents and advance directives •• Demonstrate the differences among licensure,

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certification, and accreditation

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Key Terms
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Accreditation Consent False Claims Act

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by
Administrative law Constitutional law Federal Rules of Civil Procedure

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Admissibility Counterclaim (FRCP)

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Alternative dispute resolution Court order Federal Rules of Evidence (FRE)

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Appeals Courts of appeal General consent

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Appellate courts Credentialing General jurisdiction

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Arbitration Criminal law Health Care Quality Improvement

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Authentication Cross-claim Act of 1986

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Authorization Default Hearsay

Bench trial Defendant Implied contract
Breach DepositionDestruction of records Informed consent
Breach of contract Discovery Injury
Business records exception District court Intentional tort
Causation Do-not-resuscitate (DNR) order Interrogatories
Causes of action Durable power of attorney for Joinder
Certification healthcare decisions (DPOA- Judicial law
Circuit courts HCD) Jurisdiction
Civil law Duty Legal health record
Clinical privileges E-discovery Legal hold
Complaint Express contract Licensure
223
223
AB103118_Ch08.indd 223 2/11/2020 1:16:07 PM

224 Part III Information Protection: Access, Disclosure and Archival, Privacy and Security
Limited jurisdiction Nonfeasance Statute of limitations

Litigation Personal health record (PHR) Statutory law
Living will Plaintiff Subpoena
Malfeasance Private law Subpoena ad testificandum
Mediation Privileged communication Subpoena duces tecum
Medical malpractice Public law Summons
Metadata Requests for production Supreme courts
Misfeasance Retention Tort
National Practitioner Data Bank Rules and regulations Trial court
(NPDB) Spoliation Voir dire
Negligence Standard of care Warrant
The most important purpose of the health This chapter discusses legal issues associated with
n.
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record is to document patient treatment and health information and includes an overview of ba-
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provide a means for a patient’s healthcare sic legal concepts such as types and sources of law
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providers to communicate among each other. and the court system; legal process and causes of
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However, the health record also plays an im- action that form the basis of professional liability; pa-
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portant role as a legal document. It provides tient healthcare decision making; health record crea-
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critical evidence in the legal process, including tion and maintenance; ownership and control of the
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medical malpractice and other personal injury health record; content and retention of the legal health
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lawsuits, criminal cases, healthcare fraud and record including content, retention, and destruction;
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abuse investigations and actions, and quasi- medical staff credentialing; licensure and certification
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judicial proceedings such as workers’ compen- of healthcare professionals; and licensure, certifica-
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sation determinations. tion, and accreditation of healthcare organizations.

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Basic Legal Concepts

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There are many federal and state stat- Types and Sources of Laws
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utes and regulations that provide a protective

by
Laws are classified as public or private. Public law

framework around the health record and form
20
involves the government at any level and its re-

20
its content. The most well-known laws are the

lationship with individuals and organizations. Its
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federal Privacy Rule of the Health Insurance

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purpose is to define, regulate, and enforce rights

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Portability and Accountability Act (HIPAA) and

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where any part of a government agency is a party

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the American Recovery and Reinvestment Act

(Showalter 2017). The most familiar type of pub-
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(ARRA), which are discussed in chapter 9, Data

lic law is criminal law, where the government is
Privacy and Confidentiality. However, those are
a party against an accused who has been charged
only two of the laws with which the health in-
with violating a criminal statute. In healthcare, the
formation management (HIM) professional must
Medicare Conditions of Participation (COP)—the
be familiar.
requirements set forth for healthcare providers
In addition to federal and state laws, healthcare
who accept Medicare patients—are public law.
organizations may be subject to the standards of
Public law includes both criminal and civil law
accrediting bodies such as the Joint Commission
(non-criminal law).
or the Healthcare Facilities Accreditation Pro-
Private law involves rights and duties among
gram (HFAP), which also contain requirements
private entities or individuals. For example, pri-
related to the protection and content of health
vate law applies when a contract for the purchase
records.
AB103118_Ch08.indd 224 2/11/2020 1:16:07 PM

of a house is written between two parties. Nor- powers of the three branches of the federal gov-
mally, private law encompasses issues related to ernment. The legislative branch, which is the US
contracts, property, and torts (injuries). In the med- Congress and is comprised of the House of Rep-
ical arena, it often applies when there is a breach resentatives and the Senate, creates statutory
of contract or when a tort occurs in malpractice. law (statutes). Examples of statutory law include
Private law is also civil law. Table 8.1 depicts the Medicare and HIPAA. The executive branch (the
relationship of public and private law to civil and president and staff, namely cabinet-level agen-
criminal law. cies) enforces the law. For example, the Centers for
There are four sources of public and private Medicare and Medicaid Services (CMS), an agency
law: constitutions, statutes, administrative law, within the cabinet-level Department of Health and
and judicial decisions, also known as common law Human Services (HHS), enforces the Medicare
or case law. laws. The judicial branch (the court system) inter-
n.
prets laws passed by the legislative branch. This
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Constitutions three-branch government structure is also found
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Constitutional law defines the amount and types in state governments. Each state’s constitution is
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the supreme law of that state, but it is subordi-
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of power and authority governments are given.
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The US Constitution defines and sets forth the nate to the US Constitution, the supreme law of
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the nation (Rinehart-Thompson 2017a). Figure 8.1
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illustrates each branch of the US government.
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Table 8.1 Relationship of public and private law
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to civil and criminal law io
Statutes
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Civil Law Criminal Law Statutes (which form statutory law) are enacted by
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Public Law X X legislative bodies. The US Congress and state leg-

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Private Law X islatures are legislative bodies. Local bodies, such

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Source: Rinehart-Thompson 2017a. as municipalities, can also enact statutes, sometimes

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Figure 8.1. Branches of the US government

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Constitution
by
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20
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The
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The The White House

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US Supreme
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Capitol Court
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Legislative Executive Judicial
Congress
President Vice President Supreme Court
House of Senate
Representatives
Source: ©AHIMA
AB103118_Ch08.indd 225 2/11/2020 1:16:10 PM

referred to as ordinances (Rinehart-Thompson The US court system consists of state and federal
2017a). courts. Both federal and state court systems have
a three-tier structure: trial courts (called district
Administrative Law courts in the federal system); courts of appeal or
appellate courts (called circuit courts in the federal
Administrative law is a type of public law. As
system) that hear appeals on final judgments of the
previously noted, the executive branch of govern-
trial courts; and supreme courts, the highest courts
ment is responsible for enforcing laws enacted by
in a court system that hear final appeals from in-
the legislative branch. Administrative agencies,
termediate courts of appeal. Appeals are designed
which are part of the executive branch, develop
nearly exclusively to address legal errors or prob-
and enforce rules and regulations that carry out
lems alleged to have occurred at the lower court,
the intent of statutes. For example, HHS devel-
but they are not meant to address the facts of the
oped rules and regulations to carry out the intent
n.
case again. Table 8.2 compares the nomenclatures
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of the HIPAA statute, and it has the power to en-
of state and federal court systems. In many states,
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force them. These rules and regulations are ad-
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trial courts are divided into courts of limited juris-
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ministrative law. Another example is the federal
diction which hear cases pertaining to a particular
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Food and Drug Administration (FDA), an agency
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subject (for example, landlord and tenant or juve-
within HHS, which has the power to develop rules
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nile) or involve crimes of lesser severity or civil
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that control the manufacture of drugs. The legisla-
matters of lower dollar amounts. Courts of general
an
tive branch of the federal government has given a
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jurisdiction hear more serious criminal cases or
number of administrative agencies the power to
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civil cases involving larger sums of money. Cases
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establish regulations (Rinehart-Thompson 2017a).
presented to courts of appeal or supreme courts are
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not trial reenactments. Legal documents are pre-

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Judicial Decisions pared by each party’s attorney(s), who argue the

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The fourth major source of law is judicial law merits of the case b
efore a panel of a ppellate judges.
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(that is, common law or case law), which is law

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created from court (judicial) decisions. Courts in- Legal Process

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terpret statutes, regulations, and constitutions,

This section describes a legal action from the time
and resolve individual conflicts. Judicial decisions
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a lawsuit is filed, through the phase in which in-

are the primary source of private law (Showalter
by
formation is collected by those involved in the

2017).
20
lawsuit, to trial and resolution.

20
The traditional method of resolving legal dis-

©
putes is through the court systems. In the US,

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Initiation of Lawsuit
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one court system exists at the federal level. The

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50 states, the US territories, and the District of In order to prepare for a judicial decision as the
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Columbia have their own court systems. Although ultimate outcome of a legal proceeding (litigation),
the court system is the most familiar method for a plaintiff initiates a lawsuit against a defendant
resolving legal disputes, there is growing reliance
on alternative dispute resolution to lighten court Table 8.2 Comparison of state and federal court
dockets and provide less costly and time-consuming systems
alternatives for parties to settle their differences.
State* Federal
Alternative dispute resolution includes arbitra-
State Supreme Court US Supreme Court
tion (parties agree to submit a dispute to a third
Court of Appeals Circuit Court
party to decide) and mediation (parties agree to
Trial Court (for example, District Court
submit a dispute to a third-party facilitator, who Common Pleas Court)
assists the parties in reaching an agreed-upon *Terminology may vary from state to state.
resolution). Source: Rinehart-Thompson 2017a.
AB103118_Ch08.indd 226 2/11/2020 1:16:11 PM

by filing a complaint in court, which outlines the court proceeding) or bring something, such as a
defendant’s alleged wrongdoing. After it is filed, document. There are two types of subpoenas: the
a copy of the complaint is served to the defendant subpoena ad testificandum seeks one’s testimony
along with a summons. The summons and com- and the subpoena duces tecum seeks documents
plaint give the defendant notice of the lawsuit and and other records one can bring with him or her
to what it pertains and informs the defendant that (Rinehart-Thompson 2017b). Subpoenas may di-
the complaint must be answered or some other rect that originals or copies of health records, labo-
action taken. If the defendant fails to answer the ratory reports, x-rays, or other records be brought
complaint or take other action, the court grants the to a deposition or to court. In most instances, a sub-
plaintiff a judgment by default. poena for the disclosure of an individual’s health
Usually, the defendant answers the complaint information must be accompanied by an authori-
in one of four ways: denying, admitting, pleading zation, or permission from that individual for the
n.
ignorance to the allegations, or bringing a coun- information to be disclosed. HIM professionals
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tersuit (counterclaim) against the plaintiff by fil- can be subpoenaed to testify as to the authentic-
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ing a complaint. A defendant may file a complaint ity of the health records by confirming the records
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(joinder) against a third party or against another were compiled in the usual course of business and
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defendant (cross-claim). The defendant can ask have not been altered in any way. Because the at-
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the court to dismiss the plaintiff’s complaint, but torney who subpoenas a HIM professional is most
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not without substantial reason such as lack of interested in the health record, the information is
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evidence. likely to be compelled via subpoena duces tecum.
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Another type of discovery tool is the court or-
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Discovery der. A court order is a document issued by a judge.
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The next stage of litigation is discovery, a pre- At times, a court order will be issued to compel the
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trial process and a time period in which parties production of health records. If the recipient does
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to a lawsuit use various strategies to discover or not comply with the court order, he or she risks
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obtain information about a case, held by other contempt-of-court (namely, failure to comply)
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parties, prior to trial. Discovery is encouraged in sanctions, possibly including jail time. Although
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order to determine the strengths and weaknesses both are issued through the court, any legal doc-
of the other parties’ cases. This knowledge helps ument that requests a patient’s health information
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avoid surprises at trial and perhaps encourages must be reviewed carefully to determine whether
by
pretrial settlement (Rinehart-Thompson 2017b). it is a court order or subpoena. This is because,

20
20
Thus, evidentiary rules and court decisions ad- as noted previously, a subpoena often requires an
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dressing discovery are broad, favoring discovery individual’s authorization if health information is
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when it is in doubt. There are several types of dis- being sought (Rinehart-Thompson 2017b).
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covery methods, but most likely to be encountered If health records are relevant to a criminal case,
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are the deposition, which obtains the parties’ and they may be obtained via a warrant. A specialized
other witnesses’ out-of-court testimony under type of court order, a warrant, is a judge’s order
oath; interrogatories, which are written questions that authorizes law enforcement to seize evidence
to the parties in order to obtain information; and and, often, to conduct a search as well. Criminal
requests for production of documents or other cases in which health records are most likely to be
pertinent items (Rinehart-Thompson 2017b). obtained via warrant involve healthcare fraud and
Although it is not a discovery method, an im- abuse investigations (Rinehart-Thompson 2017b).
portant discovery tool is the subpoena. Initiated
on behalf of one of the parties and issued through E-Discovery
the court, it is a legal document that facilitates dis- The concept of discovery as defined earlier seems
covery by instructing someone to do something relatively straightforward with paper health
(such as compelling attendance at a deposition or records. However, it is vastly different with
AB103118_Ch08.indd 227 2/11/2020 1:16:11 PM

electronic health records. E-discovery maintains occurred, which parts of the document or informa-
the same pretrial process as discovery, but parties tion system were affected, and what operations or
now obtain and review electronically stored data. changes (for example, creating, viewing, printing,
The Federal Rules of Civil Procedure (FRCP) in- editing) took place (Rinehart-Thompson 2018). Be-
corporated electronic information through the cre- cause the e-discovery rule affects retention and de-
ation of e-discovery rules. The FRCP applies only struction of health information, HIM professionals
to cases in federal district courts, but many states must be involved in those ongoing processes. To
have adopted similar e-discovery rules that apply protect discoverable data, they must also ensure
to both civil and criminal cases. While the role of records involved in litigation or potential litiga-
the HIM professional in paper-based discovery tion are safeguarded through a legal hold, which
was often limited to responding to a subpoena for is generally a court order to preserve a health rec-
health records or testifying as to a health record’s ord if there is concern about destruction. A legal
n.
authenticity, involvement begins much earlier hold supersedes routine destruction procedures.
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with e-discovery. For example, attorneys for the It also prevents spoliation—the act of destroy
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parties in a lawsuit must agree on matters such ing, changing, or hiding evidence intentionally
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as document discovery. Early interaction among a (Klaver 2017a).
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healthcare organization’s health information pro-
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fessionals, information technology (IT) profession- Trial
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als, and legal counsel is very important. Electronic After discovery is complete, the trial begins. A jury
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health records (EHRs) allow massive volumes of is selected through a process called voir dire or,
information to be created and stored, subjecting n
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if a jury is waived, a judge hears the case (bench
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much greater amounts of information to discov- trial). Evidence is then presented. The plaintiff’s
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ery than paper health records. Not all information attorney is the first to call witnesses and present
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is discoverable. For example, an incident report is evidence. In turn, the defendant’s attorney calls
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generally not discoverable. An incident report is witnesses and presents evidence. Typically, in
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a quality or performance management tool used both health-related and non–health-related cases
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to collect data and information about potentially that involve health records as evidence, the record
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compensable events (events that may result in custodian is called as a witness by one party or the
death or serious injury). Whether it is discovera- other to testify as to the authenticity of a health
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ble or not depends on legal protections (such as record sought as evidence. Testifying as to a health
by
a state statute that specifically protects quality record’s authenticity means the records custodian
20
20
assurance records) or the lack thereof. Any elec- is verifying that it contains information about the
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tronically stored evidence may potentially be com- individual in question, was compiled in the usual
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pelled as evidence. Discoverable data includes not course of business, and is reliable and truthful as
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only the EHR, but also emails, texts, voicemails evidence. Because individuals who document in a
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that may exist on smartphones, drafts of docu- health record do not typically falsify their entries,
ments, and information on flash drives. Other in- the truthfulness of a health record is generally not
formation that must be considered as potentially questioned. Parties to litigation often agree (stipu-
discoverable includes information housed on an- late) as to a health record’s authenticity and allow
cillary systems and other databases throughout a it to be entered into evidence without requiring
healthcare organization because they may be rel- the records custodian to appear in court and tes-
evant to a particular case. Discoverable data also tify. The parties may also agree to allow a photo-
include metadata, which are data about data, a copy of the health record or a printed version of
concept that was unheard of in paper documents. the EHR to be introduced into evidence rather
Metadata includes information that tracks ac- than the original. This generally requires the re-
tions such as who accessed or attempted to access cords custodian to certify in writing that the copy
a document or an information system, when this is an exact duplicate of the original. State laws
AB103118_Ch08.indd 228 2/11/2020 1:16:11 PM

vary on the degree to which courts will consider significant in providing information) may be

EHR printouts as evidence. deemed nonadmissible if it is outweighed as un-
Many times, a case is settled before it reaches fairly prejudicial or if presenting the evidence
trial. This saves time, money, and emotional hard- would cause undue delay. Evidence may also be
ship on the parties. A settlement may be reached excluded if it is misleading (for example, providing
between or among parties and their attorneys with statistics that do not accurately depict death rates
or without intervention from a third party. associated with a particular disease) or redundant
After the court (either a jury or the judge) has (for example, an answer from a witness that an at-
rendered a verdict, the next stage in litigation is the torney attempts more than once to belabor a point,
appeal. If at least one of the parties disagrees with such as a patient’s death) (Klaver 2017a). Hearsay
the verdict and has a legal argument on which to is also often excluded. Hearsay is an out-of-court
base its disagreement (for example, evidence was statement used to prove the truth of a matter, and
n.
wrongfully considered at trial), a case may be ap- it is inherently deemed untrustworthy because the
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pealed to the next court for review. The final stage maker of the statement was not cross-examined at
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of noncriminal litigation is collection of the judg- the time the statement was made. Hearsay can be
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ment, which is a monetary award or in equity admitted into evidence if it meets one of the hear-
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(that is, the defendant is required to do, or refrain say exceptions. The exception most common to the
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from doing, something). Examples of collection health record is the business records exception.
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of monetary judgments include single payments, This exception exists because business records are
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garnishment of wages (by court order), seizure of deemed inherently trustworthy and are admissible
property, or a lien on property. Examples of judg- n
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as long as they are made at or near the time of the
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ments in equity include ordering the completion event being recorded, are kept in the regular cours-
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of a construction project (requiring the defend- es of business, and the record was created through
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ant to do something) or requiring that a construc- the regular practice of business (Klaver 2017a).
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tion project be stopped (requiring the defendant Testimony by HIM professionals is often fo-
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to refrain from doing something). The final stage cused on the authenticity of the health record and
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of criminal proceedings is sentencing, which may refers to the document’s baseline trustworthiness
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include confinement and monetary penalties. (Klaver 2017a). HIM professionals must take care
to present a professional decorum when testify-
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Evidence ing by dressing professionally, answering ques-

by
An individual may be compelled to testify in court. tions honestly and without becoming defensive,
20
20
This may occur after an individual has provided and responding to the questions asked rather than
©
testimony at a deposition, or it may be the first time unnecessarily elaborating. If the questioning attor-
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an individual testifies in a particular case. Rules re- ney poses a question that is outside the scope of
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garding admissibility, or the court allowing con- the individual’s expertise as a HIM professional
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sideration of evidence, are much more stringent (for example, eliciting information about a pa-
than discovery rules (Rinehart-Thompson 2017b). tient’s condition or reason that medical treatment
Thus, much information can be shared during pre- was provided), the HIM professional should re-
trial discovery that is not permitted to be admitted spectfully decline to answer the question by stat-
as evidence at trial. The Federal Rules of Evidence ing that it is beyond his or her area of professional
(FRE) govern admissibility in the federal court sys- expertise.
tem. Separate rules of evidence that often mirror
the federal rules govern admissibility in each state. Causes of Action in Professional
Generally, only relevant evidence—that which Liability
makes a supposed fact either more or less prob- Professionals in many fields, including healthcare,
able—may be admitted at trial. However, even face potential liability for allegedly failing to meet
relevant evidence with probative value (that is,
the standards established in their fields of practice.
AB103118_Ch08.indd 229 2/11/2020 1:16:11 PM

Medical malpractice is the professional liability of 1. Nonfeasance is the failure to act as a prudent
healthcare providers—physicians, nurses, thera- person would, such as not ordering a
pists, or others involved in the delivery of patient standard diagnostic test
care. Breach of contract, intentional tort, and neg- 2. Malfeasance is a wrong or improper act that
ligence are all causes of action, or elements under may be unlawful, such as removal of the
which lawsuits are brought that are related to pro- wrong body part or use of a joint replacement
fessional liability. To understand how these causes of that is known to be problematic (Rinehart-
action apply, examine the elements of the physician- Thompson 2017c)
patient relationship. 3. Misfeasance is the improper performance
A physician-patient relationship is established by during an otherwise correct act, such as
either an implied contract, also referred to as consent, nicking the bladder during an otherwise
or an express contract. Implied contracts are created appropriately performed gallbladder surgery
n.
by the parties’ behaviors (for example, a patient’s
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arrival at a physician’s office). Express contracts are For a negligence lawsuit to be successful, the
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articulated, either in writing or verbally (a patient’s plaintiff must prove the following four elements:
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written or verbal agreement to treatment). A contract
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1. The existence of a duty (an obligation
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is usually created by the mutual agreement of the
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parties involved—in this case, the patient and the established by a relationship) to meet a
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physician or another healthcare provider. Termina- standard of care (degree of caution expected
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of an ordinary and reasonable person under
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tion of the contract usually occurs when the patient
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either gets well or dies, the patient and physician given circumstances)
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mutually agree to contract termination, the patient 2. Breach or deviation from that duty
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dismisses the physician, or the physician withdraws 3. Causation, the relationship between the defendant’s
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from providing care for the patient. conduct and the harm that was suffered
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No medical liability for breach of contract can 4. Injury (harm) that may be economic (medical
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exist without a physician-patient relationship. expenses and loss of wages) or noneconomic

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However, when this relationship does exist, the (pain and suffering)
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physician’s failure to diagnose and treat the pa-

tient with reasonable skill and care may cause the The causes of actions mentioned are not the
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patient to sue the physician for breach of contract. only ones that can be brought against an individ-
by
Healthcare providers also can be held responsi-

20
ual healthcare provider or a healthcare organiza-

20
ble for professional tort liability when they harm tion. Other tort actions applicable to healthcare
©
another person. A tort is a wrongful civil act that include battery (intentional and nonconsensual
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results in injury to another. Tort law is broad and contact), assault (intentional contact that causes
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includes non–healthcare-related acts (for example, apprehension of harmful or offensive contact),

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a driver runs a red light and strikes another vehi- false imprisonment (intentional confinement
cle) and healthcare-related acts (a nurse adminis- against that person’s will), infliction of emotional
ters the wrong medication). An intentional tort is distress (intentional conduct resulting in extreme
where an individual purposely commits a wrong- emotional suffering such as anxiety, sleeplessness,
ful act that results in injury. Usually, however, and inability to perform activities), defamation
professional liability actions are brought against (false communication that injures a person’s repu-
healthcare providers because of the tort of negli- tation), invasion of privacy (violation of a person’s
gence, or unintentional wrongdoing. right for his or her person and information to be
Negligence occurs when a healthcare provider left alone), and wrongful disclosure of confidential
does not do what a prudent person would nor- information by a person with which an individual
mally do in similar circumstances. The three types has a relationship protected by law (for example,
of negligence are the following: physician-patient) (Brodnik et al. 2017).
AB103118_Ch08.indd 230 2/11/2020 1:16:11 PM

Patient Rights Regarding Healthcare Decisions

It is an established right in the US that treated—or not—should the individual become
individuals generally have autonomy over their unable to communicate on his or her own behalf.
own bodies. Included in this right is the right of in- Once created, it is important that advance direc-
dividuals to make their own healthcare decisions tives become a part of an individual’s health record.
provided they are not legally incompetent (name- By creating a durable power of attorney for
ly, incompetent by virtue of a mental disability or healthcare decisions (DPOA-HCD) an individ-
status as a minor). Consents play an important role ual, while still competent, designates another
in documenting individuals’ wishes regarding the person (proxy) to make healthcare decisions con-
healthcare they will receive. Similarly, advance di- sistent with the individual’s wishes on his or her
rectives are important in documenting individu- behalf. Durable means that the document is in
n.
als’ end-of-life decisions. effect when the individual is no longer competent.
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Consent is one’s agreement to receive medical A living will is executed by a competent adult,
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treatment. It can be written (preferable because it expressing the individual’s wishes regarding
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offers greater proof) or spoken; further, it can be ex- treatment should the individual become afflicted
en
press (communicated through words) or implied with certain conditions (for example, a persistent
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(communicated through conduct or a mechanism vegetative state or a terminal condition) and no
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other than words, such as an unconscious person longer be able to communicate on his or her own
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who is brought to the emergency department). As a behalf. Living wills often address extraordinary
n
matter of practice, healthcare organizations obtain a io
lifesaving measures such as ventilator support and
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general consent from a patient for routine treatment either the continuation or removal of nutrition and
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and failure to do so can result in a legal action; gen- hydration.

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erally, for battery, or harmful or offensive contact. A third type of document that always specifies
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When a treatment or procedure becomes progres- an individual’s wish not to receive treatment (spe-
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sively more risky or invasive, it is important that cifically, cardiopulmonary resuscitation [CPR]) is
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informed consent be completed to ensure the pa- the do-not-resuscitate (DNR) order. Most often
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tient has a basic understanding of the diagnosis and used by individuals who are elderly or in chron-
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the nature of the treatment or procedure, along with ically ill health, it directs healthcare providers to
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the risks, benefits, alternatives (including opting out refrain from performing the otherwise standing
by
20
of treatment), and individuals who will perform the order of CPR should the individual experience
20
treatment or procedure. Informed consent is a proc- cardiac or respiratory arrest. Prior to executing
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ess and it is the responsibility of the provider who a DNR, the patient and physician should have a
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will be rendering the treatment or performing the discussion and the patient should sign a consent
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procedure to obtain the patient’s informed consent form for DNR. The physician then writes an order
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and answer the patient’s questions such as risks as- in the patient’s health record. State law provides
sociated with the treatment or procedure, alterna- the framework for completing DNR orders and
tives, and likely consequences if the treatment or forms. Joint Commission-accredited organizations
procedure is not chosen. Failure to obtain informed are required to implement policies regarding ad-
consent can result in legal action generally based on vance directives and DNR orders (Klaver 2017b).
negligence (Klaver 2017b). This informed consent The lack of advance directives can result in le-
must be documented in the health record. gal battles regarding the undocumented wishes
of individuals who become legally incompetent.
Highly publicized end-of-life cases regarding in-
Advance Directives dividuals and whether they would have wanted
An advance directive is a special type of consent continued life-sustaining measures in light of
that communicates an individual’s wishes to be their vegetative state include Karen Ann Quinlan
AB103118_Ch08.indd 231 2/11/2020 1:16:11 PM

(dispute between family and custodial facility the courts eventually determined that lifesaving
regarding respirator support), Nancy Cruzan (dis- measures could be removed. These cases have had
pute between family and custodial facility regarding significant legal and ethical implications on how
continuation of artificially administered nutrition healthcare providers handle right-to-die situations,
and hydration), and Terri Schiavo (dispute between prompting more providers to discuss a patient’s
husband and parents and siblings regarding con- end-of-life decisions and encourage the creation of
tinuation of artificially administered nutrition and advance directives that will state a patient’s wishes
hydration) (Klaver 2017b). In each of these cases, or name a decision-maker for the patient.
n.
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1. Laws are classified as:
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a. Public or criminal
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b. Public or private
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c. Criminal or medical malpractice
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d. Trial or appeal
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2. Administrative law is a type of:
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a. Criminal law io
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b. Private law
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c. Public law
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d. Statutory law
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3. Arbitration is the submission of a dispute to a:

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a. Mediator
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b. Third party
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c. Judge, without a jury

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d. Judge, with a jury

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4. Medical malpractice
by
a. Refers to the professional liability of healthcare providers:

20
20
b. Is related to breach of contract actions only

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c. Excludes intentional torts

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d. Is synonymous with negligence

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5. Mrs. Campbell has filed a medical malpractice lawsuit against Dr. Hall. She accomplished this by:
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a. Counterclaim
b. Voir dire
c. Cross-claim
d. Complaint
6. If a defendant fails to answer a complaint or take other action, the court grants the plaintiff a judgment by:
a. Joinder
b. Deposition
c. Default
d. Oral testimony
AB103118_Ch08.indd 232 2/11/2020 1:16:11 PM

7. A tort is:
a. A wrongful act that results in injury to another
b. A purposeful wrongful act against another
c. Mutual consent between two parties
d. The professional liability of healthcare providers
8. Identify an element of negligence.
a. Consent
b. Duty
c. Summons
d. Joinder
9. Private law:
a. Defines, regulates, and enforces rights where any government agency is a party
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b. Involves rights and duties among private parties
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c. Creates statutes
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d. Convicts individuals charged with crimes
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10. Identify a source of law.
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a. Standard
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b. Statute
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c. Accrediting body
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d. Guideline
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11. Statutes are laws created:
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a. By an administrative body
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b. Between private parties

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c. By trial and appellate courts

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d. By legislative bodies
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12. Identify a type of advance directive.

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a. Tort
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b. Jurisdiction
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c. District court
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d. Living will
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13. A physician-patient relationship:

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a. Is established by contract
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b. Is temporary
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c. Is permanent
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d. Cannot be subject to a breach of contract legal action

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14. Identify consent.

a. It is one’s agreement to receive medical treatment.
b. It must only be obtained for invasive procedures.
c. It must be in writing to be legally valid.
d. It is an element of negligence.
15. A lawsuit by a defendant against a plaintiff is a:
a. Cross-claim
b. Joinder
c. Counterclaim
d. Summons
AB103118_Ch08.indd 233 2/11/2020 1:16:11 PM

Overview of Legal Issues in Health Information

Management
For the HIM professional, legal aspects of health requirements for Medicare and Medicaid provid-
records and health information include the topics ers, private payers often have specific requirements
addressed in the following sections: about content that must be present in the health rec-
●● Creation and maintenance of health records ord for them to reimburse for treatment. Depend-
ing on the nature of the external entity that imposes
●● Ownership and control of health records,
requirements on the healthcare provider, failure to
including use and disclosure
comply with requirements will likely result in some
●● The legal health record including content, type of penalty such as loss of licensure or accredi-
retention, and destruction tation, nonpayment of claims, or fines imposed on
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Additionally, the HIM professional may be in- the healthcare organization. Thus, health informa-
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tion must be created and maintained appropriately
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volved in the medical staff credentialing process
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as well as healthcare organization licensure, certi- and in compliance with all applicable requirements.
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fication, and accreditation. Finally, in addition to governmental, accrediting
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body, and private payer requirements, professional
Creation and Maintenance of Health
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organizations such as the American Health In-
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Records formation Management Association (AHIMA) pub-
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lish best practice information. Best practice states
Requirements for creating and maintaining health re- n
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that health record entries and health records in their
cords are usually found in state rules and regulations,
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entirety must be complete, accurate, and timely.

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typically developed by state administrative agencies

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These characteristics contribute to high-quality pa-

responsible for licensing healthcare organizations.
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tient care and contribute toward a legally defensible

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Requirements often specify only that health records

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health record that can protect a healthcare organi-

be complete and accurate. However, other require-
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zation in malpractice litigation. Because health re-

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ments specify categories of information to be kept or

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cords are frequently admitted into evidence in med-

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outline the detailed contents of the health record.

ical malpractice lawsuits, the absence of complete,
In some circumstances, the federal government
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accurate, and timely documentation can result in a

stipulates specific requirements for maintaining
by
verdict against the healthcare organization.

health records. For example, the Medicare Condi-
20
Healthcare organizations take all previously

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tions of Participation contain specific requirements

mentioned external factors, as well as their unique
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that must be satisfied by healthcare organizations

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internal factors, into consideration when estab-

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that seek reimbursement to treat Medicare or Med-

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lishing their own requirements regarding health

icaid patients.
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record format and content. This is done by in-

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In addition to state and federal requirements,

corporating them in organizational policies and
accrediting bodies have established standards for
procedures and medical staff bylaws.
maintaining health records. Specifically, the Joint
In general, health record form and content should
Commission’s relevant standards are set forth in the
conform to the guidelines outlined in table 8.3.
Information Management (IM) and Record of Care,
Treatment, and Services (RC) chapters. Acute care,
long-term care, home health, and behavioral health Ownership and Control of Health
providers, among others, must follow these stan- Records, Including Use and Disclosure
dards if they are to be accredited by the Joint Com- HIM professionals must understand the concepts
mission. Private third-party payers play an impor- of health record ownership and control. The health
tant role in the maintenance and content of health record and its contents are owned by the health-
records. In addition to regulations that specify care organization that created and maintains it.
AB103118_Ch08.indd 234 2/11/2020 1:16:11 PM

Table 8.3 Documentation guidelines

• Policies should be based on applicable standards, including accreditation, state and local licensure, federal and state regulations,
reimbursement requirements, and professional practice standards.
• Content and format of health records should be uniform.
• Entries must be legible, complete, and authenticated by the person responsible for providing or evaluating the service provided.
• Only authorized individuals, as defined by organizational policies and procedures, shall document in the health record. Further,
authorship of entries should be clearly defined in the documentation.
• The definition of a legally authenticated entry should be established, with rules for prompt authentication of every entry by the author
responsible for ordering, providing, or evaluating the service. Health records must be accurately written, promptly completed, properly
filed and retained, and accessible. The system must consist of author identification and record m
aintenance that ensures the integrity of
the authentication and protects the security of the entries.
• Entries should be made as soon as possible after the event or observation is made at the point of care. Entries shall never be made in advance.
• Entries should include the complete date and time. Narrative documentation should reflect the actual time the entry was created.
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• The record should reflect facts, using specific language. Avoid using vague or generalized language.
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• For patient safety, policies must address standardized terminology, definitions, abbreviations, acronyms, symbols, and dose
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designations. Prohibited abbreviations, acronyms, symbols, and dose designations should be published.
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• Policies should specify who is authorized and responsible to receive and transcribe physician verbal and telephone orders.
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• Health record entries must be permanent. Because they are evidence in a legal action, policies and procedures must be established to
prevent alteration, tampering, and loss.
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• Documentation errors should not be obliterated or changed and should be corrected per procedure. There should be an option for
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“corrected final” in addition to “preliminary” and “final.”
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• Policy should address how the patient or patient representative requests corrections and amendments to the record. The amendment should refer
at
to the information questioned and include date and time. Documentation in question should never be removed from the record or o
bliterated. Per
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HIPAA, the patient has the right to request an amendment; however, the organization has discretion whether to grant the request.
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• Quantitative and qualitative analyses of documents should be conducted according to procedure.

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• Policies should differentiate whether research records are part of the legal health record or maintained separately, with the
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decision verified with the organization’s institutional review board.

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Source: Fahrenholz 2017.

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As the legal custodian, the healthcare organization As patient portals become more available and en-
is responsible to ensure its integrity and security. couraged by providers, this right is becoming a
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This is true regardless of whether the health record patient expectation as well.
by
is paper, imaged, or electronic. Although patients

20
20
do own the information in the health record, ulti- Use and Disclosure Under State and Federal Law
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mate responsibility for the physical health record Most states have laws that protect patient confiden-
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still rests with the healthcare organization. tiality (Brodnik 2017). Known as privileged commu-
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Control of the health record encompasses its use nication statutes, the laws generally prohibit medi-
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(how health information is used internally) and dis- cal practitioners from disclosing information during
closure (how health information is disseminated exter- litigation if that information arises from the parties’
nally). Related to disclosure is patient access to one’s professional relationship and relates to the patient’s
own health records. Although health records and other care and treatment. An example is the protection of
documents (for example, radiologic images) that relate information shared by a patient with his or her phy-
to the delivery of patient care are owned by the health- sician during an office visit (Showalter 2017). If pa-
care organization, patients and other legitimately in- tients waive their privilege, the medical provider is
terested third parties have the right to access them. no longer prohibited from making disclosures.
The federal HIPAA Privacy Rule grants individuals State law may specifically provide a patient
the right to access their protected health information, with the right to access his or her health informa-
with some exceptions that will be discussed in more tion. Even if it does not, as previously noted,
detail in chapter 9, Data Privacy and Confidentiality. HIPAA grants an individual the right to access his
AB103118_Ch08.indd 235 2/11/2020 1:16:11 PM

or her health information for as long as it is main- must be appropriate. Compliance with legal re-
tained, with limited situations where access may quirements for appropriate use and disclosure
be denied. The HIM professional should always must be ensured, as must adherence to the profes-
follow the stricter law (HIPAA or state). HIPAA sion’s ethical principles.
also establishes standards by which others may
access an individual’s health information. Use of Health Records in Judicial Proceedings
Disclosure of health information without patient The health record of an individual who is a par-
authorization may be required under s pecific state ty to a legal proceeding is usually admissible in
statutes. Examples include reporting vital statistics litigation or judicial proceedings provided it is

(for example, births and deaths) and other public material or relevant to the issue (Showalter 2017).
health, safety, or welfare situations. For example, Either a court order or subpoena is used to obtain
healthcare providers may be required to provide health information for a court that has jurisdiction
n.
information to the appropriate state agency about (legal authority to make decisions) over the pend-
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patients diagnosed with sexually transmitted and ing l itigation. These are discussed in more detail in
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other communicable diseases, injured by knives or chapter 9, Data Privacy and Confidentiality.
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firearms, or exhibiting wounds that suggest some
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Responses to court orders and subpoenas depend
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type of violent criminal activity. The treatment of on state regulations. In some instances, states allow
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suspected victims of child abuse or neglect must copies of health records to be certified and mailed to
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also be reported. Because requirements vary by the clerk of the court or to other designated individu-
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state, HIM professionals must know the reporting als. In other instances, however, original health records
requirements for the states in which they practice. n
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must be produced in person and the records custodian
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Health information has a variety of purposes—
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is required to authenticate them. Authentication af-

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from the provision of direct patient care to use by firms a health record’s legitimacy through testimony
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outside entities such as insurance and pharmaceu- or written validation that it is indeed the record of the
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tical companies—and those uses and disclosures subject individual and the information in it is valid.
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Legal Health Record

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The legal health record is the record It is also important to differentiate the legal
by
20
used for legal purposes and is the “record released health record from other types of records that are
20
upon a valid request” (Rinehart-Thompson 2017d, integral to health information. These include the
©
171). The legal health record can exist on any me- designated record set, the EHR, and the personal
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dium (paper, electronic or imaged, or a hybrid). Its health record. The designated record set (DRS),
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content is defined by the healthcare organization which is a term specific to HIPAA and described
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that maintains it rather than by law. further in chapter 9, Data Privacy and Confidential-
ity, also includes other records (for example, bill-
Importance of the Legal Health Record ing records) and, as such, is more expansive than
The legal health record distinction is important for the legal health record. The EHR is also more ex-
several reasons. First, it is important to a health- pansive because it contains components (such as
care organization’s business and legal processes metadata) that are not ordinarily included in legal
(Rinehart-Thompson 2017d). Second, because the le- health record content. The personal health record
gal health record is the record that must be produced (PHR) is owned and managed by the individual
upon request, including legal request, it becomes who is the subject of the health record. As such, it
important to ensure the legal health record is le- is not the legal business record of the healthcare
gally sound and defensible as a valid document in organization. The PHR is discussed in chapter 3,
legal situations (Rinehart-Thompson 2017d). Health Information Functions, Purpose, and Users.
AB103118_Ch08.indd 236 2/11/2020 1:16:11 PM

Content of the Legal Health Record a lawsuit (such as medical malpractice) must be
filed. In particular, the health record of a minor
Determining the content of the legal health rec-
should be retained until the patient reaches the
ord can be challenging because of the myriad of
age of majority (as defined by state law) plus the
documents that exist, the presence of documenta-
period of statute of limitations, unless otherwise
tion in multiple locations, and—for the EHR—the
provided by state law. For example, if state law
existence of documentation that does not exist in
defines the age of majority as 18 and the statute
paper health records. Healthcare organizations
of limitations is two years, then the health record
should develop and maintain an inventory of all
would need to be retained until the patient is 20
documents and data that could comprise the le-
years old. A longer retention period is necessary
gal health record, considering all locations in the
because the statute may not begin to run until a
healthcare organization where such information
potential plaintiff learns of the causal relationship
could exist (for example, separate departments
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between an injury and the care received. Other
tio
or servers). Electronic document considerations
claims must also be taken into consideration when
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include emails, text messages, electronic fetal
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determining how long to retain health records as
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monitoring strips, diagnostic images, digital pho-
evidence. For example, under the False Claims
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tography, voice files, and video (AHIMA 2011a).
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Act, claims of fraud may be brought for up to 10
Healthcare organizations should also carefully
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years after the incident (31 USC 3729). Payer re-
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consider whether to include data such as pop-up
quirements must also be considered; for example,
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reminders, alerts, and metadata.
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the Medicare Conditions of Participation, which is
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federal regulation, require five-year retention for
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Retention of the Legal Health Record hospital health records.
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Retention includes mechanisms for storing re- The standards of accreditation bodies such
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cords, providing for timely retrieval, and estab- as the Joint Commission and the HFAP must be
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lishing the length of times various types of records followed in developing a health record retention
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will be retained by the healthcare organization. policy. The Joint Commission defers to state law
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The HIM professional must consider multiple fac- by specifying that records are to be retained in
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tors when developing health record retention poli- compliance with applicable law.
cies to determine how long health records are to be Health record retention also depends on how
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kept. These factors include applicable federal and the healthcare organization uses the information
by
state statutes and regulations; accreditation stan- in the health record. For example, an acute-care
20
20
dards; operational needs of the healthcare organi- hospital may have very different retention poli-
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zation; and the type of healthcare organization (for cies than a long-term-care organization providing
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example, hospital or clinic). geriatric nursing care. Further, a healthcare or-

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Some state laws designate how long health re- ganization providing care exclusively to children
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cords must be retained in their original form and may have different retention policies than a home
specify whether they can be stored on media oth- health agency. Healthcare organizations with sig-
er than that on which they were initially created. nificant educational and research activities may
Additionally, state and local laws that require in- need to retain health records for longer periods
formation to be maintained for reporting to public than other healthcare organizations because ex-
authorities (for example, vital statistics and public isting health records can be useful for these pur-
health data) must be adhered to. poses. For example, information may be extracted
The health record must be available as evidence from health records for research studies.
in legal actions, as governed by statutes and regu- Governing boards and medical staffs of every
lations. Health records should be retained for at healthcare organization must analyze their medical
least the period specified by the state’s statute of and administrative needs to ensure health records
limitations, which is the period of time in which are available for peer review, quality assessment,
AB103118_Ch08.indd 237 2/11/2020 1:16:11 PM

and other activities. These needs must be consid- be used for each medium on which health
ered in conjunction with legal and accreditation information is housed (AHIMA 2013).
requirements. In many instances, healthcare orga-
Table 8.4 shows AHIMA’s retention recommen-
nizations retain health records longer than the law
dations for various types of health information.
requires to accommodate research or other needs
of the healthcare organization.
Destruction
Not all information must, or should, be retained
AHIMA Retention Recommendations forever. Whereas space has historically been a
AHIMA routinely publishes recommendations challenge with paper health records, it is easy to
for the retention of health records (AHIMA 2013). presume indefinite or permanent retention of elec-
HIM professionals should use these to determine tronic health records because they require little
how their healthcare organizations compare with space. However, space can become an issue for
n.
industry-wide best practices. AHIMA recom-
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electronic health records. Further, from a legal per-
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mends, at a minimum, that health record retention spective, because a health record can be retained
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schedules do the following: permanently does not mean it should be if it no
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longer serves a purpose but occupies space.
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Be designed to meet a healthcare
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●●
Just as the HIM professional must consider mul-
organization’s needs so that health
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tiple factors when determining retention, many
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information is available not only for patient
factors must also be taken into consideration re-
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care, but also for research, education, and to
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garding health record destruction. Destruction
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meet the legal requirements that apply to the
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of records is the act of breaking down the com-
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healthcare organization
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ponents of a health record into pieces that can no

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●● Be specific about the retention of longer be recognized as parts of the original health
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information, including a description of what record. The factors to be considered include appli-
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information is to be kept, how long it is to

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cable federal and state statutes and regulations,

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be kept, and the medium on which it will accreditation standards, pending or ongoing liti-
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stored (for example, electronic or imaged, gation, storage capabilities, and cost.
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paper, or hybrid) Any health record involved in investigations,

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●● Clearly specify in the policies and audits, or litigation should not be destroyed, even
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procedures the destruction method that is to if the record retention schedule would provide
20
20
Table 8.4 AHIMA retention standards

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Health information Recommended retention period

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Diagnostic images (such as x-ray film) (adults) 5 years

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Diagnostic images (such as x-ray film) (minors) 5 years after the age of majority
Disease index 10 years
Fetal heart monitor records 10 years after the age of majority
Master patient/person index Permanently
Operative index 10 years
Patient health records (adults) 10 years after the most recent encounter
Patient health records (minors) Age of majority plus statute of limitations
Physician index 10 years
Register of births Permanently
Register of deaths Permanently
Register of surgical procedures Permanently
Source: AHIMA 2011b.
AB103118_Ch08.indd 238 2/11/2020 1:16:11 PM

for destruction otherwise. This is because health physical destruction of the medium on which the
records contain valuable evidence and, further, health record resides, including pulverizing (laser
destruction of this important evidence may be in- discs) and shredding or cutting (DVDs) (AHIMA
dicative of the provider’s bad faith. When health 2013). With electronic health records, there is the
records are slated for destruction, procedures must risk of duplicate records remaining in circulation
ensure the information is not inappropriately (Rinehart-Thompson 2017d).
disclosed in the process. For paper health records, Health record destruction may be accomplished
common destruction methods include shred- by the healthcare organization that owns the re-
ding, burning, pulping, or pulverizing (Rinehart- cords, or the process may be outsourced. In either
Thompson 2017d). Care should be taken to actually case, a list of all destroyed health records and the
destroy electronic health records rather than merely manner of destruction must be documented. A cer-
deleting the pathway to access them. Destruction tificate of destruction and an agreement that en-
n.
methods for electronic health records include over- sures the protection of the information should both
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writing; magnetic degaussing or demagnetizing be obtained (AHIMA 2013; Rinehart-Thompson
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(neutralizing the magnetic field to erase data); and 2017d).
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Medical Staff Credentialing
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Another area with significant legal im- Credentialing includes both the initial appoint-
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plications that the HIM professional may become
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ment and reappointment of individuals to the
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involved in is medical staff appointments, also re- medical staff and determination of the extent of
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ferred to as credentialing. A basic understanding their privileges. The customary process by which
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of the legal issues and some of the functions in the an application for medical staff appointment and
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credentialing process are important because the privileges involves review at several levels. These
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health information professional may be involved

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include the appropriate clinical departments, cre-

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in this activity. dentials committee, medical staff executive com-

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The healthcare organization is ultimately re- mittee, and board of directors. Although the board
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sponsible for the quality of care it provides. This of directors relies on the advice and recommenda-
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includes the quality of the medical staff, which tions of the medical staff, ultimate responsibility
by
20
consists primarily of the physicians who have for making appointments and reappointments
20
been given permission to provide the healthcare and for ensuring the medical staff members are
©
organization’s clinical services. Depending on the qualified to perform the functions for which they
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healthcare organization, other providers such as have been granted privileges rests with the board
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dentists, podiatrists, advance practice nurses, and (Pozgar 2016).

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physician assistants may also serve on a healthcare An important part of the credentialing process
organization’s medical staff. is querying the National Practitioner Data Bank
A healthcare organization’s governing board (NPDB), which was established by the federal
(board of directors) is accountable to establish pol- Health Care Quality Improvement Act of 1986.
icies and procedures that ensure reasonable care One goal of the NPDB is to limit the movement of
in the appointment of medical practitioners to the physicians throughout the US where their negative
healthcare organization’s medical staff and the histories such as medical malpractice liability and
granting of clinical privileges. Clinical privileges loss of privileges at other healthcare organizations
are the defined set of services a qualified physi- may go undetected. NPDB regulations include re-
cian is permitted to perform in that organization quirements for reporting information to the NPDB
such as admitting patients, performing surgeries, and querying information from the NPDB prior
elivering infants.
or d to granting medical staff privileges (Pozgar 2016).
AB103118_Ch08.indd 239 2/11/2020 1:16:11 PM

Penalties and liability can result from failure to use professional background, credentials, previous
the NPDB. professional experience, and quality profiles. All
The HIM professional may serve as the medical this information, including that obtained from
staff coordinator, involving the collection, organ- the NPDB, is confidential. Therefore, policies and
ization, verification, and storage of all informa- procedures must be in place to specify who may
tion associated with credentialing. This includes have access to what information and under what
information about the individual staff member’s circumstances.
Licensure
Licensure is a designation given to an may include required continuing education. The
n.
individual or an organization by a governmental legal significance of licensure in healthcare is that
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agency or board that gives the individual permis- a government entity has deemed the individual or
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sion to practice, or the healthcare organization healthcare organization qualified to provide com-
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to operate, within a certain field of practice. For petent and safe patient care. HIM professionals are
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example, physicians, nurses, and physical thera- not licensed, but can be certified, meaning they are
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pists must be licensed to practice. In many states, officially recognized by a private entity as meeting
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hospitals must be licensed in order to treat pa- certain qualifications in the field. However, they
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tients. Where licensure exists for a practice area, may take part in or coordinate licensure mainte-
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it is mandatory. Once an individual or healthcare io
nance for their healthcare organization. They may
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organization becomes licensed, it is subject to fur- also assume the role of ensuring that licensure
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ther regulation by the relevant governmental body records of individual practitioners are updated
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to ensure it is maintaining at least a minimal level and maintained by the healthcare organization in
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of competence. For individuals, further regulation which they work.

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Certification
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Certification of individuals is a designa- such as the CHPS (Certified in Healthcare Privacy

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tion given by a private organization to acknowledge and Security), CCS (Certified Coding Specialist),
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a requisite level of knowledge, competencies, and and CHDA (Certified Health Data Analyst). For in-
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skills. Whether or not certification is required for an formation on these credentials, see chapter 1, Health
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individual to practice (as is licensure) is an employer Information Management Profession. In healthcare

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decision. Certification may either be entry level or organizations, certification is a designation by HHS
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mastery level. In the HIM profession, RHIA (Regis- that its Conditions of Participation have been met.
tered Health Information Administrator) and RHIT Although certification is not required for a health-
(Registered Health Information Technician) creden- care organization to operate, it is required for the or-
tials signify entry-level generalist competency. AHIMA ganization to participate in (and thus be reimbursed
also offers mastery-level specialty certifications by) the Medicare and Medicaid programs.
Accreditation
The HIM professional will likely find involve compliance with standards relating to
herself or himself in a role that involves compli- health information or coordinating a healthcare or-
ance with accreditation standards. This role may ganization’s overall compliance with the standards
AB103118_Ch08.indd 240 2/11/2020 1:16:12 PM

of the body by which it is accredited. Accredita- care settings as well, such as the Accreditation As-
tion is a designation given to a healthcare organi- sociation for Ambulatory Health Care (AAAHC)
zation by an accrediting body, demonstrating that and the Commission on Accreditation of Rehabil-
the healthcare organization has met the accrediting itation Facilities (CARF), a prevalent accreditor in
body’s requirements for excellence. Accreditation rehabilitation. By successfully completing an acute
is generally viewed as the highest level of compe- care–deemed status survey by The Joint Com-
tence or validation that a healthcare organization mission, HFAP, DNV GL Healthcare, or CIHQ, a
can demonstrate. In acute care, Joint Commission healthcare organization that is accredited by one
is the most prevalent accrediting body. Other ac- of these healthcare organizations is also deemed
creditors include the HFAP, DNV GL Healthcare, to have met Medicare and Medicaid requirements
and Center for Improvement in Healthcare Qual- and thus holds concurrent accreditation and Med-
ity (CIHQ). There are accrediting bodies in other icare and Medicaid certification.
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HIM Roles
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With familiarity in health law and a may be an ideal role for HIM professionals due
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deep knowledge of the health record, HIM profes- to their familiarity with and understanding of
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sionals can fill nontraditional roles. Many of these the health record, incident reporting, and the
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positions require advanced training to have the io analysis and monitoring of trends.
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skill set needed to apply for and be accepted into Credentialing. A long-standing position
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the following dynamic positions: for HIM professionals in some healthcare

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Medical malpractice health record analyst. This organizations, credentialing and

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re-credentialing medical staff members
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position is dedicated to facilitating health

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record review for either plaintiff or defense requires organizational and investigative
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skills. Familiarity with medical staff

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attorneys in the medical malpractice

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claims and litigation management process. requirements also makes the HIM
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professional a qualified person for this role.

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HIM professionals can assist parties and

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their legal counsel by developing case ●● Accreditation. Because of the complexity

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summaries and preparing chronologies associated with preparation for and

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of medical events that are pertinent to a compliance with accrediting body standards,
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legal case. healthcare organizations both large and

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Patient advocate. HIM professionals can small have positions for individuals who
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●●
are responsible to manage the accreditation
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serve as patient advocates in many roles,

including assistance with health literacy and process. Because of their organizational
medical bill interpretation. Included in this skills and the relationship between health
role is assisting patients toward a greater information and many accreditation standards,
understanding about healthcare decision- HIM professionals are suited to fill these roles.
making, including consents and advance ●● Medical Scribe. Some HIM professionals work
directive options. with physicians as a medical scribe. The
●● Risk Management. Identifying, monitoring, medical scribe takes on some of the clerical
and preventing risks are key initiatives in any responsibilities of retrieving test results,
healthcare organization. Although the risk navigating the EHR, and documenting in the
management function is often reserved for health record as instructed by the physician
attorneys, in smaller healthcare organizations it (Gooch 2016).
AB103118_Ch08.indd 241 2/11/2020 1:16:12 PM


1. A health record is owned by the:
a. Patient who is the subject of the record
b. Healthcare organization that created and maintains it
c. Staff members who document in it
d. Insurance company that pays for the patient’s care
2. A court’s legal authority to make decisions is called:
a. Joinder
b. Judicial law
c. Jurisdiction
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d. Litigation
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3. Identify the action of a health records custodian to affirm the legitimacy of a health record.
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a. Testimony
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d. Certification
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4. Identify a characteristic of the legal health record.
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a. It must be electronic
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b. It includes the designated record set
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c. It is the record disclosed upon request

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d. It includes a patient’s personal health record

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5. The health record content is defined by a number of standards including:

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a. Constitutional amendments
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b. Nursing licensure laws

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c. Accrediting body standards

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d. Record retention policies

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6. The principal purpose of the health record is to:

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a. Serve as evidence in litigation

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b. Support statistical analysis and research

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c. Document patient treatment and allow providers to communicate

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d. Provide a record for reimbursement purposes

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7. The National Practitioner Data Bank:

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a. Allows a healthcare organization to be reimbursed by Medicare and Medicaid

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b. Is a type of certification for healthcare providers

c. Limits movement of physicians with negative histories
d. Was repealed by Congress
8. AHIMA recommends that the operative index be retained for:
a. 5 years
b. 7 years
c. 10 years
d. Permanently
9. Identify the true statement regarding health information retention.
a. Retention depends only on accreditation requirements.
b. Retention periods differ among healthcare organizations.
AB103118_Ch08.indd 242 2/11/2020 1:16:12 PM

c. The operational needs of a healthcare organization cannot be considered.
d. Retention periods are frequently shorter for health information about minors.
10. Identify the true statement regarding the development of health record destruction policies.
a. All applicable laws must be considered.
b. The healthcare organization must find a way not to destroy any health records.
c. Health records involved in pending or ongoing litigation may be destroyed.
d. Only state laws must be considered.
11. Identify a characteristic of credentialing.
a. It is ultimately the responsibility of the medical staff.
b. It is the hiring of qualified nurses in a hospital.
c. It applies to the granting of specific clinical privileges to medical staff members.
d. It grants one level of privileges to all medical staff members.
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12. Medical staff credentialing refers to:
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a. Rewarding physicians who have treated the most patients
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b. Appointing and granting clinical privileges to physicians
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c. Renewing physicians’ medical licenses
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d. Establishing physicians’ medical malpractice premiums
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13. Defining what a physician can do is known as:
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a. Accreditation
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b. Licensure
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c. Credentialing
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d. Clinical privileges
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14. ____ gives an individual permission to practice or a healthcare organization permission to operate within a certain
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field of practice.
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a. Licensure
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b. Certification
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c. Accreditation
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d. Medicare Conditions of Participation

15. Electronic health data should be destroyed by:
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a. Pulverizing
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b. Degaussing
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c. Shredding
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d. Burning
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Real-World Case 8.1

In October 2018, Cook County (Illinois) cardiac catheterization lab. Despite the large set-
commissioners voted to approve a nearly $4 mil- tlement, CCHHS CEO noted that the settlement
lion settlement of a medical malpractice lawsuit was n either an admission of malpractice or of
at Stroger Hospital, a healthcare organization that wrongdoing by the providers or the health system.
is part of the Cook County Health and Hospital Although it is not known how much a jury would
Systems (CCHHS). The lawsuit stemmed from a have awarded the plaintiff, a jury verdict would
2013 bedside pericardiocentesis that, plaintiff’s at- have been a declaration of malpractice, which was
torneys argued, should have been performed in a avoided through the settlement (Pratt 2018).
AB103118_Ch08.indd 243 2/11/2020 1:16:12 PM

Real-World Case 8.2

Healthcare organizations develop rec- case in California, which has had a notification re-
ord retention guidelines in accordance with ap- quirement in place for several years. Additionally,
plicable laws (for example, a state’s statute of Senate Bill 1238 was presented in the California
limitations for medical malpractice and Medicare Senate in 2018 to amend Section 123106(e) and
Conditions of Participation retention requirements) 123107 of the California Health and Safety Code,
and operation needs (for example, research, ed- to require healthcare providers, by the date that
ucation, and strategic planning). If a healthcare service is first delivered or as soon possible after
organization follows its guidelines, and those emergency care, to inform the patient or patient’s
guidelines conform to applicable laws, the health- representative of the intended retention period
care organization is legally compliant. There is for the patient’s health records (California Senate
n.
generally not a requirement that patients be noti- Bill 1238 2018). Providers are also required to no-
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fied of a healthcare organization’s health record tify the patient at least 60 days before the record is
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retention periods. This, however, has not been the to be destroyed.
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References
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an
M
American Health Information Management legislature.ca.gov/faces/billTextClient.xhtml?bill_
n
io
Association. 2017. Pocket Glossary of Health Information id=201720180SB1238.
at
m
Management and Technology, 5th ed. Chicago: AHIMA. Fahrenholz, C.G. 2017. Clinical Documentation and
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fo
American Health Information Management the Health Record. Chapter 2 in Documentation for
In
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Association. 2013. Retention and Destruction of Health Medical Records. Edited by C.G. Fahrenholz. Chicago:
ea
Information (updated October 2013). http://library. AHIMA.

H
ahima.org/doc?oid=300217#.XBm0c_ZFw2w. Gooch, K. 2016. 17 Things to Know About Medical

an
ic
American Health Information Management Scribes. https://www.beckershospitalreview.com

er
/hospital-physician-relationships/17-things-to-know-
Am
Association. 2011a. Fundamentals of the legal health

record and designated record set. Journal of AHIMA about-medical-scribes.html.
e
th
82(2): expanded online version. http://library.ahima. Klaver, J.C. 2017a. Evidence. Chapter 5 in Fundamentals
by
org/doc?oid=104008#.Vw_Ty_krLDc. of Law for Health Informatics and Information

20
Management. Edited by M.S. Brodnik, L.A. Rinehart-

20

Thompson, and R.B. Reynolds. Chicago: AHIMA.
©
Association. 2011b. Retention and Destruction

ht
of Health Information. Appendix D: AHIMA’s Klaver, J.C. 2017b. Consent to Treatment. Chapter
ig
Recommended Retention Standards (2011 update). 8 in Fundamentals of Law for Health Informatics and
yr
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http://bok.ahima.org/Doc/2/0/C/105018#. Information Management. Edited by M.S. Brodnik, L.A.

C
XBqf0WhKh9M. Rinehart-Thompson, and R.B. Reynolds. Chicago:

AHIMA.
Brodnik, M.S. 2017. Access, Use, and Disclosure
and Release of Health Information. Chapter 15 in Pozgar, G.D. 2016. Legal Aspects of Health Care
Fundamentals of Law for Health Informatics and Information Administration. Burlington, MA: Jones & Bartlett
Management. Edited by M.S. Brodnik, L.A. Rinehart- Learning.
Thompson, and R.B. Reynolds. Chicago: AHIMA. Pratt, G. 2018 (October 17). Cook County Board
Brodnik, M.S. 2017. Glossary in Fundamentals of Law for votes in favor of $4 million settlement in Stroger
Health Informatics and Information Management. Edited medical malpractice case. Chicago Tribune. https://
by M.S. Brodnik, L.A. Rinehart-Thompson, and R.B. chicagotribune.com/news/local/politics/ct-met-cook-
Reynolds. Chicago: AHIMA. county-lawsuit-settlement-20181017-story.html.
Rinehart-Thompson, L.A. 2018. Introduction to Health
California Senate Bill 1238. 2018. Patient Records:
Information Privacy and Security. Chicago: AHIMA.
Maintenance and Storage. http://leginfo.
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Rinehart-Thompson, L.A. 2017a. The Legal System in L.A. Rinehart-Thompson, and R.B. Reynolds. Chicago:
the United States. Chapter 3 in Fundamentals of Law for AHIMA.
Health Informatics and Information Management. Edited Rinehart-Thompson, L.A. 2017d. The Legal Health
by M.S. Brodnik, L.A. Rinehart-Thompson, and Record: Maintenance, Content, Documentation, and
R.B. Reynolds. Chicago: AHIMA. Disposition. Chapter 9 in Fundamentals of Law for
Rinehart-Thompson, L.A. 2017b. Legal Proceedings. Health Informatics and Information Management. Edited
Chapter 4 in Fundamentals of Law for Health Informatics by M.S. Brodnik, L.A. Rinehart-Thompson, and
and Information Management. Edited by M.S. Brodnik, R.B. Reynolds. Chicago: AHIMA.
L.A. Rinehart-Thompson, and R.B. Reynolds. Chicago: Showalter, J.S. 2017. The Law of Healthcare
AHIMA. Administration. Chicago: Health Administration
Rinehart-Thompson, L.A. 2017c. Tort Law. Chapter Press.
6 in Fundamentals of Law for Health Informatics and 31 USC 3729: False Claims Act. 1986.
Information Management. Edited by M.S. Brodnik,
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AB103118_Ch08.indd 245 2/11/2020 1:16:12 PM

AB103118_Ch08.indd 246
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2/11/2020 1:16:12 PM
Chapter
9
Data Privacy and
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Confidentiality
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•• Differentiate between disclosure and use (PHI): marketing; sale of information; and
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•• Apply the HIPAA Privacy Rule, including fundraising

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American Recovery and Reinvestment Act (ARRA) •• Recommend appropriate enforcement actions due
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requirements such as breach notification, with to HIPAA Privacy Rule violations

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regard to health information use and disclosure •• Protect health information through use of disclosure
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•• Educate individuals regarding to whom and to policies and procedures that apply to both state law
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what the HIPAA Privacy Rule applies and HIPAA regulations

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•• Analyze the respective requirements of the individual •• Apply authorization requirements to the valid
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rights provided by the HIPAA Privacy Rule disclosure of health information

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•• Distinguish the key HIPAA Privacy Rule •• Identify types of medical identity theft as well as
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documents: Notice of Privacy Practices, HIPAA fraud detection activities required by the Red Flags
20
consent, and authorization Rule

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•• Differentiate authorization and right of access •• Explain role of patient advocate

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•• Assess the requirements associated with each type

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of commercial use of Protected health information

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Key Terms
Administrative simplification Complaint Fair and Accurate Credit
American Recovery and Confidentiality Transactions Act (FACTA)
Reinvestment Act (ARRA) Covered entity (CE) Federal Trade Commission (FTC)
Authorization Deidentified information Fundraising
Breach Department of Health and Human Health Information Technology for
Breach notification Services (HHS) Economic and Clinical Health
Business associate (BA) Designated record set (DRS) Act (HITECH)
Business associate agreement (BAA) Disclosure Health Insurance Portability and
Clinical Laboratory Improvement Disclosure of health information Accountability Act (HIPAA)
Amendments (CLIA) of 1988 Facility directory Health plans
247
247
AB103118_Ch09.indd 247 2/6/2020 4:46:05 PM

Healthcare clearinghouses Office of the National Coordinator Right to request accounting of

Healthcare providers for Health Information disclosures
HIPAA consent Technology (ONC) Right to request amendment
Individual Personal representative Right to request confidential
Individually identifiable health Preemption communications
information Privacy Right to request restrictions of PHI
Marketing Privacy officer Sale of information
Medical identity theft Privacy Rule Treatment, payment, and
Minimum necessary standard Protected health information (PHI) operations (TPO)
Notice of privacy practices Psychotherapy notes Unsecured PHI
Office for Civil Rights Red Flags Rule Use
(OCR) Right of access Workforce
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Privacy is a social value and is the right “to be let the Health Insurance Portability and Account-
ia
alone” (Rinehart-Thompson and Harman 2017). ability Act (HIPAA), discussed in great detail in
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The US Constitution does not grant a right of pri- this chapter.
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vacy, but courts have interpreted it to give privacy Confidentiality is similar to privacy, but it
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rights in certain areas such as religion and child- stems from the sharing of private thoughts in
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rearing. Patients have a right to their privacy. confidence with someone else. Legally, such
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Although there is no constitutional right of pri- sharing is protected when the communication is
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vacy to one’s health information, the health record between parties such as physician and patient, at-
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is not a public document and – further – privacy torney and client, or clergy and parishioner. Laws
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protections to health information have been estab- define those communications that are protected
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lished through court cases as well as laws such as (Brodnik 2017a).

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Use and Disclosure

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Use is how a healthcare organization is also able to control the use and disclosure of its
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avails itself of health information internally, such contents. Compliance with all applicable privacy
by
as a nurse reviewing a patient’s health record. Dis- and confidentiality laws and standards is impor-
20
closure is how health information is disseminated tant to avoid inappropriate use and disclosure of
20
outside a healthcare organization. An example of health information. Disclosure becomes very im-
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disclosure is providing patient information to an portant when a healthcare organization is involved

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insurance company. Use and disclosure are usu- in litigation and health information becomes key
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ally associated with the concepts of ownership evidence necessary for fact-finding during the dis-
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and control of the health record because the organ- covery process and at trial, as described in chapter
ization that owns and controls the health record 8, Health Law.
State Laws—Privacy
Laws protecting the privacy of health in- abide by the state law. State laws supersede HIPAA if
formation vary significantly from state to state. Some the state law is stricter. This is the concept of preemp-
states have laws that are very specific while others tion, which is discussed later in this chapter.
are general or even absent. Every person or organ- In addition to state laws that protect health in-
ization that is subject to HIPAA (federal law) must formation privacy, all states have laws that require
AB103118_Ch09.indd 248 2/6/2020 4:46:05 PM

the disclosure of health information, even without and other communicable diseases, have been in-
patient authorization. These include the reporting jured by knives or firearms, or have wounds that
of vital statistics (births and deaths) and other pub- suggest some type of violent criminal activity. The
lic health, safety, or welfare situations. For example, treatment of suspected victims of child abuse or
healthcare providers may be required to provide neglect also must be reported. These purposes are
information to the appropriate state agency about permitted by HIPAA and described later in the
patients who suffer from sexually transmitted chapter.
HIPAA Privacy Rule and ARRA

The HIPAA Privacy Rule is one of the highly sensitive health records such as mental
n.
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key federal regulations that governs the protec- health and HIV/AIDS, but many states had no
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tion of protected health information (PHI). This statutes or regulations to protect health informa-
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chapter provides an overview of HIPAA legislation generally. If health information was wrong-
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tion (namely, the Privacy Rule) and the accompa- fully disclosed, individuals had to resort to lawsuits,
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nying American Recovery and Reinvestment Act often alleging negligence. With the Privacy Rule,
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(ARRA) of 2009. protection was achieved uniformly across all
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the states through a consistent set of standards
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HIPAA and ARRA Overview
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affecting providers, healthcare clearinghouses,
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As shown in figure 9.1, HIPAA contains five titles. and health plans.
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The legal doctrine of preemption means that

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Title II is the most relevant title to the health in-

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formation management (HIM) professional. It federal law (for example, the HIPAA Privacy Rule)
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may supersede state law. However, the HIPAA

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contains provisions relating to the prevention of

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healthcare fraud and abuse and medical liability Privacy Rule is only a federal floor, or minimum,
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of privacy requirements so it does not preempt or

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(medical malpractice) reform, as well as adminis-

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supersede stricter state statutes (or other federal

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trative simplification. The HIPAA Privacy Rule re-

sides in the administrative simplification provision statutes). Stricter means that a state or federal stat-
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of Title II along with the HIPAA security standards, ute provides an individual with greater privacy
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national provider identifiers, and transaction and protections or gives individuals greater rights
20
with respect to their PHI. If a question arises, it is

20
code set standardization requirements. Admin-

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istrative simplification is HIPAA’s attempt to important to consult with legal counsel to deter-
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mine whether federal or state law prevails.

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streamline and standardize the healthcare indus-

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The American Recovery and Reinvestment Act

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try’s non-uniform business practices, such as bill-

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ing, to include the electronic transmission of data. (ARRA) provided significant funding for health
Before HIPAA was enacted, no federal statutes information technology and other economic stim-
or regulations generally protected the confidenti- ulus funding, and it also made important changes
ality of health information. Specific laws applied to the HIPAA Privacy and Security Rules. These
only in particular circumstances, such as to provid- changes are located in the Health Information
ers of Medicare services or to those receiving fed- Technology for Economic and Clinical Health
eral funds to provide substance abuse treatment. Act (HITECH), which is a part of ARRA.
Patient privacy protection laws governing ac-
cess, use, and disclosure had largely resided with Office of the National Coordinator for
the individual states. They varied considerably, Health Information Technology (ONC)
creating a patchwork of laws across the United The Office of the National Coordinator for
States. Many states had passed laws to protect Health Information Technology (ONC) was
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Figure 9.1 HIPAA structure
Transactions
Title I: Insurance
Portability
Identifiers
HIPPA
Title II: Administrative Simplification
Public Law 104–191
Title III: Medical Savings and Security

Tax Deduction
Title IV: Group Health

Plan Provisions
Privacy
n.
Title V: Revenue Offset
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Provisions
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Enforcement
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Source: Walsh 2016. Reprinted with permission.
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first established by presidential executive order. 1. Healthcare providers, but only those that
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It is now recognized by statute as an entity within conduct certain transactions (financial or
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the Department of Health and Human Services administrative) electronically. Healthcare
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(HHS). It has been the primary federal entity re- providers include hospitals, long-term care
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sponsible for coordinating national efforts to im- facilities, physicians, and pharmacies.
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plement and use health information technology, 2. Health plans, which pay for the cost of
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and to promote the exchange of electronic health medical care (for example, a health insurance
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information. HHS currently includes a number company).

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of offices and agencies including the Office of 3. Healthcare clearinghouses, which process
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Policy, Office of Standards and Technology, and claims between a healthcare provider and
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Office of the Chief Privacy Officer, which plays payer (for example, an intermediary that
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an important role in promoting electronic health processes a hospital’s claim to Medicare to

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information privacy and security (ONC 2018). facilitate payment).

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Electronic transactions specified in the act in-

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Applicability of the Privacy Rule

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clude but are not limited to health claims and en-

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The Privacy Rule does not apply to every person counter information, health plan enrollment and
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or every organization. It also does not apply to all disenrollment, healthcare payment and remittance
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types of information. This section identifies, first, advice, health plan premium payments, referral
to whom the Privacy Rule applies: persons or or- certification, and coordination of benefits.
ganizations identified as covered entities, busi-
ness associates, and workforce. This section also
Business Associates
discusses what the Privacy Rule protects: protected
health information (PHI). The Privacy Rule also applies to entities that are
business associates of HIPAA-covered entities.
A business associate (BA) is a person or organi-
Covered Entities zation other than a member of a CE’s workforce
A covered entity (CE) is a person or organization that performs functions or activities on behalf of
that must comply with the HIPAA Privacy Rule. or for a CE that involves the use or disclosure of
The three types of covered entities are the following: PHI. Common BAs include consultants, billing
AB103118_Ch09.indd 250 2/6/2020 4:46:06 PM

companies, transcription companies, accounting Figure 9.2 Components of a business associate

firms, and law firms. ARRA also included in the agreement
BA definition patient safety organizations (PSOs),
which utilize information to improve the safety • Parties to the BAA (CE and BA; BA and subcontractor of BA)
• Purpose of the BAA (compliance with HIPAA and ARRA)
and quality of patient care; health information or- • Definitions (breach; electronic PHI; individual; PHI; law;
ganizations (HIOs); e-prescribing gateways and Secretary of HHS; security incident)
persons who facilitate data transmissions; as well • Obligations and activities of the BA
as personal health record (PHR) vendors who, by • Permitted uses and disclosures by BA (or subcontractor)
• Obligations of the CE
contract, enable CEs to offer PHRs to their patients • Term and termination
as part of the CE electronic health record (EHR) • Indemnity for both parties
(HHS 2010, 40872). • Limitation of liability
• Miscellaneous
A BA’s subcontractors are also BAs if they re-
• Signatures, titles, contact information
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quire access to an individual’s PHI, regardless of
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whether an agreement has actually been signed
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Source: ©AHIMA 2016.
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(HHS 2010, 40873). BAs and their subcontractors
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must comply with certain HIPAA provisions and employees of outsourced vendors who routinely
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are subject to the same civil and criminal penal- work on-site in the CE’s facility.
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ties that CEs face for violating the law. In addition To illustrate this, examine the following sce-
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to the Privacy Rule, BAs and their subcontractors nario. Tidy Team, a company that contracts with
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must also comply with the HIPAA security provi- Mercy Hospital to provide janitorial services, em-
sion, which is covered in more detail in chapter 10, n
io
ploys Ted as a custodial worker. Ted has been as-
at
Data Security. signed to Mercy Hospital. As part of his duties, he
m r
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The Privacy Rule does not allow CEs to disclose routinely cleans the floors and empties the trash in
In
PHI to BAs unless the two enter into a written con- the HIM department. What is Tidy Team’s relation-
lth
ea
tract, or business associate agreement (BAA), that ship with Mercy Hospital? What is Ted’s relationship
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meets HIPAA and ARRA requirements. However, with Mercy Hospital? Does a BA relationship ex-
an
ic
if a person or organization meets the definition of ist here?

er
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a BA, they are a BA by law (even if the required In this example, the hospital contracted Tidy
agreement has not been signed) and are subject to Team to clean, not to use or disclose individually
e
th
penalties if they violate HIPAA. The BA may use identifiable health information. The fact that Ted is
by
or disclose PHI once it agrees to the CE’s require- in close proximity to such information on a regu-
20
20
ments to protect the information’s security and lar basis does not make him (or Tidy Team) a BA.
©
confidentiality. The CEs must respond to BA non- Because he routinely works in Mercy Hospital’s
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compliance, and ARRA requires BAs to respond to HIM department, however, he should be treated
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CE noncompliance. The BA does this by corrective as a workforce member and trained as such.
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action or by severing the relationship with the CE.

The BAAs must be HIPAA- and ARRA-compliant. Protected Health Information
There are components that an agreement between The Privacy Rule safeguards protected health
a CE and BA should contain. These are outlined in information (PHI). The PHI either identifies an
figure 9.2. individual or provides a reasonable basis to be-
lieve the person could be identified from the in-
Workforce Members formation given. PHI can be in any form including
Both CEs and BAs (including their subcontrac- electronic, paper, and oral. Determining whether
tors) are responsible under the Privacy Rule for information is PHI or not requires meeting all

their workforce members. A workforce consists parts of a three-part test. First, the information
not only of employees, but also volunteers, stu- must be held or transmitted by a CE or a BA in
dent interns, trainees, board of directors, and even any of the forms listed previously. Second, it must
AB103118_Ch09.indd 251 2/6/2020 4:46:06 PM

be individually identifiable health information. Rule requires the CE to do one of the following to
To be individually identifiable, the information ensure deidentification:
must either identify the person or provide a rea-
●● The CE can strip certain elements to
sonable basis to believe the person could be iden-
ensure the patient’s information is truly
tified from the information. Third, it must relate
deidentified. These elements are listed in
to a person’s past, present, or future physical or
figure 9.3 (Rinehart-Thompson 2018)
mental health condition, the provision of health-
care, or payment for the provision of healthcare. ●● The CE can have an expert apply generally
The PHI of deceased persons loses PHI status and accepted statistical and scientific principles
is no longer protected by HIPAA after the individ- and methods to minimize the risk that the
ual has been deceased more than 50 years. information might be used to identify an
individual (Rinehart-Thompson 2018)
Deidentified Information
n.
Figure 9.4 identifies methods of deidentifica-
tio
Deidentified information does not identify an
ia
tion that can be used to remove the data elements
oc
individual because personal characteristics have found in figure 9.3.
ss
been stripped from it in such a way that it can-
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Other Basic Concepts
en
not be later constituted or combined to reidentify
em
an individual. Not all patient information is PHI. In addition to understanding to whom the Privacy
ag
Deidentified information is not protected by the Rule applies and what it protects, it is important
an
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HIPAA Privacy Rule. Deidentified information is to understand other basic HIPAA concepts, which
commonly used in research. n
are discussed in the sections that follow.
io
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Information technology is powerful in assist-
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Individual
fo
ing with the collection and analysis of data, so

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it is possible to identify individuals by combin- The Privacy Rule defines an individual as the per-
lth
ea
ing specific data. Therefore, the HIPAA Privacy son who is the subject of the PHI (45 CFR 160.103).
H
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er
Figure 9.3 Data elements to be removed for deidentification of information

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Eighteen identifiers must be removed for deidentification. They pertain to the individual, relatives, employers, and household members:
th
by
• Names • Health plan beneficiary numbers

20
• Geographic subdivisions smaller than a state, • Account numbers

20
including street addresses, city, county, precinct, and zip • Certificate and license numbers
©
code if the geographic unit contains fewer than 20,000 peo-

ht
ple; the initial three digits of the zip code must be changed • Vehicle identifiers and serial numbers, including license
ig
plate numbers
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to 000 or zip codes with the same three initial digits may be
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combined to form a unit of more than 20,000 people • Device identifiers and serial numbers
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• All elements of dates, except the year, directly related to • Web universal resource locators (URLs)
an individual including birth, admission, discharge, and • Internet protocol (IP) address numbers
death dates; in addition, all ages over 89 and all elements
• Biometric identifiers, including fingerprints and voiceprints
of dates (including the year) that would identify such age
cannot be used, however individuals over 89 can be • Full-face photographic images and any comparable images
aggregated into a single category of 90 and over • Any other unique identifying number, characteristic,
• Telephone numbers or code except for permissible reidentification to match
information back to the person (code must not be derived
• Fax numbers
from or related to information about the individual, cannot
• E-mail addresses be translated to her or her identity, may not be used for
• Social Security numbers any other purpose, and may not disclose the reidentification
• Health record numbers mechanism)
Source: 45 CFR 164.514(b)(2)(i).
AB103118_Ch09.indd 252 2/6/2020 4:46:07 PM

Figure 9.4 HIPAA Privacy Rule De-Identification To ensure compliance with the minimum nec-
Methods essary standard, policies and procedures should
identify those persons or classes of persons who
HIPPA Privacy Rule work for the CE and who need to access PHI to
De-identification Methods
perform their duties. They should further identify
what PHI is needed to perform their jobs. For ex-
ample, employees working in the housekeeping
Expert
Safe Harbor department would not have the same level of ac-
Detemination
§ 164.514(b)(1)
§ 164.514(b)(2) cess to PHI as a nurse working in critical care.
ARRA has specified that, without final clari-
fication of minimum necessary, CEs are to use the
Apply statistical or Removal of 18 types of
scientific principles identifiers
limited data set (PHI with certain specified direct
n.
identifiers removed) for using or disclosing only
tio
minimum necessary information, while reverting
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No actual knowledge
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Very small risk that
residual information can back to the amount needed to accomplish the intended
ss
anticipated recipient
identify individual purpose definition when the limited data set def-
tA
could identify individual
en
inition is inadequate (AHIMA 2009). For exam-
em
Source: HHS 2015. ple, decision-making is specific to the CE, which
ag
must determine what PHI is reasonably needed
an
Personal Representative
M
to accomplish that particular purpose, given the
n
A personal representative is a person who has io
nature of its business (HHS 2006; reviewed 2013).
at
legal authority to act on another’s behalf. Per the
m r
Privacy Rule, a personal representative must be

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Treatment, Payment, and Operations

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treated the same as an individual regarding use

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and disclosure of the individual’s PHI. Treatment, payment, and operations (TPO) is
ea
an important concept because the Privacy Rule

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provides a number of exceptions for PHI that is

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Designated Record Set

being used or disclosed for TPO purposes. Treat-
er
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A designated record set (DRS) includes the health ment means providing, coordinating, or managing
records, billing records, and various claims records
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healthcare or healthcare-related services by one or

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that are used to make decisions about an individ-

by
more healthcare providers. For example, treatment

ual (45 CFR 164.501). HIPAA provisions apply to
20
includes caring for patients admitted to the hos-

20
the DRS. The DRS is broader than the legal health pital or coming for an appointment with a physi-
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record, which was discussed in chapter 8, Health cian. Treatment also includes healthcare provider
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Law, because it contains more components than consultations and referrals of the patient from one
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those that would ordinarily be produced upon provider to another.

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request. Payment includes activities by a health plan to

obtain premiums, billing by healthcare providers
Minimum Necessary or health plans to obtain reimbursement, claims
The minimum necessary standard requires that management, claims collection, review of the
uses, disclosures, and requests be limited to only medical necessity of care, and utilization review.
the amount needed to accomplish an intended The Privacy Rule provides a broad list of ac-
purpose. For example, for payment purposes, tivities that are healthcare operations. They in-
only the minimum amount of information neces- clude quality assessment and improvement, case
sary to substantiate a claim for payment should be management, review of healthcare professionals’
disclosed. The minimum necessary standard does qualifications, insurance contracting, legal and
not apply to PHI used, disclosed, or requested for auditing functions, and general business man-
treatment, payment, or operation purposes. agement functions such as providing customer
AB103118_Ch09.indd 253 2/6/2020 4:46:08 PM

s ervice and conducting due diligence. Operations her an opportunity to review or appeal the denial
do not include marketing or fundraising activities. in the following situations:
The PHI is in psychotherapy notes
Individual Rights ●●
●● The PHI was compiled in reasonable

There are two key goals to the Privacy Rule: (1)
anticipation of, or for use in, civil or criminal
to provide greater privacy protections for one’s
litigation or administrative action
health information (this also serves to limit access
by others) and (2) to provide an individual with ●● The CE is a correctional institution or
greater rights with respect to his or her health in- provider that has acted under the direction
formation. The Privacy Rule’s individual rights of a correctional institution, and an inmate’s
further the second goal. The individual rights in- request for his or her PHI creates health or
clude right of access, right to request amendment safety concerns
n.
of PHI, right to accounting of disclosures, right to The PHI is created or obtained by a covered
tio
●●
healthcare provider in research that includes
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request restrictions of PHI, right to request confi-
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dential communications, and right to complain of treatment, and an individual receiving
ss
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Privacy Rule violations. These rights are described treatment as part of a research study agrees
en
as follows. to suspend his or her right to access PHI
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temporarily, while the study is in progress
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Right of Access
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●● The PHI was obtained from someone other
M
The Privacy Rule’s right of access allows an in- than a healthcare provider under a promise
n
dividual to inspect and obtain a copy of his or
io
of confidentiality and the access requested
at
m
her own PHI contained within a designated rec- would be reasonably likely to reveal the
r
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ord set, such as a health record (45 CFR 164.524). source of the information
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The right of access extends as long as the PHI is The PHI is contained in records that are
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●●
maintained, although the Privacy Rule does not
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subject to the federal Privacy Act (5 USC

an
require health records be retained for a specified 552a) if the denial of access under the
ic
period. There are exceptions to the right of access.

er
Privacy Act would meet the requirements of

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For example, psychotherapy notes, which are that law

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behavioral health notes that document a mental

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●● The PHI is maintained by a CE that is subject

by
health professional’s impressions from private

to the Clinical Laboratory Improvement
20
counseling sessions; information compiled in rea-

Amendments (CLIA) of 1988, which
20
sonable anticipation of a civil, criminal, or admin-

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regulates the quality of laboratory testing,

istrative action or proceeding; or PHI subject to
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and CLIA would prohibit access

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the Clinical Laboratory Improvements Act (CLIA)

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are all exceptions to the right of access. Covered ●● The PHI is maintained by a CE exempt
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entities with EHRs must make PHI available elec- from CLIA requirements (Rinehart-
tronically per individual request if it is readily Thompson 2018)
producible or if the individual requests to send The PHI refers to another individual who is not
PHI to a designated person or entity electronically a healthcare provider, and a licensed healthcare
(Rinehart-Thompson 2018). professional has concluded from the documen-
Per the Privacy Rule, there are times when a CE tation that the access requested is likely to cause
can deny an individual access to PHI. These are significant harm to that other individual (45 CFR
described as follows and are generally categorized 164.524)
as no opportunity to review or opportunity to review.
No Opportunity to Review A CE can deny an in- Opportunity to Review In two instances, the Pri-
dividual access to PHI without providing him or vacy Rule requires a CE to give an individual the
AB103118_Ch09.indd 254 2/6/2020 4:46:08 PM

right to review a denial of access. These are situ- The HIPAA does not permit retrieval fees to be
ations where a licensed healthcare professional charged to patients. However, they are permitted
determines that access to requested PHI would for non-patient requests. If a CE does not wish
likely endanger the life or physical safety of the to calculate actual or average costs for electronic
individual or another person or would reasona- PHI, the Office for Civil Rights (OCR), the federal
bly endanger the life or physical safety of another agency within HHS that is responsible for enforc-
person mentioned in the PHI. ing the Privacy Rule, recommends a flat fee up to
When a denial is made, the CE must write the $6.50. Fees cannot be assessed to individuals who
denial in plain language and include a reason. access their PHI via a View, Download, and Trans-
Second, it must explain that the individual has mit function of a certified electronic health record
the right to request a review of the denial. Third, (Rinehart-Thompson 2018).
it must describe how the individual can com- A CE must provide access to the PHI in the for-
n.
plain to the CE and must include the name or mat requested if it is readily producible in such
tio
title and phone number of the person or office form or format. If not, it must be produced in a
ia
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to contact. Finally, it must explain how the indi- readable hard-copy form or other format agreed to
ss
vidual can lodge a complaint with the secretary by the CE and the individual.
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en
of HHS. The right of access gives the individual the right
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The individual has the right to have the denial to obtain his or her own PHI, or to direct a CE to
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reviewed by a licensed healthcare professional transmit PHI about that individual to a third party
an
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who did not participate in the original denial and without barriers or unreasonable delays. Disclo-
is designated by the CE to act as the reviewing of- n
sure to a patient does not require patient author-
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ficial. The CE must grant or deny access in accord- ization using the HIPAA authorization form that
mr
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ance with the reviewing official’s decision. is described later in this chapter; however, for val-
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The Privacy Rule gives individuals the right idation and record-keeping purposes the CE may
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to request access to their PHI, but the CE may re- require that the request be in writing (Rinehart-
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quire that requests be in writing. An individual’s Thompson 2018). Certain limits cannot be placed
an
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request for review of PHI must be acted on no later on individuals exercising the right of access. For
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Am
than 30 days after the request is made (or 60 days example, the patient cannot be limited to patient
if the PHI is not on-site). This may be extended portal information only and cannot be required to
e
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once by a maximum of 30 additional days if the physically appear at the CE to receive their PHI
by
individual is given a written statement (within the (HHS 2016).

20
20
30 days) explaining the reasons for the delay and The right of access becomes more complex when
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the date by which the CE will respond. A CE must an individual directs a CE to transmit PHI about
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arrange a convenient time and place for an indi- the individual to a third party. Oftentimes, these
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vidual to inspect his or her PHI; otherwise, a copy access requests appear to have been initiated by a
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of the PHI must be mailed if requested. The Pri- third party instead of from the individual. As a re-
vacy Rule allows a reasonable cost-based fee when sult, seemingly identical requests may be handled
the individual requests a copy of PHI or agrees to differently (one as a patient access request and one
accept summary or explanatory information. The as a third-party request requiring authorization)
fee may include the cost of the following: and fees assessed differently.
●● Copying, including supplies and labor of Right to Request Amendment of PHI
copying
The Privacy Rule allows an individual the right
●● Postage, when the individual has requested to request amendment. With this right, one may
that the PHI be mailed request that a CE amend PHI or a record about
●● Preparing an explanation or summary, if the individual in a designated record set (45 CFR
agreed to by the individual (45 CFR 164.524) 164.526). The CE may deny the request when it
AB103118_Ch09.indd 255 2/6/2020 4:46:08 PM

etermines that the PHI or the health record did

d ●● The basis for the denial
not comply with the following: ●● The individual’s right to submit a written
●● Was not created by the CE statement disagreeing with the denial
●● Is not part of the designated record set ●● The process by which the individual can
submit his or her disagreement
●● Is not available for inspection as noted
in the regulation of access (for example, ●● A statement explaining how, when the
psychotherapy notes, inmate of a individual does not submit a disagreement,
correctional institution, and so on) he or she may request that both the original
amendment request and the CE’s denial
●● Is accurate or complete as is (45 CFR 164.526)
accompany any future disclosures of the PHI
A CE may require that the amendment request that is the subject of the amendment
be in writing. The CE may also require the re- A description of how the individual may
n.
●●
tio
quester to include a rationale for the amendment, complain to the CE, including the name or
ia
as long as the requester was notified in advance
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title and telephone number of the contact
ss
that a rationale would be required (usually in the person or office (45 CFR 164.526)
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Notice of Privacy Practices, discussed later in this
en
The CE can prepare a written rebuttal if the in-
em
chapter).
dividual submits a disagreement statement, and
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An individual’s amendment request must be
an
acted on no later than 60 days after receipt by al- it must provide the individual with a copy of the
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rebuttal.
n
lowing it or denying it in writing. The CE may ex- io
All requests for amendments, denials, the indi-
at
tend its response once, by 30 days, if it explains the
m
vidual’s statement of disagreement, and the CE’s

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reasons for the delay in a written statement and

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rebuttal (if one was created) must be appended or

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gives a date by which it will act. If an amendment

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is granted, the Privacy Rule requires a CE to do the linked to the record or PHI that is the subject of
ea
the amendment request. Future disclosures of the

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following:
an
subject information must include this material or

ic
Identify the documentation in the a summary. If a request for amendment was de-
er
●●
Am
designated record set that is affected by the nied and the individual did not write a statement
e
amendment, append the information, and of disagreement, the request for amendment and
th
by
supply a link to the amendment’s location denial must accompany future disclosures only if
20
where applicable. For example, if the the individual requests such action.
20
diagnosis is incorrect, the amendment will

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have to appear or be linked to each report in

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the designated record set Right to Request Accounting of Disclosures

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Maintaining some type of accounting procedure

Inform the individual that the amendment
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●●
for monitoring and tracking PHI disclosures has
was accepted and have him or her identify
been a common practice in HIM departments.
the persons with whom the amendment
However, the Privacy Rule has a specific standard
needs to be shared and then obtain his or her
with respect to such recordkeeping. Per the right
agreement to notify those persons. The CE
to request accounting of disclosures, an individ-
must make reasonable efforts to provide the
ual has the right to receive an accounting of cer-
amendment within a reasonable amount of
tain disclosures made by a CE (45 CFR 164.528).
time to anyone who has received the PHI (45
The Privacy Rule requires an accounting of all
CFR 164.526)
disclosures within the six years prior to the date
Denials must be made within 60 days of the re- on which the accounting was requested. A CE
quest, be written in plain language, and contain may either account for the disclosures of its BAs
the following: or require the BAs to make their own accounting.
AB103118_Ch09.indd 256 2/6/2020 4:46:08 PM

BAs must respond to accounting requests that are in an accounting of disclosures. For example, if a
made directly to them. physician’s office reports a case of tuberculosis to
The types of disclosures that must be accounted a public health authority, that disclosure must be
for are limited, but include those made erroneously included if the patient requests an accounting. If
(that is, breaches, which are discussed later in the a CE provides PHI to a third-party public health
chapter), for public interest and benefit activities authority to review, but the third party does not
(discussed later in this chapter) where patient au- actually review it, the third-party’s access must be
thorization is not obtained, and pursuant to a court included in an accounting of disclosures.
order. Disclosures for which an accounting is not Disclosure pursuant to a court order (if without
required (that is, exceptions) are the following a patient’s written authorization) is also subject to
disclosures: an accounting of disclosure. However, disclosure
pursuant to a subpoena that is accompanied by a
For TPO (this exception only applies to CEs
n.
●●
patient’s written authorization is not subject to an
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without EHRs) accounting of disclosure because the authorization
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●● To individuals to whom the information exempts the disclosure from the accounting of dis-
ss
pertains, or the individual’s personal closure requirement. The accounting of disclosure
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representative requirement includes disclosures made in writing,
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●● Incidental to an otherwise permitted or by telephone, or orally. In some situations, an indi-
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required use or disclosure (for example, a vidual’s right to an accounting of disclosure may
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patient’s name appears on a sign-in sheet be suspended at the written request of a health
n
at a physician office; this is a permitted use io
oversight agency or law enforcement official indi-
at
cating that an accounting of disclosure would im-
m
that may be seen by [disclosed to] the next

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patient who signs in) pede its activities. This request should specify how
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long such a suspension is required. The Privacy

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●● Pursuant to an authorization
ea
Rule provides a list of exceptions to the accounting

For use in the facility directory, to persons
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●●
of disclosure requirement, but not disclosures that
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involved in the individual’s care, or for other

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must be accounted for. An accounting of disclosure

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notification purposes
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must include the following items:

●● To meet national security or intelligence
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requirements ●● Date of disclosure

by
To correctional institutions or law Name and address (when known) of

20
●● ●●
20
enforcement officials the entity or person who received the

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As part of a limited data set information

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●●
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That occurred before the compliance date Brief description of the PHI disclosed
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●●
●●
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for the CE (45 CFR 164.528) (Rinehart- Brief statement of the purpose of the
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●●
Thompson 2018) disclosure or a copy of the individual’s

written authorization or request (45 CFR
The definition of healthcare operations is broad, 164.528)
but the Privacy Rule has carved out exceptions to
this definition so the following must be included A CE must act on a request for an accounting
in an accounting of disclosures. For example, man- of disclosures no later than 60 days after receipt
datory public health reporting is not part of a CE’s (extended by no more than 30 days if the CE no-
operations (this includes state requirements to re- tifies the individual in writing of the reasons for
port births [birth certificates]; communicable dis- the delay and the date by which the accounting of
eases; and incidents of abuse or suspected abuse disclosure will be made available).
of children, mentally disabled individuals, and The first accounting of disclosure within any
the elderly). As a result, these must be included 12-month period must be provided to the p atient
AB103118_Ch09.indd 257 2/6/2020 4:46:08 PM

without charge. Additional requests within a difficult for every receptionist to recall this small
12-month period may be assessed a reasonable, restriction, particularly if other patients had sim-
cost-based fee if the individual is informed in ad- ilar restrictions on their information. The risk of
vance and given an opportunity to withdraw or violation simply becomes too great.
modify the request or avoid or reduce the fee. The individual or the CE can terminate a restric-
The Privacy Rule requires that documentation tion that was agreed upon. When the CE entity ini-
be maintained on all accounting of disclosure re- tiates termination of the agreement, it must inform
quests, including information included in the ac- the individual that it is doing so. However, the ter-
counting of disclosure, the written accounting that mination is only effective with respect to the PHI
was provided to the individual, and the titles of created or received after the individual has been
persons or offices responsible for receiving and informed (45 CFR 164.522(a)(1)).
processing requests for an accounting of disclo-
Right to Request Confidential Communications
n.
sure. Policies and procedures must be developed
tio
to ensure the PHI disclosed from all areas of the Healthcare providers and health plans must give
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CE, likely including departments outside HIM, individuals the opportunity to request that com-
ss
can be tracked and compiled when an accounting munications of PHI be routed to an alternative
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of disclosure request is received. location or by an alternative method (45 CFR
em
164.522(b)(1)). This is the right to request con-
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Right to Request Restrictions of PHI fidential communications. Healthcare provid-
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An individual can request that a CE restrict the ers must honor such a request without requiring
n
uses and disclosures of PHI to carry out TPO (45 io
a reason if it is reasonable. Health plans must
at
honor such a request if it is reasonable and if
m
CFR 164.522(a)(1)). This is the right to request

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restrictions of PHI. In almost all cases, a CE can the requesting individual states that disclosure
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decline a restriction request. However, restriction could pose a safety risk. However, providers
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requests must be complied with (unless otherwise and health plans may refuse to accommodate
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required by law) if the disclosure would be made requests if the individual does not provide in-
an
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to a health plan for payment or operations purpos- formation as to how payment will be handled or
er
Am
es and the individual had paid for the healthcare an alternative address or method by which he or
service or item completely out of pocket (Rinehart- she can be contacted.
e
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Thompson 2018). An example of a request for confidential com-

by
When a CE agrees to a restriction, whether munications would be a woman who requests

20
20
voluntarily or mandated, it must live up to the that billing information from her psychiatrist,
©
agreement. To illustrate how difficult this can be, from whom she is seeking treatment because of a
ht
ig
examine the following scenario. A patient, Mr. domestic violence situation, be sent to her work
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op
Smith, agrees to allow a hospital to tell callers that address instead of to her home.
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he has been admitted to the hospital and there-

fore is in the facility directory. Such notification Right to Complain of Privacy Rule Violations
is a hospital operation. However, he requests that A CE must provide a process for an individual to
this information be restricted and withheld only file a complaint or allegation about the entity’s
from his Aunt Mary and Uncle Jack, if they should policies and procedures, its noncompliance with
call. Should the hospital agree to this restriction re- them, or its noncompliance with the Privacy Rule
quest? In this scenario, the hospital is not required (45 CFR 164.530(d)(1)). The CE’s notice of privacy
to agree. In fact, the hospital probably should not practices, described later in this chapter, must con-
agree to this request because of the administrative tain contact information at the CE level and inform
difficulty of informing certain individuals, but not individuals of the ability to submit complaints to
others, of Mr. Smith’s status. There is also the risk HHS. All complaints must be documented along
of accidentally violating the request. It would be with corresponding dispositions.
AB103118_Ch09.indd 258 2/6/2020 4:46:08 PM


Answer the following questions
1. The right of privacy:
a. Has been granted by the US Constitution
b. Has been granted via court decisions
c. Does not apply to health information
d. Does not exist
2. One state’s law protects the privacy of health information to a greater extent than HIPAA does.
a. The state law will be preempted by HIPAA
b. The state law is invalid because it does not provide the same level of protection as HIPAA
c. The state law may supersede HIPAA
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d. The state’s law must be consistent with HIPAA
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3. Julie wants to review her health records, but she is asking about the Privacy Rule’s requirements pertaining to record
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retention. HIPAA establishes that a patient has the right of access to inspect and obtain a copy of her PHI:
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a. For as long as it is maintained
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b. For six years
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c. Forever
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d. For 12 months
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4. HIPAA regulations:
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a. Never preempt state statutes
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b. Always preempt state statutes

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c. Preempt less strict state statutes where they exist

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d. Preempt stricter state statutes where they exist

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5. The Privacy Rule applies to:

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a. Healthcare providers only

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b. Only healthcare providers that receive Medicare reimbursement

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c. Only entities funded by the federal government

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d. Covered entities and their business associates

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6. The Privacy Rule extends to protected health information:

20
a. In any form or medium, except paper and oral forms

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b. In any form or medium, including paper and oral forms

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c. That pertains to mental health treatment only

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d. That exists in electronic form only

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7. Bob is exercising his HIPAA right to request confidential communications of both Memorial Hospital and TruePlus,
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his health plan. When asked by both entities how he will handle payments, he declines to provide them with any
information. As a result:
a. TruePlus must still honor the request
b. Only Memorial Hospital may deny the request
c. Memorial Hospital must still honor the request
d. Both Memorial Hospital and TruePlus may deny his request
8. Elizabeth has requested a copy of her PHI from Memorial Hospital. Which of the following is acceptable for Memorial
Hospital to charge Elizabeth?
a. A reasonable cost-based fee
b. It may not charge Elizabeth at all
c. It may impose any fee authorized by state statute
d. It can charge only for the cost of the paper on which the information is printed
AB103118_Ch09.indd 259 2/6/2020 4:46:08 PM

9. Business associate agreements are developed to cover the use of PHI by:
a. The covered entity’s employees
b. Organizations outside the covered entity’s workforce that use PHI to perform functions on behalf of the covered entity
c. The covered entity’s entire workforce
d. The covered entity’s janitorial staff
10. The term minimum necessary means that healthcare providers and other covered entities must limit use, access, and
disclosure to the least amount to:
a. Retain records needed for patient care
b. Accomplish the intended purpose
c. Treat an individual
d. Perform research
11. DataSource is a business associate of Davis Health System. An individual who was a patient in the Davis Health
n.
System contacts DataSource, requesting an accounting of disclosures and stating that this is his right per the HIPAA
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Privacy Rule. DataSource:
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a. Does not have to respond to the patient because it is not a covered entity
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b. May refer the request to Davis Health System
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c. Does not have to respond to the patient because this is not a HIPAA individual right
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d. Must respond to the patient and provide an accounting of disclosures
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12. Deidentified information:
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a. Does not identify an individual
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b. Is information from which only a person’s name has been stripped io
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c. Can be constituted later or combined to reidentify an individual
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d. Is subject to the HIPAA Privacy Rule

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HIPAA Privacy Rule Documents

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The Privacy Rule outlines three key at a clinic), including service delivered electroni-
documents that inform patients and give them cally. Notices must be available at the site where
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a degree of control over their PHI. The notice of the individual is treated and must be posted in a
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privacy practices and the authorization—are prominent place where patients can reasonably
20
20
required, whereas the HIPAA consent to use or be expected to read them. If the CE has a website
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disclose PHI is optional. with information about their services and benefits,
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the notice of privacy practices must be promi-

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Notice of Privacy Practices

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nently posted to it. The notice of privacy practices

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Except for certain exceptions for health plans and must be updated to reflect material changes. It
inmates in correctional facilities, an individual has must state that uses and disclosures not described
the right to a notice explaining how his or her PHI in the notice will require an authorization. It must
will be used and disclosed (45 CFR 164.520). This also address marketing and the right to opt out of
notice of privacy practices must also explain in fundraising communications (both of which are
plain language the patient’s rights and the CE’s explained later in this chapter). A CE’s obligation
legal duties with respect to PHI. to comply with a restriction request if the item or
Healthcare providers with a direct treatment re- service is paid in full out-of-pocket must also be
lationship with an individual must provide the no- included in the notice. AHIMA outlines the re-
tice of privacy practices by the first service delivery quirements for the content of the notice of privacy
date (for example, first visit to a physician’s office, practices (McLendon and Rose 2013). In general,
first admission to a hospital, or first encounter the notice is to include the following:
AB103118_Ch09.indd 260 2/6/2020 4:46:08 PM

1. A header such as: “this notice describes how a. The right to request restrictions on certain
information about you may be used and uses and disclosures as provided by 45
disclosed and how you can get access to this CFR 164.522(a)(1), including a statement
information. Please review it carefully” that the CE is not required to agree to a
2. A description, including at least one example requested restriction
of the types of uses and disclosures that b. For healthcare providers only, a statement
the CE is permitted to make for treatment, indicating the right to restrict certain
payment, and healthcare operations disclosures of PHI to a health plan when
3. A description of each of the other purposes the individual pays out of pocket in full for
for which the CE is permitted or required to the healthcare item or service
use or disclose PHI without the individual’s c. The right to receive confidential
written consent or authorization communications of PHI
n.
4. A statement that other uses and disclosures d. The right to access, inspect, and receive a copy
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will be made only with the individual’s of PHI on paper, including the right to have
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written authorization and that the individual electronic copies if kept in electronic form
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may revoke such authorization e. The right to request electronic copies of
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5. When applicable, separate statements that PHI be forwarded to a third party
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the CE may contact the individual to provide f. The right to request an amendment of PHI
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appointment reminders or information about g. The right to receive an accounting of
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treatment alternatives and other health-
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related benefits and services that may be of
h. The right to be notified of the CE’s privacy
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interest to the individual

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practices
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6. A statement indicating that most uses and

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i. The right to control PHI use for marketing,

disclosures of psychotherapy notes (where
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sales, and research

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appropriate), uses and disclosures of

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j. The right to be notified of a breach to PHI

protected health information for marketing
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purposes, and disclosures that constitute a k. The right to file complaints with the Office
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sale of protected health information require for Civil Rights

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authorization. CEs that do not record or 1

0. A statement that the CE is required by law to
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maintain psychotherapy notes are not maintain the privacy of PHI and to provide
20
required to include a statement individuals with a notice of its legal duties

20
and privacy practices with respect to PHI

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7. A statement regarding fundraising

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communications and an individual’s right to 1 1. A statement that the CE is required to abide

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opt out of receiving such communications, by the terms of the notice currently in effect
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if a CE intends to contact an individual 1 2. A statement that the CE reserves the right to

to raise funds for the CE. If a CE does not change the terms of its notice and to make
make fundraising communications, then this the new notice provisions effective for all PHI
statement does not need to be included that it maintains
8. For health plans that perform underwriting 1 3. A statement describing how the CE will
activities only, a statement must be included provide individuals with a revised notice
indicating the health plan is prohibited from 1 4. A statement that individuals may complain
using or disclosing genetic information for to the CE and to the Secretary of Health and
underwriting purposes Human Services if they believe their privacy
9. A statement of the individual’s rights with rights have been violated; a brief description
respect to PHI and a brief description of how the of how one files a complaint with the CE;
individual may exercise these rights including: and a statement that the individual will not
AB103118_Ch09.indd 261 2/6/2020 4:46:08 PM

be retaliated against for filing a complaint. the patient’s agreement to use or disclose individ-
Include contact information ually identifiable information for TPO (45 CFR
1
5. The name or title and the telephone number 164.506(b)). However, some healthcare providers
of a person or office to contact for further obtain consents as a matter of policy. Except for
information special circumstances such as emergencies (dis-
1 6. An effective date, which may not be earlier cussed in this section), the HIPAA consent is usu-
than the date on which the notice is printed or ally obtained at the time care is provided and has
otherwise published no expiration date. However, the individual can
revoke the HIPAA consent as long as the revoca-
tion is in writing. HIPAA consents should be writ-
Consent to Use or Disclose PHI ten in plain language. The CE must document and
Under the Privacy Rule healthcare providers are retain signed HIPAA consents and revocations. A
n.
not required to obtain HIPAA consent, which is sample HIPAA consent is provided in figure 9.5.
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Figure 9.5 Sample HIPAA consent for the use or disclosure of individually identifiable health information
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Consent to the Use and Disclosure of Health Information
for Treatment, Payment, or Healthcare Operations
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I understand that as part of my healthcare, this organization originates and maintains health records
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describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans
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for future care or treatment. I understand that this information serves as:
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• A basis for planning my care and treatment
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• A means of communication among the many health professionals who contribute to my care
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• A source of information for applying my diagnosis and surgical information to my bill

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• A means by which a third-party payer can verify that services billed were actually provided
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• A tool for routine healthcare operations such as assessing quality and reviewing the competence of
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healthcare professionals
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I understand and have been provided with a Notice of Information Practices that provides a more
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complete description of information uses and disclosures. I understand that I have the right to review
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the notice prior to signing this consent. I understand that the organization reserves the right to change
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its notice and practices and prior to implementation will mail a copy of any revised notice to the address
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I’ve provided. I understand that I have the right to object to the use of my health information for directory
th
purposes. I understand that I have the right to request restrictions as to how my health information may
by
be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is
20
not required to agree to the restrictions requested. I understand that I may revoke this consent in writing,
20
except to the extent that the organization has already taken action in reliance thereon. Therefore, I consent
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to the use and disclosure of my healthcare information.

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□ I request the following restrictions to the use or disclosure of my health information.

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Signature of Patient or Legal Representative

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Witness
Date Notice Effective
Date or Version
□ Accepted □ Denied
Signature
Title
Date
Source: HHS 2000. 82818.
AB103118_Ch09.indd 262 2/6/2020 4:46:09 PM

Authorization r equested for disclosures by others. This section of

Written authorization by an individual, granting the Privacy Rule also generally prohibits requiring
permission for a specific use or disclosure of his or an authorization as a condition of treatment and
her health information, is a longstanding legal re- allows authorizations to be combined only in cer-
quirement and health information practice. How- tain situations (45 CFR 164.508).
ever, the authorization is a key component of the The Privacy Rule requires that authorizations
Privacy Rule. As a general requirement, the Pri- be obtained for uses and disclosures of PHI in re-
vacy Rule states that an authorization for uses and search unless the CE obtains documentation that an
disclosures must be obtained from an individual Institutional Review Board (IRB) or privacy board
(45 CFR 164.508). However, there are a number of has approved an alteration or waiver. Where au-
exceptions, outlined later in this chapter. thorizations are required, the Privacy Rule requires
Authorizations are always required for the use that the authorization contain the required core el-
n.
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or disclosure of psychotherapy notes except to ements, which are described later in this chapter.
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carry out TPO; for treatment by the originator of An individual may revoke an authorization at any
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the notes; in mental health training programs by time if it is in writing. However, revocation does not
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the CE; to defend a legal action or other proceed- apply to disclosures that have already been made.
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ing brought by the individual; or for oversight of CEs must document and retain signed authorizations
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the originator of the notes (45 CFR 164.508(a)). The and revocations and must permit individuals to re-
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Privacy Rule also provides other specifications view what was disclosed pursuant to authorizations.
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for authorization, including those requested by Table 9.1 outlines differences among the three key
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a CE for its own uses and disclosures and those Privacy Rule documents discussed in this section.
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Uses and Disclosures of Health Information:

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Authorization and Patient Right of Access

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As table 9.2 shows, PHI may not be used or dis- disclosure in writing or the Privacy Rule requires
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closed by a CE unless the individual who is the or permits such use or disclosure without the in-
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subject of the information authorizes the use or dividual’s written authorization. The Privacy
by
20
Table 9.1 Differences among notice of privacy practices, consent, and authorization
20
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Notice of privacy practices Consent Authorization

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Required? Required by HIPAA Optional Required by HIPAA

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Requirements Must explain TPO uses and Only obtains patient permission Is used to obtain for a number of
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regarding TPO disclosures, along with other types to use or disclose PHI for TPO types of uses and disclosures,
of uses and disclosures purposes although it not required for TPO
uses and disclosures
PHI this document Provides prospective and general Provides prospective and general Obtains patient permission to use
addresses information about how PHI might information about how PHI might or disclose specific information that
be used or disclosed in the future be used or disclosed in the future generally has already been created
(and includes information that may for TPO purposes (and includes and for which there is a specific
not have been created yet) information that may not have need
been created yet)
Required for May not refuse to treat an May condition treatment on May not refuse to treat an individual
treatment? individual because he or she individual signing this form because he or she declines to sign
declines to sign this form this form
Time limit on No time limit on validity of the No time limit on validity of the Time limit on validity of document
document validity document document (specified by an expiration date or event)
Source: Adapted from Rinehart-Thompson 2018.
AB103118_Ch09.indd 263 2/6/2020 4:46:09 PM

Table 9.2. Authorization requirements for use and disclosure of PHI

I. Patient authorization required:
All situations except those listed in Part II
II. Patient authorization not required:
A. When use or disclosure is required, even without patient authorization
• When the individual/patient or individual’s/patient’s personal representative requests access or accounting of disclosures (with
exceptions)
• HHS investigation, review, or enforcement action
B. When use or disclosure is permitted, even without patient authorization
• Patient has opportunity to informally agree or object
 Facility directory
 Notification of relatives and friends
• Patient does not have opportunity to agree or object
 Public interest and benefit
1. As required by law
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2. For public health activities
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3. To disclose PHI regarding victims of abuse, neglect, domestic violence
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4. For health oversight activities
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5. For judicial and administrative proceedings
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6. For law enforcement purposes (six specific situations)
7. Regarding decedents
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8. For cadaveric organ, eye, or tissue donation
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9. For research, with limitations
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10. To prevent or lessen serious threat to health or safety
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11. For essential government functions
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12. For workmen’s compensation
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 Situations other than public interest and benefit io
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13. TPO
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14. To the individual/patient

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15. Incidental disclosures

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16. Limited data set

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Source: Rinehart-Thompson 2018.

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Rule requires such use or disclosure in only two disclosed without the individual’s written author-
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situations: when the individual or individual’s ization, although the individual must be informed
personal representative requests access to or an in advance and given an opportunity to informally
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accounting of disclosures of the PHI (with the ex- agree or object (45 CFR 164.510). In both circum-
by
ceptions detailed earlier in this chapter), and when stances, the CE may inform the individual verbally
20
20
HHS is conducting an investigation, review, or and obtain his or her verbal agreement or objection.
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enforcement action. The first circumstance is when the healthcare

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In addition to the two situations where use organization maintains a facility directory of pa-
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or disclosure is required without the individual’s tients for persons who ask for individuals by name,
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written authorization (section II.A of table 9.2), and for clergy. The information may include the
there are many situations where the Privacy Rule patient’s name, location in the healthcare organi-
permits a CE to use or disclose PHI without an in- zation (room number), condition described in gen-
dividual’s written authorization (45 CFR 164.510 eral terms (such as critical or stable), and religious
and 164.512). These exceptions to the patient affiliation. Disclosure of an individual’s religious
authorization requirement are summarized in
affiliation is limited to members of the clergy.
section B of table 9.2. The CE must inform the patient of the informa-
tion to be included in the facility directory and to
Patient Has Opportunity to Agree whom information may be disclosed. The patient
or Object must have the opportunity to prohibit all uses or
As listed in table 9.2 (section II.B), the Privacy Rule disclosures from the facility directory or request
lists two circumstances where PHI can be used or restrictions of some of the uses and disclosures.
AB103118_Ch09.indd 264 2/6/2020 4:46:09 PM

When it is not possible to get the patient’s 1. As required by law. Disclosures are permitted
agreement (for example, in emergencies), the when required by laws that meet the public-
CE can use and disclose PHI in the facility direc- interest requirements of disclosures relating
tory if the disclosure is consistent with the prior to victims of abuse, neglect, or domestic
expressed preference of the patient or if the CE violence, judicial and administrative
believes it is in the patient’s best interest. When proceedings, and law enforcement purposes
it becomes possible after the emergency situation, (45 CFR 164.512(a)).
the CE must inform the patient and give him or 2. Public health activities. These include
her the opportunity to object to use and disclosure preventing or controlling diseases, injuries,
from the facility directory. and disabilities, and reporting disease,
The second circumstance is disclosing, to a fam- injury, and vital events such as births and
ily member or a close friend, PHI that is directly deaths. Examples include the reporting of
n.
relevant to his or her involvement in the patient’s adverse events or product defects to comply
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care or payment. The patient’s written authoriza-
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with US Food and Drug Administration
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tion is not required but verbal agreement is, if it (FDA) regulations and, when authorized
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can be obtained. Likewise, a CE may disclose PHI,
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by law, reporting a person who may have
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including the patient’s location, general condition, been exposed to a communicable disease
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or death, to notify or assist in the notification of a and may be at risk for contracting or
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family member, personal representative, or some
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spreading it (45 CFR 164.512(b)). Disclosure
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other person responsible for the patient’s care (45 of students’ immunization records may
CFR 164.510(b)). It must be reasonably inferred n
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be considered a public health disclosure.
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from the circumstances that the patient does not
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Where applicable law requires that a school

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object to the disclosure. obtain a student’s authorization records

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The CE may also use or disclose PHI to a public

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prior to enrollment, authorization is not

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or private entity authorized by law or by its char- required for the information to be disclosed
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ter to assist in disaster relief efforts.

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to the school. An oral agreement from the

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student’s legal guardian or the student

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Patient Does Not Have Opportunity (if age of majority has been reached) is,
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however, still required.

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to Agree or Object
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There are 16 circumstances where PHI can be used 3. Victims of abuse, neglect, or domestic violence.
20
An example is the reporting to authorities

20
or disclosed without an individual’s authoriza-

authorized by law to receive information
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tion, and the individual does not have the oppor-

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about child or other abuse or neglect. In

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tunity to agree or object. The first 12 circumstances

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non–child abuse situations, the Privacy

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are sometimes referred to as public interest and

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benefit circumstances because they are of benefit Rule requires the CE to promptly inform the
to society (45 CFR 164.512). Although the Privacy individual or personal representative that
Rule permits the 12 public interest and benefit uses a report has been or will be made unless
or disclosures without an individual’s authoriza- it believes that doing so would place the
tion, if it would violate a state law that otherwise individual at risk of serious harm or not be in
protects the patient’s information, the information his or her best interest (such as informing the
cannot be legally used or disclosed. This is be- personal representative, who is believed to
cause, as a general rule, the Privacy Rule does not be responsible for the abuse, neglect, or other
preempt state laws that provide a greater level of injury) (45 CFR 164.512(c)).
privacy protection. 4. Healthcare oversight activities. An authorized
A use or disclosure may meet more than one of the health oversight agency may receive PHI for
following 12 public interest and benefit situations: activities authorized by law such as audits,
AB103118_Ch09.indd 265 2/6/2020 4:46:09 PM

civil or criminal investigations, licensure, and of a crime (when the individual agrees
other inspections (45 CFR 164.512(d)). to the disclosure or when the CE is
5. Judicial and administrative proceedings. unable to obtain the individual’s
Disclosures of specified PHI are permitted in agreement because of incapacity or
response to a court order or an administrative other emergency circumstance). The
agency order. For subpoenas and discovery law enforcement official must show
requests, the party seeking the PHI must the information is needed to determine
assure the CE that it has made reasonable whether a violation of law has occurred,
efforts to make the request known to the that immediate law enforcement
subject individual. The CE also must be activity depends on the disclosure, and
assured that the time for the individual to that disclosure is in the best interest of
raise objections to the court or administrative the individual as determined by the CE.
n.
agency has elapsed and that either no About a deceased individual when the
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objections have been filed, all objections have CE suspects that the death may have
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been resolved, or a qualified protective order resulted from criminal conduct.
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To a law enforcement official when the CE
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has been secured (45 CFR 164.512(e)).
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6. Law enforcement purposes. The Privacy Rule believes in good faith that the information
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specifies six instances when disclosures constitutes evidence of criminal conduct
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that occurred on the CE’s premises.
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to law enforcement do not require patient
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authorization or the patient has no To a law enforcement official in
n response to a medical emergency
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opportunity to agree or object:
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when the CE believes that disclosure
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Pursuant to legal process or otherwise

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required by law: Examples of legal is necessary to alert law enforcement

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to the commission and nature of a

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process include a court order, a court-

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ordered warrant, or a subpoena or a crime, the location or victims of such

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crime, and the identity, description,

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summons issued by a judicial officer. An

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example of “otherwise required by law” and location of the perpetrator of such

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is a state law that requires certain types crime. Further, it is permitted when the
CE believes the medical emergency was
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of wounds or other physical injuries to

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the result of abuse, neglect, or domestic

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be reported to law enforcement.

violence (45 CFR 164.512(f)).
20
In response to a law enforcement

20
official’s request for the purpose of 7. Decedents. Disclosures to a coroner or medical

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identifying or locating a suspect, fugitive, examiner are permitted to identify a deceased

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material witness, or missing person. person, determine a cause of death, or for

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Only the following may be disclosed: other purposes required by law. In accordance
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name and address, date and place of with applicable law, disclosures to funeral
birth, Social Security number, ABO blood directors are permitted, as necessary, to allow
type and Rh factor, type of injury, date them to carry out their duties with respect to
and time of treatment, date and time of the decedent. This type of information also
death (if applicable), and description of may be disclosed in reasonable anticipation of
distinguishing physical characteristics an individual’s death (45 CFR 164.512(g)).
including height, weight, gender, race, 8. Cadaveric organ, eye, or tissue donation. PHI
hair and eye color, and presence or may be disclosed to organ procurement
absence of facial scars or tattoos. agencies or other entities to facilitate
In response to a law enforcement procurement, banking, or transplantation
official’s request about an individual of cadaveric organs, eyes, or tissue (45 CFR
who is, or is suspected to be, a victim 164.512(h)).
AB103118_Ch09.indd 266 2/6/2020 4:46:09 PM

9. Research. Authorizations for the use of conditioned authorizations (that is, those that
PHI in research are required except where condition research-related treatment upon
an IRB or privacy board alters or waives research participation) and unconditioned
the authorization requirement (in whole authorizations (that is, those that do not
or in part) and documents it (45 CFR condition research-related treatment upon
164.512(i)). Table 9.3 provides a detailed research participation) as long as the
analysis of the responsibilities of both the conditioned and unconditioned components
IRB and the researcher under the Privacy are clearly distinguished and the individual
Rule requirements. A CE may combine is able to opt in to the unconditioned research
Table 9.3 Actions required for use of PHI in research
n.
Research subject (patient
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Type of Information IRB Researcher or decedent)
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PHI preparatory to research None* Representation that use is None
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solely and necessary for
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research and will not be
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removed from covered entity
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Deidentified health information None* Removal of safe-harbor data None
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or statistical assurance of
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deidentification
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Limited data set None* Removal of direct identifiers None
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and data use agreement
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Individually identifiable health None* Representation that use is None

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information on decedents
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solely and necessary for

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research on decedents and

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documentation of death upon

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request of covered entity

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PHI of human subjects Waive authorization Representation that: None

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(whether research is requirement if determined that 1. Privacy risk is minimal

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interventional or record review) risk to privacy is minimal based on:

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• Plan to protect identifiers

• Plan to destroy identifiers
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unless there is a health or

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research reason to retain

20
• Written assurance that

20
PHI will not be reused or

redisclosed
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2. Research requires use of

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specifically described PHI

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3. Justify the waiver

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4. Obtain IRB approval under

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normal or expedited review

procedures
Approve alteration of Same as above Sign altered authorization form
authorization (for example, to
restrict patient’s access during
study) if determined that risk to
privacy is minimal
Approve research protocol Sign authorization combined
ensuring that there is an with consent for research or
authorization for use either sign standard authorization
combined with consent for and for use and disclosure of PHI
disclosure of PHI research or for research as described in
separate authorization
* There may be requirements imposed by the IRB, but there are none imposed by HIPAA.
Source: Amatayakul 2003.
AB103118_Ch09.indd 267 2/6/2020 4:46:09 PM

activities (HHS 2018a). This provision does work-related illness or injury or a workplace-
not apply to psychotherapy notes (Rinehart- related medical surveillance if the disclosure
Thompson 2018). complies with workers’ compensation laws
10. Threat to health and safety: Use or disclosure (45 CFR section 164.512(l)).
is allowed if thought necessary to prevent The remaining four types of uses and disclo-
or lessen a serious and imminent threat sures that do not require patient authorization or
to the health or safety of an individual or an opportunity for the patient to agree or object
the public. Disclosure must be made to are TPO; disclosure to the subject individual; inci-
a person who can reasonably prevent or dental disclosures; and limited data set. The first
lessen the threat. Disclosures are permissible two were addressed earlier in this chapter; the re-
when law enforcement officials must maining two are explained as the following:
apprehend an individual who may have
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caused harm to the victim being treated ●● Incidental uses or disclosures occur as part of a
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permitted use or disclosure (CFR 164.502(a)
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or when the individual appears to have
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escaped from a correctional institution or (1)(iii)). For example, calling out patients’
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names in a physician office is an incidental
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lawful custody. For correctional institutions
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or a law enforcement official who has disclosure because it occurs as part of office
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lawful custody of an inmate, the Privacy operations. It is permitted as long as the
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information disclosed is the minimum
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Rule allows disclosures if the institution
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states that the information is necessary to necessary (for example, the patient’s name
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provide continuing healthcare; to secure the
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with no diagnostic information).
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health and safety of the individual or other ●● A limited data set is PHI that excludes
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inmates, officers, employees, transportation direct identifiers of the individual, the

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personnel, or law enforcement on the individual’s relatives, employers, or

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premises; or to ensure the administration household members without completely

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and maintenance of the institution’s safety, deidentifying them (45 CFR 164.514(e)
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security, and good order (45 CFR 164.512(j)). (2)). Restrictions are lifted for items such
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11. Specialized government functions: These include as ages and dates, and parts of geographic
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information regarding armed forces personnel subdivisions that are deemed not too
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for military and veteran’s activities, for specific (for example, city, state, or zip
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purposes of national security and intelligence code) (Rinehart-Thompson 2018). Such PHI
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activities, for protective services for the may be used or disclosed, provided it is
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used or disclosed only for research, public

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President of the United States and others, and

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for public benefits and medical suitability health, or healthcare operations.

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determinations (45 CFR 164.512(k)).

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Table 9.4 outlines the differences between the

12. Workers’ compensation: The Privacy Rule HIPAA authorization versus the patient’s right
permits the disclosure of PHI relating to of access.

1. Notices of privacy practices must be available at the site where the individual is treated and:
a. Must be posted next to the entrance
b. Must be posted in a prominent place where it is reasonable to expect that patients will read them
c. May be posted anywhere at the site
d. Do not have to be posted at the site
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2. Janice is a well-informed patient. She knows that the Privacy Rule requires that individuals be able to:
a. Be granted all requested restrictions on uses and disclosures of PHI
b. Be granted all requested amendments to their PHI
c. Receive a copy of the notice of privacy practices
d. Receive free copies of their protected health information
3. Treatment of an individual can be conditioned on the signing of the:
a. Authorization
b. HIPAA consent
c. Notice of privacy practices
d. Research waiver
4. Which of the following describes HIPAA consents?
a. They are the same as authorizations.
b. They expire 60 days after they are executed.
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c. They are required under the Privacy Rule.
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d. They are not required to permit use and disclosure of PHI for treatment, payment, or operations.
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5. Jill’s information is included in the facility directory. This listing:
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a. Could occur only with Jill’s written authorization
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b. Is automatic upon Jill’s admission to the hospital
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c. Is present because Jill informally agreed to it
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d. Includes all PHI in Jill’s designated record set
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6. Per the opportunity to verbally agree or object: io
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a. A patient may disallow information to be sent to his or her health plan for payment purposes
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b. A hospital may communicate with family members involved in the patient’s care
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c. A patient may verbally revoke an authorization

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d. A hospital may disclose PHI to law enforcement

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7. A funeral home is contacted to retrieve a patient’s body. This contact and disclosure of information about the
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decedent is:
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a. A public interest and benefit exception to the authorization requirement

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b. Only permissible if the decedent’s next of kin has given written authorization for information about the decedent
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to be disclosed to the funeral home

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c. A violation of the HIPAA Privacy Rule

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d. Subject to a HIPAA consent by the next of kin

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8. Release of birth and death information to public health authorities:

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a. Is prohibited without patient consent

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b. Is prohibited without patient authorization

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c. Is a public interest and benefit disclosure that does not require patient authorization
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d. Requires both patient consent and authorization

9. An individual’s authorization for research purposes:
a. Is always required
b. Is not required if the research involves a clinical trial
c. Is never required
d. Is not required if an IRB or privacy board alters or waives the authorization requirement
10. A nurse called Dee by her first name in a physician’s office when Dee was to be seen by the physician. This was:
a. An incidental disclosure
b. Not subject to the minimum necessary requirement
c. A disclosure for payment purposes
d. An automatic violation of the Privacy Rule
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Table 9.4 HIPAA authorization vs. right of access

HIPAA Authorization Right of Access
Permits, but does not require, a covered entity to disclose PHI Requires a covered entity to disclose PHI,
except where an exception applies
Requires a number of elements and statements, which include a description of who Must be in writing, signed by the individual,
is authorized to make the disclosure and receive the PHI, a specific and meaningful and clearly identify the designated person
description of the PHI, a description of the purpose of the disclosure, an expiration and where to send the PHI
date or event, signature of the individual authorizing the use or disclosure of his or
her own PHI and the date, information concerning the individual’s right to revoke the
authorization, and information about the ability or inability to condition treatment,
payment, enrollment, or eligibility for benefits on the authorization.
No timeliness requirement for disclosing the PHI; Reasonable safeguards apply Covered entity must act on request no later
(for example, PHI must be sent securely) than 30 days after the request is received
Reasonable safeguards apply (for example, PHI must be sent securely) Reasonable safeguards apply, including
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a requirement to send securely; however,
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individual can request transmission by
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unsecure medium
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No limitations on fees that may be charged to the person requesting the PHI; however, Fees limited as provided in 45 CFR 164.524
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if the disclosure constitutes a sale of PHI, the authorization must disclose the fact of
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remuneration
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Source: HHS 2016.
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Breach Notification
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As originally implemented, the Privacy 1. Unintentional acquisitions made in good faith

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Rule required CEs to mitigate (lessen the harmful and within the scope of authority
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effect) of the wrongful use or disclosure of PHI as

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2. Disclosures where the recipient would not

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much as possible. However, notification to the in- reasonably be able to retain the information
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dividual was optional (Rinehart-Thompson 2018). 3. Disclosures by a person authorized to access

This changed with ARRA, which defined a breach.
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PHI to another authorized person at the CE or

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ARRA also added breach notification require-

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BA (Rinehart-Thompson 2018)
ments that specify victims of breaches be notified
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and, depending on the number of individuals A breach should be presumed following an im-
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affected, the federal government and media out- permissible use or disclosure unless the CE or BA
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lets also be notified. CEs and BAs are subject to demonstrates a low probability that the PHI has
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been compromised (Rinehart-Thompson 2018). A

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HHS-issued breach notification regulations, and

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non-covered entities and non-BAs (including PHR four-factor risk assessment is used to determine
vendors) are subject to breach notification regu- whether PHI has been compromised:
lations issued by the Federal Trade Commission
1. Nature and extent of PHI involved, including
(FTC). The FTC is a federal agency that promotes
types of identifiers involved and how likely it
consumer protection.
is that reidentification can occur
Definition of Breach 2. Who the unauthorized recipient of the PHI was
A breach is an “unauthorized acquisition, access, 3. Whether the PHI was actually obtained or
use or disclosure of PHI that compromises the se- viewed
curity or privacy of such information” (Rinehart- 4. Degree to which the CE or BA mitigated the
Thompson 2018). There are three exceptions to the risk (for example, immediate destruction of
breach definition: the PHI) (HHS 2013)
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Breach notification requirements apply only to fewer than 500 people must be logged by the CE
unsecured PHI that technology has not made unin an HHS online reporting system and submitted
usable, unreadable, or indecipherable to unauthor- annually as a report not later than 60 days after
ized persons (Rinehart-Thompson 2018). This PHI the end of the calendar year (Rinehart-Thompson
is considered to be most at risk. Using the breach 2018).
definition, list of exceptions, and four-factor risk Individuals who are notified that their PHI
assessment, covered entities must identify wheth- has been breached must be given a description of
er incidents are to be reported. Further, per their what occurred (including date of breach and date
agreements, BAs must notify CEs of breaches. Fi- that breach was discovered); the types of unse-
nally, all workforce members must be educated to cured PHI that were involved (such as name, So-
notify the appropriate contact person within the cial Security number, date of birth, home address,
CE when they learn of a breach so the required account number); steps that the individual may
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notifications can be made. take to protect himself or herself; what the CE is
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doing to investigate, mitigate, and prevent future
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occurrences; and contact information for the indi-
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Notification Requirements vidual to ask questions and receive updates.
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Breaches by CEs and BAs (both are governed by Companion breach notification regulations by
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HHS breach notification regulations) are deemed the FTC provide protection to individuals whose
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discovered when the breach is first known or rea- information has been breached by non-covered
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sonably should have been known. All individu- entities and non-BAs that are PHR vendors, third-
als whose information has been breached must n
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party service providers of PHR vendors, or other
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be notified without unreasonable delay, and not non-HIPAA covered entities or BAs that are af-
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more than 60 days, by first-class mail or a faster filiated with PHR vendors (Rinehart-Thompson
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method such as by telephone if there is the poten- 2018). In addition to notifying the individuals af-
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tial for imminent misuse. If 500 or more individu- fected by the breach, these entities must also notify
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als are affected, they must be individually notified the FTC of the breach. Third-party PHR service
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immediately, and media outlets must be used as providers shall notify the PHR vendor or entity of
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a notification mechanism as well. The Secretary the breach. Other notification requirements, such
of HHS must specifically be notified of the breach as the content and nature of breach notices, paral-
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(Rinehart-Thompson 2018). All breaches affecting lel HHS requirements (Rinehart-Thompson 2018).
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Requirements Related to Commercial Uses:

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Marketing, Sale of Information, and Fundraising

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The Privacy Rule defines marketing as commu- Some activities look like marketing but do not
nication about a product or service that encour- meet the Privacy Rule’s definition of marketing.
ages the recipient to purchase or use that product As a result, no authorization is required for the
or service (45 CFR 164.501). PHI use or disclosure following:
for marketing requires an authorization from the
●● Communications to describe health-related
individual except in certain cases. The following
products and services provided by, or
marketing activities do not require authorization:
included in the plan of benefits of, the CE
●● Occur face to face between the CE and the itself or a third party
individual, or ●● Communication for treatment of the individual
●● Concern a promotional gift of nominal value ●● Case management or care coordination for
provided by the CE the individual, or to direct or recommend
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alternative treatments, therapies, Related to the concept of marketing is the sale of

healthcare providers, or care settings information. A CE or BA is prohibited from selling
(45 CFR 164.501) (receiving direct or indirect compensation in ex-
Unless a communication fits one of the above change for) an individual’s PHI without that indi-
categories, authorization is required. vidual’s authorization. The authorization must also
Uses and disclosures for healthcare operations state whether the individual permits the recipient of
do not require authorization. The categories here the PHI to further exchange the PHI for compensa-
are not healthcare operations (even if they other- tion. Exceptions to this prohibition include public
wise meet the definition) if the CE was paid for health and research data, treatment, and healthcare
making the communication. There are exceptions, operations to a BA pursuant to a BAA, to an individ-
however. If a communication describes a currently ual who is receiving a copy of his or her own PHI,
prescribed drug, if the payment was reasonable and for other exchanges deemed by the Secretary of
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(and the CE made the communication and re- HHS to be permissible (Rinehart-Thompson 2018).
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For fundraising activities that benefit the CE, the
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ceived an authorization from the recipient), or the
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communication was made by a BA on behalf of a CE entity may use or disclose to a BA or an institu-
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tionally related foundation, without authorization,
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CE and is consistent with a BAA, then the com-
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munication will be considered a healthcare oper- demographic information (name, address or other
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ation despite payment (AHIMA 2009). If the CE contact information, age, date of birth, gender); dates
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of healthcare services provided to the individual; de-
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has received—or will receive—direct or indirect
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payment in exchange for making a communica- partment of service (for example, urology); treating
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physician; health insurance information; and out-
tion to an outside entity, this must be prominently
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come information (45 CFR 164.514(f)). However, the
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stated.
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In addition, when the communication is direct- CE must inform individuals in its notice of privacy
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practices that PHI may be used for this purpose. It

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ed toward a specific target audience (for example,

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not a broad spectrum or cross-section of patients), must also include in its fundraising materials in-
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structions on how to opt out of receiving materials

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it must instruct individuals how to opt out of

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future communications. in the future. If a fundraising activity targets individ-

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If a CE uses PHI to target an individual or group ual based on diagnosis (for example, patients with
kidney disease are solicited in a capital campaign for
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based on health status or condition, it must deter-

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a new kidney dialysis center), prior authorization is

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mine that the product or service being marketed

required. Fundraising communications that meet the
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may benefit the health of the type of individual be-

20
ing targeted before it makes the communication. definition of healthcare operations must clearly and
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Then, the communication must explain why the conspicuously provide the opportunity to opt out of
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individual has been targeted and how the product future communications. This opt-out is a revocation
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or service relates to his or her health. of authorization (Rinehart-Thompson 2018).

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HIPAA Privacy Rule Administrative Requirements

The Privacy Rule provides standards ●● Requirements for privacy training
regarding administrative requirements that are ●● Requirements for establishing privacy
important to the health information professional, safeguards for handling complaints
including the following:
●● Designation of a privacy officer and a Designation of Privacy Officer
contact person for receiving complaints The Privacy Rule requires CEs to designate an in-
●● Standards for policies and procedures and dividual as a chief privacy officer to be responsible
changes to policies and procedures for privacy practices within the CE. This position
AB103118_Ch09.indd 272 2/6/2020 4:46:10 PM

is ideally suited to the background, knowledge, be noted in the policies, procedures, or notice of pri-
and skills of the health information professional vacy practices. Health information professionals
because the role includes developing and imple- are ideally qualified for developing and oversee-
menting privacy policies and procedures, facilitating policies and procedures.
ing organizational privacy awareness, performing
privacy risk assessments, maintaining appropriate
forms, overseeing privacy training, participating Privacy Training
in compliance monitoring of BAs, ensuring that Every member of the CE’s workforce (as defined
patient rights are protected, maintaining knowl- earlier in this chapter) must be trained in privacy
edge of applicable laws and accreditation stan- policies and procedures to include maintaining
dards, and communicating with the Office for the privacy of patient information, upholding in-
Civil Rights (OCR) and other entities in compli- dividual rights guaranteed by the Privacy Rule,
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ance reviews and investigations of alleged privacy and reporting alleged breaches and other Pri-
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violations (AHIMA 2015). vacy Rule violations. Each new employee must
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Additionally, the CE must designate a person be trained within a reasonable period of time after
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or office as the responsible party for receiving in- joining the workforce. When material changes are
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itial complaints about alleged privacy violations. made to policies or procedures regarding privacy,
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This individual must be able to provide further employees must receive additional training. It is
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information about matters covered by the CE’s also recommended that refresher training be pro-
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notice of privacy practices. vided to all workforce members at least annually.
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Further, the CE must maintain documentation
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showing that privacy training has occurred. Al-
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Standards for Policies and Procedures

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though not required, a signed acknowledgment of

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The CE must implement policies and procedures training by each workforce member is helpful to
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to ensure compliance with the Privacy Rule. This show compliance.

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process includes an ongoing review of privacy pol- CEs must have safeguards and mechanisms in
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icies and procedures and ensuring that all policy place to protect the privacy of PHI. This includes
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changes are consistent with changes in the privacy appropriate administrative, technical, and physical
and security regulations. Any regulatory changes safeguards. These safeguards should work hand
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that materially affect the CE’s notice of privacy in hand with those specified in the Privacy Rule.
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practices must be reflected in the notice; thus the (See chapter 10, Data Security, for more additional
20
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notice may have to be updated. All revisions must information on HIPAA security regulations.)
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Enforcement of Federal Privacy Legislation

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and Rules
Legal responsibility for HIPAA privacy and secu- for unknowing violations; $1,000 to $50,000 per
rity violations is not limited to CEs. Employees or violation if due to reasonable cause (knew or
other individuals can be individually prosecuted. would have known of violation with reasonable
Civil and criminal penalties also apply to both diligence); $10,000 to $50,000 per violation for
BAs and CEs. willful neglect that was corrected; and $50,000 per
violation for willful neglect that was uncorrected.
There is a $1.5 million annual cap for identical
Penalties violations in each category. The nature and ex-
ARRA/HITECH established tiered penalties, tent of both the violation and the harm determine
with a range of $100 to $50,000 per violation the amount assessed within each statutory range.
AB103118_Ch09.indd 273 2/6/2020 4:46:10 PM

Compensation of individuals harmed by a Pri- with state attorneys general to bring legal ac-
vacy Rule violation was included in the ARRA tion. Individuals still cannot bring lawsuits un-
provisions, but no further action has been taken der a HIPAA cause of action (Rinehart-Thompson
for this to occur. 2018).
Legal Action by State Attorneys Audits

General HIPAA enforcement does not occur solely based
State attorneys general may bring civil actions on complaints, as it did originally. Unannounced
in federal district court on behalf of residents audits by OCR to detect Privacy and Security Rule
believed to have been negatively affected by a violations are mandated for CEs and BAs. Desk
HIPAA violation. To that end, the OCR trained all and on-site audits determine whether compre-
state attorneys general on this. Previously, only hensive policies and procedures are in place and
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the Office of Civil Rights held this enforcement whether they have been implemented to comply
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right; however, it now encourages collaboration with the Privacy and Security Rules.
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Disclosure of Health Information
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The disclosure of health informa- and specific health record information
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tion process has long been central to the health requested is entered in the computer.
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information professional’s responsibilities. Dis-
Figure 9.6 is an example of a computer
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closure of health information is the process of screen used for entering disclosure of health
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providing PHI access to individuals or entities information data.

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that are authorized to either receive or review it

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Step 2: Determine the validity of authorization.

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(Brodnik 2017b). The HIM professional will compare the

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Protecting the security and privacy of patient authorization form signed by the patient
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information is one of a healthcare organization’s with organizational requirements for

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top priorities, and the HIM department is usually authorization to determine the validity
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responsible for determining appropriate access to of the authorization form. The healthcare
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and disclosure of health information from patient organization’s requirements are based on
20
health records. For example, disclosure of health

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state and federal (for example, HIPAA)

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information may take the form of a patient’s regulations. Certain types of information
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request to mail copies of his or her health records such as substance abuse treatment records,
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to a healthcare provider. behavioral health records, and HIV records

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require that specific components be included

The Disclosure of Health Information in the authorization form per state and federal
Function regulations. If the request is valid, the HIM
professional proceeds to the next step. If the
Management of the disclosure of health informa- authorization is invalid, the problem with
tion function includes the following steps: the authorization is noted in the disclosure of
Step 1: Enter the request in the disclosure health information database and it is returned
of health information database. Generally, to the requester with an explanation.
information such as patient name, date Step 3: Verify the patient’s identity. The HIM
of birth, health record number, name of professional must verify that the patient has
requester, address of requester, telephone been a patient at the healthcare organization.
number of requester, purpose of the request, To do this, the HIM professional compares the
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Figure 9.6 Disclosure of health information database screen
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Source: ©CIOX Health eSmartlog. Used with permission.
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information on the authorization form with HIM departments outsource disclosure of health
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information in the master patient index. The information to companies that specialize in this
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patient’s name, date of birth, Social Security function. This may be done to keep pace with re-
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number, address, and phone number are used quests or to eliminate backlogs. These outsource
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to verify the identity of the patient whose companies are BAs and therefore must meet all of
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record is requested. The patient’s signature the requirements of a BA. Even with outsourcing,
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in the health record is compared with the however, the HIM department remains ultimately
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patient’s signature on the authorization for responsible for ensuring that proper practices and
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disclosure of health information form. all laws are followed.

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Step 4: Process the request: The health record

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is retrieved (paper or electronic) and only Disclosure of Health Information

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the information authorized for release is Quality Control

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copied or printed and released. The patient Quality control in disclosure of health information
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information may also be faxed or otherwise includes both productivity (that is, turnaround
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released directly from the EHR. time) and accuracy (namely, that information is
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20
To comply with the Privacy Rule, a healthcare or- released appropriately). The HIM department
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ganization must maintain an account of disclosures. receives a high volume of requests and must
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Disclosure of health information may also be a prioritize the processing of disclosure of health
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response to a subpoena duces tecum (discussed in information. Continuity of care requests are pro-
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chapter 8, Health Law). It is necessary to verify that cessed before other types of requests to align with
the subpoena is valid, and the requested informa- the mission of most healthcare organizations. The
tion may be released to the court in compliance HIM department must establish productivity stan-
with applicable state or federal law. In response dards to meet the expected turnaround time of
to a subpoena, a representative from the HIM de- various requests. With these standards the average
partment may appear in person either in court or turnaround times for disclosure of health informa-
at a deposition and give sworn testimony as to the tion may be tracked, and delays in responding
health record’s authenticity. to requests for information may be addressed.
The disclosure of health information function While productivity information may be collected
has grown immensely in the past decade, due in manually, electronic systems offer tools for data
part to the Privacy Rule. Staffing has increased in manipulation and can provide individual produc-
some departments to address this growth. Other tion statistics, departmental request volumes, and
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information regarding request turnaround times. ●● A description of the information to be used

The accuracy of disclosure of health information or disclosed that identifies the information in
must also be monitored. The following examples a specific and meaningful fashion
illustrate how the timeliness and accuracy of dis- ●● The name or other specific identification of
closure of health information can be monitored. the person(s), or class of persons, authorized
To monitor timeliness, the date a request is to make the requested use or disclosure
received and the date that health records are sent
●● The name or other specific identification of the
are entered into a disclosure of health information
person(s), or class of persons, to whom the CE
database. This information can be used to gener-
may make the requested use or disclosure
ate a report that will determine whether the health
records are being sent in a timely manner. ●● An expiration date or event that relates to
To monitor accuracy of disclosure of health in- the individual or the purpose of the use or
disclosure
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formation, random authorizations are checked to
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verify their validity and to ensure compliance with A statement of the individual’s right to
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federal and state regulations. A validation that the revoke the authorization in writing and the
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appropriate health records were released is also exceptions to the right to revoke, together
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conducted. The error rate (or, alternatively, the with a description of how the individual
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accuracy rate) can be determined and compared may revoke
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against a set standard established by the health- A statement that information used or
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●●
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care organization (Cerrato and Roberts 2013). disclosed pursuant to the authorization
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may be subject to redisclosure (subsequent
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Authorizations
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disclosure of health information) by the

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Authorizations have long been a key component recipient and no longer protected by this rule
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of the disclosure of health information process,

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●● Signature of the individual and date

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used as a tool to document and validate the legal

When the authorization is signed by a
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●●
use and disclosure of health information. While
an
personal representative of the individual, a

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the Privacy Rule generally requires authoriza-

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description of the representative’s authority

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tion for the use and disclosure of PHI and speci-

to act for the individual (45 CFR 164.508(c))
fies situations where authorization is not required
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(discussed earlier in this chapter), it also speci-

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An authorization is considered invalid when

fies requirements for a valid authorization form.
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any one of the following defects exists:

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Elements of the authorization form, such as pa-

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tient name and signature, dates of service to be ●● The expiration date has passed or the
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expiration event is known by the CE to have

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released, and names of the entities both disclosing

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and receiving the information, are well established

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in health information practice. However, with the ●● The authorization has not been filled out
passage of the Privacy Rule many established completely
health information practices have also become ●● The authorization is known by the CE to
legal requirements. have been revoked
Valid Authorization ●● The authorization lacks a required element

(for example, appropriate signature)
The Privacy Rule provides specific parameters re-
garding the content required for a valid authori- ●● The authorization violates the compound
zation. Under the Privacy Rule, an authorization authorization requirements, if applicable
must be written in plain language. A valid author- ●● Any material information in the
ization is one that contains at least the following authorization is known by the CE to be false
elements: (45 CFR 164.508(b))
AB103118_Ch09.indd 276 2/6/2020 4:46:10 PM

Health information professionals must also en- Table 9.5 Authority to grant authorization for
sure the validity of an authorization by confirming disclosure of health information
that the patient or patient’s personal representa-
Permitted
tive actually signed the form (through signature to authorize If no, who can
comparisons), the person who signed the form disclosure? authorize disclosure?
is legally competent, and evidence does not ex- Legally competent Yes N/A
adult
ist indicating the authorization form was signed
Legally No Personal representative
involuntarily or without the patient’s knowl- incompetent adult (for example, guardian)
edge (Brodnik 2017b). When the patient or other (permanent)
authorized individual picks up the health in-
Legally No Personal representative
formation, he or she must validate their identity – incompetent adult (until competency is
(temporary) restored) (for example,
generally with a drivers license. guardian)
n.
Minor No Personal representative
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Who Can Authorize Release (for example, parent or
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guardian)
Legally competent individuals have the right to
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Source: © AHIMA
authorize or refuse to authorize the disclosure
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of their own health information. As noted previ-
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ously in this chapter, the Privacy Rule provides disability (such as a developmental disability) or
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many exceptions to the authorization require- a temporary condition (for example, incompetent
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ment. Additionally, there are situations where an to stand trial until restored to competency). A le-
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individual is deemed not legally competent, and io
gal guardian then acts to handle the matters of the
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authority to authorize release of their health in- incompetent individual, including authorizing the
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formation resides with someone else. For example, release of health information. Table 9.5 highlights
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by law (and with exceptions), minors are deemed the authority to grant authorization based on the
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legally incompetent and a personal representative type of individual whose health information is
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(a parent or guardian) will provide the authoriza- involved. Where highly sensitive information is
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tion. Minors who are emancipated, given a legal involved, such as behavioral health, substance
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status that gives them full rights to make deci- abuse, HIV/AIDS, or genetic information, the
sions for themselves, can authorized the release. same principles apply regarding who has the legal
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The requirements for emancipation vary by state authority to authorize the disclosure of health in-
by
but generally apply when the minor is married, is formation. However, legal requirements and best
20
20
self-supporting, and lives on their own (Brodnik practices also dictate that individuals specifically
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2017a). In other words, they are not living with or designate their permission and forms denote indi-
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receiving support from their parents. Adults may viduals’ awareness that highly sensitive informa-
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also be legally incompetent by virtue of a permanent tion will be released.

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Medical Identity Theft

Medical identity theft is a crime that the falsifying of claims for medical services in an
challenges healthcare organizations and the health attempt to obtain money (Dixon 2006). Regardless
information profession. A type of healthcare fraud of the purpose, the individual’s health information
that includes both financial fraud and identity is either created under the wrong name or altered,
theft involves either (a) the inappropriate or un- leading to potentially deadly consequences. Medi-
authorized misrepresentation of one’s identity (for cal identity theft does not include the inappropriate
example, the use of one’s name and Social Security change of patient information if the patient’s iden-
number) to obtain medical services or goods, or (b) tity has not been assumed or abused by someone
AB103118_Ch09.indd 277 2/6/2020 4:46:10 PM

else. Likewise, using a patient’s financial informa- identity theft. As a result, medical information
tion to purchase nonmedical goods or service is about the culprit is created under the victim’s
not medical identity theft because there are finan- name, and information about the two individuals
cial, but not medical, consequences. may be intertwined (Olenik and Reynolds 2017).
Medical identity theft can be internal or external. The addition of information about another patient
Internal medical identity theft is committed by in- in the victim’s record can result in improper med-
siders in a healthcare organization, such as clinical ical treatment. For example, if the perpetrator’s
or administrative staff with access to vast amounts blood type is wrongfully entered into the victim’s
of patient information. Culprits range from indi- record, the victim could receive a transfusion of
viduals acting alone to sophisticated crime rings the wrong blood type. This is potentially fatal.
that may infiltrate a healthcare organization to The World Privacy Forum suggests that internal
commit internal medical identity theft. Individu- crimes occur more frequently than external ones
n.
als outside a healthcare organization who assume (Dixon 2006). Further, there is concern that the ev-
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a person’s identity, perhaps to utilize the victim’s olution of the EHR may assist culprits by granting
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health insurance benefits, commit external medical them broad access to patient information.
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Patient Verification
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It is important to verify a patient’s iden- as screen savers and automatic logoffs. These tech-
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tity at the beginning of a healthcare encounter by io
nical safeguards are discussed in chapter 10, Data
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requiring presentation of a driver’s license, taking Security.

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a photograph of the patient for future reference,

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or even using biometric identifiers such as finger- Fair and Accurate Credit Transactions
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prints. However, there are two caveats. Patient

Act (FACTA)
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verification does not hinder internal medical iden-

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The federal Fair and Accurate Credit Transactions

ic
tity theft. Further, the measures listed rely on valid

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Act (FACTA) requires financial institutions and

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baseline patient verification. If the information the

healthcare organization relies upon is the culprit’s creditors to develop and implement written identity
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information (for example, photo, signature, or fin- theft programs that identify, detect, and respond to
by
red flags that may signal the presence of identity

20
gerprint), all future encounters will be based on

20
fraudulent information, decreasing the chances theft. Although this law does not specifically address
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of detecting the fraud or otherwise causing the medical identity theft, many healthcare organizations
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meet the definition of creditor, which is anyone who

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healthcare organization to wrongfully identify the

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meets one of the three following criteria:

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true patient as the culprit if he or she later pres-

C
ents to that healthcare organization for treatment. 1. Obtains or uses consumer reports in
Measures to combat internal medical identity theft connection with a credit transaction
include performing background checks on new 2. Furnishes information to consumer reporting
hires and contractors (Olenik and Reynolds 2017). agencies in connection with a credit
The collection of Social Security numbers should transaction
be limited, and staff access to this sensitive in-
3. Advances funds to—or on behalf of—
formation should also be limited. EHR access and
someone, except for funds for expenses
access to other business records should only be
incidental to a service provided by the
given to the extent that people need information
creditor to that person
to complete their jobs. Technical measures also in-
clude routinely monitoring access or attempted The law includes the Red Flags Rule, which
access through audit trails and using features such consists of five categories of red flags that are used
AB103118_Ch09.indd 278 2/6/2020 4:46:10 PM

as triggers to alert the healthcare organization to a 5. Notices from customers, victims of identity
potential identity theft (16 CFR Part 681). The fol- theft, law enforcement authorities, or other
lowing are the five categories are: businesses about possible identity theft in
connection with an account (16 CFR Part 681)
1. Alerts, notifications, or warnings from a
consumer reporting agency
In addition to mandated red flags, healthcare
2. Suspicious documents providers must act to prevent, detect, and mitigate
3. Suspicious personally identifying information activities in an effort to address both external and
such as a suspicious address internal incidents. Employee awareness and train-
4. Unusual use of, or suspicious activity relating ing, and implementation of organization-wide
to, a covered account policies and procedures, are important.
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Patient Advocacy
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Over time, the role of the HIM professional best practices. However, as the healthcare industry
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has evolved. It continually becomes more multifac- has placed increasing emphasis on patient-centered
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eted. Today, it includes the role of patient advocate. healthcare, patient empowerment, and health literacy,
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As a patient advocate, the HIM professional is a stew- health information professionals must also prioritize
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ard of the patient’s health record, ensuring not only its patient rights to ensure the patients gain needed and
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integrity but also safeguarding it according to all ap- io
legal access to their health records and have the tools to
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plicable laws, policies and procedures, and industry understand the information documented about them.
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Compliance
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Compliance is an industry concept environmental regulations). This chapter has fo-

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that means conformance with applicable laws. cused on laws that regulate the privacy of patient
e
A culture of compliance within a healthcare information, most notably the HIPAA Privacy
th
organization is critical. Healthcare is a heavily

Rule. Compliance with the Privacy Rule is criti-
by
20
regulated industry and there are many healthcare- cal to safeguard individuals’ health information
20
specific laws and relevant non–healthcare-specific and preserve their dignity while, at the same time,
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laws with which healthcare organizations must avoiding penalties that are assessed as the result
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comply (for example, fair labor standards and

of noncompliance.
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HIM Roles
Health information privacy has always ●● Promotion of organizational privacy
been a core principle of the HIM profession. The awareness
HIPAA Privacy Rule has codified that principle, ●● Performance of privacy risk assessments
while also making the role of privacy officer a re-
●● Maintenance of HIPAA-required forms and
quired position. Standard privacy officer responsi-
records
bilities include the following:
●● Facilitation of privacy training sessions and
●● Development and implementation of maintenance of training records
privacy policies and procedures ●● Compliance monitoring of BAs
AB103118_Ch09.indd 279 2/6/2020 4:46:11 PM

●● Protection of patient health information ●● Internal investigation of alleged HIPAA

rights Privacy Rule violations
●● Knowledge of applicable laws and ●● Participation in breach notification analyses
accreditation standards ●● Reporting and mitigation of breaches
●● Receipt of complaints alleging HIPAA ●● Communication with OCR and other entities
Privacy Rule violations in compliance reviews and investigations

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1. Medical identity theft includes:
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a. Using another person’s name to obtain durable medical equipment
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b. Purchasing an EHR
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c. Purchasing surgical equipment
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d. Using another healthcare provider’s national provider identifier to submit a claim
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2. Per the Fair and Accurate Credit Transactions Act (FACTA), which of the following is not a red flag category?
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a. An account held by a person who is over 80 years old
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b. Warnings from a consumer reporting agency
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c. Unusual activity relating to a covered account
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d. Suspicious documents
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3. Misty is the privacy officer for a large physician practice. She is preparing training sessions about HIPAA Privacy
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policies and procedures that have been recently updated. Misty is working with administration to make some
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decisions about the training sessions. Which of the following is correct?

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a. Every member of the covered entity’s workforce should be trained.

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b. Only individuals employed by the covered entity should be trained.

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c. Training materials, such as PowerPoints, are to be retained for five years.

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d. Training attendance logs do not have to be retained.

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4. As a general rule, which of the following is a legally competent individual?

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a. A minor with a developmental disability

20
20
b. An adult with a developmental disability

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c. A minor without a developmental disability

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d. A minor’s personal representative

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5. The King’s Hospital Foundation is reviewing its protocol for an upcoming fundraising appeal. Which of the following is
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true regarding the HIPAA Privacy Rule and fundraising?

a. Fundraising materials do not have to include opt-out instructions.
b. Prior authorization is required if individuals are not targeted based on diagnosis.
c. Individuals must be informed in the Notice of Privacy Practices that their information may be used for fundraising
purposes.
d. Authorization is always required for fundraising solicitations.
6. The use or disclosure of PHI for marketing:
a. Always requires written authorization from the patient
b. Does not require written authorization for face-to-face communications with the individual
c. Requires written authorization from the patient when products or services of nominal value are introduced
d. Never requires written authorization from the patient
AB103118_Ch09.indd 280 2/6/2020 4:46:11 PM

7. Mary’s PHI has been breached. She must be informed of all of the following except:
a. Who committed the breach
b. Date the breach was discovered
c. Types of unsecured PHI involved
d. What she may do to protect herself
8. The privacy officer is responsible for all of the following except:
a. Handling complaints about the covered entity’s violations of the Privacy Rule
b. Developing and implementing privacy policies and procedures
c. Providing information about the covered entity’s privacy practices
d. Encrypting all electronic PHI
9. Beth is the privacy officer at Kings Hospital. She knows that she must report breaches to the Office for Civil Rights in
the Department of Health and Human Services. Which of the following breach notification statements is correct?
n.
a. She is only required to report breaches when 500 or more individuals are affected.
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b. She must report breaches of both secured and unsecured PHI.
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c. She must report a breach even when only one person’s PHI is breached.
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d. Breach notification only applies when 20 or more individuals are affected.
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10. A valid authorization must contain all the following except:
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a. A description of the information to be used or disclosed
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b. A signature and stamp by a notary
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c. A statement that the information being used or disclosed may be subject to redisclosure by the recipient
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d. An expiration date or event io
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Real-World Case 9.1

H
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HIPAA privacy breaches are of great con- employment separation can avoid breaches. Pro-
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cern and they occur too frequently. The Office for

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cedures that incorporated a routine termination

Civil Rights (OCR) in the Department of Health and process would have prevented an incident of this
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Human Services reported in December 2018 that a nature.

by
critical access hospital in Colorado reached a settle- The fact that this incident involved a critical
20
20
ment via a resolution agreement to pay $111,400 to access hospital, which is small by definition and
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HHS and to adopt a corrective action plan because in comparison, to its multi-hospital healthcare
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it allowed a former employee to have continued system counterparts, demonstrates that breach-
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remote access to ePHI, affecting 557 individuals. es and penalties resulting from breaches do not
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No business associate agreement had been signed occur in large organizations only. Covered en-
with the former employee (HHS 2018b). tities and business associates of all types and
This case highlights that actions as simple as sizes can commit breaches and be penalized
immediately terminating access to systems upon for them.
Real-World Case 9.2

Anndorie Cromar is a medical iden- with drugs in her system, the state’s child protec-
tity theft victim. A pregnant woman used Cro- tive services (CPS) assumed she was Cromar’s in-
mar’s medical identity to pay for maternity care fant and threatened to take Cromar’s four children
at a nearby hospital. Because the infant was born away. It required a DNA test to get her name off
AB103118_Ch09.indd 281 2/6/2020 4:46:11 PM

of the infant’s birth certificate, but years to get her ●● Routinely review credit reports for debts
health records corrected. “That first stage was the that do not belong to them
most terrifying thing I’ve ever experienced in my ●● Treat insurance cards and policy
life, getting the call from CPS and having them say, numbers with the same care as Social
‘We are coming to take your kids’” (Andrews 2016). Security numbers, and not share them
Medical identify theft is not detected and readily
stopped readily like financial fraud, where the
bank or credit card company calls when they see Additionally, consumers should not post in-
suspicious charges on a person’s account. Consum- formation about medical treatments on social
ers therefore need to be particularly vigilant about media. A criminal could use that information,
information that can be stolen to commit medical along with other personal data located online,
identity theft: personal, medical, and insurance in- to create a complete and accurate profile by
which to exploit the victim. Once the perpe-
n.
formation. Consumers should do the following:
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trator’s and victim’s medical information are
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Scrutinize insurance company explanation
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●●
intertwined, it is much more difficult to undo
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of benefits forms and correspondence from than simple financial identity theft cases. Fur-
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healthcare providers and health insurers ther, because medical identity theft involves
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●● Be suspicious of inaccurate statements and a person’s health profile, it cannot be shut
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bills, including documentation relating to down as quickly as a credit card number can
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services they did not receive (Andrews 2016).
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References
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In
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ea
Amatayakul, M. 2003. HIPAA on the job: Another Brodnik, M.S. 2017a. Introduction to the Fundamentals
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layer of regulations: Research under HIPAA. Journal of of Law for Health Informatics and Information
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AHIMA 74(1):16A–16D. Management. Chapter 1 in Fundamentals of Law for

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American Health Information Management Health Informatics and Information Management. Edited
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Association. 2016. Guidelines for a Compliant Business by M.S. Brodnik, L.A. Rinehart-Thompson, and R.B.
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Reynolds. Chicago: AHIMA.

th
Associate Agreement. http://library.ahima.org/

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doc?oid=301918#.XCp2H_ZFw2w. Brodnik, M. 2017b. Access, Use, and Disclosure

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American Health Information Management and Release of Health Information. Chapter 15

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Association. 2015. Sample (Chief) Privacy Officer in Fundamentals of Law for Health Informatics and
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Job Description. http://library.ahima.org/ Information Management. Edited by M.S. Brodnik, L.A.

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Rinehart-Thompson, and R.B. Reynolds. Chicago:

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doc?oid=107672#.Vw_3FPkrLDc.
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AHIMA.
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Association. 2017. Pocket Glossary of Health Information Cerrato, L. and J. Roberts. 2013. Health Information
Management and Technology, 5th ed. Chicago: Functions. Chapter 7 in Health Information Management
AHIMA. Technology: An Applied Approach. Edited by N. Sayles.
Chicago: AHIMA.
Association. 2009. Analysis of health care Dixon, P. 2006 (May 3). Medical identity theft: The
confidentiality, privacy, and security provisions of information crime that can kill you. World Privacy
the American Recovery and Reinvestment Act of Forum. http://www.worldprivacyforum.org.
2009, Public Law 111-5. http://library.ahima.org/ Department of Health and Human Services. 2018a.
PdfView?oid=91955. Research. https://www.hhs.gov/hipaa/for-
Andrews, M. 2016 (August 25). The rise of medical professionals/special-topics/research/index.html.
identity theft. Consumer Reports. https://www. Department of Health and Human Services. 2018b.
consumerreports.org/medical-identity-theft/medical- Colorado hospital failed to terminate former
identity-theft/. employee’s access to electronic protected health
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information. U.S. Department of Health and Human Rinehart-Thompson, L.A. 2018. Introduction to Health
Services. Resolution Agreements. https://www. Information Privacy and Security. Chicago: AHIMA.
hhs.gov/hipaa/for-professionals/compliance- Rinehart-Thompson, L. and L. Harman. 2017. Privacy
enforcement/agreements/index.html. and Confidentiality. Chapter 3 in Ethical Health
Department of Health and Human Services. 2016. Informatics: Challenges and Opportunities, 3rd ed. Edited
Individuals’ Right under HIPAA to Access their Health by L. Harman and J. Glover. Burlington, MA: Jones &
Information 45 CFR 164.524. https://www.hhs.gov/ Bartlett Learning.
hipaa/for-professionals/privacy/guidance/access/ Walsh, T. 2016 (February 23). E-mail exchange with
index.html. author. tw-Security. http://www.tw-security.com/.
Department of Health and Human Services. 2015. 5 USC 552a: Privacy Act. 1974.
Guidance Regarding Methods for De-identification
of Protected Health Information in Accordance with 16 CFR Part 681: Identity Theft Rules. 2012.
the Health Insurance Portability and Accountability 45 CFR 160.103: Definitions. 2013.
Act (HIPAA) Privacy Rule. https://www.hhs.gov/
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45 CFR 164.501: Definitions. 2013.
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hipaa/for-professionals/privacy/special-topics/de-
45 CFR 164.502(a)(1)(iii): Uses and disclosures of
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identification/index.html.
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protected health information: general rules. 2013.
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Department of Health and Human Services. 2013.
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Breach Notification Rule. https://www.hhs.gov/ 45 CFR 164.506(b): Consent for uses and disclosures
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hipaa/for-professionals/breach-notification/index. permitted. 2013.
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html. 45 CFR 164.508: Uses and disclosures for which an
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authorization is required. 2013.
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HIPAA Privacy Rule accounting of disclosures under 45 CFR 164.508(a): Authorizations for uses and
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the Health Information Technology for Economic and io
disclosures. 2013.
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Clinical Health Act. 45 CFR Part 164. Federal Register
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45 CFR 164.508(b): Implementation specifications:

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76(104):31426–31449.
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General requirements. 2013.

In

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45 CFR 164.508(c): Implementation specifications: Core

Modifications to the HIPAA Privacy, Security, and
ea
elements and requirements. 2013.

H
Enforcement Rules under the Health Information

45 CFR 164.510: Uses and disclosures requiring an
an
Technology for Economic and Clinical Health Act;

ic
Proposed Rule. 45 CFR Parts 160 and 164. Federal opportunity for the individual to agree or to object. 2013.
er
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Register 75(134):40868–40924. 45 CFR 164.510(b): Uses and disclosures for

involvement in the individual’s care and notification
e
Department of Health and Human Services. 2006

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(last reviewed 2013). How are covered entities purposes. 2013.

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expected to determine what is the minimum necessary 45 CFR 164.512: Uses and disclosures for which an
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information that can be used, disclosed or requested authorization or opportunity to agree or object is not
©
for a particular purpose? https://www.hhs.gov/ required. 2013.

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hipaa/for-professionals/faq/207/how-are-covered- 45 CFR 164.512(a): Uses and disclosures required by

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entities-to-determine-what-is-minimum-necessary/
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law. 2013.
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index.html.
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45 CFR 164.512(b): Uses and disclosures for public

Department of Health and Human Services. 2000. health activities. 2013.
Federal Register 65(250):82818.
45 CFR 164.512(c): Disclosures about victims of abuse,
McLendon, K. and A. D. Rose. 2013. Notice of Privacy neglect or domestic violence. 2013.
Practices (2013 update). AHIMA Practice Brief. http://
bok.ahima.org/doc?oid=107006#.Vtn_b_krJQI. 45 CFR 164.512(d): Uses and disclosures for health
oversight activities. 2013.
Office of the National Coordinator for Health
Information Technology. 2018. Healthit.gov. 45 CFR 164.512(e): Disclosures for judicial and
administrative proceedings. 2013.
Olenik, K. and R.B. Reynolds. 2017. Security Threats
and Controls. Chapter 13 in Fundamentals of Law for 45 CFR 164.512(f): Disclosures for law enforcement
Health Informatics and Information Management. Edited purposes. 2013.
by M.S. Brodnik, L.A. Rinehart-Thompson, and R.B. 45 CFR 164.512(g): Uses and disclosures about
Reynolds. Chicago: AHIMA. decedents. 2013.
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45 CFR 164.512(h): Uses and disclosures for 45 CFR 164.514(f): Standard: uses and disclosures for
cadaveric organ, eye or tissue donation purposes. fundraising. 2013.
2013. 45 CFR 164.520: Notice of privacy practices for
45 CFR 164.512(i): Uses and disclosures for research protected health information. 2013.
purposes. 2013. 45 CFR 164.522(a)(1): Right of an individual to request
45 CFR 164.512(j): Uses and disclosures to avert a restriction of uses and disclosures. 2013.
serious threat to health or safety. 2013. 45 CFR 164.522(b)(1): Confidential communications
45 CFR 164.512(k): Uses and disclosures for specialized requirements. 2013.
government functions. 2013. 45 CFR 164.524: Access of individuals to protected
45 CFR 164.512(l): Disclosures for workers’ health information. 2013.
compensation. 2013. 45 CFR 164.526: Amendment of protected health
45 CFR 164.514(b)(2)(i): Implementation specifications: information. 2013.
Requirements for de-identification of protected health
n.
45 CFR 164.528: Accounting of disclosures of protected
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information health information. 2013.
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45 CFR 164.514(e)(2): Implementation specification: 45 CFR 164.530(d)(1): Complaints to the covered entity.
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Limited data set. 2013. 2013.
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Chapter
Chapter
10
3
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Data Security
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Megan R. Brickner, MSA RHIA
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•• Identify threats to the security of data •• Identify the primary components of the security
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•• Demonstrate the elements of a data security program provisions of the Health Insurance Portability
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•• Demonstrate methods of incident detection and Accountability Act and extensions by the
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•• Identify methods to safeguard data from HITECH Act and American Recovery and
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inappropriate access Reinvestment Act

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•• Apply disaster planning and disaster recovery •• Recommend methods of ensuring the availability
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mechanisms to a situation where data availability of data

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has been disrupted •• Recommend methods of forensics

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Key Terms
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Access control Computer virus Disaster recovery plan

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Access safeguards Computer worm Edit check

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Administrative safeguards Context-based access control Electronic protected health

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Application control (CBAC) information (ePHI)

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Application safeguards Contingency plan Emergency mode of operations

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Audit control Cryptography Encryption

Audit trail Data availability External threats
Authentication Data consistency Firewall
Authorization Data definition Forensics
Automatic logout Data integrity HIPAA Security Rule
Backdoor program Data loss prevention Impact analysis
Baiting Data security Implementation specifications
Biometrics Decryption Incident
Business continuity plan (BCP) Digital certificates Incident detection
Chief security officer (CSO) Digital signatures Information technology
285
285
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Information Technology Asset Public key infrastructure (PKI) Social engineering

Disposition (ITAD) Ransomware Spear phishing
Internal threats Risk analysis Spyware
Intrusion detection Risk management Tailgating
Intrusion detection system (IDS) Role-based access control (RBAC) Technical safeguards
Likelihood determination Rootkit Token
Malware Security Trigger events
Network controls Security breach Trojan horse
Password Single-key encryption Two-factor authentication
Phishing Single sign-on Unsecured electronic protected
Physical safeguards Smart card health information
Private key infrastructure Sniffers User-based access control (UBAC)
n.
Privacy, as described in chapter 9, Data Privacy and ●● What, if any, data should be collected?
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Confidentiality, is a fundamental right to be undis- ●● How can it be used?
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turbed by intrusion. Privacy, within the context of
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●● Who can have access to it?
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one’s own personal data or the sensitive data be-
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longing to an organization, is the ability and the
●● How long should the data kept?
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right of an individual or organization to control ●● How does one control the access to data once
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it is obtained?
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the collection, use (how a healthcare organiza-
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tion avails itself of health information), and dis-
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closure (how information is disseminated) of that
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Once those questions are answered and stan-
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personal and sensitive data. Use and disclosure dards and thresholds are put into place, security
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are also defined in chapter 9. Security is the prac- controls can be used. Security controls protect the
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tice or means by which privacy is preserved and privacy of data by limiting the access to personal
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protected. Data security, on the other hand, is the and sensitive information and protecting the data
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process of keeping data, both in transit and at rest, from unauthorized access, use, and disclosure as
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safe from unauthorized access (access to data by well as protect the data from unauthorized altera-
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individuals who should not have access), alteration and destruction. Security controls include
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tion (unauthorized modification), or unauthorized administrative, physical, and technical safeguards

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by
destruction (destroying data without permission). that will be addressed in this chapter. It is impor-
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Very often, the terms data security and data privacy tant to note that it is impossible to establish and
20
are used interchangeably, although they have very maintain data privacy without data security. Data
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different meanings. Protecting the privacy of data security ensures that the data are kept confiden-
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starts with addressing the following questions: tial and maintains data integrity and availability.
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Ensuring the Integrity of Data

Data integrity means that data are com- data to the retrieval and, if applicable, the destruc-
plete, accurate, consistent, and up to date so the tion of the data. Data integrity also ensures data
data are reliable. Reliability is a measure of consist- recoverability and searchability by ensuring the
ency of data items based on their reproducibility accuracy and consistency of stored data. For ex-
and an estimation of their error of measurement. ample, with a database, automated error checking
In other words, data are always the same. Data in- and data validation ensure data integrity. Data in-
tegrity must be maintained over the data life cycle, tegrity is the extent to which healthcare data are
beginning with the design and implementation of complete, accurate, consistent, and timely. Data in-
the information systems that collect and store the tegrity ensures the data are of the best quality and
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accuracy throughout their life cycle. Data integ- is important because healthcare providers use
rity is a part of data governance and information it when making decisions about patient care.
governance, which are covered in chapter 6, Data Human error, software bugs, viruses, hardware
Management. Within the healthcare setting, data malfunctions, storage media and server crashes,
integrity ensures the completeness and accuracy and natural disasters such as water and fire can
of health record documentation maintained with- compromise the integrity of data. Robust security
in an electronic health record (EHR) as described programs will be able to respond to such incidences
in chapter 1, Health Information Management Pro- to ensure the data are recovered and data integrity
fession. Ensuring the integrity of healthcare data is maintained.
Ensuring the Availability of Data
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Ensuring data availability means that provide additional support for the operating
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making sure the organization can depend on the systems, be adequately and systematically backed
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information system to perform as expected, and to up, including all updates to the software which
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provide information when and where it is needed. address any vulnerabilities that occur with the
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In healthcare, it is important that patient data information system. The policy may also indicate
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are accessible and available at all times. Retrieval whether a full procedure (all data at one time) or
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and access problems occur when the information incremental procedure (only the data since the
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system is unreliable or unavailable (for example, io
last backup) is performed and the frequency with
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either planned or unplanned downtime). Patient which it should occur (such as daily or weekly).
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data should be available seven days a week, 24 Documentation should record what is backed
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hours a day to facilitate patient care. To keep the

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up and where the backed-up data are stored.

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data available, hardware must be maintained and Copies of backup media and records of backups
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replaced when necessary. Software also must be should be stored at a secure location away from
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updated to ensure any issues and security vulner- the site where the original records are stored. For
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abilities are corrected. Healthcare organizations example, the healthcare organization located in
must have backup and downtime procedures in Alabama might back their data up at a location
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place to ensure patient care and business oper- in Kansas. This action is taken so that if a disaster
by
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ations can continue in the event of a disruption; such as a fire or flood occurs at the main site, back-
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for example, if the computer network goes down up copies will be unaffected. There are many com-
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and data cannot be accessed electronically. Backup panies that specialize in digital off-site storage.
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procedures are also necessary to be in compliance To ensure the backups are working properly,
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with federal and state regulations. Data backup regular tests of restoring data and software from
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procedures may involve server redundancy (du- backed-up copies should be performed to ensure
plicate information on one or more servers) and the data can be restored if the data are lost. This loss
sending data to off-site contracted vendors or data can be due to hardware failure or other destruction
warehouses for safe and secure storage and access. of data or other failure.
Backup policies and procedures should specify Information systems have both planned and
what files and programs require backup, what type unplanned downtimes that affect information sys-
of backup should be performed, how frequently it tem availability. For example, planned downtime
should occur, and how it is to be conducted. For may occur when system upgrades are scheduled.
example, a backup policy and procedure may re- Unplanned downtime may occur due to an un-
quire that all data operating systems, which consist foreseen disruption such as an electrical outage or
of software that run the basic functions of a com- hardware failure. In either case, protocols should
puter, and utility files, which are small programs be developed to maintain data availability to the
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greatest extent possible. These protocols should be or destroys information. Therefore, the healthcare
part of the regular information technology infra- organization’s security program must have pro-
structure and incorporated into the security protections in place to monitor its employees and
gram of the healthcare organization. to keep outsiders from harming or accessing in-
Every healthcare organization is subject to se- formation resources. These protections will be
curity breaches, or unauthorized data or system addressed later in this chapter. A data loss pre-
access, by people from both inside and outside the vention strategy, which assists organizations
healthcare organization. It is essential to recognize with controlling and limiting what (sensitive)
the scope of the data security needs of the health- data are moved or transferred outside of an orga-
care organization and to develop a systematic and nization’s information technology infrastructure
comprehensive program to deal with them. Secu- by individuals, is also an essential element of data
rity breaches also can occur through hardware or availability and contributes to the overall effec-
n.
software failures and when an intruder hacks into tiveness of a data security program. Effective data
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the information system. More often, however, the security does not just happen. It requires planning,
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security breach occurs when an employee within training, and the implementation of realistic pol-
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a healthcare organization either accesses informa- icies and procedures that address both internal
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tion without authorization or deliberately alters and external threats.
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Data Security Threats n
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Before implementing a data security 2. Threats from insiders who abuse their access
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program, it is important to understand the poten- privileges to information. Examples include

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tial threats to data security. Threats from a num- employees who knowingly disclose
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ber of sources can cause the loss of data privacy, information about a patient to individuals
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and compromise data integrity or the availability who do not have proper authorization;
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of data. All threats can be categorized as either employees with access to computer files
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internal threats (threats that originate within an who purposefully snoop for information
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organization) or external threats (threats that orig- they do not need to perform their jobs; and
by
inate outside an organization) (Rinehart-Thompson employees who store information on a thumb

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2018). Both internal threats and external threats or flash drive, remove it from the organization
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can be caused by people or by environmental and on a laptop or other storage device, and
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hardware and software factors. subsequently lose the device or have it stolen.
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3. Threats from insiders who access information

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Threats Caused by People

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or computer systems for spite or profit.

Humans are the greatest threat to electronic health Generally, such employees seek information
information. Threats to data security from people to commit fraud or theft. Identity theft—
can be classified into the following five general stealing information from patients, their
categories: families, or other employees—is on the
1. Threats from insiders who make unintentional rise and can r esult in prosecution of those
errors. Examples include employees who employees who obtained that information
accidentally make a typographical error, unlawfully.
inadvertently delete files on a computer 4. Threats from intruders who attempt to access
disk, or unknowingly disclose confidential information or steal physical resources. Individuals
information. Unintentional error is one of the may physically come onto the organization’s
major causes of security breaches. property to access information or steal
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equipment such as laptop computers Social engineering techniques will be discussed

or printers. They also may loiter in the further in this chapter.
organization’s buildings hoping to access The four main types of social engineering
information from unprotected computer (phishing, spear phishing, baiting, and tailgating)
terminals or to read or take paper documents, are the following:
computer disks, or other information.
5. Threats from vengeful employees or outsiders 1. Phishing. This is the most common type of
who mount attacks on the organization’s social engineering technique. Phishing is
information systems. Disgruntled employees accomplished using email. The hackers send
might destroy computer hardware or a target what appears to be a legitimate email
software, delete or change data, or enter correspondence from a legitimate company
data incorrectly into the information system. or organization requesting that the target
click a link within the email and provide,
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Outsiders might mount attacks that can harm
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the organization’s information resources. typically, log-in and password credentials to
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For example, malicious hackers can plant an information system or application. For
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example, a target may receive a phishing
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viruses in a computer s ystem or break into
email from what appears to be his or her
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telecommunications systems to degrade
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or disrupt information system availability bank. The hacker develops an email that looks
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(Olenik and Reynolds 2017). very similar to legitimate correspondence
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from the target’s bank. The hacker then
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Four of the threats listed can involve an orga- would alert the target that there is something
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nization’s employees; therefore, it is important for wrong with his or her account and the target
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an organization to remain vigilant to ensure their must click a link and provide his or her
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employees and others with routine access to patient credentials to have the matter resolved.
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data appropriately use this data.

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2. Spear Phishing. Spear phishing is similar to

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phishing but requires a little more work on the

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Social Engineering part of the hacker. When the hacker engages

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in spear phishing, the hacker researches the

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Although sophisticated technological breaches of

data security occur and are discussed in the me- individual whose identity the hacker will
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dia, the most common way that hackers (unau- assume by looking up social media accounts
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thorized individuals) breach the security of data and researching the individual’s activity on
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is through the deployment of social engineering. the web. The hacker will typically assume
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Social engineering, within the context of data the identity of an individual in a high-level
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security, is the manipulation of individuals (or leadership position of an organization. While

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assuming this online identity, the hacker

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targets) to freely disclose personal information or

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account credentials to hackers. The hackers pose will then target other individuals within
as someone or something that the target is famil- the organization to try to obtain personal
iar with to gain access to information that would information from them.
otherwise be private and secure. Hackers can 3. Baiting. Baiting involves hackers leaving
deploy a variety of social engineering techniques. an infected USB or flash drive in a public
Some of these techniques are more sophisticated area in the hope that someone will come by,
in nature than others, but all of them can be highly pick it up, and use it out of curiosity. If it is
effective when used on an unsuspecting target. used, the individual’s computer will become
Some hackers will go so far as to research and im- infected with whatever virus was loaded
personate an unsuspecting target to gain access to onto the USB or flash drive. Another version
sensitive and valuable information; for example, of baiting involves the hacker sending out
a hacker might pretend to be the target’s boss. emails with embedded links to random
AB103118_Ch10.indd 289 2/6/2020 5:36:21 PM

recipients. When the link is clicked, it loads records, possibly because they did not have
malicious software that can then transfer backups offsite.
sensitive data to the hacker without the While this kind of devastation is not ordinary,
individual’s knowledge. healthcare organizations must protect themselves
4. Tailgating. Tailgating is a social engineering against the loss caused by environmental factors.
technique that allows a hacker, imposter, Healthcare organizations across the nation should
or other unauthorized individual to use an send backup information to vaults that are located
authorized individual’s access privileges many miles off-site, perhaps in a distant state, to
to gain access to a restricted physical area. assist in the recovery of data should a natural dis-
For example, an imposter, hacker, or other aster or other catastrophic event destroy on-site
unauthorized individual wants to gain computer systems. To recover from the devasta-
access to a building that requires badge tion caused by nature, healthcare organizations
n.
access. This unauthorized individual follows must have backup and recovery procedures in
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closely behind an individual who just place for both paper and electronic health records
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swiped his or her badge and gains access by and other important organizational data.
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Other causes of security breaches are operating
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simply following the other individual inside
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the building. It is human nature for a person system, software, and hardware failures. These
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to hold a door open for someone behind him include hardware breakdowns and software
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or her and not let the door close on that failures that cause information systems to shut
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person. The unauthorized person knows down or malfunction unexpectedly. Examples in-
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this and exploits the good nature of another io
clude a hard-disk crash that destroys or corrupts
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data, and a program that has not been updated,
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individual.
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which may make it vulnerable to attack. Another

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example is a failed, weak, or poorly configured

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firewall.
Threats Caused by Environmental
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Electrical outages and power surges also can

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and Hardware or Software Factors

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cause problems. When an electrical outage occurs,

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People are not the only threats to data security. information is unavailable to the end user. Data
Natural disasters such as earthquakes, tornadoes, might be corrupted or even lost. Power surges
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floods, forest fires, and hurricanes can demolish also can destroy or corrupt information. Thus,
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physical facilities and electrical utilities. healthcare organizations must have the appro-
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In 2017, Hurricane Harvey devastated Texas. priate equipment to protect information systems
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Hurricane Harvey affected a very large geographic from power surges and backup equipment to keep
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area, impacting that area with tremendous flood- them operating during an outage.
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ing. Although the loss of life and property was Yet another type of threat is a hardware or
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enormous, the hospitals there were appropriately software malfunction. Security breaches may be
prepared and were able, for the most part to introduced when new software or hardware is
continue to care for the influx of patients from the added to the information system or when it is not
surrounding areas due to their robust disaster properly tested.
recovery preparedness. While malfunctions of various software appli-
Further, a devastating tornado ripped through cations can corrupt data, another type of threat is
Florida in 2018, literally decimating many hos- caused by intentional software intrusions known
pitals there. Despite careful disaster planning, as malicious software or malware. Malware is
many hospitals were terribly underprepared for any type of software attack designed to disrupt
the devastation and had to turn away patients mobile or computer operations. Malware can
in their time of need. In many cases, the hospitals take partial or full control of a computer and can
were not able to access their electronic health compromise data security and corrupt both data
AB103118_Ch10.indd 290 2/6/2020 5:36:21 PM

and hard drives. Examples of malware include to computer resources, such as programs,
the following: computer networks, or entire computer
systems.
●● Phishing. Phishing is accomplished using ●● Rootkit. A rootkit is a computer program
email. The hackers send a target what appears designed to gain unauthorized access to a
to be a legitimate email correspondence from computer and assume control of and modify
a legitimate company or organization request- the operating system.
ing that the target click a link within the email ●● Ransomware. Ransomware is malicious soft-
and provide, typically, log-in and password ware that hackers employ to block access to
credentials to an information system or a computer system or particular computer
application. Phishing is also considered to files. The victim of a ransomware attack
be social engineering, which was discussed will know that his or her computer has been
n.
earlier in this chapter. attacked because an electronic ransom note
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●● Computer virus. A computer virus is a will appear in the computer screen. Typically,
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program that reproduces itself and attaches the hacker will give the victim a code to gain
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itself to legitimate programs on a computer. access to the computer or computer files
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A virus can be programmed to change or once a ransom is paid. The hacker will ask
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corrupt data. Frequently viruses can slow for the ransom to be paid in bitcoin, which is
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down the performance of a computer electronic currency.
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system.
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Malware usually gains access to computers via
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Computer worm. A computer worm is a
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●●
the internet as attachments in emails or through
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program that copies itself and spreads

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browsing a website that installs the software after

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throughout a network. Unlike a computer the user clicks on a pop-up window. To prevent the
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virus, a computer worm does not need to intrusion of malware, organizations establish anti-
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attach itself to a legitimate program. It can

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virus policies and procedures that establish the use

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execute and run itself. of antivirus software and specify: (1) what devices
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●● Trojan horse. A Trojan horse is a program should be scanned, such as file servers, mail serv-
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that gains unauthorized access to a ers, desktop computers; (2) what programs, docu-
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computer and masquerades as a useful ments, and files should be scanned; (3) how often
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function. A Trojan horse virus is capable of scans should be scheduled; (4) who is responsible for
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compromising data by copying confidential ensuring that scans are completed; and (5) what ac-
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files to unprotected areas of the computer tion should be taken when malware is detected. In
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system. Trojan horses may also copy and addition, filters can be used to filter both incoming
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send themselves to email addresses in a and outgoing email so that malware is quarantined.
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user’s computer. In addition to an antivirus policy, healthcare

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●● Spyware. Spyware is a computer program that organizations should have security awareness
tracks an individual’s activity on a computer policies and training that deal with prevention of
system. Cookies are a type of spyware. These and identification of malware in place.
programs can capture private information
such as an individual’s password, credit card
numbers, usernames, or account numbers. Strategies for Minimizing Security
The following information can then be used Threats
for identity theft. The first and most fundamental strategy in mini-
●● Backdoor program. A backdoor program is mizing security threats is to establish a secure
a computer program that bypasses normal organization that is responsible for managing
authentication processes and allows access all aspects of computer security. This involves
AB103118_Ch10.indd 291 2/6/2020 5:36:21 PM

appointing someone in the organization to coor- information security committee are the chief in-
dinate the development of security policies and formation officer (CIO), information technology
to make certain that they are followed. Gener- system directors, network engineers, and repre-
ally, this individual is called the chief security sentatives from clinical departments (lab, nurs-
officer (CSO). ing, pharmacy, radiology) as appropriate.
In addition to appointing someone to the CSO Another strategy for minimizing security
position, the healthcare organization appoints an threats is helping employees within a healthcare
advisory or policy-making group. This group is organization to be more aware of their data
called the information security committee or a security environment. Specifically, from a social
similar title. It works with the CSO to evaluate the engineering perspective, employees need to be
healthcare organization’s security needs, establish a better equipped to identify potential data secu-
security program, develop associated policies and rity threats. As described earlier, social engineer-
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procedures, including monitoring and sanction ing, specifically phishing, has become a problem
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policies, and ensures the policies are followed. across all industries. Since most people have either
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The development and enforcement of sanction a business or personal email address, would-be
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policies and procedures, which impose penalties, hackers have numerous opportunities to attempt
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are important so employees understand the con- to trick someone into giving them their personal
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sequences for noncompliance with security rules. information.
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The HIPAA Security Rule established a na- Too often healthcare organizations have a data
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tional standard for the protection of individu- security incident. A security incident is the “attempt-
ally identifiable electronic health records that are n
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ed or successful unauthorized access, use, disclo-
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created, received, and used by a covered entity. sure, modification, or destruction of information
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The rule does not specify the roles and compo- or interference with system operations in an in-
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sition of an information security committee, but formation system” (45 CFR Parts 160, 162, and
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the responsibilities extend well beyond the pro- 164 2013, 62). An example is when one employee
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tection of data and involve human resources, uses another employee’s password. Prevention is
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which typically assists in workforce clearances key to averting data security incidences. Educat-
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(that is, granting appropriate data access levels to ing employees regarding what is at stake if a data
individuals), employee termination procedures security incident occurs and arming them with
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(for example, eliminating an employee’s access knowledge to identify a potential threat is of the
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to data immediately upon severance or notice of utmost importance. Red flags that indicate an
20
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severance from the healthcare organization), and email might be a phish include the use of gmail.
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application of sanctions to employees who violate com rather than .org for an email from the admin-
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established policies (Miaoulis 2011). Other roles istrator of the healthcare organization.
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include executive-level managers who should One of the easiest ways to identify a potential
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have a high-level understanding of the data se- threat is to verify the sender of the email. When
curity policies and procedures and approve secu- hackers send a phishing email to a target, they
rity budgets. In addition, the health information often conceal the true identity of the sender for
management (HIM) director or designee should good reason. The hacker wants to trick the target
sit on the information security committee to assist into thinking the email is coming from a legiti-
in determining levels of system access, authoriza- mate sender. One way to confirm that the sender
tion (access rights and privileges based upon pol- of an email is legitimate is to hover the pointer
icy), and audit trail reviews. Access is the ability over the From display name to see what email ad-
of a subject to view, change, or communicate with dress appears. Figure 10.1 shows a sample of a
an object in a computer system. Authorizations phishing attempt. In a phishing email, the display
and audit trails are discussed later in this chap- name is vastly different from the actual sender’s
ter. Other management positions involved in the email address.
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Figure 10.1 Sample phishing email
Jane Doe <jane.doe@email.com

To john.smith @email.com
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Source: © AHIMA.
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1. External security threats can be caused by: io
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a. Employees who steal data during work time

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b. A facility’s water pipes bursting

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c. Tornadoes
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d. The failure of a healthcare organization’s software

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2. A data loss prevention strategy is an essential element to:

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a. Data availability
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b. Data integrity
c. Data infrastructure
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d. Data reliability
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3. Employees who seek information to commit fraud or theft are included in what category of
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insider threat?
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a. Abuse privileges
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b. Access systems for spite or profit

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c. Steal physical resources

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d. Vengeful employees
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4. What is the term used to indicate that data is complete, accurate, consistent, and up to date?
a. Availability
b. Confidentiality
c. Integrity
d. Security
5. Critique each option to determine the true statement related to internal security threats.
a. They are caused by people.
b. They are caused by disgruntled employees.
c. They originate within a healthcare organization.
d. They are natural disasters.
AB103118_Ch10.indd 293 2/6/2020 5:36:22 PM

6. Identify the type of malware that can copy and run itself without attaching itself to a legitimate program.
a. Computer worm
b. Backdoor program
c. Trojan horse
d. Spyware
7. This method of social engineering involves hackers leaving an infected USB or flash drive in a public area in the hope
that someone will pick it up and use it.
a. Tailgating
b. Phishing
c. Spear phishing
d. Baiting
8. Data backup policies and procedures may include:
a. Server redundancy
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b. Ensuring all data is maintained on-site
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c. Maintaining one copy of all data
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d. Avoiding the use of power generators
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9. A healthcare organization’s data privacy efforts should encompass:
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a. Patient information only
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b. Employee information only
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c. Patient and organizational information only
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d. Patient, employee, and organizational information
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10. The categories of security threats by people demonstrate an organization’s greatest potential liability group
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consists of:
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a. Patients
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b. Visitors
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c. Employees
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d. Hackers outside the organization

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11. What is the most common social engineering technique?

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a. Tailgating
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b. Phishing
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c. Baiting
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d. Trojan horse
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Components of a Security Program

The HIPAA Security Rule went into Confidentiality, have electronic data that needs to
effect in April 2005. The Security Rule focuses on be protected from unauthorized access, disclosure,
administrative, physical, and technical safeguards loss, and destruction. The authors of the HIPAA
(defined later in the chapter) as they relate to the Security Rule made the requirements and obliga-
protection of electronic protected health informa- tions of the rule flexible to allow each CE to meet
tion (ePHI). Electronic protected health informa- the obligations and requirements in ways that are
tion is protected health information that is “created, suitable and appropriate for the size and structure
received, or transmitted” electronically (45 CFR of the organization. For example, more sophisti-
Parts 160, 162, and 164 2013, 61). All covered enti- cated information technology will be expected of a
ties (CEs), as defined in chapter 9, Data Privacy and 1,000-bed hospital than a two-physician practice.
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Information technology is computer technology An effective security program will be able to

(hardware and software) combined with telecom- guarantee the triad at any given moment, even in
munications technology (data, image, and voice times of disaster recovery.
networks). An effective security program also contains the
The HIPAA Security Rule provisions and require- following components:
ments will be addressed at length later in the ●● Employee awareness including ongoing
chapter. To implement those requirements, a CE education and training
must establish a security program that meets the
●● Risk management program
requirements of the Security Rule and is effective
in doing so. Information security profession- ●● Access safeguards
als developed the Confidentiality, Integrity and ●● Physical and administrative safeguards
Availability (CIA) Triad of Information Security to ●● Software application safeguards
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determine if a security program is effective. The
Network safeguards
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●●
CIA Triad, presented in figure 10.2, is a baseline
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Disaster planning and recovery
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●●
standard for determining whether a security pro-
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gram is effective. The triad allows for the imple- Data quality control processes (Carlon 2013)
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●●
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mentation and evaluation of a security program Each component of the security program will be
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based upon three goals that are guaranteed if an discussed as it relates to the establishment of a CE’s
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information system is secured. Those goals are the
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security program. Some of these same elements
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following: will also be discussed in relation to the provisions
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of the Security Rule later in this chapter.
1. Confidentiality: Only authorized and
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appropriate individuals access the data within

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an information system. Employee Awareness

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2. Integrity: The data within the system can be

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As discussed previously, employees are often re-

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trusted. This was discussed at the beginning sponsible for threats to data security. Consequently,
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of the chapter.
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employee awareness is a particularly important

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3. Availability: The data within the system

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tool to reduce security breaches by wrongdoers

is available to the end user wherever and (either intentional or unintentional) and to make
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whenever it is needed. employees mindful of security breaches so they

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can recognize them, respond to them, and report

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20
Figure 10.2 Effective security program guarantee – them appropriately.

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CIA triad. The CE should offer a formal security aware-

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ness training that educates every new employee

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on the confidential nature of protected health

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information (discussed more in chapter 9, Data

Privacy and Confidentiality). The program should
inform employees about the CE’s security policies
Confidentiality Integrity and the consequences of failing to comply with
them. The CE should give each employee a copy
of its security policies as they relate to the em-
ployee’s job function. The CE also should require
every employee to sign a yearly confidentiality
Availability statement. Finally, because data security is such
Effective Security Program Guarantee an important part of everyone’s job, employees
CIA Triad should receive periodic and ongoing security re-
Source: © AHIMA. minders. The security reminders can include policy
AB103118_Ch10.indd 295 2/6/2020 5:36:24 PM

and procedure refreshers, tips on how to identify tablets, laptops, and so forth). These d evices are
suspicious emails, or general information about particularly at risk as they are easily lost or stolen.
the employees’ obligations from a data security Once security threats are identified, it is im-
perspective. portant for a CE to make a likelihood determi-
Included in the employee awareness program nation, which is an estimate of the probability of
should be policies and procedures regarding mo- threats occurring, and an impact analysis, which
bile devices, the use of email, faxing, and scanned is an estimate of the impact of threats on informa-
information, and appropriate and inappropriate tion assets. For example, a CE may be located in a
use of social media. region with frequent tornadoes (high likelihood).
It is known that tornadoes can be extremely de-
structive (high impact). For this CE, it would make
Risk Management Program sense to implement expensive safeguards to protect
n.
Another strategy in protecting the CE’s data is to and back up its information assets against torna-
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establish a risk management program. Risk man- does. If a threat is low likelihood and low impact
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agement is a comprehensive program of activities (for example, a tornado on the Pacific coast), ex-
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intended to minimize the potential for injuries to penditure of time and money to protect against the
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occur in a facility and to anticipate and respond to threat is not a wise use of resources. CEs on the
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ensuring liabilities for those injuries that do occur. Pacific coast would have to address mudslides,
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Risk management includes the processes in place earthquakes, and wildfires. The CE must conduct
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to identify, evaluate, and control risk, defined this type of analysis on every identified threat—
as the organization’s risk of accidental financial n
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manmade, environmental, and those caused by
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liability. CEs must take steps to prevent, detect, hardware and software factors—in order to prior-
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and mitigate both external and internal incidents. itize those that should be addressed first and to
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Mitigation is the steps taken to reduce the impact which resources should be allocated.
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that a violation of the HIPAA Security Rule has It is essential to determine the value of information
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on a patient. For example, the CE may purchase to the CE and the consequences of its loss when es-
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a year’s monitoring of a patient’s credit in the tablishing a risk management program. For exam-
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event of a security violation. A well-conceived risk ple, the CE would have to determine what impact
management program can aid prevention, detec- a security breach would have on quality of care,
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tion, and mitigation of security breaches including revenue, service, and other aspects of the CE’s
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identity theft. operations. Identification of a CE’s information

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assets includes an inventory of application soft-

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Risk Analysis ware, hardware, networks, and other information

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The Security Rule requires a CE to implement se- assets. Once information assets have been identi-
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curity measures that are sufficient to reduce risk fied, their value to the CE is determined. Value is
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and vulnerabilities. Risk management begins with determined based on a number of factors such as
a risk analysis, which involves assessing security criticality of the asset in daily operations, degree
threats and vulnerabilities, and the likely impact of harm resulting if the asset is not available, legal
of any vulnerability. and regulatory requirements, and loss of revenue
A security threat is a situation that has the should the asset be lost or damaged.
potential to damage a healthcare organization’s
information system. In addition to threats and Incident Detection
vulnerabilities, a CE should also identify how ePHI Once possible threats and vulnerabilities are
is created, managed, stored, and transmitted within known, it is important to be able to detect whether
the CE and whether vendors or consultants use a threat or incident or intrusion has occurred. An
or maintain ePHI. Of increasing importance is the incident is an occurrence or an event. Incident
threat created by the use of mobile devices (phones, detection methods should be used to identify
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both accidental and malicious events. Detection mitigating harmful effects caused by the breach,
programs monitor the information systems for and evaluating the incident as a part of the CE’s risk
abnormalities or a series of events that might in- management process (Rinehart-Thompson 2018).
dicate that a security breach is occurring or has
occurred. Intrusion detection systems can be used Access Safeguards
for this purpose. An intrusion detection system Establishing access safeguards is a fundamental
monitors the CE’s network and information sys- security strategy. This is the identification of which
tems to “detect and identify” suspicious activity employees should have access to what data. The
(Dowling 2017, 5). The CE can customize the intru- general practice is that employees should have
sion detection system to a monitoring level that is access only to data they need to do their respective
at the appropriate level for the CE (Dowling 2017). jobs. For example, a registrar in the admitting of-
In other words, it can be made stronger or weaker fice and a nurse would not have access to the same
n.
depending on the needs of the CE. kinds of data. By establishing access safeguards,
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a CE is taking steps to lessen its vulnerabilities,
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Incident Response Plan and Procedures although it cannot prevent them altogether because
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Once a security incident has been identified, there of the security threats that humans present.
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must be a coordinated response from the CE to Determining what data to make available to an
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mitigate the incident. An incident response plan employee usually involves identifying classes of
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includes management procedures and responsi- information based on the employee’s role in the
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bilities to ensure a quick response is effectively CE. So, the CE would determine what information
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implemented for specific types of incidents. For io
a registrar, for example, would need to know to do
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example, in some instances the plan may call for his or her job. Subsequently, every individual who
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a “watch and warn” response that includes moni- works as a registrar would have access to the same
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toring and notification of an incident but takes information.

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no immediate action. In other instances, a “repair Every role in the CE should be identified, along
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and report” response may be instituted, whereby with the type of information required to perform
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immediate mitigation and repair of the issue is it. This is role-based access control (RBAC) and
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initiated and reported to the team of individuals re- is the one used most often in healthcare organi-
sponsible for responding to the issue. This type of zations. Additionally, user-based access control
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response may be used in the case of a virus attack. (UBAC) grants access based on a user’s individual
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A third type of response is “pursue and prosecute,” identity. For example, every employee in the qual-
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20
which includes monitoring an attack, minimizing ity improvement department could potentially
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the attack, collecting evidence, and involving a have a different degree of access if they have
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law enforcement agency. This last example might unique responsibilities in that department. Con-
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be used in instances of suspected identity theft. text-based access control (CBAC) limits a user’s
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Under the Health Information Technology for Ec- access based not only on identity and role, but also
onomic and Clinical Health (HITECH) Act, breach on a person’s location and time of access (Rine-
notification requirements provide for those situa- hart-Thompson 2018). For example, two respiratory
tions when affected individuals must be notified therapists may be given the same access based on
about an information security breach affecting their identical roles. However, with CBAC access,
their PHI. their access will be further refined (and may dif-
The HIPAA Security Rule requires that security fer) based on the units to which they are assigned
incidents be identified, reported to the appropri- and the respective shifts they work.
ate persons (which will include the Information Access control is the restriction of access to in-
Security Officer, leadership, and IT technicians), formation and information resources (such as com-
and documented. Responses to an incident in- puters) to only those who are authorized, by role
clude workforce notification, preserving evidence, or other means. For access control to be effective,
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mechanisms that restrict access must be in place. they are allowed by the information system
There are a number of access control mechanisms in which they are used. Password policies
that can be used (discussed later in this chapter). should include mandatory changes of pass-
However, the sophistication of the method used words at specified intervals. These types of
should correspond with the value of the informa- restrictions help to limit the chance of an
tion being protected. In other words, the more intruder guessing a password or using a pro-
sensitive or valuable the information, the stronger gram called a password cracker to identify
the control mechanisms need to be. For example, passwords. To help increase security, many
access to health information about patients in a be- information systems will lock out a user after
havioral health unit will only be granted to staff a specified number of unsuccessful attempts
who work in that unit. Identification, authentica- to gain access to an information system. In
tion, and authorization are the foundation upon addition, password policies should prohibit
n.
which access control mechanisms are based. users from sharing passwords or writing
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or displaying passwords. While passwords
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Identification provide the least amount of security com-
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pared to other methods, if properly managed
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The basic building block of access control is iden-
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tification of an individual who is accessing the and used, they can be an effective security
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information system. Usually identification is per- strategy.
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formed through the username or user number. Strengths: Long passwords are harder
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Identification methods must be robust so that an to compromise.
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Weaknesses: Passwords are easy to
imposter cannot successfully pose as a legitimate io
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search and easily stolen if written
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user and enter a system illegitimately.

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down. Passwords are easily forgotten

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if long. Hackers can “sniff” or intercept

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Authentication
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The second element of access control is authen- passwords at various stages of input.
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tication. Authentication is the act of verifying a ●● Smart Cards and Tokens Smart cards and
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claim of identity. There are three different types of token cards are examples of something you
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information that can be used for authentication— have. A smart card is a small plastic card
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something you know, something you have, or with an embedded microchip that can
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something you are. The next section will discuss store multiple identification factors for a
20
methods of authentication that fall into these three specific user. Usually a smart card is used
20
categories. in combination with a user identification

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or password. A one-time password

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Passwords Examples of something you know (OTP) token is a small electronic device
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●●
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include such things as a personal identification programmed to generate and display new
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number (PIN), a password, or your mother’s passwords at certain intervals. An OTP

maiden name. Passwords are frequently used token is usually used in combination with
in conjunction with username. Policies and user identification or a password. To access a
procedures should be in place to ensure pass- system, a user puts in an identification code
words cannot be easily compromised. For and the OTP token generates a one-time
example, passwords should be of a specific password that is displayed on the token.
length, include special characters and num- Strengths: Smart cards or tokens only
bers, should be case sensitive, and should not require a pin to be remembered versus
be words that are included in a dictionary or a password. Because there is no pass-
related to the user’s identification or personal word, smart cards and tokens prevent
information. For example, “password” and dictionary attacks whereby the hacker
“12345” are weak yet popular passwords if electronically and repeatedly inputs
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different passwords in the hopes of systems involved. When the user is finished, the
guessing the correct password. single sign-off is used to log out of all of the in-
Weaknesses: Smart cards and tokens can formation systems with one action.
be stolen and access can be compromised
if a static pin number is assigned to a Authorization
specific smart card, and the user writes The third element of access control is authoriza-
the static pin on the back of the smart tion. Authorization is a right or permission given
card. to an individual to use a computer resource, such
●●Biometrics Something you are refers to as a computer, or to use specific applications and
biometrics. Biometrics is identity verification access specific data. It is also a set of actions that
based upon measurements of a person’s gives permission to an individual to perform spe-
physical characteristics. Examples of cific functions such as read, write, or execute tasks.
n.
biometrics include palm prints, fingerprints, Authorization to use an information system
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is usually addressed through identification and
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voiceprints, and retinal (eye) scans.
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Strengths: Biometrics require no pass- authentication as described previously. Author-
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words and are very hard to replicate. ization to use specific applications (for example,
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Weaknesses: Biometrics can cause false order entry, coding, and registration) and specific
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rejection or false acceptance due to the data would be different for different individuals
ag
in a CE. For example, employees in the admitting
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technology still being somewhat new.
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Also, there are people who are very and registration department would not be given
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reluctant to have their fingerprints
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the same authorization to information systems
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taken due to privacy concerns. and data as nurses.

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Strong authentication requires providing informa- Usually authorization is managed through spe-
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tion from two of the three different types of authen- cial authorization software that uses various criteria
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tication information. For example, an individual to determine if an individual has authorization for
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access, sometimes referred to as an access control

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provides something he knows and something

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he has. This is called two-factor authentication. matrix. For example, authorization may be based
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Examples of two-factor authentication include the on not only the individual’s identity but also the
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use of smart cards or tokens with user identification. individual’s role (role-based) and physical loca-
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tion of the resource (that is, access to only certain

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Two-factor authentication is a stronger method of

20
protecting data access than user identification with computers), and time of day (context-based) as de-
20
passwords. An example of two-factor identifica- scribed earlier in this chapter.

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tion is being used at Walt Disney World in Florida. Information systems may require verification
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Guests insert their park tickets and have their index that a human, not a computer, is accessing a website
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finger scanned. or storage portal. A Completely Automated Public

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Single sign-on is another authorization strategy Turing test to tell Computers and Humans Apart
that allows a user to log in to many separate, al- (CAPTCHA) requires the user to respond to a ques-
though related, information systems. Single sign- tion that it is assumed could not be answered by a
on allows a user to log in one time and be able to machine. A typical example of a CAPTCHA is when
access many information systems. This prevents access to a site requires the user to type in a string
the user from having to log in to each information of characters that appears skewed or distorted. An-
system individually; for example, an encoder and other common CAPTCHA is to identify images that
an electronic health record. contain a specified item such as a sign or a vehicle.
Different information systems have different
requirements for usernames and passwords. This
Physical Safeguards
requires the single sign-on to translate and store the Physical safeguards refer to the physical protec-
username and password for all of the information tion of information resources from physical damage,
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loss from natural or other disasters, and theft. This may be automatically logged out if there has been
includes protection and monitoring of the work- no activity within five minutes. Laptops and other
place, data center (computer room), and any type mobile devices such as personal digital assistants
of hardware or supporting information system (PDAs) pose significant threats because they can
infrastructure such as wiring closets, cables, and be easily lost or stolen. Documentation of the cus-
telephone and data lines. tody of such devices must be addressed. One such
This equipment should be in secure locations method is maintaining a custody log that docu-
and protected from natural and environmental ments who has had custody of the device, the time
hazards and intrusion. Environmental hazards in- period of custody, and what files and data were
clude such things as fire, floods, moisture, temper- on the device during the custody period. Policies
ature variations, and loss of electricity. To protect and procedures that cover laptop or mobile device
it from natural or environmental hazards, equip- use should be in place. Other security mechanisms
n.
ment should be housed in structurally sound and such as two-factor authentication (discussed pre-
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safe areas. There should be smoke and fire alarms, viously) and full disk encryption should be used
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fire suppression systems, heat sensors, and appro- (discussed later in this chapter.) Global position-
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priate monitored heating and cooling systems in ing systems (GPS) can also be installed on lap-
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place. Appropriate backup power sources such as tops as well as information systems to remotely
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uninterruptable power supply (UPS) devices or locate a computer to retrieve and delete data from
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power generators should be available if a power it, should a computer be lost or stolen. With these
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outage occurs. features, a computer can be located quickly and
To protect from intrusion, there should be prop- n
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appropriate law enforcement officials notified.
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er physical separation from the public. Doors, In any security program, employee education is
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locks, audible alarms, and cameras should be in- one of the best defenses for protection of data and
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stalled to protect particularly sensitive areas such computer resources. Training programs on data
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as data centers. Identification procedures such as security should be conducted at least annually for
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the use of badges to identify employees should be all employees and cover applicable security respon-
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in place. Processes should be established for log- sibilities, policies, and procedures.
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ging into and out of computer hardware or media.

For example, if a data disk or device is being trans-
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ported or removed from one location to another, Administrative Safeguards

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there should be a sign-out and sign-in procedure Administrative safeguards include policies and
20
20
to track access and removal. Furthermore, sign-in procedures that address the management of com-
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and sign-out logs should be in place to track access puter resources. For example, one such policy
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to sensitive areas such as data centers. might direct users to log off the information
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Backup and recovery procedures are also a part system when they are not using it or employ au-
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of physical security. Backup and recovery proce- tomatic log-offs after a period of inactivity. Other
dures should specifically include server, data, and policies include password security (inappropri-
network policies and procedures. ate sharing, minimum password requirements,
Provisions must also be made to protect work- changing the frequency of updating passwords,
stations that are more exposed to the public. For and failed log-in monitoring) and timely removal
example, locking devices can be used to prevent of terminated employees’ system access. Another
removal of hardware and other devices. Auto-
policy might prohibit employees from access-
matic logouts, which are simply timed logouts that ing the internet for purposes that are not work
reduce the chances that one’s account will be used related. Finally, a CE should have a policy on In-
by someone else, can be used to prevent access formation Technology Asset Disposition (ITAD)
by unauthorized individuals. For example, a user that identifies how all data storage devices are
AB103118_Ch10.indd 300 2/6/2020 5:36:24 PM

destroyed and purged of data prior to repurpos- Network Safeguards

ing or disposal.
Another important strategy used to guard against
security breaches is to implement network safe-
Software Application Safeguards
guards. Many networks are used to transmit
Another security strategy is to implement appli- healthcare data today, and the data must be pro-
cation safeguards. Application safeguards are tected from intruders and corruption during
controls contained in application software or transmission within and external to the organi-
information systems to protect the security and in- zation. With the widespread use of the internet,
tegrity of information. One common application network controls also are essential to prevent the
control is authentication, as previously described. threat of hackers. The following are some common
Through the use of passwords, tokens, or biomet- safeguards.
rics, an information system keeps a record of end
n.
users’ identifications and authentication mecha-
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Firewalls
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nisms and then matches the authentication mech-
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anism to each end user’s privileges. This ensures A firewall (also called a secure gateway) is a part of
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an information system or network that is designed
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that end users can access only the information they
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have permission to access. to block unauthorized access while permitting au-
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Another application control is the audit trail. The thorized communications. It is a software program
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or device that filters information and serves as a
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audit trail is a software program that tracks every
buffer between two networks, usually between a
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single access or attempted access of data in the
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private (trusted) network like an intranet (within
information system. It logs the name of the individ-
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the organization and not accessible outside) and a
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ual who accessed the data, terminal location or IP

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address (internet protocol address which identifies public (untrusted) network like the internet. Fire-
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walls allow internal users access to an external

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the computer used), the date and time accessed,

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the type of data, and the action taken (for example, network while blocking malicious hackers from
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damaging internal systems. All messages enter-

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modifying, reading, or deleting data). System ad-

ing or leaving the private network pass through
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ministrators examine audit trails using special anal-

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the firewall, which examines and evaluates each

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ysis software to identify suspicious or abnormal

message and blocks those that do not meet pre-
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system events or behavior. Because the audit trail

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defined security criteria. For example, an email

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maintains a complete log of system activity, it can

message that is believed to contain a Social Secu-
20
also be used to help reconstruct how and when an

20
incident or failure occurred. This information helps rity number may be prohibited from leaving the
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to identify ways to avoid similar problems in the private network. An email believed to contain a
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virus may be prohibited from entering the pri-

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future. Depending on the CE’s policy, audit trails

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vate network. It may control the size of the file

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are reviewed periodically, on predetermined sched-

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ules or relative to highly sensitive information. that is allowed through the firewall. A firewall is
Yet another application control is the edit configured to permit, deny, encrypt, or decrypt
check. Edit checks help to ensure data integrity by computer traffic.
allowing only reasonable and predetermined val-
ues to be entered into the computer. For example, Cryptographic Technologies
an information system using this feature would Cryptography is a branch of mathematics that is
disallow an International Classification of Diseases, based on the transformation of data by developing
Tenth Revision, Clinical Modification (ICD-10-CM) ciphers, which are codes that are to be kept secret.
code that does not exist. Application controls are Cryptography is used as a tool for data security.
important because they are automatic checks that Strong cryptography improves the security of
help preserve data confidentiality and integrity. information systems and their data. There are
AB103118_Ch10.indd 301 2/6/2020 5:36:24 PM

several types of cryptographic technologies. method uses both a public and a private key, which
Cryptographic technologies—such as encryption, form a key pair. The sending computer uses a key
digital signatures, and digital certificates—are used to encrypt the data and it gives a key to the recipi-
to protect information in a variety of situations. ent computer to decrypt the data. With this type of
This includes protecting data when they are in encryption there is a registry of public keys, called
storage (data at rest), on portable devices such a certificate authority. If one user wants to send an
as laptops and flash drives, and while they are be- encrypted message to another, the registry is con-
ing transmitted across networks. Three of these sulted, and the receiving user’s public key is used
technologies used in healthcare are discussed as to encrypt the data. Only the recipient, who knows
follows. the private key, can decrypt the message into its
original form.
Encryption Encryption is a method of encoding
n.
data, converting them to a jumble of unreada- Digital Signatures A digital signature or dig-
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ble scrambled characters and symbols as they ital signature scheme is a public key cryptog-
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are transmitted through a telecommunication raphy method that ensures that an electronic
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network so that they are not understood by per- document such as an email message or text file
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sons who do not have a key to transform the is authentic. This means that the receiver knows
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data into their original form. Data are usually who created the document and is assured the
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encrypted using some type of algorithm, or a document has not been altered in any way since
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standard set of operating rules. Upon receipt, it was created.
data can only be decoded and restored back to n
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In this method data are electronically signed
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their original readable form (decryption) by by applying the sender’s private key to the data.
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using a special algorithm. Encryption takes the The digital signature can be stored or transmit-
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message from one computer and encodes it in a ted in the data. The receiving party can then ver-
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form that only the receiving computer can de- ify the signature by using the public key of the
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code. For example, an email containing ePHI signer.

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can be encrypted whereby as the message is Digital signatures are sometimes confused with
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moving from one inbox to another, the message e-signatures. E-signature usually means a system
itself is scrambled so as not to be intercepted by for signing or authenticating electronic documents
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a would-be hacker. by entering a unique code or password that veri-

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One type of encryption is called private key fies the identity of the person and creates an indi-
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20
infrastructure, or single-key encryption. In vidual signature on a document. E-signatures do

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this method, two or more computers share the not necessarily use cryptography.
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same secret key and that key is used both to

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encrypt and decrypt a message. However, the Digital Certificates Digital certificates are used
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key must be kept secret. If it is compromised in to implement public key encryption on a large
any way, the security of the data is likely to be scale. A digital certificate is an electronic docu-
eliminated. Because the key that decodes the in- ment that uses a digital signature to bind together
formation is transmitted with the data, it could a public key with an identity such as the name
be intercepted (Rinehart-Thompson 2018). The of a person or an organization, address, and so
best-known secret key security is called the forth. The certificate can be used to verify that a
data encryption standard (DES) published by public key belongs to an individual. An independ-
the National Institute of Standards and Tech- ent source called a certificate authority (CA) acts
nology (NIST). as the middleman who the sending and receiving
A common encryption method used over the computer trusts. It confirms that each computer is
internet is a system called Pretty Good Privacy who it says it is and provides the public keys of
(PGP), or public key infrastructure (PKI). This each computer to the other.
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Web Security Protocols testing is when the CE hires a hacker to try to

Transmission protocols that allow devices to speak break into their information systems in order to
to one another when on a network are another test the quality of the security measures in place.
method of data security. Transport Layer Security
(TLS) and its predecessor Secure Sockets Layer Disaster Planning and Recovery
(SSL) are based on public key cryptography. These As discussed, CEs must prepare for emergencies
protocols are the most common protocols used to such as natural disasters. Further, CEs must prepare
secure communications on the internet between a both for events that cause minimal disruption (for
web browser and a web server. Versions of these example, short-term power outages) and for large-
protocols can be used for almost any applica- scale events such as tornadoes. A contingency
tion but are frequently used for electronic mail, plan and its component disaster recovery plan will
internet faxing, instant messaging, e-commerce guide a CE through undesirable non-routine events.
n.
transactions, and voice communications over the In CEs, the continuation of medical services to pa-
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Internet (VoIP). tients is the highest priority. An important element
oc
These protocols allow authentication of the of medical services is the protection and contin-
ss
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server. Once authentication of the server is es- ued availability of health information (Rinehart-
en
tablished, secure communication can begin using Thompson 2018).
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symmetric encryption keys. The user’s message
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is encrypted in the user’s web browser using an
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encryption key from the host website. The message Risk Analysis
n
is then transported to the host website in encrypted
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According to the Security Rule requirements, the
at
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format. Once received by the website, the message CE must assess the internal and external data se-
r
fo
is decrypted. curity risk environment and evaluate vulnerabilities

In
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(internal weaknesses) the CE has with respect to

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ePHI. Conducting risk analysis, which allows for

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Intrusion Detection Systems

an
the identification and prioritization of those risks,

ic
Intrusion detection is the process of identifying helps the CE ensure it is maintaining the confiden-
er
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attempts or actions to penetrate an information tiality, integrity, and availability of ePHI. Ongoing
system and gain unauthorized access. Intrusion
e
risk analysis allows a CE to keep up with the ever-

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detection can either be performed in real time or

by
changing threats and vulnerabilities as they happen.

after the occurrence of an intrusion. The purpose
20
When a CE prepares to conduct a risk analysis,

20
of intrusion detection is to prevent the compro- it is important to keep in mind that the Security
©
mise of the confidentiality, integrity, or availability Rule does not stipulate or require that a particu-
ht
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of a resource. lar approach be used for such an analysis. The CE

yr
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Intrusion detection can be performed manually is required, through the risk analysis, to identify
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or automatically. Manual intrusion detection potential threats compared to its identified vulner-
might take place by examining log files, audit abilities to determine the level of risk. Risk itself
trails, or other evidence for signs of intrusions. can take many forms including disruption in busi-
A system that performs automated intrusion ness, loss of privacy, and legal and financial pen-
detection is called an intrusion detection sys- alties. Based on the risk analysis, CEs can imple-
tem (IDS). Procedures should be outlined in ment policies, procedures, and other safeguards to
the CE’s data security plan to determine what counteract the risk.
actions should be taken in response to a proba-
ble intrusion. For example, typical actions to be
taken might include notification of appropriate Disaster Planning
individuals, generating an email alert, and so on. Disaster planning occurs through a contingency
Penetration testing may be conducted. Penetration plan—a set of procedures, documented by the CE,
AB103118_Ch10.indd 303 2/6/2020 5:36:24 PM

to be followed when responding to emergencies. all parts of the information system be verified after
The disaster plan identifies what a CE and its the disaster has occurred. Usually one information
personnel need to do during and after security system or one component of an information system
incidences and other events, like natural disas- is brought up at a time and processes are verified
ters, that limit or prevent access to the CE and to ensure they are working correctly.
patient information. Disaster planning typically A plan is only as good as its implementation.
includes policies and procedures to help the busi- The disaster recovery plan must be tested periodi-
ness continue operations during an unexpected cally to ensure all the parts of the plan—from dis-
shutdown or disaster. It also includes procedures aster identification to backup and recovery—work
the business can implement to restore its informa- as expected (Johns 2008).
tion systems and resume normal operation after
the disaster.
Data Quality Control Processes
n.
The contingency plan is based on information
tio
gathered during the risk assessment and analysis Ensuring data quality is an essential part of any
ia
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discussed previously. The risk assessment includes data security program. Responsibility for ensuring
ss
the probability that an unexpected shutdown will
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data quality is shared by many organization stake-
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occur. Using this information, the contingency holders. For example, data accuracy begins with
em
plan is developed based on the following steps: any individual who enters or documents data or
ag
systems that capture and provide data such as in-
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Step 1: Identify the minimum allowable time for
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tensive care unit monitoring systems. Monitoring
system disruption
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and tracking systems that ensure data quality are
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Step 2: Identify alternatives for system
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part of a data security program.

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continuation
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Data availability, consistency, and definition

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Step 3: Evaluate the cost and feasibility of each are three data quality dimensions that are often
lth
alternative
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addressed using computer tools. As described

H
Step 4: Develop procedures required for earlier, data availability means that data are easily
an
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activating the plan (Johns 2008) obtainable. Chapter 6, Data Management, covers
er
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data quality characteristics in more detail. Com-

Disaster Recovery puter tools are used to monitor unscheduled
e
th
An immediate component of a contingency plan computer downtime, determine why failures oc-
by
is the disaster recovery plan, which addresses the curred, and provide data to help minimize future
20
20
resources, actions, tasks, and data necessary to problems. Data consistency, a component of data
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restore those services identified as critical, such as integrity, means that data do not change no matter
ht
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the EHR, as soon as possible, and to manage busi- how often or in how many ways they are stored,
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ness recovery processes. The business continuity processed, or displayed. Data values are consist-
C
plan (BCP) is a set of policies and procedures that ent when the value of any given data element is
direct the CE how to continue its business oper- the same across applications and information sys-
ations during an information system shutdown. tems. Procedures are usually developed to moni-
Similarly, an emergency mode of operations pre- tor data periodically to ensure they are consistent
scribes processes and controls to be followed until across information systems.
operations are fully restored. For health informa- Data definition is describing the data. Every
tion, an important part of the disaster recovery plan data element should have a clear meaning and a
is ensuring the availability and accuracy of data range of acceptable values. For example, gender
as soon as possible after a disaster. As described should have male and female as the only accept-
earlier in the chapter, ongoing data backup is crit- able values. Data definitions and their values are
ical for this reason. Restoring system integrity and usually stored in a data dictionary, which is dis-
ensuring that all data are recovered requires that cussed in chapter 6, Data Management.
AB103118_Ch10.indd 304 2/6/2020 5:36:24 PM


1. An HIM professional using her password can access and change data in the hospital’s master patient index. A patient
accounting representative, using his password, cannot perform the same function. Limiting the class of information
and functions that can be performed by these two employees is managed by:
a. Network controls
b. Audit trails
c. Administrative controls
d. Access controls
2. Data that has been converted into unintelligible format that must be decoded before it is legible is:
a. An audit trail
n.
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b. Encryption
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c. A password
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d. A physical safeguard
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3. Identification of an organization’s security threats and vulnerabilities is conducted during:
en
a. Risk analysis
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b. Likelihood determination
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c. Impact analysis
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d. Authentication
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4. Identify a threat to data security.
at
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a. Cryptographic technologies
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b. People
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c. Intrusion detection systems

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d. Access controls
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5. Password policies should:

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a. Include mandatory scheduled password changes

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b. Permit password sharing only between good friends

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c. Require that passwords consist of numbers only

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d. Require that passwords be changed every 30 days

by
20
6. Identify an example of an administrative safeguard.

20
a. Placing heat sensors near computer equipment

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b. Writing a policy regarding automatic computer log-offs

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c. Locking data center doors

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d. Placing computer monitors to face away from public areas

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7. A firewall:
a. Is an administrative safeguard
b. Filters information between networks
c. Only limits incoming information
d. Only limits outgoing information
8. The CIA triad includes:
a. Coordination, Integrity, and Accountability
b. Confidentiality, Intrusion, and Availability
c. Confidentiality, Integrity, and Accountability
d. Confidentiality, Integrity, and Availability
AB103118_Ch10.indd 305 2/6/2020 5:36:24 PM

Coordinated Security Program

A CE employee with responsibility for is done using monitoring and evaluation systems,
data security can manage threats to data security typically on an annual basis. Many CEs use out-
with a coordinated security program. This indi- side information system auditing firms to conduct
vidual should be someone at the middle or senior their security policy evaluations. In addition to the
management level. As mentioned earlier, he or she yearly audit, the CSO will establish procedures to
is frequently called the CSO. Figure 10.3 lists some audit and evaluate current processes randomly.
of the CSO’s functions. All data security policies and procedures should
When the data security program with policies be reviewed and evaluated at least yearly to make
and procedures is in place, the CSO is responsi- sure they are up-to-date and still relevant to the
ble for ensuring that everyone follows them. This organization.
n.
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HIPAA Security Provisions
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The HIPAA Security Rule established (OCR). The HITECH Act under ARRA increased
ag
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standards to protect ePHI. The Department of enforcement of the provisions of the Privacy Rule
M
Health and Human Services established the and Security Rule through tougher penalties and
n
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HIPAA Privacy Rule (discussed in chapter 9, Data greater breach reporting requirements. Prior to
at
m
Privacy and Confidentiality) and the HIPAA Security ARRA, audits were only conducted when there
r
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In
Rule. These standards apply to every health plan, was a complaint. ARRA allowed random audits
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healthcare clearinghouse, and healthcare provider to be conducted. Enforcement of the HIPAA Secu-
ea
processing financial or administrative transac- rity Rule must be taken seriously by CEs because
H
an
tions electronically. Additional changes to the Pri- penalties are severe and include both financial
ic
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vacy and Security Rules were created as a result penalties and prison.
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of the American Recovery and Reinvestment Act Security Rule standards are grouped into five
e
(ARRA) of 2009. categories. These categories are the following:

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by
ARRA moved the enforcement for HIPAA

1. Administrative safeguards
20
security compliance from the Centers for Medi-

20
care and Medicaid Services’ Office of Electronic 2. Physical safeguards

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3. Technical safeguards
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Standards and Security to the Department of

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Health and Human Services Office for Civil Rights

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4. Organizational requirements
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Figure 10.3 Common functions of the chief security officer

● Conduct strategic planning for information system security
● Develop a data and information systems security policy
● Develop data security and information systems procedures
● Manage confidentiality agreements for employees and contractors
● Create mechanisms to ensure that data security policies and procedures are followed
● Coordinate employee security training
● Monitor audit trails to identify security violations
● Conduct risk assessment of enterprise information systems
● Develop a business continuity plan
Source: © AHIMA
AB103118_Ch10.indd 306 2/6/2020 5:36:24 PM

5. Policies and procedures and documentation Technical infrastructure, hardware, and

requirements software capabilities
Security measure costs
Essentially, the HIPAA Security Rule provisions
Probability and criticality of the potential
follow the established best practices for the devel-
risks to ePHI
opment and implementation of effective security
policy. The requirements of the HIPAA Security
●● Scalable means that the Security Rule is
Rule enforce the protection of information and ac- written so that it accommodates CEs of
cess by authorized individuals only. any size. Technology neutral means that
specific technologies are not prescribed,
allowing organizations to develop as their
General Rules technological capabilities evolve (Rinehart-
The General Rules provide the objective and scope Thompson 2018).
n.
for the HIPAA Security Rule as a whole. They spec- The HIPAA Security Rule identifies
tio
●●
ify that CEs must develop a security program that
ia
standards that CEs must comply with.
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includes a range of security safeguards to protect
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Business associates, hybrid entities,
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individually identifiable health information main- and other related entities (discussed in
en
tained (defined in chapter 9, Data Privacy and Con- chapter 9, Data Privacy and Confidentiality)
em
fidentiality) or transmitted in electronic form. The are also required to comply with these
ag
General Rules include the following:
an
standards.
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n
●● CEs must demonstrate and document that ●●Implementation specifications define
io
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they have done the following: how standards are to be implemented.
m r
Implementation specifications are either

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Ensured the confidentiality, integrity,

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and availability of all ePHI that is required or addressable. CEs must apply
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all implementation specifications that

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created, received, maintained, or

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transmitted by the covered entity are required. Addressable does not mean
an
Protected ePHI against any reasonably optional. For those implementation

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anticipated threats or hazards to the specifications that are labeled addressable,

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security or integrity of ePHI the CE must conduct a risk assessment

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Protected ePHI against any reasonable and evaluate whether the specification
by
or anticipated uses or disclosures that is appropriate to its environment. After

20
conducting a risk assessment, if the CE finds

20
are not permitted under the HIPAA

that the specification is not a reasonable and
©
Privacy Rule
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Ensured compliance with the HIPAA appropriate safeguard for its environment
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Security Rule by workforce members (for example, a small CE may decide not
op
to encrypt PHI because it deems it too

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●● The Security Rule is flexible, scalable, and

expensive to do so), then the CE must do the
technology neutral. Regarding flexibility,
following:
HIPAA allows a CE to adopt security
protection measures that are appropriate 1. Document why it is not reasonable
and reasonable for it. For example, security and appropriate to implement the
mechanisms will be more complex in specification as written.
a large hospital than in a small group 2. Implement an equivalent alternative
practice. In determining which security method if reasonable and appropriate.
measures to use, the following must be ●● Maintenance: HIPAA requires CEs and
taken into account: business associates to maintain their security
Size, complexity, and capabilities of measures. Maintenance requires review and
the CE modification, as needed, to comply with
AB103118_Ch10.indd 307 2/6/2020 5:36:24 PM

the provision of reasonable and appropriate need to use ePHI to perform their job duties
protection of ePHI (45 CFR 164.306). and must maintain appropriate oversight
of authorization and access. Likewise, the
Administrative Safeguards CE must prevent access to information
Administrative safeguards, as introduced earlier to those who do not need it and have
in the chapter, are documented, formal practices clear procedures of access termination
to manage data security measures throughout the for employees who leave the CE. These
CE. They require the CE to establish a security individuals must be removed from the
management process similar to the concepts dis- information systems immediately to prevent
cussed earlier in this chapter. disgruntled former employees from altering
The administrative safeguards detail how the or otherwise harming the data. Sanction
security program should be managed from the policies must also be in place. These
n.
CE’s perspective. Policies and procedures should sanction policies outline how employees
tio
are penalized when they violate the CE’s
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be written and formalized in a policy manual.
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The CE should issue a statement of its philoso- security policy and procedures.
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phy (why security is important) on data security. ●● Information access management. This standard
en
Further, it should outline data security authority requires the CE to implement a program
em
and responsibilities throughout the CE. There are of information access management. It
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an
a number of ways that a CE can control the use includes specific policies and procedures to
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of terminals, including user limitations such as determine who should have access to what
n
maximum allowed log-in attempts, screen sav-
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information.
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ers, and the timing out of terminals when a de- Security awareness and training. This standard
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●●
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termined period of inactivity has been reached.

In
requires the CE to provide security training

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Physically, computers should be able to be locked for all members of the workforce as
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when not in use, and a CE should maintain an in- described above.

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an
ventory such that all computers used within the ●● Security incident procedures. This standard
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CE can be identified.
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requires the implementation of policies and

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The administrative safeguards include the fol-

procedures to address security incidents,
e
lowing standards that CEs must implement:

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including responding to, reporting, and

by
●● Security management process. A CE must have mitigating suspected or known incidents.

20
a defined security management process.

20
●● Contingency plan. This standard requires

This means that there is a process in place
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the establishment and implementation of

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for creating, maintaining, and overseeing policies and procedures for responding
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the development of security policies and to emergencies or failures in systems that

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procedures; identifying vulnerabilities and

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contain ePHI. It includes a data backup

conducting risk analyses; establishing a plan, disaster recovery plan, emergency
risk management program; developing a mode of operation plan, testing and revision
sanction policy; and reviewing information procedures, and applications and data
system activity. criticality analysis to prioritize data and
●● Assigned security responsibility. Each CE must determine what must be maintained or
designate a security official to assume the restored first in an emergency.
role described earlier in this chapter. ●● Evaluation. A periodic evaluation must be
●● Workforce security. The CE must ensure performed in response to environmental or
appropriate clearance procedures to operational changes affecting the security
grant access to individually identifiable of ePHI and appropriate improvements in
information to workforce members who policies and procedures should follow.
AB103118_Ch10.indd 308 2/6/2020 5:36:24 PM

●● Business associate contracts. This standard Figure 10.4 identifies the HIPAA Security Rule
requires business associates to appropriately Administrative Safeguards.
safeguard information in their possession
and CEs to receive satisfactory assurances Physical Safeguards
that the business associates will do so (45 Physical safeguards include the protection of
CFR 164.308). hardware, software, and data from natural and
Figure 10.4 HIPAA Security rule administrative safeguards
1 Security 101 for Covered Entities
n.
tio
Security Standards Matrix (Appendix A of the Security Rule)
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ADMINISTRATIVE SAFEGUARDS
ss
Implementation Specifications
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Standards Sections (R) = Required, (A)=Addressable
en
Security 164 308(a)(1) Risk Analysis (R)
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Management Risk Management (R)
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Process Sanction Policy (R)
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Information System (R)
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Activity Review
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Assigned 164 308(a)(2) io (R)
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Security
m
Responsiblity
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Workforce 164 308(a)(3) Authorization and/or (A)

In
Security Supervision
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Workforce Clearance (A)

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Procedure
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an
Termination Procedures (A)

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Information 164 308(a)(4) Isolating Health Care (R)

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Access Clearinghouse functons

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Management Access Authorization (A)

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Access Establishment and (A)

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Modification
by
Security 164 308(a)(5) Security Reminders (A)

20
Awareness Protection from Mabolous (A)

20
and Training Sofftware

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Log-in Monitoring (A)

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Password Management (A)

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Security 164 308(a)(6) Response and Reporting (R)

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Incident
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Procedures
Contingency 164 308(a)(7) Data Backup Plan (R)
Plan Disaster Recovery Plan (R)
Emergency Mode (R)
Operation Plan
Testing and Revision (A)
Procedures
Applications and Data (A)
Criticality Analysis
Evaluation 164 308(a)(8) (R)
Business 164 308(b)(1) Writting Contract or Other (R)
Associate Arrangement
Contracts and
Other
Arrangements
Source: CMS.2007
AB103118_Ch10.indd 309 2/6/2020 5:36:25 PM

environmental hazards and intrusion. Physical be implemented for workstations with

safeguards consist of the following: access to ePHI.
●● Facility access controls. Policies and ●● Device and media controls. This standard
procedures must be implemented to requires the CE to specify proper receipt
appropriately manage not only the physical and removal of hardware and media
security of information systems, but also with ePHI and to address items as they
the buildings that house those information move within the CE. The entity must
systems. This is accomplished through also address procedures for removal or
building infrastructure as well as access disposal including reuse or redeployment
management related to the individuals who of electronic media, data backup, and the
are and are not permitted to access those identity of persons accountable for the
facilities. Restoration of data is also required process. ITAD policies are required under
n.
under this provision during and after this standard. These policies should address
tio
ia
disaster recovery as well as regular repairs end of life cycle hard drives, laptops,
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and updating of physical components of the servers, and other media that have contained
ss
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facilities with documentation to demonstrate sensitive data. Because such equipment is
en
such maintenance has taken place. often redeployed in the CE, all ePHI and any
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Workstation use. Policies and procedures other sensitive data must be removed. Before
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●●
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must relate to workstations that access hard drives, servers, or laptops are disposed
M
ePHI and include proper functions to be of, appropriate data destruction must be
n
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carried out (45 CFR 164.310).
performed, how they are to be performed,
at
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and the physical environment in which those

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Technical Safeguards
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workstations exist.
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Workstation security. Provisions under Of all the safeguards that are required to be im-
ea
●●
H
workstation security require that plemented to some degree in compliance with the
an
physical safeguards, as described earlier, HIPAA Security Rule, the technical safeguards are
ic
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Figure 10.5 HIPAA security rule physical safeguard standards

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by
20
20

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PHYSICAL SAFEGUARDS
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Standards Sections Implementation Specifications

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(R) = Required, (A)=Addressable

Facility 164.310(a)(1) Contingency (A)
Access Operations
Controls Facility Security Plan (A)
Access Control and (A)
Validation Procedures
Maintenance Records (A)
Workstation 164.310(b) (R)
Use
Workstation 164.310(c) (R)
Security
Device and 164.310(d)(1) Disposal (R)
Media Media Re-use (R)
Controls Accountability (A)
Data Backup and (A)
Storage
Source: CMS 2007.
AB103118_Ch10.indd 310 2/6/2020 5:36:26 PM

the most important aspect to a secure system due ●● Person or entity authentication. This standard
to the ever-changing and advancing of technolo- requires that those accessing ePHI must be
gies across all industries, especially healthcare. appropriately identified and authenticated
The technical safeguards, which are the technol- as discussed earlier in this chapter.
ogy and the policies and procedures regarding the ●● Transmission security. This standard
use and operation of the technology, consist of five requires the guarding of data against
broad categories. These provisions include those unauthorized access (interception) or
things that can be implemented from a technical improper modification without detection
standpoint using computer software, including when they are in transit, whether via open
the following: networks such as the internet or private
networks such as those internal to an
●● Access controls. The access controls stand-
organization. The two implementation
ard requires implementation of technical
n.
specifications—integrity controls and
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procedures to control or limit access to
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encryption—are addressable. The Security
health information. The procedures would
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Rule itself does not require encryption
ss
be executed through some type of soft-
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unless the CE deems it appropriate, but the
ware program. This requirement ensures
en
security of ePHI transmitted over public
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that individuals are given authorization to
networks or communication systems must be
ag
access only the data they need to perform
an
accomplished. Data encryption that provides
their respective jobs. The implementation
M
protection for data across transmission lines
n
specifications include unique user identifi- io is important because eavesdropping is easily
at
cations, emergency access procedures (for
m
accomplished using devices called sniffers.

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example, a break-the-glass capability that

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Sniffers can be attached to networks for the

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allows an individual who normally would

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purpose of diverting transmitted data. A

not have access to the information access to
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sniffer is a software security product that runs

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it in an emergency; however the use of this

an
in the background of a network, examining

access must be monitored), automatic log-off
ic
and logging packet traffic and serving as

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after a predetermined period of workstation

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an early warning device against crackers.

inactivity, and encryption and decryption,
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A hacker is an individual whose job is to

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discussed earlier in the chapter.

by
identify weaknesses in an information system

Audit controls. The audit control standard
20
●●
so that they can be corrected. A cracker is
20
requires that procedural mechanisms be an individual who exploits any weaknesses

©
implemented to record activity in systems that in an information system (Munson 2017).

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contain ePHI and that the output be examined

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Protecting data during transmission is only

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to determine appropriateness of access. Audit

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one role of encryption. Data at rest can also

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trails were discussed earlier in this chapter. be encrypted. Data at rest are data that are
●● Integrity. The data integrity standard in storage such as in a database. Passwords
requires CEs to implement policies and stored in a database may also be encrypted.
procedures to protect ePHI from being Thus, if a cracker breaks into the password
improperly altered or destroyed. In other database, the data will be unusable (45 CFR
words, this standard requires CEs to 164.312). Figure 10.6 is HIPAA Security Rule
provide proof that their data have not been technical safeguards.
altered in an unauthorized manner. Data
authentication can be substantiated through
audit trails and system logs that track users Organizational Requirements
who have accessed or modified data via This section includes the following two stan-
unique identifiers. dards—one addresses business associates (BA)
AB103118_Ch10.indd 311 2/6/2020 5:36:27 PM

Figure 10.6 HIPAA Security Rule Technical Safeguards
TECHNICAL SAFEGUARDS
Standards Sections Implementation Specifications
(R)= Required, (A)=Addressable
Access 164.312(a)(1) Unique User (R)
Control Identification
Emergency Access (R)
Procedure
Automatic Logoff (A)
Encryption and (A)
Decryption
(R)
n.
Audit Controls 164.312(b)
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Integrity 164.312(c)(1) Mechanism to Authenticate Electronic
ia
Protected Health Information (A)
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Person or 164.312(d) (R)
ss
Entity
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Authentication
Transmission 164.312(e)(1) Integrity Controls (A)
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Security Encryption (A)
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Source: CMS 2007.
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and similar entities and the other addresses group ePHI that is created, received, maintained, or
at
m
health plan requirements. transmitted by or to plan sponsors on behalf

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In
of the health plans (45 CFR 164.314).

1. Business associate or other contracts. CEs must
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obtain a written contract with BAs or other

H
entities (hybrid or other) that handle ePHI. Policies and Procedures and
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Documentation Requirements
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The written contract must stipulate that the

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BA will implement HIPAA administrative,

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The Security Rule requires that CEs and BAs have

physical, and technical safeguards and
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policies and procedures and that they be document-

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procedures and documentation requirements ed in writing. The following other information about
by
that safeguard the confidentiality, integrity,

20
any actions, assessments, or activities associated with

20
and availability of the ePHI that it creates, the HIPAA Security Rule also must be in writing.
©
receives, maintains, or transmits on behalf

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Policies and procedures. Entities must imple-

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of the CE. The contract must ensure any ●●

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agent, including a subcontractor, agrees ment reasonable and appropriate policies

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to implement reasonable and appropriate and procedures to comply with the HIPAA
safeguards. Specifically, HIPAA requires a BA security standards, implementation specifi-
to report to the CE any security incident or cations, and other requirements. Policies and
breach of ePHI of which it becomes aware. procedures should be developed and imple-
The CE must authorize termination of the mented considering the section on flexibility
contract if it determines that the BA has outlined in the rule.
violated a material term of the contract. ●● Documentation. Entities must maintain their
2. Group health plan requirements. Group health security policies and procedures in writing
plans must ensure their plan documents (this includes electronic format). Any
provide that the plan sponsor (an entity that actions, assessments, or activities related
provides a health plan for its employees) to the HIPAA Security Rule also must be
will reasonably and appropriately safeguard documented in writing. Documentation
AB103118_Ch10.indd 312 2/6/2020 5:36:28 PM

must be retained for six years from the date Further, it must be reviewed periodically
of its creation or the date when it last was and updated as needed, in response to
in effect, whichever is later. It must be made environmental or organizational changes
available to those individuals responsible that affect the security of ePHI (45 CFR
for implementing security procedures. 164.316).
American Recovery and Reinvestment Act of 2009

Provisions
The HITECH Act, a portion of ARRA, broadened requirements. Breaches only apply to unsecured
n.
privacy and security provisions including great- electronic protected health information, which
tio
er individual rights and protections when third is ePHI that has not been made unusable, unread-
ia
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parties handle individually identifiable health in- able, or indecipherable to unauthorized persons
ss
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formation. These changes had a significant impact (AHIMA 2013a). Thus, the need for encryption is
en
on the security provisions. clear. With regard to security, breach notification
em
The single most important change was the re- has implications for the protection of data in all
ag
quirement that business associates of HIPAA-cov- the following phases:
an
M
ered entities must comply with most of the same Data at rest—for example, data contained in
n
●●
rules as CEs. As noted in chapter 9, Data Privacy io
databases, file systems, or flash drives
at
m
and Confidentiality, BAs perform functions or activ-

r
Data in motion—for example, data

fo
●●
ities on behalf of or for a CE that involve the use or
In
moving through a network or wireless

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disclosure of PHI. Common BAs include consul-

transmission
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tants, billing companies, transcription companies,

H
accounting firms, and law firms. ●● Data in use—for example, data in the
an
ic
With the implementation of the ARRA, potential process of being created, retrieved, updated,
er
or deleted
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BA liability increased. BAs are now held d irectly

e
responsible for not complying with the adminis- ●● Data disposed—for example, discarded
th
trative, physical, and technical safeguards of the paper records or recycled electronic media. It
by
20
HIPAA Security Rule, as well as the policies and is critical to use appropriate data destruction
20
procedures and documentation requirements. methods to ensure disposed data cannot be

©
Another important change per the HITECH Act read, retrieved, or reconstructed in any way
ht
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was defining breach and adding breach notification (AHIMA 2009)

yr
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Forensics
Forensics is the process of identifying, policies and procedures. These types of events are
analyzing, recovering, and preserving data within usually called trigger events and include the fol-
an electronic environment. With appropriate poli- lowing employees viewing:
cies and procedures in place, it is the responsibility
of the CE and its managers, directors, CSO, and ●● Records of patients with the same last name
employees with audit responsibilities to review or address of the employee
access logs, audit trails, failed log-ins, and other ●● VIP records (celebrities, board members,
reports generated to monitor compliance with the political figures)
AB103118_Ch10.indd 313 2/6/2020 5:36:28 PM

●● Records of those involved in high-profile c onsistent with the employee’s expertise

events in the community (Walsh and Miaoulis 2014)
●● Records with little or no activity for 120 The CE should have specific policies and monitor-
days ing procedures in place to track employees’ access
●● Other employee’s records via sign-on and password and periodically audit all
●● Files of minors reports, especially when incidents occur or VIPs are
●● Files of those treated for infectious diseases treated. HIPAA requires a regular r eview of system
or sensitive diagnoses such as HIV/AIDS or activity such as monitoring new user access, review-
sexually transmitted diseases ing system access by users in general, and testing the
access of recently terminated employees to ensure
●● Records of patients for whom the viewing
they have, in fact, been removed from access roles.
employee did not provide care
There have been numerous cases where employees
n.
Records of a spouse (without the same
tio
●●
have inappropriately accessed the hospital records
ia
surname) of high-profile individuals. These actions have led
oc
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●● Records of terminated employees to discipline, including termination and fines, after
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●● Portions of records of a discipline not audit trails revealed unauthorized access.
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Check Your Understanding 10.3 n
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1. According to American Recovery and Reinvestment Act revisions:

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a. No changes were made to the HIPAA standards

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b. Potential business associate liability was increased under HIPAA

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c. Business associate liability was decreased under HIPAA

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d. Breaches apply to both secured and unsecured PHI

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2. A covered entity has robust policies and procedures. The government is investigating a security breach. How far back
e
th
can the government request documentation related to data security policies and procedures?
by
a. Six years
20
b. Five years
20
c. Two years
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d. Ten years
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yr
3. The patient’s address is the same in the master patient index, electronic health record, laboratory information system,
op
and other information systems. This means that the data values are consistent and therefore indicative of which of the
C
following?
a. Data availability
b. Data accessibility
c. Data privacy
d. Data integrity
4. Identify an example of a technical safeguard.
a. A policy that states that passwords cannot be shared
b. A policy that states that only authorized people can access the data center
c. Locking the door of the data center
d. Assigning passwords that limit access to computer-stored information
AB103118_Ch10.indd 314 2/6/2020 5:36:28 PM

5. According to HIPAA standards, the designated individual responsible for data security:
a. Must be identified by every covered entity
b. Is only required in large facilities
c. Is only required in hospitals
d. Is not required in small physician office practices
6. Critique each statement to determine the true statement regarding a coordinated security program.
a. The CSO must hold a lower level position so as not to create controversy.
b. All security policies and procedures should be updated every six months.
c. This type of program should only be established if an organization has sufficient funds to support it.
d. Someone inside the CE must be responsible for data security.
7. An automated flag just notified us that a VIP’s health record was accessed. This might have been as the result of a(n):
a. Trigger
n.
b. Audit
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c. Policy and procedure
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d. Monitor of data in use
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8. An employee views a patient’s electronic health record. It is a trigger event if:
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a. The employee and patient have the same last name
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b. The patient was admitted through the emergency department
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c. The patient is over 89 years old
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d. A dietitian views a patient’s nutrition care plan
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9. If an implementation specification is addressable: io
at
a. It is optional
mr
b. If not implemented, the organization must document why it is not reasonable and appropriate to do so
fo
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c. If not implemented, the organization does not have to account for its absence
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d. It must be carried out as written

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HIM Roles
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th
by
As data continue to proliferate and HIM professionals with graduate degrees can assume
20
breaches continue to occur at an alarming rate, HIM the role of the Chief Security Officer. HIM profes-
20
©
professionals will continue to play an increasing and sionals can also conduct audits and risk assessments
ht
vital role in leading initiatives and efforts to reduce and otherwise participate in the security program of
ig
yr
and prevent data breaches. As health information a CE. Additional roles will continue develop within
op
C
has become more electronic in nature, HIM roles in the HIM field to meet the new needs and challenges
general have taken more of a technology emphasis. brought about by new technology.
Real-World Case 10.1

The Department of Health and Hu- ecurity information, and more. Touchstone did
S
man Services reported on its website a $3,000,000 not investigate the matter in a timely manner.
settlement with Touchstone Medical Imaging. The investigation also found that a risk anal-
One of Touchstone’s servers allowed access to ysis had not been conducted and business
ePHI via the internet. More than 300,000 patients associate agreements were not in place (Source:
were impacted. The ePHI included names, Social HHS 2019).
AB103118_Ch10.indd 315 2/6/2020 5:36:28 PM


You are the Chief Security Officer of A quick and thorough response to this incident is
Anywhere Hospital. You just received a frantic of the utmost importance and is crucial to avoid
email from one of your help desk employees in disrupting patient care systems.
the Information Technology department. There A little while later, you discover that the mal-
is a suspected malware infection that is spread- ware was launched from within the network via
ing across your computer network. You ask your email; specifically, the malware was launched on
staff member whether there has been data loss or the vice president’s workstation in his office when
corruption. Your team member responds by say- he opened an email containing the malware. The
ing that she does not know yet; the security team hospital’s Network Intrusion Detection System
has been called and will begin the investigation did not pick up abnormal traffic coming through
n.
tio
process, starting with the origin of the malware. the firewall.
ia
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en
References
em
ag
an
American Health Information Management Dowling, K. 2017. AHIMA Guidelines: The
M
Association. 2017. Pocket Glossary of Health Cybersecurity Plan. http://journal.ahima.org/
n
Information Management and Technology, 5th ed. io
wp-content/uploads/2017/12/AHIMA-Guidelines-
at
Chicago: AHIMA. Cybersecurity-Plan.pdf.
mr
fo
American Health Information Management Institute of Medicine. 2011. Health IT and Patient
In
Association. 2013a. Analysis of Modifications to the Safety: Building Safer Systems for Better Care.
lth
HIPAA Privacy, Security, Enforcement, and Breach Consensus Report. http://www.iom.edu/

ea
H
Notification Rules Under the Health Information Reports/2011/Health-IT-and-Patient-Safety-Building-

an
Technology for Economic and Clinical Health Act and Safer-Systems-for-Better-Care.aspx.

ic
the Genetic Information Nondiscrimination Act; Other

er
Johns, M.L. 2008. Privacy and Security in Health

Am
Modifications to the HIPAA Rules. http://library. Information. In Electronic Health Records: A Guide
ahima.org/PdfView?oid=106127.
e
for Clinicians and Administrators, 2nd ed. Edited

th
American Health Information Management by J. Carter. Philadelphia: American College of

by
Association. 2009. Analysis of the Interim Final Rule, Physicians.

20
20
August 24, 2009: Breach Notification for Unsecured McCann, E. 2014 (January 2). 4-Year Long HIPAA
©
Protected Health Information. http://library.ahima. Breach Uncovered. HealthITNews. http://www.

ht
org/PdfView?oid=100232. healthcareitnews.com/news/four-year-long-hipaa-
ig
yr
Carlon, S. 2013. Information Security. Chapter 17 in data-breach-discovered.

op
Health Information Management Technology: An Applied

C
Miaoulis, W.M. 2011. Preparing for a HIPAA Security

Approach. Edited by N.B. Sayles. Chicago: AHIMA. Compliance Assessment. Chicago: AHIMA.
Centers for Medicare and Medicaid Services. 2007. Munson, L. 2017. What are the Main Differences
Security 101 for Covered Entities. https://www. Between Hackers and Crackers? http://www.security-
hhs.gov/sites/default/files/ocr/privacy/hipaa/ faqs.com/what-are-the-main-differences-between-
administrative/securityrule/security101.pdf. hackers-and-crackers.html.
Department of Health and Human Services. 2019. National Institute of Standards and Technology. 2008.
Tennessee diagnostic medical imaging services An Introductory Resource Guide for Implementing
company pays $3,000,000 to settle breach exposing the Health Insurance Portability and Accountability
over 300,000 patients’ protected health information. Act (HIPAA) Security Rule. http://csrc.nist.gov/
https://www.hhs.gov/about/news/2019/05/06/ publications/nistpubs/800-66-Rev1/SP-800-66-
tennessee-diagnostic-medical-imaging-services- Revision1.pdf.
company-pays-3000000-settle-breach.html.
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Olenik, K., and R. Reynolds. 2017. Security Threats version, as amended through March 26). https://
and Controls. Chapter 13 in Fundamentals of Law for www.hhs.gov/sites/default/files/ocr/privacy/
Health Informatics and Information Management. Edited hipaa/administrative/combined/hipaa-
by M.S. Brodnik, L.A. Rinehart-Thompson, and R.B. simplification-201303.pdf.
Reynolds. Chicago: AHIMA. 45 CFR 164.306: Security standards: General
Rinehart-Thompson, L.A. 2018. Introduction to rules. 2006.
Health Information Privacy and Security. Chicago: 45 CFR 164.308: Administrative safeguards. 2006.
AHIMA.
45 CFR 164.310: Physical safeguards. 2006.
Walsh, T, and W. M. Miaoulis. 2014. Privacy and
Security Audits of Electronic Health Information (2014 45 CFR 164.312: Technical safeguards. 2006.
Update). Journal of AHIMA 85(3):54-59. 45 CFR 164.314: Organizational requirements. 2006.
45 CFR 160, 162, and 164. HIPAA administrative 45 CFR 164.316: Policies and procedures and
simplification regulation text. 2013 (unofficial documentation requirements. 2006.
n.
tio
ia
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In
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by
20
20
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AB103118_Ch10.indd 317 2/6/2020 5:36:28 PM

AB103118_Ch10.indd 318
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2/6/2020 5:36:28 PM
n.
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PART
Informatics, M
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IV
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io
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Analytics, and
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In
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ea
Data Use
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Am
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by
20
20
©
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319
AB103118_Ch11.indd 319 2/11/2020 1:18:11 PM

AB103118_Ch11.indd 320
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©
20
20
by
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ea
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2/11/2020 1:18:11 PM
Chapter
11
Health Information
n.
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Systems
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en
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Margret K. Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS
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Learning Objectives
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m
•• Identify the scope of health information systems ongoing management of health information
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and how they have evolved to their current state systems

In
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of implementation in hospitals, ambulatory care, •• Utilize a systems approach to achieve systems

ea
and other settings integration so health information systems support

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•• Apply the systems development life cycle in the national mission to improve health and
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the planning, selection, implementation, and healthcare, and reduce healthcare costs
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er
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Key Terms
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th
3D printing Best of breed Clinical decision support (CDS)

by
Accredited Standards Committee Best of fit Clinical decision support system

20
X12 (ASC X12) Big data (CDSS)

20
Adoption Billing system Clinical Document Architecture

©
ht
Alert fatigue Biometrics (CDA)

ig
Alternative payment models Business intelligence (BI) Clinical Laboratory Improvement

yr
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(APMs) Certificate authority Amendments (CLIA) of 1988

C
Analytics Certification Clinical transformation

Ancillary systems Change control program Closed-loop medication
Application program interface Chart conversion management
(API) Chart tracking Cloud computing
Application service provider (ASP) Chief medical informatics officer Computerized provider order entry
Artificial intelligence (AI) (CMIO) (CPOE)
Auto-analyzer Claims data CONNECT
Automated drug dispensing Clearinghouse Consent directive
machines Client/server system Consent management systems
Bar code medication administration Clinical data repository (CDR) Consolidated Clinical Document
record (BC-MAR) Clinical data warehouse (CDW) Architecture (C-CDA)
321
AB103118_Ch11.indd 321 2/11/2020 1:18:12 PM

322 Part IV Informatics, Analytics, and Data Use
Continuity of care document (CCD) Identity proofing Portals

Contraindication Implementation Power user
Customer relationship Inference engine Primary care physician (PCP)
management (CRM) Information Process interoperabilityProject
Data Interface management office (PMO)
Data conversion Interface engine Protocol
Data dictionary Interoperability Provider
Data governance framework (DGF) Issues management Radio-frequency identification
Data model Kiosk (RFID)
Data quality Knowledge Radiology information system
Data Use and Reciprocal Support Knowledge sources (RIS)
Agreement (DURSA) Laboratory information Record locator service (RLS)
Diagnostic studies system (LIS) Registration-admission, discharge,
Digital certificate Logical Observations, Identifiers, transfer (R-ADT)
n.
Digital Imaging and Names, and Codes (LOINC) Registry
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Communications in Medicine Machine learning Requirements specification
ia
oc
(DICOM) Meaningful Use Results management
ss
Direct Project Meaningful Use (MU) program Revenue cycle management
tA
Discrete reportable transcription Medication five rights (RCM)
en
(DRT) Medication reconciliation Rules engine
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Document imaging Message format standards RxNorm
ag
Drug knowledge database Metadata Scribe
an
Due diligence National Council for Prescription SCRIPT
M
n
eHealth Exchange Drug Programs (NCPDP) io Semantic interoperability
at
End user National Drug Codes (NDC) SMART goals
m
Enterprise architecture (EA) Natural language processing Smart peripherals

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e-prescribing (e-Rx) (NLP) Software as a Service (SaaS)

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e-prescribing for controlled Nursing information system Source systems

ea
substances (EPCS) Office of the National Coordinator Speech dictation

H
Evidence-based medicine (EBM) (ONC) for Health Information Steering committee

an
e-visits Technology Storage management

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Fast Healthcare Interoperability Online analytical processing Structured data

Am
Resource (FHIR) (OLAP) Sunsetting

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Federal Health IT Strategic Plan Online transaction processing System

th
2015–2020 (OLTP) System build

by
Go-live Operating rules System configuration

20
20
Health information exchange Optimization Systems development life cycle

©
(HIE) Opt in/opt out (SDLC)

ht
Health information organization Patient acuity staffing Technical interoperability

ig
(HIO) Patient financial system (PFS) Telehealth

yr
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Health information system Patient portal Template

C
Health Information Technology for Patient safety Transaction

Economic and Clinical Health Personal health record (PHR) Two-factor authentication
(HITECH) Personalized medicine Unintended consequence
Health Insurance Portability and Pharmacy information system Unstructured data
Accountability Act of 1996 Physician champion Use
(HIPAA) Picture archiving and Value
Health IT communications system (PACS) Value-based care (VBC)
Health Level Seven (HL7) Point-of-care (POC) documentation Vendor selection
Hospital in the home Policy interoperability Virtual private network (VPN)
Human computer interfaces (HCI) Population health Web services architecture (WSA)
Identity management (IdM) Population health management Workstations on wheels (WOWs)
Identity matching algorithm (PHM) XML (eXtensible markup language)
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The Office of the National Coordinator (ONC) Figure 11.1 Federal Health IT Strategic Plan
for Health Information Technology is the agency 2015–2020
within the federal government tasked to be the
health information technology (typically referenced
as health IT) resource to the nation. In 2015, the
ONC issued the Federal Health IT Strategic Plan Goal 1
2015–2020 in which it describes a vision and mis- Advance person-centered
and self-managed
sion for the United States’ use of health information health
technology (IT):
Vision: High-quality care, lower costs, Goal 2 Goal 3
healthy population, and engaged people. Transform health Foster research,
care delivery and scientific
Mission: Improve the health and well-being community knowledge
n.
of individuals and communities through the health and innovation
tio
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use of technology and health information
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that is accessible when and where it matters Goal 4
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most (ONC 2015). Enhance nation’s
en
health it infrastructure
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In addition, the Federal Health IT Strategic Plan
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identified four overarching goals for health IT,
an
which are both sequential as enumerated below,
M
Source: ONC 2015
and interdependent as shown in figure 11.1. The

n
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evidence of actions taken. Data are raw facts and
at
following goals ultimately focus on improving the
m
figures without context or meaning; information

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health and well-being of the nation:

is data that have been processed in a useful and
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●● Advance person-centered and self-managed meaningful manner.

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health This chapter discusses the scope of health in-

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●● Transform healthcare delivery and formation systems, the importance of standards,

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and the need to take a systems approach to planning,

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community health
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selecting, implementing, and managing health in-

●● Foster research, scientific knowledge, and
e
formation systems so that the ultimate result meets

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innovation
by
the national vision and mission for healthcare and

Enhance the nation’s health IT infrastructure
20
●●
the goals for each healthcare provider (hospital,
20
Dissemination of knowledge is stated as a goal physician, nursing home, and others). The role health
©
in the Federal Health IT Strategic Plan. Knowledge information management (HIM) professionals play
ht
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is more than information; knowledge is the appli- in acquiring, implementing, gaining adoption, and
yr
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cation of experience to information that provides optimizing use of health information systems is
C
value to the information beyond only serving as also discussed in this chapter.
Health Information Systems

The term health IT, or health informa- useful information. Information technology in-
tion and technology, is used by the ONC because cludes communication and network technologies
of its focus on information technology for health- that enable data and information to be exchanged
care. Information technology used by healthcare across various computers. Such technology, how-
entities includes computer hardware and software ever, would apply in any environment. In addition,
to enable the collection and processing of data into technology alone does not achieve the ultimate
AB103118_Ch11.indd 323 2/11/2020 1:18:14 PM

goal of gaining benefits from its use. People, pol- ●● Operational and cultural adaptations
icy, and process elements must be addressed for necessary to use the technologies in
healthcare professionals to learn how to use and performing diagnostic studies (all
make the most effective use of the hardware, soft- diagnostic services of any type, including
ware, communications, and network technologies. history, physical examination, laboratory,
Health information system is used to describe x-ray and others that are performed or
the full scope of adopting health information tech- ordered pertinent to the patient’s reasons
nology. The term system refers to components that for the encounter) on various specimens
work together to accomplish a goal. The term collected from patients and applying
health information system may be considered to in- professional judgment in evaluating the
clude technical components and people, policy, quality of the data representing the results
and process components that work together to ●● Policies and standards from the local
n.
support the goal of improving the health and healthcare organization in which the
tio
well-being of the nation.
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information system is housed as well as
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Health information systems may be considered accrediting and licensing bodies that must
ss
narrowly or broadly. For example, a laboratory
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be followed for design of the technology
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information system (LIS) in a hospital is a health and its use. For example, policies and
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information system with a narrow focus on receiv- standards for a LIS may include use of
ag
ing and processing orders for laboratory testing,
an
certain terminologies, such as the Logical
M
collecting and processing specimens, and docu- Observations, Identifiers, Names, and
menting, delivering, and storing results. LISs n
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Codes (LOINC), which is federally
at
also support department management, including
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mandated for ordering and reporting

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staffing, equipment maintenance, supplies, and lab results. The Clinical Laboratory
In
compliance.
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Improvement Amendments (CLIA) of

ea
As such, a health information system for a hos- 1988 are federal regulatory standards that
H
pital laboratory includes the following:

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ensure quality laboratory testing. They were

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modified in 2014 to ensure patients may

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●● Hardware: computers, printers, laboratory

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have direct access to their test results, even

devices
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prior to review by their ordering provider

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●● Software: computer programs designed

by
(Federal Register 2014).

to process orders for lab tests, produce
20
●● Workflow and process designs ensure the

20
specimen collection lists for hospitalized

most efficient and effective use of the tech-
©
patients, produce labels for specimen

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nology (chapter 17, Management, covers

containers, produce test results, and conduct
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workflow in more detail).

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quality assurance on lab testing processes

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●● Communications and network technologies An EHR system is broader in scope than a LIS.
(connections with a computerized provider An EHR supports physicians, nurses, and other
order entry [CPOE] system), used by healthcare professionals in their documentation
providers to enter orders for lab tests as and communications concerning patients within
well as medications and other procedures, the healthcare enterprise. An EHR has connec-
laboratory testing devices, pharmacy tion points to many focused health information
systems to obtain drug information that may systems in a healthcare organization. These health
impact test results, and destination systems, information systems include the LIS, pharmacy
such as the electronic health record (EHR) information system, radiology information sys-
system to convey results to providers and tem, nursing information system, dietary informa-
billing systems to capture charges for the tion system, emergency department system, and
lab tests many others. There are also an increasing number
AB103118_Ch11.indd 324 2/11/2020 1:18:14 PM

of connections with other healthcare and related and others. While such a broad health information
organizations, such as physician offices, health system is not likely to exist as a single entity, the
plans, public health departments, immunization goal is to ultimately support the sharing of health
registries, ambulance services, quality measure information to achieve the best possible healthcare
registries, vendors, and others. Healthcare organi- and experience of care at a reasonable cost.
zations are using EHRs to connect with patients As suggested by the many health information
in multiple ways. Connections may be available systems that exist and which may continue to be
through portals (windows into information sys- developed or enhanced as new information tech-
tems), personal health records (PHRs), personal nology emerges, it is important to recognize that
medical devices, apps on smart phones, and tele- many health information systems need to be peri-
health services that assist in providing remote odically updated and expanded, or even phased
diagnosis and treatment through telecommunica- out and replaced with new technology. The sections
n.
tions technology. that follow will discuss the current state of health
tio
Another health information system that may be information systems and their scope—including
ia
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either narrow or broad is afforded by health in- source systems, core EHR applications, specialty
ss
formation exchange (HIE) services. HIEs enable systems, HIE systems, automated medical de-
tA
en
sharing of health information across disparate en- vices, supporting infrastructure, and connectivity
em
tities. While EHRs are accessible within a given systems.
ag
healthcare entity, the primary purpose of an HIE
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Current State of Health Information
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is to support authorized exchange of health data
across entities that subscribe to the service. This n
Systems
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function extends data sharing more broadly than
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Health information systems for lab, pharmacy, and

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an EHR but is often relatively narrow in scope. other ancillary services are not new. Physicians and
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It may serve only to share where an EHR for a

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nurses have relied on these information systems

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patient is located; or it may maintain a repository as an important means to exchange diagnostic

H
of limited data, such as lab results and medication

an
reports, medication, and other information since

ic
lists that can be accessed by subscribers. In this the early 1970s. EHRs were initially conceived
er
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narrow context, the HIE maintains patient and pro- around this time, but did not become a primary
vider directories and provides consent manage-
e
focus for healthcare providers until 2009 with

th
ment and security services. To support such basic

by
the passage of the Health Information Technol-

services at low or no cost to providers, many HIEs
20
ogy for Economic and Clinical Health (HITECH)

20
provide additional services. These broader ser- Act legislation. HITECH provided eligible hospi-
©
vices vary by HIE. Some HIEs offer clearinghouse tals and professionals with financial incentives, in
ht
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services for revenue cycle management. Others terms of healthcare payment adjustments, to make
yr
op
may offer data mapping to reconcile differences meaningful use of EHRs. This incentive program
C
between coding systems or versions of coding sys- is commonly referred to as the Meaningful Use
tems. Increasingly, many HIEs offer data aggrega- (MU) program (now known as promoting inter-
tion and analysis, quality measure data collection operability) and describes an EHR that is qualified
and reporting, and business intelligence services for earning incentives as one that:
(HealthIT.gov. 2018; HIMSS 2012a; AHIMA 2013).
Perhaps the broadest possible health informa- includes patient demographic and clinical
tion system is one that does not exist, but could health information, such as medical history
be viewed as a virtual system of all EHRs (encom- and problem lists; and has the capacity to
passing all of the narrow systems within an or- provide clinical decision support, support
ganization), all HIEs (to support exchange across physician order entry, capture and query
organizations), and potentially other information information relevant to healthcare quality,
systems, such as ancestry and genomic systems and exchange electronic health information
AB103118_Ch11.indd 325 2/11/2020 1:18:14 PM

with and integrate such information from administration using the technology.
other sources (HealthIT.gov. 2016). Physicians may use an EHR to review lab
results and other information collected
While most hospitals and many healthcare pro-
by other healthcare professionals. Often
fessionals have implemented an EHR within their
“use” has not addressed workflow and
healthcare organizations, the MU program started
process changes that enable intended users
winding down in 2016. Since then, requirements
to seamlessly incorporate the technology
for using an EHR have been incorporated into
into their everyday operations. Simple
alternative payment models (APMs), which are
usage should begin immediately after
new ways the federal government is paying for
implementation, but within a few months
care. Such payment models are used in what is
users should be moving to adoption.
now being referred to as value-based care (VBC)
strategies to improve the quality of care and drive ●● Meaningful Use, as noted above, is a term
n.
down its cost. In this context, value refers to im- used by the federal government for the
tio
ia
proving the quality of care to achieve a healthier program designed to incentivize use of
oc
EHRs. The term meaningful was chosen to
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nation, which can result in reducing the cost of
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care overall. For example, for physicians to be reflect the purposeful desire to go beyond
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paid under Medicare, they must supply data to simply using the EHR as a search tool. There
em
the federal government via their EHR for qual- were two components to the MU program.
ag
an
ity measurement. Different payment models are One component was managed by the ONC
M
then applied based on provider factors, including and specified the functionality an EHR must
n
io
have in order for a provider to qualify to
the level of risk a provider is willing to assume
at
m
(QPP,CMS.gov/apms. 2018; Feeley and Mohta earn the incentives. The other component
r
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of the MU program was the degree of use

In
2018). (Reimbursement is discussed in chapter 15,

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Revenue Management and Reimbursement.) providers should make of the qualified

ea
The degree to which EHRs are used by health- EHR as specified by CMS (CMS 2014). CMS
H
an
care professionals varies significantly. As a result, supplied monetary incentives through its
ic
Medicare and Medicaid reimbursement

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EHRs are “never done” (Gue 2018); they require

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continuous updating and improvement. The terms systems. Three stages were initially planned,
e
and definitions that describe the various stages in with two stages fulfilled and the third stage
th
by
which any new information system may exist in moved to CMS’s VBC programs (QPP.CMS.
20
healthcare, include the following: gov/mips. 2018).

20
●● Adoption is a term frequently associated

©
Implementation refers to technology having

ht
●●
with the intent of MU. Adoption of health
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been installed and configured to meet the ba- information systems reflects that the
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sic requirements of the healthcare organiza- healthcare organization has implemented

C
tion. Demonstration to end users has taken all the major components of technology,
place. End users are those persons who will although there may be some available
use the information system in the course of technology that is more specialized, costly,
their daily processes and procedures. and time-consuming to implement that has
●● Use refers to the fact that those who are not yet been implemented. Adoption with
supposed to apply the technology to their respect to the EHR requires users to rely
daily work have been trained and are on technology to enter and retrieve most
starting to apply the technology at a simple information, and where decision support
level. For example, nurses may enter data is included to use it when appropriate.
into nurse assessment templates (a guide for Adoption of EHRs demonstrates effective
documentation) and document medication integration into the daily routines of
AB103118_Ch11.indd 326 2/11/2020 1:18:14 PM

healthcare. Adoption also should indicate it Scope of Health Information Systems

generally takes no more time to use an EHR
Health information systems have evolved over
than the paper health record, and generally
time to automate an increasing number of informa-
yields greater value to the user than the
tion processing functions. Figure 11.2 summarizes
paper health record. Unfortunately, adoption
health information systems in the sequence in
of EHRs has yet to be fully achieved, as
which they have generally been adopted within
many healthcare professionals find that
hospitals. This sequence started with various ad-
EHRs are more time-consuming than paper
ministrative and financial systems, then depart-
and some find them to be distracting during
mental clinical systems, and subsequently some or
patient care. In general, hospitals find them
all specialty clinical systems and “smart” periph-
more helpful than not, and have supported
erals (such as clinical equipment with electronic
physicians in using medical scribes (an
components that support information collection
n.
assistant who gathers information and
tio
and alerts). Collectively, these are referred to as
documents care into the EHR) and other
ia
source systems because they are the source of basic
oc
workarounds that enable them to achieve
ss
data for the core clinical systems that comprise the
EHR benefits. Some physician offices
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EHR. Many core clinical systems have been imple-
en
delayed implementation, others have
mented with the help of the MU program. Both
em
abandoned the EHRs they implemented,
ag
source systems and core clinical systems depend
and a number of them are in the process of
an
on supporting infrastructure technology (various
M
replacing initially acquired systems with
types of input/output devices and databases) and
newer and improved systems (Spitzer 2018). n
io
connectivity systems (network technology and
at
m
●● Optimization is the state that demonstrates standards). The major types of health information
r
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not only effective adoption of health

In
systems are summarized in more depth and vari-

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information systems for routine operations, ations between hospitals and physician practices
ea
but also an understanding and appropriate are described after figure 11.2.
H
an
use of the technology’s features with

ic
workflow and process improvements that

er
Source Systems
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can improve clinical efficiency (Monica

Source systems capture and supply the EHR and
e
2018) and improve a healthcare entity’s

th
other broad health information systems with data.

by
bottom line (Siwicki 2018). At this state, the

Source systems may include administrative and fi-
20
healthcare organization implements all or

20
almost all the technology available to it. nancial applications, ancillary/clinical departmen-
©
The user who optimizes health information tal applications, specialty clinical systems, and
ht
ig
systems has fully embraced the standard “smart” peripherals.

yr
op
vocabularies supported by the technology,

C
pays attention to alerts and reminders, is Administrative and Financial Applications

able to generate various reports that meet Administrative and financial applications are usu-
unique needs, frequently tailors the system ally managed by specific departments, such as
to further take advantage of documentation admitting, patient financial services, revenue cy-
aids, and may be considered a power user. cle management, business intelligence, and health
Power users, people whose expertise in the information management. However, they are not
information system is above others, are able considered departmental systems because they
to use technology to significantly improve manage patient-specific data needed for all other
their productivity and will likely see applications, and do not process data that aid in
healthcare quality and cost benefits as well management of the departments as do ancillary,
(HIMSS Analytics 2017). or departmental systems (see the next section).
AB103118_Ch11.indd 327 2/11/2020 1:18:14 PM

Figure 11.2 Overview of health IT systems in hospitals
Source Systems
Administrative and Financial Applications
R-ADT
MPI PFS HIM EDMS QA OC/RR
PMS
Departmental Clinical Applications
Others
Blood PACS Inpatient
Lab Radiology pharmacy
bank Dietary
Specialty Clinical Systems
Intensive Perioperative/ Emergency
Cardiology Labor & delivery Log-term care
care surgical medicine
“Smart” Peripherals
n.
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Monitoring Infusion Dispensing
Robotics
ia
equipment pumps devices
oc
Core Clinical “EHR” Systems
ss
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Medication Management
en
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Results POC
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CPOE BC-MAR CDSS Reporting
management documentation
an
Supporting Infrastructure
M
n
io
at
m
HCI – CDR – SAN – Rules Engine – Knowledge – Registry – CDW

r
sources
fo
In
Connectivity Systems
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LAN Portals CCR CCD PHR WAN Telehealth HIE NHIN

H
an
ic
er
Key to acronyms for figure 11.2 LAN: local area network

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BC-MAR: bar code medication administration recording MPI: master patient index
CCR: continuity of care record NHIN: nationwide health information network
e
th
CDR: clinical data repository OC/RR: order communication results retrieval

by
CDSS: clinical decision support system PACS: picture archiving and communication systems
20
CCD: continuity of care document PFS: patient financial systems

20
CDW: clinical data warehouse PHR: personal health record

©
CPOE: computerized provider order entry POC: point of care

ht
EDMS: electronic document management system QA: quality assurance

ig
yr
HCI: human computer interfaces SAN: storage area network

op
HIE: health information exchange WAN: wide area network

C
LAB: laboratory
Source: © Margret\A Consulting, LLC. Reprinted with permission.
In general, administrative and financial applica- ●● Revenue cycle management (RCM)

tions include the following: systems
●● Registration-admission; discharge transfer
●● Quality measurement, reporting, and
(R-ADT) systems (in hospitals) improvement systems (Quality)
●● Practice management systems (PMS) (in
●● Health information management (HIM)
physician offices) systems
●● Human resources, physician compensation,
●● Master patient index (MPI)
procurement, and many others
●● Patient financial systems (PFS)
AB103118_Ch11.indd 328 2/11/2020 1:18:15 PM

Increasingly, healthcare organizations are adopt- Patient Financial Systems Patient financial
ing business intelligence (BI) systems, which inte- systems (PFSs), frequently called billing systems
grate, analyze, and supply financial and clinical in a physician practice, serve to check patient in-
data to support both administrative/financial surance eligibility, capture charges for services (in-
and clinical decision-making. (Chapter 6, Data cluding codes for office visits), compile and send
Management, describes the specifics on business claims to payers, receive payment and remittance
intelligence.) advice, and identify unpaid or denied claims for
which other collections efforts must be made. Rev-
Registration, Admission, Discharge, Transfer enue cycle management (RCM) system is a term
Systems Registration-admission, discharge, trans- that often refers to the broader process of not only
fer (R-ADT) systems in hospitals register patients creating, submitting, analyzing, and obtaining
for inpatient admission or outpatient services. The payment for healthcare services, but also negotiating
n.
R-ADT captures demographic and insurance data contracts with health plans, coding and clinical
tio
and supplies this data to other applications as documentation integrity, conducting utilization
ia
oc
needed. An R-ADT system tracks when patients review, and other functions. The full scope of RCM
ss
are admitted to the hospital and opens an account
tA
is enumerated in figure 11.3 (Amatayakul 2017a).
en
for them. It also tracks all patient transfers within (Chapter 15, Revenue Management and Reimburse-
em
the hospital, such as a patient moving from an ment, covers the revenue cycle management in
ag
intensive care unit to a cardiac unit. Finally, the more detail.)
an
M
R-ADT system closes the account when a patient The RCM functions that exchange data be-
is discharged, transferred to another healthcare n
io
tween providers and health plans are referred
at
organization, or dies. Other related information to as transactions. Each transaction, such as eli-
m r
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systems keep track of the healthcare organization’s gibility verification, claims status inquiry, and
In
census, track who is in what bed, compile length so forth have mandated standards for use under
lth
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of stay information, and maintain an MPI. In a the Health Insurance Portability and Accounta-
H
physician practice, an equivalent system might be bility Act of 1996 (HIPAA). The standards spec-
an
ic
a practice management system, although in some ify in what format the data should be compiled
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cases only a scheduling system is in place. and what data should be exchanged with payers.
e
th
by
Figure 11.3 Scope of Revenue Cycle Management

20
20
• Claims review and edits (“cleaning” /

©
• Contract negotiation
scrubbing”)
ht
• Patient demographics and insurance

ig
capture • Claims submission

yr
op
• Eligibility and benefits verification • Filing for contractual payments and

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shared risk arrangements

• Co-pay collection
• Claim status determination
• Patient financial counseling
• Claim attachments
• Prior approval for certain service
coverage • Remittance advice and payment
posted to accounts receivables
• Case management
• Audits, denials, and appeals
• Utilization management
• Accounts receivables follow-up and
• Charge capture and chargemaster collections
maintenance
• Bad debt/charity management
• Coding and clinical documentation
integrity • Analytics and reports
AB103118_Ch11.indd 329 2/11/2020 1:18:16 PM

These standards are developed by the American health plans. Many providers also find it valuable
National Standards Institute Accredited Stan- to send their quality data to commercial services
dards Committee X12 (ASC X12). For example, that can aid in assuring its accuracy and complete-
the ASC X12 837 standard specifies the data and ness and provide analytical services for compara-
format for a claim. Also required are standard op- tive information.
erating rules that further explain the standards, Increasingly claims data (data supplied on
so their use is consistent across health plans. Figure a claim for reimbursement purposes) are being
11.4 illustrates the HIPAA transactions and their integrated with clinical data (namely, the data docu-
relationship to clinical data. mented about a patient’s health status and treat-
Capturing, reporting, analyzing, and using clinical ment) for alternative payment initiatives and to
quality measure data is an important application aid in strategic planning for the overall healthcare
to comply with governmental and private health organization. As claims data and clinical/quality
n.
plans. It is becoming increasingly important for data, which is discussed in chapter 4, Health Re-
tio
information from quality measure reporting to be cord Content and Documentation, are used together,
ia
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used at the point of care. Quality measure report- healthcare quality and cost improvements can be
ss
ing required by Medicare is aided by CMS provid- made. This integration of financial and clinical
tA
en
ing electronic Clinical Quality Measure (eCQM) data provides BI that helps support business deci-
em
specifications. Data required for the eCQMs must sions by both the administrative and clinical lead-
ag
be downloadable from an EHR. When data are ership of healthcare organizations. For example,
an
M
documented only in narrative form, they cannot with more complete clinical information available
be automatically downloaded to the eCQM collec- n
io
at the time of admission, a hospital is better able
at
tion system; these data must be manually abstract- to verify a patient’s eligibility for health plan ben-
rm
fo
ed from the EHR. Some health plans may require efits so that it is not faced with a denied claim later.
In
quality measures data be collected from other Information that shows the hospital how many
lth
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source systems, for example healthcare costs, in- and what type of patients are readmitted within
H
strumentation, or other elements not typically 30 days of discharge for the same condition is an-
an
ic
documented in an EHR. HIM and nursing profes- other example of BI that will enable a hospital to
er
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sionals generally perform quality data capture. take proactive measures to monitor these patients
Quality data may be sent directly to the entity more closely after discharge. Physicians are also
e
th
requiring the data, such as Medicare and other starting to use integrated claims data and clinical
by
20
20
Figure 11.4 HIPAA transactions and clinical data

©
ht
Enrollment
ig
Sponsor Health plan

yr
Premium payment
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Eligibility verification
Provider
Pre-adjudication
Admitting UR expert system
Prior authorization/
diagnosis Change capture referral request
and response
Charges for
Billing Claim/encounter
clinical
services Claim Disease
Claim status inquiry adjudication management
A/R and reponse

remittance advice
A/P
Electronic funds
transfer
Business
Quality
intelligence
of care
AB103118_Ch11.indd 330 2/11/2020 1:18:17 PM

data to evaluate medical necessity for repeat di- discussed in more detail in chapter 3, Health In-
agnostic studies, assess the value of costly drugs, formation Functions, Purpose, and Users.
and help patients make informed decisions about Health Information Technology departments
their healthcare options (Horstmeier 2017). are similar to HIM departments with respect to
not necessarily having departmental management
Health Information Management departments systems but having responsibility for supporting
typically do not have a specific departmental in- the information technology infrastructure and
formation system but do manage and use several connectivity systems to enable effective use of all
separate applications that assist in performing var- of an entity’s information systems.
ious tasks within the department. As noted above,
HIM departments may manage some of the RCM Clinical Departmental Applications
functions such as coding of diagnoses, procedures, Clinical departmental applications, also called
n.
and professional services and clinical documenta- ancillary systems, serve primarily to manage the
tio
tion integrity to ensure the documentation in the department in which they exist, while at the same
ia
oc
EHR supports the diagnoses, procedures, and time providing key clinical data for the EHR. There
ss
professional services identified. HIM departments are three main departmental systems that are nec-
tA
en
may also support some of the applications that essary for an EHR to function in a hospital. They
em
complement the EHR. Complementary systems are the following:
ag
include document imaging systems (when used
an
The Laboratory information system (LIS)
M
●●
only to scan paper forms), electronic document
n
management systems (EDMS) (when scanning is io will receive an order for a lab test; generate
at
coupled with workflow tools), or electronic doc- a work list for specimen collection, labels for
m r
specimen containers, and accession numbers

fo
ument/content management (ED/CM) systems

In
(when both documents and the data in a docu- to track specimens; retrieve results from an
lth
auto-analyzer (device that analyzes the spec-

ea
ment have XML [eXtensible markup language]

H
tags applied for ease of searching for content). imen); perform quality control; maintain an
an
inventory of equipment and supplies needed

ic
Also included may be speech dictation sys-

er
to perform lab tests; and manage information

Am
tems that enable speech to be translated directly

into a narrative document and discrete reporta- on departmental staffing and costs. The LIS
e
th
ble transcription (DRT) systems that combine supplies the lab results to the user, either as
by
speech dictation with natural language process- a paper copy printout or an electronic print
20
file, which is structured data (data able to be

20
ing (namely, the ability for a computer to not only

processed by the computer) to an EHR. The
©
convert speech to words, but apply sophisticated

ht
blood-banking and clinical pathology systems

ig
computer processes to put the words into appro-

yr
are often separate from the LIS.

op
priate context). Today, DRT can populate prede-

C
fined templates with structured data. Consent ●● The Radiology information system
management systems are those that help maintain (RIS) performs functions similar to the
patient preferences about who may have access to LIS—receiving an order for a procedure;
their health information. These may be managed scheduling it; notifying hospital personnel
in conjunction with release of information (ROI) or the patient if performed as an outpatient;
systems, the EHR, and HIE services. HIM applica- tracking the performance of the procedure
tions vary by how far the healthcare organization and its output (that is, images in analog
has progressed in implementing its EHR applica- or digital form); tracking preparation of
tions. For example, if the healthcare organization the report; performing quality control;
continues to retain some paper health records, maintaining an inventory of equipment
the HIM department may have a chart tracking and supplies; and managing departmental
system to manage location of paper records (or to staffing and budget. Radiology departments
manage archived paper records). HIM systems are also obtain picture archiving and
AB103118_Ch11.indd 331 2/11/2020 1:18:18 PM

communication systems (PACS), which (such as cardiology, nephrology, and many others).
digitize the results of radiological modalities, Other clinical system needs may be unique to the
such as x-rays, computerized tomography services being provided and those systems are of-
(CT) systems, and others, and provide ten stand-alone systems. These include long-term
special viewing capabilities of these images and post-acute care (LTPAC), dentistry, behavioral
via a computer. Standardization for PACS health (BH), and various therapy services (such as
is established by the Digital Imaging and physical therapy, respiratory therapy, occupational
Communications in Medicine (DICOM) therapy).
organization. Some PACS also can connect Population health is defined as “the science and
directly with a RIS, thereby providing the art of preventing disease, prolonging life, and pro-
ability to integrate images with data. moting health through the organized efforts and
●● The Pharmacy information system receives informed choices of society, organizations, public
n.
an order for a drug in a hospital; aids and private communities, and individuals” (cit-
tio
ed in Health Catalyst 2019). As such, population
ia
the hospital’s pharmacist in checking for
oc
contraindications (situations that should health management (PHM) is the aggregation of
ss
data across multiple health information system re-
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be avoided as potentially harmful to a
en
patient); directs staff in compounding sources and the analysis of that data into actions
em
any drugs requiring special preparation; providers can use to improve both clinical and fi-
ag
nancial outcomes (Phillips 2018). PHM information
an
assists in dispensing the drug in the
M
appropriate dose and for the appropriate systems are less a separate system than a repur-
n
route of administration; maintains inventory
io
posing of existing information systems (especially
at
Quality and BI) and use more advanced supporting
m
(documenting medications in stock using

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the National Drug Codes (NDC), the infrastructure (such as analytics and artificial intelli-
In
gence) to aid in managing healthcare most effectively

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terminology maintained by the Food and

ea
Drug Administration (FDA) for use in in general, and patients in a value-based care en-
H
vironment. The most common functions of PHM

an
identifying FDA-approved drugs; supports

ic
staffing and budgeting; and performs other systems are those to support care coordination, care
er
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departmental operations. transformation, patient engagement, and care ana-

lytics to reduce practice variation while accounting
e
th
Other clinical departments in a hospital, such as for social determinants of health which are believed
by
dietary and nutrition, have information systems to account for 80 percent of what affects health
20
that are similar to LIS, RIS, and Pharmacy. They

20
outcomes outside of the traditional boundaries of

receive orders and supply results (or services) to
©
healthcare delivery (Health Catalyst 2019).

ht
users, as well as manage the respective depart-

ig
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ment operations. “Smart” Peripherals

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C
Automated medical devices (also called smart pe-

Specialty Clinical Systems ripherals), until recently, have generally not been
Specialty clinical systems are acquired to support considered information systems, even though they
the unique needs of specialty services. Examples of have generated data as well as information—for ex-
systems used primarily in hospitals or specialty or- ample a measurement of a person’s blood pressure
ganizations are intensive care units, perioperative on a display screen is a data point as well as informa-
and surgical services, labor and delivery services, tion for the provider and patient. A smart system
and emergency departments. In addition to these in- can also be a continuous feed of data such as a fe-
formation systems that serve to aid in management tal monitoring strip or blood sugar level. Other ex-
of a department as well as to support documenta- amples of automated medical devices include vital
tion of services provided to patients, various clini- signs monitors, cardiac output monitors, defibril-
cal specialties may also have unique functionality, lators, electrocardiographs, infusion pumps, physi-
ideally as part of the healthcare organization’s EHR ologic monitors, and ventilators (HIMSS Analytics
AB103118_Ch11.indd 332 2/11/2020 1:18:18 PM

2010). Increasingly, these medical devices not only used in a hospital or in a physician practice. One
collect and report data, but they use the data to pro- main difference is that in a hospital, the EHR appli-
vide “smart” services, such as monitoring response cations are often implemented separately; whereas
to medications and making adjustments, or alerting in a physician practice, EHR applications tend to
nursing staff. Many healthcare organizations are also be more integrated. Other differences are noted as
connecting these devices to their EHR via medical each of these core applications is described more
device integration (ECRI Institute 2014). fully in the following sections.
Core Clinical EHR Systems Results Management

There are generally five main applications that Results management is an EHR application that
define an EHR. These include the following and enables diagnostic study results (such as lab re-
are illustrated in figure 11.5, as a closer look at the sults) to be reviewed in a report format and for the
n.
EHR section of figure 11.2. data within the reports to be processed. Users can
tio
ia
1. Results management compare, trend, and graph the results. Depend-
oc
ing on their level of sophistication, results man-
ss
2. Point-of-care (POC) clinical documentation
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agement systems may also be able to compare
3. Medication management encompassing
en
lab results with other clinical data. For example, a
em
CPOE and bar code medication administration
graphic display could depict lab results as a func-
ag
recording (BC-MAR) systems
an
tion of medications administered or be compared
4. Clinical decision support (CDS) systems
M
with a patient’s vital signs. Lab results can also be
n
(CDSS) (of various types) io
extracted directly from the EHR for use in qual-
at
5. Analytics and reporting
m
ity measurement studies, clinical research, and

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The EHR applications include the basic func- BI systems. For a healthcare organization to have
In
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tionality required for earning incentives in the MU results management, all data to be processed must
ea
program and now for participation in alternative be in structured format and ideally stored within a
H
an
payment models. To earn MU incentives and to clinical data repository (see Supporting Infrastruc-
ic
participate in alternative payment models, an EHR ture below).

er
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application must have certification from an ONC- The importance of results management cannot
e
designated certifying body indicating that the EHR be emphasized enough, as 70 percent of the ability
th
to reach a diagnosis for a patient depends on lab

by
meets all of the required functionality criteria for

20
the program. The criteria, however, do not require results (Wians 2009). Similarly, as medications are
20
all possible EHR functionality that is available, increasingly powerful in their impact on the human
©
some of which is critical for most providers. For ex- body, monitoring vital signs and lab results in asso-
ht
ig
ample, program requirements do not include sup- ciation with medication administration is critical
yr
op
port for charge capture even though most health- to appropriate medication management.
C
care providers find this an essential part of their

EHR that needs to link to their patient financial Point of Care Documentation
services and revenue cycle management systems. Another EHR component is point-of-care (POC)
It is also important to note that there are some documentation. The intent of these applications is
variations in the core EHR applications as they are to inform the user what data needs to be recorded
Figure 11.5 Core clinical EHR systems
AB103118_Ch11.indd 333 2/11/2020 1:18:18 PM

for the patient and to use that data to supply clin- including staffing, credentialing, training, budget-
ical decision support (CDS), including alerts and ing, and other managerial functions. Clinical data
reminders, at the time when the clinician is able to may be combined with department operations
be most responsive to alerts and reminders. POC data in a nursing information system to provide
documentation systems supply templates to the patient acuity staffing levels, where the number
user to be completed primarily via point-and-click, of staff needed for any shift or day is determined
drop-down, type-ahead, and other data-entry by how acutely ill the current patients are.
tools. Usually the EHR has a library of templates. In a hospital, physicians are expected to docu-
The user may choose the appropriate template, or ment a problem list, history and physical exam,
the user’s dashboard may display the appropriate consults, operative reports, and a discharge sum-
template based on the user’s profile as indicated mary. These are largely dictated and electronically
via the log-in or by the patient’s admitting diagno- fed as an image into the EHR. Physician progress
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sis or chief complaint at the time of a physician’s notes may be handwritten and scanned into the
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office visit. Some templates are extremely sophis- EHR. Medical scribes may be used to support
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ticated and as the user enters data, the data fields direct data entry into the EHR. According to
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adjust accordingly. As a simple example, a tem- the American Health Information Management
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plate for conducting a history and physical exam Association (AHIMA) (2012), a medical scribe is
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for a male patient would not display data fields an individual who enters clinical documentation
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applicable to females. If the information system into the EHR to reduce administrative burden.
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detects that the patient’s condition involves heart Scribes may also assist providers in navigating
disease, additional data fields may be displayed n
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EHRs, respond to messages on behalf of physi-
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for associated signs, symptoms, and potential cians as directed, locate information, or perform
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complications. The result is structured data that research. An American Medical Association study
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the computer is essentially processing into clinical has determined that scribes can cut physician
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documentation. More information on dashboards documentation time in half, and with their ad-
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can be found in chapter 12, Healthcare Information. ditional roles can increase revenue to offset their
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POC documentation systems include support cost (AMA 2017). The Joint Commission provides
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for documentation of all patient care administered guidelines recognizing scribe usage; and, in 2017
by healthcare professionals. While ideally all such the American Healthcare Documentation Profes-
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documentation should be integrated, frequently sionals Group announced it would offer a scribe
by
such documentation is compartmentalized, espe- certification (Bresnick 2017).

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cially in hospitals. This is often the case because The problem list is increasingly managed
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the nature of the data to be collected and volume through a combination of sources including the
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varies considerably. Nursing staff may have sep- admission order for the admitting diagnosis and
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arate screens for nurse admission assessments, directly from a drop-down menu for discharge
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nursing problem lists, nurses’ notes, vital signs diagnoses and procedures. The MU program
(which may also be captured directly from patient required that the problem list ultimately be auto-
monitoring systems), intake and output records, mated and coded with either ICD or SNOMED-
and other nursing documentation. Medication CT codes. Physician orders are documented in a
administration is also a nursing documentation CPOE system (discussed later in this chapter).
requirement, but such systems are typically In physician practices, physicians (and their
grouped under medication management systems, scribes) and nurses often enter clinical documen-
as described in the next section. tation directly into the EHR as structured data.
A nursing information system is generally Structured data refer to data elements that are
considered a departmental system, not a clinical uniquely captured by the computer in fields that
documentation system. Similar to LIS, RIS, and can then be processed. An example is drug–lab
pharmacy information systems, a nursing infor- checking, where it may be necessary to have lab
mation system manages the nursing department, data (such as the results of a liver function study)
AB103118_Ch11.indd 334 2/11/2020 1:18:18 PM

before ordering a certain type of drug that may value in the CDS for drug choices and in manag-
adversely affect the liver. Drug–lab checking can ing prescription refills and renewals.
be performed in a CDS system, however such
CDS depends on the selection of a specific drug CPOE Systems CPOE systems can be used for
programmed into the information system and lab entering all orders such as patient admission, labo-
data results also programmed into the computer ratory tests, x-rays and other diagnostic studies,
that are available to the CDS system. The CDS dietary and nutrition, therapies, nursing services,
system then can compare what drug is ordered consults, discharge of patient, referrals, and even
against a patient’s lab values to determine if there building personal task lists, as well as entering or-
are contraindications. Structured data is contrasted ders for medications. In the past, these orders were
with unstructured data, or narrative information usually handwritten by the physician and were
not able to be uniquely processed by a comput- either internally faxed to various departments as
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er. For example, a lab value posted to a specific applicable or transcribed by nursing personnel (such
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field can be compared with other such lab values. as ward secretaries or unit clerks) into an order
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A lab value simply documented in a note, com- communication system. This type of system, however,
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ment field, or as a scanned image of paper cannot included no CDS. While some physicians prefer not
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be processed by the computer in the same way as to have to enter their own orders or pay attention
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structured data. to CDS alerts, it is believed that such support ulti-
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mately will improve the quality of healthcare.
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Medication Management
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CDS in CPOE systems initially provided many
Medication management refers to the use of certain n
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alerts that may not have been specific or relevant
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information systems that help ensure patient safety, to a given patient, resulting in alert fatigue, or the
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or preventing harm to patients, learning from ignoring of alerts due to their volume and irrele-
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errors, and building a culture of safety (Hughes 2008). vancy. For example, reminding a provider to check
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These are often referred to as closed-loop medica- for an allergy to a drug should not be necessary
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tion management systems because they automate if a comprehensive medication history is being ob-
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the processes from the point a drug is ordered to tained and documented by a nurse or pharmacist.
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the point it is administered. These systems include Such an allergy alert should only appear if the phy-
CPOE, e-prescribing (e-Rx) as a special type of sician is ordering a contraindicated medication.
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CPOE, BC-MAR, medication reconciliation sys- Appropriate alerting to drug–allergy and drug–
by
tems that compare drugs ordered against drugs drug contraindications (situations that should be
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dispensed and administered, and automated drug avoided as potentially harmful to a patient) is a
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dispensing machines, as well as the policies, pro- complex process that requires not only accurate
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cedures, and workflows associated with ensuring data from the patient and throughout the patient’s
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proper drug ordering, dispensing, administer- care, but an up-to-date drug knowledge database
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ing, and monitoring of reactions. Although there (namely, a subscription service that provides cur-
is no recommended sequence for implementing rent information about drugs and is accessible to
these information systems, many hospitals in the users and the CDS).
past implemented CPOE last because it is dif- Another concern with CPOE systems is that
ficult to get physicians to use such information they are often based on standard order sets. Stand-
systems in the hospital. This is changing as MU ard order sets are lists of specific diagnostic studies
incentives require use of a CPOE system first, and treatments as appropriate for specific diagno-
then medication administration record systems. ses or procedures to be performed. These order
In the ambulatory setting, e-Rx has sometimes sets reflect the current knowledge about patient
been implemented as a stand-alone system be- care from research, experts, and other sources of
fore an EHR (and its CPOE functionality) because evidence-based medicine (EBM). A standard order
some insurers and Medicare were providing in- set is frequently used for patients with common
centives for its use. Physicians also found great conditions. For example, a standard order set is
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ften used for admissions for normal pregnancies,

o by the National Council for Prescription Drug
where the obstetrician only needs to approve of the Programs (NCPDP), a standards development or-
standard items or make applicable changes rather ganization that sets standards for the pharmacy
than having to document the entire set of items industry. The NCPDP SCRIPT standard is the
normally required. However, although EBM may standard developed for electronically transmit-
reflect the best scientific evidence on how to treat a ting a prescription. As such, the SCRIPT stand-
patient with a specific condition, one size does not ard is used in ambulatory settings, including
always fit all human beings. Even a woman with not only the physician practice but when a pa-
a normal pregnancy may have certain preferences, tient is discharged from the hospital or emergency
allergies, or additional conditions that must be service with a prescription and in hospital outpa-
taken into account when using the standard order tient departments or clinics. The e-Rx system in-
set for normal pregnancy. As a result, most stand- cludes medication alerts and reminders just as the
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ard order sets need to be modified for each patient. hospital-based CPOE system, but also includes
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In haste, a physician may accept the standard orders formulary information that identifies whether
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or may make an error in modifying them—which the patient’s health plan covers the cost of a drug
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may result in unintended consequences (AHRQ and what co-pay may be required. Physicians can
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2011). An unintended consequence is an unantic- then work with their patients to find the most cost-
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ipated and undesired effect of implementing and effective as well as clinically suitable drug. Because
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using an EHR (Rollins 2012). While these often e-Rx systems are able to transmit prescriptions
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have been attributed to the EHR software itself directly to retail pharmacies, physicians benefit
as early as in 2006 (Campbell et al. 2006) and con- n
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from fewer calls from pharmacies not able to read
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tinue to be cited today (Vanderhook and Abraham their handwriting or needing to advise the physi-
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2017), they often reflect that a user may not have cian that a drug ordered is not going to be covered
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applied professional judgment or due diligence in by the patient’s insurance because it is not on the
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using the EHR. list (formulary) of covered drugs; that is, it is con-
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CPOE systems also generate the patient’s med- sidered “off formulary.” Physicians are also able
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ication list. The medication list is required under to receive electronic communications from retail
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the MU program to be coded using one of the pharmacies, such as for renewal approvals that
code sets standardized under RxNorm, which is can significantly save time in a practice. In 2010,
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a system maintained by the National Library of the Drug Enforcement Administration (DEA),
by
Medicine to normalize drug names across dispa- which previously banned use of e-prescribing for
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rate vocabularies. Caution must be applied here, controlled substances (EPCS) such as narcotics,
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as the medication list will only be as accurate and set special requirements allowing for use of EPCS.
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complete as all systems contributing information These requirements include use of a product that
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to it. For instance, if a medication is ordered prior provides identity proofing (authentication creden-
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to surgery, suspended during surgery, reinstated tials used to electronically sign such prescriptions)
after surgery but then changed before adminis- and two-factor authentication—a signature type
tration, not only must the CPOE and BC-MAR con- that includes at least two of the following three
tribute correct medication information, but the elements: something known, such as a password;
surgery information system may also need to in- something held, such as a token or digital certificate;
terface with the medication management systems, and something that is personal, such as biometrics
which is not always the case. (fingerprints, retinal scan, or other) to enable such
use. Digital certificates are issued by a certificate
E-Rx E-Rx is a special type of CPOE used exclu- authority, an organization that verifies a person’s
sively to write a prescription and transmit it elec- credentials (such as the provider’s DEA num-
tronically to retail pharmacies. The format and ber for EPCS) and can revoke the certificate if the
content of the prescription transmitted is standardized credentials are revoked.
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BC-MAR Bar code medication administration be administered. BC-MAR systems provide some
recording is the documentation of administer- CDS as do CPOE systems, often including links
ing medication to a patient and is a function per- to additional information about drugs. BC-MAR
formed by nurses in a hospital. Nurses use a bar systems also generate reports on timely adminis-
code reader to positively identify the patient and tration of drugs.
the medications to be administered to the pa- There are some issues with using BC-MAR
tient. Bar codes are parallel arrangements of dark systems. One is that the bags that are specially
elements, referred to as bars, and light elements, compounded with multiple drugs administered
referred to as spaces, that represent information, intravenously require labels to reflect all the drugs
such as the patient name, drug name, and other in the compound. Not all hospital pharmacy in-
data. The frequency and care that must be taken formation systems can produce such labels. In
to ensure a nurse administers the right drug, in this case, special care must be taken to manually
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the right dose, through the right route, at the right check and enter the medications being adminis-
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time, and to the right patient (the medication five tered. The other important issue associated with
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rights) is critical to avoid medication errors. As a using BC-MAR systems is bringing the computer,
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bar-code wand, and medication to the patient
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result, computerized systems have been created.
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Early medication administration systems were bedside. Some hospitals use wireless worksta-
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simply electronically generated paper lists of med- tions on wheels (WOWs). Because WOWs can
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ications from the pharmacy information system become heavy with their various devices plus a
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after it processed physician orders. Later, the lists long-life battery, an alternative is to carry (some-
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were retained on the computer and nurses were io
times by wearing a sling) a tablet computer that
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expected to post the date and time of medication may be outfitted with a wand device and the med-
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administration to the computer. Any exceptions or ication. Walking around all day with such equip-
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issues with medication administration, however, ment, however, is also not comfortable. Finally, it
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were still included in handwritten nurses’ notes. is important for the hospital to fully define what
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Most importantly, these systems, while providing constitutes a medication administration error—a
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a legible list of medications did not fully address wrong time, for instance, may or may not be due
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the medication five rights. to an error but rather the availability of the patient.
BC-MAR systems require the hospital to have
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each patient identified with a bar code (usually Medication Reconciliation The medication rec-
by
on a wrist band) and to package (or buy prepack- onciliation process can be automated, although
20
not as easily as the other elements of medication

20
aged) drugs in unit dose form, each with a bar

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code or radio-frequency identification (RFID) tag management. Each time a patient is transferred
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across levels of care, such as when admitted,

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that identifies the drug, dose, and intended route

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transferred into an intensive care unit, or sent to

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of administration. (An RFID tag serves the same

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function as a bar code but enables wireless trans- surgery, the medications the patient should be
mission of the data rather than requiring a bar administered need to be reviewed. Often certain
code to be read with a scanner.) At the time the medications must be discontinued, or a dose altered
drug is to be administered to a patient, the nurse as a result of the change in level of care. Because
logs into the BC-MAR system and scans the pa- the clinicians who work with the patient are dif-
tient’s wrist band and unit dose package. The ferent at each different level of care, connecting all
information system automatically dates and time the information systems at the different levels of
stamps the entry made through this process. As care has been a challenge, and only a few hospitals
a result, the medication five rights have been fol- have been successful.
lowed. Most BC-MAR systems also enable notes to
describe exceptions; for example, that the patient Automated Drug Dispensing Machines Finally
was in surgery at the time the next dose was to with respect to medication management, automated
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drug dispensing machines, which are technically to as a separate clinical decision support system
smart peripherals, are available that both secure and (CDSS), even though it may be fully integrated
make drugs more readily available to nursing staff. into the core EHR applications through supporting
These machines are typically filled by pharmacy de- infrastructure. Other examples of separate CDSSs
partment staff based on the physician orders. that are integrated into the EHR include the tem-
plates used in clinical documentation, standard
Clinical Decision Support order sets used in CPOE, and clinical pathways
Clinical decision support (CDS) is a key com- that guide nursing services. While some EHR
ponent of the EHR and sets it apart from simply products build a basic set of templates directly
automating paper documents. CDS functionality into their clinical documentation systems, others
in the EHR helps physicians, nurses, and other require a separate CDSS to generate the templates,
clinical professionals—collectively referred to as or provide more sophisticated and customizable
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clinicians—as well as patients themselves make templates than exist in the basic clinical documen-
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decisions about patient care. Some examples of tation applications.
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CDS as previously discussed include alerts about CDSSs that are used in a stand-alone fashion
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potential drug contraindications, out-of-range lab are often those specific to a unique function. For
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results, and standard order sets in CPOE. In ad- example, a CDSS that is used in a stand-alone
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dition, CDS templates can help determine what manner in a hospital includes an information sys-
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documentation of clinical findings is necessary; tem to alert infection control nurses of a potential
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provide suggestions for prescribing less expen- hospital-acquired infection. It provides advice on
sive but equally effective drugs; supply protocols n
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which medication may be most effective in com-
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(specification of appropriate processes, based on bating the infection given the causative agent. Such
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expert best practices and clinical research find- an information system compiles data from clinical
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ings) for certain health maintenance procedures; documentation (such as documentation of a high
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and alert that a duplicate lab test is being ordered. temperature), lab results (such as the strain of bac-
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There are countless other decision-making aids for teria that is causing the infection), x-ray results
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all stakeholders in the care process. (such as a finding of pneumonia), and other sourc-
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CDS may be built into each of the core EHR es processed against automated clinical reference
applications. However, CDS is also acquired as information to produce the specific findings.
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separate information systems that work in con- An example of a CDSS used in a stand-alone
by
junction with the EHR applications. In general, the fashion by physicians is a differential diagnosis
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CDS found in the core EHR applications is rudi- system. This system may compare diagnostic im-
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mentary because it typically can only process data ages against a library of images and their known
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within the given application. More sophisticated conditions, which is especially useful for radi-
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CDS requires the convergence of different types ologists, dermatologists, pathologists, and others.
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of data from the various EHR components. As a Other differential diagnosis CDS systems compare
result, separate applications are used to help inte- data from clinical documentation, especially the
grate and analyze these data. history of present illness and review of systems,
Separate CDS applications may be fully in- with a library of known signs and symptoms for
tegrated with the core EHR applications or em- specific diagnoses. Some of these are used only
ployed in a stand-alone fashion. An example of when the differential diagnosis is obscure. Others
a separate CDS application is one that provides may be a routine part of a protocol, such as for
drug–lab checking, such as whether a drug is con- assessing a patient presenting to the emergency
traindicated for a patient with poor liver function. department with chest pain. Still another CDSS can
This is not a routine function of CPOE or LIS but aid in identifying whether a patient’s symptoms
requires the combination of data from both sourc- are due to a new condition or are the result of
es and the ability to deliver the alert back to the an adverse reaction to a medication. Figure 11.6
appropriate system(s). This is commonly referred summarizes the different forms of CDS and CDSS.
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Figure 11.6 Types of clinical decision support
Data display Data retrieval

Data always available Single sign-on (for multiple applications)
Flow sheets (for example, problem list, medication list) • Overcomes interface versus integration (through one sys-
• Maintain longitudinally tem or repository) issues
• Across continuum Ease of navigation aids adoption
Dynamic displays Density of screen
• Flow sheet, graphic, table, narrative—helps review data • “Flip-ability”
• Clinical imaging integration • Avoids getting lost in “drill downs”
• Search tools Specialized formats focus information
• Query support Customized screens
Summaries or abstracts • Standards versus personal preference
• Quickens access, supports continuity of care Data entry
• Flags problems Context-sensitive templates and order sets guide
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Workflow documentation
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In-basket Provides immediate access to active decision support
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• Reminders in support of timeliness, compliance • Alerts and reminders
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• Clinical calculations
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Schedule and patient list
• Patient status continuously • Therapy critiquing and planning
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Workgroup tools Patient self-assessment and PHR
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• Easy handoffs Medication list maintenance (by patient or claims consolidator)
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Refills choice lists Structured data and registry support
• Contributes to downstream knowledge
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Integrated clinical and financial
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• Medical necessity checking • Wellness or disease management reminders, interven-
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• Overcomes inability to pay for treatment io tions due, recalls
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Telephony (the process of connecting a telephone to an Access to reference information
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electronic device), e-mail and visits, instant messaging • Context-insensitive, portal

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• Quick response • Context-sensitive, direct links

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CDS is an increasingly important tool in value- supplying the results of analytics to the intended
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based care, as it helps healthcare professionals recipient.

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encourage healthy lifestyles – thereby improving Analytics goes beyond the simple use of descrip-
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the overall health of the individual and lower- tive statistics, such as how many patients were
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ing costs. For example, an alert that a patient is seen for a specific condition, to questions such as
by
a smoker could trigger a suggestion for smoking which form of treatment for the specific condition
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cessation. Another example might be the abil- had the best outcomes. The ability to produce
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ity of the information system to calculate the such reports is increasingly important as there is
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patient’s body mass index (BMI) for recommend- ever more pressure to improve quality and reduce
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ing weight counseling. Caution must be applied the cost of healthcare. Analytics, however, entail
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in displaying and using some of these alerts, such sophisticated processes to be performed on data—
that they should be able to be tailored to the pa- such as data mining, forecasting, neural networks
tient. This may mean that an alert is turned off (mathematical modeling that makes connections
or frequency reduced for a given patient. Many between data to discover relationships).
ambulatory EHRs include reminders for preven- In healthcare, analytics has been primarily per-
tive or chronic care services, such as dates when a formed in academic and research institutions, by
vaccine, cancer screening, diabetes care, or other health plans, at pharmaceutical manufacturers, and
services are due. for public health departments. Analytics has pro-
duced many clinical benefits for the healthcare
Analytics and Reporting industry, such as in genomic research and person-
Analytics and reporting are the final core EHR ap- alized medicine (also known as precision medi-
plication. Analytics refers to statistical processing cine) that tailors treatment to the individual, given
of data to reveal new information. Reporting is not only comorbidities but genomic characteristics
AB103118_Ch11.indd 339 2/11/2020 1:18:18 PM

and predispositions (SAS n.d.). Analytics are also information systems so that the results of analysis
used to create BI, such as in predicting prescribing can be as accurate as possible. Data quality re-
patterns of physicians or the impact of a disaster fers to adherence to standard data definitions and
on local emergency services (Strome 2013). For more metadata (that is, data about data) requirements.
specifics on analytics, refer to chapter 12, Healthcare Data models that organize data to depict relation-
Information. ships among data help ensure the quality of data
Although most information systems can gen- collected by health information systems. Standard
erate some data for analysis and reporting, there vocabularies (the compilation of terms formally
has been strong interest for the EHR to provide adopted for use in health information systems)
more robust analysis of data. Unfortunately, the are used for data exchange across different health
nature of the type of database required for POC information systems. This exchange capability is
documentation and CDS, referred to as a clinical referred to as semantic interoperability, or the
n.
data repository (CDR), does not support complex ability to share common meanings for data across
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analytics and reporting. The purpose of a CDR is systems. Another important element that improves
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primarily online transaction processing (OLTP), data quality in health information systems is a
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where each access, entry, or other process performed data dictionary that lists all data elements used in
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on data is a transaction. Often it is necessary to a health information system with their definitions
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move data from the CDR to a separate database and characteristics. For example, a data diction-
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that has been optimized to perform analytics and ary for a given health IT system would include
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reporting (online analytical processing [OLAP]). the term temperature and specify that it must be
This type of database is referred to as a clinical n
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documented in centigrade. AHIMA developed a
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data warehouse (CDW). In addition, healthcare data quality management model to illustrate these
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organizations that want to perform sophisticated characteristics (AHIMA 2015).(The data dictionary
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analytics need staff highly skilled in such statisti- and the AHIMA Data Quality Management Model
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cal techniques. It may be that a given hospital or are explained in chapter 6, Data Management.)
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physician practice cannot perform the analytics Health plans have analyzed data from healthcare
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and reporting itself, but it sends data to a vendor claims for a long time, and now they are receiving
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who performs the analytics. An increasing number additional data from commercial labs, claims at-
of EHR vendors are supplying such services, often tachments, patient-entered data, and other sources
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aggregating data from many customers to enlarge to perform even more sophisticated analytics. Such
by
the pool of data, making the results of analysis on information may impact whether the hospital or
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the data more valid and reliable. When this data physician practice receives a favorable discount
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pool has a large volume of data, it is referred to as rate on its fees for services. Quality benchmarking
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big data. Big data offers greater reliability and va- depends on analytics. (Benchmarking is discussed
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lidity. Big data analytics implies massive amounts in chapter 18, Performance Improvement.) Consum-
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of data that can be analyzed quickly in near real ers are beginning to look at which hospital excels
time to return new information to users at the in cardiac care or has a center of excellence for
POC. When data are collected from active patient orthopedics. Having aggregated data to under-
health records, the data reflect current experience stand why one healthcare organization is ahead
and analytics is then able to produce new knowl- in its quality metrics over another can help poorer
edge as well as new information. performers improve. Analytics and reporting are
Another trait of big data in addition to its vol- not only used for retrospective quality or research
ume and velocity is that all the data do not need to studies; an important set of reports include rule-
be structured. Unstructured data can be analyzed based lists for patient follow-up. Patient follow-up
and parsed into structured data as part of process- lists have not been easy to generate in the past, as
ing big data. It is still important to ensure the qual- much of the data had to be manually abstracted
ity of unstructured data being captured in health from paper records, transcription, or scanned
AB103118_Ch11.indd 340 2/11/2020 1:18:18 PM

images of documents. However, the ability to when coupled with artificial intelligence (AI)
identify all patients requiring follow-up after dis- (which is the application of algorithms that analyze
charge, for chronic disease care, to notify them of data and make applicable recommendations [Pearl
a drug or device recall, to send preventive care 2018]) will help providers at the POC improve clin-
reminders, or any of many other similar types of ical decision-making. Examples of such improved
reports or lists is integral to quality patient care. decision-making include the ability to select afford-
Most analytics implementations are still retrospec- able therapies (Chaiken 2011) and make earlier di-
tive. However, it can be anticipated that the use agnoses of complex conditions such as rheumatoid
of big data analytics in near real time, especially arthritis and multiple sclerosis (Kalatzis et al. 2009).
n.
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1. Identify a source system.
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a. Clinical decision support system
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b. Laboratory information system
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c. Results management system
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d. Medication reconciliation system
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2. A _______________ is considered a core clinical EHR component.
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a. Computerized provider order entry system
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b. Pharmacy information system

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c. Document imaging
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d. Registration-admission, discharge, transfer system

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3. Dr. Smith always orders the same 10 things when a new patient is admitted to the hospital in addition to some
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patient-specific orders. What would assist in ensuring that the specific patient is not allergic to a drug being
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ordered?
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a. Clinical decision support

b. Pharmacy information system
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c. Electronic medication administration record system

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d. Standard order set

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4. What provides alerts and reminders to clinicians?

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a. Clinical decision support system

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b. Electronic data interchange

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c. Point-of-care charting system

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d. Workflow system
5. E-prescribing systems are used to:
a. Inventory and dispense drugs in retail pharmacies
b. Write orders for drugs to be administered in hospitals
c. Send prescriptions to retail pharmacies
d. Report adverse drug events
6. Which factor in a BC-MAR system supports medication five rights?
a. Bar code reading
b. Documentation of medication administered
c. List of medications to be administered to the patient
d. Reports of accuracy of medication administration
AB103118_Ch11.indd 341 2/11/2020 1:18:18 PM

7. Why is medication reconciliation the most difficult function of closed-loop medication management systems to implement?
a. Bar code systems contain only limited information.
b. Multiple systems, potentially across healthcare settings, must be connected
c. Nurses do not have sufficient time to obtain a medication history.
d. Vendors are reluctant to design such systems due to cost.
8. What stage describes when users are not yet using all the available EHR functionality?
a. Adoption
b. Implementation
c. Optimization
d. Meaningful use
9. Templates are intended to:
a. Afford free text entry of narrative information
b. Provide data entry support consistent with patient type
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c. Require use of a standard set of orders for every patient
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d. Support copy and paste of content from one record to another
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10. Which of the following characterizes the current state of EHRs?
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a. EHRs aid in comparing the quality of care rendered across healthcare organizations.
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b. EHRs enable complex analysis of all patient data for the healthcare organization.
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c. EHRs provide data and support for data collection about one patient at a time.
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d. EHRs support the ability to generate lists of patients with similar characteristics.
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Supporting Infrastructure information systems. In healthcare, many basic ap-

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Supporting infrastructure (see figure 11.2) refers to plications were developed before the internet and
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the technology that allows the various applications World Wide Web (WWW) were widely available.
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to work. This includes hardware and software of As such, application software was written using
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various forms and sophistication. Hardware in- message format standards to structure the format
cludes human computer interfaces (HCI), which of the data that are processed by the applications
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are any form of input device used by humans, in- and which could only support point-to-point com-
by
cluding monitors, keyboards, printers, scanners, munications. The ASC X12 standard for exchang-
20
20
and many other devices that enable human inter- ing claims and other administrative and financial
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action with computing technology. Hardware also data and the NCPDP standard for exchanging
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includes all the computer servers and associated prescriptions between an e-prescribing system
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cabling and other tools for processing and storage. and a retail pharmacy previously described are
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A key component of supporting infrastructure examples of message format standard. Diagnos-

is the need to provide interoperability. Interoper- tic study results data, POC documentation, med-
ability is the term used to describe the ability of ication management data, and other such clinical
one information system to exchange data with an- documentation are exchanged among applications
other information system in a way that the data using similar standards from the Health Level
exchanged are usable to each part of the exchange. Seven (HL7) standards development organization.
Interoperability comes in several forms. For exam- The HL7 is a not-for-profit, standards-developing
ple, with semantic interoperability, the terminol- organization dedicated to providing a compre-
ogy used carries the same meaning to all parties to hensive framework and related standards for the
an exchange. exchange, integration, sharing, and retrieval of
Technical interoperability is the most basic electronic health information that supports clinical
form of interoperability. Technical interoperability practice and the management, delivery, and evalu-
refers to the exchange of any data element across ation of health services.
AB103118_Ch11.indd 342 2/11/2020 1:18:18 PM

As a result of the early development of health is a “master” computer that “serves” the needs of
information systems software, most technical in- many end-user computers.) The differences between
teroperability today requires an interface, which is two major server functions were previously de-
software that serves as a translator between different scribed: a CDR (typically used to house and proc-
applications which may have different structures for ess the broader range of LIS, RIS, EDMS, EHR, and
data or may use different vocabularies to encode many other applications being brought together)
data. For example, if the R-ADT system needs to and a CDW (to integrate at least some of the data
send patient demographic data to the LIS, an in- from the CDR and perform analytics). A registry
terface will identify what data should be sent from is another type of application that typically hous-
what fields in the R-ADT system to the fields in the es and performs analysis and data reporting on a
LIS. In the software used by most health informa- subset of clinical data. A common example is a tu-
tion systems today, interfaces are required because mor registry. When quality measurement data are
n.
communications may also be used to exchange submitted to a vendor, the vendor is essentially
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data between one organization and another, such compiling a registry. The server that supports a
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as between a physician’s office and a commercial registry is something of a cross between these two
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laboratory. Interfaces, however, are costly to write server functions.
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and maintain. Every exchange between two appli- There are also special servers. Examples are the
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cations requires an interface. Since there are many interface engine previously described and an in-
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applications in any given entity, many interfaces ference engine (also called a rules engine), which
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are required. Furthermore, anytime one informa- supplies the rules that govern clinical decision
tion system is upgraded or modified in some way, n
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support. An example of such a rule might be: If a pa-
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the interface between it and all other applications tient is allergic to penicillin, generate an alert when
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with which it exchanges data must be adjusted. a physician orders any medication with the same
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It also must be noted that each application in any active ingredients as in penicillin. Such servers
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given entity is unique to that entity. As a result, need to have access to knowledge sources, which
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interface engines are often required to manage all are resources that provide information about the
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the interfaces for a given entity, and with a very properties of drugs, the latest research about new
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limited number of external entities. surgical procedures, and other information need-
Because applications, and hence their interfaces, ed to support clinical decision-making. Because
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are unique to a given entity, interfacing is not an knowledge sources must always be kept up to
by
effective way to exchange data across many dif- date with new information about drugs, surgical
20
20
ferent organizations. For example, a physician’s protocols, and much other information, they are
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office likely needs to exchange prescription in- generally provided through a vendor that operates
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formation with many different retail pharmacies. through a subscription service.

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Today for such exchanges to occur, a go-between While this description of many interfaces and
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that can manage the translation process is used, unique server types paints a rather bleak picture
for which entities pay a fee each time an exchange for interoperability in healthcare, progress is being
takes place. The go-between is a vendor, typically made to take advantage of web services architec-
called a clearinghouse. Some health information tures (WSA) that utilize tools to aid in exchanging
exchange organizations also serve this purpose for data in a one-to-many (rather than point-to-point)
other forms of health information (see Connectiv- manner. WSA refers to the use of web-based forms
ity Systems in the next section). of interfaces—such as XML structures—to enable
Over time, health information systems software sharing across multiple parties.
was written or modified to encompass many of the Another important element of supporting in-
applications needing to exchange data within a frastructure, however, is management of the
given healthcare organization. As such, computer infrastructure. As such, a plan describing what
servers were configured to support the larger vol- technology will be adopted, how the technology
ume of data across the various applications. (A server will be procured, and how the technology will
AB103118_Ch11.indd 343 2/11/2020 1:18:18 PM

work together is needed. This plan is often in the office (PMO) (in a larger healthcare organization)
form of an enterprise architecture (EA). An EA is or project manager aids in compiling a project’s
needed because large hospitals may have nearly a budget, allocating resources, maintaining a task
thousand applications, with hundreds of applications list, identifying dependencies among tasks, estab-
being common in medium-sized hospitals. Physi- lishing timelines, and managing a schedule. The
cian practices may have only one combined PMS PMO may focus only on health information sys-
and EHR, but frequently have some ancillary and tems or may be broader in scope to encompass
specialty systems—potentially accumulating 10 to other major projects, such as building construc-
20 or more information systems. An EA helps keep tion, mergers and acquisitions, and others.
track of all the applications and how they work to- Supporting infrastructure also must address
gether. Drilling down further, a data governance security. Healthcare is facing increasing security
framework (DGF) provides a logical structure for threats – both internal and external. Security pro-
n.
managing all of the healthcare organization’s data. cesses can take time and attention that is often
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A DGF addresses data governance and steward- thought to detract from the primary purpose of
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ship, data quality management, specifications of healthcare, which is highly time sensitive. Until
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terminologies for data, roles and responsibilities recently, it has also been thought that healthcare
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for collection and use of data, metadata manage- data carry little monetary value and hence are
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ment, data storage and warehousing, and data “safer” than other data. This is not true, and theft
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security. The EA and DGF are vital for managing of healthcare data can carry much more severe
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the different applications necessary for today’s ramifications for individuals whose information is
health information needs. n
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compromised. Data security is discussed in chapter
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Infrastructure also must consider the process- 10, Data Security.
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es and policies for using applications. These are

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increasingly being referred to as process inter- Connectivity Systems

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operability and policy interoperability. Process Connectivity systems (see figure 11.2) help sup-
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interoperability refers to the use of workflows port the exchange of data across separate informa-
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and procedures that best support use of technol- tion systems within a healthcare organization and
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ogy. Some process interoperability can be aided across organizations, and also with individuals.
by software. For example, if there are a series of To exchange data among health information
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steps to be taken by different people, in different systems, computers must be networked together.
by
departments, with different information systems, When exchanging data within the organization,
20
20
software can be supplied to direct the sharing of the network is referred to as a local area network
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data in the appropriate sequence as each person, (LAN), and when exchanging data across organi-
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department, and system completes its work. In zations, such as from a provider to a payer, the net-
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other cases, process interoperability may be a hu- work is referred to as a wide area network (WAN).
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man factor to be addressed in training and op- WANs need a secure connection, which is often a
timization. Policy interoperability refers to the virtual private network (VPN), which is an encrypt-
rules that govern exchange of data. These rules ed private connection over the internet.
are incorporated into software development. Increasingly, both hospitals and physicians not
For example, access controls are security rules only exchange information among providers and
built into information systems to ensure only with patients for treatment and payment, but also
the appropriate access is afforded. In fact, virtu- move data for operational functions, such as for
ally every aspect of computer use is impacted by supplying quality data to a registry as previously
some form of policy. described, and to store data. Various data storage
Acquiring these information systems is also a key management (archiving data organized for
part of infrastructure, requiring a strategic plan retrieval) techniques exist. These may include
and project management. A project management a storage area network (SAN) that supports the
AB103118_Ch11.indd 344 2/11/2020 1:18:18 PM

ability to retrieve data from any storage location All these challenges are being addressed where
for use in the EHR. Some SANs may be local to the there is high need. For example, robots have been
healthcare organization. Others may use cloud developed to reach injured soldiers. The Veterans
computing, which refers to using computing Administration (VA) has constructed all its tele-
services remotely over the internet, often through health services to rely solely on dial-up telephone
a vendor or vendors to archive data and in some connections because many veterans needing tele-
cases to provide application software, including health are in remote areas. Telehealth is experi-
an EHR (Knorr 2018). encing increasing interest to reach prison inmates,
In addition to operational needs for connectivity inner city communities where there are safety is-
systems, there is also a growing need to exchange sues, and in various care coordination activities
health information with disparate providers and where patients have transportation limitations.
patients for care purposes. There are essentially Medicare reimbursement for telehealth services
n.
three general forms of connectivity processes continues to expand.
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used today in healthcare—telehealth, patient- In addition to telehealth, new forms of healthcare
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exchanged information, and health information delivery are being adopted. Some are very “low-
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exchange. tech” such as e-visits (telephone communications
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between patient and provider) and others such as
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Telehealth and Newer Forms of Healthcare hospital-in-the-home (where new connectivity
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Delivery mechanisms help monitor patients at home) have
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The oldest form of exchanging health informa- more technology requirements (Carollo 2018).
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tion is telehealth—a process that uses telecommu- io
What is also new relating to these technologies is
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the level of reimbursement for such services, the
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nications to send voice, still pictures, and video

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between a remote location (where the patient is) recognition that keeping people outside of a phys-
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and a base location (such as a hospital) for the pur- ician’s office waiting room or even a hospital bed
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poses of diagnosis and, in some cases, treatment. may reduce spread of infection, and make people
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Some might not consider telehealth to be a form more comfortable and happier which can also con-
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of health information system because its primary tribute to health improvement.

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purpose in providing remote healthcare is so often New technologies that have an information sys-
conveyed in sound or picture, though most tele- tem component to them include new medical pro-
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health conducted today does include the exchange cedures, prosthetics, and machine learning. New
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of health information. medical procedures include techniques such as liq-

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Telehealth, however, has many challenges, uid biopsies that monitor tumors noninvasively.
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some of which are only now being addressed. For 3D printing is creating new prosthetics and ways
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example, connectivity is a challenge because tele- to improve organ and tissue repairs (Das 2016). It
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health is so often used to reach remote parts of was previously described that AI is the ability for
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the country, on a battlefield, and across the world. software algorithms to analyze data and make ap-
Telecommunications technology is not always the plicable recommendations (including to 3D print-
best in such areas. Broadband, for example, is still ers). Extending beyond AI is machine learning, in
not available, or at least reliable, in all parts of the which AI applications adjust the algorithms sup-
US. Physician licensure has been another major plied in the software based on additional data,
challenge, where a physician may not be licensed to potentially providing ever more sophisticated
practice in another state, hence precluding the abil- clinical decision support (Garbade 2018).
ity to cross state lines when conducting telehealth.
Reimbursement for telehealth is not always pro- Patient-Exchanged Health Information
vided by health plans, or only under certain, lim- Another form of exchanging health information is
ited conditions. Specialized equipment must also to use the patient as the go-between. This might
be brought to the site where the patient is located. be considered even older than telehealth when
AB103118_Ch11.indd 345 2/11/2020 1:18:18 PM

considering the patient—or patient’s family mem- system for PHRs is encouraged by AHIMA, many
ber or caregiver—has always been the knowledge more patients use a paper-based file folder as their
base for history of present illness and other informa- PHR rather than an electronic offering. Whether elec-
tion. However, from a technology perspective, tronic or paper-based, patients are expected to own
portals, electronic personal health records, and the and manage the information in the PHR, which comes
continuity of care document are technologies that from both healthcare providers and the individual.
are newer than telehealth. The PHR is maintained in a secure and private en-
A patient portal is special software that environment, with the patient determining rights of
ables patients to log on to a website from home access. It is separate from and does not replace the
or a kiosk (special form of input device geared to legal health record of any provider or their EHR.
people less familiar with computers) in a provid- Today, PHRs are in a state of transition. The PHR
er’s waiting room to have access to some of their may be provided through a portal offered by a pro-
n.
health information and other services. In many vider or may be a stand-alone system offered via
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cases, the portal is used primarily for administra- a vendor, employer, or affinity group that may be
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tive functions, such as to request an appointment managed by the stand-alone entity or by the pa-
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and even directly schedule an appointment, pay tient. A PHR offered by a healthcare provider is an
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bills, obtain patient educational material, sign in- excellent tool if there is only one PHR for all who
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formed consents, exchange email with a provider, treat the patient, and especially if it enables more
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and request release of information. Under the MU than minimal functionality. If a patient has multiple
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program, the portal has been a common way for healthcare providers, however, it is likely that the
patients to access their health summary informa- n
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patient will also have multiple PHRs. Today, there
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tion. In some cases, the portal only provides health is little connectivity between the PHRs. The patient
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summary information. In other cases, it may pro- might as well have a paper-based record system
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vide a view into parts of the EHR or even the entire of their own if they wish to have any integration
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EHR. A portal may also be a way to access a per- of data across these PHRs. PHRs offered by many
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sonal health record supplied by a provider. (How- healthcare providers also do not allow patients
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ever, the MU program does not require a PHR.) In to enter data, rather they can only view lab re-
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some cases, patients are starting to enter their own sults and other summary health information. This
health history using a template that directs them somewhat defeats the purpose of having a central-
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to enter specific information via the portal that is ized place that can be used to document changes in
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then available to providers during the visit. Some personal health status or communicate in real time
20
20
providers are supporting e-visits through a portal, with providers about changes in a patient’s health
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where existing patients can exchange email in lieu status, such as high blood sugars or weight gain in
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of visiting the physician’s office for follow-up or a patient with congestive heart failure.
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recurring care needs. E-visits are now reimbursa- PHRs have been most popular with patients
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ble by some insurance companies. Portals are also who have chronic illnesses or with caretakers of
used by providers to connect from their office to a elderly patients having to manage multiple pro-
hospital or other healthcare organization, and to viders, many drugs, and other data.
health plans, such as for eligibility verification or The continuity of care document (CCD) is yet an-
for submitting prior authorization requests. other effort to supply patients with more informa-
The personal health record (PHR) has been de- tion about their healthcare. The CCD is essentially
fined by AHIMA as an electronic or paper health a set of summary data about an episode of care. It
record maintained and updated by an individual uses the Clinical Document Architecture (CDA)
for himself or herself; a tool that individuals can standard developed by HL7 that aids in the creation
use to collect, track, and share past and current and exchange of XML documents between health
information about their health or the health of information systems. When the CCD is rendered
someone in their care. Although use of an electronic as an XML document, the CDA provides structure
AB103118_Ch11.indd 346 2/11/2020 1:18:18 PM

(including a description of document content for transportation services for patients to get to their
users and discrete data for computer processing), physician offices for follow-up visits (Auer 2015).
vocabulary standards, and codes for sharing clini- CRM systems can also aid in provider networking
cal documents in XML format. Subsequently, HL7 tasks and patient engagement.
has created a transport mechanism not only for the
CCD, but for a number of other healthcare docu-
Health Information Exchange
ments. These document templates are collectively
referred to as the Consolidated Clinical Document Health information exchange (HIE) is another way
Architecture (C-CDA). to exchange information across multiple organiza-
The C-CDA may be transmitted electronically tions and individuals. HIE is most often managed by
via HL7 standard messages, in attachments to an organization referred to as a health information
emails, or via standard internet file transfer proto- organization (HIO). The HIO typically provides
governance, fee structure, and policies and proce-
n.
cols, such as file transfer protocol (FTP).
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Because the traditional HL7 (and other healthcare dures for exchanging health information; it is a busi-
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information standards) only enable point-to-point ness associate under HIPAA. HIOs have struggled
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exchange of data rather than seamless, on-de- financially, as paying for exchanging health informa-
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tion when generally provider-to-provider exchange
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mand information exchange such as is performed
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on the WWW, HL7 has created a new standard has been free of charge—albeit a slow process—has
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it is calling the Fast Healthcare Interoperability not been accepted as well as expected.
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In general, an HIO provides several key servic-
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Resource (FHIR). FHIR is a set of resources that
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address common use cases in exchanging health es, shown in figure 11.7. These include:
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information. They are based on application
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Patient identification, usually using an

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program interface (API) technology, which pro-

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identity matching algorithm in which

vides a set of tools for building software applica-
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specified patient demographic information

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tions. FHIR resources each have a tag that acts as

is compared to select the patient for whom
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a unique identifier, much like the URL of a web

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information is to be exchanged. The algo-

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page. A FHIR resource can support the exchange

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rithmic process is determined by the vendor

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of text (including documents from the C-CDA),

supplying the service but uses sophisticated
structured data elements, and metadata across
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probability equations to identify patients.

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a wide variety of devices from computers to cell

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phones (Bresnick 2016).

●● The record locator service (RLS) is a process
20
that seeks information about where a

20
Another set of technologies that are supporting

patient, once identified, may have a health
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patient-exchanged health information are those

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record available to the HIO.

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from other industries. Non-healthcare companies

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Identity management (IdM) (not to be

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merging with healthcare organizations or even ●●

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planning to offer new forms of support for patients confused with patient identification)
are lending considerable knowledge and skills to provides security functionality, including
healthcare, including new applications for typically determining who (or what information
non-healthcare information systems. Something as system) is authorized to access information,
simple as customer relationship management authentication services, audit logging,
(CRM) systems (which serve as a database of encryption, and transmission controls.
customers [patients] and relationships they may ●● Consent management is yet another HIO
or could have with service providers, such as service. In consent management, patients
transportation companies, home health agencies, have opt in/opt out privileges for having
meals-on-wheels, and others) can be helpful. For their health information exchanged. As noted
example, care coordinators and patient navigators previously, the patient will often provide
could use a CRM system as they attempt to arrange a consent directive for this purpose.
AB103118_Ch11.indd 347 2/11/2020 1:18:18 PM

Figure 11.7 HIO services HIE is developing across the nation. Initially
referred to as the nationwide health information
Hospital
Integrated
delivery
network (NHIN), the federal government wants
system
such a network to be grounded in both federal and
Directory:
private sector needs. Today this is referred to as the
Patient-identifiable eHealth Exchange. It includes federal agencies in-
data, record locator
Lab service Public
health
volved in healthcare and nonfederal organizations
coming together (with assistance from a federal
IdM
security
contractor) to offer a secure, trusted, and interoper-
able health information exchange service (The Se-
Health
plan
Consent
Pharmacy
quoia Project 2018). Today, the eHealth Exchange
management connects all 50 states and is used by the Depart-
n.
ment of Defense, VA, CMS, and Social Security
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Administration as well as 30 percent of all US hos-
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Nursing
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home Clinic
pitals, 10,000 medical groups, 8,200 pharmacies,
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and more than 900 dialysis centers—essentially
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connecting more than 100 million patients. Par-
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ticipants sign a Data Use and Reciprocal Support
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In addition to these basic services, each HIO Agreement (DURSA), participant agreement, and
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establishes what type of data exchange it will testing agreement. There are both testing and ex-
support. For example, there are some that only n
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change fees for use.
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conduct e-prescribing—exchanging prescriptions There are two ways to connect using the eHealth
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between providers who write prescriptions and Exchange. They are the following:
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retail pharmacies. Some states sponsor an HIO;

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if so, the HIO helps support public health activi- 1. Direct exchange uses an initiative called the
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ties (for example, immunization registry report- Direct Project for securely pushing patient
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health information to a known, trusted

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ing) and often some basic exchange of emergency

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receiver using secure email technology

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information. Because such HIOs must help ex-

change information across many disparate types (HIMSS 2013).
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of health information systems, usually only a 2. CONNECT is an alternative way to connect

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limited amount of information is able to be ex- with the eHealth Exchange. CONNECT is
20
20
changed. To exchange more comprehensive infor- open-source software that implements health
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mation (and perhaps also to gain market share), exchange specifications. It enables discovery
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EHR vendors have started to support exchange of of where there may be information as well as
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health information across all organizations using directly retrieving it from the source (HIMSS
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the same EHR vendor. 2012b).

1. Software that is written to help exchange data between two applications is:
a. Interoperability
b. Interface
c. e-Health Exchange
d. Systems integration
AB103118_Ch11.indd 348 2/11/2020 1:18:20 PM

2. Which of the following describes telehealth?
a. It is the diagnosis or treatment of a patient who is not physically present with the provider.
b. It is an exchange of email for routine clinic visits.
c. It is call center services for disease management.
d. It is remote monitoring.
3. The Consolidated Clinical Document Architecture (C-CDA) is a:
a. Summary health record
b. Collection of healthcare document templates in XML format
c. Standard for formatting structured data in healthcare
d. Specification for the content of an EHR
4. An HIO provides identity management to:
a. Help locate a specific patient
n.
b. Assure appropriate security services
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c. Validate a patient’s consent for sharing information
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d. List all providers participating in the exchange
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5. True or false: Cloud computing is a process where data (and software) are housed on remote servers accessible
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through the internet.
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6. True or false: The HL7 FHIR standard brings interoperability into the world of web-based connectivity.
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7.
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True or false: In order to locate where a patient has health information, the Direct Project is used in a health
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information exchange environment.
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8. True or false: A patient must access a PHR via a portal. io
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9. True or false: The eHealth Exchange is a free service available to all healthcare providers.
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Systems Development Life Cycle

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As described, health information sys- for adoption of new standards, the healthcare or-
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tems include both technology (hardware and ganization must address needed changes in the
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software) and operational elements addressing system, or obtain a replacement, to continue to

20
20
the needs of people (users), required policies, and produce desired results. The general nature of an
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process improvement. Health information systems SDLC is illustrated in figure 11.8.

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also reflect a life cycle. This life cycle demonstrates There may be variations in how the steps in the
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the need to manage changes so the system contin- SDLC are described depending on the context in
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C
ues to produce the desired results. which it is used. For example, a hardware or soft-
The systems development life cycle (SDLC) ware developer may go through an SDLC when
refers to the steps taken from an initial point of creating a new product. The vendor may iden-
recognizing the need for a desired result, through tify the need for a new product, then determine
the steps taken to ensure all components needed the feasibility of creating the new product with
for the system to achieve the desired result are specifications that would satisfy the new product
addressed. This cycle is repeated whenever the needs, design the product, develop it for mass pro-
system fails to continue to produce the desired duction, maintain the product as small changes in
result (NIST 2008). Failure of an information sys- the environment impact it, and monitor sales to
tem to produce the desired result may be due to justify continued maintenance or sunsetting (that
internal or external changes. For example, if a is, no longer selling or supporting) the product.
health information system was acquired a number In a healthcare provider setting, the SDLC helps
of years ago and there is a new federal mandate identify a need for health information systems
AB103118_Ch11.indd 349 2/11/2020 1:18:20 PM

support. The healthcare provider will then specify organization or may be mandated by the federal
requirements needed to achieve the need, acquire government, health plans with which the healthcare
a new information system, implement the new organization contracts, or other external sources.
information system, maintain it, and monitor that Commonly referred to as needs identification, a
it continues to meet needs over time. Sometimes a healthcare organization may periodically conduct
health information system may need to be replaced, strategic planning that identifies a need; for exam-
in which case the SDLC of acquiring a new prod- ple, more timely data available to infection control
uct is repeated. nurses, or that the surgical suite needs to improve
While the SDLC is most often applied when in- communications with other departments. A hospi-
formation systems are being developed or acquired, tal may find that its major commercial health plan
it can be applied as part of a continuous improve- has decided to promote VBC, wherein access, price,
ment process to ensure that any system meets quality, efficiency, and alignment of incentives, rather
n.
ongoing and new needs. For example, taking a sys- than volume alone factor into payment for care. Ne-
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tems view and applying the SDLC can be a useful gotiating a VBC contract will necessitate significant-
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process when planning any new service offerings. ly more integration of financial and clinical data.
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A hospital may be considering developing a cen- Needs are most commonly expressed as goals.
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ter of excellence in orthopedics or acquiring small Goals for what and how health information systems
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community hospitals. A physician’s office may be will achieve desired results reflect current and an-
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considering a merger or expansion of services into ticipated needs and should drive all elements of
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retail offerings. An integrated delivery network planning for the systems. Ideally, these should
may be evaluating the usefulness of spinning off n
be written as SMART goals, or statements that
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long-term care facilities it operates. The key value identify results that reflect the following:
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of the SDLC is to apply a formal logical process to

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●● Specific
ensure all components needed for a system to op-
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Measurable
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●●
timally achieve its value are in place. Each of the
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components in the SDLC is discussed next. ●● Attainable

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Relevant
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●●
Identify Needs
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●● Time-based
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Needs for a healthcare organization that a health

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Figure 11.9 is an example of a SMART goal for a

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information system should address arise from

hospital performing strategic planning for a health
20
various activities conducted by the healthcare

20
information system.
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Figure 11.8 Systems development life cycle

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Figure 11.9 Example of a SMART goal

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Identify need Example of a SMART goal

(Note: SMART goals must contain all S-M-A-R-T components, but to
read the goal statement easily, the comporents do not have to be in
a S-M-A-R-T sequence.
Monitor Specify
results requirements Goal: Improve the near-miss medication error rate by 80 percent
using a BCMAR system that is implemented with adequate training
and process improvement over a period of one year.
Specific: Improve the near-miss medication error rate

Design or
Maintain Measurables: by 80 percent
acquire
Relevant: using a BCMAR system
Attainable: that is implemented with adequate training and
Develop or process improvement
implement Time-based: over a period of one year
Source: © Margret\A Consulting, LLC. Reprinted with permission. Source: © Margret\A Consulting, LLC. Reprinted with permission.
AB103118_Ch11.indd 350 2/11/2020 1:18:22 PM

Any given organization will have several SMART for a specific health information system are met.
goals for its health information system. For exam- Members of the steering committee for health
ple, a clinic may include the following goal in its information systems should include heavy rep-
planning: resentation from physicians, nurses, and other
health professionals, including a physician cham-
Physicians will reduce unnecessary
pion. The physician champion is a well-respected
diagnostic studies tests by 10 percent
physician who can informally help the physician
(measurable) over the next two years (time-
community adapt to and ultimately adopt health
based) using the interoperability capability
information systems. The position of chief medi-
of the system (realistic) that, when a test
cal informatics officer (CMIO) is being created in
order is placed, makes available (attainable)
hospitals and large clinics. The CMIO is a salaried
the results from previous tests performed
physician (most often part time so that he or she re-
across the continuum of care for the patient
n.
tains credibility with other practicing physicians)
specific to type of test and patient needs
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who is heavily involved in policy development,
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(specific).
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workflow and process improvement, and ongo-
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SMART goals should address all system coming maintenance of CDS and other systems requir-
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ponents, including desired functionality, specific ing significant physician input. Both the physician
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technology requirements to support the desired champion and CMIO help achieve a clinical trans-
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functions, and the expectations for people to adopt formation—a fundamental change in how medi-
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new policies and processes to ensure achievement
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cine is practiced using health information systems
of goals and, therefore, provide value back to the or-
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to aid in diagnosis and treatment.
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ganization for its investment (Amatayakul 2017b). In addition to the healthcare professional repre-
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sentation, IT representatives, the health information

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Specify Requirements management professional, key operational staff,

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Once needs are identified, a healthcare organiza- the procurement officer, and potentially others will
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tion will want to specify detailed requirements for round out the steering committee membership.
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how the needs can be met. For health information Guided by the SMART goals that define the over-
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systems, most healthcare organizations convene a all need, the steering committee will seek input
steering committee that will identify and docu- from the specific health information system’s key
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ment a detailed set of specifications, often referred stakeholders to enumerate specific requirements.
by
to as a requirements specification. For example, when planning for a BC-MAR system,

20
20
A steering committee may be an overarch- nurses, pharmacists, IT staff, physicians, and quality
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ing committee comprised of key stakeholders to assurance professionals may be the key stakehold-
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health information systems in general, or, less ers. They will review the literature, consult with
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commonly, a steering committee will be convened peers in other healthcare organizations, and per-
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for each specific health information system proj- haps attend a trade show or visit another healthcare
ect and include only stakeholders associated with organization with a BC-MAR system to understand
that project. The latter is normally not advisable more about it and what users like and do not like.
because of the systems nature of health IT. For
example, a BC-MAR will be impacted by CPOE Design or Acquire
and a pharmacy information system. Ultimately, it Today, most healthcare organizations acquire health
will also need to be integrated with a medication information systems from a commercial vendor.
reconciliation system and may need to interoperate There are few healthcare organizations left in the
in the future with a home medication administra- US that have and continue to support a home-
tion system. grown, or self-designed information system—
The broadest possible set of stakeholders in these are gradually being discarded in favor of
a steering committee will ensure that all needs commercial systems.
AB103118_Ch11.indd 351 2/11/2020 1:18:22 PM

Commercial systems have several important Whatever their status, healthcare organiza-
a dvantages. First, they are generally cheaper in tions should acquire health information systems
the long term because they offer economies of through a formal vendor selection process. The
scale by selling the same product to many others. steps in vendor selection are the following:
Second, they can be more interoperable. Vendors
1. Needs identification. This step entails under-
know they will have to do some integration with
standing and documenting the goals for the
systems from other vendors in any given health-
information system being acquired.
care organization. In addition, with federal goals
2. Requirements specification. This involves
for interoperability (including changing the name
determining and documenting the detailed
of the program requiring an EHR from MU to Pro-
features and functions desired in the
moting Interoperability in its alternative payment
information system in order to meet the
models [CMS 2019]), vendors know they will not
healthcare organization’s specific goals.
n.
survive in the marketplace if their systems do not
tio
support interoperability. Third, the unique con- Requirements specification must also describe
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figurations that are often the hallmark of home- the way the healthcare organization will ac-
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grown systems are feasible with many commercial quire the health information system. Client/
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products. These products offer toolkits that allow a server systems are those where commercial
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user organization to tailor the information systems software is installed on servers housed and
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to their needs, while not impacting the underlying maintained within the healthcare organi-
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product’s architecture—thus assuring both cus- zation itself, housed within the healthcare
tomization for users and interoperability with oth- n
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organization and managed by an outsourced
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er information systems. Finally, vendor longevity company, or housed and maintained by a con-
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in the marketplace is more assured than that of the tractor for the healthcare organization. The
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custom programmer hired for a specific job for one benefit to client/server systems is the e xtent
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organization who then moves on to another cus- to which the software can be configured
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tom job for another organization—leaving the first to meet the special needs of the healthcare
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organization without ongoing support for mainte- organization. The primary disadvantage is
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nance of the system. that the healthcare organization must man-

Acquiring a health information system may be age the IT infrastructure or hire a contractor
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performed in one of two ways. If a healthcare to do so. An alternative is an application

by
organization already has many health information service provider (ASP) or Software as a
20
20
system components from one vendor (often de- Service (SaaS) arrangement. There are both
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scribed as a best-of-fit environment), the healthcare similarities and differences between these
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organization likely will acquire additional compo- two. Both essentially offer health informa-
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nents from the same vendor. A small amount of tion systems on a subscription basis, with the
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due diligence (steps taken to confirm various facts software and servers housed remotely. In an
about the product) may be performed to ensure ASP arrangement, only a moderate amount
the healthcare organization that it does not need of custom configuration is feasible, and the
to go to another vendor to acquire the product, healthcare organization pays for 100 percent
thus moving toward a best-of-breed environment usage time, but it does not have responsibility
where different components are acquired from dif- for managing the technology infrastructure.
ferent vendors. Much like home-grown systems, Functionality is delivered to the user via ded-
best-of-breed environments started disappearing icated communications technology. The SaaS
during the MU program era, but may be returning arrangement is similar to the ASP, but there
as a result of the HL7 FHIR standard that supports is generally less custom configuration ability.
much easier interoperability, thus enabling acqui- The SaaS offers a pay as you go model, where
sition of more specialty products. you only pay for the actual time using the
AB103118_Ch11.indd 352 2/11/2020 1:18:22 PM

information system. This may work well for and potentially conducting site visits to see
physician offices, but generally not for hospi- the product in actual use. Depending on the
tals that have 24-hours a day, 7-days a week, size and location of the healthcare organi-
365-days a year use requirements. The SaaS zation, a product demonstration might be
model may be delivered via dedicated com- conducted on-site or via a webinar. However,
munications technology or cloud computing. it is conducted, there should be plenty of time
3. Request for Proposal (RFP). An RFP includes set aside to fully put the product through its
developing and disseminating a description paces. Because most vendors will spend a lot
of the healthcare organization, its goals for the of time before the actual product demonstra-
information system, its requirements speci- tion discussing the values and history of the
fication, and a statement of how the vendor company, the healthcare organization needs
should respond to the request for proposal. to take charge of the demonstration and set
n.
In recent years, an RFP was considered too timelines for how much time should be spent
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much work both for organizations to compile on such introductory information, how much
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and vendors to respond to. Many healthcare should be spent with the vendor conducting
ss
a demonstration, and how much time should
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organizations were so new to health informa-
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tion systems that they did not know what be allowed for further discussion and even
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requirements they wanted met. However, with more in-depth review of certain features and
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more experience, many are realizing that it is functions. Demonstrations may range from a
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probably the only way to ensure a comprehen- two-hour webinar to a full day or even longer
n
sive understanding of requirements and their io
on-site for large organizations. At least half of
at
the time allotted should be spent on a detailed
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availability in a product. Dissemination of the

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RFP was also challenging in the past with so review of features and functions. At the con-
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clusion of all forms of due diligence, a vendor

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many vendors. Small providers often relied

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on their specialty society recommendations or and one backup should be chosen.

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“friends,” who may have been biased and too 6. Contract negotiation. This may be the most
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narrow in scope should the practice expand critical, and often not well-performed, step in
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beyond the one specialty. Today, the consumer the vendor selection process. If money is to be
is more informed and has had an opportunity
e
spent on the vendor selection process, a con-

th
to learn about a variety of vendors. Sending sultant who knows the marketplace should be
by
20
the RFP to four to six vendors is realistic and hired and legal counsel should be involved.
20
doable. Vendor contract offerings are notoriously one-

©
4. Analysis of RFP responses. This is a formal sided. Recently, many small providers have
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review of the responses to the RFPs against realized that they did not negotiate that feder-
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the requirements specification. This process ally regulated updates to information systems
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should be done as objectively as possible. must occur on a timely basis and at no cost to
Often the requirements analysis is used as a the healthcare organization. Many contracts
score sheet to help identify gaps or potential also include payment schedules that require
issues. While it cannot be expected that any between 50 percent and 90 percent of the cost
one vendor will be able to fully address every upfront—which should be far less. Contracts
requirement, prioritizing the requirements must also recognize the responsibilities of the
and determining which vendors should be vendor under HIPAA. The best form of
further considered is a key step. At this point contract negotiation is for the healthcare
the four to six vendors should be narrowed to organization or organization representative to
three or four at the most. prepare a list of issues to be addressed, present
5. Due diligence. This involves requesting a it to the vendor, and then hold a series of con-
product demonstration, checking references, versations to address each issue. Price should
AB103118_Ch11.indd 353 2/11/2020 1:18:22 PM

be the final negotiation step. An important ca- option. This is usually insufficient for most new
veat in contract negotiation, however, is that users, even when the user has experience with a
the result should be a win-win situation, not different vendor’s information system. In addi-
a win-loss, where the vendor loses so much tion, training is not a one-time event—there needs
money on the deal that they are unwilling or to ongoing orientation, introduction to principles,
become unable to deliver on their promises. training, reinforcement, sometimes certification of
Implementation should not begin with an users, and re-training or focused training. When
adversarial relationship between the vendor the system is upgraded, modified, or enhanced,
and the organization. training is needed again. Most of such training is
left to the healthcare organization. For additional
Develop and Implement information on training, see chapter 20, Human
Once a commercial product has been acquired, Resources Management and Professional Development.
n.
there are development and implementation steps Other implementation steps for which the health-
tio
to be taken by the healthcare organization and care organization is responsible are management
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vendor. A large part of acquiring a commercial of the vendor and elements of implementation re-
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product is associated with the implementation of lated to people, policy, and processes. Most health-
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the product. The vendor installs the software on care organizations find it necessary to also appoint
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specified hardware. Usually the vendor is also a project manager who is responsible for managing
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contracted for managing the implementation and vendor relations, including issues management
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appoints a project manager to do so. During im- where any issues that arise during the implemen-
plementation, system configuration (sometimes n
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tation are documented, brought to the attention of
at
called system build) is conducted. This process the vendor, and hopefully resolved or escalated so
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provides customization of templates, review and that resolution is accomplished. Most (but not all)
In
customization of decision support, and other func- vendors typically do not perform change manage-
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tions; in addition, master files and directories are ment that helps new users become acclimated to
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loaded, and potentially some data conversion the significant change in not only documentation
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is performed. For example, a physician’s office but the practice of medicine that results from us-
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would want to have their logo displayed on the ing health IT, (additional) training, go-live (first
system, a list of all their patients made available use of the information system in actual practice)
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to the application, fee schedules loaded, and data support, monitoring usage post implementation,
by
conversion to move their current accounts receiv- workflow and process analysis and redesign, and
20
20
ables to the new information system. Depending policy development. Experience has shown that
©
on whether there was a previous EHR, either EHR these elements may be more critical to the success
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data must be moved to the new information sys- of a health information system than the hardware
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tem (data conversion), typically by a vendor or and software. Change management is discussed in
C
other contractor; or key parts of the paper health chapter 17, Management.
record content must be entered (chart conversion). Workflow, process analysis, and redesign are
This entry may be done by staff, a contractor, or often acknowledged by a vendor as important, but
new users as patients are seen. While new users most vendors do not have time to provide such
usually do not want to do this, it is an excellent services. Those vendors who are at the top of the
way to learn the information system and reduce pricing scale do provide workflow and process
unnecessary chart conversion steps. analysis and redesign—and their results dem-
Training is also a critical element of implemen- onstrate the value of this. Unfortunately, many
tation. Some vendors will include, or sell for a healthcare organizations are so overwhelmed by
separate price, training on using the information the amount of effort required in an implemen-
system, and may use a contractor for this. Other tation that they either do not have the energy or
vendors supply a CD or webinar as their training overlook this critical step. As noted previously,
AB103118_Ch11.indd 354 2/11/2020 1:18:22 PM

unintended consequences can occur from use of done and this should be compared with policy, is-
health IT and most have been related to lack of sues logs, and change requests. In an ASP or SaaS
training, lack of policy surrounding appropriate environment, most system maintenance will be
use of the information systems, and lack of atten- performed by the vendor except for maintenance
tion to workflow and process changes (Amatay- on local hardware and any software not covered
akul 2011). by the ASP or SaaS vendor. Healthcare organi-
Testing of the software to guarantee it works with zations are advised to keep track of issues they
the hardware selected, has been configured prop- report to the ASP or SaaS vendor and confirm they
erly, and users understand how to use the informa- are appropriately addressed.
tion system is also challenging. Many vendors will
claim that their system has already been tested by Monitor Results
virtue of their numerous customers, but each cus- To complete the SDLC, monitoring results is an
n.
tomer will have a unique information system build essential element that ensures health information
tio
so this argument is not fully valid. Testing is often
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systems continue to meet the healthcare organi-
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left to either super users using the information sys- zation’s goals and identify when there are new
ss
tem in advance of go-live and finding issues the ven-
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needs. A formal monitoring program should begin
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dor must address, or by the end users themselves as immediately after go-live. The project manager
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they start to use the information system. The latter is or a compliance officer (or both) may be respon-
ag
not desirable, as the end users are already fearful of
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sible for monitoring. The monitoring program
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the change. Unfortunately, time often runs out and should include formal processes such as user
users want to begin using the system before it can be n
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surveys, observations, benefits realization stud-
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fully tested by super users.
m
ies, and results analysis, as well as informal pro-

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cesses like the proverbial bagel breakfasts, pizza

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Maintain
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lunches, or milk and cookie breaks. During and

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System maintenance refers to numerous tasks immediately after go-live, it is helpful to have a
H
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that keep the health information system running break room set up where new users can unwind
ic
smoothly. Some tasks are routine in nature, such and talk about the system. Food is always invit-
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as preventive maintenance including the applica- ing and often eases tensions when there are issues.
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tion of security patches or upgrades as delivered Other forms of celebration for getting through the
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by
by vendors; others are corrective, modifying, or go-live day and reaching other milestones are also
20
enhancing and performed based on calls to the helpful. As time passes to more routine use, infor-
20
help desk with issues or change requests for a mal feedback mechanisms may move to weekly,
©
modification or enhancement. Any changes to the monthly, or quarterly opportunities, but should
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fundamental system should be documented in a continue indefinitely. Feedback from both formal
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formal change control program. A change control and informal methods should be documented and
C
program ensures there is documented approval addressed. Users must see that their concerns are
for the change to be made and evidence that all given attention.
elements of implementation, testing, rollout, train- Although results monitoring is improving,
ing, and such are performed. many healthcare organizations do not monitor re-
In a client/server environment, routine and sults well. Staff complaints, technology issues, and
some corrective system maintenance is left to low levels of use are often known, but not tracked
the healthcare organization’s staff or contractors; in any formal manner. Often changes are not made
while other corrective, modifying, or enhancing until a crisis occurs or the next federal mandate
maintenance may require consultation or direct is enforced. Monitoring use, however, can result
work performed by the original vendor. Whoever in achieving full adoption and even optimization,
performs system maintenance should provide which leads to goals being achieved more quickly
regular reports on what maintenance has been and comprehensively.
AB103118_Ch11.indd 355 2/11/2020 1:18:22 PM

HIM Roles
Health information professionals’ roles (such Amazon, JPMorgan, and Berkshire Hath-
will continue to evolve as health information sys- away). It can be anticipated that in the next few
tems enhancements occur. Health information years, significantly more changes will come about
systems is very dynamic today. Constantly, new that impact healthcare. Examples of those changes
information technologies are being developed may include the following:
and new applications are being adopted for use
in healthcare. In addition, there are many changes ●● Use of CRM applications for care coordination
in regulations, standards, accreditation require- ●● Just-in-time delivery of services
ments, and practices that can significantly alter the
●● Increasing number of retail clinics and other
n.
course of health information systems. HIM profes-
tio
delivery mechanisms to overcome access
sionals are able to identify new applications that
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issues
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are coming about as a result of new technology in
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general and in particular from mergers, acquisi- ●● Consumer (patient) empowerment
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tions, and ventures of non-healthcare businesses ●● Analytics and artificial intelligence
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Check Your Understanding 11.3 io
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1. Which of the following is a characteristic of the systems development life cycle?

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a. It lists the components of a health information system so that organizations do not have gaps in their strategic
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planning.
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b. It describes the steps to ensure all components needed for a system to achieve its desired results are addressed.
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c. It is a roadmap for vendor selection of any products needed to meet an organization’s vision, mission, and goals.
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d. It serves as a guide to vendors on health information system requirements.

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2. The systems development life cycle is cyclical because:

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by
a. There are six steps that are repeated continuously

20
b. Feedback from monitoring results initiates repetition of the steps in the cycle
20
c. It varies with the stages in which an organization has adopted health IT

©
d. System theory reinvents itself periodically

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3. In the systems development life cycle, desired outcomes may be best specified as:
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a. Requirements specifications
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b. Steps in product selection

c. SMART goals
d. Request for proposal
4. A health information system steering committee that best guides an organization’s technology plans includes:
a. Physician leadership
b. All information technology staff that will work on the project
c. Legal counsel
d. EHR vendor
5. Steps taken to confirm various facts about a product are referred to as:
a. Vendor selection
b. Systems development life cycle
c. Certification
d. Due diligence
AB103118_Ch11.indd 356 2/11/2020 1:18:22 PM

6. Which of the following is true in contract negotiation?
a. Price is the most important thing to negotiate.
b. It is best to use an attorney who can ensure the product acquired will work.
c. All issues with terms of the contract can and should be negotiated.
d. Vendors should take charge of payment schedules to ensure payback.
7. Moving data from an old system to a new system requires which of the following?
a. Data conversion
b. Chart conversion
c. Loading master files
d. System build
8. An approach to help new users acclimate to the new technology is:
a. Change control
n.
b. Change management
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c. Training
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d. Testing
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9. A situation in which a healthcare organization has multiple vendors represented in its applications is referred to as:
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a. Best of breed
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b. Best of fit
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c. Application service provider
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d. Legacy environment
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10. During implementation of health IT, the step most often not performed or not performed well is:
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a. Contract negotiation
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b. Issues management
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c. Maintenance
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d. Workflow and process analysis and design

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20
A diabetic patient, John, moves to John asks his former hometown physician to
20
a new city and uses the internet to select a local send information to his new PCP. The physi-
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primary care physician (PCP), who is a general- cian does so using standard content and format
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ist physician and will coordinate his overall care. specifications for exchanging referral information
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He can select a PCP who appears to have strong between providers. With the information supplied
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outcomes in diabetes and positive patient satisfac- by the PHR and his former PCP, the new PCP’s
tion scores. John schedules an appointment via the EHR is prepopulated with a current problem list,
physician’s website and is set up with a user ID recent laboratory results, and other data. Addi-
and password to link the PCP with John’s PHR, tionally, the new PCP can add John’s medication
which is a record he maintains himself by upload- history to the EHR by linking to information avail-
ing copies of records from various providers he has able from John’s health plan.
seen over the years. This enables the PCP to view When John visits the new PCP, information from
and retrieve pertinent information from other pro- these various sources will be validated and updat-
viders and information John has recorded about ed. The new PCP can document all components
his diet, over-the-counter medications taken, and of John’s visit at the time of the visit, including
other information related to compliance with his demonstrating medical necessity for lab work by
diabetic treatment regimen. applying ICD diagnosis codes and generating
AB103118_Ch11.indd 357 2/11/2020 1:18:22 PM

a ppropriate evaluation and management (E/M) to quality metrics. This improves the quality of
codes for the level of service provided. The PCP healthcare and reduces costs in an assigned pop-
decides to put John on a strict smoking-cessation ulation of patients. As a result, the hospital has
program and exercise routine, with plans to ad- access to John’s previous lab and x-ray results, so
just medications according to John’s vital signs repeating these lab tests is not necessary—saving
and blood sugar levels, which will be monitored John time and potential health risks and reducing
remotely through a medical device. overall costs. In selecting the physical therapy
All is going well until John has an accident at referral, the hospitalist has access to John’s health
work that requires a visit to the emergency de- plan benefits information, so no time is wasted in
partment, subsequent admission to the hospital, arranging for physical therapy to begin.
and outpatient physical therapy. All his providers, John’s PCP also continuously monitors the impact
however, are members of a health information or- of the accident on John’s diabetes during his hos-
n.
ganization (HIO). As a result, each provider has pitalization and makes appropriate adjustments.
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immediate access to the specific information need- After John is discharged and in physical therapy,
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ed to treat John throughout his care and for which the health plan can monitor whether he is follow-
ss
John has provided a consent directive enabling ing the prescribed exercise routine and can notify
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him to opt in to the sharing of such information the PCP to follow up if necessary. John can access
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with all participants in the HIO. tailored discharge instructions that superimpose
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At the hospital, the physician providing care his picture on the exercise instructions so that it
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can reconcile all of John’s medications in accord- is clear how to avoid further injury. In addi-
ance with the Joint Commission requirements and n
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tion, each provider John encountered throughout
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select medications that have been screened against this episode of care follows up with him on the
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John’s known allergies. The hospital is also part of a smoking-cessation program he started with his
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health reform mechanism that ties reimbursement PCP, motivating him to stop smoking.
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Clinic for Kids is a provider practice nurse practitioners, who are also taking on the role
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with three pediatricians, two nurse practitioners, of care coordinators to further the VBC initiatives,
20
three licensed practical nurses, a half-time be- find the EHR limiting in “customer relationship
20
havioral health therapist, and a part-time office management” tools and the lack of interoperabil-
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manager. It earned initial certification as a patient- ity with their patients, other providers, schools,
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centered medical home and acquired an EHR over and social service agencies. The behavioral health
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10 years ago from a small, start-up company which therapist, as a contractor, maintains separate paper-
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provided the EHR via a subscription service and based records. At the time of the conversion to
which also maintained the clinic’s computers. ICD-10-CM a few years ago, the EHR company
One of the pediatricians refused to use the EHR went out of business. As a result, the clinic’s office
but agreed to allow a nurse practitioner to scribe. manager hired a part-time medical coder and IT
Another pediatrician reviews the EHR at the point support person who created a small registry on
of care, but documents notes on scraps of paper an Access database and documented ICD-10-CM
and takes them home at the end of the day to enter data therein, which a healthcare claims clearing-
into the EHR. The third pediatrician and the nurse house then merged with claims data.
practitioners are power users of the EHR, although All members of the clinic recognize they need
the pediatrician is often frustrated with the lack of a new EHR, but they are now frustrated with
analytics support, especially as the clinic wants the affordable offerings that do not incorporate
to participate in alternative payment models. The the latest of technologies. Their primary hospital
AB103118_Ch11.indd 358 2/11/2020 1:18:23 PM

a ffiliation has one of the major EHR vended systems. care use with a better EHR and hence see more pa-
The hospital has offered to supply a small-office tients. At least two of the physicians are convinced
version of the product to the clinic. The clinic is that in a VBC environment, they would gain more
evaluating the cost differential, as the product than they would lose because their quality of care
costs more but the cost could be outweighed by has always been outstanding. One of the clinic’s
cost reductions in compiling the coding database health plans and the local school are also looking
and clearinghouse fees. They also believe their into ways to support the clinic in its IT manage-
nurse practitioners could be put to better patient ment needs.
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healthcare-102465.html. Unintended consequences of EHR systems: A
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Siwicki, B. 2018 (October 25). EHR optimization
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leads to 53% increase in cash collections at rangely
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hospital. Healthcare IT News. https:// doi/abs/10.1177/2327857917061048.
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Spitzer, J. 2018 (April 16). 30% of physician practices
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content/40/2/105.full.
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plan to replace EHR by 2021: 4 things to know. io
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2/11/2020 1:18:23 PM
Chapter
12
Healthcare Information
n.
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Hertencia Bowe, EdD, MSA, RHIA, FAHIMA
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Learning Objectives
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•• Justify the importance of healthcare information to •• Explain the connection between consumer
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the healthcare industry information access, health literacy, telehealth,
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•• Explain the role of data analytics in healthcare navigational tools, and healthcare information
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information •• Differentiate between the benefits and challenges of

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•• State the strategic uses of healthcare information sharing healthcare information

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•• Define consumer informatics

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Key Terms
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Clinical data analytics Data standards Natural language processing

Clinical data repository Data visualization (NLP)
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Clinical data warehouse Decision support system (DSS) Patient portal

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Clinical decision support system Discrete data Patient safety

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(CDSS) eHealth Exchange Personal health record (PHR)

20
Dashboard Executive information system (EIS) Point-of-care charting

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Database Healthcare data analytics Scorecard

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Data abstraction Health informatics Social media

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Data analytics Health information exchange (HIE) Structured data

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Data capture Health literacy Telehealth

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Data mining Key indicator Unstructured data
Healthcare information is used to monitor the provider use in the management of patient care.
quality of patient care, conduct medical research, Data collection techniques include traditional
and accurately reimburse healthcare organiza- methods such as paper health records as well
tions. Healthcare information is based on per- as eHealth tools such as templates. “A template
sonal health data about individuals primarily for is an EHR documentation tool utilized for the
363
363
AB103118_Ch12.indd 363 2/6/2020 5:41:38 PM

c ollection, presentation, and organization of clini- Per the Federal Health IT Strategic Plan for
cal data elements” (Buttner et al. 2015). The sources 2015-2020, the benefits of electronic health in-
of health information include the healthcare pro- formation include lower healthcare cost, in-
vider through documentation in the health record creased healthcare quality, improved population
and the individual through the use of a personal health, and an improvement in consumer en-
health record. A personal health record (PHR) is gagement. The Federal Health IT Strategic Plan is
a record created and managed by an individual in illustrated in figure 12.1.
a private, secure, and confidential environment. With the implementation of the EHR and the
The personal health record will be covered later in changes that result, the roles and career options
this chapter. In addition, the federal incentives for for health information management (HIM) pro-
the adoption of the electronic heath record (EHR) fessionals is growing. Some of the new roles
have progressed healthcare information exchange, include data analytics, consumer engagement,
n.
including returning a patient care summary to the and health information exchange (HIE). This
tio
patient. Databases of healthcare information col- chapter discusses HIE information from the
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lected or maintained by healthcare providers, in- perspective of data analytics and explores the
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stitutions, payers, and government agencies are of strategic uses of health information. In addition,
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great importance to those who use them; for exam- the consumer’s link to healthcare information—
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ple, researchers or public health agencies. These specifically their needs for information, ease of
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databases are used for administrative purposes, access, navigational tools, telehealth, and PHRs—
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including determination of payment for services is described. The various aspects of sharing
provided, measurement of quality performance n
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and exchanging healthcare information are also
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indicators, and research. addressed.
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Figure 12.1 Strategies to achieve health IT goals

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Goal 1: Expand adoption of health IT

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Goal 2: Advance secure and interoperable health information

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Individual
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Provider Community
Goal 4: Advance the health and

Goal 3: Strengthen health care
well-being of individuals and
delivery
communities
Goal 5: Advance research, scientific knowledge, and

innovation
Source: ONC 2014a
AB103118_Ch12.indd 364 2/6/2020 5:41:39 PM

Role of Data Analytics in Healthcare Information

Data are needed to arrive at information. in one town could be combined with measles oc-
Health data are not health information until they currence in a state or a region and that information
are interpreted, evaluated, and appropriately dis- could then be communicated on a n ational level if
played (RWJF 2015). The difference between data the rate of measles in children has increased from
and information is described in chapter 3, Health previous years. Analytics has the potential to play a
Information Functions, Purpose, and Users. Data role in leveraging data to improve healthcare qual-
analytics is the science of examining raw data ity and patient outcomes. For example, the data
with the purpose of drawing conclusions about compare the health of a group from one region or
that information. For example, data analytics state to another. The following is an introduction
can help hospitals with staffing by predicting the to analytics, its tools, and the knowledge areas for
n.
number of patients treated at a healthcare organi- HIM professionals in data analytics.
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zation each month. The raw data examined in this
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Introduction to Analytics
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example are admissions data, such as admissions
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records, rates, and patterns, which are analyzed There are different types of analytics. Descrip-
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over a period of time. Data analytics of admissions tive analytics answers the question “what hap-
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data can lead to the development of a web-based pened,” diagnostic analytics answers the question
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interface that enables physicians, nurses, and “why did it happen,” predictive analytics answers
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hospital administrators to forecast visits and “what will happen,” and prescriptive analytics an-
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admission rates for the future (Sreenivasan 2018). io
swers “how can we make it happen” (Laney et al.
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The role of data analytics depends on the type 2012). To further illustrate for clinical data analyt-
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of data being captured, reviewed, and used for the ics, descriptive analytics could be centered on the
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purpose of turning them into healthcare informa- increase in the incidence of Legionnaires’ disease
ea
tion. Multiple types of data exist, two of which— in individuals 65 years and older in a specific state
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administrative and clinical—are further explained over a five-year period of time. Diagnostic analyt-
an
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in the next section. If the data are of a clinical na- ics would review the why of increased rates of Le-
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ture, then the analytics revolve around the contents gionnaires’ disease. For predictive analytics, once
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of the health record. Clinical data could include the why is found, it could be extrapolated that an
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elements such as lab values, number of patients increase will be seen in other states if certain con-
by
20
with pneumonia, and so on. Administrative data ditions are found. Using this same situation, pre-
20
are focused on other components such as finan- scriptive analytics would examine ways to reduce
©
cial data. A type of data analytics that uses clinical the potential rate of increase of Legionnaires’ dis-
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data is a clinical decision support (CDS) system. ease in individuals over age 65 even if certain con-
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A CDS is a type of data analysis since it takes in- ditions (as found in the diagnostic phase) occur.
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formation from more than one source and provides Analytics involves acquiring, managing, study-
an avenue for clinicians to make observations and ing, interpreting, and transforming data into useful
decisions. “Clinical decision support provides cli- information. Types of data include clinical, finan-
nicians, staff, patients or other individuals with cial, and operational data and the types of analytics
knowledge and person-specific information, intel- include healthcare data analytics and clinical data
ligently filtered or presented at appropriate times, analytics. Healthcare data analytics is the practice
to enhance health and healthcare” (ONC 2013). of using data to make business decisions in health-
Clinical data about an individual can also be care, whereas clinical data analytics is the process
combined with clinical data from other individuals to by which health information is captured, reviewed,
form population-based healthcare data. The result- and used to measure quality of care provided. What
ing information may be used to improve the health of data are involved, the consumer of the information,
the public. For example, the occurrence of measles and the decision the analysis supports influences the
AB103118_Ch12.indd 365 2/6/2020 5:41:39 PM

analytic process and choice of tools. However, there another can mean the difference between correct or
are certain steps that occur to prepare healthcare data incorrect data representation and drawing an accu-
for data analysis. The first step is data c apture, which rate or erroneous conclusion. For example, tables
helps ensure the data needed are available and that display exact values whereas graphs show trends.
the data are correct. Data collection is discussed later Following established guidelines for data visu-
in this chapter. The second is data provisioning, which alization results in the delivery of a clear message.
ensures that the data are in a format that can be ma- Those overall guidelines for creating any visual
nipulated for data analysis. For example, in the data presentation, including the following:
field gender, male might be “1” and female “2.” Data
●● Understand the data
analysis, where data are interpreted, is the final stage
of transforming raw data into meaningful analytics. ●● Evaluate the information to communicate
and the way it should be visualized
n.
Analytics Tools ●● Define your audience and examine how they
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process visual information
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The amount and types of data available for analysis
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Display the intended information to the
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have increased as more data are available electroni- ●●
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cally. In addition, as technology advances, the vari- appropriate audience in the clearest,
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ous tools available to perform analytics allow for new simplest form (SAS 2018)
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ways to study and present the data. A few of the more Tables are used to organize quantitative data
an
common tools are those used for visualization, to re- or data expressed as numbers. Charts (such as pie
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port on process measures, to capture the data, and for
n
charts and bar charts) and graphs (such as line
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extracting and examining data from a database.
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graphs) are appropriate when presenting relation-
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ships. For example, in figure 12.2 the first pie chart

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Data Visualization shows percentages that add up to more than 100

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Data visualization is the presentation of data using percent, while percentages in the second chart
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a graph, diagram, or chart. The graphic display of are a part of the whole and add up to 100 percent.
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data can help the viewer understand the data trend. Each tool has specific features to keep in mind
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For example, it can identify areas that need action, when depicting the data. For more information on
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such as addressing a decline in the number of pa- presenting statistical data using tables, charts, and
e
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tients or an increase in the infection rate. Types of graphs, see chapter 13, Research and Data Analysis.
by
data visualization tools include tables, charts, and Figure 12.2 provides an example of a poor and
20
graphs. Choosing one visualization method over an improved pie chart display.
20
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Figure 12.2 Poor and improved data display

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Education level of attendees at conference Education level of attendees at conference

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1%
11%
73.8% 61.7% GED GED
High School High School
38% 19%
Bachelor’s Bachelor’s
66.7% 64.7% Master’s Master’s
PhD/MD PhD/MD
62.2% 31%
Source: ©AHIMA.
AB103118_Ch12.indd 366 2/6/2020 5:41:41 PM

Dashboard MAP App for use by healthcare providers to check

The dashboard is a data analytics tool that is revenue cycle performance and evaluate against
a computerized visual display of specific data provider peer groups (HFMA 2019). The HFMA’s
points. Typically, a dashboard focuses on a proc- key performance indicators can be used to track,
ess and the rate of achievement. A dashboard is monitor, and improve revenue cycle performance.
different from a scorecard. A scorecard, which can
also be a computerized visual display, focuses on Data Capture Tools
outcome or goal achieved, such as money raised Data capture is the process of recording data in
for an event or cause. Both a dashboard and a a health record system or database. A database is
scorecard can involve key indicators. A key in- an organized collection of data, text, references,
dicator is a quantifiable measure used over time or pictures in a standardized format, typically
to determine whether some structure, process, or stored in an information system for multiple ap-
n.
outcome in the provision of care to a patient sup- plications. A database contains a large amount of
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data, often from multiple sources. Additionally,
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ports high-quality performance measured against
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best practice criteria. For example, a key indicator a database can provide comparisons using tools
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could monitor death rates or infections. Chapter from within the database software. One of the
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18, Performance Improvement, discusses scorecards most common healthcare databases is the relation-
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in more detail. al database, which stores data in predefined tables
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consisting of rows and columns. Healthcare pro-
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Health information management professionals
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use dashboards to monitor a number of indicators viders as well as patients may be the source of the
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to improve performance and meet quality goals
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data. There are several tools available for acquir-
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such as reducing the infection rate. To track the ing health-related data. Historically, data capture
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process measure over time, metrics (way to meas- into a health record was via written notes or tra-
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ure something) or benchmarks are established. In- ditional voice dictation that was transcribed and
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formation is displayed on a dashboard to show the typed into a paper report. Another method for
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data capture is scanning documents into electronic

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status of predetermined benchmarks. Often dash-

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boards use color such as red, yellow, and green in document management systems that create a pic-
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a stoplight scheme. Similar to a traffic light, red ture of the scanned document, making it accessi-
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means stop and go back, yellow means caution, ble electronically. Devices also include traditional
th
and green means all good. Dashboards provide keyboard or touch screen handheld computers or
by
20
early warning signals and alert the manager to patient-generated health data devices (discussed
20
areas in need of attention. later in this chapter). When the software applica-
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For example, a recent HIM trend is institut- tion is run on a mobile platform such as a tablet
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ing a clinical documentation integrity (CDI) or cellular phone, system and application software
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program. Since this is not a small undertaking, (often referred to as apps) is needed for the device
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dashboards can assist in measuring whether the to function and perform the desired tasks.
program is successful. A monthly dashboard might Electronic healthcare data capture is a funda-
show the number of clarifications requested by a mental function of the EHR (HealthIT 2018). The
CDI specialist that impacted a diagnosis-related EHR is an information system with several compo-
group based on a benchmark. The dashboard nents and data capture is an element in each com-
would show green if the metric is met, yellow if ponent. The components include source systems
it is in progress or halfway met, and red if the metric (such as the laboratory information system), core
is below standard. clinical EHR systems (such as point-of-care chart-
Dashboards are also used to manage revenue ing), supporting infrastructure such as human–
cycle management performance. For example, computer interfaces, and connectivity systems
the Healthcare Financial Management Associa- such as personal health records (Amatayakul 2013,
tion (HFMA) has a web-based application called 16–19). In point-of-care charting, the information
AB103118_Ch12.indd 367 2/6/2020 5:41:41 PM

is entered into the health record at the time and ●● Facilitate data accuracy using guidelines for
location of service. Nurses entering data using a documentation per governmental and other
tablet as they conduct patient assessments at the stakeholder standards
bedside is an example of point-of-care charting. ●● Create and evaluate data integrity policies
A human–computer interface is the device used
●● Establish information governance guidelines
by humans to access and enter data into an in-
(AHIMA 2019)
formation system. A number of mobile devices are
used for data entry into point-of-care charting sys- Additionally, key areas such as patient identifi-
tems. These handheld devices include tablet com- cation, the use of documentation templates, copy
puters, laptop computers, and smartphones. These and paste functionality, making amendments and
devices often contain built-in methods to facilitate corrections, and the incorporation of data captured
the capture of structured data such as predefined or in other areas of a healthcare organization not net-
n.
custom-built templates or forms with drop-down worked to the EHR such as outpatient services
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menus and point and click fields and word macros. should be part of the role of HIM (AHIMA 2019).
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These devices exist to make data collection easier. Data capture may also occur with word process-
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The outcome of point-of-care charting can be ing software. The word processing copy and paste
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unstructured or structured data. Unstructured functionality in an EHR system must be carefully
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data are nonbinary, human-readable data, whereas monitored and limited or prohibited to prevent
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structured data are binary, machine-readable data data quality issues. Examples of data quality issues
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in discrete fields. An example of unstructured data include copying outdated information or copying
is free text that describes the patient’s description n
content from one patient to another that does not
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of his or her condition. An example of structured apply. Measures for preventing data quality prob-
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data is using checkboxes to indicate patient symp- lems include the following:
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toms. Structured data has many advantages over

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Clearly label the information as copied from

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●●
unstructured data when it comes to data analytics
another source
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and health information exchange. Structured and

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Limit the ability for data to be copied and

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unstructured data are covered in more detail in ●●

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pasted from other information systems

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chapter 6, Data Management.

The structured data’s entry fields and the poten- Limit the ability of one author to copy from
e
●●
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tial entries in those fields are controlled, defined, another author’s documentation
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and limited, resulting in discrete data. Discrete Allow a provider to mark specific results as
20
●●
20
data represent separate and distinct values or ob- reviewed

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servations; that is, data that contain only finite Allow only key, predefined elements of
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numbers and have only specified values. Stored in reports and results to be copied or imported
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databases and data warehouses, these standard-

Monitor a clinician’s use of copy and paste
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●●
ized data are available in a usable and accessible
(AHIMA Work Group 2015)
form. However, physicians and other healthcare
providers may express frustration when limited to For additional information on the copy and
recording only certain data in specific fields. While paste function and risks associated with it, refer
a set format ensures consistency and provides to chapter 3, Health Information Functions, Purpose,
standard meaning, it may limit details considered and Users.
important by clinicians. Two other technologies—speech recognition
When considering methods for EHR data cap- (speech-to-text) and natural language processing
ture, follow these best practices: (NLP)—provide yet another way to acquire health
data. NLP is a technology that converts human
●● Collect data at the point of care directly from language (structured or unstructured) into data
the patient that can be translated and then manipulated by
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computer systems. Integration of these technolo- such as a clinical data repository and clinical data
gies within the EHR can result in the provision warehouse. A clinical data repository is a cen-
of clinical information needed by providers to tral database that focuses on clinical information.
inform decision-making. The clinical data warehouse allows access to data
Back-end speech recognition (BESR) is a specific from multiple databases and combines the re-
use of speech recognition technology (SRT) in an sults into a single query and reporting interface.
environment where the recognition process occurs Specific applications of data mining methods are
after the completion of dictation by sending voice customized for certain uses of the extracted data.
files through a server. In BESR, an employee edits For example, data mining may be used to extract
or corrects the dictation. Front-end speech recogni- clinical data directly from the EHR for the purpose
tion (FESR) is a process where the provider speaks of compiling content for reporting clinical quality
into a microphone or headset attached to a PC and measures. The clinical data warehouse lends itself
n.
upon speaking, the words are displayed as they to data mining as it encompasses multiple sources
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are recognized. The physician corrects misrecog- of data. The varying sources of data that feed a
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nitions at the time of dictation. Use of FESR inte- clinical data warehouse may include data sets,
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grated with an EHR provides the best outcome, as clinical data repositories, a case-mix system, lab-
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the provider is able to respond to prompts from oratory information systems, or a health plans
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the EHR resulting in more complete, accurate, and database. The data in the clinical data warehouse
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timely documentation (AHIMA 2013). Templates depends on how they will be used. For example, if
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and macros are also tools used with SRT to capture the clinical data warehouse is going to be used to
data. Macros are used by transcriptionists to in- n
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determine what treatment is most effective, then
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sert content into a transcribed document with just data would need to include data that would sup-
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a few keystrokes. For example, the transcription- port that research. In this case, the clinical data
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ist might create shortcuts to insert commonly used warehouse might include blood pressure, test re-
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phrases or other content. As the output of SRT is sults, symptoms, treatments, and more. In the clin-
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digital text, combining it with NLP results in the ical data warehouse, the data from these sources
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conversion of the text or any free text narrative into can be “mined” to identify and implement better
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data that can be translated and then manipulated evidence-based solutions.

by computer systems. Once transformed, it becomes Systematically analyzing the data uncovers
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searchable along with other structured data. hidden patterns or trends for use in predicting
by
behaviors. The information discovered from data

20
20
Data Mining mining databases aids clinical research. For exam-

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Data mining is the process of extracting and ana- ple, data mining could be used to detect early sig-
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lyzing large volumes of data from a database for nals of potential adverse drug events. Other data
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the purpose of identifying hidden and sometimes mining applications are used for the evaluation of
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subtle relationships or patterns and using those re- treatment effectiveness, management of health-
lationships to predict behaviors. It is a key piece of care, customer relationship management, and
analytics and of the knowledge discovery process. detection of fraud and abuse (Koh and Tan 2005).
There are several knowledge discovery process
models such as the Knowledge Discovery in Da- HIM Professionals and Analytics
tabases (KDD), Sample, Explore, Modify, Model, Analytics start with data and HIM professionals,
Assess (SEMMA), and Cross-Industry Standard with their understanding of healthcare data, help
Process for Data Mining (CRISP-DM) as well as ensure correct and accurate data are captured.
hybrid models. Each has defined steps, with data HIM professionals are also proficient in business
mining being one of them. operations and clinical processes. However, data
The available data for analytics strategy and analytics require going beyond these into compe-
mining can come from EHRs and various databases tencies such as business intelligence (see chapter 6,
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Data Management), database administration, in- ●● Data mining

ferential and descriptive statistics (see chapter 13, ●● Quality standards, processes, and outcome
Research and Data Analysis), health information measures
technology (see chapter 11, Health Information Sys-
●● Risk adjustment
tems), and project management (see chapter 17,
Management) (Sandefer et al. 2015). ●● Business practices (for example, workflow or
AHIMA lists the following knowledge topics as payer guidelines)
important for data analytics: ●● Medical terminology
●● Healthcare reimbursement methodologies
●● Clinical, financial, and operational
data ●● Classification systems
●● Understanding of database queries (such as ●● Source data
structured query language [SQL]) Qualitative and quantitative analysis
n.
●●
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Understanding statistical software (AHIMA 2015a)
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Strategic Uses of Healthcare Information
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There are many reasons to collect data the DSS can help administration decide whether
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and turn it into information, including administra- to add an additional operating room. Manage-
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tive uses such as claims submission, revenue cycle io
ment is the primary user of a DSS for operational
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management, meeting quality measurement re- as well as strategic decisions. It is not used for
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porting requirements, assessing health status and day-to-day decisions such as scheduling staff.
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outcomes, and performing clinical research. As A clinical decision support system (CDSS) is a
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health information technology (IT) systems evolve, “special subcategory of clinical information sys-
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the ability to aggregate the collected data improves tems designated to help healthcare providers
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and the information from it better supports strate- make knowledge-based clinical decisions” (Fenton
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gic analytics and organizational decision-making. and Biedermann 2014, 39). (Clinical information
Through interpretation and evaluation of aggre- systems are discussed in more detail in chapter 11,
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gated data from a variety of sources, development Health Information Systems.) In DSS and CDSS,
by
of strategies to improve patient care outcomes, typically the problem in need of solving is un-
20
20
reduce costs, and plan the future are possible structured or the circumstances are unknown. A
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through decision support, quality measurement, CDSS could deliver targeted clinical decision sup-
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and clinical research, which are addressed in the port by supplying clinical reminders and alerts
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following sections. impacting the quality and efficiency of care. For

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example, within an EHR the clinician may receive

Decision Support a reminder that it is time for the patient’s annual
Information systems in healthcare are adopted for gynecological exam.
a variety of reasons. One of these is to improve With data, analytical models, and visual tools at
the outcome in decision-making tasks. A decision their disposal, the user can perform simulations of
support system (DSS) is an information system patterns based on various assumptions, monitor
that gathers data from a variety of sources and and assess key indicators, or perform data com-
assists in providing structure to the data by us- parisons to look for trends. For example, to eval-
ing various analytical models and visual tools to uate the success or failure of interventions, track
facilitate and improve the ultimate outcome in trends, and identify opportunities for improve-
decision-making tasks associated with nonrou- ment, a manager may monitor readmission rates
tine and nonrepetitive problems. For example, using a scorecard generated by the DSS.
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An executive information system (EIS), a type enterprise-wide policies and guidelines, to help
of DSS, facilitates and supports senior managerial the executive find actionable insights to drive en-
decisions. Given that information is an enterprise terprise performance. Organization-wide opera-
strategic asset, an EIS is required to consider the tional and informational processes improve with
broad needs of the healthcare organization. An EIS an EIS because business problems can be exposed,
can transcend the organizational structure, trans- or business opportunities discovered. Examples of
form the business by standardizing and describ- organization-wide operational and informational
ing solutions throughout the enterprise, and drive process key indicators executives may monitor
information-centric decision-making (3e Services include surgical volume and patient satisfaction.
LLC 2015). Figure 12.3 provides an example of a dashboard.
The EIS is the source for identifying high-level
strategic, operational, financial, or clinical issues. Quality Measurement
n.
Rather than managing at the individual depart- Using healthcare information to improve the quality
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mental level, an EIS can pull together financial, of healthcare is not a new strategic initiative. What
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operational, and clinical information, with has changed, however, is the health IT a vailable
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Figure 12.3 Example of dashboard
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by
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Source: © AHIMA Virtual Lab dashboard created with Tableau Software. Used with permission.
AB103118_Ch12.indd 371 2/6/2020 5:41:43 PM

to collect and analyze the data for the purpose of Clinical Research
turning it into healthcare information. For exam-
Besides patient care, one of the original reasons
ple, instead of manual data abstraction, which is
for collecting data and analyzing its information
the identification of data elements by an individ-
is to research and study diseases and interven-
ual through health record review, data mining can
tions. Information systems can support research
extract clinical data directly from the EHR using
by supplying the health data needed to inform
standards and guidelines. Then the mined data
clinical research programs and population and
can be compiled and used to report clinical quality
public health surveillance. In these cases, multiple
measures. Healthcare information can also be used
sources of data are integrated into a central repos-
to improve care effectiveness; for example, alerts
itory where it is possible to find early markers of
can be sent to administrators and physicians when
disease, and historical data can be used to sim-
measures related to quality and patient safety fall
ulate and model trends in long-term care needs.
n.
outside a normal range along with notifications of
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For example, healthcare information such as an
what may be causing these abnormalities. Also,
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individual’s genetic profile and local trends in dis-
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health system effectiveness (for example, knowing
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ease prevalence may be used in patient-centered
which intervention was ineffective) could result in
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outcomes research. (Chapter 13, Research and Data
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better healthcare outcomes for patients based on
Analysis, covers research in more detail.)
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standards of care.
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Check Your Understanding 12.1 n
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Match the terms with the definitions.

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1. Scorecard
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2. Data mining
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3. Dashboard
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4. Data capture
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5. Speech recognition
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a. Reports outcome measures

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b. Reports process measures

20
c. Speech-to-text conversion
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d. Extraction and analysis of data

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e. Process of recording data

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Consumers and Healthcare Information

Consumers have become the focus for Health Information Technology (ONC) has a
when it comes to healthcare as a result of health- strategic initiative to focus on technology and in-
care reform initiatives and the growth of digital formation to provide a higher quality of health.
technology. For example, quality reporting is often Terms such as patient-centered care, patient-centric
available to patients as is information on diseases care, and even person at the center are utilized and
that is written in a way that the average person can indicate the shift to the individual as the focal point
understand. The Office of the National Coordinator when it comes to healthcare. The stated mission of
AB103118_Ch12.indd 372 2/6/2020 5:41:43 PM

the ONC is to make a positive impact on health at with care providers. For example, through social
the community level and individual level by en- networking sites consumers can connect with oth-
gaging consumers and making health information ers who have the same condition and learn about
accessible (Executive Summary, n.d.). their experiences.
What follows is a brief introduction to consumer
health informatics, and an overview of informa- Health Literacy
tion access and navigation tools such as patient An important piece of patient-centered healthcare
portals. Social media in relation to health informa- is health literacy. Over the years, the definition of
tion is discussed. Information sharing specific to health literacy has evolved. Previously health lit-
personal health records (PHRs) is then discussed. eracy was thought of as merely a person’s ability
to read health information (Cutilli and Bennett
Introduction to Consumer Health 2009). Current definitions of health literacy focus
Informatics
n.
on specific skills needed to navigate the health-
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Health informatics is the field of information sci- care system and the importance of clear commu-
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ence concerned with the management of all as- nication between healthcare providers and their
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pects of health data and information through the patients. Health literacy is “the degree to which
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application of computers and computer technolo- individuals have the capacity to obtain, process,
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gies (Fenton and Biedermann 2014, 2). Adding and understand basic health information and serv-
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consumers to health informatics makes them the ices needed to make appropriate health decisions”
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focus for the technology that acquires, manages, (HHS 2010). People’s ability to navigate, share,
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maintains, and uses the data and information. io
and engage in their own healthcare is impacted
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Thus, “consumer informatics is the field devoted by health literacy skills. Second to privacy and
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to informatics from multiple consumer or patient security concerns, health literacy is the leading
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views” (AMIA n.d.). Consumer health informatics barrier to lack of consumer use of patient portals
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is a subtype of health informatics. A patient portal and mhealth technologies (Arcury et al. 2017).
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to a provider’s website where a PHR can be devel- Today’s healthcare consumers are empowered
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oped and maintained is an example of consumer to take part in managing their own health by be-
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health informatics. Clinical email communication, coming more health literate. However, many
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such as a physician reviewing lab results with a adults may not be proficient in health literacy and
th
patient by sending the patient an email is another may lack the skills needed to manage their health
by
20
example of consumer health informatics. and prevent disease (USDHHS 2008). Many fac-
20
With any number of computer technologies tors contribute to the current state of inadequate
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available to the consumer, such as mobile health health literacy, including “lack of coordination
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(mhealth), health information is only a click away. among health care providers, confusing forms and
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Mobile health includes applications available for instructions, limited use of multimedia to con-
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smartphones that provide health information. For vey information, insufficient time and incentives
example, wearable devices that show how many for patient education, differences in language and
steps a person takes in a day or the distance they cultural preferences and expectations between
walk is a type of mhealth device. The focus of a physicians and patients, overuse of medical and
mhealth tool is on patient self-care. Patients can technical terms to explain vital information” (HHS
engage in their care through numerous health IT 2010, 25).
technologies designed for information access and Health information management professionals
navigation as well as those that allow the sharing of support health literacy by ensuring patients’ abil-
information. These health IT technologies improve ity to understand and act on health information
patient–provider communication, allow for closer (JC 2010). According to the National Action Plan
patient monitoring, and increase information ac- to Improve Health Literacy, strategies that health
cess, all of which facilitate patient involvement information professionals can endorse to improve
AB103118_Ch12.indd 373 2/6/2020 5:41:43 PM

health information, communication, informed often becomes outdated or is forgotten. Further-

decision-making, and access to clinical and public more, health information provided to patients in
health services include the following: a traumatic or unfamiliar situation is not likely to
be retained.
●● “Help to train all health care staff in the Studies have shown that people who are more
principles of health literacy and plain health literate are less likely to be misinformed
language about the body and natural causes of disease and
●● Create collections or repositories of their relationships to lifestyle factors. For example,
materials (for example, insurance forms and without knowledge, patients may not understand
instructions, informed consent and other how lifestyle factors such as diet and exercise
legal documents, aftercare and medication affect many health outcomes.
instruction, and patient education Skills necessary to be health literate include
n.
materials) in several languages and review reading, listening, analytical and decision-making
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the materials with members of the target skills, as well as the ability to apply these skills to
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population various healthcare situations. For example, it in-
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cludes the ability to know when to seek medical
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●● Help to disseminate existing
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communication tools and resources for care, understand instructions on prescription drug
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patients” (HHS 2010, 30) bottles, appointment information, medical educa-
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tion brochures, physician’s directions and consent
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Health information management profession- forms, and the ability to navigate complex health-
als support health literacy as they take on the re- n
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care systems (NNLM, n.d.). Another important
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sponsibility for encouraging the development of health literacy skill is numeracy, the ability to un-
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competent healthcare consumers. Health literacy derstand and use numbers. Examples of numer-
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actions that HIM professionals engage in include acy skills include understanding nutrition labels,
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providing consumers, or their designee, access measuring medications, and calculating choles-
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to their personal health information in “useable terol and blood sugar levels. Each of these tasks
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standardized electronic form” (Heubusch 2010) requires mathematical skills. Another example is
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or explaining to patients and families what their electing a health plan or comparing prescription
health information says and how to use it (Czahor drug coverage, which requires calculating premiums,
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et al. 2016). Furthermore, HIM professionals can co-pays, and deductibles (HHS n.d.a). Figure 12.4
by
educate consumers on the importance of compil- shows the four levels of literacy.
20
20
ing and maintaining a PHR, along with what type Addressing health literacy issues is not the sole
©
of information to include and how to obtain the in- responsibility of those providing healthcare serv-
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formation (Grebner 2015). During a patients’ initial ices. Healthcare policymakers, purchasers and
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navigation on a patient portal, HIM professionals payers, regulatory bodies, healthcare consumers,
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can serve as patient advocates by educating pa- and patients themselves all play important roles
tients on HIPAA compliance with web-based and in ensuring health literacy. Culture is also a very
mobile device PHR applications (Grebner 2015). important part of health literacy. Recognizing the
Health literacy training programs can also be de- role that culture plays in how people communi-
veloped by HIM professionals to give healthcare cate, understand, and respond to health informa-
consumers the ability to understand these top- tion helps better to understand health literacy
ics as well as where to find additional reputable (HHS n.d.b).
information about their health conditions.
Health information can be overwhelming, even Telehealth
for people with advanced literacy skills (HHS The use of technology to connect a patient and a
2008). As medical science continues to evolve rap- clinician across a distance is the chief component
idly, information learned during the school years of telehealth (see chapter 11, Health Information
AB103118_Ch12.indd 374 2/6/2020 5:41:43 PM

Figure 12.4 Four levels of Literacy
Four Levels of Literacy

The 2003 National Assessment of Adult Literacy was the first large-scale national survey of
ability to read, understand, and apply health-related information. It assigned proficiency to
four categories associated with key abilities and sample tasks.
Levels Key abilities Sample Tasks
Below Basic • Locating easily • Searching a short, simple
identifiable information text to find what a
A grasp of no in short, commonplace patient may drink before
more than the prose texts a medical test
simplest, most
concrete literacy • Locating easily • Signing a form
skills identifiable information
and follwing written
insructions in simple
14% documents, such as
charts or forms
• Locating numbers and
using them to perform
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simple quantitative
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operations
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Basic • Reading and • Giving two reasons a
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understanding person with no
Skills needed to
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information in short, symptoms of a disease
perform simple commonplace prose should be tested for it
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everyday literacy texts
activities • Entering names and birth
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• Reading and dates in a health
understanding insurance application
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information in simple
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documents • Calculating what time to
22% take a medication by
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• Locating easily combining two pieces of
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identifiable quatitative information
information and using it io
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to solve simple one-step
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problems
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Intermediate • Reading and • Consulting reference

understading materials to determine
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Skills necessary to moderately dense, less which foods contain a

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perform commonplace prose particular vitamin

moderately texts, making simple
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challenging interferences, determining • Finding the age range

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literacy activities cause and effect, and during which children

should receive a
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recognizing the author’s

particular vaccine by
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purpose
using a chart showing all
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• Locating information in childhood vaccines and

dense, complex the ages when children
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53% documents and making should receive them

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simple interference about

the information • Determining a healthy
by
weight range for a person

of a specified height,
20
• Locating less familier

quantitative information based on a graph that
20
and using it to solve relates height and weight

problems when the to body mass index
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arithmetic operation is
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inferred
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Proficient • Reading lengthy, • Comparing the power of

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complex, abstract prose attorney with a living will

Skills neccssary to texts and synthesizing and determining the
perform more information and making advantages of the power
complex and complex inferences of attorney
challenging
literacy activities • Integrating, • Interpreting a table
synthesizing, and about blood pressure,
analyzing multiple age, and physical ability
12% pieces of information
located in complex • Computing the price per
docments year of an insurance
policy
• Locating more abstract
quantitative in formation
and using it to solve
multistep problems
when arithmetic
operations are not easily
inferred and problems
are more complex
Source: AHIMA 2010.
AB103118_Ch12.indd 375 2/6/2020 5:41:44 PM

Systems, for more information.). Telehealth can Information Access and Navigational
also be used to send clinical information on the Tools
daily status of a patient’s health to a physician
The Medicare and Medicaid EHR Incentive Pro-
via technology. In the evolving area of consumer
grams funded by the American Recovery and Re-
health informatics, telehealth is being focused on
investment Act of 2009 stimulated the healthcare
to increase access to and provide quality health-
industry to adopt EHRs. One of the objectives to
care. Telehealth is an option utilized to monitor
achieve Meaningful Use (MU) (now Promoting In-
chronic disease in patients and to provide access
teroperability) for certified EHR technology is to
to medical care in locations that are lacking in clin-
provide patients with the ability to electronically
ical staff. This allows for patients as consumers to
view, download, and transmit their health informa-
be active in decisions related to their health and to
tion within a certain number of days of the informa-
use digital technology to gain access to healthcare
tion being available to the eligible professionals
n.
(Demiris 2016). Telehealth can be used to track vi-
tio
(physicians and other healthcare professionals iden-
tal signs and monitor other clinical information
ia
tified by the law). By providing patients access to an
oc
such as blood sugar. Telehealth provides a way
ss
electronic copy of their health information they and
to interact with patients and caregivers and to
tA
their caregivers can be more engaged in their care.
en
engage them in short-term and long-term health-
em
(Promoting Interoperability is explained in more
related decision-making. Short-term conditions
ag
detail in chapter 16, Fraud and Abuse Compliance.)
are nonurgent or nonemergency medical situa-
an
Consumer health IT applications for informa-
M
tions. For example, a short-term condition might
tion access and navigation include hardware, soft-
be an ear infection or an upper respiratory infec- n
io
at
ware, and applications accessed via a computer,
tion. Long-term use of telehealth can be focused
m
tablet, or phone. The ability to use mobile devices,

r
fo
on more intensive healthcare intervention such as

In
patient portals, and social networking websites al-

cardiac monitoring. As the consumer, an individ-
lth
lows consumers to not only manage their health

ea
ual with a chronic condition can be more involved

H
information electronically but also to participate

in their healthcare. Another factor of telehealth for
an
in their healthcare via electronic means.

ic
the consumer may be the cost. Telehealth medi-

er
Am
cal visits may cost less than an office visit, making

them advantageous for the consumer (Wicklund Mobile Devices
e
th
2018). One barrier is patient adoption of telehealth Portable, wireless computing devices or mobile de-
by
options. The ONC recognized this barrier in a vices include tablet computers, laptop computers,
20
20
published white paper, Designing the Consumer- and smartphones. These devices combined with
©
Centered Telehealth & eVisit Experience: Consid- mobile medical apps can help consumers gain ac-
ht
ig
eration for the Future of Consumer Healthcare cess to useful information wherever they may be
yr
op
(Bobinet and Petito n.d.). With the ability to ac- and whenever it is needed. Apps for smartphones
C
cess urgent care and emergency centers, the role include pharmaceutical references with informa-
of telehealth is still being examined by stakehold- tion about side effects and dosage amounts, access
ers especially in areas where remote access may to licensed healthcare professionals allowing
not be warranted. In the white paper, the ONC video chats about a medical problem, and guides
identified nine important principles of consumer- providing step-by-step first aid instructions.
focused telehealth design and incorporation as a According to the US Food and Drug Adminis-
part of the healthcare option tools. Several of these tration (FDA), a mobile medical app is a mobile
principles focus on the technology aspects. For the app that meets the definition of device in the Fed-
consumer, the vital principles center on the experi- eral Food, Drug, and Cosmetic Act and either is in-
ence for the patient and ensuring there is a balance tended “to be used as an accessory to a regulated
between accessibility, data overload, meaningful medical device; or to transform a mobile platform
care, and quality of care (Bobinet and Petito n.d.). into a regulated medical device” (FDA 2015).
AB103118_Ch12.indd 376 2/6/2020 5:41:44 PM

The FDA considers the mobile app’s intended to the patient portal to learn more about symptoms
use in determining whether the definition of a de- he or she is experiencing. An interactive decision
vice has been met. The FDA guidance states a mo- tool would help the patient assess the symptoms
bile app intended for use in performing a medical through a series of questions. If the patient visits
device function (such as for diagnosis of disease the portal to better understand a current diagno-
or other conditions) is a medical device, regardless sis, a link to educational material about the con-
of the platform on which it is run (FDA 2015). An dition is available. Either scenario may result in
example would be mobile apps intended to run on communication with the provider via secure mes-
smartphones to analyze and interpret EKG wave- saging about what was learned.
forms to detect heart function irregularities.
Social Media
Patient Portals Social media is defined as websites or applications
n.
A patient portal is an information system that that provide an avenue for personal network-
tio
allows consumers to log in to a secure online web- ing and the sharing of information. A number of
ia
oc
site to gain access to personal health information healthcare-focused social networks are available
ss
tA
and navigate around it once inside the informa- to consumers as individuals come together to in-
en
tion system. The types of patient portals and the teract and receive support from others with sim-
em
modules implemented will offer the following ilar interests. Online communities specific to a
ag
different functionalities: condition or disease provide the consumer with
an
M
information about the condition and which treat-
n
●● Accessing a subset of the patient’s health io
ments may have greater success than others.
at
records (for example, medical history, health
m
Providers use social media to inform consum-

r
issues, medication list, test results, care

fo
ers about diseases, conditions, and treatments. For

In
plans, allergy list) example, Mayo Clinic’s website contains patient

lth
ea
●● Sending a secure message to the patient’s care and health information on many diseases and
H
healthcare provider(s) conditions. In addition, the site has a symptom

an
ic
Uploading clinical information and checker; a list of tests and procedures that in-
er
●●
Am
telemetry (for example, blood pressure, cludes a definition of each, how the test or proce-
dure is performed, and how to prepare; risks and
e
blood glucose values, and weight measured

th
at home) results; and details about drugs and supplements.

by
Large well-known healthcare institutions such as

20
●● Completing forms electronically instead of

20
on paper (e-forms) the Cleveland Clinic and Johns Hopkins Medi-

©
cine publish photos and videos. For example, the

ht
Accessing a child’s or elderly parent’s

ig
●●
Cleveland Clinic provides patient education vid-
yr
records with appropriate authorization

op
eos that contain actual surgery images.

(proxy access)
C
Government agencies also use social media to

●● Scheduling appointments inform consumers about healthcare. The Centers
●● Requesting medication refills for Disease Control and Prevention (CDC) lists
●● Accessing billing records a number of mobile social activities including
●● Paying bills online (Carayon et al. 2015) apps, a CDC video streaming station, and info-
graphics. The Department of Health and Human
A patient portal is a way to engage patients by Services Office of Disease Prevention and Health
giving them an avenue to access and review their Promotion has initiatives aimed at healthcare
health history (AHIMA 2016). Patient portals are consumers, which contain evidence-based health
one element in the focus on increasing communi- information and tools to help consumers make
cation, using technology, and engaging patients informed health choices along with their health-
(AHIMA 2016). For example, a patient may come care providers.
AB103118_Ch12.indd 377 2/6/2020 5:41:44 PM

Personal Health Records on the type of healthcare received, the following

An important piece of patient-centered health- reports are common to most health records:
care is information sharing. Patients generate data ●● Identification sheet. Form originated at
outside of provider settings. Sharing it with their the time of registration that contains
providers expands the depth, breadth, and conti- demographic information
nuity of information resulting in the potential for
●● Problem list. List of significant illnesses and
improved healthcare outcomes.
operations
Health IT tools connect patients and provid-
ers and allow them to share information, which ●● Medication record. List of medications
strengthens the consumer engagement experi- prescribed or administered
ence. Patient portals discussed previously are ●● History and physical. Past and current
one such tool. Another tool is the personal health illnesses and surgeries, current medications
n.
record. A PHR is a record created and managed and family history, as well as a physical
tio
exam performed by the physician
ia
by an individual in a private, secure, and con-
oc
fidential environment. It differs from an EHR, Progress notes. Notes made by the physicians,
ss
●●
tA
which is created and managed by the healthcare nurses, therapists, and social workers that
en
provider. A PHR can be about the individual’s reflect their observations, the patient’s
em
health or the health of someone in his or her care response to treatment, and plans for
ag
an
and be used as a tool to collect, track, and share continued treatment
M
past and current information. Sharing the con- Consultation. Opinion about the patient’s
n
●● io
tents of a PHR with providers can enhance ex-
at
condition made by a physician other than
m
isting data, fill in information gaps, and provide the attending physician
r
fo
a more complete picture of a patient’s health.

In
Physician’s orders. Physician’s directions to

lth
●●
Other benefits of a PHR are improved patient
nurses and other members of the healthcare
ea
engagement and enhanced provider–patient

H
team regarding medications, tests, diets, and

an
communication.
treatments
ic
Data from a PHR is patient-generated health

er
Am
data (PGHD). ONC identified PGHD as an impor- ●● Imaging and x-ray reports. Findings of x-rays,
mammograms, ultrasounds, and scans
e
tant issue for advancing patient engagement be-

th
cause patients may become more involved with

by
●● Lab reports. Results of tests conducted on

20
their care when patient–provider communication body fluids

20
includes the use of the patient-generated data as Immunization record. Documentation of

©
●●
part of healthcare decision-making. According to
ht
immunizations given for diseases such as

ig
ONC, PGHD are “health-related data created, re- polio, measles, mumps, rubella, and the flu
yr
op
corded, or gathered by or from patients (or fam-

Consent and authorization forms. Consents for
C
●●
ily members or other caregivers) to help address
admission, treatment, surgery, and release of
a health concern” (ONC 2018a). Examples of
information (AHIMA 2015b)
PGHD include health and treatment history and
data from a wearable monitor, such as an exercise- Other health information such as exercise and
tracking device diet plans, health goals, and home monitoring sys-
tem results such as blood pressure levels may also
Information in Personal Health Records be a part of the PHR.
PHRs can contain information from several sources
including patients and healthcare providers. While Models of Personal Health Records
there is not a standard set of data and reports to A PHRs can be as simple as paper documents
include in a PHR because specific content depends placed into a folder. However, an electronic PHR
AB103118_Ch12.indd 378 2/6/2020 5:41:44 PM

is better because of the accessibility factor and Data Privacy and Confidentiality, provides more
to gather, update, integrate, and manipulate the detail on HIPAA.)
information more easily.
The two main types of electronic PHRs are the Patient Safety
following: The World Health Organization (WHO) de-
1. Stand-alone. Patients fill in information they fines patient safety as “the prevention of errors
want to share with their healthcare provider. and adverse effects to patients associated with
The information is stored on patients’ health care” (WHO 2018). Sharing the contents
computers or through an online system. Some of a PHR with providers can enhance existing
stand-alone PHRs accept data from external data, fill in information gaps, and provide a
sources, such as healthcare providers and more complete picture of a patient’s health, cre-
laboratories. Patients choose with whom they ating an opportunity to improve patient safety.
n.
For example, a PHR with information about al-
tio
share the information.
lergies, medications, and adverse drug reactions
ia
2. Tethered or connected. A type of PHR that is
oc
compiled from multiple sources can be used by
ss
linked to a specific healthcare organization’s
tA
a provider to reconcile the information against
EHR. A tethered PHR allows patients to
en
what is contained in the EHR, thus preventing
em
access their records through a secure portal
medication errors or adverse events leading to
ag
(HealthIT 2014).
patient harm. PHRs also support telehealth ca-
an
M
There are many sources of PHRs. In addition pabilities where access to the health information
n
to those listed, employers and independent ven- io
could impact clinical decision-making. In a med-
at
m
dors offer PHRs. Connecting the PHR to the pa- ical emergency situation, a PHR may provide
r
fo
tient’s legal health record protects it under the information when the patient cannot. Telehealth
In
lth
Health Insurance Portability and Accountability is covered in more detail in chapter 11, Health
ea
Act (HIPAA) Privacy Rule (ONC n.d.). (Chapter 9, Information Systems.

H
an
ic
er
Am
e
th

by
20
20

©
ht
1. True or false: One type of electronic PHR is the tethered PHR.

ig
yr
2. True or false: Scheduling appointments is a required functionality for a patient portal.

op
C
3. True or false: Home monitoring system results such as blood pressure levels are part of a PHR.
4. True or false: Consumer health IT applications for information access and navigation include smartphones.
5. True or false: PHRs can contain information from patients but not from healthcare providers.
6. True or false: Telehealth is used to provide patients direct email access to physicians.
7. True or false: Health literacy is required to be able to complete pre-visit online medical questionnaires.
8. True or false: For PHRs there is a data standard.
9. True or false: Telehealth is a way to provide patients more correct information on common diseases such as diabetes
and hypertension.
10. True or false: Data found in a PHR can be termed patient-generated health data.
AB103118_Ch12.indd 379 2/6/2020 5:41:44 PM

Health Information Exchange

Health information exchange (HIE) r egulations mandate HIE functionality and its use.
is an important part of the healthcare industry. A qualified EHR under HITECH includes, as one
While there are several definitions of HIE, all of of the criteria, that the EHR has the capacity to
them note the exchange of information is done exchange electronic health information with and
electronically, and the capacity exists for different integrate such information from other sources (45
information systems and software applications to CFR 170.102). A health information exchange or-
exchange data. These definitions are the following: ganization is one that supports, oversees, or gov-
erns the exchange of health-related information
●● A HIE is the exchange of health information
among organizations according to nationally rec-
electronically between providers and others
ognized standards. These health information ex-
with the same level of interoperability, such
n.
change organizations provide the means for HIE
tio
as labs and pharmacies.
to occur. The health information exchange organi-
ia
oc
●● A HIE “allows physicians, nurses, zation compiles data from a number of healthcare
ss
pharmacists, other healthcare providers, and
tA
providers so that the physician currently treating
en
patients to appropriately access and securely the patient has a complete picture of the patient’s
em
share a patient’s vital medical information medical history and treatment including all current
ag
electronically—improving the speed, quality, medications.
an
safety and cost of patient care” (ONC 2018b).
M
With the introduction of the Medicare Access
n
●● A HIE “provides the capability to io
and CHIP Reauthorization Act of 2015 (MACRA),
at
m
electronically move clinical information the MU mandate for participating in the Medicare
r
fo
among disparate healthcare information EHR Incentive Program transitioned to become

In
systems and maintain the meaning of the

lth
one of four components of a new Merit-Based In-

ea
information being exchanged” (HIMSS 2014). centive Payment System (MIPS) (HealthIT 2019).
H
The focus of the new MIPS remains on quality,

an
Determining a course of treatment having only

ic
cost, and use of certified EHR technology (CEHRT)

er
the information contained in a single health rec-

Am
in a cohesive program that avoids redundancies

ord or encapsulated by a single provider of care is
e
(HHS 2016). Ultimately the MACRA establishes

th
shortsighted and could result in duplicative treat-

new ways to pay physicians for caring for Medi-
by
ments. While not an easy task, moving away from

20
care beneficiaries (NRHI n.d.) and further enables

an ownership view of health data to a continuity
20
data sharing. For details about the MACRA and

of care perspective facilitates coordinated patient
©
the MIPS, refer to chapter 11, Health Information

ht
care. Successfully exchanging and integrating the

ig
Systems.
yr
information into clinical work practice fills in-

op
Health information exchanges are achieving

formation gaps and provides a more complete pic-
C
national healthcare reform goals of better-quality

ture of a patient’s health situation resulting in more
care, improved population health, and lower costs.
informed clinical decisions by the healthcare team.
Recent studies show when physicians, nurses,
The remaining portion of this chapter provides an
pharmacists, and other healthcare providers can
introduction to HIE, lists its forms, describes the ben-
share a patient’s computerized medical informa-
efits and users of HIE, explains eHealth exchange,
tion electronically, decreased duplicated proce-
states the challenges with sharing healthcare informa-
dures, reduced imaging, lowered healthcare costs,
tion, and identifies HIE roles for HIM professionals.
and improved patient safety occur (Landi 2018).
An acronym that is sometimes confused with
Impact of HIE HIE is HIX, or health insurance exchange. A HIX is
Health Information Technology for Economic and a marketplace where patients can choose a health
Clinical Health (HITECH) legislation and MU insurance plan based on price. A HIX evolved as
AB103118_Ch12.indd 380 2/6/2020 5:41:44 PM

a result of the ACA in efforts to assist with the patient information is sent electronically and
health insurance market reform. While the Afford- securely between parties with an established
able Care Act (ACA) itself refers to these entities relationship. For example, directed exchange
as exchanges, the endorsed term when referring to is used to report public health data to the state
Americans using the exchange is health insurance health department.
marketplace. Health insurance exchanges are also 2. Query-based exchange is the “ability for
known as marketplaces, health benefits exchange, providers to find and/or request information
health care exchange, health insurance market- on a patient from other providers, often used
place, and affordable insurance exchanges (Karl for unplanned care…. Query-based exchange
2012; Obamacare Facts 2018). Health insurance ex- is used to search and discover accessible
changes are discussed in more detail in chapter 15, clinical sources on a patient” (ONC 2018b).
Revenue Management and Reimbursement. For example, a query-based exchange can
n.
assist a provider in obtaining a health record
tio
Interoperability on a patient who is visiting from another
ia
oc
Health information exchange and health informa- state, resulting in more informed decisions
ss
tA
tion interoperability are not the same. Interopera- about the care of the patient.
en
bility is defined as the ability of computers to share 3. Consumer-mediated exchange is the “ability for
em
information. An interoperable health IT environ- patients to aggregate and control the use of
ag
an
ment is one in which seamless health information their health information among providers”
M
exchange is possible across diverse EHR systems (ONC 2018b). For this form of exchange the
n
and the information is understood and shared
io
patient, not the provider, is the driver. For
at
m
with those in need of it at the time it is needed. example, a patient portal may allow personal
r
fo
There needs to be some exchange for interopera- health information to be uploaded for
In
lth
bility to occur. What happens to the information provider access.

ea
after it is exchanged determines whether interop-

H
an
erability occurs. If the information is accepted—

ic
for example, an email is sent from one computer to Benefits of Health Information Exchange
er
Am
another—then there was an exchange. However, if There are many benefits to HIE. One of the primary
benefits is enhanced patient care coordination.
e
the information exchanged is understood by both

th
Other potential benefits for patients, providers,

by
computer systems and no meaning is lost when

payers, and communities include the following:
20
exchanged resulting in seamless use of it, this se-

20
ries of events meets the definition of interoperabil- Reduction of duplicative treatments

©
●●
ity. For additional information on interoperability,
ht
Elimination of redundant or unnecessary

ig
●●
see chapter 6, Data Management.
yr
testing
op
C
Forms of Health Information Exchange ●● Fewer medication and medical errors, which
can be costly and have a negative impact on
The three key forms of HIE. Standards, policies,
the patient
and information technology serve as the founda-
tion for the following three forms: ●● Increased patient safety
●● Achievement of a basic level of
1. Directed exchange is the “ability to send and interoperability
receive secure information electronically
●● More informed decision-making for more
between care providers to support
effective care and treatment
coordinated care” (ONC 2018b). Examples
of patient information include ancillary test ●● Improved public health reporting and
orders and results, patient care summaries, monitoring
and consultation reports. The encrypted ●● Improved transitions of care
AB103118_Ch12.indd 381 2/6/2020 5:41:44 PM

●● Improved population health a common set of standards and specifications.

●● Improved efficiency in the healthcare system Components of an eHealth Exchange include the
following:
●● Reduction in paperwork, allowing more
time for discussions about health concerns ●● A Legal/Trust Framework, where
and treatments participants agree to one set of legal/trust
documents in order to be able to exchange
Users of Health Information Exchange data with all other participants
Essential to changing from a fragmented provid- ●● A governance model that incorporates a
er-centric healthcare system to a patient-centered broad spectrum of perspectives by involving
one are the users of the health information. Phy- a representative set of participants from
sicians, laboratories, hospitals, pharmacies, con- industry and government
sumers, health plans, payers, and communities are
n.
●● Defined operating policies and procedures,
tio
all examples of users of electronically exchanged so that all participants know what is
ia
information. For example, a primary care pro-
oc
expected of them and their end users, and in
ss
vider electronically sends a clinical summary that turn, they know what they can expect from
tA
includes basic clinical information regarding the
en
other participants
em
care provided such as medications, problems, up-
Technical services, such as a service registry
ag
●●
coming appointments, or other instructions to the
directory of the other Exchange participants,
an
patient portal.
M
a security layer based upon a public key
n
Health information exchange requires a team ef- io
infrastructure, and interoperability testing
at
fort to be successful. Technologically capable and
m
Operational support, such as interoperability

r
willing exchange partners need to exist. Function- ●●

fo
subject matter expertise, convening

In
ality within the EHR needs to exist so a conver-

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sation with the vendor is necessary to determine capabilities and meeting support,
ea
governance expertise, technical expertise

H
HIE capability or the time frame for availability.

an
Even if the functionality is there, a lack of cooper- and services, and outreach (The Sequoia
ic
Project 2016)
er
ation among EHR vendors can hinder exchange.

Am
In addition, how the data are integrated into exist- The eHealth Exchange has been successful in
e
th
ing records and workflow can be challenging for interoperable sharing of clinical information such
by
providers. There may also be state laws blocking as care summaries and quality data. In 2012 the
20
access to patient data. Other barriers to HIE us-

20
eHealth Exchange transitioned its management to

ers are competing priorities, financial concerns,
©
The Sequoia Project, a nonprofit 501(c)(3) to ad-

ht
issues related to data ownership, and privacy and vance the implementation of secure, interopera-
ig
yr
security. Also, there must be a mechanism to al- ble nationwide health information exchange. The
op
low patients to opt in or opt out of participating

C
eHealth Exchange has become the nation’s largest

in HIE. health data sharing network, supporting 120 mil-
lion patients (HealthIT n.d.).
eHealth Exchange
The HIE can occur at the local, state, regional, and Challenges with Sharing Healthcare
national levels. The eHealth Exchange is a nation- Information
wide community of exchange partners. The com- ONC’s principal objective for electronic health in-
munity of federal and state agencies, large provider formation exchange is for “information to follow
networks, hospitals, medical groups, pharmacies, a patient where and when it is needed, across or-
technology vendors, payers, and others agree to ganizational, health IT developer and geographic
securely share information via the internet using boundaries” (ONC n.d.). For example, health
AB103118_Ch12.indd 382 2/6/2020 5:41:44 PM

information that can follow a patient as they en- 1. “Records for different patients are mistakenly
counter healthcare at a physician office, in an matched. When medical records for different
acute-care hospital, and at a skilled nursing facil- patients are mistakenly matched (known as
ity; all are examples of possible times when health a “false positive”), it can present safety and
information would cross cities and different types privacy concerns for patients. For example, a
of healthcare organizations. While this is a cred- provider may inadvertently use information
itable goal, there are challenges to sharing health about the wrong patient, such as diagnoses
information among stakeholder groups from a or medication lists, to make clinical decisions.
cultural as well as technical standpoint. Two such In addition, if the wrong patient’s medical
challenges are patient identity and data standards. information is added to a patient’s record, it
could result in disclosure of that information
Patient Identity to a provider or patient who is not authorized
n.
When it comes to patient identity and HIE, integ- to view it” (United States Government
tio
rity is of prime importance to linking the patient Accountability Office 2019).
ia
oc
to the correct information. The ability to match 2. “Records for the same patient are not
ss
tA
patients and health information begins with com- matched. When medical records for the
en
plete and accurate data collection. Errors identi- same patient are not matched (known as
em
fied should be corrected immediately to prevent a “false negative”), it can affect patient
ag
issues with patient care that can result in poor data care. For example, providers may not have
an
M
quality. Sophisticated algorithms such as those access to a relevant part of the patient’s
n
discussed in chapter 3, Health Information Func- io
medical history—such as current allergies
at
m
tions, Purpose, and Users, should be used to help or prior diagnostic test results—which could
r
fo
confirm a patient’s identity (AHIMA 2017). help them avoid adverse events and also
In
Matching patient records to the correct person

lth
provide more efficient care, such as by

ea
becomes increasingly difficult as organizations share not repeating laboratory tests already
H
records electronically using diverse information conducted” (United States Government

an
ic
systems, and in a mobile culture where patients seek Accountability Office 2019).
er
Am
care in many healthcare settings. Some healthcare

Because of its complexity, establishing and main-
organizations use multiple information systems
e
th
taining patient identity and integrity is fraught with

for clinical, administrative, and specialty services,
by
challenges, some of which include the following:

which increases the chances of identity errors oc-
20
20
curring when matching health records. Also, many ●● Not requiring proof of identification at the
©
regions experience a high number of individuals time data are collected

ht
ig
who share the exact name and birthdate, leading to Not making accurate registration a priority
yr
●●
op
the need for additional identifying attributes to be in the emergency department

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used when matching patient records.

●● Data quality issues with patient
Other issues and circumstances that lead to un-
identification data stored and managed in
matched or mismatched health records include
siloed legacy systems
differences in how names and addresses are for-
matted in various information systems, the quality ●● Not correcting data errors in a timely and
of data as it is entered into information systems at comprehensive manner (AHIMA Work
patient registration, and the creation of duplicate Group 2014)
records for the same patient within an information
system (ONC 2014). Data Standards
There are two ways in which patient records fail Data standards are the agreed-upon specifications
to match accurately: for the values acceptable for specific data fields.
AB103118_Ch12.indd 383 2/6/2020 5:41:44 PM

Data standards allow healthcare organizations healthcare provider to another for

to exchange health information in a format that continued care. The data is what the
ensures the data remain comparable. A number healthcare provider needs to continue
of different types of data standards are used in patient care.
healthcare to capture all of the administrative and ●● Digital Imaging and Communications in
clinical data that is needed. Some of these include Medicine (DICOM) is the standard used to
the following: exchange images used in radiology (Sayles
●● Logical Observations Identifiers Names and Kavanaugh-Burke 2018).
and Codes (LOINC) is a standard that
ONC is harmonizing the standards utilized
provides the structure for lab tests
in healthcare. Harmonization is reviewing simi-
and clinical observations to be shared
lar standards and working out the differences in
electronically.
n.
the standards through a committee (ASTM Inter-
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●● Clinical Document Architecture (CDA) national 2005). An example of a specific criterion
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creates documents in the health record developed by ONC in the data standard selection
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such as discharge summaries and progress process is whether the standard is used by fed-
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notes so that the information can be
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eral agencies to electronically exchange health
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shared electronically with other healthcare information with organizations engaging in the
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providers. eHealth Exchange. An outcome of this work is the
an
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●● Continuity Care Record identifies key data publication of best available lists. Table 12.1 shows
that is needed as the patient moves from one n
examples from these lists.
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Table 12.1 Best available standards and implementation specifications

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Implementation
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Purpose Standard(s) specification(s)

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Vocabulary, code set, and Lab tests LOINC

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terminology Patient “problems” SNOMED CT

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Content and structure Care plan HL7 Clinical Document HL7 Implementation Guide for
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Architecture (CDA) Release 2.0, CDA Release 2: Consolidated

by
Normative Edition CDA Templates for Clinical Notes

Data element based on query Fast Healthcare Interoperability (US Realm) Draft Standards for
20
for clinical health information Resources (FHIR) Trial Use Release 2

20
Transport
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Simple way for participants to Simple Mail Transfer Protocol

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push health information directly (SMTP) RFC 5321 For security,

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to known, trusted recipients Secure or Multipurpose

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Internal Mail Extensions

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(S/MIME) Version 3.2 Message

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Specification, RFC 5751

Data sharing through service- Hypertext Transfer Protocol
oriented architecture (SOA) (HTTP) 1.1, RFC 723X (to
that enables two systems to support RESTful transport
interoperate together approaches) Simple Object
Access Protocol (SOAP) 1.2
For security, Transport Layer
Security (TLS) Protocol Version
1.2, RFC 5246
Services Data element based query Fast Healthcare Interoperability
for clinical health information Resources (FHIR)
Image exchange Digital Imaging and
Communications in Medicine
(DICOM)
Source: ONC 2015.
AB103118_Ch12.indd 384 2/6/2020 5:41:45 PM


1. Identify which of the following is a form of HIE.
a. Provider-mediated exchange
b. Data exchange
c. Consumer-mediated exchange
d. Collected exchange
2. Identify the true statement about patient identity issues.
a. Patients should provide proof of identity.
b. Identity issues result only from poor quality data.
c. Identity issues do not include merging two patients’ health records together.
n.
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d. Correcting errors is not a priority.
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3. All definitions of HIE mention:
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a. The exchange of information is manual or done electronically
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b. The exchange of information is manual
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c. The exchange of information is done electronically
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d. The exchange of information maintains the meaning of the information being exchanged
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4. Identify the standard that should be used to share radiological images.
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a. DICOM at
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b. LOINC
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c. CDA
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d. CCR
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5. Identify which of the following is a benefit of HIE.

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a. A basic level of interoperability is met.

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b. An advanced level of interoperability is met.

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c. Billing records are accessible.

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d. Medication refills can be sent electronically.

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6. Per the ONC, HIE capabilities include:

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a. Providing health insurance market reform

20
b. Sharing patient health information and e-prescribing

20
c. Using mobile devices to engage patients as consumers

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d. Providing health insurance portability both inside and outside of the US

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7. HIX provide:
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a. Patient portals and PHR templates

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b. Standards on executive information and clinical decision support systems

c. Consumers the ability to choose a healthcare plan and reform the health insurance market
d. Consumers web-based healthcare applications, social networking sites, and a tethered PHR
8. The data standard for representing lab tests is:
a. HTTP
b. DICOM
c. LOINC
d. ONC
9. True or false: Data integrity is a vital element of HIE.
10. True or false: Query-based exchange is the preferred model of HIE when sharing data with the health department.
AB103118_Ch12.indd 385 2/6/2020 5:41:45 PM

HIM Roles
The roles for HIM professionals in guidelines for data stewardship and data gov-
healthcare information can be expanded to include ernance, developing data integrity and quality
positions focused on HIE and consumer informat- standards, identifying strategies to ensure accu-
ics. For the area of consumer information, the roles rate patient identity, ensuring that privacy and
include working within a healthcare organization, security requirements are met, and performing
physician practice group, or directly with consum- provider and patient education about why HIE
ers. Specific HIM roles could include patient portal is important. A study conducted on trends in
representative, consumer advocate, PHR liaison, HIE organizational staffing found the data inte-
or patient information coordinator. Figure 12.5 lists gration and master patient and client index roles
the recommended best practices for HIM practitio- as the primary staffing challenge and top jobs
n.
ners in a consumer or patient engagement role. in demand (AHIMA and HIMSS 2012). Figure
tio
The roles for HIM professionals in HIE include 12.6 lists additional HIM skills of value to HIE
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defining the data exchange model, developing leadership.
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Figure 12.5 Recommended best practices for consumer or patient engagement
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• Establish or participate in an organizational committee, council, or information governance board whose charge is to address facilita-
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tion of patient engagement. This group should review all existing and proposed policies and procedures related to health information
M
access with an eye toward gaps and barriers to patient engagement.
n
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• When health information is accessed electronically by patients through portals, ensure requests for clarifications, corrections,
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or amendments can be supported by automated workflow that confirms receipt of the request and routes the requests to the
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appropriate place and person.

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• Reach out to community groups as a speaker on patient engagement.

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• Work with clinicians to include a comprehensive set of clinical information, including physicians’ notes and other forms of
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documentation, within the patient portal that goes beyond limited information such as appointment dates and lab results.
an
• Take on a leadership role with the patient portal managing portal processes.
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• Establish a central and convenient (to patients) location for receiving and processing requests for all types of health information
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regardless of media, department, or source. This means establishing a one-stop shop for archived paper records, compact discs,
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diagnostic imaging media, pathology slides, and such.

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• Create policies and design workflows for accepting and managing patient-generated health information.
by
20
• Eliminate fees to patients for providing them with electronic copies of their health information.
20
• Stay up to date with public policy proposals and standards development that addresses and supports consumer engagement.
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Source: Washington 2014.

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Figure 12.6 HIM contributions to HIE

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HIM professionals can bring a variety of much-needed skills to HIEs. HIE leadership can look to HIM principles to provide support
and guidance in the following areas:
• Drafting data governance and stewardship policies, including • Creating release of information policies, procedures,
data ownership, data integrity, and data quality and practices
• Managing master patient index and enterprise master patient • Addressing state and federal requirements for patient
index data conversions, development, and maintenance confidentiality
• Developing and implementing HITECH privacy and security • Meeting breach notification requirements
rule requirements
• Developing and implementing HIPAA privacy and security • Integrating data elements from multiple systems,
rule requirements organizations, and providers
• Identifying best practices in information management and
records retention
Source: AHIMA 2010.
AB103118_Ch12.indd 386 2/6/2020 5:41:45 PM


A research project conducted by Geis- At McGill University Health Centre, a medica-
inger Health System looked at the interaction tion reconciliation research project was conducted
between patients and their providers and phar- using a newly developed web-based software
macists with medication lists were made avail- tool, RightRx. The objective of reconciliation at the
able through a patient portal. For this r esearch hospital level was focused on patient safety and to
project, prior to an upcoming appointment, pa- align the community and hospital medication lists
tients were able to review their medication lists (Tamblyn et al. 2018). RightRx provided a way to
and submit changes if the content was inaccu- automate the drug information and to sort drug
rate. A pharmacist followed up with the patient orders from physicians. This study concluded that
either by phone or secure online messaging. “future development should focus on standardi-
n.
The pharmacist reviewed the information sub- zation of medication administration data, order
tio
mitted by the patient via the portal, revised the sentences to support dose-based prescribing, and
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medication record, and informed the patient’s patient-friendly information about medication
ss
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provider. The revision was also documented in changes” (Tamblyn et al. 2018). Both studies fo-
en
the EHR along with the source of the change cused on the use of electronic tools in the area of
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(Deering 2013). pharmacological management.
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A local community hospital is planning of the most commonly seen diseases in the United
lth
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a health fair. At the event, the clinical staff will pro- States: diabetes, hypertension, Alzheimer’s disease,
H
vide free blood-pressure screening and basic dental and chronic kidney disease. The team planning this
an
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exams. There will also be a 20-minute exercise clinic event includes HIM professionals. When reviewing
er
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and information on healthy eating, smoking cessa- the planned events at the health fair and brochures,
tion, and maintaining a healthy lifestyle. Also, in- the HIM committee members are concerned about
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formation will be presented via brochures on some health literacy for this community outreach event.
by
20
20
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References
ht
ig
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medication-reconciliation-through-the-development-
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mhealthintelligence.com/news/telehealth-may-
and-adoption-of-a-computer-assisted-tool-with-
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Communication, Cultural Competence, and

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assets/1/6/ARoadmapforHospitalsfinalversion certification criteria and certification programs for

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health information technology. 2012.

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AB103118_Ch12.indd 390 2/6/2020 5:41:45 PM

Chapter
13
Research and Data
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Analysis
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Lynette M. Williamson, EdD, MBA, RHIA, CCS, CPC, FAHIMA
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Learning Objectives
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•• Apply graphical tools for data presentation •• Analyze data to identify trends in quality, safety,
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•• Utilize descriptive statistics in healthcare and outcomes of care

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decision-making •• Explain common research methodologies

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• • Understand the normal distribution and •• Explain how research methodologies are used in
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how it affects the use of certain types of healthcare

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statistics •• Explain purpose of randomization

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•• Determine when to use inferential •• Differentiate between the roles of various healthcare
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statistics research organizations

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Key Terms
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Agency for Healthcare Research Descriptive studies Interval variables

20
and Quality (AHRQ) Discrete variable Line graph

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Aggregate data Ethnography Mean

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Analysis of variance (ANOVA) Experimental study Measures of central

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Bar chart Frequency tendency

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Box-and-whisker plots Frequency polygon Measures of variability

Bubble charts Graph Median
Centers for Disease Control Grounded theory Mixed-methodology
and Prevention (CDC) Healthcare research Mode
Chart organizations Nominal variables
Chi-square test Histogram Normal distribution
Comparative data Incidence rate Ordinal variables
Confounding factors Independent variable Pareto chart
Continuous variable Individual data Percentile
Correlational studies Inferential statistics Pie chart
Descriptive statistics Institutional Review Board (IRB) Presentation software
391
391
AB103118_Ch13.indd 391 2/6/2020 5:42:28 PM

Proportion Randomization Standard deviation

Prospective study Range Statistical packages
Qualitative research Ratio variables Stem and leaf plots
Qualitative variables Regression equations t-tests
Quantitative study Research methodologies Table
Quantitative variables Retrospective study Variance
Quasi-experimental study Scatter charts World Health Organization (WHO)
Data is a part of our lives, it is used in personal This chapter discusses the presentation of
dealings and work settings multiple times every statistical data and provides information on
day. Data presented via social media, in digital and descriptive and inferential statistics, research
printed documents (newspapers, magazines, and methodologies, how to analyze information,
n.
so on), and in daily newscasts can be abundant healthcare research organizations, and ethics
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and perhaps at times overwhelming. In the area of in research. Data presentations include the use
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healthcare, data collection and data use are a vital of tables, charts, and graphs. Descriptive statis-
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component to remain competitive. Since healthcare tics and the normal distribution are discussed to
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data such as information on admissions, clinical demonstrate methods of quantifying data using
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facts, reimbursement figures, and data related to frequencies and percentiles, measures of central
ag
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medical coding are so abundant, methods to ana- tendency (mean, median, mode), and measures
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lyze and present the data in an understandable and of variability (range, variance, standard devia-
n
useful fashion are needed. Healthcare providers
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tion). Data analysis is described using examples
at
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are inundated with healthcare data and struggle to that relate to quality and safety. Quantitative,
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find the meaning of data in a quick and efficient qualitative, and mixed-methods approaches are
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manner. Health information management (HIM) discussed in the research methodologies section
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professionals are the bridge between data and in- of this chapter. The Centers for Disease Control,
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formation. HIM professionals take data, present it the World Health Organization, and the Agen-
ic
clearly, and provide it to those who will use it to cy for Healthcare Research and Quality are de-
er
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make important decisions. (Data and information scribed in this chapter. The discussion concludes
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are defined and discussed in detail in chapter 3, with ethics and HIM roles as they relate to the
th
Health Information Functions, Purpose, and Users.) research arena.

by
20
20
©
Presentation of Statistical Data

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ig
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The key to presenting data is to make it can be counted such as 204, 65, and 534. For ex-
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clear, concise, and understandable. Tables, charts, ample, in a college parking lot there are a finite
and graphs (discussed later in this chapter) can amount of parking slots; therefore, when counting
be used to do this. When deciding whether to use cars in spaces, the total will be a discrete variable.
a table, graph, or chart to present data, one must The opposite of a discrete variable is a continuous
consider the type of data or variables that are be- variable. Continuous variables include any nu-
ing presented. In general, “variables are character- merical value that goes from one whole number
istics that are measured and may take on different to the next whole number. An example of a con-
values” (Forrestal 2017a). In research, quantitative tinuous variable could be weight; if the athletes
variables are numerical variables that can be clas- on a team weigh between 150 and 200 pounds,
sified as discrete or continuous. Discrete variables then each individual athlete’s weight (150, 155,
are variables that can take on a finite number of 160, and so forth) would be a continuous variable.
values, usually whole numbers, or numbers that Another example of a continuous variable is the
AB103118_Ch13.indd 392 2/6/2020 5:42:29 PM

cost of a patient’s hospital stay ($30,567.32) or a to rank a category in an ordered series, but the
patient’s height presented as 62.596 inches. Quan- numbers do not indicate the magnitude of the dif-
titative variables can be further broken down into ference between any two data points. An example
interval and ratio variables. Interval variables are of a ranked variable is a response for a question
those that have equal units with an arbitrary zero on a patient satisfaction questionnaire such as: The
point. An example is temperature on the Fahren- wait time to see your physician was appropriate,
heit scale. The temperature difference between where 1 = strongly agree, 2 = agree, 3 = disagree,
45 degrees and 50 degrees is the same as the tem- 4 = strongly disagree. Table 13.1 summarizes the
perature difference between 30 degrees and 35 different types of variables and gives examples of
degrees. Zero does not equal absence of tempera- each. Electronic spreadsheets and spreadsheet soft-
ture. Ratio variables are the most common quan- ware can be used to construct nearly all the charts,
titative variables used in healthcare. These include graphs, and tables explained in this chapter.
n.
numbers that can be compared meaningfully with
tio
one another (four grapefruits are twice as many
ia
Tables
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as two grapefruits). Zero is truly zero on the ratio
ss
scale. Examples include height (inches or meters) Tables, which can include both numbers and text,
tA
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and weight (pounds or kilograms). are an excellent way to display data. Tables can be
em
Qualitative variables are categorical, mean- used to organize and categorize data and to exam-
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ing that the variable is from a specific category or ine the detail of a specific concept, category, or re-
an
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group such as gender or age. Qualitative variables sponse. Table 13.2 demonstrates the demographic
are given or assigned to items that are not numer- n
characteristics of physicians who participated in a
io
at
ical. An example is eye color. There are several eye focus group to discuss the effects of the Interna-
rm
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colors, including blue, green, and brown; none of tional Classification of Diseases, Tenth Revision, Clin-
In
them are numerical. But if a research study is ical Modification (ICD-10-CM) and the International
lth
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collecting data on eye color, then each possible eye Classification of Diseases, Tenth Revision, Procedure
H
color is assigned a number (brown = 1, green = Coding System (ICD-10-PCS) on their physician
an
ic
2, blue = 3) to allow for a statistical formula to be practices. It can be easily seen from table 13.2 that
er
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conducted. All qualitative variables are discrete; 75 percent of the physicians in this focus group
qualitative variables can be subdivided into nom- had no exposure to ICD-10-CM or ICD-10-PCS.
e
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inal or ordinal type. Nominal variables are those in The key to building a table is to make it stand
by
which a number is assigned to a specific category alone so anyone reading it can understand the
20
20
such as 1 = male and 2 = female. Ordinal variables are information displayed. All tables should include
©
ranked variables in which numbers are assigned the following elements: the table legend or title;
ht
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Table 13.1 Examples of types of variables: quantitative and qualitative

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Quantitative or numerical variables

Continuous Discrete
Interval: Temperature Number of medical records coded
Ratio: Height, weight, costs, charges Number of patients who receive a colonoscopy
Qualitative or categorical variables
All discrete variables
Nominal (discrete categorical variables) Gender (1 = male, 2 = female), race (1 = Caucasian, 2 = African American, and such),
smoking status (1 = nonsmoker, 2 = smoker)
Ordinal (discrete ordered variables) Patient satisfaction scores (1 = not satisfied to 5 = very satisfied), quality of life
scores (1 = not healthy to 5 = very healthy), pain scales (0 = no pain, 5 = moderate
pain, 10 = worst pain)
Source: ©AHIMA
AB103118_Ch13.indd 393 2/6/2020 5:42:29 PM

column titles; the body of the table, which includes (Brewer et al. 2012). Various types of charts and
the actual data; lines that divide certain parts of graphs are discussed in the following sections.
the table; and a footnote or reference citation if the
table text was taken from an article or other source. Charts and Graphs
Some data are better presented in a format other Charts and graphs provide a picture of the numer-
than a table, because it may take readers longer to ical data being processed into information. Charts
review and understand a table than another form by definition “generally display nonquantitative
of presentation. For example, when presenting information such as the flow of subjects through
data for clinicians using patient test results from a process” (APA 2012). Graphs are data presenta-
electronic health records (EHRs), a bar chart or pie tions that show the relationship of the included
chart may be a more effective format than a table variables (APA 2012). Information presented in
charts or graphs can be used for data analysis and
n.
decision-making. It can be difficult to succinctly
tio
Table 13.2 Demographic characteristics of physician
ia
participants in a focus group study on the effects of describe what is happening with large amounts of
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data. Charts and graphs can be the perfect choice
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ICD-10-CM/PCS on their practice
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Respondents (N = 12)
to present data in part because they are easy to un-
en
N = number of physicians responding derstand and can provide a clear picture of the data
em
Demographics being reviewed. There are different types of charts
ag
an
Standard and graphs to use when transforming data into in-
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Mean deviation formation. Each graph or chart has guides or rules
n
Age 54.67 12.71 io
to follow to determine whether it is appropriate
at
m
Years of experience 23.42 12.48 for presentation of the data. Bar charts, pie charts,
r
fo
Gender # % line graphs, histograms, frequency polygons, scat-

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Male 9 75 ter charts, bubble charts, stem and leaf plots, and
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Female 3 25 box-and-whisker plots are some of the charts and

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Setting # %
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graphs explained in the following sections.

ic
Hospital (or other facility) only 5 41.6

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Bar Charts
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Private practice only 2 16.7

Bar charts are simple charts used to describe
e
Both 5 41.6
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Medical specialty # % qualitative, categorical, or discrete variables such

by
as nominal or ordinal data. The bars may be drawn

20
Emergency medicine 2 16.7

20
Ophthalmology 1 8.3 vertically in which the value represents the height

©
Internal medicine, geriatrics 1 8.3 of the bar drawn or horizontally in which the value
ht
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Plastic or reconstructive surgery 1 8.3 represents the length of the bar drawn. There are
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General surgery 1 8.3 several types of bar charts. The easiest bar chart to
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Obstetrics and gynecology 1 8.3 build is the one-variable bar chart, which displays a
Psychiatry 2 16.7 bar to represent the amount of the specific category.
Family medicine 1 8.3 For example, figure 13.1 presents a hypothetical
Hematology and oncology 1 8.3 example of a one-variable bar chart for the num-
Physical medicine 1 8.3 ber of healthcare organizations located in an urban,
Previous use of EHR # % suburban, or rural setting in a specific region.
Yes 10 83.3 Two-variable bar charts can also display an im-
No 2 16.7 portant summary of healthcare data. Figure 13.2
Exposure to ICD-10-CM/PCS # % demonstrates a two-variable chart and includes
Yes 3 25 not only the number of healthcare organizations in
No 9 75 the region but also the number of trauma units in
Source: Watzlaf et al. 2015. each of those settings. The two-variable bar chart
AB103118_Ch13.indd 394 2/6/2020 5:42:29 PM

Figure 13.1 Example of a one-variable bar chart

Number of healthcare organizations in Region 1
50
45
45
Number of healthcare
40
35
30
facilities
25
25
20
15
15
10
5
0
Urban Suburban Rural
n.
tio
Region
ia
oc
Source: ©AHIMA
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tA
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Figure 13.2 Example of a two-variable bar chart
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Number of healthcare organizations and trauma units in Region 1
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50
n
45 io
Number of healthcare
at
40 45
m
organizations
35
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In
30
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25
25
ea
20
H
15
an
10 15
ic
10
er
5 2
5
Am
0
e
th
Region
by
Number of healthcare organizations Number of trauma units

20
20
Source: ©AHIMA
©
ht
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can further distinguish or classify additional vari- When titles get longer or if data is shown from
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ables. Figures 13.3 through 13.5 demonstrate other the smallest at the top to the largest at the bottom
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examples of bar charts. The horizontal bar chart as well as showing proportions of two areas, the
is used when label titles are long and therefore horizontal stacked bar chart can be used. Figure
more difficult to read and when sorting the data 13.5 provides an example of a horizontal stacked
from the smallest amount at the top to the largest bar graph.
amount at the bottom. When constructing bar charts, it is important
The stacked bar chart can also be used when to know the audience, keep it simple, and make it
demonstrating a comparison of the proportion of clear, colorful, and concise. When using a bar chart,
two things. Shown in figure 13.4, the stacked bar the main goal is to succinctly provide clear and
chart demonstrates the proportion of the number easy to understand data. This includes providing a
of trauma units in relation to the number of health- title, axes labels, legend, a number within or above
care organizations. The stacked bar chart can help the bars, percentages if it helps to clarify an aspect
visualize the proportion. of the data, and appropriate colors to distinguish
AB103118_Ch13.indd 395 2/6/2020 5:42:31 PM

Figure 13.3 Example of a horizontal bar chart
2
Rural
15
Region
5
Suburban
25
10
Urban
45
0 10 20 30 40 50
n.
Number of healthcare organizations
tio
Number of trauma units Number of healthcare organizations
ia
oc
ss
Source: ©AHIMA.
tA
Figure 13.4 Example of a stacked bar chart with percentage of the whole
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Number and percent of healthcare organizations and trauma units in Region 1
ag
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100%
10 5 2
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90%
n
80% io 15
45 25
at
70%
m r
60%
Percent
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In
50%
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40%
ea
30%
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20%
an
10%
ic
er
0%
Am

Region
e
th

by
20
Source: ©AHIMA.
20
Figure 13.5 Example of a horizontal stacked bar char

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Rural 15 2
Region
Suburban 25 5
Urban 45 10
0 10 20 30 40 50 60
Number of healthcare organizations and trauma units
Source: ©AHIMA.
AB103118_Ch13.indd 396 2/6/2020 5:42:34 PM

between groups. Everyone is different and some- It shows how a billing manager collected data
times what is clear to one person may not be to over a period of time to determine the causes for
another, so knowing the audience ensures the ap- claim denials for Medicare inpatient stays. The
propriate type of bar chart is constructed to meet chart (figure 13.6) illustrates four categories: cod-
the audience’s preferences. Review figure 12.3 for ing error, medical necessity, registration error, and
examples of a poorly designed and an improved other. For each category the number of denials is
pie chart data representation. presented with a bar. After reviewing the chart,
the billing manager can determine that coding
Pareto Charts errors are the largest cause for Medicare denials.
A Pareto chart is similar in appearance to a bar Therefore, this could be the first area to review
chart, but the highest-ranking value is listed as to improve and decrease Medicare denials. The
the first column, the next highest ranking is sec- cumulative data line with bullets identifies what
n.
ond, and so on, to the lowest ranking. This type the result will be if all four categories are added
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of graphical presentation was created by Vilfredo together moving from left to right for a cumula-
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Pareto and is based on his theory that “the signifi- tive effect.
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cant few things will generally make up 80 percent
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of the whole, while the trivial many will make up Pie Charts
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about 20 percent” (Productivity-Quality Systems Pie charts are simple graphs that use the slices of
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2015). In other words, 80 percent of the data is the pie to explain numerical proportion in relation
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significant while 20 percent is not. Pareto charts to the whole, or 100 percent. Pie charts are used a
n
show data in terms of arranging it into categories io
great deal in healthcare because they can depict a
at
m
and then ranking each category according to its breakdown of numerical data elements by percent-
r
fo
importance. An example of a Pareto chart is found ages. Pie charts, as shown in figure 13.7, can be used
In
lth
in figure 13.6. In healthcare, a Pareto chart can to provide information on percentages. In figure
ea
help analyze data about the frequency or causes of 13.7 the slices of the pie relate to the percentage of
H
problems in a process. Pareto charts also display healthcare organizations by regional setting: ur-
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a cumulative line that shows the overall effect of ban, suburban, rural, and total. Pie charts, however,
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each of the categories that make up the whole. may not be the best format to use when compar-
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Pareto charts are useful in quality improvement ing data elements or when using many data elements
th
processes. Chapter 18, Performance Improvement, because the slices of the pie can become too small
by
20
covers pareto charts in more detail. to interpret. When explaining simple types of data,
20
©
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Figure 13.6 Example of a Pareto chart

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Medicare claims denials pareto chart

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30
25
Number of denials ë100
20
15
10
0
Coding error Medical necessity Registration error Other
Reason for denial
Source: ©AHIMA.
AB103118_Ch13.indd 397 2/6/2020 5:42:35 PM

roken down into percentages, the pie graph may

b and is explained later in this chapter. A line graph
be a good statistical graphic to use. Using the same is best to use when there are many different data
numbers that were used in figure 13.1, figure 13.7 points or more than one set of data to plot; multiple
provides not only the slices of the pie but also the lines can be put on one graph for very useful com-
individual percentages within each slice for easier parisons. The data used to create the line graphs in
reading and interpretation. figures 13.8 and 13.9 are shown in table 13.3.
Line Graphs Histograms

A line graph is a graphical device used to display A histogram is a graph that represents the fre-
continuous data and to show changes or trends of quency distribution of numerical data. A frequency
the data over time. The x-axis on the line graph, distribution is a visual display of data that dem-
from left to right, designates time (such as month, onstrates where data falls. For example, table 13.4
n.
day, or year) and the y-axis shows the quantity of is a frequency distribution table. It provides the
tio
ia
the plotted data. A line graph could be used as illus- number of patients that fall into each of the weight
oc
trated in figure 13.8 to show the healthcare expen- categories listed. It also provides the percent of
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ditures for one hospital over the period of 10 years the total number of patients that fall within each
en
from 2000 to 2011. A line graph looks similar to a weight category.
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frequency polygon although its purpose is different A histogram should be used with continuous
ag
data that is part of a frequency distribution. It dif-
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Figure 13.7 Example of pie chart fers from a bar graph because histograms use con-
n
io
tinuous data, there are no spaces between the bars,
at
Percent of healthcare facilities in region 1
m
and each bar has a class interval at its base and the
r
fo
frequency or percentage of cases in that class

In
lth
interval at its height. See figure 13.10 for an exam-

ea
Urban ple of a histogram with six groups of body mass

H
26%
index (from underweight to extremely obese) on the
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Suburban
ic
50%
x-axis and percentage of population on the y-axis.
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Rural
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15%
Total
9%
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Frequency Polygons
th
by
A frequency polygon is another graphical means to

20
Source: ©AHIMA. display a frequency distribution using continuous

20
©
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Figure 13.8 Example of a line graph

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yr
op
King County healthcare expenditures

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2000–2011 ($ million)
$250
$200
$ Million
$150
$100
$50
$0
1998 2000 2002 2004 2006 2008 2010 2012
Year
Source: CMS 2016.
AB103118_Ch13.indd 398 2/6/2020 5:42:37 PM

Figure 13.9 Example of a line graph comparing two types of data

Comparison of healthcare expenditures King County,
Washington, and the nation 2000–2011
$3,000
$2,500
$2,000
Dollars
$1,500
$1,000
$500
$0
1998 2000 2002 2004 2006 2008 2010 2012
Year
n.
Exp. ($mill) National ($bill)
tio
ia
Source: CMS 2016.
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Table 13.3 Data used to build line graphs for figures data in a line form. A single data point placed at the
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13.8 and 13.9 midpoint of the interval is used to mark the spe-
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Expenditures National cific number of observations within that interval.
an
Year ($ million) ($ billion) Each point is then connected by a line. Figure 13.11
M
2000 $86 $1,377.20 shows a frequency polygon over an outline of a
n
io
at
2001 $95 $1,493.40 histogram for the same data. In this example from
m
2002 $113 $1,638.00 the Centers for Disease Control and Prevention
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In
2003 $115 $1,778.00 (CDC), it is easier to see the peak of the epidemic
lth
2004 $133 $1,905.70 in the frequency polygon. Frequency polygons

ea
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2005 $139 $2,035.40 differ from line graphs in that frequency polygons
an
2006 $152 $2,166.70 (and histograms) display the entire frequency dis-
ic
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2007 $159 $2,302.90 tribution (counts) of the continuous variable; a line

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2008 $177 $2,411.70 graph plots only the specific data points over time.
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2009 $192 $2,504.20

by
2010 $185 $2,599.00

Scatter Charts
20
2011 $191 $2,692.80

20
A scatter chart, scatter plot, scatter diagram, or

©
Source: ©AHIMA.
scatter graph is used to demonstrate a relationship
ht
ig
between two variables. For example, if per the

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Table 13.4 Example of a frequency distribution table

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researched data a relationship between age and a

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Frequency Percent medical condition such as myocardial infarction

Valid 123.00 1 10.0 has been found, this connection can be shown in a
125.00 1 10.0 scatter chart. For this type of chart, one of the two
145.00 1 10.0 variables is plotted on the x-axis, and the other
155.00 2 20.0 is plotted on the y-axis. A strong relationship be-
165.00 1 10.0 tween the two variables is seen as the data come
176.00 1 10.0 closer to forming a straight line. For example,
187.00 1 10.0 figure 13.12 demonstrates a strong positive relation-
201.00 1 10.0 ship between age and income. When both variables
233.00 1 10.0 increase and decrease at the same time, the scatter
Total 10 100.0 chart will show a positive relationship. When one
Source: ©AHIMA. variable increases and the other variable decreases,
AB103118_Ch13.indd 399 2/6/2020 5:42:38 PM

Figure 13.10 Example of a histogram that shows the distribution of body mass index in adults with
diagnosed diabetes in the United States, 1999–2002
35%
Under Normal Overweight Obese 1 Obese 2 Extremely
weight obese
30%
Percentage of population
25%
20%
15%
10%
5%
n.
0%
tio
ia
<18.5 18.5–24.9 25.0–29.9 30.0–34.9 35.0–39.9 ≥40.0
oc
Body mass index (kg/m2)
ss
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Source: CDC 2004.
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Figure 13.11 Example of a frequency polygon and histogram
ag
an
The histogram shows number of cases as columns. The frequency polygon shows number of cases as data points connected
M
by lines. The midpoints of intervals of the histogram intersect the frequency polygon. For the frequency polygon, the first
n
io
data point is connected to the midpoint of the previous interval on the x-axis. The last data point is connected the midpoint
at
m
of the following interval.

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15
In
Histogram
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Frequency polygon
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ic
10
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Cases
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th
Midpoints of
by
intervals are
20
connected for a
5 frequency polygon
20
©
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0
1 2 3 4 5 6 7 8 9
Week of Onset of Illness
First data point Last data point

connected to connected to
mid-point of mid-point of
previous interval following interval
on x-axis on x-axis
Source: CDC 2012.
the scatter chart will display a negative relation- level of physical activity. In figure 13.14, a scatter
ship. In figure 13.13, the scatter chart shows a nega- chart shows no relationship between age and the
tive relationship between age and physical activity, number of pets a person has in their household. As
demonstrating that as age increases, physical ac- illustrated by figures 13.12, 13.13, and 13.14, scatter
tivity decreases. In figure 13.13 physical activity is charts, or graphs, show the nonlinear relationships
ranked from 0 = no physical activity to 5 = high between variables. Therefore, researchers can use
AB103118_Ch13.indd 400 2/6/2020 5:42:40 PM

Figure 13.12 Scatter chart showing a strong positive relationship between age and income
Age and income

$140,000
$120,000
$100,000
Income in dollars
$80,000
$60,000
$40,000
$20,000
n.
0
tio
0 10 20 30 40 50 60 70 80
ia
Age
oc
ss
Source: ©AHIMA.
tA
en
Figure 13.13 Scatter chart showing a strong negative relationship between age and physical ability
em
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Age and physical ability
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6
M
Ranked score for physicial ability
n
5
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at
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4
In
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3
ea
H
an
2
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er
1
Am
e
th
0
0 10 20 30 40 50 60 70 80
by
Age
20
20
Source: ©AHIMA.
©
ht
Figure 13.14 Scatter chart showing no relationship scatter charts to determine quickly whether further
ig
yr
between age and number of pets a person has in calculations are needed—if the scatter chart dem-
op
their household onstrates nonlinear relationships, then no further

C
Age and number of pets

calculations, such as correlation or regression statis-
8
tics, are needed.
7
Number of pets
6 Bubble Charts
5 A bubble chart is like a scatter chart except that
4
it compares three data variables. Therefore, when
3
2
presenting information, a bubble chart can illus-
1 trate more data if that meets the needs and focus
0 of the situation. For example, if a healthcare or-
0 20 40 60 80 100
Age
ganization is reviewing the socioeconomic levels
Source: ©AHIMA.
of its patients and the cost of their care during
AB103118_Ch13.indd 401 2/6/2020 5:42:43 PM

Figure 13.15 Bubble chart showing a relationship of three variables
Income, cost of hospital admission, percent of cost of

admission on income
$120,000
$100,000
Percentage of income
$80,000
$60,000
$40,000
n.
$20,000
tio
ia
oc
$0
$0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000
ss
tA
Annual Income
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Source: ©AHIMA.
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ag
an
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i npatient admissions, a bubble chart can show three Table 13.5 Example of stem and leaf plot using
n
discharges across a state for MS-DRG 39, extra-
data points: income, cost of admission, and the re- io
at
lationship to the patient’s personal income. This is cranial procedures without CC or MCC
m r
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shown in figure 13.15. This bubble chart shows that Stem Leaf
In
the larger the bubble, the more that group of patients

lth
1 44,588
ea
had to pay for their hospital admission in relation to 2 145,779

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their income. Looking at the size of the bubbles, the

an
3 1,234
ic
patients who earned $20,000 per year had to pay the 4 35

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greatest proportion of their income for their hospital 5 1

admission, and the patients who made $80,000 had
e
6 67
th
to pay the lowest proportion of their income for their

by
Source: CMS 2014.

hospital admission. This could be useful information
20
20
to researchers looking at patients who do not have To develop the stem and leaf plot, the numbers
©
health insurance and are self-pay upon admission. are separated into two parts. The first digit (in this
ht
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example, the tens digit) is listed once as per occur-

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rence in the stem column, and the last digit(s) (in

Stem and Leaf Plots
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this example, the ones digit) are placed in the leaf

In stem and leaf plots, data can be organized so that
column. The first number, 14, is separated so that
the shape of a frequency distribution is revealed.
1 goes in the stem column and 4 is the first listing
As an example, a stem and leaf plot is constructed
in the leaf column. In the second 14, the first digit
on the number of discharges across cities in one par-
is already in the stem column (1) so the second (4)
ticular state for Medicare severity diagnosis-related
is placed in the leaf column as the second entry
group (MS-DRG) 39, extra-cranial procedures with-
(44). Table 13.5 displays a continuation of the list
out complication or comorbidity (CC) or major
of numbers in the given example.
complication or comorbidity (MCC) (CMS 2014).
The completed stem and leaf plot shows the distri-
The data are listed as follows and ranked from the
bution of the data set. The stem and leaf plot shows
smallest to largest number of discharges:
that the lowest value in the distribution is 14 (created
14, 14, 15, 18, 18, 21, 24, 25, 27, 27, 29, 31, 32, by using the digit in the first row in the first column
33, 34, 43, 45, 51, 66, 67 [1] and the first digit in the first row of the second
AB103118_Ch13.indd 402 2/6/2020 5:42:44 PM

column [4]) and the highest is 67 (the digit in the last participants (or hospitals as in figure 13.16), then
row in the first column [6] and the second digit in the each box on the graph shows the data range for
last row of the second column [7]) and that there are each group.
six observations in the 20s group (created by adding
the number of digits in the row that displays the tens Statistical Packages and Presentation
digits for 2). With this type of display it is easy to see Software
that the largest number of discharges is 67 (the digit There are many statistical packages that can be used
in the last row in the first column and the second to facilitate the data collection and analysis process-
digit in the last row of the second column). es. These packages simplify the statistical analysis of
data and are often used in addition to spreadsheet
Box-and-Whisker Plots software. Table 13.6 displays the types of data that
Box-and-whisker plots visually summarize can be entered when using statistical software pack-
n.
several main factors: median, range, and outli- ages as well as the output that can be generated.
tio
ia
ers. In this type of data presentation, the box rep- Presentation software is software used to build
oc
resents quartiles, or quarters. The lines coming slides when presenting a specific topic, idea, re-
ss
tA
from the boxes (or quarters) are termed whisk- search data, or any type of information. Presen-
en
ers and illustrate the range of data values. “The tation of data and information is an important
em
median line is in the center of a box formed by the function of HIM. For example, key performance
ag
an
upper and lower quartiles” (Forrestal 2017b 177). indicators such as length of stay or nosocomial in-
M
Box-and-whisker plots can be used to provide a fection rates are often reported on a monthly basis.
n
io
visual comparison of multiple data sets in a suc- The HIM professional may be asked to present this
at
m
cinct way; for example, the results of a patient information in a way that clearly displays the in-
r
fo
satisfaction survey that had questions with a pos- formation and identifies trends that may need to be
In
lth
sible scaled response, such as highly agree, agree, addressed. Different graphic designs, animations,
ea
neutral, disagree, and highly disagree. The box- and polls can also be added to slides to enhance
H
an
and-whisker plot in figure 13.16 shows the pro- and support the data presented. For example, an
ic
portion of African-American patients and their HIM professional would need to use presenta-
er
Am
30-day mortality rates categorized by amount of tion software when demonstrating how coding
e
hospitals. In general, a box-and-whisker graphi- productivity changed after the implementation of

th
by
cal display provides information on the range of ICD-10-CM/PCS and the slides would show an
20
data results. If the research focuses on groups of increase or decrease in coder productivity.
20
©
ht
Figure 13.16 Example of a box-and-whisker plot

ig
yr
op
30-day risk-standardized mortality rate (%)

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25
20
15
10
1,776 292 292 292 291
hospitals hospitals hospitals hospitals hospitals
5
0
<5 5–8 9–14 15–25 >25
Proportion of African-American patients (%)
Source: CMS 2010, 14.
AB103118_Ch13.indd 403 2/6/2020 5:42:46 PM

Table 13.6 Common data configurations for statistical software

Data type Description Example
Data list or Data list or input includes the name of Name of variable: codingtestscore, coderstatus
input the variable, the type of the variable such Variable type (numeric or string): numeric
as string, numeric, how long the variable Width of variable: 4
is, and how many decimal places to keep Number of decimals: 2
in the number
Value labels Value labels assign a value to a specific Coder Status
variable and appears in the output for 1 = advanced
easy interpretation. 2 = intermediate
3 = beginner
Missing Missing values are values that do not Statistics
values have a number or value assigned to the Variable Name Variable Name
variable. Missing values can be displayed codingtestscore coderstatus
in output and can be recoded by the user
n.
if necessary. One may need to recode or N Valid 8 8
tio
ia
add a number in case it was missed by Missing 2 2
oc
the data entry.
Key:
ss
N = population; n = sample
tA
Valid = all variables that have a value assigned to them
en
Missing = variables that do not have a value assigned to them
em
The numbers in the first column show the valid number of individuals that
ag
have a coding test score and the number of individuals that are missing a
an
coding test score.
M
The numbers in the second column show the valid number of individuals
n
io
that have a coder status assigned (advanced, intermediate, beginner) and
at
the number of individuals that are missing a coder status.
rm
Output Output includes statistics that can be Report

fo
In
generated from the data that is col- codingtestscore

lth
lected and entered into the software or

ea
spreadsheet. Statistics can be generated coderstatus Mean N Standard Deviation

H
such as descriptive statistics (frequency advanced 93.0000 3 5.00000

an
tables, percentiles, graphs, measures of

intermediate 89.5000 2 0.70711
ic
central tendency) as well as advanced

er
statistics beginner 73.3333 3 6.42910

Am
Total 84.7500 8 10.51190

e
th
by
Source: ©AHIMA.
20
20
©
ht
ig

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1. An HIM professional is creating a data presentation. The data in the presentation is from the Center for Medicare
and Medicaid Services website and illustrates the condition of pneumonia and readmission rates for all hospitals in a
specific state.
Of the options provided below, identify the best choice to graphically display data with this type of focus.
a. Pareto chart
b. Pie chart
c. Line graph
d. Table
2. True or false: The two-variable bar chart cannot be used to display summary data.
AB103118_Ch13.indd 404 2/6/2020 5:42:46 PM

3. Identify the two graphs that are the best option for displaying frequency distributions using continuous data.
a. Histogram and frequency polygon
b. Bar chart and line graph
c. Scatter chart and stem and leaf plot
d. Pie chart and frequency polygon
4. Identify the best chart to compare three data variables (healthcare spending per person, country population, and
gross domestic product) of the included countries.
a. Bar chart
b. Pie chart
c. Bubble chart
d. Scatter chart
5. Identify an example of a value label variable.
a. Coder status
n.
tio
b. Coder test score
ia
c. Weight
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ss
d. Height
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6. True or false: A pie chart presents information on range and outliers.
en
em
7. A scatter plot is best used to illustrate:
ag
a. A frequency distribution
an
b. Continuous data changes
M
n
c. Numerical percentages io
at
d. A relationship between two variables
mr
8. True or false: A box-and-whisker plot graphically depicts data set medians.

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In
9. Identify the best graphical form to be used when examining a problem and a process.
lth
ea
a. Pareto chart
H
b. Pie chart
an
ic
c. Line graph
er
d. Histogram
Am
10. Identify an example of a ratio variable.

e
th
a. 0 to 10 degrees Fahrenheit
by
b. A height measurement of 5 feet 11 inches

20
20
c. 1 = female
©
d. 5 = strongly agree, 4 = agree, 3 = disagree

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Descriptive Statistics
Descriptive statistics include frequen- the frequency of the number of HIM professionals
cies, percentiles, measures of central tendency that believe they are leaders in information govern-
(mean, median, and mode) and measures of var- ance or the age of patients for a particular month
iability (range, variance, and standard deviation). in a healthcare organization vary. Range, variance,
Descriptive statistics are used to give information and standard deviation, termed measures of varia-
on data and for organization and summarization. bility, are components of this area of statistics. For
Generally, descriptive statistics do not provide example, descriptive statistics such as range could
information on data relationship (such as between be used to show the physical weights of a group of
groups of data results) or any results focused on patients recently diagnosed with diabetes mellitus.
cause and effect found by the research. In HIM Further, measures of variability fall into the 25th,
research, descriptive statistics can be used to show 50th, or 75th percentile, and the mean, median,
AB103118_Ch13.indd 405 2/6/2020 5:42:46 PM

and mode of DRG can be used to further exam- percentiles. One can see that age 36 is at the 25th
ine the spread of data and how outliers influence percentile, age 45 is at the 50th percentile, and age
the distribution of the data. Frequency, percentile, 53.25 is at the 75th percentile. This shows that age
measures of central tendency, and measures of var- 36 is the age below which 25 percent of the oth-
iability are discussed in the following sections. er ages fall, 45 is the age below which 50 percent
of the other ages fall, and 53.25 is the age below
Frequency and Percentile which 75 percent of the other ages fall within this
Frequency is the number of times something occurs particular group of subjects. This demonstrates
in a particular population or sample over a specific that the majority of the subjects are not considered
period of time. For example, if researchers wanted elderly, since elderly would include those equal to
to determine how often subjects considered them- or over the age of 65.
selves a leader in information governance (IG), they
n.
could ask the subjects whether they consider them- Measures of Central Tendency
tio
ia
selves a leader in IG and then count how many of Measures of central tendency include the mean,
oc
the subjects said yes and how many said no.
ss
the median, and the mode. These measures are de-
tA
The researchers could then build a frequency fined as representing “the clustering of the major-
en
table based on this question and its results. The ity of a data set’s values around its middle value”
em
results could be displayed in a frequency table like
ag
(Forrestal 2017b 177). Mean, median, and mode
an
table 13.7. relate to location within a researched or gathered
M
A percentile is a measure used in descriptive sta- set of numerical data.
n
tistics that shows the value below which a given
io
at
m
percentage of scores in a given group of scores fall. Mean

r
fo
For example, the 40th percentile is the score below

In
The mean is the average of a group of numerical

lth
which 40 percent of the other scores in a given values. To calculate a mean, first the data group
ea
group of scores fall. Also, if a score is in the 95th

H
must be obtained. For example, a data group could

an
percentile, it is higher than 95 percent of the other be patients admitted to the cardiac unit of a hospi-
ic
scores. A percentile can be broken up into quar-

er
tal. Using the patients’ lengths of stay (LOS) for

Am
tiles. Quartiles are values that break up a list of the month of January, a mean LOS could be calcu-
e
numbers into quarters such as the 25th percentile,

th
lated. The LOS for the six patients was 5, 8, 6, 4, 7,

by
or first quartile; 50th percentile, or second quartile; and 3 days. To calculate the mean of these lengths
20
and 75th percentile, or third quartile. For example, of stay, add the days of stay together:
20
if a researcher wanted to determine how the age of

©
their subjects were separated based on quartiles, 5 + 8 + 6 + 4 + 7 + 3 = 33 total days

ht
ig
they could collect the age for each subject, create Then divide by 6, the total number of patients:
yr
op
a spreadsheet, and use statistical software to pro-

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vide percentiles of the data collected. 33/6 = 5.5 days

Table 13.8 demonstrates how the age of 250 in- The mean LOS per cardiac patient is 5.5 days.
dividuals is categorized in 25th, 50th, and 75th
Table 13.8 Example of percentiles

Table 13.7 Example of a frequency table Statistics
Do you consider yourself Age in years
a leader in IG? Frequency N Valid 250
Yes 150 Missing 0
No 45 Percentiles 25 36.00
50 45.00
No response 5
75 53.25
Total 200
N = Population
Source: ©AHIMA. Source: ©AHIMA.
AB103118_Ch13.indd 406 2/6/2020 5:42:46 PM

Median tendency. The measures of variability include the

When values are ranked, the median is the value in range, variance, and standard deviation.
which there is the same amount of numbers above
and below. It is the middlemost value when arranged Range
in numerical order. For an odd number of observa- The range is the simplest measure of variation to
tions, the median is the middle number in an ordered compute and is calculated by taking the difference
set of numbers; for an even number of observations between the highest and lowest values. It is quick
it is the mean or average of the middle two numbers. and easy to do, but not that useful since it only
For example, the systolic blood pressure of five considers extremes and not the entire sample of
patients is provided as follows. data values. The range in the systolic blood pres-
140, 190, 120, 116, 109 sure data set is: 190 – 109 = 81.
n.
The first step to compute the median is to rank
tio
Variance
these values from lowest to highest:
ia
The variance is the average of the squared devia-
oc
ss
109, 116, 120, 140, 190 tions from the mean. Its symbol is σ2 for populations
tA
and s2 for samples.
en
The median is 120 since it is the middlemost
em
value when counting from left to right and from
ag
right to left. If one more systolic blood pressure Standard Deviation
an
value were added to this data set, then the median
M
The standard deviation is the measure of variabil-
would be determined by counting to the middle n
ity that is used most often and displays how data
io
at
from left to right and right to left and then taking are related to the mean. The variance and stand-
m r
fo
the average of the two middle values. For exam- ard deviation can be cumbersome to compute by
In
ple, if 140 is added to the existing values, then the hand, but statistical applications make it easy to
lth
ea
new data set will include the following: automatically generate results. Using the same ar-
H
ray of data for the systolic blood pressure, table 13.9

an
109, 116, 120, 140, 140, 190

ic
provides the mean, range, variance, and standard

er
The new median will be: deviation. The interpretation of these measures is
Am
what is most important. In table 13.9, the variance

e
120 + 140 = 260/2 = 130

th
and standard deviation are both fairly large val-

by
ues, which means there is great variability of the

20
Mode
20
systolic blood pressure scores around the mean.

The mode is the value that occurs most frequently
©
This makes sense since the mean is 135.8 and the

in a given set of observations or values. In the sys-
ht
scores range from 109 to 190, which does demon-

ig
tolic blood pressure scores example, the mode is

yr
strate large amounts of variability.

op
140 because it occurs more than any of the other

C
values. Sometimes data sets have two modes and

are then called bimodal. Table 13.9 Example of range, variance, and
Modes are used mostly with nominal variables, standard deviation
medians are used mainly for ordinal or ranked Statistics
variables, and the mean is used primarily with Systolic blood pressure
continuous or quantitative variables, such as inter- N Valid 6
val or ratio. Continuous and quantitative variables
Missing 0
are defined earlier in this chapter. Mean 135.8333

Standard Deviation 29.43750
Variance 866.567
Measures of Variability Range 81.00
Measures of variability examine the spread of N = Number
different values around the measures of central Source: ©AHIMA.
AB103118_Ch13.indd 407 2/6/2020 5:42:46 PM


1. Why are descriptive statistics used?
a. To illustrate the relationship between age and cause of pneumonia in patients admitted to a hospital from
2015 to 2020
b. To graph how often patients within a specific age range and gender are being readmitted due to a cardiac condition
c. To illustrate the frequency of an element such as a hemoglobin rate below 12.0 in a group of patients
d. To illustrate the relationship between cases of measles and pertussis before and after vaccination
2. Identify which of the following is not a measure of central tendency.
a. Mean
b. Mode
n.
tio
c. Percentile
ia
d. Z-score
oc
ss
3. Identify which of the following measures examine the spread of different values around the middle value.
tA
a. Measures of central tendency
en
em
b. Measures of variability
ag
c. Measures of frequency
an
d. Measures of percentile
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4. Identify which of the following measures is simple to compute and calculated by taking the difference between the
n
io
highest and lowest values.
at
m
a. Mean
r
fo
b. Median
In
lth
c. Range
ea
d. Standard deviation
H
an
5. The measure used in descriptive statistics that shows the value below which a given percentage of scores in a given
ic
group of scores fall is called a:

er
Am
a. Percentile
b. Frequency distribution
e
th
c. Standard deviation
by
d. Median
20
20
©
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ig
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Normal Distribution
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When presenting data graphically, if infinitely in both directions (positive and

the data follows a symmetrical or bell curve, then negative).
the data is termed a normal distribution. In a nor- ●● The total area under the curve equals 1, so
mal distribution, the mean, median, and mode the area of one half of the curve is equal to
are equal. An example of a normal distribution or 0.50 and the area of the other half is equal to
curve is shown in figure 13.17. 0.50. Also, the area under the curve between
The properties of a standard normal distribu- two points can be interpreted as the relative
tion include: frequency of the values included between
●● The appearance of a bell-shaped curve that those points. One standard deviation from
is symmetrical about the mean and extends the mean = 68.26 percent of the area, two
AB103118_Ch13.indd 408 2/6/2020 5:42:46 PM

standard deviations = 95.45 percent of the deviations from the mean or (2.6 x 2 = 5.2)
area, and three standard deviations = 99.74 5.2 standard deviations from 17 (17 ± 5.2) or
percent of the area under the curve.
Figure 13.17 Example of a normal curve
●● Being defined by two parameters: the mean,
Distribution Plot
m, and the standard deviation.
Figure 13.18 provides an example of a nor-
mal curve superimposed on a histogram. The
center of the distribution, or mean, is 17. (The
median and the mode also are 17.) The standard
deviation is 2.595 or, with rounding, 2.6. This
means that 68 percent of the observations in the .50 .50
frequency distribution fall within 1 standard
n.
tio
deviation from the mean or 2.6 standard devia-
ia
oc
tions from 17 (17 ± 2.6). Thus, approximately
ss
68 percent of the observations fall between 14.4 Area under the normal curve = 1
tA
and 19.6; 95 percent fall between 2 standard
en
Source: ©AHIMA.
em
ag
Figure 13.18 Example of a histogram with a normal curve
an
M
Statistics
n
Hospital LOS io
at
m
N Valid 100
r
fo

Missing 0
In
lth
Mean 17.25
ea
Median 17.00
H
Mode 17
an
ic
er
Histogram
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25 Mean = 17.25
e
Std.Dev. = 2.595
th
N = 100
by
20
20
20
©
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ig
yr Frequency
15
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10
0
10 15 20 25 30
Hospital LOS
LOS = length of stay
Source: ©AHIMA.
AB103118_Ch13.indd 409 2/6/2020 5:42:48 PM

etween 11.8 and 22.2; and 99.7 percent fall be-

b Z-scores represent the number of standard
tween 3 standard deviations from the mean or eviations above or below the mean, so a Z-score
d
(2.6 x 3 = 7.8) 7.8 standard deviations from 17 of –2.5 represents a score that is 2.5 standard
(17 ± 7.8) or between 9.2 and 24.8. deviations below the mean.
Normal distribution plays a key role in statis- For example, if a prospective employee scores
tics because many variables such as height, cho- a 95 percent on a billing exam, with an employee
lesterol, and body temperature follow a normal average of 80 percent and a standard deviation of
distribution. Determining if data follow a normal 5, using the given formula, the Z-score will be:
distribution is important because certain statis-
95 - 80
tics can be computed on data that is distributed =3
normally. One way to do this is by computing a 5
Z-score. A Z-score is a standardized unit that pro- This means that the score of 95 percent is 3 stan-
dard deviations above the mean.
n.
vides the relative position of any observation in
tio
the distribution and is also the number of standard Sometimes data do not follow a normal dis-
ia
oc
deviations that the observed value lays away from tribution and are pulled toward the tails of the
ss
the mean. Transforming the raw observations to curve. When this occurs, it is referred to as having
tA
en
Z values makes it possible to make comparisons a skewed distribution. Because the mean is sensi-
em
between distributions. Using inferential statistics tive to extreme values or outliers, it gravitates in
ag
(defined in the next section), researchers can then the direction of the extreme values, thus making
an
a long tail when a distribution is skewed. When
M
make inferences about certain types of data. In-
ferential statistics are techniques that can be used n
the tail is pulled toward the right side, it is called
io
at
to make deductions based on the evidence of the a positively skewed distribution; when the tail is
mr
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data and reasoning. pulled toward the left side of the curve it is called
In
a negatively skewed distribution. Figure 13.19

lth
Observation or x - Mean(m )
ea
Z - score = shows a positively skewed and negatively skewed

H
Standard Deviation(s) curve.

an
ic
er
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Inferential Statistics
e
th
by
20
As discussed above, inferential sta- tests, regression equations, and analysis of

20
tistics is the process of making deductions for v ariance.

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a larger population based on the statistical re-

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t-tests
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sults taken from a sample. Within this area, there

yr
op
are several methods that can be used to present A t-test is a type of inferential statistical test that
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research judgments including t-tests, chi-square can examine means or averages from a group of
Figure 13.19 Negatively skewed and positively skewed distribution
Mode Mode
Median Median
Mean Mean
Left-skewed (negative skewness) Right-skewed (positive skewness)

Source: ©AHIMA.
AB103118_Ch13.indd 410 2/6/2020 5:42:51 PM

data. The focus of a t-test is to use the mean from test is to examine if there is a difference between
a research sample group and then infer how that data gathered from a sample population.
mean would be found in the larger population. A
Number of Variables Chi-Square Test
t-test can also be conducted when looking at re-
One Chi-square goodness of fit
search study groups to determine if the means of two
Two Chi-square test for independence
groups are statistically significant. A foundational
element of t-testing is the establishment of both a
null and an alternative hypothesis. The null hypoth-
Regression Equations
esis is centered on the prediction that there will be no There are several types of regression equations:
difference found between the groups of the research simple, multiple, logistic, multinominal, and mul-
study. The alternative hypothesis is just that, a dif- tiple logistic. Regression equations are used to de-
ferent or opposite statement of the null hypothesis. termine if there is a relationship between variables
and to identify what type of relationship is present.
n.
An example of null and alternative hypotheses
tio
can be seen in a scenario where a researcher is The two types of relationship are correlation and
ia
oc
researching health information technology (HIT) predictable. In healthcare, regression equations
ss
graduates’ Registered Health Information Techni- and statistical presentations of these findings can
tA
en
cian (RHIT) exam scores and grade point averages be used to identify trends and make forecasts. An
em
(GPA). The research question could be: Do students example of the use of regression equations would
ag
with a high GPA score above the national aver- be to review data on hospital LOS and cost of care
an
during that stay. A regression equation could be
M
age on the RHIT exam? The null hypothesis is
that the students with a GPA score of 3.5 or high- n
applied to data from these elements over a period
io
at
er score above the national average on the RHIT of three years and the results used to infer or pre-
m r
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exam. The alternative hypothesis is that students dict what the trends will be for LOS and increased
In
with a GPA score of 3.5 or higher do not score above or decreased cost of care in the future.
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ea
the national average on the RHIT exam.

H
Then using a one-sample t-test, the difference be- Analysis of Variance

an
ic
tween the population mean and the research sample Another type of inferential statistical testing is
er
Am
mean can be determined. To narrow the population, analysis of variance (ANOVA). An ANOVA is a
the research sample could be the past two years of test used to find and examine the differences in the
e
th
graduates of a specific college or university-based determined averages (means) within and between
by
HIT program. The mean from their RHIT exam data groups. There are several types of ANOVAs,
20
20
results and their GPAs could then be statistically including one-way ANOVA, two-way ANOVA,
©
evaluated. The data from this sample could then be and multivariate ANOVA. An example of when
ht
ig
used statistically to form a conclusion for the overall and how an ANOVA could be used is provided at
yr
op
population of students taking the RHIT exam. The the end of this section. In general, if the researcher
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goal of the t-test is to determine if the averages be- is seeking to examine the average results of survey
tween the chosen two groups of the research study responses obtained from two groups of study par-
is statistically significant. ticipants, an ANOVA could be the statistical test to
calculate.
Chi-square Tests In the earlier example, two groups were used for
Chi-square tests are a type of inferential statistical a t-test. For an ANOVA test to be applied, three or
testing done to determine and present information more groups of data must be used. An ANOVA
on data frequency. There are two general types cannot be done with just two data groups or two
of chi-square tests: goodness of fit and test for sets of responses. Additionally, the configuration of
independence. The determining factor in choosing the data variables determines the type of ANOVA.
which chi-square test to use is the number of nomi- The two possible data variable types are depend-
nal variables. Also, the focus of using this type of ent and independent. An independent variable is
AB103118_Ch13.indd 411 2/6/2020 5:42:51 PM

defined as a research element that is changed or groups of students do not have any recorded video
controlled by the research environment or the re- lectures in their online class. The independent var-
searcher. The dependent variable is the element iable is the recorded video lectures. The dependent
being examined by the research or researcher. If variable is the students’ perception of isolation.
there are two independent variables and a contin- In the examination of the results of this study, an
uous dependent variable, then a two-way ANOVA ANOVA test would be done and presented. If the
test can be done to show differences. study has at least two dependent variables, then a
For example, a research study is being conduct- multivariate ANOVA, or MANOVA, is the statis-
ed with students enrolled in online courses as the tical test used. Using the same example as above,
participants. The students participating in the re- if an additional variable, such as the graduation
search study must complete a survey. The research rates for both groups, were added, then a MANO-
is focused on the students’ perceived sense of iso- VA would be used to show results based on hav-
n.
lation when taking online courses. One group of ing two dependent variables (students’ perceived
tio
students participating in the study have record- sense of isolation and graduation rates), neither of
ia
oc
ed video lectures in their online class. The other which are controlled by the researcher.
ss
tA
en
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ag
an
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n
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1. True or false: In a normal distribution, the mean, median, and mode are not equal.
at
m
r
2. True or false: The total area under the curve of a normal distribution equals 1.
fo
In
3. True or false: Z-scores represent the number of standard deviations above or below the mean, so a Z-score of –1.5
lth
represents a score that is 1.5 standard deviations above the mean.

ea
H
4. Determining if data follow a normal distribution is important because certain statistics can be computed on data that
an
are distributed normally. Which of the following is one type of these statistics?
ic
er
a. Mean
Am
b. Median
e
th
c. Z-score
by
d. Mode
20
5. Two standard deviations from the mean in a normal distribution equals what percent of the area?
20
a. 68.26 percent
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b. 95.45 percent
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yr
c. 99.74 percent
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d. 100 percent
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6. A curve or distribution in which the tail is pulled to the right is called which of the following types of distribution?
a. Negatively skewed
b. Positively skewed
c. Normal
d. Bimodal
7. If a student scores an 82 percent on an ICD-10-CM/PCS coding exam and the class average is 60 percent with a
standard deviation of 4, what is the Z-score and what does this tell us about the student’s coding exam score?
a. Z = 5.5; the score of 82 percent is 5.5 standard deviations above the mean
b. Z = 5.5; the score of 82 percent is 5.5 standard deviations below the mean
c. Z = 5; the score of 82 percent is 5 standard deviations above the mean
d. Z = 7.5; the score of 82 percent is 7.5 standard deviations above the mean
AB103118_Ch13.indd 412 2/6/2020 5:42:52 PM

8. True or false: An analysis of variance statistical test would be used to summarize a data sample such as gender or
reported job roles.
9. True or false: Regression is used to determine relationships between the variables.
10. True or false: A null hypothesis is an important element that must be done before conducting an ANOVA statistical test.
How to Analyze Information

After data have been collected and is on a survey, which is how the data for the proj-
reviewed, the statistical test(s) to use can be de- ect discussed were gathered. After the data have
n.
termined. This determination is based on several been analyzed, the information will be presented
tio
elements that include the research goal, the objec- to the board of the corporation. The first part of
ia
oc
tive of the presentation, and the audience seeking figure 13.20 presents the background on how the
ss
information from the data. Deciding which type data were gathered. The second portion lists the
tA
en
of descriptive statistical graphic to present (bar analysis process steps.
em
chart, pie chart, histogram, and so on) is part of
ag
the analysis process. This is also part of taking the
an
Quality, Safety, and Effectiveness
M
data and transforming it to information. In gen-
of Healthcare
eral, d
escriptive statistics are used if the intention n
io
at
of the presentation is to describe or summarize. Using data to assess quality, safety, and healthcare
m
r
fo
If the goal is to make predictions or judgments outcomes such as the effectiveness of healthcare is
In
based on the data collected, inferential statisti- prominent throughout healthcare organizations
lth
ea
cal tools can be used (Johnson and Christensen today. In fact, several federal government agen-
H
2017). The steps for information analysis include cies such as the Centers for Medicare and Medi-
an
ic
the following: caid Services (CMS) provide financial incentives

er
Am
1. Determine the objective of the information for healthcare organizations that demonstrate
high levels of quality, safety, and effectiveness
e
being presented. What are you trying to say

th
of healthcare services. Quality measures devel-

by
or show with the data? What was the research

oped by CMS are used in the pay-for-reporting
20
focused on and how does that relate to the

20
problem? programs for specific healthcare providers. The

©
Joint Commission also uses data analysis to make

ht
2. Consider who the information will be

ig
decisions regarding patient safety and other

yr
presented to. How can you make the informa-

op
measures of effectiveness of care. How is this

tion clear and concise for the audience?
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data examined and how can HIM professionals

3. Review the information on the various
assist? When the healthcare organization wants
statistical tests to determine which one fits the
to measure variations within healthcare units—
needs of your presentation.
such as identifying variability across nursing
4. Consider a team approach that includes units for the number or percentage of falls that
an individual well-versed in statistics. If occurred—a line graph would be an appropriate
working with clinical data, a person with tool. Descriptive statistics in a table can also be
a background in that area should be on the used alongside the graph to provide more detail
team. Also, consider having an editor to on the percentage of falls in total and by nurs-
review the work before it is finalized. ing unit across the healthcare organization. Qual-
Figure 13.20 illustrates how data can be ana- ity, safety, and effectiveness of healthcare are
lyzed for a presentation. In this example, the focus also assessed by many other organizations such
AB103118_Ch13.indd 413 2/6/2020 5:42:52 PM

Figure 13.20 Example of how data can be analyzed for presentation
Background:
Greenfield Corporation conducted a survey of healthcare providers in the states of Delaware, Maryland, and Pennsylvania. The
focus of the survey was on the adoption of an electronic health record (EHR) or electronic medical record (EMR) in the physician office
setting. Those surveyed where internal medicine, family practice, and allergy physicians with private office practices (the physician
practices were not owned by a healthcare network, group, or hospital entity). The goal of the survey was to determine if the physicians
had adopted an EHR/EMR in their office and if not, what the barriers were to doing so (for example, financial or psychological). Survey
questions included demographic information such as age and gender of the physician and basic information on the practice such as
number of patients seen daily and monthly.
The health information management (HIM) company of D & A Associates has been hired by Greenfield to review and present the
results of the surveys at an upcoming board meeting. The company is reviewing the results of this data as part of a strategic plan to
develop an EHR product specifically for the physician practice market that is not part of a larger health network.
Surveys were returned from 150 physicians.
n.
tio
Analysis Process:
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1. D & A Associates reviews the objective of the scheduled presentation to the Greenfield board of directors.
ss
2. D & A Associates assigns a team to this project. The team includes a team leader, an HIM professional, a statistician, an HIM assistant,
tA
and an editor.
en
3. D & A Associates reviews the data and determines if descriptive statistics should be used or if inferential statistics could be applied
em
or both. Is it enough to summarize and describe the data collected from the surveys or should judgments be made? The strategic
ag
plans of the Greenfield Corporation and its ideas for the EHR/EMR product are considered. The best way to present the data con-
an
cisely is also considered. Various statistical tests are then conducted based on the team’s d ecision.
M
4. Once these decisions have been made, drafts of the presentations are created. The team and the editor review the draft proposals before
the final board presentation.
n
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at
m
r
fo
In
lth
ea
as the National Commission for Quality Assur- Structure and Use of Health
H
ance (NCQA), which has developed Healthcare

an
Information and Healthcare Outcomes

ic
Effectiveness Data and Information Set (HEDIS)

er
Data can be structured in many ways. Health-

Am
measures; Patient-Centered Outcomes Research

care organizations collect data that can fall into
Institute (PCORI), which focuses on the patient
e
th
three different groups—individual, comparative,

and engages the patient in the all phases of research
by
and aggregate.
20
related to healthcare outcomes; and the Agency

20
for Healthcare Research and Quality (AHRQ),

Individual Data
©
whose mission is to make healthcare safer, higher

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Healthcare data that is housed within the EHR, or

ig
quality, more accessible, equitable, and afforda-

yr
data collected from a case study, a focus group of

op
ble. The American Health Information Manage-

C
ment Association (AHIMA) provides examples individuals, or during an interview or survey are
of publicly reported data by organizations such all considered individual data. This data can be
as the ones previously mentioned (AHIMA 2013). helpful in providing direct care to patients, and
Much of the data collected is considered “big for quality improvement studies or for larger de-
data” since it incorporates multiple sources from scriptive studies. However, when using this type of
not only healthcare data but also financial, geo- data to make decisions related to a certain area
graphical, and human resource data. Analysis of of healthcare by evaluating it against other levels
big data does not necessarily mean that upper of data, then it becomes comparative data.
level statistics must be used. One can start with
descriptive levels of statistics and then move on Comparative Data
to inferential statistics if the problem to be solved When individual data is organized numerically
needs this higher level of statistics. and collated to evaluate against standards or
AB103118_Ch13.indd 414 2/6/2020 5:42:52 PM

benchmarks, it is described as comparative data. and analyzed to draw conclusions about a spe-
For example, when a healthcare organization cific topic or area. For example, in a focus group
collects individual data on whether a patient ac- study, data, observation, and interview data were
quired a healthcare-associated infection, such as compiled into an aggregate format so that none
ventilator-associated pneumonia (VAP), it is first of the individuals in the multiple healthcare or-
documented in the individual patient’s EHR. ganizations that participated could be identified
Queries throughout the entire EHR system will in any way. Varying methods and skills of lead-
provide output on the number of cases of VAP ership among HIM leaders and facilities were
that develops 48 hours or longer after mechanical compared and contrasted in order to generate
ventilation is given by means of an endotracheal conclusions. However, since the focus group
tube or tracheostomy, in order to designate it as a sample was small, not all the conclusions could
healthcare-associated infection. This type of infec- be generalized (Sheridan et al. 2016). In fact, any
n.
tion is referred to as a hospital-acquired infection data compiled from samples of data have limi-
tio
(HAI). Once this data is gathered and collated, it tations since the sample of data may not accu-
ia
oc
can then be compared to other rates of VAP across rately reflect the characteristics across that entire
ss
the state, region, or nation. population. One way to reduce this is to compare
tA
en
the sample’s demographic characteristics to the
em
Aggregate Data population’s demographics (if this information is
ag
Aggregate data is when individual, comparative, available); if the characteristics prove similar, it
an
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or other multiple sources of data are compiled increases the reliability of the sample data.
n
io
at
r m
fo

In
lth
ea

H
an
1. The first step in information analysis is:

ic
er
a. Determining who the information will be presented to

Am
b. Determining the appropriate statistical test to use

e
c. Using a team with members with different skill sets

th
by
d. Determining the objective of the information

20
2. Individual data can be used to:

20
a. Compare two groups

©
ht
b. Determine relationship between variables

ig
c. Provide patient care

yr
op
d. Group data together

C
3. Comparing a healthcare organization’s death rate to the death rates of similar healthcare organizations across the
country uses ________ data.
a. Comparative
b. Individual
c. Aggregate
d. Big
4. The research study requires data to be compiled and summarized. This is _________data.
a. Individual
b. Comparative
c. Aggregate
d. Evaluative
AB103118_Ch13.indd 415 2/6/2020 5:42:52 PM

5. Analysis of big data does not necessarily mean that upper level statistics must be used. One can start with levels of
_______ statistics and then move on to _______statistics if the problem that needs to be solved requires this higher
level of statistics.
a. Inferential; descriptive
b. Descriptive; inferential
c. Random; nonrandom
d. Social; scientific
Research Methodologies
n.
There are several types of research of literature and ending with the reporting of the
tio
ia
methodologies that can be used to perform research research results.
oc
ss
on healthcare and HIM topics. Research studies
1. The literature on CAC software, anti-fraud
tA
can range from exploratory or descriptive studies
en
software within CAC systems, and the extent
that strive to generate new hypotheses based on
em
of fraud and abuse related to CAC systems
data collected to experimental studies that pro-
ag
was reviewed
an
vide interventions or treatments that can reduce
M
the spread of an existing disease. These research 2. Interviews with federal agencies were con-
n
io
ducted to gather information about instances
methodologies can be classified as quantitative,
at
of improper reimbursement or potential fraud
m
qualitative, and mixed methods. Typically, institu-

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fo
involving the use of CAC software

In
tional review boards must approve any research

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study before it is conducted. These methods and 3. A description of products was developed
ea
the institutional review board will be covered in based on a product information form com-
H
an
the next few sections. pleted by vendors

ic
4. Researchers then interviewed vendors and

er
Am
Quantitative Studies users about CAC and anti-fraud software to

e
determine how they used these products

th
Research results that are numerical in nature

by
5. Descriptive statistical results were reported

and can be illustrated with descriptive or in-
20
through matrices, flowcharts, and tables to

20
ferential statistics are quantitative and would

demonstrate the impact of automated coding
©
be a quantitative study. Types of quantitative

ht
tools on coding and billing accuracy. A model

studies include descriptive, correlational, ret-
ig
yr
was designed that summarized features,

rospective, prospective, and experimental and
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processes, and staffing (Garvin et al. 2006)

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quasi-experimental.
Descriptive Studies Correlational Studies

Descriptive studies include research that is Correlational studies are similar to descriptive
exploratory in nature and generates new hypoth- studies except that the correlational study deter-
eses from the data collected. For example, a de- mines if a relationship may exist between two
scriptive study approach was used to explore how variables. This means that the researcher will try
the use of automated coding software (computer- to determine if an increase or decrease in one vari-
assisted coding [CAC]) could be used to enhance able corresponds to an increase or decrease in the
anti-fraud activities. This study used a tradition- other variable. The purpose of performing correla-
al descriptive study approach that consisted of tional studies is to determine which variables are
the five steps that follow beginning with a review connected in some way. However, correlation does
AB103118_Ch13.indd 416 2/6/2020 5:42:52 PM

not equal causation. For example, a researcher may by recruiting subjects who also were treated by the
be interested in patterns related to whether the use same healthcare organization as the cases or were
of electronic cigarettes, or e-cigs, affects school per- friends or siblings of the cases. The more similar
formance in teenagers. To determine a correlation, the controls are to the cases for everything except
the researcher will interview teens to determine the disease under study (colon cancer), the better.
if and how often they smoke e-cigs and compare The research team would then review the women’s
this to their grades in the past month. A correlation health records to determine if they ever used ERT.
coefficient is then used to determine how strong The research team might also want to validate the
the association is between the two variables. The information found in the health records by inter-
closer the correlation coefficient is to +1 or –1, the viewing the subjects and asking them if they ever
stronger the relationship between the variables. took ERT. This type of study is also called an analyt-
A strong positive relationship (closer to +1) means ic study because it tries to determine causation, or
n.
that as one variable increases, the other also increases. whether an independent variable (ERT) produced
tio
A strong negative relationship (closer to –1) means the dependent variable (colon cancer). Statistics
ia
oc
that as one variable decreases, the other variable used to determine causation include the odds
ss
increases. Hypothetically, if the research team col- ratio or the odds of getting the disease under study
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lected data on the number of times a teen smoked if you have the determinant variable or indepen-
em
an e-cig and on their SAT score, they might find dent variable. Often the odds ratio is displayed in a
ag
that the correlation coefficient is a –0.845. The cor- two-by-two table, as shown in table 13.10.
an
M
relation coefficient of –0.845 is very close to –1. The formula used to compute the odds ratio is
This indicates a negative correlation, which in this n
io
AD/BC = (70 x 80) / (20 x 30) = 5,600/600 = 9.3
at
example means that as e-cig use increases, SAT The interpretation of this result for the odds
m r
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scores decrease. There are two types of correlation ratio is that someone who takes ERT is approxi-
In
coefficients: Pearson correlation coefficient and mately nine times more likely to get colon cancer
lth
ea
Spearman correlation coefficient. If the researcher than someone who does not take ERT.
H
collects continuous variables, then the Pearson

an
ic
correlation coefficient should be used. If ordinal or Prospective Studies

er
Am
ranked variables are collected, then the Spearman A prospective study is defined as research that
correlation coefficient should be used.
e
is designed to follow the study participants into

th
the future to see if there is a relationship that de-

by
Retrospective Studies
20
velops for the study variables. An example of a

20
A retrospective study is one in which the researcher prospective study is one in which a cohort of in-
©
is looking into the past for data; the data is histori- dividuals are followed to determine if a particular
ht
ig
cal and not currently obtained. In epidemiology, re- characteristic or risk factor(s) such as smoking or
yr
op
searchers conduct retrospective studies (also called exposure to a specific substance may be causing
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case-control studies) by reviewing records and ask- the disease or outcome under study. This type of
ing the subjects to recall past events in order to de- study does something that the retrospective, case-
termine the presence or absence of the independent control design does not—it determines whether
variable under study. This is compared in samples
Table 13.10 Example of odds ratio for the
of subjects with the disease under study (cases)
retrospective (case-control) study
and without the disease (controls). For example, if
Independent Dependent variable (colon cancer)
a researcher were interested in whether the use of
variable ERT Colon cancer No colon cancer Total
estrogen replacement therapy (ERT) caused colon
ERT use 70 (A) 30 (B) 100
cancer in postmenopausal women, they would re-
No ERT use 20 (C) 80 (D) 100
cruit a group of women with colon cancer (cases)
Totals 90 110 200
and another group of women without colon cancer
(controls) as subjects. Controls could be selected Source: ©AHIMA.
AB103118_Ch13.indd 417 2/6/2020 5:42:52 PM

the characteristic(s) or risk factor(s) under study of participants was recruited, which included the
truly preceded the disease. The prospective study grandchildren of the original cohort. Clinicians use
starts with subjects who have the risk factor (exposed many of the findings from the Framingham Heart
group) but are free of the disease and compares Study when treating CVD, since it identified ma-
them to individuals without the risk factor (unex- jor risk factors of CVD such as high blood pressure,
posed group) who are also free of the disease. The high cholesterol, smoking, lack of physical activity,
two groups are then followed to determine if and diabetes, and obesity. It was also instrumental
when the subjects develop the disease. To begin, in finding related factors that play a part in the
subjects are examined at a baseline to ensure they development of CVD, such as triglyceride and

do not have the disease when the study commenc- HDL cholesterol levels, as well as psychosocial is-
es. To do this, the researcher must collect data relat- sues, age, and gender (FHS 2015). Prospective stud-
ed to their occupation, medical history, and social ies generate incidence—the number of new cases
n.
habits. Physical exams and lab tests may also be that occurred during a specific period of time in a
tio
necessary. It is important to collect other general population at risk for developing the disease—not
ia
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characteristics such as age, sex, race, and such in the prevalence of a disease. The calculation for the
ss
addition to the characteristic of interest, in order incidence rate is given in table 13.11. Incidence
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to account for the influence of any factors known rates can then be used to calculate the relative risk
em
to be related to the disease. These are called con- (table 13.12). The formula for calculating incidence
ag
founding factors. Confounding factors are those rate follows. Incidence Rate =
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characteristics other than the characteristic of in-
Number of new casesover a time
terest that may also be related to the disease under n
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period ´1, 000
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study. If subjects cannot be correctly categorized IncidenceRate =
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Population at risk *
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into exposed and unexposed groups, the prospective

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design should not be used.

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*Those free of disease at the start of the study

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It is important to have correct classification of An example of computing the incidence rates

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exposure because if participants’ exposure to cer- and relative risk is shown as follows.
an
ic
tain elements is not correctly classified, it may lead Therefore, using this hypothetical data, one can
er
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to invalid study results. The most widely known say that the risk of developing CVD with a BMI
example of a prospective study is the Framingham
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th
Heart Study, which began in 1948, is a project of Table 13.11 Example computing the incidence rates
by
the National Heart, Lung, and Blood Institute and

20
Disease No Disease
20
Boston University, and is still in progress today Exposed (A) (B)

©
(FHS 2015). Its original goal was to identify risk

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Not exposed (C) (D)

ig
factors for cardiovascular disease (CVD) since the

yr
Totals
op
causes of heart disease and stroke were not known

C
Incidence rate of exposed = A/[A + B]

and the death rates were steadily increasing. The Incidence rate of unexposed = C/[C + D]
researchers decided to study this over a long pe- Relative risk: [A/(A + B)]/[C/[C + D]]
riod of time using a large group of participants Source: ©AHIMA.
who had not yet developed CVD or had a heart at-
tack or stroke. The researchers recruited 5,209 men Table 13.12 Example of computing relative risk
and women between the ages of 30 and 62 from CVD No CVD
Framingham, Massachusetts, and started physi- BMI > 27 50 (A) 20 (B)
cal exams and interviews to determine any type of BMI < 27 10 (C) 60 (D)
CVD. The participants returned to the study every Totals 60 80
two years for follow-up physical exams, lab tests,
Incidence rate of exposed = A/(A+B) = 50/(50+20) = 0.71
and so forth, and in 1971 the researchers enrolled a
Incidence rate of unexposed = C/(C + D) = 10/(10 + 60] = 0.14
second-generation cohort of the participants’ adult Relative risk: [A/(A + B)]/[C/(C + D)] = 0.71/0.14 = 5.1
children and spouses. In 2002, a third generation Source: ©AHIMA.
AB103118_Ch13.indd 418 2/6/2020 5:42:53 PM

greater than 27 is approximately 5 times that of ●● Eligibility of appropriate participants

developing CVD with a BMI less than 27. The dif- (inclusion and exclusion criteria)
ference between the odds ratio and the relative risk ●● Randomization
is that the odds ratio is an estimate of the risk since ●● Ethical issues
the study from which it was taken is based on ret-
rospective data. The relative risk from a prospective Eligibility of appropriate participants includes
study is considered “true risk” since it demonstrates the development of certain criteria so that the prop-
that the risk factor under study came before the dis- er participants are recruited for the experimental
ease since participants were followed to collect the study. For example, in a study entitled, “Evaluation
data and, therefore, determine the risk of disease. of a Stepped Care Approach to Manage Depression
in Diabetes” some of the inclusion criteria include
Experimental Studies the following:
n.
The experimental study design is the most pow-
tio
erful when trying to establish cause and effect. ●● Age greater than or equal to 18 and less than
ia
oc
In healthcare, experimental research studies can or equal to 70
ss
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entail exposing participants to different inter- ●● Diabetes mellitus
en
ventions in order to compare the results of these ●● Elevated depressive symptoms
em
interventions with the outcome. The intervention
ag
may include testing experimental drugs, new ap- Some of the exclusion criteria include the
an
f ollowing:
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proaches to surgery, or other types of interventions
n
such as smoking cessation treatments. Experimen- io
Severe depressive episode
at
●●
m
tal studies can also be referred to as clinical tri-

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Current psychotherapeutic or psychiatric

fo
●●
als. The National Institutes of Health (NIH) has a
In
treatment
service that provides a registry and a database of
lth
ea
results of clinical trials that have been conducted ●● Current anti-depressive medication
H
or are currently being conducted across the world Severe physical illness (that is, cancer,
an
●●
ic
(NIH 2015a). Pretests and posttests are used in ob- multiple sclerosis, dementia)
er
Am
servational experimental research. The pretest is ●● Terminal illness (NIH 2015b)

performed to determine the baseline level of the
e
th
independent variable under study and the post-

by
test is determined to measure the same independ- Quasi-Experimental Studies

20
20
ent variable after the intervention. For example, The quasi-experimental study is similar to the
©
blood pressure is taken before and after an ex- experimental study except that randomization of
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ig
perimental medication is used as the intervention participants is not included in a quasi-experimen-

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op
in a sample of participants that were previously tal study. Also, the researcher may not manipulate
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unable to control their blood pressure with other the independent variable and there may be no
medications. The independent variable is the ex- control or comparison group. Quasi-experimental
perimental medication and the dependent varia- studies can be performed over time and may not
ble is the blood pressure. In experimental research include individual participants but whole health-
studies like clinical trials, researchers must pay at- care systems. For example, researchers performed
tention to many things, but three main areas are a quasi-experimental study to examine the associ-
extremely important because experiments are a ation between implementation of a certified outpa-
part of this study design. For healthcare, there are tient EHR and control of diabetes in patients with
several important factors since experimental or the disease. They implemented the EHR across
clinical trials involve human participants. These 17 medical centers and then tested the difference in
factors are the following: certain lab tests before and after implementation.
AB103118_Ch13.indd 419 2/6/2020 5:42:53 PM

They found the EHR improved drug treatment all the previous research and possibly the research-
intensity, monitoring, and control for patients with ers that have defined and discussed information
diabetes (Reed et al. 2012). governance. Data collection may include several
types of data—qualitative, quantitative, or a mix-
Qualitative Research ture of both—in the particular topic area. Data
can be from sources such as articles, news reports,
Qualitative research designs involve collecting
pictures, photographs, videos, recordings, and the
types of data that reflect a participant’s percep-
like. It can also include conversing with individu-
tions, feelings, or attitudes about a certain subject.
als or groups. For example, to learn more about in-
The methods used to collect qualitative data can
formation governance, the researcher may choose
include observations, focus groups, case studies,
leaders in the field of IG and create focus groups of
informal conversational interviews, and in-depth
individuals with a background in IG and ask them
interviews. An example of observation can be as
n.
questions about the topic. In grounded theory,
tio
simple as taking time to observe a physical ob-
the researcher codes the data as it is collected and
ia
ject on your desk at home or at work. Look at the
oc
makes memos and observations simultaneously
ss
object in relation to its shape, size, color, material
so that at the end of this refining process, the re-
tA
composition, and its purpose and write these ob-
en
search is used to develop a theory. It is also impor-
servations down. This also can be performed in an
em
tant that the researcher be familiar with literature
ag
HIM department, where the researcher observes
on the topic so that his or her theory coincides with
an
how coders react to their first exposure to the use
M
what is currently published and accepted. The re-
of a clinical documentation improvement software
n
io
searcher’s theory is then published or presented
system. The researcher could observe them as they
at
in a model that can be used by others to conduct
m
are trained on the information system or as they

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further research in that area.

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use the information system and then document

lth
their observations. Qualitative research is chosen

ea
Ethnography
because it can provide robust data on a new topic
H
Ethnography is a methodology where the research-

an
or it can provide background for larger studies on

ic
er delves into a particular culture or organization

er
the same topic. Grounded theory and ethnography

Am
in great detail in order to learn everything there is

are explained in more detail since HIM profession-
to know about them and to develop new hypoth-
e
th
als may find themselves conducting research in

eses. Ethnography is not objective and includes
by
these areas.
opinions of the researcher. No two ethnographers
20
20
will examine a specific culture or organization the

©
Grounded Theory same way. Ethnography’s focus is on people, cul-

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Grounded theory is a research method that enables ture, and life. The researcher takes notes while out
yr
op
the researcher to develop a theory that is substan- in the field observing the people and their experi-
C
tiated or confirmed by the data. It is a systematic ences in a particular culture, so the researcher can
method that can use multiple methods (both quan- create a more thorough and specific description
titative and qualitative findings) and pull it all of all interactions, experiences, perceptions, and
together to develop a theory. Because it includes opinions. In one particular example of an ethno-
data collected through methods such as convers- graphic study, a researcher examined the social re-
ing with subjects on a specific topic, it is usually lationship between a physician and patient as the
categorized under qualitative research, but it can patient is diagnosed with clinical illness. The spe-
also include quantitative information (Grounded cific aims of the research were to identify and de-
Theory Institute 2014). First, the researcher should scribe the most important social practices between
identify the topic area such as information urologists and patients as they are diagnosed
governance (IG). The researcher will then consult with cancer. The researcher worked in urology
AB103118_Ch13.indd 420 2/6/2020 5:42:53 PM

offices and hospitals primarily using participant ●● Focusing the research within philosophical
observation to collect his data, which is one of the and theoretical positions (Creswell et al. 2011)
primary tools of ethnographic research. He found
According to a report sponsored by the NIH,
that a healing relationship between the patient
mixed-methods research is more than collecting
and clinician emerged as the diagnosis unfolded
qualitative data from interviews or observations
(Meza 2013).
or gathering multiple types of quantitative evidence
through surveys and diagnostic tests (Creswell et al.
Mixed-Methods Approach 2011). It involves the intentional collection of both
A mixed-methodology approach includes using quantitative and qualitative data in order to com-
both quantitative and qualitative data in a research bine the strengths of both to answer the research
study design. According to the published report questions. Mixed-methods research designs are
sponsored by the NIH Office of Behavioral and usually performed when qualitative or quantitative
n.
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Social Science Research, mixed-methods research data alone are not sufficient to answer the research
ia
includes the following aspects: question. For example, if an HIM professional
oc
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wanted to explore the underutilization of the can-
tA
●● Using research questions that focus on
cer registry at one healthcare organization, he or
en
real-life, multilevel perspectives, across
she could first collect quantitative data on the
em
many cultures
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number of requests the cancer registry received.
an
●● Using multiple methods (for example, However, more qualitative informal interviews
M
intervention trials and in-depth interviews) with physicians and other potential users may also
n
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Integrating these multiple methods or com be needed. Therefore, a mixed-methods approach
at
●●
m
bining them to extract the strengths of each would be the best research design in this case.
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Randomization
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When study participants are ran- before they were randomized into the experi-
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domly chosen to be in the experimental, control, mental or control group. They would then pro-
by
or comparison group using an indiscriminate vide the medication over a period of time and
20
20
method, so each participant has an equal chance collect data via interviews on the anxiety levels
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of being selected for one of the groups, it is called of participants in both the experimental and con-
ht
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randomization. Randomization is important in trol groups. Anxiety level data should provide a
yr
effectively testing whether the specific inter- score that can be compared pre- and post-inter-
op
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vention made a difference in the outcome of the vention. Once this data is collected, the difference
disease. For example, if researchers wanted to in the average anxiety scores can be compared
determine whether an experimental medication before and after the intervention in both the ex-
made a difference in a person’s anxiety level, perimental and control groups. The paired t-test
they would recruit participants who were diag- is a statistical test that can be used to determine
nosed with anxiety and then randomly assign if the differences seen pre- and post-intervention
them to a group that will take the experimen- are significantly different statistically and not
tal drug or a group that will take a placebo or due to chance. If significant values are found
pill that does not include the experimental drug. more in the experimental group than in the con-
The researchers would also collect pretest data trol group, then the researchers can conclude
on participants’ anxiety level through interviews that the experimental drug was successful.
AB103118_Ch13.indd 421 2/6/2020 5:42:53 PM


Match the research study design with its appropriate description.
1. Uses a combination of quantitative and qualitative data
2. Exploratory, generates new hypotheses
3. Determines if a relationship exists between two variables
4. Another name for case-control study
5. The Framingham Heart Study is an example
6. Uses randomization to determine who receives the medication under study
7. Type of study used when examining the impact of the implementation of an EHR on outcomes of diabetes patients
n.
8. Studies a particular culture in great detail
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9. Uses multiple methods to determine a new theory
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10. Collect robust types of data
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a. Qualitative research
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b. Quasi-experimental study
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c. Retrospective study
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d. Prospective study
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f. Ethnography
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g. Experimental study
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h. Grounded theory
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i. Descriptive study
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j. Correlational study
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Institutional Review Board

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20
©
The Department of Health and Hu- most closely related to HIM fall into the follow-
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man Services (HHS) describes the role of the ing three main categories:
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Institutional Review Board (IRB) as one that

1. Research conducted in an educational setting
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protects human subjects involved in research

involving normal education practices such as
activities. The IRB determines whether research
testing different teaching methods
conducted on human subjects is appropriate
2. Research that includes using tests, interviews,
and protects the participants’ rights. The major
or observations, unless identifiable and pose
focus of the IRB is not whether the research is
risks
appropriate for the organization or researcher to
conduct, but that it contains all the appropriate 3. Collection or study of existing data or
protections for human subjects involved in the specimens as long as it has been deidentified
research (45 CFR 46). There are three major cat- (45 CFR 46)
egories for IRB review and approval, and they Expedited research includes those studies
include exempt, expedited, and full board ap- that pose only minimal risk to human subjects;
proval. Exempt research activities that are the e xamples include those studies that collect

AB103118_Ch13.indd 422 2/6/2020 5:42:53 PM

identifiable information on human subjects that the exempt category, then the researcher does not
may include sensitive information such as iden- have to renew the study annually, as they must do
tifiable health information on subjects that are under expedited and full board reviews. Also, in-
HIV positive. formed consent is normally not required under ex-
Full board approval is required for those studies empt research as it is for expedited and full board
that do not fall under exempt or expedited. Most study reviews (45 CFR 46).
of the studies performed by HIM professionals are Researchers should always remember that when-
categorized as exempt or expedited. It is best to ever any human subjects are used in research, the
meet with a member of the IRB at the healthcare IRB should be consulted, and the research protocol
organization to determine under which category should be submitted to the organization’s IRB for
the research study would fall. Once the review cat- review and approval. Even if research is conducted
egory is determined, the researcher must then sub- on individuals that are not patients—such as inter-
n.
mit their research protocol to the IRB for review viewing employees, students, or even collecting
tio
and approval. This takes about two weeks and if data on human subjects from existing records—
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a decision is made that the research falls under IRB approval should still be obtained.
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Healthcare Research Organizations
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There are many types of healthcare emerging health threats and disparities (CDC
n
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research organizations that conduct, promote, 2014). The CDC employs researchers to meet
at
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or support research across the healthcare system. many of these goals, but they also provide funding
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fo
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The Centers for Disease Control and Prevention and support to other researchers who can then use
lth
(CDC), the World Health Organization (WHO) grants to conduct research to meet their objectives.
ea
and the Agency for Healthcare Research and The CDC and the National Center for Health Sta-
H
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Quality (AHRQ) are all key healthcare research tistics provides mounds of data, statistical reports,
ic
er
organizations. Their roles in healthcare research and surveys that can be used to conduct research
Am
are discussed in the following sections. as well (CDC 2015).

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Centers for Disease Control World Health Organization

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and Prevention
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The World Health Organization (WHO) works

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The Centers for Disease Control and Prevention to direct and coordinate authorities on inter-
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(CDC) is a US government agency whose mission national health through the United Nations.
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is to collaborate with the public to create the exper- WHO’s health-related focus areas include the
C
tise, information, and tools people and communi- following:

ties need to protect their health, through health ●● Health systems
promotion, prevention of disease, injury, and dis-
●● Noncommunicable diseases such as heart
ability, and preparedness for new health threats.
disease, cancer, stroke, diabetes, chronic lung
The CDC does this by confronting global diseases
disease, and mental health conditions
such as helping to combat the recent Ebola virus
outbreak, tracking diseases (like influenza and ●● Promoting health throughout the course
foodborne outbreaks) to find out what is causing of life to include environment and social
individuals to become ill, helping healthcare orga- determinants of health as well as gender,
nizations, and cultivating public health. The CDC’s equity, and human rights
role extends to public health workforce devel- ●● Communicable diseases such as HIV,
opment and providing processes for monitoring tuberculosis, and malaria
AB103118_Ch13.indd 423 2/6/2020 5:42:53 PM

●● Preparedness, surveillance, and response provides funding to researchers to perform

through emergencies that occur worldwide research that is patient-centered and patient-
●● Corporate services that include all of WHO’s engaged. Every research study funded
tools, functions, and resources by PCORI must include patients within
all aspects of the research methodology
WHO provides data, publications, and funding process
support to researchers across the world (WHO ●● Making healthcare safer by preventing
2015).
healthcare-associated infections (HAI),
accelerating patient safety in healthcare
Agency for Healthcare Research organizations, reducing harm associated
and Quality with obstetrical care, improving safety and
The Agency for Healthcare Research and Qual- reducing medical liability, and accelerating
n.
ity (AHRQ) is a federal agency within HHS whose patient safety in nursing homes
tio
mission is to make healthcare safer, higher quality,
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●● Increasing accessibility to healthcare
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more accessible, equitable, and affordable, and to
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●● Improving healthcare affordability,
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work within HHS and with other partners to make
efficiency, and cost transparency through
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sure that the evidence is understood and used. Its
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improved data measures and public
priority areas of focus include the following:
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reporting strategies
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●● Improving healthcare quality by accelerating
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implementation of patient-centered Similar to the CDC and WHO, AHRQ also pro-
io
at
outcomes research (PCOR). This priority vides multiple sources of data, information, fund-
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is being met through the Patient-Centered ing, and support to researchers in the healthcare
fo
In
Outcomes Research Institute (PCORI), which sector (AHRQ 2015).

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Ethics in Research
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Ethics, as discussed in chapter 21, participants and how to reduce the potential
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Ethical Issues in Health Information Management, of risk.

by
are a set of principles used for both under- The American Educational Research Associa-
20
20
standing and decision-making. In the arena of tion (AERA) has published a code of ethics that
©
research, ethics center on the treatment of re- outlines the professional competence and respon-
ht
search participants and the professional actions sibilities of researchers (AERA 2018). The first prin-
ig
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of the researcher (Johnson and Christensen ciple is professional competence, which includes
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2017). “Treatment of research participants is researchers understanding their limits and striv-
the most important and fundamental issue that ing to provide an excellent work product (AERA
researchers confront. Conduct of research with 2011). Additionally, NIH also provides guidance
humans has the potential for creating physical for ethical research. The seven elements per the
and psychological harm” (Johnson and Chris- NIH include validity, informed consent, respect
tensen 2017 128). A key word in this statement for participants, review of risk-benefit, subject se-
is potential. Research can be designed and con- lection, social/clinical worth, and independent
ducted in a way to reduce participant risk. All assessment (NIH n.d.). After researcher training,
researchers should have training in how to the IRB process is a vital element to ensure the
conduct ethical research. This training should planned research is being created and conducted
include how to communicate risk to potential in an ethical manner.
AB103118_Ch13.indd 424 2/6/2020 5:42:54 PM

HIM Roles
The roles for HIM professionals in data collection and analysis, which is part of
r esearch are evolving. AHIMA provides a career research.
map (https://my.ahima.org/careermap) that This evolving change for HIM professionals is
highlights career pathways that include aspects also evidenced by the focus of AHIMA Founda-
of emerging research roles such as provider re- tion’s research journal, Perspectives in HIM. This
imbursement analyst, informatics researcher, and online journal provides an avenue for publishing
data analytic mapping specialist. For additional research related to the HIM field. The objective of
information on the AHIMA Career Map, refer to this journal is twofold: to provice a way to connect
chapter 1, Health Information Management Profes- research to the daily functions of HIM profession-
sion. Research can be part of many jobs and roles. als and to provide a method to support interpro-
n.
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Having a research mindset and skill set can be fessional collaboration that will allow for HIM to
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useful in many capacities that are part of various be a vital element of the healthcare landscape mov-
ss
HIM job functions. Roles such as HIM depart- ing forward (Perspectives in Health Information
tA
en
ment manager and coding manager can include Management n.d.).
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at
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1. Which of the following examines research study plans to determine appropriateness for human subjects?
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a. AHIMA
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b. IRB
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c. NIH
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d. WHO
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2. An HIM researcher would most likely be involved in _________ IRB research.

by
a. Exempt
20
b. Expedited
20
c. Full board approval

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d. HIM does not do IRB research

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3. This type of research includes those studies that pose only minimal risk to human subjects.
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a. Exempt
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b. Expedited
c. Full board approval
d. Clinical trial research
4. Maria Smallwood is an HIM researcher. Maria is seeking data that will allow her to benchmark her healthcare
organizations against others in the prevention of disease and injuries. Identify which of the following organizations
listed can provide the data Maria is seeking.
a. ADRQ
b. AHIMA
c. CDC
d. WHO
AB103118_Ch13.indd 425 2/6/2020 5:42:54 PM

5. Identify which of the following organizations provides funding for research that is focused on patient engagement and
is patient centered.
a. CDC
b. HHS
c. PCORI
d. WHO
6. The ___________ strives to improve the quality and accessibility of healthcare.
a. CDC
b. AHRQ
c. WHO
d. HHS
7. The organization whose primary focus is improving healthcare across the world is the:
a. CDC
n.
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b. WHO
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c. AHRQ
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d. Joint Commission
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8. Patients must be involved in the design of the research study if the researcher is to receive funding from which of the
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following organizations?
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a. PCORI
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b. CDC
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c. WHO
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d. AHA
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ea

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Researchers were interested in as- ●● Estrogen receptor analysis

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sessing the relationship between obesity and ●● Progesterone receptor analysis

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breast cancer recurrence and fatality in postmeno- ●● Site of distant metastasis

by
pausal African-American and Caucasian women

20
with primary breast cancer. Data was collected on

●● First course of treatment (surgery, radiation,
20
women with primary breast cancer and included chemotherapy)

©
Additional treatment
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the following variables: ●●

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●● Five-year recurrence and survival rates

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●● Age
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●● Age at diagnosis of breast cancer Recurrence and survival status were determined
●● Weight by reviewing the cancer registry follow-up data
and health record information across the multiple
●● Height
healthcare sites involved in this study. The cancer
●● Data of diagnosis of breast cancer registries were accredited by the American College
●● Menopausal status of Surgeons and used active follow-up on all cancer
●● Diagnosis and coding of tumor patients. Postmenopausal status was determined
(histopathology and topography) as subjects older than 55 years. In subjects younger
●● Stage of tumor than age 55, postmenopausal status was determined
by consulting the cancer registry data and health re-
●● Size of tumor
cords (hospital and physician office). Premenopau-
●● Number of positive lymph nodes sal patients and patients whose menopausal status
AB103118_Ch13.indd 426 2/6/2020 5:42:54 PM

could not be determined from the data were ex- diagnosis only. Values greater than 27 were con-
cluded from the study. Body mass index (BMI) sidered to indicate obesity. The effect of weight
was based on height and weight collected from changes during the follow-up period was not
the health record or cancer registry at the date of evaluated.

An HIM Director for a large health- maintain AHIMA’s continuing education unit
care network is seeking to increase the HIM (CEU) requirements. The director has researched
budget and add departmental line items for two information on the cost, the various credentials
areas: the e mployees’ annual HIM membership within the HIM departments for the network,
n.
cost and professional development training. The and the needs in terms of professional develop-
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healthcare network is comprised of 3 acute-care ment for the next fiscal year. The HIM employee
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hospitals, 30 physician office practices, and 2 re- composition is the following:
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habilitation centers. There are HIM employees
en
at each hospital and rehab center, and there is a ●● 50 HIM employees
em
centralized HIM office for the physician practic-
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●● 3 with CHDA credential
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es. In total, there are 50 HIM employees, all with
M
various levels of certification from CCA to RHIA. ●● 2 with CDIP credential
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Currently, the healthcare network does not pay
at
●● 15 with CCS credential
m
for the annual AHIMA membership cost. Nor

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does the network provide in-house professional 20 with RHIT credential

In
●●
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development opportunities for HIM employees.

10 with RHIA credential
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●●
However, the network will only hire HIM staff
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with credentials and requires that the employees ●● 30 with more than one credential
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References
20
20
©
Agency for Healthcare Research and Quality. 2015. American Psychological Association. 2012. Publication
ht
http://www.ahrq.gov/. Manual of the American Psychological Association, 6th ed.

ig
yr
American Educational Research Association. 2018. Washington, DC: APA.

op
Research Ethics. https://www.aera.net/About- Brewer N.T., M.B. Gilkey, S.E. Lillie, B.W. Hesse, and
C
AERA/Key-Programs/Social-Justice/Research-Ethics. S.L. Sheridan. 2012. Tables or bar graphs? Presenting

American Educational Research Association. 2011 test results in electronic medical records. Medical
(February). Code of Ethics. https://www.aera.net/ Decision Making 32(4):545–553.
Portals/38/docs/About_AERA/CodeOfEthics(1).pdf. Centers for Disease Control and Prevention. 2015.
American Health Information Management http://www.cdc.gov/about/organization/mission.htm.
Association. 2017. Pocket Glossary of Health Information Centers for Disease Control and Prevention. 2014
Management and Technology, 5th ed. Chicago: AHIMA. (April). Mission, Role and Pledge. https://www.cdc.
American Health Information Management gov/about/organization/mission.htm.
Association. 2013. Understanding publicly Centers for Disease Control and Prevention. 2012.
available healthcare data. Journal of AHIMA 84(9): Principles of Epidemiology in Public Health Practice, 3rd
expanded web version. http://library.ahima.org/ ed. http://www.cdc.gov/ophss/csels/dsepd/ss1978/
doc?oid=300183#.VxE-MvkrK9I. ss1978.pdf.
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Centers for Disease Control and Prevention. 2004. Johnson, R. B. and L. Christensen. 2017. Educational
Prevalence of overweight and obesity among adults Research: Quantitative, Qualitative, and Mixed
with diagnosed diabetes–United States, 1988–1994 Approaches, 6th ed. Washington, DC: SAGE
and 1999–2002. MMWR Morbidity and Mortality Weekly Publications.
Report 53:1066–1068. Meza, J.P. 2013. The Diagnosis Narratives and the Healing
Centers for Medicare and Medicaid Services. 2016. Ritual [dissertation]. Paper 848. Detroit, MI: Wayne
National Health Expenditure Data. https://www.cms. State University.
gov/Research-Statistics-Data-and-Systems/Statistics- National Institutes of Health. 2015a. ClinicalTrials.gov.
Trends-and-Reports/NationalHealthExpendData/ https://clinicaltrials.gov/ct2/home.
index.html.
National Institutes of Health. 2015b. Evaluation of
Centers for Medicare and Medicaid Services. 2014. a Stepped Care Approach to Manage Depression
Inpatient Prospective Payment System (IPPS) in Diabetes, https://clinicaltrials.gov/ct2/show/
Provider Summary. https://data.cms.gov/Medicare/ NCT01812291.
Inpatient-Prospective-Payment-System-IPPS-
n.
National Institutes of Health. n.d. Guiding Principles
tio
Provider/97k6-zzx3.
for Ethical Research. https://www.nih.gov/health-
ia
oc
Creswell, J.W., A.C. Klassen, V.L. Plano Clark, and information/nih-clinical-research-trials-you/guiding-
ss
K.C. Smith for the Office of Behavioral and Social principles-ethical-research.
tA
Sciences Research. 2011 (August). Best Practices for
en
Mixed-Methods Research in the Health Sciences. https:// Perspectives in Health Information Management, n.d.
em
www2.jabsom.hawaii.edu/native/docs/tsudocs About. https://perspectives.ahima.org/about-the-
ag
/Best_Practices_for_Mixed_Methods_Research_ journal/.
an
Aug2011.pdf. Productivity-Quality Systems. 2015. Pareto Diagram.
M
n
Forrestal, E. J. 2017a. Research Frame and Designs. http://www.pqsystems.com/qualityadvisor/
io
at
Chapter 1 in Health Informatics Research Methods: DataAnalysisTools/pareto_diagram.php.
m
r
Principles and Practice, 2nd ed. Edited by V. Watzlaf and Reed, M., J. Huang, I. Graetz, R. Brand, J. Hsu,
fo
In
E. J. Forrestal. Chicago: AHIMA Press. B. Fireman, and M. Jaffe. 2012. Outpatient electronic
lth
Forrestal, E. J. 2017b. Applied Statistics. Chapter 9 health records and the clinical care and outcomes
ea
of patients with diabetes mellitus. Annals of Internal

H
in Health Informatics Research Methods: Principles

Medicine 157(7):482–489.
an
and Practice, 2nd ed. Edited by V. Watzlaf and E. J.

ic
Forrestal. Chicago: AHIMA. Sheridan, P., V. Watzlaf, and L. Fox. 2016. HIM
er
Am
Framingham Heart Study. 2015. A Project of the Leaders and the practice of leadership through the
lens of Bowen theory. Perspectives in Health Information
e
National Heart, Lung and Blood Institute and Boston

th
University. https://www.framinghamheartstudy.org/. Management. Spring.

by
Watzlaf, V., Z. Alakrawi, S. Meyers, and P. Sheridan.

20
Garvin, J.H., V. Watzlaf, and S. Moeini. 2006.

20
Development and Use of Automated Coding Software 2015. Physicians’ outlook on ICD-10-CM/PCS and
©
to Enhance Anti-fraud Activities. Perspectives in Health its effect on their practice. Perspectives in Health
ht
Information Management, CAC Proceedings. http:// Information Management. Winter:1–23.

ig
yr
library.ahima.org/PdfView?oid=65240. World Health Organization. 2015. http://www.who.int/en/.

op
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Grounded Theory Institute. 2014. http://www. 45 CFR 46: Basic HHS policy for protection of human
groundedtheory.com/what-is-gt.aspx. research subjects. 2009.
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Chapter
14
n.
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Healthcare Statistics
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Marjorie H. McNeill, PhD, RHIA, CCS, FAHIMA
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Learning Objectives
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•• Explain the meaning of measurement and the data •• Calculate community-based morbidity and
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In
collection process mortality rates

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•• Differentiate among nominal-level, ordinal-level, •• Calculate the case-mix index

ea
interval-level, and ratio-level data •• Calculate ambulatory care statistical

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•• Identify various ways in which statistics are used in data

an
healthcare •• Calculate population-based statistics

ic
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•• Explain hospital-related statistical terms •• Differentiate between incidence and prevalence

Am
•• Calculate hospital-related inpatient and outpatient rates

e
statistics •• Calculate incidence and prevalence rates

th
by
•• Differentiate between community-based morbidity •• Identify the use of the National Notifiable Diseases
and mortality rates Surveillance System
20
20
©
Key Terms
ht
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Ambulatory care Consultation rate Hospital-acquired (nosocomial)

yr
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Ambulatory surgery center/ Continuous data infection rate

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ambulatory surgical center (ASC) Coroner Hospital autopsy

Average daily census Crude birth rate Hospital autopsy rate
Average length of stay (ALOS) Crude death/mortality rate Hospital death rate
Bed count Daily inpatient census Hospital inpatient
Bed count day Discrete data Hospital inpatient autopsy
Bed turnover rate Emergency patient Hospital newborn inpatient
Case fatality rate Encounter Hospital outpatient
Case mix Fetal autopsy rate Incidence rate
Case-mix index (CMI) Fetal death (stillborn) Infant mortality rate
Cause-specific mortality rate Fetal death rate Inpatient admission
Census Gross autopsy rate Inpatient bed occupancy rate
Clinic outpatient Gross death rate (percentage of occupancy)
429
429
AB103118_Ch14.indd 429 2/7/2020 12:24:06 PM

Inpatient discharge Net death rate Postoperative infection rate

Inpatient service day (IPSD) Newborn (NB) Prevalence rate
Interval-level data Newborn autopsy rate Proportion
Length of stay (LOS) Newborn death rate Proportionate mortality rate (PMR)
Maternal death rate (hospital Nominal-level data Rate
based) Nosocomial (hospital-acquired) Ratio
Maternal mortality rate infection Ratio-level data
(community based) Notifiable disease Referred outpatient
Measurement Occasion of service Scales of measurement
Medical examiner (ME) Ordinal-level data Surgical operation
National Vital Statistics System Outpatient Surgical procedure
(NVSS) Outpatient visit Total length of stay
Neonatal mortality rate Population-based statistics (discharge days)
Net autopsy rate Postneonatal mortality rate Vital statistics
n.
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Complete and accurate information is at the heart either continuous or discrete. Continuous data are
ia
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of good decision-making. The health information those that represent measurable quantities but are
ss
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management (HIM) professional is responsible for not restricted to certain specified values while dis-
en
ensuring that data collected are accurate and orga- crete data represent separate and distinct values
em
nized into information that is useful to healthcare or observations. These characteristics influence
ag
decision makers. the type of graphic technique used to display the
an
M
The primary source of clinical data in a health- data and the types of statistical analyses that can
n
care organization is the health record. To be useful io
be performed. Weight, height, and temperature
at
m
in decision-making, data taken from the health re- are examples of continuous data. The number of
r
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cord must be as timely, complete, and accurate as students in a class and the number of new cancer
In
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possible. Secondary sources of data are generated cases are examples of discrete data.
ea
by abstracting data from the health record and plac- Nominal-level data fall into groups or categories.
H
ing it into an index, registry, or database. Data are This is a scale that measures data by name only. The
an
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compiled in various ways to help make decisions groups or categories are mutually exclusive; that is,
er
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about patient care, the healthcare organization’s a data element cannot be classified to more than one
financial status, and for planning for the future of group. Some examples of nominal data collected in
e
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the healthcare organization. This chapter discusses healthcare are related to patient demographics such
by
20
common statistical measures and types of data used as mailing address, race, or gender. There is no or-
20
by organizations in different healthcare settings. A der to the data collected within these categories.
©
discussion of normal distribution and descriptive Data that fall on the ordinal scale have some
ht
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statistics is given, chapter 13, Research and Data inherent order, and higher numbers are usually
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Analysis, also covers these topics in more detail. associated with higher values. In ordinal-level
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Before discussing statistical measures used in data, the order of the numbers is meaningful, not
healthcare, it is important to define measurement the number itself. Staging of Parkinson’s disease
and how collected data are classified. Measurement is an example of a variable that has order. Parkin-
refers to the systematic process of data collection, son’s disease is often classified in five stages—
repeated over time or at a single point in time. The with stage I showing mild symptoms, to stage V
process of collecting the data must be consistent in that takes over a patient’s physical movements.
order to ensure the results are the same no matter In this example, the higher number is associated
who is collecting the data. If there is consistency with the most severe type of symptoms; how-
in the data collection, comparisons can be made ever, we cannot measure the difference between
within and across organizations. the levels in exact numerical terms. A Likert scale
Data collected falls on one of four scales of is often used in this level of measurement. A Lik-
measurement: nominal, ordinal, interval, or ratio. ert, or rating, scale is commonly used in question-
Furthermore, the data collected is described as naires to gather data. It primarily has five potential
AB103118_Ch14.indd 430 2/7/2020 12:24:07 PM

choices (strongly agree, agree, neutral, disagree, Table 14.1 Scales of measurement
strongly disagree) but will sometimes include 10 Scale of measurement Examples
or more (BusinessDictionary.com 2019). Nominal Name, gender, race
The most important characteristic of interval- Ordinal Likert scale (a rating scale),
level data is that the intervals between successive anything that is ordered
values are equal. On the Fahrenheit scale, for ex- Interval Temperature
ample, the interval between 20°F and 21°F is the Ratio Age, height, length of stay
same as between 21°F and 22°F. But because there Source: © AHIMA.
is no true zero on this scale, it is not appropriate to
say that 40°F is twice as warm as 20°F. ratio character, but addition of a constant to a ratio
In ratio-level data there is a defined unit of mea- measure does. For example, if two days is added to
sure and a real zero point, and the intervals between each LOS so that the stays are eight and five days
n.
successive values are equal. A real zero point means respectively, the ratio of their stays is no longer 2:1.
tio
there is an absolute zero. Only when a zero on a scale However, if the respective lengths of stay is multi-
ia
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truly means the total absence of a value can the scale plied by two (for example, 6 × 2 and 3 ×2), the ratio
ss
be described as ratio-level. For example, consider
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between the two lengths of stay remains 2:1.
en
the variable length of stay (referring to the time a This fourfold structure is a useful classification
em
patient is in a healthcare organization). Length of for data and the four levels are hierarchically
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stay (LOS) has a defined unit of measurement, day, arranged so that higher levels include the key
an
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and a real zero point—0 days. Because there is a real properties of the levels so that ratio-level data
zero point, we can state that a LOS of six days is n
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include the three key properties found in nominal,
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twice as long as a LOS of three days. Multiplication ordinal, and interval level data. Table 14.1 lists the
m r
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on the ratio scale by a constant does not change its scales of measurement and examples.
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Discrete versus Continuous Data

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er
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Another way to classify data involves same as the difference between four and five; and
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categorizing them as either being discrete or continu- the number of births is restricted to whole num-
by
ous. Data that are nominal or ordinal are also consid- bers (a woman cannot give birth 2.3 times). For the
20
20
ered discrete. Discrete data are finite numbers; that most part, measurements on the nominal and or-
©
is, they can have only specified values. The number dinal scales are discrete (Horton 2017).
ht
ig
of children in a family is an example of discrete data. Continuous variables are either interval or ratio-
yr
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A family can have two or three children but cannot level, but some ratio-level variables are discrete.
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have 2.25 or 3.5 children. The numbers represent ac- Continuous data represent measurable quantities
tual measurable quantities rather than labels. but are not restricted to certain specified values. A
Other examples of discrete data include the num- variable that is continuous can take on a fractional
ber of motor vehicle crashes in a particular commu- value. For example, a patient’s temperature may be
nity, the number of times a woman has given birth, 102.6°F. Another example is height. One could say
the number of new cases of cancer in a state within that someone is approximately 6 feet tall, refine it to
the past five years, and the number of beds available 5 feet 10 inches, and refine it still further to 5 feet 10.5
in a hospital. inches. Age is yet another example. A person may
In discrete data, a natural order exists among have been 20 years old on his or her last birthday, but
the possible data values. In the example of the now the person would be over 20 years some part
number of times a woman has given birth, a larger of another year. Arithmetic operations—addition,
number indicates that she has had more children; subtraction, multiplication, and division—may be
the difference between one and two births is the performed on continuous variables (Horton 2017).
AB103118_Ch14.indd 431 2/7/2020 12:24:07 PM


Identify the scale of measurement for each of the following variables and indicate whether each variable is
discrete (d) or continuous (c).
1. __________ Gender
2. __________ Height
3. __________ Zip code
4. __________ Blood pressure
5. __________ Heart failure classification I, II, III, IV
6. __________ Age
n.
6. __________ Ethnicity
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8. __________ Marital status
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9. __________ Length of stay
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10. __________ Discharge disposition (home, skilled nursing facility [SNF], and such)
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11. __________ Weight
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12. __________ Level of education
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13. __________ Race
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14. __________ Temperature in degrees Fahrenheit
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15. __________ Types of third-party payers

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Common Statistical Measures Used in Healthcare

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Healthcare data are collected to describe public health officials, researchers, and more. For
by
the health status of groups or populations. The data example, organizations use health statistics to de-
20
20
reported about healthcare organizations and com- termine patient outcomes, calculate resource utili-
©
munities describe the occurrence of illnesses, births, zation, and provide performance data.
ht
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and deaths for specific periods of time. Data that Reporting statistics for a healthcare organization
yr
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are collected may be either facility based or popu- is similar to reporting statistics for a community.
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lation based. The sources of facility-based statistics Rates for healthcare organizations are reported
are acute-care facilities, long-term care facilities, as per 100 cases or percent; a community rate is
and other types of healthcare organizations. The reported as per 1,000, 10,000, or 100,000 people. For
population-based statistics are gathered from cities, example, if a hospital experienced 4 deaths in a giv-
counties, states, or specific groups within the popula- en month and 100 patients were discharged in the
tion, such as individuals affected by diabetes. same month, the death rate would be 4 percent ([4 ×
Health statistics assist in improving the quality 100]/100). If there were 400 deaths in a community
of patient care. Statistics also provide information of 80,000 for a given period of time, the death rate
for important decision-making in the daily opera- would be reported as 50 deaths per 10,000 popula-
tion of a healthcare organization. Statistical data is tion ([400 × 10,000]/80,000) for the same period of
used by various healthcare professionals, including time. The following terms are common for the HIM
providers, administrators, department managers, professional to use in determining statistics.
AB103118_Ch14.indd 432 2/7/2020 12:24:08 PM

Three Common Examples of live discharges is written as 10:90 and verbalized

Ratio-Level Data: Ratios, Proportions, as 10 to 90. In the second example, x is part of the
and Rates whole (x + y). The ratio represents the number of
patients discharged alive compared to all patients
Many healthcare statistics are reported in the form discharged. This is written as 10:100. Both expres-
of a ratio, proportion, or rate. A ratio is a calculation sions are considered ratios.
that compares two quantities found by dividing
one quantity by another. A proportion is the rela- Proportion
tion of one part to another or to the whole with A proportion is a type of ratio in which x is a por-
respect to magnitude, quantity, or degree. A rate is a tion of the whole (x + y). In a proportion, the nu-
measure used to compare an event over time. merator is always included in the denominator.
These measures are used to report morbid- For example, if 4 males out of a group of 24 have
ity (illness), mortality (death), and natality (birth) had prostate cancer, where x = 4 (males who
n.
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at the local, state, national, and international lev- have had prostate cancer) and y = 20 (males who
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els. These measures indicate the number of times
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have not had prostate cancer), the calculation
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something happened relative to the number of would be 4 divided by 24 (20 + 4) or 4/24. The
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times it could have happened. All three measures
en
proportion of males who have had prostate cancer
em
are based on formula 14.1. is 0.1666 = 0.17. Figure 14.1 describes the procedure
ag
for calculating ratios and figure 14.2 describes the
an
Formula 14.1 General formula for calculating procedures for calculating proportions.
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rates, proportions, and ratios io
at
The following list of equations differentiates Rate
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Rates are often used to measure events over a period

fo
among ratio, proportion, percentage, and rate,

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where x = 5 men and y = 3 women. of time. Rates are commonly expressed as a per-
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x 5 centage and therefore should include the percent

Ratio: =
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y 3 (%) sign after the number value.

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Like ratios and proportions, rates may be report-

ic
Proportion: x 5
er
= ed daily, weekly, monthly, or yearly. This allows

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( x + y ) ( 5 + 3)
for trend analysis and comparisons over time.
e
Part P
th
Rate: R= , or R = The basic formula for calculating a rate is

by
Base B
20
number of times something happened

´ 100
20
Ratio number of times it would have happened

©
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In a ratio, two quantities are compared, such as pa-

ig
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tient discharge status (x = alive, y = dead), and may

op
be expressed so that x and y are completely inde- Figure 14.1 Calculation of a ratio; discharge status
C
pendent of each other, or x may be included in y. of patients discharged in a month

For example, the outcomes of patients discharged 1. Define x and y:
from Community Hospital are compared in one of x = number of patients discharged alive
two ways: y = number of patients who died
2. Identify x and y:
Alive/dead, or x/y x = 250
y = 20
Alive/(alive + dead), or x/( x/y ) 3. Set up the ratio x/y:
250/20
In the first example, x is completely independent 4. Reduce the fraction so that either x or y equals 1:
of y. The ratio represents the number of patients 12.5/1
discharged alive compared to the number of
There were 12.5 live discharges for every patient who died.
patients who died. If 10 patients died and 90 pa-
tients were discharged alive, the ratio of deaths to Source: © AHIMA.
AB103118_Ch14.indd 433 2/7/2020 12:24:17 PM

Figure 14.2 Calculation of a proportion; discharge Figure 14.3 Calculation of a rate; C-section rate
status of patients discharged in a month for June 20XX
1. Define x and y: During June, 705 women delivered; of these, 45 deliveries
x = number of patients discharged alive were by C-section. What is the C-section rate for June at
y = number of patients who died University Hospital?
2. Identify x and y: 1. Define the numerator (number of times an event
x = 250 occurred) and the denominator (number of times an
y = 20 event could have occurred):
3. Set up the ratio x/(x + y): Numerator = total number of C-sections performed
250/(250 + 20) = 250/270 during the time period
4. Reduce the fraction so that either x or y equals 1: Denominator = total number of deliveries, including
0.93/1 C-sections, in the same time period
2. Identify the numerator and the denominator:
The proportion of patients discharged alive was 0.93. Numerator = 45
Denominator = 705
n.
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Source: © AHIMA.
3. Set up the rate:
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45/705
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When multiplying by 100, the decimal point is 4. Multiply the numerator by 100 and then divide by the
ss
denominator:
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in the correct place to be expressed as a percentage.
([45 ´ 100]/705) = 6.38%
en
There is a big difference between the values 0.123
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percent (not multiplied by 100) and 1.23 percent. The C-section rate for June is 6.438 percent.
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Healthcare organizations calculate many types
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Source: © AHIMA.
of morbidity and mortality rates. For example, the
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cesarean-section (C-section) rate is a measure of the io
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proportion, or percentage, of C-sections performed at University Hospital during the month of June
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during a given period of time. C-section rates are were C-sections. In the formula, the numerator is
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the number of C-sections performed in June (the

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closely monitored because they present more risk

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to the mother and infant and because they are more given period of time) and the denominator is the
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expensive than vaginal deliveries. In calculating the total number of deliveries including C-sections
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ic
C-section rate, the number of C-sections performed (the population at risk) performed within the same
er
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during the specified period of time is counted and time frame. In calculating the rate, the numerator
is always included in the denominator. Also, when
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this value is placed in the numerator. The number

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of cases, or the population at risk, is the number of calculating a facility-based rate, the numerator is
by
first multiplied by 100, and then divided by the

20
women who delivered during the same time per-

20
iod. This number is placed in the denominator. By denominator.

©
convention, inpatient hospital rates are reported Because hospital rates rarely result in a whole
ht
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as the rate per 100 cases and are expressed as number, they are usually rounded. The hospital
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percentages. The formula for calculating the risk of should set a policy on whether rates are to be re-
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contracting a disease is shown in formula 14.2. ported to one or two decimal places. Before round-
ing, the division should be carried out to at least
Formula 14.2 Calculating risk for contracting a one more decimal place than desired.
disease When rounding, if the last number is five or
greater, the preceding number should be increased
Number of cases occurring
one digit. In contrast, if the last number is less than
during a given time period
Risk rate = five, the preceding number remains the same. For
Total number of cases or population
example, in figure 14.3, when rounding 6.38 per-
at risk during thee same time period
cent to one decimal place, the rate becomes 6.4
percent because the last number is greater than
Figure 14.3 shows the procedure for calculat- five. When rounding, for example, 2.563 percent
ing a rate. In the example, 45 of the 705 deliveries to two places, the rate becomes 2.56 percent
AB103118_Ch14.indd 434 2/7/2020 12:24:19 PM

ecause the last digit is less than five. Rates of

b than 1 percent, a zero should precede the decimal
less than 1 percent are usually carried out to three to emphasize that the rate is less than 1 percent; for
decimal places and rounded to two. For rates less example, 0.56 percent.

Indicate if the statement represents a rate, a ratio, or a proportion.
1. In a study of acute myocardial infarction, there were seven males to nine females.
2. In many healthcare insurance policies, the insurance company covers 0.80 of the amount.
3. Medicare admissions outnumber commercial insurance admissions three to two.
n.
4. At the annual state HIM meeting, 85 of the registrants were female and 35 were male. Therefore, 0.71 percent of the
tio
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registrants were female.
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5. Of the 250 patients admitted in the past six months, 36 percent had type 2 diabetes mellitus.
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Acute-Care Statistical Data
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io
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In the daily operations of any organiza- Information Management Association (AHIMA),
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tion, whether in business, industry, or healthcare, is a resource commonly used to describe the types
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data are collected for decision-making. To be ef- of healthcare events for which data are collected. It
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fective, the decision makers must have confidence includes definitions of terms related to healthcare
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in the data collected. Confidence requires that the organizations, health maintenance organizations
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data collected be accurate, reliable, and timely. The (HMOs), and other health-related programs and
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types of data collected in the acute-care setting are facilities and emerging HIM and health informa-
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discussed in the following sections. tion technology (HIT) topics. The following terms
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and definitions will be used in this chapter:

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Administrative Statistical Data

20
20
Term Description
Hospitals collect data on inpatients and outpa-
©
Hospital • A patient who is provided with room, board,

tients on a daily basis. Hospitals use these statis-
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inpatient and continuous general nursing service in an

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tics to monitor the volume of patients treated daily, area of an acute-care hospital where patients
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weekly, monthly, annually, or within some other generally stay at least overnight
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specified time frame. The statistics give healthcare Hospital • A hospital patient who receives services in one
outpatient or more of the hospital’s facilities when he or
decision makers the information needed to plan she is not currently an inpatient or home care
healthcare organizations and services and to mon- patient
• An outpatient who is classified as either an
itor inpatient and outpatient revenue streams. For
emergency patient or a clinic outpatient
these reasons, the HIM professional must be well • An emergency patient who is admitted to the
versed in data collection, reporting, and analysis emergency services department of a hospital
for the diagnosis and treatment of a condition
methods. that requires immediate medical, dental, or al-
Standard definitions have been developed to en- lied health services to sustain life or to prevent
sure all healthcare providers collect and report data critical consequences
• A clinic outpatient who is a patient admitted to
in a consistent manner. The Pocket Glossary of Health a clinical service of a clinic or hospital for diag-
Information Management and Technology, currently in nosis and treatment on an ambulatory basis
its 5th edition, developed by the American Health continued
AB103118_Ch14.indd 435 2/7/2020 12:24:20 PM

Term Description can be any other time, but it must be consistent

Hospital • A patient who is born in the hospital at the be- throughout the healthcare organization and occur
newborn ginning of the current inpatient hospitalization at the same time each day.
inpatient • Newborns who are usually counted separately
because their care is very different from that of
The result of the official count taken at midnight
other inpatients is called the daily inpatient census. This is the
• Infants who are born on the way to the hospital number of inpatients present at the census-taking
or at home and later admitted to a hospital are
considered hospital inpatients, not hospital time each day plus any patients who were admit-
newborn inpatients ted and discharged that same day. For example,
Inpatient • An acute-care hospital’s formal acceptance of a if a patient was admitted to the ICU at 1:00 p.m.
admission patient who is to be provided with room, board, on June 1 and died at 4.00 p.m. on the same day,
and continuous nursing service in an area of the
healthcare organization where patients generally he would be counted as a patient who was both
stay at least overnight admitted and discharged on the same day. Most
n.
Inpatient • The termination of hospitalization through the healthcare organizations have a census-taking
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discharge formal release of an inpatient by the hospital
policy that outlines the process for census report-
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• Patients who are discharged alive (by physi-
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cian’s order) who are discharged against medi- ing and tracking.
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cal advice (AMA), or who died while hospitalized Because patients admitted and discharged on the
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Unless otherwise directed by your healthcare
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organization’s administration, inpatient
same day may not be present at the census-taking
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discharges include deaths time, hospitals must account for them separately.
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If they did not, credit for the services provided to
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Source: © AHIMA 2017
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these patients would be lost. The daily inpatient
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census reflects the total number of patients treated
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Inpatient Census Data during the 24-hour period. Figure 14.4 displays a
m
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The HIM professional is responsible for verifying sample daily inpatient census report.
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the census data that are collected daily. The cen- A unit of measure that reflects the services
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sus reports patient activity for a 24-hour reporting received by one inpatient during a 24-hour peri-
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period. Included in the census report is the num- od is called an inpatient service day (IPSD). The
an
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ber of inpatients admitted and discharged for the number of IPSDs for a 24-hour period is equal
er
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previous 24-hour period as well as the number of to the daily inpatient census; that is, one service
intra-hospital transfers. An intra-hospital trans- day for each patient treated. In figure 14.4, the
e
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fer is a patient who is moved from one patient total number of inpatient service days for June 2
by
care unit to another (for example, a patient may is 260.

20
20
be transferred from the intensive care unit [ICU]

©
to the medicine unit). The usual 24-hour report-

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Figure 14.4 Daily inpatient census

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ing period begins at 12:01 a.m. and ends at 12:00

yr
report—A&C
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midnight. In the census count, adults and children

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June 2
(A&C) are reported separately from newborns.
Number of patients in hospital at midnight, June 1 250
Before compiling census data, however, it is
+ Number of patients admitted June 2 +40
important to understand the related terminology.
– Number of patients discharged, including
The census is the number of hospital inpatients deaths, June 2 −35
present in a hospital at any given time. For example,
the census in a 300-bed hospital may be 250 pa- Number of patients in hospital at midnight, June 2 255
tients at 2:00 p.m. on June 1, but 245 patients an hour + Number of patients both admitted and
later. Because the census may change throughout discharged, including deaths +5
the day as admissions and discharges occur, hos-

Daily inpatient census at midnight, June 2 260
pitals designate an official census-taking time. In
Total inpatient service days, June 2 260
most healthcare organizations, the official count
takes place at midnight. The census-reporting time Source: © AHIMA.
AB103118_Ch14.indd 436 2/7/2020 12:24:20 PM

Table 14.2 Number of IPSDs Formula 14.4. Calculating the average daily
Same day census for adults and children
admissions and Inpatient
Day Census discharges service days Total number of inpatient
Day 1 250 0 250 Average service days for
Day 2 255 0 255 daily A&C for a given period
=
Day 3 240 2 242 census Total number of days
Total 747 for A&C in the same time period
Source: © AHIMA.
The formula for calculating the average daily

IPSDs are compiled daily, weekly, monthly, and census for newborns is shown in formula 14.5.
annually. They reflect the volume of services pro- For example, the total number of IPSDs provided
vided by the healthcare organization—the greater
n.
to adults and children for the week of June 1 is
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the volume of services, the greater the revenues to 1,825, and the total for newborns is 125. Using
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the healthcare organization. Daily reporting of the the formulas, the average daily census for adults
ss
number of IPSDs is an indicator of the healthcare
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and children is 261 (1,825/7) and for newborns it
organization’s financial condition.
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is 18 (125/7). Notice that the answer to the new-
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As mentioned, the daily inpatient census is born average daily census was 17.9 but using
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equal to the number of IPSDs provided for that the standard practice of reporting census infor-
an
day as shown in table 14.2.
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mation as a whole number, the figure reported
n
The total number of IPSDs for a week, a month, io
would be 18. The average daily census for all
at
and so on can be divided by the total number of hospital inpatients for the week of June 1 is 278.6
rm
days in the period of interest to obtain the aver-

fo
or 279 ([1,825 + 125]/7). Table 14.3 compares

In
age daily census. Referring to table 14.2, 747 IP- the various formulas for calculating the average
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SDs is divided by three days to obtain an average

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daily census.
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daily census of 249. The average daily census is

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the average number of inpatients treated during

ic
Formula 14.5 Calculating the average daily

er
a given period of time. The general formula for

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census for newborns

calculating the average daily census is shown in
e
th
formula 14.3. Average Total number of inpatient serv vice

by
In calculating the average daily census, A&C daily days for NBs for a given period
=
20
and newborns (NB) are reported separately. census Total number of days
20
for NBs in the same time period

©
This is because the intensity of services pro-

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vided to adults and children is greater than it

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is for newborns. To calculate the A&C average

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Table 14.3 Calculation of census statistics

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daily census, the general formula is modified as

Indicator Numerator Denominator
shown in formula 14.4. Many healthcare orga-
Average daily Total number of Total number of
nizations use a whole number when reporting inpatient census inpatient service days for the same
the census. days for a given period
period
Formula 14.3 Calculating the average daily inpatient census for inpatient service days for the same
census adults and children days for A&C for a period
(A&C) given period
Total number of inpatient
Average daily service days for a given period
= inpatient census for inpatient service days for the same
census Total number of days newborns (NBs) days for NBs for a period
given period
in the same time period
Source: © AHIMA.
AB103118_Ch14.indd 437 2/7/2020 12:24:25 PM


1. Community Hospital reported the following statistics for their newborn unit at 12:01 a.m. June 1: Census 10; Births 5;
Discharges 3; 1 Newborn born and transferred to University Hospital. Calculate the following for June 2:
a. Inpatient census
b. Daily inpatient census
2. Community Hospital reported the following statistics for their intensive care unit at 12:01 a.m. June 1: Census 12; 1
patient admitted directly from the Emergency Services Department (ESD); 1 patient transferred from the surgery unit;
1 patient transferred from the medicine unit; 1 patient transferred to the medicine unit; 1 patient admitted and died the
same day. Calculate the following for June 2:
a. Inpatient census
n.
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3. Community Hospital reported the following statistics for adults and children at 12:01 a.m. April 1: Census 160;
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Admissions 20; Discharges 15; 1 patient admitted and died the same day; 1 patient admitted and discharged alive the
ss
same day. Calculate the following for April 2:
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a. Inpatient census
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c. Inpatient service days
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Inpatient Bed Occupancy Rate The denominator in this formula is actually the
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total possible number of inpatient service days.

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Another indicator of the hospital’s financial po-

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That is, if every available bed in the hospital were

sition is the inpatient bed occupancy rate, also
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occupied every single day, this would be the maxi-

H
called the percentage of occupancy. The inpatient

an
mum number of IPSDs that could be provided. The

bed occupancy rate is the percentage of official
ic
IPSDs are based on the bed count. The bed count is

er
beds occupied by hospital inpatients for a given

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the number beds available in the hospital that have

period of time. In general, the greater the occupan-
e
the staff and resources necessary to care for patients

th
cy rate, the greater the revenues for the hospital.

by
at any given point in time. This is an important con-

For a bed to be included in the official count, it
20
cept, especially if the official bed count changes for

must be set up, staffed, equipped, and available
20
a given reporting period. For example, if the bed

©
for patient care. The total number of inpatient ser-

count changed from 300 beds to 310, the bed occu-
ht
vice days is used in the numerator because it is

ig
pancy rate would reflect the change. The total num-

yr
equal to the daily inpatient census or the number

op
ber of inpatient beds times the total number of days

C
of patients treated daily. The occupancy rate com-

in the period is called the total number of bed count
pares the number of patients treated over a given
days. The general formula for the inpatient bed oc-
period of time to the total number of beds available
cupancy rate is shown in formula 14.6.
for the same period of time.
For example, if 250 patients occupied 300 beds on Formula 14.6 Calculating the inpatient bed
June 2, the inpatient bed occupancy rate would be occupancy rate
83.3 percent ([250/{300 × 1}] × 100). If the rate were Total number of
for more than one day, the number of beds would be inpatient service days
multiplied by the number of days within that par-
for a given period
ticular time frame. For example, if 1,830 IPSDs were Inpatient bed = ´10
Total number of
provided during the week of June 1 in the same hos- occupancy rate
pital, the inpatient bed occupancy rate for that week inpatient bed count
would be 87.1 percent ([1,830/{300 × 7}] × 100). days for the same period
AB103118_Ch14.indd 438 2/7/2020 12:24:26 PM

What happens when the bed count changes? For Table 14.4 Calculation of inpatient bed occupancy
example, the bed count changed on June 20 from Rate Numerator Denominator
300 beds to 310 beds and the total number of inpa- Inpatient bed Total number of Total number of
tient service days provided was 8,327. To calculate occupancy rate inpatient service inpatient bed count
the inpatient bed occupancy rate for June, the total days for a given days for the same
period × 100 period
number of bed count days must be determined.
Inpatient bed Total number of Total number of
There are 30 days in June; therefore, the total num- occupancy rate for inpatient service inpatient bed count
ber of bed count days is calculated as: adults and children days for A&C for a days for A&C for
(A&C) given period × 100 the same period
Number of beds, June 1-June 19 = 300 ´ 19 days Newborn (NB) bed Total number of NB Total number of
occupancy rate inpatient service bassinet bed count
= 5, 700 bed count days days for a given days for the same
Number of beds , June 20 -June 30 = 310 ´ 11 days period × 100 period
= 3 , 410 bed count days
n.
Source: © AHIMA.
tio
5, 700 + 3 , 410 = 9, 110 bed count days
ia
ccupancy rate for December 5 was 108 percent
o
oc
ss
The inpatient bed occupancy rate for the ([135/125] × 100).
tA
month of June is 91.4 percent ([8,327/9,110] × 100).
en
Bed Turnover Rate
em
As with the average daily census, the inpatient
The bed turnover rate is a measure of hospital
ag
bed occupancy rate for adults and children is report-
an
ed separately from that of newborns. To calculate utilization. It includes the number of times each
M
hospital bed changed occupants. The formula for
n
the total number of bed count days for newborns, io
the bed turnover rate is shown in formula 14.7.
at
the official count for newborn bassinets is used.
m
For example, Community Hospital had 2,120 dis-

r
Table 14.4 reviews the formulas for calculating

fo
charges and deaths for the month of October. Its

In
inpatient bed occupancy rates.

lth
It is possible for the inpatient bed occupancy bed count for October averaged 700. The bed turn-
ea
over rate is 3.1 (2,120/700). This simply means that

H
rate to be greater than 100 percent. This occurs

an
when the hospital faces an epidemic or disaster. on average, each hospital bed had three occupants
ic
during October.
er
In this type of situation, hospitals set up tem-

Am
porary beds that usually are not included in the

e
Formula 14.7 Calculating the bed turnover rate

th
official bed count. As an example, Community

by
Hospital experienced an excessive number of ad- Bed Total number of discharges,

20
missions in December because of an outbreak of

20
turnover including deaths, for a given period

pneumonia. In December, the official bed count rate =
©
Average bed count for

ht
was 125 beds. On December 5, the daily inpatient

ig
me period
the same tim
yr
census was 135. Therefore, the inpatient bed

op
C

1. On July 1, Community Hospital expanded the number of patient beds from 165 to 200. Use the following information
in table 14.6 to determine the inpatient bed occupancy rate for January to June; July to December; and the total for
the year (non-leap year).
2. Fill in table 14.5 with the inpatient bed occupancy rate for each of the following patient care units at Community
Hospital for the month of September. Calculate to one decimal point.
3. Use the information in table 14.5 to determine the inpatient bed occupancy rate for Community Hospital—all A&C
(exclude newborns). Calculate to one decimal point.
AB103118_Ch14.indd 439 2/7/2020 12:24:29 PM

Table 14.5 Community Hospital occupancy rate

for September
Inpatient Service Bed Occupancy
unit days count rate
Medicine 680 38
Surgery 790 37
Pediatric 235 20
Psychiatry 927 40
Obstetrics 252 12
Newborn 252 16
Source: © AHIMA.
Table 14.6 Community Hospital number of service
n.
tio
days and bed count
ia
oc
Months Service days Bed count
ss
tA
January–June 25,720 165
en
July–December 27,852 200
em
ag
Source: © AHIMA.
an
M
n
io
at
m
Length of Stay Data Table 14.7 Length of stay for five patients
r
fo
In
discharged June 9
LOS data is calculated for each patient after he or
lth
ea
Patient LOS
she is discharged from the hospital. It is the number
H
1 3
of calendar days from the day of patient admission
an
2 7
ic
to the day of patient discharge. When the patient

er
3 2
Am
is admitted and discharged in the same month, the

4 1
LOS is determined by subtracting the date of ad-
e
th
5 19
mission from the date of discharge. For example,
by
Total 32
the LOS for a patient admitted on June 12 and dis-
20
20
charged on June 17 is five days (17 – 12 = 5). Source: © AHIMA.

©
When the patient is admitted in one month and

ht
ig
discharged in another, the calculations must be also is one day. Thus, the LOS for a patient who
yr
op
adjusted. One way to calculate the LOS in this case was admitted to the ICU on June 10 at 9:00 a.m.
C
is to subtract the date of admission from the total and died at 3:00 p.m. on the same day is one day.
number of days in the month the patient was ad- Likewise, the LOS for a patient admitted on June
mitted and then add the total number of hospital- 12 and discharged on June 13 is one day.
ized days for the month in which the patient was When the LOS for all patients discharged for a
discharged. For example, the LOS for a patient given period of time is summed, the result is the
admitted on June 28 and discharged on July 6 is total length of stay (discharge days). As an exam-
eight days ([June 30 – June 28 = two days] and [July ple, five patients were discharged from the pediat-
1 – July 6 = 6 days]; LOS = 8 days). ric unit on June 9. The LOS for each patient was as
When a patient is admitted and discharged on follows in table 14.7.
the same day, the LOS is one day. A partial day’s stay In the preceding example, the total LOS is 32
is never reported as a fraction of a day. The LOS days (3 + 7 + 2 + 1 + 19). The total LOS is also re-
for a patient discharged the day after admission ferred to as the number of days of care provided to
AB103118_Ch14.indd 440 2/7/2020 12:24:29 PM

patients who were discharged or died (discharge newborns. Table 14.8 reviews the formulas for
days) during a given period of time. ALOS. Table 14.9 displays an example of a hospital
The average length of stay (ALOS) is calculated statistical summary prepared by the HIM depart-
from the total LOS. The total LOS divided by the ment using census and discharge data.
number of patients discharged is the ALOS. Us- Formula 14.8 Calculating the average length of stay
ing the data in the preceding example, the ALOS
Total length of stay for a
for the five patients discharged from the pediatric Average
given period
unit on June 9 is 6.4 days (32/5). length of stay =
The general formula for calculating ALOS is Total number of discharges,
shown in formula 14.8. As with the measures including deaths, for the
already discussed, the ALOS for adults and chil- same period
dren is reported separately from the ALOS for
n.
tio
ia
Table 14.8 Calculation of LOS statistics
oc
ss
Indicator Numerator Denominator
tA
Average LOS Total length of stay (discharge days) for a given Total number of discharges, including deaths,
en
period for the same period
em
ag
Average LOS for adults and Total length of stay for A&C (discharge days) Total number of discharges, including deaths,
an
children (A&C) for a given period for A&C for the same period
M
Average LOS for newborns (NB) Total length of stay for all NB (discharge days) Total number of NB discharges, including
n
for a given period io deaths, for the same period
at
m
Source: © AHIMA.
r
fo
In
Table 14.9 Statistical summary, Community Hospital, for the period ending July 20XX
lth
ea
July 20XX Year-to-Date 20XX

H
an
Admissions Actual Budget Actual Budget

ic
Medicine 728 769 5,075 5,082

er
Am
Surgery 578 583 3,964 3,964

e
OB/GYN 402 440 2,839 3,027

th
by
Psychiatry 113 99 818 711

20
Physical medicine and rehab 48 57 380 384

20
Other adult 191 178 1,209 1,212

©
Total adult 2,060 2,126 14,285 14,380

ht
ig
Newborn 294 312 2,143 2,195

yr
op
Total admissions 2,354 2,438 16,428 16,575

C

Average length of stay Actual Budget Actual Budget
Medical 6.1 6.4 6.0 6.1
Surgical 7.0 7.2 7.7 7.7
OB/GYN 2.9 3.2 3.5 3.1
Psychiatry 10.8 11.6 10.4 11.6
Physical medicine and rehab 27.5 23.0 28.1 24.3
Other adult 3.6 3.9 4.0 4.1
Total adult 6.3 6.4 6.7 6.5
Newborn 5.6 5.0 5.6 5.0
Total ALOS 6.2 6.3 6.5 6.3
continued
AB103118_Ch14.indd 441 2/7/2020 12:24:31 PM

Table 14.9 Statistical summary, Community Hospital, for the period ending July 20XX (continued)
Patient Days Actual Budget Actual Budget
Medical 4,436 4,915 30,654 30,762
Surgical 4,036 4,215 30,381 30,331
OB/GYN 1,170 1,417 10,051 9,442
Psychiatry 1,223 1,144 8,524 8,242
Physical medicine and rehab 1,318 1,310 10,672 9,338
Other adult 688 699 4,858 4,921
Total adult 12,871 13,700 95,140 93,036
Newborn 1,633 1,552 12,015 10,963
Total patient days 14,504 15,252 107,155 103,999
n.
tio
ia
Other key statistics Actual Budget Actual Budget
oc
Average daily census 485 482 498 486
ss
tA
Average beds available 677 660 677 660
en
Clinic visits 21,621 18,975 144,271 136,513
em
Emergency visits 3,822 3,688 26,262 25,604
ag
an
Inpatient surgery patients 657 583 4,546 4,093
M
Outpatient surgery patients 603 554 4,457 3,987
n
io
at
Source: © AHIMA.
m
r
fo
In
lth

ea
H
an
Use the data provided for patient discharges in table 14.10 to answer the questions that follow. Round to two
ic
decimal points.
er
Am
Table 14.10 Patient discharges

e
th
by
Number of patients
20
Day discharged Discharge days

20
September 1 10 82
©
September 2 12 75
ht
ig
September 3 17 68
yr
op
September 4 8 153
C
September 5 9 43
September 6 11 101
September 7 18 77
September 8 12 93
September 9 13 42
September 10 15 97
Source: © AHIMA.
1. Calculate the number of patients discharged.

2. Calculate the total length of stay.
3. Calculate the average length of stay.
4. Calculate the ALOS for September 10th.
5. Calculate the ALOS for September 1st to (and including) September 5th.
AB103118_Ch14.indd 442 2/7/2020 12:24:31 PM

Patient Care and Clinical Statistical Data

The collection of data related to morbid- As an example, Community Hospital experienced
ity and mortality is an important aspect of evalu- 15 deaths (A&C and NBs) during the month of June.
ating the quality of hospital services. Morbidity There were 278 total discharges, including deaths.
and mortality rates are reported for all patient The gross death rate is 5.4 percent ([15/278] × 100).
discharges within a certain time frame. They also
may be reported by service or by physician or other Net Death Rate
variable of interest to identify trends, issues, or The net death rate is an adjusted death rate. It is
opportunities for improvement that may require calculated with the assumption that certain deaths
corrective action. The most frequently collected should not count against the hospital. The net death
morbidity and mortality rates are presented in this
n.
rate is an adjusted rate because it does not include
tio
section. patients who die within 48 hours of admission. The
ia
oc
reason for excluding these deaths is that historically
ss
it has been believed that 48 hours is not enough
tA
Hospital Death (Mortality) Rates
en
time to positively affect patient outcome. In other
em
The hospital death rate is based on the number words, the patient was not admitted to the hospital
ag
of patients discharged, alive and dead, from the in a manner timely enough for treatment to have an
an
hospital. Deaths are considered discharges because
M
effect on his or her outcome. The formula for calcu-
they are the end point of a period of hospital-
n
lating the net death rate is shown in formula 14.10.
io
at
ization. In contrast to the rates discussed in the
m
preceding section, newborns are not counted sep-

r
Formula 14.10 Calculating the net death rate

fo
In
arately from adults and children. The following

lth
sections discuss the different statistics for death Total number of inpatient deaths,
ea
Net
H
including gross, net, newborn, fetal, and maternal including NBs, minus deaths
an
death rates. death

ic
< 48 hours for a given period

er
rate = ´100
Am
Total number of discharges,

e
Gross Death Rate including A & C and NB deaths,

th
by
The gross death rate is the proportion of all hos- minus deaths < 48 hours for the
20
pital discharges that ended in death. It is the basic

same period
20
indicator of mortality in a healthcare organization.

©
The gross death rate is calculated by dividing the

ht
Continuing with the preceding example of the

ig
total number of deaths occurring in a given time

yr
15 patients who died at Community Hospital in June,

op
period by the total number of discharges, includ- three died within 48 hours of admission. There-
C
ing deaths, for the same time period. The formula fore, the net death rate is 4.4 percent ([{15 – 3}/
for calculating the gross death rate is shown in {278 – 3}] × 100). The fact that the net death rate is
formula 14.9. less than the gross death rate is favorable to Com-
Formula 14.9 Calculating the gross death rate munity Hospital because lower death rates may be
an indicator of better care.
Total number of inpatient deaths ,
Gross
including NBs, for a given period ´ 100 Newborn Death Rate
death rate =
Total number of discharges, Even though newborn deaths are included in the
including A&C and NB deaths , hospital’s gross and net death rates, the newborn
for the same period death rate is often calculated separately. Newborns
include only infants born alive in the hospital. The
AB103118_Ch14.indd 443 2/7/2020 12:24:35 PM

newborn death rate is the number of newborns Table 14.11 Classifications of fetal death
who died in comparison to the total number of Length of
newborns discharged, alive and dead. To qualify Classification gestation Weight
as a newborn death, the newborn must have been Early fetal death Less than 20 weeks 500 g or less
delivered alive. A stillborn infant is not included Intermediate fetal 20 weeks completed, but 501 to 1,000 g
in either the newborn death rate or the gross or net death less than 28 weeks
death rate. The formula for calculating the new- Late fetal death 28 weeks completed Over 1,000 g
born death rate is shown in formula 14.11. Source: © AHIMA.
fetal deaths. The fetal death rate is 4.9 percent ([{3

Formula 14.11 Calculating the newborn death rate + 2}/{97 + 3 + 2}] × 100).
Total number of NB
Newborn Formula 14.12 Calculating the fetal death rate
deaths for a given period
n.
death rate = ´100 Total number of intermediate
tio
Total number of NB
ia
and late fetal deaths
oc
discharges, including deaths,
ss
Fetal for a given period
tA
for the same period death rate = ´ 100
Total number of live births
en
em
pllus total number of
ag
For example, Community Hospital experienced
intermediate and late fetal
an
three newborn deaths during the month of June.
M
deaths forr the same period
n
There were 47 newborn discharges (including io
at
these three deaths). The newborn death rate is 6.4
m
r
percent ([3/47] × 100). Maternal Death Rate

fo
In
Hospitals are also interested in calculating ma-

lth
Fetal Death Rate ternal death rates (hospital based). A maternal

ea
H
In healthcare terminology, the death of a stillborn death is the death of any woman from any cause
an
infant is called a fetal death. A fetal death is defined related to, or aggravated by, pregnancy or its man-
ic
er
as a fetus who is spontaneously expelled from the agement, regardless of the duration or site of the
Am
uterus at any time during the pregnancy. Fetal death pregnancy. Maternal deaths that result from acci-
e
th
more commonly occurs later in pregnancy- usually dental or incidental causes are not included in the
by
at 20 weeks of gestation or more. Thus, fetal deaths maternal death rate.

20
are neither admitted nor discharged from the hos- Maternal deaths are classified as either direct or
20
pital. A fetal death occurs when the fetus fails to

©
indirect. A direct maternal death is the death of a

ht
breathe or show any other evidence of life, such as woman resulting from obstetrical (OB) complica-
ig
yr
a heartbeat, a pulsation of the umbilical cord, or a tions of the pregnancy, labor, or puerperium (the
op
movement of the voluntary muscles.

C
period including the six weeks after delivery). Di-

Fetal deaths also are classified into categories rect maternal deaths are included in the maternal
based on length of gestation or weight (see table death rate. An indirect maternal death is the death
14.11). To calculate the fetal death rate, divide the of a woman from a previously existing disease or
total number of intermediate and late fetal deaths a disease that developed during pregnancy, labor,
for the period by the total number of live births or the puerperium that was not due to obstetric
and intermediate and late fetal deaths for the same causes, although the physiological effects of preg-
period. The formula for calculating the fetal death nancy were partially responsible.
rate is shown in formula 14.12. For example, during The maternal death rate may be an indicator
the month of June, Community Hospital experi- of the availability of prenatal care in a community.
enced 97 live births and 3 intermediate and 2 late The hospital also may use it to help identify
AB103118_Ch14.indd 444 2/7/2020 12:24:38 PM

c onditions that could lead to a maternal death. The Formula 14.13 Calculating the maternal death rate
formula for calculating the maternal death rate is Total number of direct maternal
shown in formula 14.13. For example, during the Maternal
deaths for a given period
month of June, Community Hospital experienced death = ´100
rate Total number of maternal
150 maternal discharges. Two of these patients died.
The maternal death rate for June is 1.33 percent (OB) discharges, including
([2/150] × 100). Table 14.12 summarizes hospital- deaths, for same period
based mortality rates.
Table 14.12 Calculation of hospital-based mortality rates
Rate Numerator (x) Denominator ( y)
n.
Gross death rate Total number of inpatient deaths, including NBs, Total number of discharges, including A&C
tio
ia
for a given period × 100 and NB deaths, for the same period
oc
Net death rate (institutional Total number of inpatient deaths, including NBs, Total number of discharges, including A&C
ss
death rate) minus deaths <48 hours for a given period × 100 and NB deaths, minus deaths <48 hours for
tA
the same period
en
em
Newborn death rate Total number of NB deaths for a given period × 100 Total number of NB discharges, including
deaths, for the same period
ag
an
Fetal death rate Total number of intermediate and late fetal deaths Total number of live births plus total number of
M
for a given period × 100 intermediate and late fetal deaths for the same
n
io period
at
Maternal death rate Total number of direct maternal deaths for a given Total number of maternal (obstetric) discharges,
m
period × 100 including deaths, for the same period

r
fo
In
Infant death rate Number of deaths under one year of age during a Number of live births during the same time
lth
given time period period

ea
H
Source: © AHIMA.
an
ic
er
Am
e

th
by
20
Use the data provided on deaths and discharges at Community Hospital for the past calendar year in table 14.13
20
to answer the questions that follow. Round to two decimal points.

©
ht
ig
Table 14.13 Community Hospital death and

yr
discharge data
op
C
Type of death or discharge Total

Total discharges, including deaths (A&C) 2,703
Total deaths (A&C) 43
Deaths less than 48 hours after admission (A&C) 2
Fetal deaths (intermediate and late) 5
Live births 175
Newborn deaths 1
Newborn discharges, including deaths 175
Maternal deaths (direct) 1
OB discharges, including deaths 175
Source: © AHIMA.
AB103118_Ch14.indd 445 2/7/2020 12:24:40 PM

1. Calculate the gross death rate for adults and children.

2. Calculate the gross death rate for adults and children and newborns combined.
3. Calculate the net death rate for adults and children.
4. Calculate the net death rate for adults and children and newborns combined.
5. Calculate the newborn death rate.
6. Calculate the fetal death rate.
7. Calculate the maternal death rate (direct).
n.
Autopsy Rates 19 deaths. Autopsies were performed on three of
tio
the patients. The gross autopsy rate is 15.8 percent
ia
An autopsy is the postmortem (after death) exami-
oc
([3/19] × 100).
ss
nation of the organs and tissues of a body to deter-
tA
mine the cause of death or pathological conditions, Formula 14.14 Calculating the gross autopsy rate
en
also known as a postmortem examination or nec-
em
Total inpatient autopsies
ag
ropsy examination. An autopsy is a powerful tool Gross
for a given period
an
for medical or legal purposes. The postmortem autopsy rate = ´ 100
M
examination can establish the cause and manner of
n
io
death and can determine whether disease or injury deaths for the same period
at
m
was present at the time of death. In addition, the

r
fo
In
autopsy can alert family members to conditions or

Net Autopsy Rates
lth
diseases for which they may be at risk.

ea
The bodies of patients who have died are not al-

Two categories of hospital autopsies are con-
H
ways available for autopsy. For example, a coro-

an
ducted in acute-care hospitals: hospital inpatient

ic
ner or medical examiner may claim a body for an

er
autopsies and hospital autopsies. A hospital in-

Am
autopsy for legal reasons. A coroner is the official

patient autopsy is an examination performed on
(elected or appointed, physician or nonphysician)
e
th
the body of a patient who died during an inpatient

who is responsible for determining the cause,
by
hospitalization by a hospital pathologist or a phy-

time, and manner of death in unattended, violent,
20
sician of the medical staff who has been delegated

20
or unexplained deaths, or a case where a law may

the responsibility.
©
have been broken. Coroners may also have other

ht
A hospital autopsy is a postmortem examina-

ig
duties depending on their state.

yr
tion on the body of a person who at some time

op
In some areas of the country, the coroner has been

in the past was a hospital patient but was not a
C
replaced with a medical examiner (ME). The ME

hospital inpatient at the time of death. A patholo-
is usually an appointed official who is a physician,
gist or some other physician on the medical staff
commonly holding a specialty in pathology or
performs this type of autopsy as well. The follow-
forensic medicine. Large metropolitan areas usu-
ing sections describe the different types of autopsy
ally have a forensic pathologist who acts as the cor-
rates calculated by acute-care hospitals.
oner and performs the postmortem examination.
In smaller areas, the coroner may be a physician
Gross Autopsy Rates practicing in the community who is not trained as
A gross autopsy rate is the proportion or percent- a pathologist. Or a mortician or sheriff may serve
age of deaths that are followed by the performance of as the coroner. A body released to a coroner or ME
autopsy (see formula 14.14). For example, during is not available for autopsy by the hospital pathol-
the month of June, Community Hospital experienced ogist (Horton 2017).
AB103118_Ch14.indd 446 2/7/2020 12:24:42 PM

The hospital calculates a net autopsy rate. In Formula 14.16 Calculating the hospital
calculating the net autopsy rate, bodies that have autopsy rate
been removed by the coroner or ME are exclud-
ed from the denominator because they were not Total number of hospital
available for an autopsy. The formula for calculat- Hospital
autopsies for the period
ing the net autopsy rate is shown in formula 14.15. autopsy rate = ´ 100
Total number of deaths of
Continuing with the example in the preceding
hospital patients with bodies
section, the ME claimed three of the patients for
autopsy. The numerator remains the same because available for hospital autopsy
three autopsies were performed by the hospital for the period
pathologist. However, because three of the deaths
were identified as ME’s cases and removed from Generally, it is difficult to determine the num-
n.
the hospital, 3 is subtracted from 19. The net au- ber of bodies of former hospital patients who may
tio
topsy rate is 18.8 percent ([3/{19 – 3}] × 100).
ia
have died in a given time period. In the formula,
oc
Formula 14.15 Calculating the net autopsy rate the phrase available for hospital autopsy involves
ss
tA
Total inpatient autopsies several conditions, including the following:
en
em
on inpatient deaths ●● The autopsy must be performed by the
ag
Net for a given period hospital pathologist or a physician who
an
autopsy rate = × 100 treated the patient at some time at the
M
n
deaths miinus unautopsied
io hospital.
at
The report of the autopsy must be filed in the
m
●●
coroners’ or medical examiners’
r
fo
patient’s health record and in the hospital

In
cases forr the same period

laboratory or pathology department.
lth
ea
●● The tissue specimens must be maintained in

H
Hospital Autopsy Rates

an
the hospital laboratory.

ic
A third type of autopsy rate is called the hospi-

er
tal autopsy rate. This is an adjusted rate that in- Figure 14.5 explains how to calculate the hospi-
Am
cludes autopsies on anyone who may have been tal autopsy rate.
e
th
a hospital patient. The formula for calculating the

by
hospital autopsy rate is shown in formula 14.16. Newborn Autopsy Rates

20
Autopsy rates usually include autopsies per-

20
The hospital autopsy rate includes autopsies per-

©
formed on any of the following: formed on newborn infants unless a separate rate
ht
is requested. The formula for calculating the new-

ig
Bodies of inpatients, except those removed

yr
●●
born autopsy rate is shown in formula 14.17.
op
by the coroner or ME. When the hospital

C
For example, three newborn deaths occurred

pathologist or other designated physician at Community Hospital in June, and one of the
acts as an agent in the performance of an deaths was autopsied. This represents 33.3 percent
autopsy on an inpatient, the death and the ([1/3] × 100).
autopsy are included in the percentage.
Formula 14.17 Calculating the newborn
●● Bodies of other hospital patients, including
autopsy rate
ambulatory care patients, hospital home care
Total number of autopsies
patients, and former hospital patients who
on NB deathss for a given
died elsewhere, but whose bodies have been Newborn
period of time
made available for autopsy to be performed autopsy = ´100
by the hospital pathologist or other designated rate Total number of NB deaths
physician. These autopsies and deaths are for the same period
included in computations of the percentage.
AB103118_Ch14.indd 447 2/7/2020 12:24:46 PM

Figure 14.5 Calculation of hospital autopsy rate
In June, 19 inpatient deaths occurred at Community Hospital. Three of these were medical examiner’s cases. Two of the
bodies were removed from the hospital and so were not available for hospital autopsy. One of the medical examiner’s
cases was autopsied by the hospital pathologist. Three other autopsies were performed on hospital inpatients that died
during the month of June. In addition, autopsies were performed in the hospital on:
• A child with congenital heart disease who died in the emergency department
• A former hospital inpatient who died in an extended care facility and whose body was brought to the hospital for
autopsy
• A former hospital inpatient who died at home and whose body was brought to the hospital for autopsy
• A hospital outpatient who died while receiving chemotherapy for cancer
• A hospital home care patient whose body was brought to the hospital for autopsy
• A former hospital inpatient who died in an emergency vehicle on the way to the hospital
Calculation of total hospital autopsies:
n.
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1 autopsy on medical examiner’s case
ia
+3autopsies on hospital in patients
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ss
+6autopsies on hospital patients whose bodies were available for autopsy
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10 autopsies performed by the hospital pathologist
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Calculation of number of deaths of hospital patients whose bodies were available for autopsy:
ag
19 inpatient deaths
an
-2medical examiner’s cases
M
+6deaths of hospital patients
n
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23 bodies available for autopsy
at
m
r
fo
Calculation of hospital autopsy rate:

In
Total number of hospital autopsies for the period

lth
Hospital autopsy rate = ´1

100
ea
Total number of deaths of hospital patients with bodies

H
available for hospital autopsy for the period

an
ic
(10 × 100)/23 = 43.5%

er
Am
e
Source: © AHIMA.
th
by
20
20
Fetal Autopsy Rates Formula 14.18 Calculating the fetal autopsy rate
©
Oftentimes, fetal autopsy rate will be calcu- Total number of autopsies

ht
ig
lated independently of the overall hospital au- Fetal on intermediate and late fetal
yr
autopsy = deaths for a given period of time ´100

op
topsy rate. This is done to provide data which

C
may be used in determining fetal cause of Total number of intermediate

rate
death. Fetal autopsies are performed on still- and late fetal deaths for
born infants who have been classified as ei- the same period
ther intermediate or late fetal deaths (see table
14.11). This is the proportion or percentage of In a previous example there were five interme-
autopsies performed on intermediate or late diate and late fetal deaths at Community Hospital
fetal deaths out of the total number of inter- during a year. Three of the deaths were autopsied.
mediate or late fetal deaths. The formula for The fetal autopsy rate is 60.0 percent ([3/5] × 100).
calculating the fetal autopsy rate is shown in Table 14.14 summarizes the different hospital
formula 14.18. autopsy rates.
AB103118_Ch14.indd 448 2/7/2020 12:24:52 PM

Table 14.14 Calculation of hospital autopsy rates

Rate Numerator Denominator
Gross autopsy rate Total number of autopsies on inpatient deaths Total number of inpatient deaths for the same period
for a given period × 100
Net autopsy rate Total number of autopsies on inpatient deaths Total number of inpatient deaths minus unautopsied
for a given period × 100 coroner or medical examiner cases for the same period
Hospital autopsy rate Total number of hospital autopsies for a given Total number of deaths of hospital patients whose bodies
period × 100 are available for hospital autopsy for the same period
Newborn (NB) Total number of autopsies on NB deaths for a Total number of NB deaths for the same period
autopsy rate given period × 100
Fetal autopsy rate Total number of autopsies on intermediate and Total number of intermediate and late fetal deaths for the
late fetal deaths for a given period × 100 same period
Source: © AHIMA.
n.
tio
ia
oc
ss
tA
en
Use the information in the following table to answer the questions that follow. Round to one decimal point.
em
ag
Community Hospital January through June Total
an
M
Number of inpatient deaths (all deaths) 35
n
Hospital inpatient autopsies (all autopsies) 9 io
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Coroner’s cases 2
m
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Former patient brought to hospital for autopsy 1

In
Newborn deaths 5
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ea
Newborn autopsies 1
H
Fetal deaths (intermediate and late) 12

an
ic
Fetal autopsies 1
er
Am
1. Calculate the hospital autopsy rate.

e
th
2. Calculate the gross autopsy rate for this month.

by
20
3. Calculate the net autopsy rate for this month.

20
4. Calculate the newborn autopsy rate.

©
ht
5. Calculate the fetal autopsy rate.

ig
yr
op
C
Healthcare-Associated Infection Rates respiratory, gastrointestinal, surgical wound, skin,

urinary tract, septicemias, and infections related
The most common morbidity rates calculated for
to intravascular catheters. Hospitals strive for a
hospitals are related to hospital-acquired infections,
low infection rate which is an indicator of qual-
called nosocomial (hospital-acquired) infections.
ity patient care.
Morbidity refers to the state of being ill. The hos-
pital must continuously monitor the number of in-
fections that occur in its various patient care units Healthcare-Associated Infection Rates
because infection can adversely affect the course of Hospital-acquired (nosocomial) infection rates, now
a patient’s treatment and possibly result in death. referred to as healthcare-associated infections (HAIs)
Examples of the different types of infections are by the CDC, may be calculated for the entire hospital
AB103118_Ch14.indd 449 2/7/2020 12:24:52 PM

or for a specific unit in the hospital. They also may be is any single, separate, systematic process upon
calculated for the specific types of infections. Ideally, or within the body that can be complete in itself.
the hospital should strive for an infection rate of zero. It is normally performed by a physician, dentist,
The formula for calculating the hospital-acquired, or or some other licensed practitioner, with or with-
nosocomial, infection rate is shown in formula 14.19. out instruments, to do the following:
For example, Community Hospital discharged 226 ●● Restore disunited or deficient parts
patients during the month of June, 13 of whom ex- ●● Remove diseased or injured tissues
perienced hospital-acquired infections. The hospital-
acquired infection rate is 5.8 percent ([13/226] × 100).
●● Extract foreign matter
If, of those 13 patients who had infections, there were ●● Assist in obstetrical delivery
8 who had a catheter-associated urinary tract infec- ●● Aid in diagnosis
tion (CAUTI), the rate would be 61.5 percent ([8/13]
A surgical operation involves one or more sur-
n.
× 100). This information would be extremely impor-
tio
tant to the Infection Control Committee because, if gical procedures that are performed at one time for
ia
oc
they could control CAUTIs, then more than half of one patient by way of a common approach (means
ss
the infections would be eliminated. by which the surgery was performed) or for a com-
tA
mon purpose. An example of a surgical operation
en
em
Formula 14.19 Calculating the nosocomial is the resection of a portion of both the intestine
ag
infection rate and the liver in a cancer patient. This involves two
an
Total number of hospital- procedures, removal of a portion of the liver and re-
M
Hospital acquired infections for a
n
moval of a portion of the colon; but it is considered
io
acquired given period of time
at
= ´1000 only one operation because there is only one opera-

m
infection
r
Total numberr of tive approach or incision. In contrast, an esopha-

fo
In
rate discharges, including gogastroduodenoscopy (EGD) and a colonoscopy

lth
deaths, for the performed at the same time are two procedures
ea
H
same period with two different approaches. In the former, the ap-
an
proach is the upper gastrointestinal tract; in the lat-

ic
er
ter, the approach is the lower gastrointestinal tract.

Am
Many healthcare organizations report their infec-

tion rates to the CDC. The CDC is primarily inter- In this case, the two procedures do not have a com-
e
th
ested in central line-associated bloodstream infection mon approach or purpose.

by
(CLABSI), catheter-associated urinary tract infection The formula for calculating the postoperative
20
infection rate is shown in formula 14.20. For exam-

20
(CAUTI), surgical site infection (SSI), and ventilator-

ple, Community Hospital reported that 258 surgi-
©
associated pneumonia. These rates are reported as

ht
cal operations were performed during the month

ig
indicators of unsafe practices such as failure to wash

yr
of June. There were two postoperative infections

op
hands and other means to reduce infections.

in clean surgical cases. The postoperative infection
C
Postoperative Infection Rates rate is 0.78 percent ([2/258] x 100).

Hospitals often track their postoperative infec-
tion rate. The postoperative infection rate is the Formula 14.20 Calculating the postoperative
proportion or percentage of infections in clean infection rate
surgical cases out of the total number of surgical Number of infections
operations performed. A clean surgical case is one in clean surgical cases
in which no infection existed prior to surgery. The for a given period
postoperative infection rate may be an indicator of Postoperative of time
a problem in the hospital environment or of some = ´100
infection rate Total number of
type of surgical contamination.
surgical operations for
Two terms must be considered here—surgical pro-
the same period
cedure and surgical operation. A surgical procedure
AB103118_Ch14.indd 450 2/7/2020 12:24:58 PM

Consultation Rates During June, Community Hospital had 226 dis-

A consultation is the response by one healthcare charges and deaths. Of those, 57 patients received
professional to another healthcare professional’s consultations. The consultation rate for June is 25.2
request to provide recommendations or opin- percent ([57/226] × 100).
ions regarding the care of a particular patient or Formula 14.21 Calculating the consultation rate
resident. The attending physician requests the Total number of patients
consultation and explains his or her reason for receiving consultations for
doing so. The consultant then examines the pa- Consultation a given period of time
tient and the patient’s health record and makes = ´100
rate Total number of
recommendations in a written report. The for- discharrges and deaths
mula for calculating the consultation rate is for the same period
shown in formula 14.21.
n.
tio
ia
oc
ss
tA
en
em
ag
Answer the following questions. Round all answers to two decimal point.
an
M
1. Use the following information to answer the questions that follow.
n
io
a. Calculate the postoperative infection rate.
at
m
b. Calculate the consultation rate.

r
fo
In
2. During the month of September, Community Hospital discharged 278 patients. Of those 278 patients, 12 were seen by
lth
a consultant. Six patients had an infection acquired in the hospital.

ea
a. Calculate the consultation rate.

H
an
b. Calculate the healthcare-associated infection rate.

ic
er
Am
e
th
by
20
Case-Mix Statistical Data

20
patients. MS-DRGs are covered in chapter 15, Revenue

©
Case mix is a description of a patient population Management and Reimbursement.

ht
ig
based on any number of specific characteristics in- When calculating case mix using MS-DRGs,
yr
op
cluding age, gender, type of insurance, diagnosis, the case-mix index (CMI) is the average relative
C
risk factors, treatment received, and resources used. weight of all cases treated at a given healthcare or-
It is generally used as a distribution of patients into ganization or by a given physician, which reflects
categories reflecting differences in severity of ill- the resource intensity or clinical severity of a spe-
ness or resource consumption. An example of case cific group in relation to the other groups in the
mix is male patients under the age of 35 who pres- classification system. (Chapter 15 also discusses
ent with right lower quadrant pain and undergo an case mix in more detail.)
appendectomy. Medicare severity diagnosis-related The CMI is a measure of the resources used in
groups (MS-DRGs) are often used to determine treating the patients in each hospital or group of
case mix in hospitals. MS-DRGs are the US govern- hospitals. A sample of a case-mix report by payer
ment’s revision of the DRG system. MS-DRGs were (table 14.15), by physician (table 14.16), and by
developed to allow the CMS to provide greater top 10 MS-DRGs (table 14.17) is given for Com-
reimbursement to hospitals who serve severely ill munity Hospital. As shown in formula 14.22 the
AB103118_Ch14.indd 451 2/7/2020 12:25:00 PM

Table 14.15 Case-mix index by payer, Community Table 14.17 Calculation of case-mix index for the
Hospital, 20XX top 10 MS-DRGs, Community Hospital, 20XX
Payer CMI N MS-DRG N X MS-DRG
Commercial 1.8830 283 MS-DRG Number (N) weight weight
Government managed care 0.9880 470 286 84 2.1240 178.4160
Managed care 1.4703 2,326 293 62 0.6762 41.9244
Medicaid 1.3400 962 982 61 2.8150 171.7150
Medicare 2.0059 1,776 986 51 1.0453 53.3103
Other 1.3251 148 434 45 0.6229 28.0305
Self-pay 1.3462 528 391 43 1.1976 51.4968
Average case mix by payer 1.4798 6,493 378 41 1.0021 41.0861

287 40 1.1290 45.1600
Source: © AHIMA.
n.
871 31 1.8072 56.0232
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689 26 1.1172 29.0472
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Table 14.16 Case mix of physicians, 20XX Total 484 696.2095
ss
CMI 1.4384
tA
Physician CMI N
en
A 1.0235 71 Source: © AHIMA.
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B 1.6397 71
ag
In table 14.15, you can see that Medicare patients,
an
C 1.1114 86
M
Average case mix by physician 1.2582 228 as expected, have the highest CMI at 2.0059.
n
io
Other data analyzed by MS-DRG include LOS
at
Source: © AHIMA.
and mortality rates. LOS and mortality data are
r m
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CMI is calculated by multiplying the number of benchmarked against a particular hospital and
In
national data. The process of benchmarking involves

lth
cases for each MS-DRG by the relative weight of

ea
the MS-DRG, summing the result (696.205) and di- comparing the hospital’s performance against
H
an external standard or benchmark. An excellent

an
viding by the total number of cases (484). In other

ic
words, CMI is calculated by adding the MS-DRG source of information for benchmarking purposes
er
Am
relative weights for all Medicare discharges and is the Healthcare Cost Utilization Project database
(HCUPnet). HCUPnet is an online query system
e
dividing by the number of Medicare discharges.

th
that provides access to statistics from the Healthcare

by
By convention, the CMI is calculated to five deci-

Cost and Utilization Project (HCUP, pronounced
20
mal points and rounded to four.

20
“H-Cup”). HCUP is a family of healthcare databases

©
and related software tools and products developed

ht
Formula 14.22
ig
through a Federal-State-Industry partnership and

yr
Sum total of MS-DRG relative weights for all

op
sponsored by the Agency for Healthcare Research

C
harges = CMI
Medicare disch and Quality (AHRQ). HCUP databases bring
Total number of Medicare discharges together the data collection efforts of state data
organizations, hospital associations, private data

696.205 / 484 = 1.4384 organizations, and the federal government to create
a national information resource of encounter-level
healthcare data (HCUP 2019). HCUP includes the
largest collection of longitudinal hospital care data
The CMI can be used to indicate the average in the United States, with all payer, encounter-level
reimbursement for the hospital. From table 14.15, information beginning in 1988. These databases
the reimbursement is approximately 1.4798 multi- enable research on a broad range of health policy
plied by the hospital’s base rate. It also is a mea- issues, including cost and quality of health services,
sure of the severity of illness of Medicare patients. medical practice patterns, access to healthcare
AB103118_Ch14.indd 452 2/7/2020 12:25:02 PM

programs, and outcomes of treatments at the na- Table 14.18 Benchmark data, Community Hospital
tional, state, and local market levels (HCUP 2019). versus national average for MS-DRG 293, Heart
A comparison of hospital and national data for failure and shock without complication/comorbidity/
MS-DRG 293 appears in table 14.18. major complication/comorbidity (CC/MCC)
Gross analysis of the data indicates that Com- Mortality Average
munity Hospital’s mortality rate and ALOS are ALOS rate charges
slightly better than the national average. But, at Community Hospital 2.5 0.9% $22,375
the same time, the hospital’s average charges are National average 2.6 1.1% $18,192
higher than the national average. Source: © AHIMA.
n.
tio
Answer the following questions. Round to four decimal points.
ia
oc
1. A name given to describe an infection acquired in a healthcare organization is _______.
ss
tA
2. Identify the term the CDC uses for hospital-acquired infections.
en
3. During June, Community Hospital had 127 patients discharged. Of those 127 patients, 57 patients had consultations
em
from specialty physicians. What was the consultation rate for June?
ag
an
4. Last month, Community Hospital had 68 discharges from its medicine unit. Six patients developed a catheter-
M
associated urinary tract infection (CAUTI) while in the hospital. Calculate the CAUTI rate for the last month.
n
io
5. Dr. Green discharged patients from medicine service during the month of August. Table 14.19 presents the number of
at
m
patients discharged by Dr. Green by MS-DRG. Determine the total number of patients, calculate the total weight for
r
fo
each MS-DRG, and the CMI for Dr. Green.

In
lth
Table 14.19 Community Hospital number of patients Dr. Green discharged by MS-DRG, August, 20XX
ea
H
MS-DRG MS-DRG title Relative weight Number of patients Total weight

an
179 Respiratory infections and inflammations w/o 0.9693 5

ic
er
CC/MCC
Am
187 Pleural effusion w/ CC 1.0691 2

e
th
189 Pulmonary edema and respiratory failure 1.2136 3

by
194 Simple pneumonia and pleurisy w/ CC 0.9688 1

20
208 Respiratory system diagnosis w/ ventilator 2.2969 1

20
support < 96 hours

©
280 Acute myocardial infarction, discharged alive w/ 1.7289 3

ht
ig
MCC
yr
op
299 Peripheral vascular disorders w/ MCC 1.4094 2

C
313 Chest pain 0.6138 4

377 G.I. hemorrhage w/ MCC 1.7775 1
391 Esophagitis, gastroenteritis, and miscellaneous 1.1976 1
digestive disorders w/ MCC
547 Connective tissue disorders w/o CC/MCC 0.7985 1
552 Medical back problems w/o MCC 0.8698 1
684 Renal failure w/o CC/MCC 0.6085 1
812 Red blood cell disorders w/o MCC 0.8182 2
872 Septicemia w/o MV 96+ hours w/o MCC 1.0528 1
918 Poisoning and toxic effects of drugs w/o MCC 0.6412 1
Total
Case-mix index =
Source: © AHIMA.
AB103118_Ch14.indd 453 2/7/2020 12:25:03 PM

Ambulatory Care Statistical Data

Ambulatory care includes healthcare therapeutic services by a hospital on an
services provided to patients who are not hospi- ambulatory basis but whose medical care
talized (that is, who are not considered inpatients remains the responsibility of the referring
or residents and do not stay in the healthcare or- physician
ganization overnight). Such patients are referred ●● Outpatient visit. A patient’s visit to
to as outpatients. Most ambulatory care services one or more units or facilities located
today are provided in freestanding physicians’ in the ambulatory services area (clinic
offices, emergency care centers, and ambulatory or physician’s office) of an acute-care
surgery centers that are not owned or operated hospital in which an overnight stay does
by acute-care organizations. However, hospi- not occur
n.
tio
tals do provide many hospital-based healthcare
Encounter. The face-to-face contact between
ia
●●
services to outpatients. Hospital outpatients
oc
a patient and a provider who has primary
ss
may receive services in one or more areas within
responsibility for assessing and treating the
tA
the hospital, including clinics, same-day surgery
en
condition of the patient at a given contact
em
departments, diagnostic departments, and emer-
and exercises independent judgment in the
ag
gency departments.
care of the patient
an
Outpatient statistics include health records of the
M
number of patient visits and the types of services
●● Occasion of service. A specified, identifiable
n
io
service involved in the care of a patient that
at
provided. Many different terms are used to describe
m
outpatients and ambulatory care services, including is not an encounter (for example, a lab test
r
fo
ordered during an encounter)

In
the following:
lth
●● Ambulatory surgery center or ambulatory

ea
●● Ambulatory care. Preventive or corrective

surgical center (ASC). Under Medicare,
H
healthcare services provided on a

an
an outpatient surgical facility that has

ic
nonresident basis in a provider’s office,

er
its own national identifier; is a separate

Am
clinic setting, or hospital emergency

entity with respect to its licensure,
setting
e
accreditation, governance, professional

th
Outpatient. A patient who receives

by
●●
supervision, administrative functions,
20
ambulatory care services in a hospital-based clinical services, recordkeeping, and

20
clinic or department financial and accounting systems; has as

©
ht
●● Emergency patient. A patient who is its sole purpose the provision of services in
ig
admitted to the emergency services connection with surgical procedures that

yr
op
department of a hospital for diagnosis do not require inpatient hospitalization;

C
and treatment of a condition that requires and meets the conditions and requirements
immediate medical, dental, or allied health set forth in the Medicare Conditions of
services in order to sustain life or to prevent Participation. May be referred to as short-
critical consequences stay surgery, one-day surgery, or same-day
●● Clinic outpatient. A patient who is admitted surgery (White 2020).
to a clinical service of a clinic or hospital for Because outpatient care represents a large part
diagnosis or treatment on an ambulatory of a healthcare organization’s activity, statistics are
basis collected and calculated on this group of patients.
●● Referred outpatient. An outpatient Many of the statistics covered in this chapter apply
who is provided special diagnostic or to ambulatory care.
AB103118_Ch14.indd 454 2/7/2020 12:25:03 PM


Match the definitions with the terms.
1. _________ Preventive or corrective healthcare services provided on a nonresident basis in a provider’s office, clinic
setting, or hospital emergency setting
2. _________ A patient who receives ambulatory care services in a hospital-based clinic or department
3. _________ An outpatient who is provided special diagnostic or therapeutic services by a hospital on an ambulatory
basis but whose medical care remains the responsibility of the referring physician
4. _________ The face-to-face contact between a patient and a provider who has primary responsibility for assessing and
treating the condition of the patient at a given contact and exercises independent judgment in the care of the patient
5. _________ A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis
n.
tio
6. _________ A hospital patient who receives services in one or more of a hospital’s facilities when he or she is not
ia
currently an inpatient or a home care patient
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ss
7. _________ A patient who is admitted to the emergency services department of a hospital for diagnosis and treatment
tA
of a condition that requires immediate medical, dental, or allied health services in order to sustain life or to prevent
en
critical consequences
em
8. _________ An outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure,
ag
an
accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial
M
and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not
n
require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation
io
at
9. _________ An ambulatory surgery center that is owned and operated by a hospital but is a separate entity with
rm
respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services,
fo
In
recordkeeping, and financial and accounting systems

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10. _________ A patient’s visit to one or more units or facilities located in the ambulatory services area (clinic or
ea
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physician’s office) of an acute-care hospital in which an overnight stay does not occur
an
11. _________ A specified, identifiable service involved in the care of a patient that is not an encounter (for example, a
ic
er
lab test ordered during an encounter)

Am
a. Ambulatory surgery center

e
b. Outpatient visit
th
by
c. Encounter
20
d. Occasion of service
20
e. Referred outpatient
©
f. Clinic outpatient
ht
ig
g. Emergency outpatient
yr
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h. Hospital outpatient
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i. Hospital ambulatory care

j. Outpatient
k. Hospital-affiliated ambulatory surgery center
Public Health Statistics and Epidemiological

Information
Just as statistics are collected in the healthcare or- example of data collected and reported at these lev-
ganization, they also are collected on a community, els. The term vital statistics refers to the collection
regional, and national basis. Vital statistics are an and analysis of data related to the crucial events in
AB103118_Ch14.indd 455 2/7/2020 12:25:04 PM

life: birth, death, marriage, divorce, fetal death, and The certificate of live birth is used for registra-
induced terminations of pregnancy. These statistics tion purposes and is composed of two parts. The
are used to identify trends. For example, a higher- first part contains the information related to the
than-expected death rate among newborns may be child and the parents. The second part is used to
an indication of the lack of prenatal services in a collect data about the mother’s pregnancy. This
community. A number of deaths in a region due information is used for the collection of aggregate
to the same cause may indicate an environmental data only. No identification information appears
problem. For example, the World Health Organiza- on this portion of the certificate, nor does it ever
tion (WHO) has found that poor outdoor air qual- appear on the official certificate of birth. Pregnan-
ity is a cause of lung cancer deaths. cy-related information includes complications of
These types of data are used as part of the effort pregnancy, concurrent illnesses or conditions af-
to preserve and improve the health of a defined fecting pregnancy, and abnormal conditions or
n.
population—the public health. The study of fac- congenital anomalies of the newborn. Lifestyle
tio
tors that influence the health status of a popula- factors such as use of alcohol and tobacco also are
ia
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tion is called epidemiology. The following sections collected. Thus, the birth certificate is the major
ss
will cover national vital statistics and population- source of maternal and natality statistics. A list-
tA
en
based statistics. ing of pregnancy-related information appears in
em
figure 14.6.
ag
National Vital Statistics System Data collected from death certificates are used to
an
M
The National Vital Statistics System (NVSS) is compile causes of death in the United States. The
n
the oldest example of intergovernmental data io
certificate of death contains decedent information,
at
place of death information, medical certification,
m
sharing in the US public health, and the shared re-

r
fo
lationships, standards, and procedures that form and disposition information. The US uses the cur-
In
the mechanism by which the National Center for rent edition of the International Classification of
lth
ea
Health Statistics (NCHS) of the Centers for Disease Diseases (ICD) for classifying causes of death. Ex-
H
Control and Prevention (CDC) collects and dis- amples of the content of death certificates appear
an
ic
seminates the nation’s official vital statistics. These in figure 14.7.

er
Am
data are provided through contracts between A report of fetal death is completed when a preg-
NCHS and vital registration systems operated in nancy results in a stillbirth, regardless of the gesta-
e
th
the various jurisdictions and legally responsible tional age. This report contains information on the
by
for the registration of vital events—births, deaths, parents, the history of the pregnancy, and the cause
20
20
marriages, divorces, and fetal deaths. of the fetal death. Information collected on the
©
To facilitate consistent data collection, the NVSS pregnancy is the same as that recorded on the birth
ht
ig
uses standard forms and procedures for the uni- certificate. To assess the effects of environmental ex-
yr
op
form registration of events and recommends posures on the fetus, the parents’ occupational data
C
that each state use the same forms. The stand- are collected. A listing of the content of the fetal
ard certificates represent the minimum basic data death certificate appears in figure 14.8.
set necessary for the collection and publication of The report of induced termination of pregnancy
comparable national, state, and local vital statistics records information on the place of the induced
data. The standard forms are revised about every termination of pregnancy, type of termination pro-
10 to 15 years. To effectively implement these new cedure, and patient (see figure 14.9).
certificates, the NCHS collaborates with its state A tool for monitoring and exploring the in-
partners to improve the timeliness, quality, and terrelationships between infant death and risk
sustainability of the vital statistics system, along factors at birth is the linked birth and infant
with collection of the revised and new content of death data set. This is a service provided by the
the certificates that were originally created in 2003 NCHS. In this data set, the information from the
(CDC 2019a). death certificate (such as age and underlying or
AB103118_Ch14.indd 456 2/7/2020 12:25:04 PM

Figure 14.6 Content of US certificate of live birth, 2003

Child’s information Pregnancy history
Child’s name Date of first prenatal care visit
Time of birth Date of last prenatal care visit
Sex Total number of prenatal visits for this pregnancy
Date of birth Mother’s height
Facility (hospital) name (if not an institution, give street Mother’s prepregnancy weight
address)
City, town, or location of birth Mother’s weight at delivery
County of birth Did mother get Women Infant Child (WIC) food for herself
uring this pregnancy?
d
Mother’s Information Number of previous live births
n.
Current legal name Number now living
tio
Date of birth Number now dead
ia
oc
Mother’s name prior to first marriage Date of last live birth
ss
Birthplace Number of other pregnancy outcomes
tA
en
Residence (state) Other outcomes
em
County Date of last other pregnancy outcomes
ag
City, town, or location Cigarette smoking before and during pregnancy
an
Street number Principal source of payment for this delivery
M
n
Apartment number Date last normal menses began
io
at
Zip code Mother’s medical record number
m r
fo
Inside city limits? Risk factors in this pregnancy

In
Mother’s mailing address Infections present and treated during this pregnancy
lth
ea
Mother married? Obstetric procedures

H
If no, has paternity acknowledgment been signed in the Onset of labor

an
hospital?
ic
er
Social Security number (SSN) requested for child? Characteristics of labor and delivery
Am
Mother’s SSN Method of delivery

e
th
Education Maternal mortality

by
Hispanic origin? Newborn Information

20
Race Newborn medical record number

20
Place where birth occurred Birth weight

©
ht
Attendant’s name, title, and National Provider Identifier Obstetric estimate of gestation
ig
yr
Mother transferred for maternal, medical, or fetal indications for Apgar score (1 and 5 minutes)
op
delivery?
C
Father’s Information Plurality

Current legal name If not born first (born first, second, third )
Date of birth Abnormal conditions of newborn
Birthplace Congenital anomalies of the newborn
Education Was infant transferred within 24 hours of delivery?
Hispanic origin? Is infant living at time of report?
Race Is infant being breastfed at discharge?
Father’s SSN
Source: CDC 2019a.
AB103118_Ch14.indd 457 2/7/2020 12:25:04 PM

Figure 14.7 Content of US certificate of death, 2003

Decedent information Medical certification
Name Date pronounced dead
Sex Time pronounced dead
Social Security number Signature of person pronouncing death
Age Date signed
Under 1 year—month; days Actual or presumed date of death
Under 1 day—hours; minutes Actual or presumed time of death
Date of birth Was medical examiner contacted?
Birthplace Immediate cause of death
Residence (state) Due to
County Due to
City or town Due to
n.
tio
Street and number Other significant conditions contributing to death
ia
oc
Apartment number Was an autopsy performed?
ss
Zip code Were autopsy findings available to complete the cause of death?
tA
Inside city limits? Did tobacco use contribute to death?
en
Ever in US armed forces? If female, indicate pregnancy status
em
ag
Marital status at time of death Manner of death
an
Surviving spouse’s name (if wife, give name prior to first m
arriage) For deaths due to injury:
M
Father’s name Date of injury
n
Mother’s name (prior to first marriage) Time of injury
io
at
m
Informant’s name Place of injury

r
fo
Relationship to decedent Injury at work?

In
Mailing address Location of injury

lth
ea
Decedent’s education Describe how injury occurred

H
Hispanic origin? If transportation injury, specify if driver or operator,

an
passenger, pedestrian, other

ic
er
Race Certifier information

Am
Disposition information Certifier

e
Method of disposition Name, address, and zip code of person completing cause of death
th
by
Place of disposition (cemetery, crematory, other) Title of certifier

20
Location—city, town, and state License number

20
Name and complete address of funeral facility Date certified

©
Signature of funeral service licensee or other agent

ht
ig
License number
yr
op
Place of death information

C
Place of death
If hospital, indicate inpatient, emergency department or
outpatient, dead on arrival
If somewhere other than hospital, indicate hospice, nursing
home or long-term care facility, decedent’s home, other
Facility name
City or town, state, zip code
County
Source: CDC 2019a.
AB103118_Ch14.indd 458 2/7/2020 12:25:04 PM

Figure 14.8 Content of US standard report of fetal death, 2003

Mother’s information Number of other pregnancy outcomes
Name of fetus (optional—at the discretion of the Other outcomes
parents)
Time of delivery Date of last other pregnancy outcomes
Sex Cigarette smoking before and during pregnancy
Date of delivery Date last normal menses began
City, town, or location of delivery Plurality
Zip code of delivery If not born first (born second, third)
County of delivery Mother transferred for maternal, medical, or fetal indications for
delivery?
Place where delivery occurred Medical and health information
n.
Facility name Risk factors in this pregnancy
tio
Facility ID Infections present and treated during this pregnancy
ia
oc
Mother’s current legal name Method of delivery
ss
Date of birth Maternal mortality
tA
en
Mother’s name prior to first marriage Congenital anomalies of the newborn
em
Birthplace Father’s information
ag
Residence of mother (state) Current legal name
an
M
County Date of birth
n
City, town, or location Birthplace
io
at
Street number Disposition
m
r
fo
Apartment number Method of disposition

In
Zip code Attendant and registrant information

lth
ea
Inside city limits? Attendant’s name, title, and National Provider

H
Identifier
an
Education Name of person completing report

ic
er
Hispanic origin? Date report completed

Am
Race Date received by registrar

e
th
Mother married at delivery, conception, or any time Cause of fetal death

by
between?
20
Date of first prenatal care visit Initiating cause or condition

20
Date of last prenatal care visit Other significant causes or conditions

©
Total number of prenatal visits for this pregnancy Weight of fetus

ht
ig
Mother’s height Obstetric estimate of gestation at delivery

yr
op
Mother’s pre-pregnancy weight Estimated time of fetal death

C
Mother’s weight at delivery Was an autopsy performed?

Did mother get WIC food for herself during this Was a histological placental examination performed?
pregnancy?
Number of previous live births Were autopsy or histological placental examination
results used in determining the cause of fetal
death?
Number now living
Number now dead
Date of last live birth
Source: CDC 2019a.
AB103118_Ch14.indd 459 2/7/2020 12:25:05 PM

Figure 14.9 Content of US standard report of induced termination of pregnancy, 1997

Place of induced termination Hispanic origin?
Facility name Race
City, town, or location of pregnancy termination Education
County of pregnancy termination Elementary/secondary
Patient information College
Patient identification Date last normal menses began
Age at last birthday Clinical estimate of gestation
Marital status Previous pregnancies
Date or pregnancy termination Live births
Residence (state) Other terminations
County Type of termination procedure
n.
Other information
tio
City, town, or location
ia
Inside city limits? Name of attending physician
oc
ss
Zip code Name of person completing report
tA
Source: CDC 2019a.
en
em
ag
ultiple causes of death) is linked to the informa-
m Birth Rates and Measures of Infant Mortality
an
tion in the birth certificate (such as age, race, birth
M
Two community-based rates that are commonly
weight, prenatal care, maternal education, and so
n
io
used to describe a community’s health are the
at
on) for each infant who dies in the United States, crude birth rate and measures of infant mortal-
mr
fo
Puerto Rico, the Virgin Islands, and Guam. The ity. WHO’s definition of a live birth is “the com-
In
purpose of the data set is to use the many addi- plete expulsion or extraction from its mother of
lth
ea
tional variables available from the birth certifi- a product of conception, irrespective of the du-
H
cate to conduct a detailed analysis of infant mor- ration of the pregnancy, which after such separa-
an
tality patterns.
ic
tion, breathes or shows other evidence of life such

er
Birth, death, fetal death, and termination of preg-

Am
as beating of the heart, pulsation of the umbilical

nancy certificates provide vital information for cord, or definite movement of voluntary muscles,
e
th
use in medical research, epidemiological studies, whether or not the umbilical cord has been cut or
by
and other public health programs. In addition, the placenta is attached” (WHO 2019).
20
20
they are the source of data for compiling mor- Rates that describe infant mortality are based on
©
bidity, birth, and mortality rates that describe the age. Therefore, the definitions for the various age
ht
health of a given population at the local, state, or

ig
groups must be strictly followed. Table 14.20 sum-

yr
national level. Because of their many uses, the

op
marizes the calculations for community-based

C
data on these certificates must be complete and birth and infant mortality rates. These mortalities,
accurate. or death, rates are broken down as follows.
Crude birth rate is the number of live births
Population-Based Statistics divided by the population at risk, meaning the
Population-based statistics are based on the mor- population affected (as shown in table 14.20).
tality and morbidity rates from which the health Community rates are calculated using the multi-
of a population can be inferred. The entire defined plier 1,000, 10,000, or 100,000. The purpose is to
population is used in the collection and reporting bring the rate to a whole number, as discussed
of these statistics. The size of the defined popula- earlier in the chapter. The result of the formula is
tion serves as the denominator in the calculation stated as the number of live births per 1,000 pop-
of these rates, which are discussed in the following ulation. Formula 14.23 for calculating the crude
sections. birth rate is as follows.
AB103118_Ch14.indd 460 2/7/2020 12:25:05 PM

Table 14.20 Calculation of community-based birth and infant death (mortality) rates
Measure Numerator (x) Denominator ( y) 10n
Crude birth Number of live births for a given community for a speci- Estimated population for the same community 1,000
rate fied time period and the same time period
Neonatal Number of deaths of infants from birth up to, but not Number of live births during the same time 1,000
mortality rate including, 28 days of age during a given time period period
Postneonatal Number of deaths of infants from 28 days of age up to, but Number of live births minus neonatal deaths 1,000
mortality rate not including, one year of age during a given time period during the same time period
Infant mortality Number of deaths of infants under one year of age during Number of live births during the same time 1,000
rate a given time period period
Source: © AHIIMA.
n.
Formula 14.23 Calculating the crude birth rate For example, in your community there were 5,392
tio
live births and 12 infants who died within the neo-
ia
Number of live births
oc
natal period in 20XX. The neonatal mortality rate is
ss
for a given community
2.2 per 1,000 live births for the period ([12/5,392]
tA
Crude for a specified period of time
en
= ´1, 000 × 1,000).
birth rate Estimated population
em
The postneonatal mortality rate is often used
ag
for the same community as an indicator of the quality of the home or com-
an
and the same time period
M
munity environment of infants. The postneonatal
n
period is from 28 days of age up to, but not includ-
io
at
For example, if there were 5,392 live births in a ing, one year of age. In the formula for calculating
m
r
fo
community of 500,000 in 20XX, the crude birth rate the postneonatal mortality rate, the numerator is
In
for that year would be 10.8 per 1,000 population the number of deaths among infants from 28 days
lth
ea
([5,392/500,000] × 1,000). of age up to, but not including, one year of age
H
The neonatal mortality rate can be used as a during a given time period and the denominator is
an
ic
measure of the quality of prenatal care and the the total number of live births minus the number
er
Am
mother’s prenatal behavior (for example, alcohol, of neonatal deaths during the same time period.
drug, or tobacco use). The neonatal period is the The formula for calculating the postneonatal mor-
e
th
period of an infant’s life from the hour of birth tality rate is shown in formula 14.25.
by
through the first 27 days, 23 hours, and 59 minutes

20
20
of life. In the formula for calculating the neona- Formula 14.25 Calculating the postneonatal
©
tal mortality rate, the numerator is the number of mortality rate

ht
Number of deaths
ig
deaths of infants in the neonatal period during a

yr
given time period and the denominator is the total of infants from 28 days
op
C
number of live births during the same time period. of age up to, but not
See formula 14.24 to calculate the neonatal mortal- including, one year of
ity rate. agge during a given
Postneonatal time period
Formula 14.24 Calculating the neonatal = ´1, 000
mortality rate Number of live
mortality rate
births minus neonatal
Number of deaths of infants
deaths during the
from birth up to, but not
same time period
including, 28 days of age
Neonatal
during a givven time period
mortality = ´1,000 For example, in your community there were
rate Number of live births during
5,392 live births, 12 neonatal deaths, and 9 post-
the same time period
neonatal deaths during 20XX. The postneonatal
AB103118_Ch14.indd 461 2/7/2020 12:25:09 PM

ortality rate is 1.7 per 1,000 live births minus

m the crude death/mortality rate is found in for-
neonatal deaths for the period ([9/{5,392 – 12}] mula 14.27.
×1,000).
The infant mortality rate is the summary of the Formula 14.27 Calculating the crude death/
neonatal and postneonatal mortality rates. In the mortality rate
formula for calculating the infant mortality rate, Total number of
the numerator is the number of deaths among in- deaths for a population
fants under one year of age (364 days, 23 hours, during a specified
and 59 minutes from the moment of birth) and Crude death/ period of time
= ´1, 000
the denominator is the number of live births dur- mortality rate Estimated populaation
ing the same period. The infant mortality rate is for the same time period
the most commonly used measure for comparing
n.
health status among nations. All the rates are ex- For instance, in our previous examples we used
tio
pressed in terms of the number of deaths per 1,000
ia
a community population of 500,000. There were
oc
live births. The formula for calculating the infant 1,327 deaths in 20XX. Dividing 1,327 by 500,000
ss
mortality rate is found in formula 14.26.
tA
equals 0.002654. Using a multiplier of 1,000 gives a
en
crude death rate of 2.7 deaths per 1,000 population
em
Formula 14.26 Calculating the infant
for 20XX ([1,327/500,000] × 1,000).
ag
mortality rate
an
As its name indicates, the cause-specific mortal-
Number of deaths of infants
M
ity rate is the rate of death due to a specified cause.
n
under one year of age during io
It may be calculated for an entire population or for
at
Infant a given period of time
m
= ´1,000 any age, sex, or race. In the formula, the numera-

r
mortality Number of live birth

fo
hs tor is the number of deaths due to a specified cause

In
during the same period

lth
for a given time period and the denominator is the

ea
estimated population for the same time period.

H
For example, in your community there were 12

an
Table 14.21 displays cause-specific mortality rates

ic
neonatal deaths, 9 postneonatal deaths, and 5,392 for men and women due to influenza and pneu-
er
Am
live births in 20XX. The infant mortality rate is 3.9 monia for the year 2013. The cause-specific death
per 1,000 live births in that year ([{12 + 9}/5,392]
e
rates for each age group are consistently higher for

th
× 1,000).
by
men than for women, but the overall rate is high-

20
er for women. This information could lead to an

20
Other Death (Mortality) Rates investigation of why this occurs. The formula for
©
Other measures of mortality with which the calculating the cause-specific mortality rate can be
ht
ig
HIM professional should be familiar include the found in formula 14.28.

yr
op
following.
C
Crude death/mortality rate is a measure of the Formula 14.28 Calculating the cause-specific
actual or observed mortality in a given population. mortality rate
Crude death rates apply to a population without Total number of
regard to characteristics such as age, race, and sex. deaths due to a
They measure the proportion of the population specific cause
that has died during a given period of time (usu- during a specified
ally one year) or the number of deaths in a com- Cause-specific period of time
munity per 1,000 for a given period of time. In the = ´100 , 000
mortality rate Estimaated
formula, the numerator is the total number of deaths
population
in a population for a specified time period and
for the same
the denominator is the estimated population for
time period
the same time period. The formula for calculating
AB103118_Ch14.indd 462 2/7/2020 12:25:12 PM

Table 14.21 Cause-specific mortality rates, by sex, due to influenza and pneumonia (ICD-10 codes
J09–J18.9), age 45+, in the United States, 2017
Women Men
Age group Population Deaths Rate/100,000 Population Deaths Rate/100,000
45–54 21,468,595 937 4.4 20,906,357 1,076 5.1
55–64 21,737,855 2,219 10.2 20,257,803 2,826 14.0
65–74 15,806,306 4,002 25.3 13,877,140 4,782 34.5
75–84 8,298,676 6,746 81.3 6,407,875 7,056 110.1
85+ 4,189,013 14,430 344.5 2,279,669 9,846 431.9
Total 71,500,445 28,334 39.62 63,728,844 25,586 40.1
Source: CDC 2019b.
n.
The case fatality rate measures the total number Formula 14.30 Calculating the proportionate
tio
of deaths among the diagnosed cases of a specific
ia
mortality rate
oc
disease, most often acute illness. In the formula for Total number of deaths
ss
tA
calculating the case fatality rate, the numerator is the due to a specific cause
en
number of deaths due to a specific disease that oc- during a specified
em
curred during a specific time period and the denomi- Proportionate period of time
ag
nator is the number of diagnosed cases during the = ´100
an
mortality rate Total number of deaths
M
same time period. The higher the case fatality rate, from all causes during the
n
the more virulent the infection. The formula for calcu- io
same time periiod
at
lating the case fatality rate is found in formula 14.29.
r m
fo
In
Formula 14.29 Calculating the case fatality rate The maternal mortality rate (community based)
lth
ea
Total number of deaths measures the deaths associated with pregnancy for a
H
due to a specific specific community for a specific period of time. It is

an
disease during a specified

ic
calculated only for deaths that are directly related

er
Case fatality period of time to pregnancy. In the formula for calculating the ma-
Am
= ´100
rate Total number off ternal mortality rate, the numerator is the number
e
th
cases due to a specific of deaths attributed to causes related to pregnancy

by
disease during the during a specific time period for a given commun-
20
20
same time perriod ity and the denominator is the number of live births
©
reported during the same time period for the same

ht
ig
For example, in our community there were seven community. The maternal mortality rate is expressed
yr
as the number of deaths per 100,000 live births. The

op
cases of meningitis resulting in two deaths. The case

C
fatality rate of meningitis is 28.6 percent ([2/7] × 100). formula for calculating the maternal mortality rate
The proportionate mortality rate (PMR) is a (community based) is found in formula 14.31.
measure of mortality due to a specific cause for a
specific time period. In the formula for calculating Formula 14.31 Calculating the maternal mortality rate
the PMR, the numerator is the number of deaths Total number of deaths
due to a specific disease for a specific time period due to pregnancy - related
and the denominator is the number of deaths from conditions during a
all causes for the same time period. Table 14.22 Maternal
specified period of time
displays the PMRs for influenza and pneumonia mortality = ´1100 , 000
rate Total number of live
in the United States in 2017 by age groups. The births during the same
formula for calculating the proportionate mortal- time period
ity rate is found in formula 14.30.
AB103118_Ch14.indd 463 2/7/2020 12:25:17 PM

Table 14.22 Proportionate mortality rates for influenza and pneumonia (ICD-10 codes J09–J18.9), all
ages, in the United States, 2017
Influenza and
Age group pneumonia deaths Total deaths PMR/100
< 1 year 157 22,335 0.70
1–4 104 3,880 2.68
5–14 113 5,571 2.03
15–24 190 32,025 0.59
25–34 405 60,215 0.67
35–44 782 79,796 0.98
45–54 2,013 170,142 1.18
55–64 5,045 372,006 1.36
n.
65–74 8,784 531,610 1.65
tio
75–84 13,802 657,759 2.10
ia
oc
85+ 24,276 878,035 2.76
ss
tA
Source: CDC 2019b.
en
em
ag
an
Table 14.23 Calculation of community-based mortality rates
M
n
Measure Numerator (x) Denominator (y)
io 10n
at
Crude death/ Total number of deaths for a population during Estimated population for the same time 1,000 or 10,000
m
mortality rate a specified time period period or 100,000

r
fo
In
Cause-specific Total number of deaths due to a specific cause Estimated population for the same time 100,000
lth
mortality rate during a specified time period period

ea
Case fatality rate Total number of deaths due to a specific dis- Total number of cases due to a specific 100
H
ease during a specified time period disease during the same time period
an
ic
Proportionate Total number of deaths due to a specific cause Total number of deaths from all causes N/A
er
mortality rate during a specified time period during the same time period
Am
Maternal mortality Total number of deaths due to pregnancy-re- Total number of live births during the 100,000
e
rate lated conditions during a specified time period same time period
th
by
Source: CDC 2019b.

20
20
©
For example, there were 3,932,181 live births and are compared using rates instead of raw numbers be-
ht
ig
1,111 maternal deaths. This is a maternal mortality cause rates adjust for differences in population size.
yr
op
rate of 29 maternal deaths per 100,000 live births The incidence rate is the probability or risk of illness
C
([1,111/3,932,181] × 100,000). Table 14.23 shows in a population over a period of time. The denomina-
how to calculate community-based mortality rates. tor represents the population from which the case in
the numerator arose, such as a nursing home, school,
Measures of Morbidity or organization. For 10n, a value is selected so that the
Two measures are commonly used to describe the smallest rate calculated results in a whole number. In
presence of disease in a community or specific lo- a small population such as a nursing home you might
cation (for example, a nursing home)—incidence select 100, in studying a larger population you might
and prevalence rates. Disease is any illness, injury, select 1,000. For example, in a local nursing home of
or disability. Incidence and prevalence measures 174 patients, 8 new cases of H1N1 (a strain of influ-
can be broken down by race, sex, age, or other enza A virus) occurred during January. Using this
characteristics of a population. formula, the incidence rate is 5.5 percent ([8/147] ×
An incidence rate is used to compare the frequency 100). The formula for calculating the incidence rate is
of new cases of disease in populations. Populations found in formula 14.32.
AB103118_Ch14.indd 464 2/7/2020 12:25:17 PM


Use the information in table 14.24 to answer the questions that follow. Round to one decimal point.
1. Review the mortality data in table 14.24 to answer the questions that follow.
a. Calculate the crude death rate per 10,000 for men of all ages.
b. Calculate the crude death rate per 10,000 for women of all ages.
c. Calculate the crude death rate per 10,000 for the entire group.
d. Calculate the crude death rate per 10,000 for men ages 15 to 24.
e. Calculate the crude death rate per 10,000 for women ages 15 to 24.
2. In a community of 750,000, 4,899 live births were reported. Calculate the crude birth rate.
3. In this same community eight infants died in the neonatal period. Calculate the neonatal mortality rate.
n.
4. In this same community 14 children died in the neonatal period. Calculate the postneonatal mortality rate.
tio
ia
oc
Table 14.24 Mortality Rates, United States, 2017
ss
tA
Female Male
en
Age group Population Deaths Population Deaths
em
Less than 1 year 1,924,145 9,867 2,015,150 12,468
ag
an
1–4 years 7,818,747 1,648 8,180,818 2,232
M
5–14 20,109,479 2,302 20,973,213 3,269
n
15–24 21,100,662 8,522
io 22,149,633 23,503
at
m
25–34 22,351,311 18,066 22,991,361 42,149

r
fo
35–44 20,506,270 29,004 20,369,100 50,792

In
lth
45–54 21,468,595 66,338 20,906,357 103,804

ea
55–64 21,737,855 146,671 20,257,803 225,335

H
an
65–74 15,806,306 227,679 13,877,140 303,931

ic
75–84 8,298,676 321,088 6,407,875 336,671

er
Am
85+ 4,189,013 543,169 2,279,669 334,866

e
Total
th
by
Source: CDC 2019b.

20
5. Calculate the infant mortality rate in this community.

20
©
6. In this same community there were 4,012 live births. Two mothers died of causes associated with their pregnancies.
ht
ig
Calculate the maternal mortality rate.

yr
op
7. In this same community there were 4,225 deaths. Calculate the crude death rate.
C
8. In this same community, 125 people died of lung cancer. Calculate the cause-specific mortality rate.
9. In this same community, 37 people reported a Clostridium difficile (C. diff) infection; of these, four people died. What is
the case fatality rate?
10. What is the proportionate mortality rate for Clostridium difficile (C. diff) in this community?
Formula 14.32 Calculating the incidence rate The prevalence rate is the proportion of per-
Total number of new cases sons in a population who have a particular dis-
of a specified disease ease at a specific point in time or over a specified
Incidence during a given period of time period of time. The prevalence rate describes the
= ´10 n magnitude of an epidemic and can be an indicator
rate Total population at rissk during
the same time period of the medical resources needed in a community
for the duration of the epidemic. For example, in
AB103118_Ch14.indd 465 2/7/2020 12:25:20 PM

a community of 750,000 individuals, 1,875 indi- at the national level. In 1912, the states and US
viduals were identified as having AIDS and an territories recommended that infectious diseases
additional 93 cases were identified in 20XX. The be immediately reported by telegraph. By 1928,
prevalence rate is 2.6 cases per 1,000 population all states, the District of Columbia, Hawaii, and
([{1,875 + 93}/750,000] × 1,000). The formula for Puerto Rico were participating in the national re-
calculating the prevalence rate is found in for- porting of 29 specified diseases. In 1961, the CDC
mula 14.33. assumed responsibility for the collection and pub-
lication of data concerning nationally notifiable
Formula 14.33 Calculating the prevalence rate diseases.
All new and A notifiable disease is one that must be re-
preexisting cases ported to a government agency so that regular,
of a specific disease frequent, and timely information on individual
during a given
n.
cases can be used to prevent and control future
tio
Prevalence period of time cases of the disease. The list of notifiable dis-
ia
= ´10 n
oc
rate Total population eases varies over time and by state. The Council
ss
of State and Territorial Epidemiologists (CSTE)
tA
duuring the same
en
time period collaborates with the CDC to determine which
em
diseases should be reported. State reporting to
ag
It is easy to confuse incidence and prevalence the CDC is voluntary. However, all states gen-
an
M
rates. The distinction is in the numerators of erally report the internationally quarantinable
n
diseases in accordance with WHO’s Interna-
their formulas. The numerator in the formula io
at
tional Health Regulations. Completeness of
m
for the incidence rate is the number of new cases

r
fo
occurring in a given time period. The numera- reporting varies by state and type of disease
In
and may be influenced by a number of factors;

lth
tor in the formula for the prevalence rate is all

ea
cases present during a given time period. In ad- for example, type of illness and resources for
H
dition, the incidence rate includes only patients reporting.

an
ic
whose illness began during a specified time per- Information that is reported includes date,
er
Am
iod whereas the prevalence rate includes all pa- county, age, sex, race and ethnicity, and disease-
specific epidemiologic information; personal
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tients from a specified cause regardless of when

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the illness began. Moreover, the prevalence rate identifiers are not included. A strict CSTE Data
by
Release Policy regulates dissemination of the

20
includes a patient until he or she recovers or

20
passes away. data. A list of nationally notifiable infectious dis-

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eases appears in figure 14.10. The list is updated

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annually; the list in figure 14.10 is not an exhaus-

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National Notifiable Diseases

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tive list.
Surveillance System
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Selected national morbidity data are reported

In 1878, the US Congress authorized the US Ma- weekly by the 50 states, New York City, the Dis-
rine Hospital Service, the precursor to the Public trict of Columbia, and the US territories. Then they
Health Service, to collect morbidity reports on are collated and published by the CDC in the Mor-
cholera, smallpox, plague, and yellow fever from bidity and Mortality Weekly Report. Public health
US consuls overseas. This information was used managers and providers use the reports to rapidly
to implement quarantine measures to prevent the identify disease epidemics and to understand pat-
spread of these diseases to the United States. To terns of disease occurrence. Case-specific informa-
provide for more uniformity in data collection, tion is included in the reports. Changes in age, sex,
Congress enacted a law in 1902 that directed the race and ethnicity, and geographic distributions
surgeon general to provide standard forms for the can be monitored and investigated as necessary
collection, compilation, and publication of reports (CDC 2019c).
AB103118_Ch14.indd 466 2/7/2020 12:25:21 PM

Figure 14.10 Nationally notifiable infectious and noninfectious diseases in the United States, 2017
Anthrax Measles (Rubeola)

Arboviral neuroinvasive and non-neuroinvasive diseases Meningococcal disease
Babesiosis Mumps
Botulism, C.botulinum Novel influenza A virus infections
Brucellosis Pertussis (Whooping cough)
Campylobacteriosis Pesticide-related illness and injury, acute
Cancer Plague
Carbon monoxide poisoning Poliomyelitis, paralytic
Chancroid Poliovirus infection, nonparalytic
Chlamydia trachomatis, infection Psittacosis (Ornithosis)
Cholera Q fever
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Coccidioidomycosis/Valley fever Rabies, animal
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Congenital syphilis Rabies, human
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Cryptosporidiosis Rubella (German measles)
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Cyclosporiasis Rubella, congenital syndrome (CRS)
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Dengue virus infections Salmonellosis
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Diphtheria Severe acute respiratory syndrome–associated coronavirus
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(SARS) disease
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Ehrlichiosis and anaplasmosis Shiga toxin-producing Escherichia coli (STEC)
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Food-borne disease outbreak Shigellosis
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Giardiasis Silicosis
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Gonorrhea Smallpox (Variola)

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Haemophilus influenzae, invasive disease Spotted fever rickettsiosis

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Hansen disease and leprosy Streptococcal toxic-shock syndrome (STSS)

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Hantavirus infection, non-Hantavirus pulmonary syndrome Syphilis

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Hantavirus pulmonary syndrome (HPS) Tetanus, c. tetani

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Hemolytic uremic syndrome, post-diarrheal (HUS) Toxic-shock syndrome (other than streptococcal) (TSS)
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Hepatitis A, B, and C, acute; Hepatitis B chronic and p

erinatal Trichinellosis (Trichinosis)
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infection
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HIV infection (AIDS has been reclassified as HIV stage III) (AIDS/HIV) Tuberculosis (TB)
20
Influenza-associated pediatric mortality Tularemia

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Invasive pneumococcal disease (IPD), Streptococcus Typhoid fever

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pneumoniae, invasive disease

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Lead, elevated blood levels Vancomycin-intermediate Staphylococcus aureus and

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vancomycin-resistant Staphylococcus aureus (VISA/VRSA)

Legionellosis (Legionnaire’s disease) or Pontiac fever Varicella (Chickenpox)
Leptospirosis Varicella deaths
Listeriosis Vibriosis
Lyme disease Viral hemorrhagic fevers (VHF)
Malaria Waterborne disease outbreak
Yellow fever
Zika virus
Source: CDC 2019d.
AB103118_Ch14.indd 467 2/7/2020 12:25:21 PM

HIM Roles
The health information management Health statistics provide data to assist health-
(HIM) professional has a vital role in managing in- care providers, researchers, health planners, policy
formation within all healthcare arenas. As managers makers, legislators, and consumers. Researchers
of data flow, HIM professionals utilize technology and physicians use data-driven statistics to study
to link clinical settings, public health agencies, re- the health problems that describe the character-
search institutions, and consumers with health in- istics of specific populations. By identifying sta-
formation. HIM professionals serve traditional roles tistical trends, public health officials can monitor
in ensuring quality, collection, storage, organization, local diseases and injuries in comparison to state,
interpretation, analysis, security, and sharing of data. national, and international trends. Health plan-
Moreover, the role of HIM has extended outside the ners use data to understand and allocate health
n.
traditional hospital setting. As technology and the resources. Legislators reference health statistics
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accessibility to health information have increased, when enacting laws, conducting program oversight,
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the role HIM professionals play in public health re- and considering funding. The consumer uses health
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search and policy development has expanded. information and statistics to understand their per-
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The HIM professional generates health statistics sonal risks, illnesses, and health status compared
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that provide various healthcare providers with re- to the general population.
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liable and multidimensional information. Health The HIM professional has the knowledge and
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statistics include data related to health, such as skills to assume the lead role in statistical analysis
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mortality, morbidity, risk factors, health service
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practices in the healthcare environment. Increas-
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coverage, and health systems. Health statistics ingly, roles and responsibilities have resulted in
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provide information for understanding, monitor- diversified employment opportunities in areas

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ing, and planning the use of resources to improve such as data analytics, informatics, and informa-
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the overall health and well-being of populations. tion governance.

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by

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1. What is a notifiable disease?

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2. What are the definitions of the terms incidence rate and prevalence rate?
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3. Calculate the incidence rate, per 100,000, for the following hypothetical data: In 20XX, 189,000 new cases of coronary
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artery disease were reported in the United States. The estimated population for 20XX was 301,623,157.
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4. In a community of 50,000, there were four cases of hantavirus pulmonary syndrome during the first half of 20XX.
Calculate the incidence rate.
5. In the same community, three more cases of hantavirus pulmonary syndrome were reported for the remaining months
of the year. Calculate the prevalence rate.

The performance improvement commit- i nfections with MCC (major complication or comor-
tee of Community Regional Medical Center want- bidity) because of wide variations in length of stay
ed to study MS-DRG 689 kidney and urinary tract (LOS) and total charges (refer to chapter 15, Revenue
AB103118_Ch14.indd 468 2/7/2020 12:25:22 PM

Management and Reimbursement, for more informa- Community Hospital was prepared using informa-
tion on MS-DRGs and MCCs). The committee tion found in the hospital’s online database. Further
asked the HIM director to prepare a profile of pa- research was performed on the individual patient
tients discharged from MS-DRG 689. A summary records to determine if there was a correlation
of the patients discharged from MS-DRG 689 at between the LOS and the MCCs for the patients.
Real World Case 14.2

University Hospital is preparing for an infection control policies and procedures since in-
upcoming onsite survey with the Joint Commis- fections can lead to serious complications, longer
sion. With an expanded focus on patient safety, the patient stays, and death.
n.
Joint Commission has identified infection preven- A low infection rate can be an indicator of qual-
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tion as a focal area in the survey process. Survey- ity care. University Hospital has determined that
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ors will specifically target prevention strategies the infection rate for each physician should be
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and outcomes during reviews of the hospitals 1 percent or lower.
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University Hospital
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Physician Profile
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January – June 20XX
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Physician number Medical service Number of discharges Number of infections Infection rate
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101 Surgery 275 3 3/275 x 100 = 1.09%

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111 Surgery 130 4 4/130 x 100 = 3.08%

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125 Surgery 366 3 3/366 x 100 = 0.82%

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216 Medicine 567 5 5/567 x 100 = 0.88%

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302 Medicine 132 2 2/132 x 100 = 1.52%

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420 Medicine 154 0 0/154 x 100 = 0%

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502 Obstetrics 288 2 2/288 x 100 = 0.69%

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517 Gynecology 132 1 1/132 x 100 = 0.76%

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815 Newborn 176 2 2/176 x 100 = 1.14%

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927 Pediatrics 154 1 1/154 x 100 = 0.65%

20
TOTAL 2,374 23 23/2,374 x 100 = 0.97%

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References
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American Health Information Management Centers for Disease Control and Prevention. 2019c.
Association. 2017. Pocket Glossary of Health Morbidity and Mortality Weekly Reports.
Information Management and Technology, 5th ed. Centers for Disease Control and Prevention. 2019d.
Chicago: AHIMA. National Notifiable Conditions. https://wonder.cdc.
BusinessDictionary.com. 2019. Likert Scale. http:// gov/nndss/nndss_annual_tables_menu.asp.
www.businessdictionary.com/definition/Likert-scale. Healthcare Cost and Utilization Project. 2019. https://
html. www.hcup-us.ahrq.gov/overview.jsp.
Centers for Disease Control and Prevention. 2019a. White, S. 2020. Calculating and Reporting Healthcare
“2003 Revisions of the U.S. Standard Certificates of Live Statistics, 6th ed. Chicago: AHIMA.
Birth and Death and the Fetal Death Report.” 1 Jan. 2019.
World Health Organization. 2019. Health Statistics
Centers for Disease Control and Prevention. 2019b. and Information Systems. http://www.who.int/
CDC Wonder. http://wonder.cdc.gov. healthinfo/statistics/indmaternalmortality/en/.
AB103118_Ch14.indd 469 2/7/2020 12:25:22 PM

AB103118_Ch14.indd 470
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2/7/2020 12:25:23 PM
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PART
Revenue Cycle M
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Management and
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Compliance
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471
AB103118_Ch15.indd 471 2/11/2020 1:23:10 PM

AB103118_Ch15.indd 472
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2/11/2020 1:23:10 PM
Chapter
15
Revenue Management
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and Reimbursement
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Morley L. Gordon, RHIT
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Learning Objectives
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•• Identify health insurance and how it is used in the •• Identify how utilization management is performed
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United States in healthcare settings

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•• Identify revenue cycle management •• Examine how case management is performed in

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•• Examine new trends in revenue management healthcare settings

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•• Identify healthcare reimbursement methodologies

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Key Terms
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Accept assignment Civilian Health and Medical Federal poverty level (FPL)
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Adjudication Program of the Department of Fee-for-service reimbursement

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Affordable Care Act (ACA) Veterans Affairs (CHAMPVA) Fee schedule

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Ambulatory payment classification Claims Global payment

20
(APC) Clinical data Health insurance marketplace or

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Ambulatory surgery center Coinsurance exchange

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(ASC) Concurrent review Health maintenance organization

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Ambulatory surgery center (ASC) Consumer-directed health plans (HMO)

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payment rate (CDHP) Healthcare insurance

Balance billing Coordination of benefits (COB) Home health prospective payment
Beneficiaries Cost sharing system (HH PPS)
Capitation Copayment Hospital-acquired condition HAC)
Case management Deductible Indian Health Service (IHS)
Case-mix index (CMI) Demographic data Inpatient prospective payment
Centers for Medicare and Medicaid Disproportionate share hospital (DSH) system (IPPS)
Services (CMS) Dual eligible Managed care
Charge description master Eligibility Managed care organization (MCO)
(CDM) Episode-of-care (EOC) reimbursement Mandatory eligibility groups
Chargemaster Exclusive provider organizations Medicaid
Children’s Health Insurance (EPO) Medical necessity
Program (CHIP) Explanation of benefits (EOB) Medicare
473
473
AB103118_Ch15.indd 473 2/11/2020 1:23:11 PM

474 Part V Revenue Cycle Management and Compliance
Medicare Access and CHIP Policy Retrospective review

Reauthorization Act (MACRA) Policyholder Revenue cycle
Medicare administrative Precertification Skilled nursing facility prospective
contractors (MAC) Preferred provider organization (PPO) payment system
Medicare Advantage (MA) Plan Premium Technical component
Medicare Part A Present on admission (POA) Third-party administrator
Medicare Part B Preventive services (TPA)
Medicare Part D Prior approval Third-party payer
Medicare severity diagnosis-related Private healthcare insurance Traditional fee-for-service
groups (MS-DRGs) Professional component reimbursement
National Committee for Quality Prospective payment system (PPS) TRICARE
Assurance (NCQA) Prospective review Usual, customary, and reasonable
Out of pocket Quality Payment Program (UCR) charges
Outpatient prospective payment Reimbursement Utilization management (UM)
n.
system (OPPS) Remittance advice (RA) Value Based Purchasing (VBP)
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Patient Assessment Instrument Resource-based relative value scale Veterans Health Administration (VA)
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Point-of-service plans (POS) (RBRVS) Workers’ compensation
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Payment for healthcare services, called reim- and supplies provided to a patient during his or
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bursement, is very complex in the United States. her encounter with the facility or provider, for re-
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Reimbursement begins before a patient enters a imbursement to insurance companies on behalf of
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healthcare facility with the collection of demo- patients. Health information management (HIM)
graphic data which is patient-specific data like date n
professionals play a vital role in the submission
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of birth, address, and insurance coverage informa- of accurate claims by ensuring the documentation
m
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tion. The process ends with the final adjudication supports the services billed, assigning proper diag-
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of all medical charges. Adjudication is a term used by nostic and procedure codes, and ensuring accurate
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the insurance industry that refers to the process of information is captured throughout the patient’s
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paying, denying, and adjusting claims based on encounter with the healthcare organization. Ac-
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the patient’s healthcare insurance coverage ben- curate information is paramount to the success of
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efits. Information about a patient is collected dur- healthcare organizations. The balance of care pro-
ing the course of receiving healthcare services. This vided, and getting paid for the service delivered,
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includes demographic data, used to identify an in- relies on the accuracy of documentation and codes
by
dividual, and clinical data, which is the patient’s for reimbursement.

20
20
medical condition or treatment. This information This chapter discusses healthcare insurance, reve-
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is used to bill for healthcare services. Reimburse- nue cycle management, reimbursement systems (in-
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ment for services is what keeps healthcare providers cluding private and government plans), new trends,
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and organizations in business. Healthcare provid- managed care, utilization and case management,
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ers submit claims, which represent the services and healthcare reimbursement methodologies.
Healthcare Insurance
Healthcare is expensive in the United get the services they need (Henry J. Kaiser Family
States, and health insurance can be unaffordable Foundation 2018). Healthcare insurance protects
for some people. Therefore, millions of Americans a person from paying the full cost of healthcare by
go without health insurance. Americans without prepaying for a healthcare coverage plan. Before
health insurance must pay for healthcare expenses the early 1900s, Americans paid for their entire
out of pocket, meaning they pay for the services healthcare services out of pocket. There was not
provided with their own funds, or they do not an organized way to pay for services and charging
AB103118_Ch15.indd 474 2/11/2020 1:23:11 PM

patients and paying for services was done through insurance program. He did not win the presidency
trial and error between the provider of the serv- and, therefore, national healthcare insurance was
ices and the patient. The cost of healthcare in the not implemented at that time (CMS 2015a). Many
early 1900s was not a significant part of an Amer- politicians and presidents throughout the years
ican family’s budget and the need for healthcare championed for universal health coverage and
insurance was not considered by people of that almost 100 years after Theodore Roosevelt cam-
time. During this time hospitals were places for in- paigned for national health coverage, the Afford-
jured soldiers, those who were very sick, the poor, able Care Act (ACA) was signed into law in 2010,
and those who had contagious diseases. Hospitals providing health coverage for all Americans. The
were known as a last resort—a place where peo- ACA mandated many changes in reimbursement
ple went to die (Ferenc 2014). By the 1920s, with methodologies, which are discussed in this chap-
modern medicine and the discovery of antibiotics, ter. (Chapter 2, Healthcare Delivery Systems, covers
n.
hospitals started marketing themselves as places ACA in more detail.)
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with positive health outcomes. In return for those To understand the process of healthcare re-
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positive outcomes, hospitals began to charge more imbursement as defined later in this chapter, it
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than most people could afford. In 1929, in Dallas, is important to understand basic terms used in
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Texas, Baylor Hospital started a prepaid hospital insurance reimbursement. When a person has
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insurance program with a local teachers’ union. healthcare insurance, they receive a policy, which
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This program began to pre-pay for future hospital is a contract between the insurer and the person, in
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services and became the predecessor to Blue Cross which they pay a premium, which is a set amount
(Griffin 2017). n
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per month or per year—to help cover the cost of
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Health insurance coverage for all Americans medical expenses. The policyholder is the person
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began to be a political hot topic as early as 1912. covered by the policy. The purchaser of a health-
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While campaigning for the US presidency, Theo- care insurance policy can be an individual, group,
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dore Roosevelt called for a national healthcare or employer.

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Revenue Cycle Management

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The revenue cycle is the process of every aspect of it having accurate and complete
by
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patient financial and health information moving information and data capture. Management of the
20
into, through, and out of the healthcare organiza- revenue cycle is the process of supervising the en-
©
tion, culminating with the healthcare organization tire claims process, including determining patient
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receiving reimbursement for services provided. eligibility for insurance, collecting money owed
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HIM professionals are vital to the management of on copayments (co-pays) and deductibles, and en-
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the revenue cycle. The revenue cycle begins with suring correct and timely capture of all charges.
patient registration, known as the front end of the Monitoring, or working, the revenue cycle from
cycle. The documentation of the encounter in the the patient’s first contact with the organization to
health record, charge capture, coding, and charge the final account balance of zero includes numer-
entry comprise the middle section of the cycle. The ous steps and professionals (NueMD 2018).
back end of the revenue cycle includes claims trans-
mission and accounts receivable management. The Patient Registration
HIM professional provides vital expertise in cod- Patient registration is the first step to ensuring that
ing, documentation management, and accounts claims submitted to a payer will receive proper
receivable management and other knowledge of reimbursement. Responsibilities include prereg-
the revenue cycle. Financial viability of the health- istration, registration, insurance verification, and
care organization rests with the revenue cycle and prior approval (authorization) for some services.
AB103118_Ch15.indd 475 2/11/2020 1:23:11 PM

The patient registration department of a hos- require a breast ultrasound yearly. If this service
pital is frequently called Patient Access and is does not receive prior approval, the insurance
responsible for capturing demographic informa- company may deny the claim for payment.
tion for each patient. If correct information is not
captured on the front end, it will delay the entire Documentation, Coding, and Charge
process and cause extra work with resubmitting Capture
denied claims and cleaning up the errors. Captur- Healthcare services should be documented in the
ing a patient’s demographic information begins health record and captured through an electronic
before the patient encounter with preregistration, system or manually entered into the patient’s
which involves collecting the patient’s name, date financial account as they are provided. The charge
of birth, insurance coverage, and address. If a pa- capture process involves entering codes for all
tient is not covered by an insurance plan, he or she procedures and supplies provided during patient
n.
is considered a self-pay patient and is responsible care. The codes include diagnoses, procedure, and
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for all charges incurred during his or her encoun- supply codes.
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ter. The term third-party payer is used to identify A charge description master (CDM), sometimes
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an insurance company that pays for the medical
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called chargemaster, is a financial management
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care of covered individuals. The terms first party, list that contains information about the organiza-
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the patient, and second party, the healthcare pro- tion’s charges for healthcare services it provides
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vider, are not used as frequently. to patients. As the patient is seen at the healthcare
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If a patient is covered by more than one insur- organization, charges are captured for services
ance, coordination of benefits (COB)—determining n
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such as the following:
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which insurance coverage is the primary, second-
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Accommodations (room and board)

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●●
ary, and tertiary payer—takes place. For example, a
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patient is covered under the group plan A offered ●● Room use (for example, emergency
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at her place of work and is also covered under the department, recovery room, operating room)
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group plan B, offered at her spouse’s place of work. Supplies used during the course of
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●●
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Her own insurance A is primary and her spouse’s stay (bandages, splints, venipuncture
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insurance B is billed after her plan A has made its tray)

payment. For children covered by both their par-
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Ancillary services (such as radiology,

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●●
ents’ insurance, the birthday rule is used to de-

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laboratory, pharmacy)
termine which coverage is billed first. The parent
20
●● Clinical services (such as anesthesia,

20
whose birthday falls first in the calendar year (not

cardiology, physician rounds)
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who is oldest, or who has insurance for the long-

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est amount of time) is primary; for example, if the Hospitals charge facility fees—the technical
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mother’s birthday is January 21 and the father’s component of healthcare services, for laboratory
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birthday is March 14, the mother’s insurance plan and radiology tests. It covers the cost and over-
is primary because her birthday is in January and head for providing the service. The portion of
falls first in a calendar year. work performed by a physician or other health-
Some medical procedures require prior approval care professional is the professional component
(authorization) for services, which involves obtain- of the charge capture. More information on the
ing approval from the insurance company before professional and technical components of health-
receiving services. The registration staff moni- care charges is found in the global payment section
tors the healthcare organization’s appointments of this chapter. The charge capture process flow
and schedules and is responsible for contacting for a physician practice is outlined in figure 15.1.
the health insurance carriers for procedures that When the patient checks in, the front office staff
require prior approval. For example, a patient
records demographic information in the electronic
with a strong family history of breast cancer may health record (EHR) or on paper, verifies payment
AB103118_Ch15.indd 476 2/11/2020 1:23:11 PM

Figure 15.1 Charge capture process for a physician practice
Charge Capture Process
• Collect demographic information

• Payment method determined
Registration • Insurance verified – co-pay collected
• Documentation of services
Support staff
• Documentation of services
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Provider
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• Prepare claim form
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• Submit to insurance or bill patient
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Business • Monitor accounts receivable
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Source: © AHIMA.
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method and insurance coverage, and collects the Coding System (ICD-10-PCS) codes that classify the
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copayment for the visit. The clinical support staff diagnosis for the inpatient encounter. The ICD-
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and physicians or providers update the EHR as 10-CM and ICD-10-PCS codes reflect the reason
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services are rendered. The front office staff then the patient is being treated. Healthcare Common
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discharge the patient. Finally, the business office Procedure Coding System (HCPCS) codes are
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prepares the claim for billing and send it to the used to identify healthcare procedures, supplies,
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insurance company. The business office monitors and equipment for outpatient encounters and
the claim for payment and follow-up as needed. If have dollar values associated with them. (Chap-
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the patient does not have insurance coverage, the ter 5, Clinical Terminologies, Classifications, and Code
by
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front office staff collects the payment for services Systems, covers ICD-10 CM/PCS, and HCPCS
20
rendered (NueMD 2018). codes in more detail.)

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The third-party payer receives the claim for re-

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Healthcare Claims Processing

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imbursement and determines the eligibility of the

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After all the charges for an episode of care are cap- patient for coverage and the medical necessity of
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tured, the healthcare organization creates a claim the services. Eligibility is verification that the pa-
for reimbursement based on the CDM fees listed tient is covered by the plan on the date of serv-
for each service. The Health Insurance Portabil- ice and the services provided are covered by the
ity and Accountability Act (HIPAA) mandated the plan. Medical necessity is the determination that
use of electronic transactions for healthcare claims the services provided will benefit the patient and
using the HIPAA X12 837 Healthcare Claim: Profes- are needed. For example, a patient receiving plas-
sional for professional charges and HIPAA X12 837 tic surgery to improve the look of his or her face
Healthcare Claim: Institutional for facility and tech- may not be covered; however, if the surgery is be-
nical component claims. Claim forms include In- ing done to repair scars from an accident, it may
ternational Classification of Diseases, Tenth Revision, be covered.
Clinical Modification (ICD-10-CM) and International The insurance policy determines the amount
Classification of Diseases, Tenth Revision, Procedure the patient pays for deductible, coinsurance, and
AB103118_Ch15.indd 477 2/11/2020 1:23:12 PM

copayment. Deductible is the amount of cost, usu- remainder of the costs not paid by the insurance
ally annually, the policyholder must incur before plan. Therefore, there may be different payments
the plan will assume liability for the remaining of services within a healthcare organization for the
covered expenses. For example, a person who has same service depending on the contracted price
a $1,000 deductible must pay that amount each for that service with each third-party payer. Using
year before the insurance policy will start paying the previous example with Mr. Sanders, if the pro-
for services. Coinsurance is a pre-established per- vider accepts assignment from ABC HealthCare,
centage of eligible expenses after the deductible is the physician agrees to accept $75.00 for the physi-
met (such as 20 percent, though the amount varies cian visit instead of his normal $100.00 fee.
by policy). Copayment (co-pay) is a cost-sharing Healthcare insurance payers have a variety of
measure in which the policyholder pays a fixed reimbursement plans and contracts with individ-
dollar amount (flat fee) per service, such as $15 ual providers and employers for payment such
n.
per physician office visit. Out-of-pocket costs are that the same type of service to two different pa-
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healthcare costs a patient must pay because the to- tients may be paid differently depending on each
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tal cost is not covered by insurance. For example, patient’s contract or insurance. After a claim is
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David Sanders is seen in the urgent care clinic for processed, the third-party payer will send notifica-
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removal of a fishhook from his thumb. The pro- tion to the patient in the form of an explanation of
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vider was not sure about the placement of the hook benefits (EOB), detailing how the payer processed
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and needed to take an x-ray of the hand before re- the claim for payment. The third-party payer will
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moval. After the hook was removed, the wound also send a remittance advice (RA) to the health-
was cleaned and Mr. Sanders was given a shot of n
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care provider explaining the process used for the
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cefitraxone antibiotic. Mr. Sanders is covered by claim and how much it is paying the healthcare
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his employer’s healthcare plan, ABC HealthCare, provider.

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which has a $500 yearly family deductible, 20 per-

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Working the Accounts Receivable

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cent coinsurance, and $15 co-pay for physician

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visits. Table 15.1 displays how the payer will proc- Billing department employees (billers) are respon-
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ess the claim. sible for maintaining and working the organiza-
er
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A provider may choose to accept assignment, tion’s accounts receivable (AR). AR is a record of
meaning payment is based on a fee schedule, a the payments owed to the organization by outside
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list of services and the amount that the healthcare entities such as third-party payers and patients.
by
insurance plan will pay for healthcare claims. The Billers work the AR by monitoring charges, pay-
20
20
provider will accept the amount paid as payment ments, adjustments, and write-offs. If a claim has
©
in full for the service, as opposed to balance bill- not been paid, billers will resubmit the claim to in-
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ing where the provider charges the patient for the surance carriers or determine why the claim has
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Table 15.1 Example of claim processing

Cost (fee Deductible Coinsurance Copayment Total insurance Patient
Service schedule) ($500 per year) (20%) ($15 per visit) pays responsibility
Physician visit $100.00 $50.00 $10.00 $15.00 $25.00 $75.00
Comment Patient has already 20% of cost of visit Patient pays $15
paid $450 this year, after the deductible out of pocket for
he has now met his is paid. $100 − $50 each visit
deductible = $50 and 20% of
$50 = $10
X-ray $250.00 $0.00 $50.00 $0.00 $200.00 $50.00
Antibiotic $50.00 $0.00 $10.00 $0.00 $40.00 $10.00
Total $400.00 $50.00 $70.00 $15.00 $265.00 $135.00
Source: © AHIMA.
AB103118_Ch15.indd 478 2/11/2020 1:23:12 PM

not been paid. When a healthcare organization has If the payer accepted a claim, but payment
a contract with a third-party payer for services, the was denied for any reason, it is important for
difference between what the healthcare provider the billers to explore the reason for the denial
charges and what is paid by the payer is the con- and correct any errors in the claim or submit
tractual adjustment (NueMD 2018). The billing de- additional documentation requirements request-
partment has a detailed list of adjustment codes to ed by the payer. This process is called denials
monitor all adjustments made to AR. management.
n.
Match the definitions with the terms.
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1. Fixed amount paid by policyholder per month
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2. Pre-established percentage of eligible expenses after the deductible is met, such as 20 percent
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3. Policy or contract in which the purchaser (insured) pays a set amount to help cover the cost of medical expenses
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4. Paying for services provided with own funds
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5. Amount of cost (usually annually) the policyholder must incur before the plan will assume liability for the remaining
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covered expenses
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6. Process of how patient financial and health information moves into, through, and out of the healthcare facility
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7. A list of services and the amount that the healthcare insurance plan will pay for healthcare claims.
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8. A financial management list that contains information about the organization’s charges for healthcare services it
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provides to patients
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a. Healthcare insurance
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b. Premium
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c. Fee Schedule
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d. Chargemaster
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e. Out of pocket
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f. Deductible
20
g. Coinsurance
20
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Healthcare Insurers
Healthcare insurance types include Commercial Insurance
commercial, managed care, and government-
Many Americans are covered by commercial in-
sponsored plans. Each insurer or payer has its
surance plans. The plans may be obtained through
own set of reimbursement guidelines, defined by
their employer, purchased individually, or through
payer contracts with providers, or insurers may
a group, such as a professional association. For
follow federal regulations for payment of health-
example, a healthcare organization may pay for
care claims. This section discusses the different
its employees to have commercial insurance, or a
types of healthcare insurers.
AB103118_Ch15.indd 479 2/11/2020 1:23:12 PM

person may purchase coverage individually from Companies set aside the cost they would have
a commercial company. A person who is a member paid for premiums for health coverage and used
of a national association or group may purchase those funds to pay the healthcare claims. Employer-
coverage through that company. Healthcare plans based self-insurance is a self-funding arrangement
can be private, employer-based self-insurance, in which an employer funds medical expenses for
not-for-profit, and for-profit. the covered beneficiaries (individuals who are eli-
gible for benefits from a health plan) and contracts
Private Healthcare Insurance with a third-party administrator (TPA) to provide
Individuals, self-employed professionals, and the administrative oversight to process the medical
groups of people (such as associations and religious claims payments for the employer. A third-party
organizations) are able to purchase commercial in- administrator is responsible for payment of health-
surance, called private healthcare insurance, for care claims on behalf of the company. For example,
n.
themselves and their dependents. Typically, these Community Hospital has 4,000 employees and
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plans have high deductibles (for example $2,500 offers healthcare insurance coverage for those em-
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per year) or limited covered services (for example, ployees. Community Hospital is self-insured and
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contracts with ABC Insurance Provider to admin-
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a policy may only cover emergency services and
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not dental and vision services). A premium for cov- ister the insurance plan for the hospital. Commun-
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erage is paid each month to the third-party payer ity Hospital sets aside the amount of money they
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and those funds are used to help pay for healthcare would pay for premiums for healthcare coverage.
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services. Private healthcare insurance plans use the When an employee healthcare claim is sent to ABC
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premiums collected from policyholders to pay for io
Insurance Provider, the claim is paid from the funds
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Community Hospital has allocated. Many factors af-
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healthcare incurred by all the members of the plan

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who are covered during a particular month. fect an employer’s decision to self-fund, particularly
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the ability to assume the risk involved when a claim

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Employer-Based Coverage for high-cost services is experienced. For example,

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Employer-based coverage is obtained when em- one case of cancer in an employee may cost the em-
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ployees and employers share the cost of premium ployer a large amount of money in a short period of
er
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payment—the employer contributes a portion of time causing the employer to not be able to assume
the risk for future high-cost medical cases.
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the premium amount and the employee also con-

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tributes, usually with a direct deduction from his or

by
Not-for-Profit and For-Profit Healthcare Plans

20
her paycheck. For example, an employer might pay

20
for 80 percent of the cost of coverage and the em- Commercial healthcare insurance plans are either
©
ployee would cover the additional 20 percent of the not-for-profit or for-profit plans. Not-for-profit
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premium. Employees are usually able to pay an ad- third-party payers do not focus on making money;
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ditional premium amount to cover dependents. For the premiums collected pay for the administrative
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example, Sue’s Safe Shelter for Women employs 74 costs of running the company and the company re-
people and pays to enroll the employees and their ceives tax breaks that the for-profit plan does not. As
dependents in a Blue Cross Blue Shield plan. Blue part of the Affordable Care Act (ACA), Consumer
Cross Blue Shield offered the first healthcare plans Operated and Oriented Plans, or CO-OPs, were
in the United States in 1929 and remains an insurer created. CO-OPs allow nonprofit, customer-owned
to this day. Employers with fewer than 50 full-time health insurance companies to provide insurance
employees are not required to provide healthcare coverage to nonprofit organizations through low-
insurance to their employees. interest loans CO-Ops offer insurance to individu-
als and small businesses (CMS 2015b).
Employer-Based Self-Insurance Plans A for-profit plan exists to make money from the
In the 1970s, large companies started to self-insure premiums collected. The ACA requires health-
employees instead of paying into private plans. care insurance companies to report the amount of
AB103118_Ch15.indd 480 2/11/2020 1:23:12 PM

premium revenue that is spent on clinical services Health Maintenance Organizations

and quality improvement; this is known as the A health maintenance organization (HMO) is an
medical loss ratio (MLR). The MLR requires com- entity that combines the provision of healthcare
panies to spend at least 80 percent of premium insurance and the delivery of healthcare services. It
money on medical care. The ACA also requires the is characterized by an organized healthcare deliv-
company to issue rebates to enrollees if the per- ery system to a specific geographic area. The HMO
centage falls below these standards (CMS 2018a). has a set of basic and supplemental health mainte-
nance and treatment services that are provided to
Managed Care voluntarily enrolled members. The members pay
a predetermined fixed amount per month or year
Managed care is a healthcare delivery system, or as prepayments for coverage. HMOs provide for
network, organized to manage cost, utilization, and care within their network, where patients are seen
n.
quality. Managed care plans contract with health- by providers and within healthcare organizations
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care providers and medical facilities to provide care
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the HMO controls and owns. HMOs offer health-
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for members of the plan at reduced costs. Plans re- care services such as family health, gynecology,
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stricting choices usually cost less while a flexible
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well-child visits, radiology, surgical, obstetrics,
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plan will cost more. There are three types of man- inpatient, or therapies. Typically, HMOs offer a
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aged care plans addressed. They are the following: broader range of preventative healthcare services
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1. Health maintenance organizations (HMO) than other managed care plans (CMS 2016a).
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2. Preferred provider organizations (PPO) HMOs started as a way to provide healthcare at
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reduced cost to the consumer. The Health Mainte-
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3. Point of service (POS) (NLM 2019)
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nance Organization Act of 1973 established fed-

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A managed care organization (MCO) is a type eral rules defining the operation of HMOs. The Act
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of healthcare organization that delivers medical

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made it easier for HMOs to grow and attract clients

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care and handles all aspects of the care and pay- and required all employers that offered traditional
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ment for care by limiting providers of care, dis-

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healthcare to their employees to sign up for an

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counting payment to providers of care, or limiting HMO if they had more than 25 employees. Under
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access to care. For example, a provider may agree all types of HMOs, every employer pays the same
to see enrollees of an MCO for a set payment per
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monthly premium for services. Each employee is as-

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member per month (PMPM), also referred to as signed a primary care physician—a physician who
by
capitation, which is discussed in full later in the

20
bears the ultimate responsibility for ensuring the

20
chapter. Members of an MCO are called enrollees employee receives the medical care he or she needs.
©
and have access to services including physician, If an employee has a medical condition, he or she
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inpatient, preventive, prenatal, emergency, and first visits the primary care physician. If the condi-
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home healthcare (Casto 2018). The National Com- tion is beyond the physician’s expertise or scope, the
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mittee for Quality Assurance (NCQA) is a private, physician refers the employee to another physician
not-for-profit organization whose mission is to im- within the HMO. If emergency treatment is need-
prove healthcare quality by accrediting, assessing, ed, the employee is referred to hospitals within the
and reporting the quality of managed care plans. HMO; likewise, the employee obtains medication
Enrollees can find information regarding the qual- from pharmacies within the HMO network. Most
ity of care, access, and cost, and compare managed HMOs are extensive enough to offer a wide variety
care plans, because the Centers for Medicare and of providers, described as the following:
Medicaid Services (CMS) collects data via the
Healthcare Effectiveness Data and Information Set ●● Group model HMOs. In this model the HMO
(HEDIS) (NCQA 2019). CMS is the Department contracts with more than one physician;
of Health and Human Services (HHS) agency re- for example, a medical group that includes
sponsible for Medicare and parts of Medicaid. physicians in multiple fields of expertise.
AB103118_Ch15.indd 481 2/11/2020 1:23:12 PM

The members of the medical group provide one or more counties, and this area is approved by
the care to the HMO enrollees on a fee-for- CMS. Regional PPOs were introduced to help ben-
service basis (Casto 2018). eficiaries who live in rural areas. There are specific
●● Open-panel model or independent practice locations established by CMS (CMS 2016b).
associations. This model is created when the
HMO contracts with a physician who has Point-of-Service Plans
his or her own practice and the physician A point-of-service (POS) plan allows enrollees to
agrees to see the patients who belong to the choose between an HMO or PPO each time they
HMO in addition to their regular patients are in need of care. For example, a patient is able to
(Casto 2018). choose an in-network primary provider but is also
●● Network model HMOs. In this model the able to seek care outside of the network. Payment
HMO contracts with a network of providers for services outside of the network is covered by
n.
who provide multispecialty group practices. the plan with the patient paying a percentage of
tio
the bill. If the primary care provider refers a pa-
ia
Reimbursement for healthcare is either on a
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tient outside the network of providers, the plan
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fee-for-service or capitation basis.
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pays all or most of the bill. If the patient sees a
Staff model HMOs. In this model the HMO
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●●
provider outside the network and the service is
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employs the physicians. Physicians see
covered by the plan, the patient will have to pay a
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only members of the HMO and are paid a
percentage of the bill as coinsurance, or if the ser-
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salary by the HMO. The premiums paid by
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vice is not covered by the plan, the patient will pay
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enrollees to the HMO are used to cover the io
out of pocket for the entire bill.
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cost of services and facilities.
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Exclusive Provider Organizations

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Preferred Provider Organizations

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Exclusive provider organizations (EPO) are hybrid

A preferred provider organization (PPO) is a
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MCOs in that they provide benefits to subscribers

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managed care contract-coordinated care plan with

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only when network providers perform healthcare

the following elements:
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services. Self-insured (self-funded) employers or

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●● Contains a network of providers who associations use this model that has characteristics
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have agreed to a contractually specified of both HMOs and PPOs.

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reimbursement for covered benefits with the

by
20
organization offering the plan

Government-Sponsored Healthcare
20
●● Provides for reimbursement for all

Plans
©
covered benefits regardless of whether the

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benefits are provided with the network of The US government is the largest payer of health-
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providers care insurance. According to CMS, 100 million

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people are covered through Medicare, Medic-

●● Offered by an organization that is not
aid, the Children’s Health Insurance Program
licensed or organized under state law as an
(CHIP), and the Health Insurance Marketplace
HMO (CMS 2016b)
(CMS 2015c). Medicare Part A, Part B, and Part
A PPO is a form of managed care closest to a D; the Medicare Advantage Plan; and the Con-
fee-for-service plan where providers agree to ac- ditions of Participation will be described in the
cept lower fees from the insurer for services to be sections that follow, as well as Medicaid eligi-
part of the network, with the patient paying a set bility criteria, services, the Medicare–Medicaid
copayment. If a patient sees a provider outside relationship, State Children’s Health Insurance
the network, the patient will pay a higher fee. The plans, TRICARE, the Veterans Health Adminis-
PPO can be local or regional. Local PPOs offers tration, CHAMPVA, Indian Health Services, and
plans within a specific area, usually consisting of workers’ compensation.
AB103118_Ch15.indd 482 2/11/2020 1:23:12 PM

Medicare Medicare Part B Medical Insurance Under

Medicare was enacted as the Title XVIII amend- Medicare Part B, medical insurance is an optional
ment to the Social Security Act of 1935. Imple- and supplemental portion of Medicare for which
mented in 1965, Medicare extended health beneficiaries pay a monthly premium. Part B as-
coverage to most Americans age 65 or older or sists with coverage for physicians’ services and
those receiving retirement benefits from Social outpatient care. It also insures other medical ser-
Security or the Railroad Retirement Board (CMS vices not covered under Part A, such as some
2015d). Medicare is financed through payroll physical and occupational therapists’ services, and
taxes paid by workers. CMS is responsible for some home healthcare. Part B pays for these covered
management of the Medicare program. To be el- services and supplies when they are medically nec-
igible for Medicare coverage, enrollees—called essary (CMS 2018b). Services covered may include
beneficiaries—must fall into one of six benefit physicians’ services, outpatient care, home health,
n.
categories: be age 65 or older, be a retired fed- durable medical equipment, ambulance, and pre-
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ventive services. Preventive services include
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eral employee who is enrolled in the civil service
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retirement system, have end-stage renal disease, healthcare services to prevent illness (for example,
ss
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be a disabled adult, have become disabled be- vaccinations to prevent diseases like polio) or ear-
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fore the age of 18, or be a spouse of an entitled ly detection tests and diagnostic tools, when treat-
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individual. Medicare contracts with Medicare ment is most likely to be effective (CMS 2018b).
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Administrative Contractors (MAC), which are
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private insurance companies that serve as Medi- Medicare Advantage Plans Medicare Advan-
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care’s agents in the administration of the Medi-
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tage (MA) Plans were created as part of the
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care program, including processing and paying Balanced Budget Act (BBA) of 1997. They are some-
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claims (CMS 2015e). times called Part C or MA Plans and are managed
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care plans offered by private companies approved

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The next section will define Medicare Parts A and

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B, Part C (also known as the Medicare Advantage by Medicare. For example, United Healthcare in-
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surance plan contracts with Medicare to cover

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Plan), and Medicare Part D. The Medicare Condi-

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tions of Participation are also discussed. beneficiaries who choose this plan. MA Plans cov-
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er all Medicare services, but may also offer extra

coverage, such as dental, vision, and acupuncture.
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Medicare Part A Hospital Insurance Medicare

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Part A hospital insurance assists in covering Beneficiaries who join a MA Plan have Medicare
by
Part A and B coverage through the MA Plan and

20
inpatient care in hospitals, including critical ac-

20
cess hospitals and skilled nursing facilities (not not from original Medicare Part A (CMS 2018c).
©
custodial or long-term care). It also assists in Medicare pays a fixed amount for the benefi-
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covering hospice care and some home healthcare. ciary’s care each month to the companies offering
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Beneficiaries must meet certain conditions to re- MA Plans. Each MA Plan can charge different out-
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ceive these benefits such as having paid enough of-pocket costs and have different guidelines for
Medicare taxes while they were working, being how services are received; for example, requiring
age 65 or older, or being disabled before the age a referral before seeing a specialist (CMS 2018c).
of 65 (CMS 2015f). Most people do not have to
pay for Part A coverage because they, or a spouse, Medicare Part D, Prescription Drug Coverage
paid Medicare and payroll taxes while working Medicare Part D provides various plan options for
which funds their Part A coverage. Individu- beneficiaries to obtain prescription drug coverage.
als may be able to buy coverage if they are not The Medicare Prescription Drug Improvement
entitled to Medicare, if they did not pay enough and Modernization Act (MMA) created Medicare
Medicare taxes while working. Some states may Part D in 2003. Under this Act, Medicare contracts
help people with limited income and resources with private insurance companies to provide drug
pay for Part A (CMS 2018b). coverage to beneficiaries. Enrollment is voluntary
AB103118_Ch15.indd 483 2/11/2020 1:23:13 PM

and only available to people who are covered receives in a year. The FPL is determined by HHS
under Parts A and B. Benefits and cost vary by the and is updated annually on the Medicaid website
plan in which the beneficiary is enrolled, and can (CMS 2015c). The ACA set the national Medicaid
be as low as $15 per month, with an annual deduct- minimum eligibility level at 133 percent of the FPL
ible and co-pay required (CMS 2018d). for nearly all Americans under the age of 65. This
means if the FPL for a family of one is $11,770 per
Out-of-Pocket Expenses and Medigap Insurance year, the 133 percent FPL would be $15,651 (11,770
Medicare does not pay 100 percent of billed medi- × 133% = 15,651).
cal claims by healthcare organizations and provid- Non-financial eligibility criteria include proof
ers. Medicare beneficiaries pay out of pocket for of federal and state residency, immigration status,
the deductible, co-pay, and non-covered services and documentation of US citizenship.
portions of healthcare claims. Beneficiaries may
n.
purchase supplemental insurance—known as Medicaid Services States establish and admin-
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Medigap—to help cover those expenses. ister Medicaid programs and determine the type,
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amount, duration, and scope of services within
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Medicaid broad federal guidelines. Common mandatory
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Medicaid helps with medical costs for millions of benefit services include coverage of the following
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Americans with low incomes and limited resources care and services:
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including the mandatory eligibility groups of
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●● Inpatient hospital
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children, pregnant women, elderly adults, people
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●● Outpatient hospital
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with disabilities, and low-income adults. The US
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●● Nursing facility
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federal government, and state governments, both

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help fund this program (CMS 2018d). Each state ●● Physician

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administers its own Medicaid program, and de- ●● Home healthcare

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termines the type, amount, duration, and scope of

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●● Rural health clinic

services above and beyond the basic broad federal
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●● Laboratory and x-ray

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guidelines. This means that Medicaid programs

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●● Family planning
can vary widely between states. The federal gov-
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ernment establishes a set of mandatory benefits ●● Tobacco cessation

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and states can choose to provide additional op-

by
Common optional benefits include coverage of

20
tional benefits beyond the required benefits.

the following care and services:
20
States can apply to CMS for a waiver of federal

©
law to expand health coverage beyond the man- ●● Prescription drugs

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datory eligibility groups. Many states have opted ●● Physical, occupational, speech, hearing, and
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to expand Medicaid coverage, especially for chil- language therapy

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dren, above the federal minimums because they ●● Optometry

feel that the federal minimums do not provide
●● Dental
enough coverage. Medicaid eligibility criteria,
●● Chiropractic
services, the Medicaid–Medicare relationship, and
the state Children’s Health Insurance Plan are de- ●● Hospice
fined as follows.
The Medicare–Medicaid Relationship
Medicaid Eligibility Criteria Medicaid eligibility The Federal Coordinated Healthcare Office
is based on the annual income of a person or his or (Medicare–Medicaid Coordination Office) serves
her family and is calculated in relation to a percent- people who are enrolled in both Medicare and
age of the federal poverty level (FPL), which is the Medicaid and are known as dual eligible, mean-
minimum amount of gross income that a family ing they are covered under both Medicare and
AB103118_Ch15.indd 484 2/11/2020 1:23:13 PM

Medicaid. The goal is for enrollees who are dual ystem and is the healthcare program for uni-
S
eligible to have full access to seamless, high-quality formed service members (active, Guard or Reserve,
healthcare and to make the system as cost-effective and retired) and their families. TRICARE is man-
as possible (CMS 2018e). The Medicare–Medicaid aged by the Defense Health Agency under lead-
Coordination Office, established by the ACA, works ership of the Assistant Secretary of Defense for
across federal and state agencies to align coordina- Health Affairs and is a regionally managed health-
tion of benefits (COB) between the programs. COB care program with an expansive provider network
determines the financial responsibility for payment that combines the resources of military hospitals
of medical claims when one or more payers are in- and clinics with civilian healthcare networks (DHA
volved. The goals of the office are to do the following: 2018). Several healthcare plan options are available
for members, depending on their circumstances,
●● Provide access to people who are covered by
and include emergency care, urgent care, preven-
both Medicare and Medicaid
n.
tive services, hospitalization, dental, and phar-
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●● Make the process easier for dual-eligible people macy coverage. Table 15.2 displays some of the
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●● Provide quality healthcare plan options.
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●● Help with understanding the programs
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●● Eliminate regulatory conflicts Veterans Health Administration
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The US Department of Veterans Affairs operates
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●● Prevent shifting costs from one program to
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the other the nation’s largest integrated healthcare system,
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the Veterans Health Administration (VA), with
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●● Improve the transitions of care io
more than 1,700 hospitals, clinics, community
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Improve the quality of service and suppliers
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●●
living centers, domiciliary, readjustment coun-
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(CMS 2018e) seling centers, and other facilities. The VA of-

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fers a variety of healthcare services from basic

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State Children’s Health Insurance Plan The primary care to nursing home care for eligible
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Children’s Health Insurance Program (CHIP)

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veterans. The number of veterans who can be en-

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provides healthcare coverage to eligible children rolled in the healthcare program is determined
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through both Medicaid and individual state CHIP

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by the amount of money Congress gives the VA

programs. Eligibility is based on a percentage of the
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each year.
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family’s annual income based on the FPL for the

by
current year. Like all Medicaid programs, CHIP

20
Civilian Health and Medical Program of the

20
is administered by states according to federal re- Department of Veterans Affairs

©
quirements and is funded jointly by states and the

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The Civilian Health and Medical Program of the

federal government. States can choose to impose
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Department of Veterans Affairs (CHAMPVA)

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limited enrollment fees, premiums, deductibles,

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is a comprehensive healthcare program in which

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coinsurance, and copayments for children and

the VA shares the cost of covered healthcare ser-
pregnant women, usually 5 percent of a family’s
vices and supplies with eligible beneficiaries. The
annual income. Cost sharing is prohibited for
Chief Business Office Purchased Care (CBOPC)
some services. Cost sharing is the amount that a
administers the program. CHAMPVA covers most
patient pays for a medical service out of pocket;
healthcare services that are medically and psycho-
for example, a healthcare provider who performs
logically necessary. To be eligible for CHAMPVA,
a well-baby check must accept the amount Medic-
a person cannot be eligible for TRICARE and must
aid pays as payment in full.
be in one of the following categories:
TRICARE ●● The spouse or child of an eligible veteran
The US Department of Defense operates TRICARE, ●● The spouse or child of a veteran who died as
which is a major part of the Military Health the result of a service injury
AB103118_Ch15.indd 485 2/11/2020 1:23:13 PM

Table 15.2 TRICARE options

Option Definition Annual fee Annual deductible Co-pay amount
TRICARE Prime and Managed care option offering the No annual fee No deductible No co-pay
Prime Remote most affordable and comprehensive
coverage
Prime remote covers remote US
stations
Overseas options for active duty
families living overseas
TRICARE Standard A fee-for-service plan available to all No annual fee $50/Individual 15% of
and Extra nonactive duty beneficiaries negotiated fee
Most freedom to choose providers $100/Family
TRICARE Reserve A premium-based healthcare Monthly premiums $50/Individual No co-pay
Select and Retired plan that qualified National Guard apply $100/Family
n.
Reserve and Reserve members may
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purchase
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TRICARE For Life Offers secondary coverage to No annual fee but No deductible No co-pay
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people who have Medicare must have Medicare
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Parts A and B
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TRICARE Young Adult A premium-based, worldwide Monthly premiums No deductible $12 per
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Options healthcare plan that qualified adult apply visit outpatient
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children of eligible sponsors may
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$11 per day
purchase
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inpatient
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US Family Health Plan Available through networks of Enrollment is
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community-based, not-for-profit required with one
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healthcare systems in six areas of the year commitment

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United States to receive care from

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the plan
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Source: Adapted from TRICARE 2015.

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●● The spouse or child of a veteran who was is responsible for the healthcare of its tribal mem-
totally disabled at the time of his or her bers. The IHS is divided into 12 physical areas of
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death the United States, Alaska, Albuquerque, Bemidji,

by
Billings, California, Great Plains, Nashville, Nav-

20
●● The spouse or child of a military member

20
who died while serving in the military ajo, Oklahoma, Phoenix, Portland, and Tucson.
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(VA 2018) Each area works collaboratively to provide health-

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care services to all American Indians and Alaska

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Natives who live within its areas (IHS 2019). For

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Indian Health Services example, a Native Alaskan living in California can

The Indian Health Service (IHS) is an HHS agency receive care at an IHS facility in California. If an
responsible for providing healthcare to American IHS facility is not available for a patient, the tribe
Indians and Alaska Natives within the United may use contract funds to pay for coverage at an-
States. The provision of health services to mem- other healthcare organization. This relationship,
bers of federally recognized Native tribes grew out established in 1787, is based on Article I, Section 8
of a special government-to-government relation- of the Constitution. Numerous treaties, laws, Su-
ship between the federal government and Indian preme Court decisions, and executive orders are
tribes. The Indian Self-Determination Act of 1975 responsible for what the agency is today. The IHS
turned control of healthcare organizations and is the principal federal healthcare provider and
programs over to Native and Indian tribes within health advocate for American Indian and Native
the United Sates (IHS 2019). Each tribal government people, and its goal is to raise their health status
AB103118_Ch15.indd 486 2/11/2020 1:23:13 PM

to the highest possible level (IHS 2019). Every IHS or their dependents if the employee is injured at
facility in the United States sets its own standard work. The four programs include the following:
of coverage and services. For example, in Alaska
1. Division of Federal Employees’ Compensa-
there are 10 service areas, some with hospitals,
tion (DFEC)
clinics, or small rural health centers.
2. Division of Energy Employees Occupational
Illness Compensation (DEEOIC)
Workers’ Compensation
3. Division of Longshore and Harbor Workers’
Most employers in the United States are required
Compensation (DLHWC)
to carry workers’ compensation insurance to
cover employees who are injured on the job. 4. Division of Coal Mine Workers’ Compensation
Workers’ compensation laws are regulated by (DCMWC)
state and federal government and vary by state. The benefits include disability, wage replace-
n.
The employee and provider complete a notice of ment, medical treatment, and vocational rehabili-
tio
injury report, which details what happened and
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tation for workers injured on the job (DOL 2015).
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how the injury occurred, for claim payments
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to be processed. The healthcare provider adds State Workers’ Compensation Funds Before state
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details to the report indicating the diagnosis workers’ compensation laws were introduced,
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and anticipated healthcare services that will be companies were reluctant to provide insurance
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required. When a claim is sent to the workers’ coverage for employees because of the high costs
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compensation insurance carrier the notice of infor workers injured on the job. Most states ad-
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jury report must be submitted with each claim io
dressed the concern by introducing state work-
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for payment. ers’ compensation insurance funds as a source of

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coverage for claims occurring because of work-

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Federal Workers’ Compensation Funds Federal place injury. State workers’ compensation funds
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employees are covered under the Federal Employees’ are maintained by each state from employer-paid
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Compensation Act (FECA) of 1916. The Depart- premiums. Benefits may include compensation
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ment of Labor’s Office of Workers’ Compensation for burial, life insurance coverage for dependents
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Programs (OWCP) administers four major disabil- upon death, compensation for lost income, and
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ity compensation programs for federal employees health coverage for medical care (Casto 2018).
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1. The number of beneficiaries who can be enrolled in the healthcare program for military members is determined by the
amount of money Congress allocates to the ______________ each year.
a. VA
b. TRICARE
c. CHAMPVA
d. Workers’ compensation
2. Mandatory eligibility groups fall under which insurance?
a. CHAMPVA
b. Medicare
c. IHS
d. Medicaid
AB103118_Ch15.indd 487 2/11/2020 1:23:13 PM

3. Identify the insurance that provides coverage to most Americans age 65 or older.
a. TRICARE
b. IHS
c. Medicare
d. Medicaid
4. What is a healthcare delivery system or network organized to manage cost, utilization, and quality?
a. HMO
b. Managed care
c. Not-for-profit
d. Employer-Based Self-Insurance
5. Which health insurance typically has a high deductible or limited covered services?
a. Private Healthcare Insurance
n.
b. CHAMPVA
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c. Medicare
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d. CHIP
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6. An employee for the HIM department is on their way to a forms committee meeting when they trip going up the stairs
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and twist their knee. Which type of insurance would they be eligible for?
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a. Workers’ compensation
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b. Medicaid
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c. IHS
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d. TRICARE
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7. Which government health program was introduced out of a special government-to-government relationship?
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a. Medicare
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b. Tricare
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c. IHS
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d. Workers’ compensation
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New Trends
by
20
20
Revenue management and reimburse- exchange where uninsured, eligible Americans are
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ment professionals must stay current with changes able to purchase federally regulated and subsidized
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in laws and regulations that affect the revenue cycle healthcare insurance. People who are not covered by
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yr
and billing guidelines. New trends in recent years insurance through a job, Medicare, Medicaid, CHIP,
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include the healthcare insurance marketplace, con- or another source are able to purchase insurance
sumer-directed healthcare plans, hospital-acquired through a marketplace exchange. The exchange of-
conditions, ACA, Medicare Access and CHIP Reau- fers healthcare insurance to members based on their
thorization Act (MACRA), and present on admission income. Most people who apply qualify for pre-
indicator reporting. These trends can affect reim- mium tax credits, which lower the cost of coverage.
bursement positively or negatively, which means All plans cover essential health benefits, pre-existing
keeping up with these regulations is imperative. conditions, and preventive care (HealthCare 2017).
Health Insurance Marketplace or Consumer-Directed Health Plans

Exchange Consumer-directed health plans (CDHP), also
The Patient Protection and Affordable Care Act known as high-deductible plans (HDPs) because
(ACA) was signed into law in 2010. The ACA the deductible is at least $1,200 per year, are man-
established a health insurance marketplace or aged care organizations that influence patients and
AB103118_Ch15.indd 488 2/11/2020 1:23:13 PM

clients to select cost-efficient healthcare through Medicare Access and CHIP

the provision of information about health benefit Reauthorization Act
packages and through financial incentives. Em-
The Medicare Access and CHIP Reauthoriza-
ployers shift payment responsibility to plan mem-
tion Act (MACRA) was signed into law in April
bers causing employees to opt for the HDP option
of 2015. MACRA created the Quality Payment
to save money on premiums. The ACA mandates
Program, which requires providers to concentrate
that HDPs purchased after March 2010 provide
their healthcare efforts on the value of the care
free preventive services even if the deductible has
they provide instead of the volume, or number of
not been met.
patients, they see in a day. Providers’ performance
is measured through data collection reports that
Hospital-Acquired Conditions and measure the following four areas:
Present on Admission Indicator
n.
Reporting 1. Quality: Providers measure six areas of
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performance for their practice, including
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The ACA established the hospital-acquired con-
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avoiding harm to patients, providing effective
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ditions (HAC) reduction program to encourage
service, providing respectful care, reducing
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hospitals to reduce HACs. An HAC is a reason-
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wait times, avoiding waste, and providing
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ably preventable condition that a patient did not
quality care that is equitable for all patients.
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have upon admission to a hospital, but that devel-
2. Improvement activities: This performance
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oped during the hospital stay. Examples of HACs
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area measures the activities a provider uses to
include foreign object retained after surgery, blood
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increase the coordination of care for patients,
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incompatibility, falls, and infections.
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include the patient in the decision-making

Hospital performance under the HAC reduc-
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process for care, and expand access to care for

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tion program is determined based on a hospital’s

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all patients.
total HAC score, which can range from 1 to 10.
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3. Promoting interoperability: This performance

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The higher a hospital’s total HAC score, the worse

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the hospital performed under the HAC reduction area measures the activities a provider uses to
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proactively share electronic health information

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program. Hospitals are given an opportunity to re-

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view their data and request a recalculation of their with other providers by sharing test results
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and plans to coordinate healthcare.

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scores if they believe an error in the score calcula-

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tion has occurred. The law requires the Secretary 4. Cost: This performance area measures the
20
of HHS to reduce payments to hospitals that rank total cost of care for a year or for a hospital
20
in the quartile of hospitals with the highest total inpatient encounter.

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HAC scores by one percent (CMS 2015d). Present

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MACRA created two ways to participate in the

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on admission (POA) indicates that a condition

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Quality Payment Program. One is a Merit-Based

was present at the time the patient was admitted
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Incentive Payments System (MIPS) that stream-

to the hospital. When submitting claims to Medi-
lines multiple quality payment programs into one
care for MS-DRG reimbursement the POA indica-
system. It was created to tie healthcare payments
tor includes:
to the quality and cost efficiency of care. with the
goals of improving healthcare processes and out-
Y: Diagnosis was present at the time of
comes and reducing costs while increasing provid-
admission
ers’ use of healthcare information when treating
N: Diagnosis was not present patients (CMS 2018a). The MIPS uses the calendar
year for providers to report data to be eligible for
U: Documentation is insufficient to determine
an increase in payment or to avoid a reduction
if condition was present
for the next year. Providers must report data by
W: It is clinically undetermined if the condition March 31 of each year. The other program is the
was present (CMS 2015e) Advanced Alternative Payment Models (APMs)
AB103118_Ch15.indd 489 2/11/2020 1:23:13 PM

where providers are able to earn a Medicare incen- and includes comprehensive healthcare insurance
tive payment if they participate in an innovative reforms. For example, Medicare’s hospital read-
payment model. For example, a medical practice missions reduction program requires a reduction
can apply for payment under an APM if they in- in payment to a hospital if the hospital has what
vest in practice innovation and care redesign and is considered excessive readmission rates. A re-
enhance the coordination of care for their patients. admission includes hospital admission within 30
MACRA also required social security numbers to days of a subsequent hospitalization (CMS 2015d).
be removed from Medicare cards by April 2019 to Another outcome of the ACA is the creation of ac-
help prevent Medicare fraud (CMS 2018a). countable care organizations (ACOs). The ACO
agrees “to be held accountable for improving the
Patient Protection and the Affordable health and experience of care for individuals and
Care Act improving the health of populations while reduc-
n.
The ACA includes a number of provisions designed ing the rate of growth in healthcare spending”
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to encourage improvements in the quality of care (CMS 2015d).
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Utilization Management
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Utilization management (UM) is the timeliness of the delivery of medical care from the
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evaluation of the medical necessity, appropriate- time of admission until discharge. Retrospective
ness, and efficiency of the use of healthcare services, n
review includes review and analysis of actual uti-
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procedures, and facilities under the provisions of the lization data after the patient has been discharged.
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applicable health benefits plan, sometimes called The retrospective review may be conducted by a
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utilization review. Prospective review refers to the committee of the organization or an outside quality
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review that takes place prior to elective procedures improvement organization (QIO), which is an or-
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and admissions. This is achieved through a precer- ganization hired by CMS to perform medical peer
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tification process for elective admissions, certain review of coding information for completeness, ad-
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diagnostic procedures, and outpatient surgeries. equacy, and quality of care, as well as the appropri-
Utilization management professionals, who may be ateness of payments. An outside review may find
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clinical nurses, physicians or mid-level providers, errors in daily operations performance that the or-
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use clinical screening processes to apply consistent ganization missed. The UM professionals monitor
20
20
standards when determining if a service is medi- inpatient utilization daily by reviewing a list of all
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cally necessary. One tool is preauthorization, which patients, their diagnoses, the requested length of
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reviews proposed surgeries and other inpatient and stay versus the actual length of stay, and other in-
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outpatient healthcare services before the patient is formation that helps to continually manage inpa-
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admitted. Concurrent review involves screening tient activity to determine medical necessity as well
for medical necessity and the appropriateness and as reimbursement for the inpatient stay.
Case Management
Case management is collaboration be- communication and coordination of available
tween healthcare and service providers to aid in resources to promote quality and cost-effective
the process of assessment, planning, facilitation, outcomes. The primary reason for case manage-
care coordination, evaluation, and advocacy to ment is the facilitation of care across the contin-
meet the comprehensive health needs of an indi- uum of care for the patient. For example, a patient
vidual or family. This is accomplished through newly diagnosed with cancer may require surgery,
AB103118_Ch15.indd 490 2/11/2020 1:23:13 PM

laboratory services, chemotherapy, radiation, and or her family; for example, continued care or social
counseling services. Case management helps nav- services. They accomplish this by identifying the
igate all the services and providers for the patient. continued needs of the patient and determining
The goal of case management is for the individ- the resources that are available to the patient. Case
ual to reach the optimum level of wellness and managers use a multi-disciplinary approach to op-
functional capability. A case manager is usually a timize the outcome. This approach brings together
nurse, physician, or social worker who arranges many services from medical, social service, thera-
all services that are needed by a patient and his pies, and such (CMS 2018f).
Healthcare Reimbursement Methodologies
n.
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Healthcare services can be reimbursed improve the quality, efficiency, and overall value
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in a number of ways depending on the type of in- of healthcare. The ACA expands the use of pay for
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surance coverage and the type of service provided. performance in Medicare with the idea that pay-
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This section discusses fee-for-service reimburse- ing providers to achieve better outcomes should
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ment, episode-of-care reimbursement, capitation, improve those outcomes (CMS 2017).
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global payment, resource-based relative value The typical VBP program provides a bonus to
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scale, skilled nursing payment, and prospective healthcare providers if they meet or exceed agreed-
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payments. upon quality or performance measures; for exam-
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ple, reductions in catheter-associated urinary tract
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Fee-for-Service Reimbursement
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infections. Each year measures are added or deleted

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Fee-for-service reimbursement is a reimbursement to ensure patient safety is the highest priority. The
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programs may also reward improvement in per-

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method through which providers retrospectively

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receive payment based on either billed charges formance over time, such as year-to-year decreas-
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for services provided or annually updated fee es in the rate of avoidable hospital readmissions
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schedules. A provider submits a claim form to a (CMS 2017).

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healthcare plan with all charges itemized. In fee-

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for-service reimbursement, the itemized charges Traditional Fee-for-Service

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are individually assessed and paid based on the Reimbursement

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20
healthcare insurance coverage the patient holds. In traditional fee-for-service (FFS) reimburse-
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For example, if a healthcare provider submits ment systems, third-party payers or patients issue
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a claim for services for an annual exam and the

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payments to healthcare providers after healthcare

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patient’s healthcare coverage includes annual

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services have been received (for example, after

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exam coverage, the healthcare insurance plan will the patient has been discharged from the hospi-
pay the claim. tal). Payments are based on the specific services
delivered.
Value-Based Purchasing After services are rendered, an itemized claim
Value-based purchasing (VBP) is a type of incen- for all service charges is submitted to a healthcare
tive to improve clinical performance using the plan for payment. Payment is based on the billed
EHR and resulting in additional reimbursement charges, taking into account discounted charges,
or eligibility for grants or other subsidies to sup- negotiated rates, and usual or customary charges
port further health information technology efforts. for a geographic area. Usual, customary, and rea-
Examples of types of incentives used include sonable (UCR) charges is a type of fee-for-service
better healthcare for patients and populations of payment method in which the third-party payer
people and lower healthcare costs. The goal is to remunerates fees that are usual for the provider’s
AB103118_Ch15.indd 491 2/11/2020 1:23:13 PM

practice, customary for the community, and rea- flat fee for the entire episode of pregnancy and
sonable for the situation. For example, the amount delivery or a patient receiving follow-up care for the
of reimbursement for a mammogram at a rural first 60 days after a stroke. In home health services,
hospital may be significantly more than for a large all services and supplies provided to a patient for a
urban hospital because the cost of doing business 60-day period are paid by EOC reimbursement.
in the rural area is higher and justified for that
geographic area. Capitation
Many commercial insurance companies use the Capitation is a specified amount of money paid to
traditional FFS reimbursement methodology for a healthcare plan or physician to cover the cost of
visits to physician’s offices. a healthcare plan member’s services for a certain
length of time (CMS 2016c). The healthcare plan
Managed Fee-for-Service negotiates with an employer or agency for a pre-
n.
Reimbursement established amount of money to care for the health
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services of members. The MCO agrees to provide
Managed FFS reimbursement involves utiliza-
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health services for a period of time, usually one year.
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tion controls for reimbursement under traditional
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Capitated premiums are calculated on the projected
fee-for-service insurance plans, in that managed
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cost of providing covered services PMPM.
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care plans control costs by handling their mem-
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bers’ use of healthcare services. Managed care plans
Global Payment
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negotiate with providers to develop discounted
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fee schedules. Global payment methodology involves payment
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Controlling utilization of services includes both that combines the professional and technical com-
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prospective and retrospective reviews of planned ponents of a procedure and disperses payments
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healthcare services. Precertification is a type of as a lump sum to be split between the physician
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prospective review. For example, a patient with a and the healthcare organization. The professional
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strong family history of colon cancer needs prior component of a service is considered the part of
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approval to receive a screening colonoscopy before the service supplied by physicians (for example,
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the age approved by a healthcare plan. the radiologist). The technical component (for ex-
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The retrospective utilization review process ample, supplies, equipment, and support services)
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involves evaluation of utilization information af- is supplied by a hospital or freestanding surgical

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ter the patient has been discharged or the care has center. For example:
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been completed. Utilization review also includes

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A patient receives a chest x-ray.

discharge planning—coordinating the activities
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Professional component: Services of the

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related to the release of a patient when inpatient

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radiologist
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hospital care is no longer needed. The managed

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Technical component: Radiology department

care plan controls costs by providing a less inten-
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use, x-ray equipment

sive, and therefore less expensive, care setting as Global payment: The facility received a lump-sum
soon as possible. payment for the radiologist reading the
x-ray and the facility fees to take the x-ray
Episode-of-Care Reimbursement
Methodologies Prospective Payment
An episode-of-care (EOC) reimbursement is giv- A prospective payment system (PPS) is a method
en for a relatively continuous medical treatment of reimbursement in which Medicare payment is
provided by the healthcare professional in relation made based on a predetermined, fixed amount.
to a particular clinical problem or situation. For The payment amount for a particular service is
example, an obstetrician who charges a patient a derived based on the classification system of that
AB103118_Ch15.indd 492 2/11/2020 1:23:13 PM

service. CMS uses separate PPSs for reimbursement shortly after admission and upon discharge. Based
of the following: on the patient’s condition, services, diagnosis, and
medical condition, a payment level is determined
●● Acute inpatient hospitals
for the inpatient rehabilitation stay. Comprehensive
●● Home health agencies outpatient rehabilitation facilities have separate
●● Hospice Medicare guidelines.
●● Hospital outpatient
●● Inpatient psychiatric facilities Medicare Severity Diagnosis-Related
●● Inpatient rehabilitation facilities Groups
●● Long-term care hospitals The DRG system was updated to MS-DRG to bet-
●● Skilled nursing facilities (CMS 2014b) ter account for severity of illness and resource use
for inpatient services. The three levels of severity
n.
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in the MS-DRG system are the following:
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Medicare Acute Inpatient Prospective
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1. Major complication/comorbidity (MCC):
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Payment System
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The patient has a medical condition that
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The inpatient prospective payment system (IPPS) arises during an inpatient stay, like a wound
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under Medicare Part A is a payment methodology infection (complication) or a medical condition
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in which payment is based on the diagnosis of the
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that coexists with the primary reason for
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patient. An inpatient stay is categorized into a Med- admission and affects the patient’s treatment
icare severity diagnosis-related group (MS-DRG). n
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or length of stay (comorbidity)
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A DRG is a unit of case-mix classification in a PPS
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2. Complication/comorbidity (CC): The patient

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where diseases are placed into groups because re- has a medical condition that is not considered
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lated diseases and treatments tend to consume

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similar amounts of healthcare resources and incur

3. Non-CC: All severity levels are based on
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similar amounts of cost to the hospital. A patient’s

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the secondary diagnosis; this level of severity

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hospitalization may fall into one of more than 500

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indicates the patient does not have a CC

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diagnostic classifications in which cases demon-

(CMS 2016b)
strate similar resource consumption and length of
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stay patterns. Hospitals are paid a set fee for treat- A hospital’s case-mix index (CMI) represents
by
ing patients in a single DRG category, regardless of the average MS-DRG relative weight for a partic-
20
20
the actual cost of care. A hospital may receive an ular hospital. The CMI is calculated by looking at
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adjustment or an additional reimbursement if it is the Medicare discharges for a defined period of

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a disproportionate share hospital (DSH), a hospital time (month, quarter, year), adding them together,
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that treats a high percentage of low-income patients then dividing by the number of total discharges
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(CMS 2015e). The IPPS works in conjunction with within that period of time. The CMI allows admin-
coding and ICD-10 CM/PCS, where the codes are istration to measure the hospital’s performance
grouped together. This data is used to look at qual- based on MS-DRG cases. CMIs are calculated us-
ity measures, such as readmission rates and HACs. ing both transfer-adjusted cases and unadjusted
An inpatient rehabilitation hospital or unit within cases, meaning that a patient who is transferred
a hospital is a free-standing facility that provides an from facility A to facility B to receive a higher level
intensive rehabilitation program for patients. Pa- of care and is only at facility A for one day will not
tients must be able to tolerate three hours of intense receive the entire DRG payment for the patient’s
rehabilitation services per day. These facilities are diagnosis because the patient was transferred out
paid under the IRF PPS. A patient assessment in- of the first facility. The payment rate is based on
strument (PAI) is completed on Medicare patients the type of case and resources required to treat the
AB103118_Ch15.indd 493 2/11/2020 1:23:13 PM

patient. By analyzing the CMI of a facility a man- Outpatient Prospective Payment

ager is able to compare the CMI against other simi- System
lar facilities in the area, or the year-to-year changes
As part of the BBA, CMS started using the outpa-
of the facility in its CMI. This analysis allows cod-
tient prospective payment system (OPPS)—the
ing managers to correct coding errors resulting in
Medicare prospective payment system used for
improper MS-DRG payments in a timely manner
hospital-based outpatient services and procedures
and allows administrators to understand the type
that is predicated on the assignment of ambula-
of patient in the healthcare organization to allow
tory payment classifications (APC). A single pay-
and plan for future clinical allocations.
ment is made for all outpatient services that fall
within an APC, which is a group consisting of di-
Resource-Based Relative Value agnoses and procedures that are similar in terms
Scale System of resources used, complexity of illness, and con-
n.
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A resource-based relative value scale (RBRVS) ditions represented. A single payment is made for
ia
system is a payment methodology in which phy- the outpatient services provided. A single visit
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sician payments are determined by the resource can result in multiple APC groups. APC groups
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costs needed to provide care. The RBRVS contains consist of five types of services: significant proce-
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national uniform relative values for all physicians’ dures, surgical services, medical visits, ancillary
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services. The relative value of each service must services, and partial hospitalization. The OPPS
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be the sum of relative value units representing the reimburses some hospital outpatient services and
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physicians’ work, practice expenses net of mal- certain Medicare Part B services furnished to hos-
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practice insurance expenses, and the cost of pro- pital inpatients when Part A payment cannot be
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fessional liability insurance. The calculation for made; for example, implantable devices used in
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payment is based on the three components listed. diagnostic testing (CMS 2014a).
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There may also be an adjustment based on geo-

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Ambulatory Surgery Center

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graphical resource costs (CMS 2017).

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Prospective Payment System

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Skilled Nursing Facility Prospective For Medicare purposes, an ambulatory surgery cen-
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Payment System ter (ASC) is a distinct entity that operates exclusively

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Skilled nursing facilities (SNFs) are paid based on for the purpose of furnishing surgical services to pa-
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a case-mix classification system under the skilled tients who do not require hospitalization and when
20
the expected duration of services does not exceed 24

20
nursing facility prospective payment system, the

hours following admission. This definition applies
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SNF Value-Based Purchasing Program (VBP), and

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to the ASC no matter who pays for the ASC’s serv-

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the SNF Quality Reporting Program (QRP). This pay-

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ices (CMS 2019c. Medicare makes a single payment

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ment methodology shows a commitment by CMS to

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shift payment models from volume to value based to ASCs for covered surgical procedures, including
systems. The case-mix model is called the Patient- ASC facility services furnished in connection with
Driven Payment Model (PDPM), and the focus is on the covered procedure; this is known as the ambula-
the condition and care requirements of the patient tory surgery center (ASC) payment rate. Examples
rather than on the amount of care provided to the of ASC-covered services include nursing, surgical
patient in order to determine the Medicare payment. dressing, administrative costs for the facility, and
The payment system also encourages SNFs to inno- ancillary services (CMS 2019a).
vate in terms of meaningful quality measure report-
ing, reducing paperwork and administrative costs. Home Health Prospective Payment
The goal is for SNFs to treat the needs of the whole System
patient not just the services the patient receives, The home health prospective payment system
which requires substantial paperwork to track. (HH PPS) was mandated by the BBA. The HH
AB103118_Ch15.indd 494 2/11/2020 1:23:13 PM

PPS uses the Patient-Driven Groupings Model ambulance and if the facility to which the patient is
(PDGM) for payment, which is based on a 30-day taken is appropriate. For example, a patient living
period of time for service. The 30-day periods of on an island with only a small clinic healthcare
time are categorized into 432 case-mix groups and facility is in a motor vehicle crash, resulting in a bro-
5 subgroups, which include source of admission, ken femur. The clinic calls an air ambulance service
timing, clinical grouping, functional impairment to transport the patient to a larger trauma center
level, and comorbidity adjustments (CMS 2018b; on the mainland. Payment for ambulance services
CMS 2019b). includes a base rate payment plus a mileage pay-
ment to the nearest healthcare organization. So, if
Ambulance Fee Schedule the base rate for air ambulance for the patient with
The BBA mandated the implementation of a na- the broken femur is $3,000 and the mileage was 100
tional ambulance fee schedule for Medicare Part miles at $45 per mile, the total payment would be
n.
B. Ambulance transport includes both vehicular $3,000 (base rate) + $4,500 ($45 per mile) for a total of
tio
and air travel. Medicare will determine the medi- $7,500. Rates vary based on geographic area across
ia
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cal necessity for the transportation of a patient by the United States (CMS 2019c).
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HIM Roles
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During almost every legislative session organizations understand incentive programs
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of Congress, changes are made to healthcare reim- that focus on quality and provide the data and in-
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at
bursement methodologies and healthcare cover- formation needed for reporting purposes for reim-
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age options for Medicare and Medicaid patients. bursement. They provide knowledge on different
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Health insurance providers make great efforts to reimbursement models, which is invaluable to
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ensure they are paying for services that are med- healthcare organizations. Professional coders use
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ically necessary, reasonable, and covered by their their expertise to ensure compliance with regula-
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plans. Healthcare reimbursement methodologies tions for reimbursement; for example, a coder will
ic
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are very complex and change based on the type determine the code needed for POA requirements.
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of service, location, type of provider, and so HIM auditors are able to review claim denials to
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on. HIM professionals know the complexities of determine what documentation is needed to proc-
by
reimbursement rules and regulations. They help ess a claim form for reimbursement.
20
20
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Match the terms to the descriptions.

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a. Resource-based relative value scale

b. Concurrent review
c. Utilization management
d. Hospital-acquired conditions
e. Ambulatory surgery center
1. Payments for services are determined by the resource costs needed to provide them.
2. The evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services,
procedures, and facilities under the provisions of the applicable health benefits plan.
3. A group of reasonably preventable conditions that patients do not have upon admission to a hospital, but which
develop during the hospital stay.
4. A distinct entity that operates exclusively for the purpose of furnishing surgical services to patients who do not require
hospitalization.
5. Screening for medical necessity and the appropriateness and timeliness of the delivery of medical care from the time
of admission until discharge.
AB103118_Ch15.indd 495 2/11/2020 1:23:13 PM


David, a student from an accredited process, he discovered that the additional doc-
HIM program, was given a professional practice uments required were similar for each claim.
experience project that required him to review Also, because of the settings on the organiza-
reimbursement denials for Medicare patients tion’s EHR, the required diagnosis codes for the
over the course of the past year. He noticed that radiological services performed were not being
the denials were higher when the claim included submitted on the claim form, although the pro-
services from the radiology department. He cedure code was included on the claim. David
researched the claims and resubmitted them
communicated his findings to the manager, and
with additional documentation. Through this they discussed potential next steps.
n.
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Emily Kelley was taken to Kirklake to the hospital for Emily’s surgery was less than
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Community Hospital for pain in her side. She was it should have been based on APC grouping. The
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admitted and taken into surgery, where her ap- billers noticed a decrease in reimbursement and
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pendix was removed. In recovery her temperature discussed it with the manager. The HIM manager
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spiked, and after looking at Emily’s labs it was de- approached the performance improvement man-
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termined that she had developed an infection from ager to discuss the spike in HACs. She was able to
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the surgery. This was not the first surgery where provide the data to support an investigation into
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an infection subsequently developed, and the cur- why this was happening. It was determined that
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rent total HAC score for this hospital was 8. As a the infections were occurring when a particular
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result of the high HAC score, the reimbursement provider was on staff.
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References
e
th
by
American Health Information Management Centers for Medicare and Medicaid Services. 2019b.
20
Association. 2017. Pocket Glossary of Health Information Skilled Nursing Facility Prospective Payment System.
20
Management and Technology, 5th ed. Chicago: http://www.cms.gov/Outreach-and-Education/

©
AHIMA. Medicare-Learning-Network-MLN/MLNProducts/
ht
downloads/snfprospaymtfctsht.pdf.
ig
American Medical Association. 2015. Overview

yr
of the RBRVS. http://www.ama-assn.org/ama/ Centers for Medicare and Medicaid Services. 2019c.
op
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pub/physician-resources/solutions-managing- Ambulatory Surgical Center Fee Schedule. https://

your-practice/coding-billing-insurance/medicare/ www.cms.gov/Outreach-and-Education/Medicare-
the-resource-based-relative-value-scale/overview-of- Learning-Network-MLN/MLNProducts/downloads/
rbrvs.page. AmbSurgCtrFeepymtfctsht508-09.pdf.
Case Management Society of America. 2015. http:// Centers for Medicare and Medicaid Services. 2094d.
www.cmsa.org/. Home Health Prospective Payment System. http://www.
Casto, A.B. 2018. Principles of Healthcare Reimbursement. cms.gov/Outreach-and-Education/Medicare-Learning-
6th ed. Chicago: AHIMA. Network-MLN/MLNProducts/Downloads/Home-
Health-Prospective-Payment-System-Text-Only.pdf.
Centers for Medicare and Medicaid Services. 2019a.
Hospital Outpatient Prospective Payment System. Centers for Medicare and Medicaid Services. 2019e.
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Medicare-Learning-Network-MLN/MLNProducts/ Medicare/Medicare-Fee-for-Service-Payment/
downloads/HospitalOutpaysysfctsht.pdf. AmbulanceFeeSchedule/.
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Centers for Medicare and Medicaid Services. 2018a. Regulations-and-Guidance/Guidance/Manuals/

MACRA. https://www.cms.gov/Medicare/ downloads/mc86c01.pdf.
Quality-Initiatives-Patient-Assessment-Instruments/ Centers for Medicare and Medicaid Services. 2016c.
Value-Based-Programs/MACRA-MIPS-and-APMs/ Resource-Based Relative Value Scale. https://www.
MACRA-MIPS-and-APMs.html. cms.gov/apps/glossary/search.asp?Term=resource-
Centers for Medicare and Medicaid Services. 2018b. based+relative+value&Language=English&SubmitTer
Medicare Advantage Organizations, Cost Plans and mSrch=Search.
Prescription Drug Plan Sponsors. https://www.cms. Centers for Medicare and Medicaid Services.
gov/Medicare/Medicare-Advantage/Plan-Payment/ 2015a. Tracing the History of CMS Programs:
Downloads/Release-of-Medical-Loss-Ratio-MLR- From President Theodore Roosevelt to President
Reporting-Tool-for-Contract-Year-2017.pdf. George W. Bush. https://www.cms.gov/About-
Centers for Medicare and Medicaid Services. 2018e. CMS/Agency-Information/History/Downloads/
Medicare Part A. https://www.cms.gov/Medicare/ PresidentCMSMilestones.pdf.
Medicare-General-Information/MedicareGenInfo/
n.
Centers for Medicare and Medicaid Services. 2015b.
tio
Part-A.html. Loan Program Helps Support Customer-Driven
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Centers for Medicare and Medicaid Services. 2018f. Non-Profit Health Insurers. https://www.cms.gov/
ss
Medicare Part B. https://www.cms.gov/Medicare/ CCIIO/Resources/Grants/new-loan-program.html.
tA
Medicare-General-Information/MedicareGenInfo/ Centers for Medicare and Medicaid Services. 2015c.
en
Part-B.html.
em
Medicare. https://www.cms.gov/Medicare/
Centers for Medicare and Medicaid Services. 2018g. Medicare.html.
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Health Plans—General Information. https://www.cms. Centers for Medicare and Medicaid Services. 2015d.
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gov/Medicare/Health-Plans/HealthPlansGenInfo/. History: CMS’ Program History. https://www.cms.
n
io
Centers for Medicare and Medicaid Services. gov/About-CMS/Agency-Information/History/
at
m
2018h. Medicaid and CHIP Eligibility Levels. http:// index.html?redirect=/History/.

r
fo
www.medicaid.gov/medicaid-chip-program- Centers for Medicare and Medicaid Services. 2019.

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information/program-information/medicaid-and-
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Fact Sheet: Medicare issues fiscal year 2019 payment

chip-eligibility-levels/medicaid-chip-eligibility-levels.
ea
& policy changes for skilled nursing facilities. July 31,

H
html. 2018 https://www.cms.gov/newsroom/fact-sheets/

an
Centers for Medicare and Medicaid Services. 2019i. medicare-issues-fiscal-year-2019-payment-policy-

ic
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Federal Policy Guidance. http://www.medicaid. changes-skilled-nursing-facilities

Am
gov/federal-policy-guidance/federal-policy-guidance. Defense Health Agency. 2015. TRICARE. http://www.

e
html.
th
tricare.mil.
by
Centers for Medicare and Medicaid Services. 2018j. Department of Health and Human Services. 2018.
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About the Medicare-Medicaid Coordination Office. About the Affordable Care Act. https://www.hhs.
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Advancing Care for People with Medicaid and gov/healthcare/about-the-aca/index.html.

©
Medicare. https://www.cms.gov/Medicare-Medicaid-
ht
Coordination/Medicare-and-Medicaid-Coordination/ Ferenc, D. 2014. Understanding Hospital Billing and

ig
Coding, 3rd ed. St. Louis, MO: Elsevier.

yr
Medicare-Medicaid-Coordination-Office.
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Griffin, J. 2017 (March 7).”The History of Healthcare

C

Hospital Value-Based Purchasing. https://www.cms. in America.” Employee Benefits Consultants - JP
gov/Outreach-and-Education/Medicare-Learning- Griffin Group. https://www.griffinbenefits.com/
Network-MLN/MLNProducts/downloads/Hospital_ employeebenefitsblog/history_of_healthcare.
VBPurchasing_Fact_Sheet_ICN907664.pdf. Indian Health Service. 2019. https://www.ihs.gov/.
Centers for Medicare and Medicaid Services. 2016a. The Henry J. Kaiser Family Foundation. 2018
Capitation. https://www.cms.gov/apps/glossary/ (December 10). “Key Facts about the Uninsured
search.asp?Term=capitation&Language=English&Sub Population.” https://www.kff.org/uninsured/
mitTermSrch=Search. fact-sheet/key-facts-about-the-uninsured-population/.
Centers for Medicare and Medicaid Services. National Committee for Quality Assurance. 2019.
2016b. Medicare Managed Care Manual: Chapter About NCQA Overview. http://www.ncqa.org/
1—General Provisions. https://www.cms.gov/ AboutNCQA.aspx.
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National Library of Medicine, MedlinePlus. 2019. US Department of Labor. 2015. Office of Workers’
Managed Care Summary. https://www.nlm.nih.gov/ Compensation Programs (OWCP). http://www.dol.
medlineplus/managedcare.html. gov/owcp/.
NueMD. 2018 (November 19). Revenue Cycle US Department of Veterans Affairs. 2018. CHAMPVA
Management 101. https://www.nuemd.com/revenue- Family Members Insurance. http://www.va.gov/hac/
cycle-management/rcm-101. forbeneficiaries/champva/handbook.asp.
TRICARE. 2015. Compare Plans. http://www.tricare.
mil/Plans/ComparePlans.aspx.
n.
tio
ia
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ss
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In
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by
20
20
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AB103118_Ch15.indd 498 2/11/2020 1:23:14 PM

Chapter
16
Fraud and Abuse
n.
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Compliance
ss
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en
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Darline A. Foltz, RHIA, CHPS, CPC
an
Karen M. Lankisch, PhD, MHI, RHIA, CHDA, CPC, CPPM
M
n
io
at
•• Examine the benefits of a coding compliance plan
m
Learning Objectives
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•• Explore the need for the involvement of health

In
•• Differentiate among fraud, abuse, and waste information management (HIM) professionals in
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•• Identify the elements of a compliance program clinical documentation integrity

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•• Examine the legal and regulatory requirements •• Identify clinical documentation integrity
H
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related to the management of a compliance metrics

ic
program •• Differentiate between the organizations involved in

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•• Examine the purposes of audits the federal regulations and initiatives

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Key Terms
by
20
Abuse Computer-assisted coding (CAC) Office of Inspector General (OIG)

20
Anti-Kickback Statute Denial Overpayment

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Appeal Exclusions Program Physician Self-Referral Law

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Audit False Claims Act Qui tam

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Automated review Fraud Reasonable cause

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Balanced Budget Act of 1997 Health Care Fraud Prevention Reasonable diligence
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Clinical documentation and Enforcement Action Team Recovery audit contractor (RAC)
integrity (CDI) (HEAT) Risk analysis
Clinical validation audit Health Insurance Portability and Semi-automated reviews
Coding audit Accountability Act (HIPAA) Stark Law
Coding compliance plan Medical necessity audit Unbundling
Compliance Medicare Fraud Strike Force Upcoding
Compliance program Merit-Based Incentive Payment Waste
Complex review System (MIPS) Whistleblower Protection
Comprehensive Error Rate Natural language processing (NLP) Act (WPA)
Testing (CERT) Noncovered services Willful neglect
499
499
AB103118_Ch16.indd 499 2/6/2020 5:50:11 PM

Payers of healthcare services, including federal and business, so one or two errors will not usually
state governments, private insurance companies, result in accusations of abuse. It is only when a
and patients trust that physicians and all health- consistent pattern is evident that abuse allegations
care professionals render high-quality medical occur. Some examples of abuse include a pattern
care to their patients and submit accurate claims of coding errors such as upcoding or unbundling.
for payment while upholding the highest ethical Unbundling is the practice of using multiple
standards. While most healthcare professionals procedure codes to bill for the various individual
strive to meet these expectations, there are some steps in a single procedure rather than using a sin-
dishonest healthcare professionals who illegally gle code that includes all of the steps of the com-
exploit the healthcare system for personal gain. prehensive procedure code. For example, a code
In addition to dishonest healthcare professionals, for a complete laboratory blood count should be
there are healthcare organizations that have poor used rather than individual codes for a red blood
n.
billing policies and procedures or improperly count, a white blood count, a hematocrit, and all
tio
trained billing and coding staff resulting in unin- the other tests that make up a complete blood count.
ia
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tentional billing errors. These instances have created Unbundling can result in the healthcare organiza-
ss
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the need for laws to combat fraud and abuse to tion receiving an overpayment and is considered
en
ensure proper reimbursement. abuse as it violates coding guidelines.
em
While the terms fraud and abuse are often used to- Upcoding is the practice of assigning diagnostic
ag
gether, there is a distinct difference between them. or procedural codes that results in higher payment
an
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Fraud is “when someone intentionally executes or rates than the codes that actually reflect the servic-
n
attempts to execute a scheme to obtain money or io
es provided to patients; for example, billing with
at
property of any healthcare benefit program” (CMS the procedure code for an open procedure when
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2017c, 4). The key word in this definition is inten- the procedure was actually laparoscopic. This
In
tionally. Some examples of fraud are the following: difference in surgical approach would provide
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the healthcare provider with an overpayment—a

Billing for services not provided to the
H
●●
higher reimbursement than deserved. Overpay-
an
patient
ic
ments typically occur in the following situations:

er
Falsely documenting in health records,

Am
●●
such as documenting a higher severity of ●● There is insufficient documentation to

e
th
diagnosis or completely falsifying diagnoses; support the amount billed

by
for example, a diagnosis of malnutrition that A treatment or service does not meet the
20
●●
does not meet the definition of or have the

20
definition of medically necessary (medically

©
supporting health record documentation of necessary is defined as the likelihood that a

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severe protein calorie malnutrition should

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healthcare service will have a reasonably

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not be coded to this level of severity as

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beneficial effect for the patient)

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additional reimbursement may result from ●● Duplicate payments for the same service are
this incorrect coding
made
●● Directing others to falsely document or bill ●● There are administrative or processing errors
●● Paying for or getting paid for referring patients (CMS 2017a)
Abuse occurs “when healthcare providers or sup- Noncovered services are healthcare services that
pliers perform actions that directly or indirectly are not reimbursable under a healthcare plan.
result in unnecessary costs to any healthcare ben- These services vary by medical plan. Some exam-
efit program” (CMS 2017c, 4). In the case of abuse, ples of healthcare services that might be consid-
the healthcare provider is entitled to payment ered noncovered are cosmetic surgery such as
but requests more reimbursement than he or she liposuction and breast augmentation. Infertility
deserves. Mistakes happen in the course of doing treatments, weight loss programs, mental health
AB103118_Ch16.indd 500 2/6/2020 5:50:11 PM

services, and dental services are treatments and resources. Bending the rules is the next level of
procedures that are not typically covered by medi- improper payments, and meets the definition of
cal insurance. abuse, since it demonstrates that a healthcare pro-
Another related term is waste. Waste is the over- vider consistently chooses to bill in the provider’s
utilization or inappropriate utilization of services favor when billing rules allow for some interpre-
and the misuse of resources. Waste is typically not tation. Intentional deception is clearly the most
a criminal or intentional act. Examples of waste in- serious and highest level of improper payments
clude having too many supplies on hand and be- since this reflects a healthcare provider’s purposeful
ing required to destroy them when the expiration incorrect billing to result in improper payments,
date passes or ordering more ancillary tests than falling under the definition of fraud. This progres-
may be required to treat the patient (CMS 2018b). sion is shown in figure 16.1.
Any inappropriate payment made to a health- The risk for fraud and abuse exists in all orga-
n.
care organization for any reason is considered nizations so compliance measures must be taken.
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an improper or inappropriate payment. Improp- Compliance is the process of establishing an or-
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er payments are discussed later in this chapter. ganizational culture that promotes the prevention,
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Mistakes will occur in the process of billing for detection, and resolution of instances of conduct
en
healthcare services and may result in an incorrect that do not conform to federal, state, or private
em
payment to a healthcare organization. A mistake payer healthcare program requirements or the
ag
is considered the most innocent of improper pay- healthcare organization’s ethical and business pol-
an
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ments since there is no intent to falsely receive an icies. In other words, compliance actively prevents
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incorrect payment from a healthcare plan. The io
fraud and abuse. This chapter will review fraud
at
next level in the spectrum of improper payment and abuse regulations and initiatives related to
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is inefficiencies. This is a more serious type of er- coding and billing fraud and abuse. Programs and
In
ror that occurs when billing insurance companies tools used by healthcare organizations to ensure
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since ongoing inefficiencies may demonstrate a accurate coding and billing, such as compliance
H
lack of effort to bill correctly, resulting in improper and clinical documentation integrity programs,
an
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payments and waste of insurance plan staff and will also be discussed.
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Figure 16.1 Progression, types, and causes of inappropriate payments

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by
Type of
20
Mistake Inefficiencies Bending the rules Intentional deception

inappropriate payment
20
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Cause of Error Waste Abuse Fraud

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inappropriate payment
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yr
Accidentally charging Failure to run Hospital coders that Purposely selecting

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Example
the wrong patient for software edits on a consistently select the wrong principal
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a physician office visit claim, which results in the higher paying diagnosis to upcode
the following: the DRG when more than claims
insurance company one DRG is
rejects the claim, the acceptable to bill
healthcare
organization has to
rebill, and the
insurance company
reprocesses the
claim—a waste of
staff time and
resources
Moderate Serious
Source: CMS 2014a.
AB103118_Ch16.indd 501 2/6/2020 5:50:12 PM

Federal Regulations and Initiatives

While there is no way to accurately available to the citizens of the United States. Fraud
measure how much healthcare fraud exists in the and abuse of federal funds earmarked for health-
United States, from the audits conducted by the care puts beneficiaries’ health and welfare at risk
federal government and commercial insurance as monies paid for fraudulent claims reduce the
companies, billions of dollars are involved. With amount of funds available for legitimate healthcare
the federal government as the largest payer of services. A discussion of the federal government
healthcare services, federal laws, programs, and regulations and initiatives for the control and pre-
enforcement are necessary to protect the monies vention of healthcare fraud and abuse follows.
n.
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Office of the Inspector General
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The Office of Inspector General (OIG) The OIG is organized into five divisions, catego-
en
works to combat fraud, waste, and abuse and to im- rized as follows and illustrated in figure 16.2.
em
prove the efficiency of Health and Human Services
ag
1. Office of Audit Services. The Office of Audit
(HHS) programs (OIG 2019a). The HHS is the prin-
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Services is responsible for auditing HHS
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cipal agency of the US federal government that is re-
programs to ensure the agencies and their
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sponsible for protecting the health of all Americans io
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contractors are meeting their responsibilities.
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and providing essential human services. The HHS

Their findings can be used in criminal and
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reports to the OIG. The mission of the OIG is to pro-

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other investigations.
tect the integrity of the HHS programs as well as the
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2. Office of Evaluation and Inspections. This

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health and welfare of individuals enrolled in federal

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division evaluates HHS programs to make

programs such as Medicare and Medicaid. The OIG
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them more effective and to prevent fraud,

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is responsible for monitoring Medicare and Medi-

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abuse, or waste within HHS.

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caid, which provide health insurance to one in three

Americans at the cost of hundreds of billions of tax- 3. Office of Management and Policy. This division
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payer dollars annually. The sheer size of Medicare ensures that the OIG has the resources that
by
they need to fulfill their responsibilities.

20
and Medicaid make these programs vulnerable

20
to criminals. One of the vital roles of the OIG is to 4. Office of Investigations. This is the OIG d
ivision
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keep these programs less prone to waste, fraud, and responsible for monitoring and enforcing
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abuse. The OIG has the federal government’s larg- fraud and abuse regulations in HHS pro-
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grams, operations, and beneficiaries. These

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est team of auditors and is the premier healthcare

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law enforcement agency. Every year the OIG inves- efforts include operating the fraud hotline
tigates, prosecutes, and convicts hundreds of indi- where individuals can call and report fraudu-
viduals who misuse or steal taxpayer dollars. This lent activities, working with the Department
results in the annual recovery of billions of dollars of Justice (DOJ) to coordinate fraud investiga-
for the federal government (OIG 2019a). tions, protecting the Secretary of HHS and
The majority of the OIG’s resources go to the participating in public safety and security
oversight of Medicare and Medicaid, but also ex- management activities, and working to enforce
tend to programs under other HHS institutions, and update the fraud and abuse efforts of the
including the Centers for Disease Control and Pre- OIG to continue to improve programs.
vention (CDC), the, National Institutes of Health 5. Office of Counsel to the Inspector General. The
(NIH), and the Food and Drug Administration Office of Counsel to the Inspector General
(FDA) (OIG 2019a). provides legal advice to the OIG (OIG 2019a).
AB103118_Ch16.indd 502 2/6/2020 5:50:12 PM

Figure 16.2 OIG organizational structure
AB103118_Ch16.indd 503
Inspector General
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Principal Deputy
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20
Deputy Deputy Inspector General
Deputy Inspector General Chief Counsel to Deputy Inspector General
for Evaluation and for Management and Chief of Staff
by Inspector General
to Audit Services the Inspector General for Investigations
Policy
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Assistant Inspector Assistant Inspector Assistant Inspector Assistant Inspector Assistant Inspector
er
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General for General for Legal General for Evaluation General for General and Deputy
Policy
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Audit Services Affairs and Inspections H Investigations Chief Financial Officer
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Assistant Inspector Assistant Inspector Assistant Inspector Assistant Inspector Assistant Inspector
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General for General for Legal General for Evaluation In General for General and Chief Chief Medical Officer
Audit Services Affairs and Inspections Investigations
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r Information Officer
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Assistant Inspector Assistant Inspector
io Assistant Inspector Senior Counselor for
General for General for
n General and Chief Health Information
Audit Services Investigations
M Data Officer Technology
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Assistant Inspector em
General for Chief Healthcare
Economist
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Audit Services tA
Source: OIG n.d.a. ss
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2/6/2020 5:50:13 PM
There are a number of federal regulations and ●● Violation of law

initiatives used to combat fraud and abuse. These ●● Significant mismanagement or waste of
include the False Claims Act, Whistleblower federal funds
Protection Act (WPA), Anti-Kickback Statute, Stark ●● Abuse of authority
Law, Balanced Budget Act of 1997, Health Insurance
Portability and Accountability Act (HIPAA), Health
●● Significant danger or risk to the public
Care Fraud Prevention and Enforcement Action health and/or safety
Team, OIG, recovery audit contractor, quality im- Further, the WPA also prevents any personnel
provement organizations, Recovery Audit Contrac- actions to be taken against a federal employee
tor, and Quality Improvement Organizations. or applicant for reporting one of these situations
or actions. So, if an employee of a federal employ-
False Claims Act er, such as a Veterans hospital, experiences retali-
n.
Individuals have been committing crimes of fraud ation for reporting abuse, violation, or waste of
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for hundreds of years. In fact, the False Claims Act, federal funds, this would be unlawful.
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also known as Lincoln’s Law, was passed during
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the Civil War to address the fraudulent billing of Anti-Kickback Statute
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Union Army supplies. The False Claims Act allows The Anti-Kickback Statute dictates that physicians
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penalties to be awarded to those who knowingly cannot receive money or other benefits for refer-
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submit fraudulent claims to the US government for ring patients to a healthcare organization (OIG
an
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payment. “Knowingly” does not only mean that n.d.b). For example, a hospital cannot give a physi-
the individual has actual knowledge of the fraud- n
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cian $100 for every patient referred to the hospital for
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ulent claim but also includes deliberately being
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care. Frequently, physicians are owners or co-owners

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ignorant regarding the fraudulent claim and disre- of healthcare organizations such as lab or diagnostic
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gard of the fraudulent claims (FindLaw 2019). The

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testing facilities, so they need to be careful about re-

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law has been the foundation upon which fraud and ferring patients to these facilities. There are some ex-
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abuse efforts have been based, with revisions and ceptions to when a physician is lawfully permitted to
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other legislation added to it over the years. One of refer patients to organizations with which they have
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the key components of the False Claims Act is qui a financial interest; however, these are typically only
tam. Qui tam is the whistleblower provisions of
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in geographical areas that are sparsely populated.

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the False Claims Act—private persons, known as

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relators, may enforce the Act by filing a complaint, The Stark Law
20
20
under seal (meaning kept secret), alleging fraud The Physician Self-Referral Law, otherwise known
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committed against the government. For example, as the Stark Law, builds on the Anti-Kickback Stat-
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if a coder is told to assign codes in violation of cod- ute and prohibits a physician from referring pa-
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ing rules, then he or she can anonymously report tients to a business in which he or she or a member
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the healthcare organization for fraud. The indi- of the physician’s immediate family has financial
vidual who submits the allegations can receive as interests (OIG n.d.b.). For example, if the physi-
much as 30 percent of the penalties collected by cian owns an imaging center, he or she cannot refer
the federal government (DOJ 2018a). a patient for images such as x-rays at that location.
If he or she does refer a patient to the imaging cen-
Whistleblower Protection Act ter, then the physician cannot receive Medicare
A whistleblower is someone who reports wrong- or Medicaid funding. There are exceptions to the
doing by an organization or individual. The Whis- Stark Law; for example, healthcare organizations
tleblower Protection Act (WPA) protects federal can help physicians with limited costs of imple-
employees and applicants for federal jobs when mentation of an electronic health record (EHR),
they report situations or actions that they believe and in areas of low population per geographic
qualifies as one of the following situations: area such as a rural area, patient referrals may be
AB103118_Ch16.indd 504 2/6/2020 5:50:13 PM

made to physician-owned or family-owned busi- in preventing fraud as well as how to report fraud
nesses if there are no other options available. when they identify it. It also gives Medicare benefi-
ciaries the right to receive a copy of their detailed bill
Balanced Budget Act of 1997 and the from the healthcare provider (BBA 1997).
Exclusions Program
The Exclusions Program is a database of individuals Health Insurance Portability
and healthcare organizations that are not permitted and Accountability Act
to participate in or receive payment from any federal The Health Insurance Portability and Accounta-
healthcare program due to past healthcare-related bility Act (HIPAA) of 1996 addresses many topics
crimes they committed against the federal govern- such as privacy and security of health informa-
ment. The Balanced Budget Act of 1997 (BBA) is the tion as well as fraud and abuse. HIPAA created
law that gives the OIG the authority to exclude in- a joint venture between the HHS and the DOJ
n.
dividuals and healthcare organizations that are con- (HHS 2009). HIPAA also increased the civil mone-
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victed of healthcare-related crimes from receiving tary penalty for fraud and abuse convictions. The
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payment from any federal healthcare program, in- penalty was increased from $2,000 per incident
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cluding Medicare and Medicaid programs. In addi- to $10,000 per incident plus three times the total
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tion, the BBA does not allow healthcare providers or amount of the fraudulent claims (OIG 1998). Every
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healthcare organizations to hire or contract with some- year the penalties are increased to account for in-
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one on the excluded database. Healthcare providers flation. Incidents occurring after January 29, 2018,
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and healthcare organizations that hire or contract increased to $11,463 per incident (OIG 2019c). For
n
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with an excluded individual or healthcare organiza- additional information on HIPAA, refer to chapter 9,
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tion are in violation of law and may be penalized or Data Privacy and Confidentiality, and chapter 10, Data
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fined. The terms of an individual’s or healthcare or- Security. Figure 16.3 is an example of how civil
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ganization’s exclusion is based on a number of factors monetary penalties work. It is clear from this ex-
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such as whether the crime is a felony or misdemeanor, ample that committing fraud and abuse can have
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whether this is a first conviction, the scope of the significant monetary consequences for individuals
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crime, and so forth. However, mandatory terms for a and healthcare organizations.
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felony begin at five years of exclusion from the Med- Healthcare providers must make a concerted
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icare and Medicaid programs and three years for a effort to comply with best practices regarding reim-
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by
misdemeanor. Reinstatement of the excluded individ- bursement and monitoring for fraud and abuse. Best
20
ual or healthcare organization is not automatic at the practices include monitoring and auditing (covered
20
end of the time period, rather the individual or organi- later in this chapter). When HHS determines the
©
zation must apply to the OIG for reinstatement to par- civil monetary penalties for the instance of fraud or
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ticipate in federal healthcare programs (OIG 2019b). abuse, the level of efforts that a healthcare provider
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The BBA also permits Medicare to refuse to allow or healthcare organization has put into fraud and
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convicted felons into the Medicare program and ed- abuse prevention is considered. These efforts can be
ucates Medicare beneficiaries on how they can assist grouped into the three categories that follow.
Figure 16.3 Example of civil monetary penalties
ABC Hospital submitted 150 claims where they unbundled laboratory charges. They were overpaid $100 on each claim.
If the OIG considered this to be fraud or abuse, the civil monetary penalty/fine would be three times the overpayment plus
$11,463 for each incident.
150 claims x $100 overpayment = $15,000
3 x total amount of overpayment = $15,000 x 3 = $45,000
$11,463 x 150 claims (each claim is considered an incident) = $1,719,450+45000
ABC Hospital would be fined $1,764,450.
Source: Adapted from OIG 2019c and OIG n.d.b.
AB103118_Ch16.indd 505 2/6/2020 5:50:13 PM

1. Reasonable cause. It would be unreasonable fraudulent coding and billing of physical therapy
to expect the healthcare provider to comply services that were not done and for falsely docu-
with the requirements of HIPAA menting in health records (OIG 2019d).
2. Reasonable diligence. The healthcare
provider has taken reasonable actions Recovery Audit Contractor
to comply with the legislative requirements Recovery Audit Contractor (RAC) is a governmen-
3. Willful neglect. Intentionally failing to tal program whose goal is to identify improper
comply with or being indifferent to the payments made on claims of healthcare services
HIPAA provisions (45 CFR 160.401) provided to Medicare beneficiaries. Improper pay-
ments may be overpayments or underpayments.
Health Care Fraud Prevention RACs review claims on a post-payment basis for
and Enforcement Action Team the purposes of detecting and correcting past
n.
improper payments so that Centers for Medicare
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Since 2009 the Health Care Fraud Prevention and
and Medicaid Services (CMS), fiscal intermedi-
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Enforcement Action Team (HEAT) and the Med-
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aries, and Medicare Administrative Contractors
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icare Fraud Strike Force teams, which are a com-
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(MACs) can implement actions that will prevent
ponent of HEAT, have worked to fight healthcare
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future improper payments (CMS 2019a).
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fraud. HEAT is one of many programs used to
RAC was established as a demonstration project
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combat Medicare fraud. It combines the efforts of
to test the Medicare program on payments made to
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HHS, OIG, and the DOJ (DOJ 2016).
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healthcare providers. The program was found to
The Medicare Fraud Strike Force teams consist of
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be effective by identifying over one billion dollars in
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local, state, and federal law enforcement individuals
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overpayments and so it was implemented across

who combine their resources and data analytics to
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the country as per the Tax Relief and Health Care

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identify instances of fraud. Strike forces are located

Act of 2006. Medicare contracted with several
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in specific areas of the country where instances of

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organizations to conduct the audits required by the

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fraud are high. Strike forces exist in Miami, Florida;

program (OIG 2013). The RAC program has signifi-
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Los Angeles, California; Detroit, Michigan; Hous-

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cantly impacted the workload of health informa-

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ton, Texas; Brooklyn, New York; Baton Rouge and

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tion management (HIM) departments primarily

New Orleans, Louisiana; Tampa and Orlando,
in the functions of release of information, coding,
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Florida; Chicago, Illinois; Dallas, Texas; Washington,

and auditing. The RAC program requests copies of
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DC; Newark, New Jersey, Philadelphia, Pennsylva-

health records to conduct the post-payment audits
20
nia; and the Appalachian Region. The Appalachian

20
so the release of information staff in hospitals and

strike force, the most recent strike force to be added,
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other providers have seen a tremendous increase in

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was established in October 2018 to combat illegal

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workload, some receiving hundreds of requests per

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opioid prescriptions. HEAT and the strike forces have

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year. The increased scrutiny of coding with the RAC

been successful in their efforts to identify fraud and to
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audits has providers focused on coding practices

recoup monies for the federal government. As of Janu-
and accuracy, resulting in more internal audits and
ary 2018, strike force statistics were as follows:
education of coders, adding to their workload.
●● Criminal Actions Identified: 1,938 A request for additional documentation from
●● Indictments Made: 2,498 a healthcare provider to support the submitted
claim is an additional documentation request
●● Money Recouped: $3,005,849,223 (OIG 2019d)
(ADR). ADRs are sent to providers on a 45-day cy-
Many fraudulent activities involve kickbacks, cle. A baseline annual ADR limit is established for
bribes, and unnecessary opioid prescriptions as each healthcare provider, such as a hospital. Table
well as fraudulent coding and billing. For exam- 16.1 provides an example of how to calculate ADR.
ple, in November 2018, two clinic workers were Most affected are HIM departments that handle
sentenced for their roles in a $5.9 million case of the health record requests for an entire healthcare
AB103118_Ch16.indd 506 2/6/2020 5:50:13 PM

enterprise. Enterprise is a term that describes all of begin with the automated review process and con-
the healthcare providers within one company. For vert to a semi-automated review when providers
example, an enterprise may consist of a hospital, opt to submit supporting documentation to sub-
multiple physician offices, ambulatory surgical stantiate the claim. A complex review involves the
centers, outpatient therapy sites, a rehabilitation fa- review of health records by a qualified healthcare
cility, and a long-term care facility, all of which are coder or clinician as the type of review warrants.
owned by one company. An HIM department that If the RAC review identifies an improper pay-
handles all HIM functions for an enterprise would ment, overpayment or underpayment, the healthcare
experience a significant increase in workload since provider is sent an informational l etter that describes
they would be handling health record requests for the RAC determination. Letters describing com-
all of the healthcare providers in the enterprise. plex review findings are more detailed than those
HIM departments of healthcare providers that have describing automated and semi-automated review
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a higher Medicare payment denial rate also experi- determinations and also include information to as-
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ence a higher number of ADRs, because CMS assist providers in avoiding future billing errors. The
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sociates a high payment denial rate with potential letters regarding overpayments include instruction
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coding and billing errors and therefore increases to refund the improper payment (CMS 2016a).
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the number of RAC audits for these healthcare or- The healthcare organization has the right to ap-
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ganizations to ensure compliance as noted above. peal the request for the refund and needs to make
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CMS publishes the areas that are the focus of a decision whether or not to appeal the RAC find-
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RAC audits and those that are being proposed for ings. An appeal is a request for reconsideration of
future audits. HIM departments should consider n
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a denial of coverage or rejection of claim decision.
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conducting coding audits prior to billing claims in Table 16.2 provides some potential reasons for ap-
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the areas that RAC audits are targeting with the pealing or not appealing the RAC findings.
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goal of avoiding coding and billing errors. Cod- The five levels in the appeal process are displayed
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ing audits are good professional practice because in figure 16.4 and described as the following:
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they not only potentially improve the accuracy of

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1. Redetermination. A redetermination is the first

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claims processing but also provide data for health

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level of appeal after the initial determination

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information managers regarding areas of educa-

tion needed for coders. on a claim. It is a look at the claim by MAC
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RACs utilize three review processes to identify staff not involved in the initial determination.
by
improper payments. These review processes are 2. Reconsideration by a Qualified Independent Contrac-
20
20
automated, semi-automated and complex. Data tor (QIC). If the redetermination does not rule
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analysis of claims data is conducted during the au- in their favor, the healthcare organization has
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the right to appeal to the qualified independent

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tomated review process. Semi-automated reviews

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Table 16.1 Calculation of Additional Documentation Request (ADR)

Rule Example Calculation
This baseline ADR number is based on A hospital that billed and received payment 22,530 claims x 0.005, which is 112.65, the
the number of Medicare claims paid for 22,530 Medicare claims in a previous annual ADR limit.
to the hospital in a previous 12-month 12-month period would not receive more 112.65/8 = 14.08
period multiplied by one half of one than 14 ADRs in a 45-day period.
112 is the limit of ADRs for the year, 8 is
percent (0.5%).
the number of 45-day cycles in a year. With
rounding, the maximum number of ADRs in
a 45-day cycle is 14.
A hospital bills and receives payment for The ADR limit for a 45-day cycle is 159.
255,000 Medicare claims in a previous (255,000 x 0.005 =1,276; 1,276/8 = 159).
12-month period.
Source: CMS 2018a.
AB103118_Ch16.indd 507 2/6/2020 5:50:13 PM

Table 16.2 Appealing RAC findings

Reasons to appeal after review of the RAC findings Reasons not to appeal after review of the RAC findings by the
by the coding manager or physician reviewer coding manager or physician reviewer
The healthcare provider’s review of the health record When the healthcare provider’s review of the health record referenced
referenced in the demand letter does not match the in the demand letter matches the findings of the RAC audit; there
findings of the RAC audit. would not be any point to an appeal and would be a waste of the
organization’s time and money.
The amount of repayment specified in the demand letter is The amount of repayment specified in the demand letter is such a low
significant and the staff time involved in an appeal will be amount that it would not be worth the healthcare organization’s time
time well spent and money to file an appeal as appeals can be very labor intensive in
terms of staff reviewing the record
Source: ©AHIMA
Figure 16.4 Five levels in the RAC Appeal Process
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Administrative law Appeals council Final judicial

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Redetermination Reconsideration
judge review review
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by
20
20
©
Source: ©AHIMA.
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contractor, an outside organization contracted 5. Judicial review in US District Court. The final
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by Medicare to audit the reconsideration. level of appeal is to the US District Court

3. Administrative Law Judge (ALJ) Hearing or (CMS 2017b).
Review by Office of Medicare Hearings and
Appeals (OMHA). There are two options in the Quality Improvement Organization
third level of appeal, a hearing by an adminis- A Quality Improvement Organization (QIO) is a
trative law judge or a review by the Office of group of health quality experts, clinicians, and con-
Medicare Hearings and Appeals (OMHA). sumers organized to improve the quality of care
4. Review by the Medicare Appeals Council. The delivered to people with Medicare and is one of
fourth level of appeal is a Council review, the largest federal programs that is dedicated to
which is conducted by the HHS Departmental increasing the quality of care for Medicare ben-
Appeals Board (DAB) Medicare Operations eficiaries. QIOs have gone through a number of
Division. transitions since their inception in 1972 when they
AB103118_Ch16.indd 508 2/6/2020 5:50:14 PM

were known as Medicare Professional Standards and they request copies of health records from the
Review Organizations (MPSRO). In 1982, the MP- HIM department. Healthcare organizations should
SROs transitioned to Peer Review Organizations analyze the QIO requests for patterns related to
(PROs). In 2002, the PROs became Quality Improve- specific diagnosis-related groups, diagnoses, pro-
ment Organizations (QIOs) (QIO 2019a) and most cedures, and physicians to identify opportunities
recently, in 2014, the QIOs went through another for education and improvement.
restructuring. With each evolution, the quality of
care for Medicare beneficiaries has been the focus Merit-Based Incentive Payment System
of the mission. The 2014 restructuring of the QIOs Merit-Based Incentive Payment System (MIPS),
separated them into two types of QIOs: Beneficiary which includes the program that was originally
and Family Centered Care (BFCC)-QIOs and Qual- known as Meaningful Use (MU) is a regulation that
ity Innovation Network (QIN)-QIOs. The (BFCC)- was issued by CMS on July 28, 2010, outlining an
n.
QIOs handle the Medicare beneficiary complaints incentive program for eligible professionals (EPs),
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and quality of care reviews such as, appeals of a hospitals, and critical access hospitals participat-
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healthcare provider’s decision to discharge a Medi- ing in Medicare and Medicaid programs that adopt
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care beneficiary from a hospital or discontinue oth-
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and successfully demonstrate meaningful use of
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er types of services; or review of validity of hospital certified EHR technology (ONC 2019).
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diagnosis and procedure coding data completeness, MIPS was a three-stage program with specific
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adequacy, and quality of care; and appropriateness requirements for the use of certified EHR technol-
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of prospective payments for outlier cases and non- ogy for each stage. Each stage became gradually
emergent use of the emergency department. While n
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more sophisticated in the demands of the EHR.
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the RAC audits focus on payments, the QIO au-
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EPs were not mandated to implement certified EHR

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dits focus on the quality of patient care. technology but those who chose not to implement
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There are fourteen (14) regions of Quality In- certified EHR technology forfeited the incentive
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novation Networks (QIN-QIOs). Each QIN-QIO payments and realized reduced Medicare payments
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region encompasses between two to six states, at the end of the program (ONC 2019).
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depending on population size. The QIN-QIOs are In 2015, with the introduction of the Medicare Ac-
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composed of Medicare beneficiaries, healthcare cess and CHIP Reauthorization Act (MACRA), MU
providers, and community representatives whose was renamed the Medicare EHR Incentive Program
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goals are to identify ways to increase patient safe- (later renamed Promoting Interoperability Pro-
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ty, make communities healthier, better coordinate gram), and was transitioned to become one of the
20
20
post-hospital care, and improve clinical quality three components of the new Merit-Based Incentive
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by engaging in data-driven initiatives, such as Payment System (MIPS), which itself is part of MA-
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“reducing disparities in access and quality for pri- CRA. MIPS took the existing CMS quality programs,
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ority populations, increasing use of health informa- including meaningful use, the Physician Quality
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tion technology, reducing adverse events related to Reporting System, and Value-Based Payment Modi-
healthcare-acquired infections, increasing care fiers and consolidated these multiple, quality pro-
efficiency by promoting value within the health grams into a single program to improve quality care
system, and improving the quality of life for pa- (ONC 2019). Figure 16.5 illustrates the structure of
tients nearing the end of life by alleviating pain MIPS. (Quality improvement is discussed in more
with palliative care measures” (QIO 2019b). detail in chapter 18, Performance Improvement.)
Because of their role in monitoring coding qual- Timely access to health information is key in
ity, QIOs are an important part of Medicare’s monitoring fraud and abuse. With healthcare pro-
fraud and abuse efforts. QIOs are required to re- viders implementing EHRs health data will be
port any evidence of fraud that they identify. Ob- more readily available for analysis by the OIG,
viously, the QIOs must review health records to Medicare Fraud Strike Force, and others involved
be able to carry out the duties listed previously in fighting fraud and abuse.
AB103118_Ch16.indd 509 2/6/2020 5:50:14 PM

Figure 16.5 Merit-Based Incentive Payment System (MIPS)
VBPM
Value-Based
Payment Modifier
MIPS
Merit-Based
Incentive
Payment
System
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PQRS Promoting
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Physician Quality Interoperability
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Reporting System Program
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Source: ONC 2019
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1. A hospital’s baseline ADR limit is adjusted by which of the following?

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a. A percentage (%) that is set by CMS on a quarterly basis

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b. The hospital’s denial rate

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c. The focus topics established by RAC on an annual basis

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d. The number of claims billed by the hospital in a previous 12-month period

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2. Identify the organization that is responsible for coordinating the Medicare fraud programs.
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a. Quality improvement organizations

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b. Recovery audit contractor

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c. Office of Inspector General

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d. The Joint Commission

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3. Identify which of the federal fraud and abuse laws prohibits a physician’s referral of designated health services for
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Medicare and Medicaid patients if the physician has a financial relationship with the entity.
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a. False Claims Act

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b. Anti-Kickback Statute
c. Stark Law
d. HIPAA
4. Identify an example of fraud.
a. Accidentally overbilling for healthcare services
b. Charging an inappropriate amount for healthcare services or supplies
c. Knowingly submitting bills for healthcare services not provided
d. Unbundling codes
5. Identify an example of abuse.
a. Billing for healthcare services
b. Knowingly charging an inappropriate amount for healthcare services or supplies
c. Unbundling codes
d. Consistently upcoding to receive higher payments
AB103118_Ch16.indd 510 2/6/2020 5:50:15 PM

Compliance Program
Every healthcare organization should typically reports directly to the governing
have a compliance program. A compliance program board. The governing board has ultimate re-
is a set of internal policies and procedures that a sponsibility of compliance for the healthcare
healthcare organization puts into place to comply organization. The compliance committee will
with applicable state and federal laws. An effective also review the OIG work plan and then de-
compliance program can enhance a healthcare termine what items they want to include in
organization’s operations, improve quality of care, their compliance activities and review for the
reduce overall costs, as well as reduce the organi- upcoming year. This plan will change from
zation’s liability with regards to fraud and abuse. year to year as the OIG focus and the needs of
The compliance program can help the healthcare the healthcare organization change.
n.
organization identify problems and correct them 3. Educating staff. It is imperative that all staff be
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before they become systemic and costly. trained in compliance policies, procedures,
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There are seven basic elements that should be
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and standards of conduct as they apply to
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included in an effective compliance program. They their position in the healthcare organization.
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are the following: The level of knowledge and competency of
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understanding of compliance varies depending
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1. Policies, procedures, and standards of conduct.
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A healthcare organization should put all on the position within the healthcare organ-
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ization. For example, the compliance officer
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policies, procedures, and standards of conduct io
needs to know everything about compliance
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related to their compliance program in writing.
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in order to educate and answer questions

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These are discussed later in this chapter.

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within the Health Information Management

2. Identifying a compliance officer and committee.
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Department. A coder needs to understand

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The chief compliance officer and compliance

compliance in regards to coding and re-
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committee are responsible for the overall

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imbursement, whereas an insurance claim

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compliance program for the healthcare

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specialist needs a more basic knowledge of

organization. Besides the chief compliance
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compliance compared to a coder. This training

officer, the compliance committee should
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should occur, at a minimum, in their orienta-

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consist of representatives from the health-

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tion training and on an annual basis. This is

care organization’s departments that have
20
discussed later in this chapter.

20
the most responsibility for monitoring com-

4. Establish communication channels. There should
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pliance within the healthcare organization.

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These departments would likely include be methods in place for employees to report
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HIM, revenue cycle management, patient fraud and abuse; this can be a confidential
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hotline or comment box where employees can

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billing, medical staff, and patient accounting.

The privacy officer, general counsel, and risk report fraud and abuse without fear of reprisal.
management should also be represented on 5. Perform internal monitoring. Healthcare organi-
the committee. A healthcare organization may zations must be diligent to ensure compliance
also want to include members from adminis- with policies and procedures such as through
tration such as the chief executive officer or the use of audits and data analysis. Audits are
chief operations officer as the support and in- discussed later in this chapter.
volvement of upper management signifies that 6. Penalties for noncompliance with standards.
the healthcare organization has a high level There should be appropriate consequences for
of commitment to compliance. The healthcare employees who do not comply with policies
organization may consider adding a mem- and procedures and who participate in fraud
ber of the governing board to the compliance and abuse activities. These consequences
committee since the compliance committee might include some form of disciplinary
AB103118_Ch16.indd 511 2/6/2020 5:50:15 PM

action or termination, depending on the se- of the findings and creation of audit and
verity of the employee’s action. work plans. For example, the supervisor of
7. Taking immediate corrective action when a problem coding should not conduct the risk analysis
is identified. Healthcare organizations must take of the coding department and staff but
action when fraud and abuse are identified should be an integral part in establishing
such as completing an internal review to de- work plans and audit schedules for
termine where the problem first occurred and eliminating or controlling the risks of fraud
implementing specialized training on problem and abuse that are identified in the results of
areas; failure to do so could increase their risk the risk analysis (CMS 2013).
of fraud and abuse accusations (OIG n.d.). ●● Education of employees and medical staff of the
These elements of an effective compliance pro- healthcare organization. Laws and regulations
gram as they relate to fraud and abuse prevention change regularly. A healthcare organization’s
n.
employees and medical staff must be kept
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strategies and audits are discussed in the following
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sections. up to date on all changes in laws and
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regulations that impact the work they do.
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Employees and medical staff members must
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Fraud and Abuse Prevention Strategies also understand their role in preventing
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fraud and abuse and what to do if they are
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Healthcare providers can use a number of preven-
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tion strategies to protect themselves from fraud requested to act in a fraudulent manner.
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and abuse allegations. These strategies include the Anyone that plays a role in the coding
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and billing of healthcare services such as
following:
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billers, coders, physicians, case managers,

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●● Policies and procedures. Policies and documentation improvement specialists,

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procedures are a critical part of a compliance

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and others must stay informed of annual

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program and tell “who” and “what” should changes in codes and coding guidelines.
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be done to combat fraud and abuse. Policies

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A component of compliance training is

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should include internal coding procedures, typically a part of a healthcare organization’s

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how and when to write physician queries, orientation programs for newly hired
billing practices, and audits. Healthcare
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employees and newly appointed medical

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providers that have written policies and

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staff members. All employees need basic

procedures in place and are diligent about
20
information about compliance such as

20
enforcing these policies and procedures with what constitutes fraud and abuse, how to
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their staff demonstrate a commitment to report any concerns, annual compliance

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compliance. Not only is compliance the right training for rules and regulations, rights
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and ethical thing to do but it may also save and responsibilities, incident reporting
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a provider from higher penalties and fines if process, and standards. More detailed and
abuse is identified. complex compliance training should be
●● Risk analysis. Healthcare providers should conducted for employees whose positions in
regularly conduct a risk analysis, which the healthcare organization require a more
is the process of identifying areas of in-depth knowledge and understanding
compliance risk. The risk analysis can then of the rules and regulations surrounding
be used to establish work plans and auditing healthcare compliance. For example,
schedules with the goals of eliminating employees involved in the revenue cycle
or controlling the risk of fraud and abuse. should receive education regarding the
Individuals should not conduct a risk False Claims Act and coders should receive
analysis of their own areas of responsibility; frequent education regarding current coding
however, they should participate in a review guidelines and results of coding audits.
AB103118_Ch16.indd 512 2/6/2020 5:50:15 PM

●● Routine review of coding and billing reports. education of employees, medical staff,
There are billing and coding reports that contracted organizations, and so forth. In the
healthcare organizations use on a routine health information world, the phrase, “if it
basis to gauge the status of the billing and wasn’t documented, it wasn’t done” is well-
coding processes. A routine review of these known and applies to compliance activities
coding and billing reports can be useful as well. Providers will want to maintain a
in the identification of significant changes thorough, complete record of documentation
in coding and billing practices as they activities to prove to auditors and surveyors
could show changes in the most frequently that they are committed to and striving to
assigned codes or other significant changes ensure compliance within their healthcare
in coding practices. Identified coding organization.
changes may or may not be justified. For ●● Share successes. Healthcare providers may
n.
example, there may have been a change want to internally share their successful
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in coding rules that would justify the use
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compliance efforts by publishing
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of different codes. A consultant may have dashboards, scorecards, self-assessment
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given the healthcare organization improper
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tools, and other mechanisms to demonstrate
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information regarding coding, billing, or the healthcare provider’s commitment to
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other reimbursement practices that resulted compliance. This will keep compliance in
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in changes that should not have occurred.
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the minds of all employees. Obviously,
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Another example is reviewing coding and senior management and legal counsel
billing reports for the frequency of code use n
io should review the data that are shared to
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may identify codes that are being over- or
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ensure confidential information was not

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underused, identifying topics for continuing inadvertently published (CMS 2013).

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coder education. The data that can be

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reviewed are discussed later in this chapter. Audits

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●● Clinical documentation strategies. A strong An audit is a function that allows retrospective

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clinical documentation integrity (CDI)

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reconstruction of events, including who executed

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program is important to fighting fraud and the events in question, why, and what changes
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abuse through the focus on quality and were made as a result. An audit is also an indepen-
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accuracy. CDI is discussed later in this chapter.

by
dent review of electronic system records and activ-

20
An example of a documentation issue is the ities in order to test the adequacy and effectiveness
20
use of the copy and paste functionality in of data security and data integrity procedures and
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an EHR. Although this practice saves time

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to ensure compliance with established policies

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by allowing clinicians to duplicate previous and procedures. Audits are an important tool in
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documentation and insert it into current notes, a compliance program as issues can be identified
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it also creates an opportunity for incorrect data by watching for changes in practices, violations of
to be carried forward and may result in the policies, comparisons between periods (such as
appearance of fraud or abuse (AHIMA 2016). year to year), and more.
Refer to chapter 3, Health Information Functions,
Purpose, and Users, for more information Types of Audits
regarding documentation requirements. Internal audits or reviews are conducted routinely
●● Documentation of compliance activities. It is by employees of healthcare organizations where-
imperative for a healthcare provider to detail as external audits are conducted by a third-party
documentation of their compliance activities payer, hired consultant, accrediting agency, and
including the risk analyses, work plans, audit any other individual or group that is not employed
plans, meeting minutes, results of audits, by the healthcare organization. Audits can be a
completion of planned compliance activities, one-time occurrence or may be performed on an
AB103118_Ch16.indd 513 2/6/2020 5:50:16 PM

ngoing basis such as monthly, annually, or by

o Medical necessity audits are conducted to deter-
some other schedule. Audits allow the healthcare mine if healthcare services performed were needed
organization to confirm that the policies and proce- based on the patient’s condition and prognosis. Med-
dures of the healthcare organization are being met icare and other payers do not pay for procedures
and to identify problems that need to be addressed that are not medically necessary. There are obvious
and corrected. Audits that are fraud and abuse re- procedures that are not medically necessary such as
lated serve a number of the following purposes: elective cosmetic surgeries but there are many situ-
ations that are less obvious because of the patient’s
●● Reducing improper reimbursement
physical condition or prognosis for recovery. For
●● Improving the accuracy of healthcare example, open heart surgery on a patient that has
claims terminal cancer with a one-month life expectancy
●● Improving patient care would not be considered medical necessary. In fact,
n.
●● Showing commitment to complying with an ethical provider would probably consider surgery
tio
laws and regulations to be an unnecessary cause of pain. Most unneces-
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sary procedures that are performed are simple diag-
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The types of audits that relate to fraud and abuse nostic procedures such as preoperative tests that do
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include coding, medical necessity, clinical valida-
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not warrant being performed due to the condition of
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tion, and comprehensive error rate testing audits. the patient or the type of planned surgery. For exam-
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Coding audits are conducted to ensure claims ple, a patient without a history of heart disease or re-
an
are being coded correctly as incorrect coding may
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lated conditions would not need a preoperative EKG
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result in over- and underpayments. Providers may in preparation for a simple eye surgery such as cat-
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conduct internal coding audits for new coding staff, aract surgery. The American Board of Internal Med-
m
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for previously identified problematic areas, and for

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icine (ABIM) created a foundation to advance the

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high-risk areas that have been identified by external core values of medical professionalism as a force to
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reviewers such as CMS and OIG. Internal reviews

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improve the quality of care. This foundation started

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should only be considered as a first step in achiev- an initiative in 2010 called Choosing Wisely as a type
an
ing coding compliance. Providers should also con-

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of collaborative between physicians and patients

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tract with coding consultant(s) to provide expert

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to reduce the provision of unnecessary procedures.

coding audits. Using only an internal auditing proc- With this initiative physicians and patients are rec-
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ess increases the risk of accepting incorrect coding ommended to ask, “Does this patient really need this
by
as correct because that is how claims have always procedure? Do I really need this procedure?” (ABIM
20
been coded. In addition, if a coding supervisor or

20
2019). Medical necessity audits will continue to be

lead coder incorrectly interprets one or more cod-
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an important part of fighting fraud and abuse and

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ing guidelines, this could lead to a systemic proc-

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will continue to become more sophisticated as more

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ess of incorrect coding. The following questions

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health data and data analysis become available with

should be asked when monitoring and auditing
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increased use and complexity of the EHR.

the coding process at a healthcare organization: Clinical validation audits are conducted to de-
●● Is the diagnosis-related group correct? termine if health records contain the necessary
●● Is there any unbundling? documentation, such as lab results, diagnostic test
results, operative reports, and so forth to support
●● Are the codes assigned for the appropriate
the diagnoses made by the physician. Historically,
level of service?
physicians were able to diagnose conditions and
●● Are codes changed so that a noncovered diseases without supportive proof; however, those
service is billed as a covered service? days are in the past. Providers who do not have
●● Is there a discrepancy between the codes health record documentation that substantiates
provided by the physician and the hospital their diagnoses based on clinical criteria generally
(Prophet 1997)? accepted by the medical community will likely
AB103118_Ch16.indd 514 2/6/2020 5:50:16 PM

experience reductions in payment or denials of pay- and regulations. When the reviewers identify an
ment. Clinical validation audits can be conducted improper payment, they assign one of the following
internally or externally. External clinical validation improper payment categories:
audits are typically conducted on Medicare patients ●● Insufficient documentation—the health
by RACs and, as discussed earlier in this chapter, record documentation submitted does not
there are appeal mechanisms in place for providers if support the claim
they do not agree with a RAC audit. The appeal pro-
●● Medical necessity—the health record
cess can be expensive though when staff time and
documentation submitted does not support
legal counsel expenses (if used) are factored in so
the medical necessity of the services provided
each provider must make a decision on a case by case
basis of whether or not to appeal a RAC decision. ●● Incorrect coding—the health record
Knowing that clinical validation audits may be con- documentation submitted does not support
the code that was billed; or indicates that the
n.
ducted, coders are also responsible for ensuring that
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the documented diagnoses are substantiated prior service was performed by a provider other
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to finalizing coding (Butler 2018). Again, long gone than the billing provider; or that the billing
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are the days of coding directly from a physician- service was unbundled; or that an incorrect
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discharge disposition was coded
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documented list of final diagnoses.
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The Improper Payment Elimination and Recovery ●● No documentation—the provider did not
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Improvement Act (IPERIA) of 2012 requires federal submit any health record documentation to
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agencies to audit programs they administer annual- repeated requests
ly to ensure payments have been made properly and n
●●
io Other—there was an improper payment
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requires the agencies to recover improper payments.
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that does not fall into one of the previous

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Included in the audits, each agency must identify categories (CMS 2019b)
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programs that might be susceptible to improper

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Improper payments (both under- and overpay-

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payments, which may indicate patterns of fraud

ments) are calculated and recouped from the
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and abuse; to estimate the amount of improper pay-

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providers and then a calculation of the improper

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ments; to report this information to the US Congress

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payment rate is calculated and reported to the US

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and the public; and to describe the actions taken by

Congress and the public. Refer to figure 16.6 for an
the agency to reduce future improper payments.
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example of a coding audit tool.

The Comprehensive Error Rate Testing (CERT) pro-
by
The following section addresses preparing for

gram is the program that CMS uses to measure pay-
20
and conducting internal and external audits.

20
ment compliance with Medicare Fee-For-Service

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(FFS) program federal rules, regulations, and re-

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Preparing for and Conducting Audits

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quirements. The CERT process involves a random

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sampling of claims followed by requests for health Before an audit can be conducted, the healthcare
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records. Medical professionals, including physicians, organization must identify the objective of the au-
nurses, and certified coders, review the claims and dit. For example, an objective of an audit may be
health record documentation. The reviewers deter- to monitor billing practices or coding quality. Once
mine whether the claim was paid properly or de- the objective is established, the audit method can be
nied properly, such as through a RAC audit, accord- determined. Audit methods include analyzing elec-
ing to Medicare coverage, coding, and billing rules tronic data, reviewing documents, collecting data,
Figure 16.6 CERT Process
Medical Calculation of
Claim Medical
record improper Reporting
selection review
request payment rate
Source: CMS 2019b
AB103118_Ch16.indd 515 2/6/2020 5:50:17 PM

adding and inputting it into a database, or assem- The general rule for documentation in the health
bling data using a manual data collection tool. The record is “if it is not documented, it was not done”.
method will control the resources needed such as the That is true in compliance as well. The documenta-
health record, bills, queries, and so forth. The number tion of audits is a significant part of this proof. The
of cases needed and how the cases will be identified documentation should include where the data was
must be established using statistical methods and are obtained, why it was gathered, what was done with
therefore outside the scope of this chapter. For exam- the data, what the healthcare organization learned
ple, the healthcare organization may determine that it and what the audit tells the organization (CMS 2015).
needs to review 20 percent of the queries written ev- The HIM professional is the keeper of the health
ery month. The following are the statistical methods record and, therefore, must control the release of data
that can be used to select the specific queries: needed for the audit. In preparation for an audit, the
HIM professional must review the audit request
●● Simple random sampling. This model gives
n.
documents to validate the auditor’s right to review
every bill, patient, and so forth so that each
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the health record. The HIM professional must also
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has the same chance of being chosen.
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ensure the audit will take place in an atmosphere that
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●● Systematic random sampling. In this model, a maintains the security of protected health informa-
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pattern such as selecting every 10th patient
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tion (PHI) during audit activities. The healthcare or-
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admitted is used. ganization will be best served if the audit processes in
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●● Convenience sampling. In this model, the bills, place are proactive rather than reactive. A proactive
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for example, are chosen based on which ones
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approach enables a healthcare organization to iden-
are available to the auditor.
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tify areas of concern, opportunities for documenta-
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tion improvement, and educational needs, and to
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While audits vary based on what is being au-

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dited, there is a basic process—identify areas of address and correct these issues prior to any audit
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request from an external organization such as a RAC.

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risk that need to be monitored, conduct audits on

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these areas of risk, document the findings of the The HIM professional should plan audit activi-
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ties, keeping in mind that both internal and exter-

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audit, analyze the data, and correct any problems

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identified. To conduct the audit, the auditors need nal audit requests can arrive at any time. Audit
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access to the resources being audited. The areas of planning should include the following:
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risk can be HHS focus areas, problems that have

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●● Identification of the audit requestor

by
previously been identified at the healthcare organ-

Information requested
20
ization, or areas where problems are suspected. ●●

20
There should be a database, spreadsheet, or other ●● Information needed

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tool where the audit is recorded. The data ele-

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●● Identification of individuals from the

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ments collected during the audit vary based on the healthcare organization that need to be
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audit objective. For example, auditing a claim for involved in the audit, keeping in mind
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healthcare services in the emergency department that these individuals may be from other
might consider the following areas: departments such as patient accounting,
●● Procedures are reported at the appropriate revenue management, charge description
level master control, clinical services, clinical
●● Claims are not submitted more than once documentation integrity (CDI), or utilization
review (UR)
●● Coding guidelines such as not unbundling
are followed
●● Timeline of audit activities
●● Documentation support services are
●● Designation of individual responsible for the
reported on the claim management of the audit activities
●● Copayments and deductibles are collected
●● Determination of when audit results will be
from the patient (CMS 2015) reviewed and who will review them
AB103118_Ch16.indd 516 2/6/2020 5:50:17 PM

The traditional role of the HIM professional in the appeal is a request for reconsideration of a denial
audit process typically includes providing the health of coverage or rejection of claim decision. A health-
records to be audited or auditing health r ecords. The care organization generally has a limited amount
audit may have particular requirements, specifica- of time to submit the appeal. A common appeals
tions, and criteria regarding the health records to process that a healthcare organization follows
be included. Then the HIM professional will apply includes the following:
privacy regulations and organizational policies and ●● Review the notification of denial from the
procedures to ensure the audit is lawful and that
insurer
the health record may be used or released.
●● Determine the type of denial (medical
External Audits necessity, coding change, and so forth)
External audits are performed to confirm that a ●● Route the denial to the appropriate
n.
healthcare organization’s internal audits are valid; department or individual (HIM, utilization
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in other words, that the internal audits are identify- management, and so forth)
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ing all of the compliance issues. External auditors Determine if the denial is warranted (agree
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●●
are hired by a healthcare organization to conduct
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or disagree with the insurer’s findings)
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the review. The auditors are impartial and typi- Write an appeal letter if warranted
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●●
cally have not had a previous relationship with
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●● Document the decision, including a copy of
the healthcare organization. An external audit
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the appeal letter, as per policy
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ensures the healthcare organization’s policies and
procedures are in compliance with laws, regula- n
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The individuals or departments that address
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tions, and their own policies and procedures. An
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an appeal depend on the type of appeal. For ex-

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example of an external audit is an audit of coders to ample, the physician would write a medical ne-
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validate their accuracy. Another example is an ex- cessity appeal letter, and the coding supervisor
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ternal audit to determine the compliance with the would write an appeal letter related to a change
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Joint Commission standards regarding patient’s in coding. Generally, the health record would be
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rights. The goal of an external audit is to determine reviewed to determine whether or not an appeal
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the healthcare organization’s level of compliance. is appropriate. For example, the coding supervisor
may review the health record and determine that
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Denials and Appeals the coder made a mistake and the codes assigned
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A denial is when a bill has been returned unpaid in the denial are appropriate.
20
20
for any of several reasons (for example, sending An appeal letter would identify the claim being
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the bill to the wrong insurance company, patient denied including the patient name, dates of service,
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not having current coverage, inaccurate coding, reason for denial, and other identifying informa-
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lack of medical necessity, and so on). For example, tion. The appeal letter would then explain the
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Mary Smith’s admission was denied due to lack reason why the healthcare organization deserves
of medical necessity. The claim had already been the reimbursement that has been denied. For
paid so the Medicare Administrative Contractor example, with a medical necessity denial, the
takes back the funds. physician would explain why the patient needed
When the healthcare organization receives a de- hospitalization. This could be through content
nial or the insurer either does not submit payment from the health record or additional informa-
for healthcare services or takes back payment that tion. For a denial letter that addresses a change in
was previously paid for healthcare services, the coding, the coding supervisor would quote from
healthcare organization must review the denial to the health record the documentation that sup-
determine if it agrees or disagrees. Based on the ported the original code or quote from the coding
review of the health record and the denial, the rules. Supporting evidence from the health record
healthcare organization can appeal a denial. An should be attached when appropriate.
AB103118_Ch16.indd 517 2/6/2020 5:50:17 PM

The healthcare organization should track the was upheld or overturned. This can help the
activities related to denials and appeals. This healthcare organization identify patterns and
includes the number of denials, number of ap- take the necessary steps to reduce the number
peals, types of denials, and whether the denial of denials.
Coding and Fraud and Abuse

Codes are used to determine reimburse- organization’s compliance plan. A coding compli-
ment; therefore, code assignment is critical since ance plan focuses on the rules and guidelines spe-
the healthcare organization’s revenue is involved. cifically related to coding and the responsibility of
With the ever-increasing focus on proper payments coders. It should contain the same components as
n.
by federal, state, and private healthcare payers, the healthcare organization’s compliance plan but
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accurate coding is imperative and is constantly with the focus on coding. Benefits of the coding
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scrutinized by these payers, creating additional re- compliance plan include the following:
ss
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sponsibilities and pressures for coders. With accu- ●● Improved documentation in the health record
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sations of improper payments, some falling under
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the definitions of fraud or abuse, it is more impor-
●● Retention of a high standard of coding
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tant than ever for coders to follow AHIMA’s Stan- Reduction in denials of healthcare services
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●●
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dards for Ethical Coding (see inside front cover for reimbursement based on coding errors
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how to access the Standards on the student website). ●●
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Correction of coding-related risks
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These 11 standards should be reviewed thoroughly
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(Schraffenberger and Kuehn 2011)

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and completely as part of a coder’s orientation to a

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coding position and as a part of routine continuing The coding compliance plan should include ex-
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pectations for coding quality, such as 98 p ercent

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education. Coding compliance relies on these ethical

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standards. Refer to the AHIMA Standards of Ethical accuracy in code assignment, use of official cod-
an
ing guidelines and official resources such as the

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Coding which is found in the online resources (see

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American Health Association’s Coding Clinic for

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inside front cover to register for access).

Coders who follow official coding guideline rules ICD-10-CM and ICD-10-PCS and CPT Assistant.
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and regulations, follow their employer’s policies and Coding staff are expected to be almost perfect
by
procedures, follow AHIMA’s Ethical Standards of in their code assignments as there is so much at
20
stake for the healthcare organization based on

20
Coding (see inside front cover for how to access the

the codes used for billing, including the accurate
©
Standards on the student website), and so forth will

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reimbursement for healthcare services rendered

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still make mistakes. Mistakes are made in all jobs,

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as well as the external audits conducted by the

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coding included, but it is how mistakes are handled

federal government and commercial insurance
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when they are identified that determines whether the

same mistakes will be prevented in the future. Coders payers.
and all provider employees are best served, both per- The following are strategies that can be used to
sonally and professionally, by being upfront and hon- combat fraud and abuse in coding:
est, which includes reporting incorrect or improper ●● Provide ongoing training to all coding staff
coding practices of their own or others (Bryant 2018).
The following section addresses coding com-
●● Implement comprehensive policies and
pliance and computer-assisted coding. procedures
●● Examine the quality of coding through the
Coding Compliance use of audits
Healthcare organizations should have a cod- ●● Ensure the coding practices follow official
ing compliance plan in addition to the healthcare coding guidelines
AB103118_Ch16.indd 518 2/6/2020 5:50:17 PM

●● Ensure there is a corresponding or clarification. The query should never direct the
supporting diagnosis code for each physician what to document. For example, the cod-
procedure code er should never tell the physician to add a diagno-
●● Support codes with health record sis or ask a question that can only be answered yes
documentation or no. Another best practice is that the physician
should always have access to the health record
●● Support evaluation and management code
when asked to make a decision. The query can be
assignment with the documentation
written or electronic.
●● Educate physicians on how to improve their The use of queries should be monitored to ensure
documentation it meets the best practices for writing queries. The
●● Use best practices to write a query to clarify monitors should include whether queries were
documentation only written to increase documentation or not, the
n.
●● Disseminate memorandums on changes in appropriateness of the query, and whether or not
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regulations and insurers’ policies it meets the other best practices.
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Verify the advice of consultants prior to The query should become a permanent part of
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●●
the health record and the physician’s response to
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implementation of their recommendations
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the query should be documented in the health
Monitor changes in regulations
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●●
record by the physician.
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●● Compare organization metrics with national
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data Computer-Assisted Coding
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Monitor claims denials and coding changes n
●● io
Computer-assisted coding (CAC) is the process of
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●● Review data to identify any significant extracting and translating dictated and then tran-
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changes in the organization’s case-mix index scribed free-text data (or dictated and then com-
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puter-generated discrete data) into International

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or coding practices
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Ensure the person maintaining the Classification of Diseases, Tenth Revision, Clinical
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●●
Modification (ICD-10-CM) and Current Procedural

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chargemaster is knowledgeable in coding,

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billing, and documentation Terminology (CPT) codes for billing and coding
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purposes. CAC assists to reduce issues with fraud

●● Report any possible fraud to the healthcare
and abuse by incorporating coding principles
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organization’s compliance officer or attorney

and guidelines (Garvin et al. 2006). CAC does
by
(Prophet 1997)
this by incorporating prompts and decision-
20
20
Other issues that must be addressed in the coding support tools to assist in the accurate and timely
©
compliance plan include upcoding and unbun- selection of correct codes. CAC facilitates the
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dling, discussed earlier in this chapter. creation of an audit trail to identify coding errors
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(Rudman et al. 2009).

Queries
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CAC uses natural language processing (NLP) to

A query is “a communication tool or process used review the documentation in the EHR and assign
to clarify documentation in the health record” diagnosis and procedure codes. NLP is a technol-
(Bossoondyal et al. 2019). For example, a query ogy that converts human language into data that
should be written if one place in the health record can be translated then manipulated by computer
states the fracture is the left arm and in another, systems and is a branch of artificial intelligence.
it says right arm. When documentation issues are In 2013, the AHIMA Foundation conducted a re-
identified, the coder should query the physician. search study to determine whether coding timeli-
The query should be clearly written and should ness and accuracy are affected by the use of CAC.
address the problem with the documentation rather The study determined that the best scenario for
than any impact on reimbursement. The question coding accuracy is for a credentialed coder to code
should include the documentation that needs in conjunction with the use of a CAC. Study results
AB103118_Ch16.indd 519 2/6/2020 5:50:17 PM

demonstrated that credentialed coders that used validate the codes assigned by the computer rather
a CAC were able to reduce the amount of time it than assign the code. The CAC can help prevent
took to code a health record by 22 percent. A coder fraudulent coding and ensure consistent, complete
that did not use a CAC or the use of a CAC alone coding due to the NLP. Inaccurate coding results
without a credentialed coder resulted in lower in inaccurate reimbursement and possibly charges
coding accuracy (AHIMA 2013). of fraud or abuse. Figure 16.7 is an example of how
CAC does not eliminate the need for coders, the EHR documentation is used to assign codes
but the role of the coder changes as he or she will via computer-assisted coding.

n.
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1. True or false: Internal monitoring should be part of a compliance program.
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2. True or false: In systematic random sampling a pattern such as every 10th patient admitted is used to select patients.
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3. True or false: A compliance program is a reconstruction of events that include who executed the events in question,
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why, and what changes were made as a result.
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4. Identify a benefit of a compliance plan.
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a. Reduction in denials
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b. Elimination of denials
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c. Maintenance of the status quo
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d. Documentation audits
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5. The coder assigned separate codes for individual tests when a combination code exists. This is an example of:
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a. Upcoding
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b. Complex coding
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c. Query
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d. Unbundling
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Figure 16.7 ICD-10-CM CAC example

by
20
In this example, the CAC software assigned the code T15.91xA based on documentation in the emergency department
20
record that states the patient had a “foreign body in the right eye.” The coder is presented with the decision to accept
©
the code or reject it based on further analysis.

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Review of the documentation revealed that the foreign body was located on the edge of the cornea, which changes the
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fourth character in ICD-10-CM from 9 to 0. The coding professional replaces the T15.91xA with T15.01xA, Foreign body
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in cornea, right eye.

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Emergency Department Record
A patient is brought to the emergency department with a foreign body in the right eye. He was working with metal, and
a piece flew in his eye. He reports slight irritation to the right eye but no blurred vision. A slit lamp shows a foreign body
approximately 2 to 3 o’clock on the edge of the cornea. The foreign body appears to be metallic. The iris is intact.
Procedure:
Two drops of Alcaine were used in the right eye. Foreign body is removed from the right eye.
Computer-Generated Codes:
T15.91xA, Foreign body, external eye, right
Final Coding Decision:
Coding professional selects the more specific code for foreign body of cornea, T15.01xA
Source: Smith and Bronnert 2010.
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Clinical Documentation Integrity

Clinical documentation Integrity (CDI) systems can assist with documentation through
is the process a healthcare organization undertakes edits, reminders, structured data (chapter 3, Health
to improve clinical specificity and documenta- Information Functions, Purpose, and Users), and more.
tion. The role of a HIM professional in CDI is to Suggestions for improvement in documentation can
educate physicians and other healthcare profes- be made by these information systems throughout
sionals on best documentation practices. The HIM the patient’s care. These suggestions can improve
professional is uniquely qualified because of their the specificity of the documentation in the EHR,
clinical understanding and knowledge of docu- indicate conditions that might need to be added,
mentation, coding, and reimbursement systems. and so forth. Information systems can also be used
The improved documentation will allow coders in the query process to request clarification from
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to assign more precise diagnosis and procedure physicians. An electronic query can save the phy-
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codes; for example, ensuring that the organism for sician a trip to the HIM department and therefore
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pneumonia is documented and coded. The CDI may result in a quicker turnaround time. Queries
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process can be performed either concurrently or may be retained in an information system and be-
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retrospectively to the patient encounter. Concur- come part of the healthcare organization’s legal
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rent CDI is performed while the patient is admit- health record. Information systems can monitor the
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ted and still in the hospital and can enhance the metrics regarding the CDI program (Arrowood
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quality of care as the improved documentation is et al. 2016).
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available for all care providers. Retrospective CDI
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is performed after the patient is discharged. The Clinical Documentation Integrity

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review is frequently performed during the cod- Monitoring and Metrics

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ing process. The CDI review of the health record

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The CDI program must be monitored to determine

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looks for “conflicting, incomplete, or nonspecific

how successful it is. A monthly dashboard show-
an
provider documentation” (AHIMA 2015). The im-

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ing the metrics (something that is measured) for

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proved documentation helps ensure the docu-

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the month should be created. These metrics can be

mentation supports code assignment. For example,
used to compare results from month to month and
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the documentation should indicate whether the

year to year. The metrics can address volume of
by
fractured arm is the left or right one so that the

reviews, number of queries, physician response to
20
proper code can be chosen. This is important be-

20
queries, turnaround time, case-mix index, diagno-

cause reimbursement is based on the codes that
©
sis-related group proportions, trends, physicians

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are assigned according to the documentation. If

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who were queried the most, denials, and more. A

yr
the documentation is open to interpretation, the

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threshold should be created as a target for the CDI

healthcare organization could be accused of fraud
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program to meet. For example, physicians should

or abuse. Refer to chapter 6, Data Management, for
agree with the CDI specialist 90 percent of the
more information on CDI. The following sections
time. Monitoring the metrics in the dashboard will
address the role of information systems in CDI,
indicate areas of concern to address. For example,
metrics used in monitoring CDI, and clinical out-
if the number of queries suddenly increases, the
come measures and monitoring.
healthcare organization will need to research the
reason for the increase. It could be due to a new
Information Systems and CDI physician, a new service, or another reason. The
Information systems are used throughout the CDI action(s) to be taken will vary based on the findings
process – from initial documentation to monitoring but could include training, revision of the program,
the CDI program. The EHR and other information and more (Arrowood et al. 2016).
AB103118_Ch16.indd 521 2/6/2020 5:50:17 PM

HIM Roles
HIM professionals are actively involved systems and the health recommend
in fraud and abuse compliance. Two common roles documentation.
are CDI specialist and coding auditor. ●● Coding Auditor. A coding auditor monitors the
●● CDI Specialist. A CDI specialist works with quality of the codes assigned by the coders
physicians on documentation issues, and addresses any issues identified through
monitors metrics collected, and addresses training and other communication. The coding
issues that are identified. The CDI auditor may also handle coding denials that
specialist must understand classification are received by the healthcare organization.
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In June 2018, HHS and OIG along mitting false claims for treatments that were not
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with state and federal law enforcement charged medically necessary and often never provided.
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more than 600 individuals with participating in Some patient recruiters, beneficiaries, and others
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false billings of Medicare and Medicaid totaling received kickbacks in return for supplying ben-
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about $2 billion in Medicare and Medicaid loss- eficiary information to providers for the purpose
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es. This is the largest ever healthcare fraud law of submitting fraudulent claims to Medicare. It
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enforcement action. Of the 600 defendants, 165 is particularly disconcerting to note that almost
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were medical professionals including physicians, every healthcare fraud scheme requires a cor-
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nurses, and pharmacists. Many of the defen- rupt medical professional to be involved for the
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dants were charged for their roles in prescribing fraud to be successful. These medical profession-
ea
and distributing opioids and other dangerous als preyed on vulnerable patients who turned to
H
an
narcotics. Other defendants participated in sub- them for care and treatment (DOJ 2018b).
ic
er
Am

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th
by
20
The University of New Mexico Hospi- ity of Illness (SOI), Risk of Mortality (ROM), and
20
tals had a number of unsuccessful efforts to im- the patient’s condition. In the first five months
©
prove the quality of documentation in the health of 2015, the University of New Mexico Hospitals
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record. These efforts failed due to a lack of physi- realized an increase in revenue of more than $1.8
yr
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cian buy-in and qualified staff. Subsequently they million as a result of improved documentation.
C
created a CDI program that utilized physician In the first 16 months of the program, the hospi-
advisors to educate physicians on the importance tals’ CMI improved by 18.6 percent. The hospitals
of clinical documentation in the health record. have also seen improvement in the quality of care
The focus was on the accuracy of patient’s record. they provide based on SOI and ROM measures
Physicians focused on documentation of Sever- (Precyse n.d.).
References
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Wisely, An Initiative of the ABIM Foundation. http:// Association. 2017. Pocket Glossary of Health Information
www.choosingwisely.org/. Management and Technology, 5th ed. Chicago: AHIMA.
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American Health Information Management Centers for Medicare and Medicaid Services. 2018b.
Association. 2016. Standard of Ethical Coding. http:// Medicare Learning Network: Combating Medicare
bok.ahima.org/CodingStandards#.XDqGEM17nIU. Parts C and D Fraud, Waste and Abuse. https://
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Association. 2015. So What Exactly is Clinical Learning-Network-MLN/MLNProducts/Downloads/
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doc?oid=300922#.XQrV-3dFyUk. Centers for Medicare and Medicaid Services.
American Health Information Management 2017a. Medicare Learning Network Fact Sheet-
Association. 2013. Study Reveals Hard Facts on CAC. Medicare Overpayments. https://www.cms.gov/
http://bok.ahima.org/doc?oid=106668#.Vu9SIebx2b8. Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads/
Arrowood, D., L. Bailey-Woods, E. Barnette, T. overpaymentbrochure508-09.pdf.
Combs, M. Endicott, and J. Miller. 2016. Clinical
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Bryant, G. 2018. Coding Compliance and Ethics: Centers for Medicare and Medicaid Services. 2017c.
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PdfView?oid=302483. Abuse: Prevention, Detection and Reporting. https://
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Bossoondyal, S., G. Bryant, T. Combs, K. DeVault, M. www.cms.gov/Outreach-and-Education/Medicare-
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Endicott, C. Ericson, O. Ewoterai, K. Good, T. Grier, W. Learning-Network-MLN/MLNProducts/downloads/
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Murphy, L. Prescott, S. Schmitz, C, Seluke, S. Wallace,

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Butler, M. 2018. You Got Proof? Payers, Auditors Statistics-Data-and-Systems/Monitoring-Programs/

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Increase Clinical Validation Checks. Journal of AHIMA Medicare-FFS-Compliance-Programs/Recovery-

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Medicare Fee for Service Recovery Audit Program. Centers for Medicare and Medicaid Services. 2015.
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https://www.cms.gov/Research-Statistics-Data- Self-Audit Toolkit. https://www.cms.gov/Medicare-

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and-Systems/Monitoring-Programs/Medicare-FFS- Medicaid-Coordination/Fraud-Prevention/Medicaid-
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Compliance-Programs/Recovery-Audit-Program/. Integrity-Education/documentation-matters.html.
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Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. 2014a.
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2019b. Comprehensive Error Rate Testing Medicare Fraud and Abuse. https://www.cms.
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Program-Improper Payment Measurement in gov/Outreach-and-Education/Medicare-Learning-

yr
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the Medicare Fee-For-Service (FFS) Program. Network-MLN/MLNProducts/downloads/fraud_

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and-Systems/Monitoring-Programs/Medicare- Centers for Medicare and Medicaid Services. 2013.
FFS-Compliance-Programs/CERT/Downloads/ Compliance Program Element VI, Monitoring, Auditing
IntroductiontoComprehensiveErrorRateTesting.pdf. and Identification of Compliance Risks. https://www.
Centers for Medicare and Medicaid Services. 2018a. cms.gov/Medicare/Compliance-and-Audits/Part-
Medicare Fee-for-Service Recovery Audit Program C-and-Part-D-Compliance-and-Audits/Downloads/
Additional Documentation Limits for Medicare Element-VI-Focused-Training-Power-Point-.pdf.
Providers (Except Suppliers and Physicians). https:// Department of Health and Human Services.
www.cms.gov/Research-Statistics-Data-and-Systems/ 2009. Testimony. http://www.hhs.gov/asl/
Monitoring-Programs/Medicare-FFS-Compliance- testify/2009/10/t20091028a.html.
Programs/Recovery-Audit-Program/Downloads/
ADR-Limits-Institutional-Provider-Facilities-May- Department of Justice. 2018a. Justice Department
2016-revised-12-21-18508ao.pdf. Recovers Over $2.8 Billion from False Claims Act
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Cases in Fiscal Year 2018. https://www.justice.gov/ and Accountability Act of 1996. Federal Register.
opa/pr/justice-department-recovers-over-28-billion- 63(57):14393-14402. http://oig.hhs.gov/authorities/
false-claims-act-cases-fiscal-year-2018. docs/hipaacmp.pdf.
Department of Justice. 2018b. National Health Care Office of Inspector General. n.d. Health Care
Fraud Takedown Results in Charges Against 601 Compliance Program Tips. http://oig.hhs.gov/
Individuals Responsible for Over $2 Billion in Fraud compliance/provider-compliance-training/files/
Losses. https://www.justice.gov/opa/pr/national- Compliance101tips508.pdf.
health-care-fraud-takedown-results-charges-against- Garvin, J.H., V. Watzlaf, and S. Moeini. 2006.
601-individuals-responsible-over. Automated Coding Software: Development and Use
Department of Justice. 2016. Fact Sheet: The Health to Enhance Anti-Fraud Activities. https://www.ncbi.
Care Fraud and Abuse Control Program Protects nlm.nih.gov/pmc/articles/PMC1839655/.
Consumers and Taxpayers by Combating Health Office of the National Coordinator for Health
Care Fraud. https://www.justice.gov/opa/pr/fact- Information Technology. 2019. Meaningful Use.
sheet-health-care-fraud-and-abuse-control-program-
n.
https://www.healthit.gov/topic/meaningful-use-
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protects-conusmers-and-taxpayers. and-macra/meaningful-use.
ia
oc
FindLaw. 2019. What is the False Claims Act? https:// Office of the National Coordinator for Health
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employment.findlaw.com/whistleblowers/what-is- Information Technology. n.d. Organizational Chart.
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the-false-claims-act.html. https://oig.hhs.gov/about-oig/organization-chart/
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Office of Inspector General. 2019a. About Us. http:// index.asp.
oig.hhs.gov/about-oig/about-us/.
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Quality Improvement Organizations. 2019a. The
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Office of Inspector General. 2019b. Exclusions History of the QIO Program. https://qioprogram.org/
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Program. https://oig.hhs.gov/exclusions/index.asp. qionews/articles/history-qio-program.
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Office of Inspector General. 2019c. Civil Quality Improvement Organizations. 2019b. QIO
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Monetary Penalties Inflation Adjustment Program 11th Scope of Work 2014-2019. https://
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documents/2019/02/07/2019-00603/civil-monetary- Assessment-Instruments/QualityImprovementOrgs/
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penalty-adjustments-for-inflation. Current.html.
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Office of Inspector General. 2019d. Medicare Fraud Precyse. n.d. UNM Hospitals Turns the Tide on
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Strike Force. https://oig.hhs.gov/fraud/strike-force/. Clinical Documentation. https://www.precyse.com/

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resources/Precyse%20UNMH%20CDI%20Success%20
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Office of Inspector General. n.d.a. Organizational

Chart. http://oig.hhs.gov/about-oig/organization- Story%20Web%20Version.pdf.
e
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chart/index.asp. Prophet, S. 1997. Fraud and abuse implications

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Office of Inspector General. n.d.b. A Roadmap for for the HIM professional. Journal of AHIMA 68(4):
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52–56.
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New Physicians: Fraud & Abuse Laws. https://

oig.hhs.gov/compliance/physician-education/ Rudman, W. J., J. S.Eberhardt, W. Pierce, and S. Hart-
©
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01laws.asp. Hester. 2009. Healthcare fraud and abuse. Perspectives

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in Health Information Management 6(Fall):1g.

yr
Office of Inspector General. 2013. Medicare Recovery

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Audit Contractors and CMS’s Actions to Address Schraffenberger, L.A. and L. Kuehn. 2011. Effective
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Improper Payments, Referrals of Potential Fraud, and Management of Coding Services, 4th ed. Chicago: AHIMA.
Performance. http://oig.hhs.gov/oei/reports/oei-04- Smith, G. and J. Bronnert. 2010. Transitioning to CAC:
11-00680.pdf. The skills and tools required to work with computer-
Office of Inspector General. 1998. 42 CFR Parts assisted coding. Journal of AHIMA 81(7):60–61. http://
1003, 1005 and 1006. Health care programs: Fraud library.ahima.org/doc?oid=101090#.VxUObfkrLDc.
and abuse; revised OIG civil money penalties 45 CFR 160.401: Definitions. 2009.
resulting from the Health Insurance Portability
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AB103118_Ch17.indd 525
PART
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VI
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Leadership
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AB103118_Ch17.indd 526
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Chapter
17
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Management
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Learning Objectives
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•• Identify the four functions involved in management •• Examine financial management in healthcare
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•• Examine the principles of organizational behavior •• Analyze the management and allocation of
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•• Articulate the organizational structure in a resources used in healthcare

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healthcare organization •• Examine the management of venders and contracts

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•• Verify the process for strategic and operational in healthcare

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planning •• Utilize enterprise information management

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•• Analyze the basics and tools of project •• Analyze the management of mergers in healthcare
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management, including work analysis and change •• Examine the management of corporate compliance
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management and patient safety

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by
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Key Terms
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Accounting External analysis Organizational behavior

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Accrual accounting Financial management Organizational chart

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Budget Gantt chart Organizational structure

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Budget adjustment Impact analysis Planning

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Budget management Internal analysis Policies

Budget variance Job classification Principles of organization
Cash basis accounting Job description Procedures
Change management Job evaluation Program evaluation and
Controlling Leading review technique (PERT)
Corporate compliance Management chart
Cultural competence Market assessment Project management
Enterprise information Mergers Project management life cycle
management (EIM) Middle management Resource allocation
Executive management Operational planning Revenue
Expenses Organization Risk management
527
527
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528 Part VI Leadership
Staffing Strategic planning SWOT analysis

Strategic information systems Strategy Variable costs
planning Supervisory management Work analysis
Strategic plan Supply management Workflow
All organizations, from businesses with a small A strategy is a course of action designed to pro-
number of employees to large corporations with duce a desired (business) outcome and a strategic
several thousand employees, use the practice plan is the document in which the leadership of a
called management. Management is the process of healthcare organization identifies the overall mis-
planning, controlling, leading, and organizing the sion, vision, and goals to help define the long-term
activities of an organization. In healthcare, man- direction of the organization as a business entity.
agement is necessary for the entire organization, Strategic planning includes an analysis of how an
n.
as well as for the departments making up the orga- organization will react to changes in the external
tio
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nization. Securing effective management practices environment in the foreseeable future. Success-
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within an organization or department establishes a ful management practices also encompass work
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positive direction to successfully deliver end results, processes, project management and finance, all of
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and to do this, strategic planning is necessary. which are described throughout this chapter.
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Management
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The practice of health information man- staffing, processes, and procedures to determine
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agement (HIM) ensures the availability, accuracy, what changes will be necessary in preparing, im-
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and protection of the clinical information needed to plementing, and managing the new information
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deliver healthcare services and to make appropri- system. Short-term planning may involve staffing
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ate healthcare-related decisions. HIM managers, coverage for an employee who is taking leave time.
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directors, and supervisors use the four functions Controlling is the function in which performance
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of management—planning, controlling, leading, is monitored according to policies and procedures

and organizing—in the day-to-day and long-term (defined later in the chapter). In HIM, controlling
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operations of the HIM department to ensure the includes monitoring the performance of employees
by
healthcare organization complies with laws and for quality, accuracy, and timeliness of completion
20
20
regulations that mandate the management of HIM of duties. For example, the policy of the depart-
©
functions. ment may include a 97 percent accuracy rate for all

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The HIM director uses the planning function codes for surgical procedures. The coding supervi-
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of management to develop goals for the depart- sor will monitor accuracy for all coders to ensure
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ment. Planning is the examination of the future compliance with this standard. If an employee falls
and preparation of action strategies to attain goals below the stated standard, training will be provided
of the department or healthcare organization; for to the employee.
example, a director in the HIM department may Leading is the function in which people are di-
use the planning function to prepare for the fu- rected and motivated to achieve the goals of the
ture state of the department after the implemen- healthcare organization. In an HIM department,
tation and installation of a new electronic health leading involves assigning responsibilities to the
record (EHR) application. She will determine the tasks the department needs to accomplish. For
impact of the EHR on the policies and proce- example, in the case of a disaster where multiple
dures, the budget, and other aspects of the depart- patients are brought to the healthcare organization,
ment. The director will anticipate the changes in the HIM director may ask all personnel to report
AB103118_Ch17.indd 528 2/11/2020 1:35:57 PM

to the emergency staging area to help with health to manage, or low, with few employees to
record management. The day-to-day operations of manage. High span of control may cause the
the department require the director to understand manager to be ineffective because too many
the policies and procedures to determine when a people report to him or her, or a manager
change may be needed. with low span of control may feel he or she
The HIM director uses the function of organizing is not being used effectively and is capable
on a daily basis, for both long-term and short-term of more responsibility.
tasks and goals. Organization is coordinating all ●● Specialization. All employees have special
of the tasks and responsibilities of a department qualifications or skills that allow them to
to guarantee the work to be accomplished is com- perform their job to the best of their ability;
pleted correctly and in a timely manner. A director managers who employ this principle assign
or supervisor is responsible for the decisions work among their reporting employees
n.
concerning the division of labor for the HIM according to their specialization, such as
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department, such as coding responsibilities and
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assigning the most complex coding cases
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information disclosure. The billing department may to the coder who has the highest quality
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have a priority list of health records to complete performance on coding reviews. The
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first for reimbursement purposes. The supervisor manager can divide and conquer the work
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will ensure the employees are responsible for spe- of the department using each employee’s
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cific health records first.
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strengths, which results in a positive
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Organization is the planned coordination of outcome for the healthcare organization.
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activities of multiple people to achieve a common io
Delegation. The process by which managers
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●●
purpose or goal. For a healthcare organization,
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distribute work to the employees of the

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organization is vital for structure and allows

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department along with the authority to

employees at all levels to understand their job du-
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make decisions and to act on those decisions.

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ties, to whom they report, and what is expected

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of them. Managers at all levels use the following

●● Directing. The process of assigning the tasks
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for the day to employees and providing

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principles of organization to manage in an effec-

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training, instructions, and advice to help

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tive manner:
with accomplishing the responsibilities.
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●● Unity of command. In this management ●● Coordinating. The process of ensuring activities

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principle, each employee reports to one happen in the order they need to. It is
20
manager. The employees in the scanning

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important, for example, for the coding process

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department report to the scanning to be completed before the billing is performed.

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department supervisor and the supervisor

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●● Controlling. Performance is monitored in

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reports to the HIM director.

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accordance with policies and procedures and

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●● Span of control. The number of employees changed based on the situation at hand at
a person manages is called the span of each moment of the day (McConnell 2019).
control and is influenced by the size of
the organization (such as a department This chapter discusses management roles as they
with only two employees compared to relate to healthcare organizations. Organizational
a department with 100 employees), the behavior and structure, the fundamentals of work
skill level of the employees (entry-level planning, change management, project manage-
employees require more supervisor time), ment, financial management, resource and vendor
and the responsibilities of the supervisor management, enterprise information and manage-
and employees. Span of control can be ment of mergers, corporate compliance, patient
high, where there are a lot of employees safety, and risk management are also addressed.
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Organizational Behavior
Humans are social by nature and usu- affects the way its members interact with each
ally live within groups of their own kind. Organi- other. For example, if an HIM director works in
zational behavior is a field of study that explores a healthcare organization that does not have clear
how people act within organizations and their be- lines of supervision defined, multiple people may
havior individually, in a group, and collectively direct him or her, causing confusion and frustration.
across a department. Understanding manage- A data analyst supervisor speaking negatively
ment must include the study of organizational about the HIM director to the people who report
behavior and the culture of people. Cultural com- to him demonstrates the organizational behavior
petence is the ability to accept and understand of that particular department, meaning the super-
the beliefs and values of other people and groups visor is creating a behavior of negativity within
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and is vital to the overall health of an organiza- the department and the supervisor’s direct em-
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tion. Cultural competence is discussed in detail ployees may view such speech as an indication
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in chapter 21, Ethical Issues in Health Information that it is acceptable to speak negatively about oth-
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Management, and is important for healthcare pro- ers in the department and about the people above
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fessionals to understand because they are required them. Supervisors and managers should be aware
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to work with different people, both as coworkers of the culture of their department and control the
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and as patients, from diverse backgrounds who organizational behavior, as best as they are able,
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have varying beliefs, values, and goals. The orga- to provide positive human interaction and work
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nizational behavior of a healthcare organization environment.
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Organizational Structure
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Healthcare organizations have an a manager to supervise a lot people, and it could

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rganizational structure—the framework of author-

o make them less effective. The ideal number of direct
ity and supervision for the employees within the reports for a supervisor is a hotly debated topic,
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organization. The organizational structure defines with the general consensus being 5 to 11.
by
the hierarchy of reporting and responsibility for each Organizational structure is how the organization
20
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level of decision-making authority and the responsi- is arranged in terms of functions or responsibili-
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bilities within the institution. The structure follows ties. It starts at the top with a board of directors and
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a chain of command, or the hierarchical structure ends with employees throughout the institution.
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within an organization. This helps employees to The board of directors is an elected or appointed
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know whom they report to and who reports directly group of people who bear ultimate responsibil-
to them. A person should never report to more than ity for the successful operation of the organization.
one person at a time for a given task because it could Managers and directors are responsible for differ-
cause frustration and confusion if they are being told ent aspects of the business and operations of the
different things. Some people may split their time organization. It is important to understand man-
between departments and could, therefore, report agement levels and organizational tools, including
to more than one person but never for a single task. organizational charts; mission, vision, and values;
For example, a person who works in the registration and policies and procedures and how they direct
department in the morning reports to the registra- and govern individual departments and entire
tion manager; in the afternoon that employee works organizations. These management levels are dis-
in the billing department and reports to the billing cussed in this section. The organizational tools are
manager for those responsibilities. It is difficult for discussed later in this chapter.
AB103118_Ch17.indd 530 2/11/2020 1:35:57 PM

Management Levels shows the relationships among staff, supervisors, and

managers within a single department. Figure 17.1
Management generally includes three levels: ex-
is an example of an org chart for a healthcare organi-
ecutive, middle, and supervisory. Executive man-
zation and figure 17.2 is an example of an org chart
agement is the senior management of a healthcare
for an HIM department.
organization, the people who oversee a broad func-
tional area or group of departments or services. This
Mission, Vision, and Values Statements
level of management establishes the organization’s
future direction and monitors the organization’s Chapter 1, Health Information Management Profession,
operations in those areas. The executive manager defines mission, vision, and values—which are
includes the chief information officer (CIO) who is tools healthcare organizations use to set the direc-
responsible for HIM and information technology tion and define their purpose and philosophies.
(IT). CIOs are responsible for the strategic direction A mission statement is a written statement that
n.
identifies the core purpose and philosophies of a
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for the organization in terms of information gover-
healthcare organization; it defines the healthcare
ia
nance (IG) and the technology related to IG (chapter
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organization’s general purpose. The vision state-
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6, Data Management). Middle management involves
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the people within the organization who oversee the ment is a short description of an organization’s
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operation of a broad scope of functions; for example, ideal future state, and the values statement is a
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short description that communicates an organi-
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the HIM manager may oversee coding, transcription,
zation’s social and cultural belief system. These
an
and disclosure of information at the departmental
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level or they may oversee a defined product or line statements can range from analytical to creative,
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but they are always a screenshot of what the
of service, such as in the case of a radiology depart-
at
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ment manager. Supervisory management oversees healthcare organization represents, its goals for
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the staff-level employees and monitors the effec-

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tiveness of everyday operations and individual Figure 17.1 Organizational chart for a healthcare
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performance against pre-established standards. In organization

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HIM a coding supervisor is an example of this level

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Board of
er
of management—this individual may have inpa- directors

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tient and outpatient coders, discharge analysts,

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and clerks reporting to him or her. The focus of this CEO

by
chapter is management, not leadership. Leadership

20
is covered in chapter 19, Leadership.

20
CFO CIO CMO

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Organizational Tools
ig
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Managers and supervisors rely on tools to help Billing HIM Nursing

op
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with their functions. These tools include organiza-

tion charts, policies, procedures, strategic planning, Finance IT Lab
and the organization’s mission, vision, and values.
Each of these is discussed in further detail.
HR Radiology
Organizational Chart
An organizational chart, sometimes called an org Pharmacy
chart, is a visual graphic or diagram showing the
structure and reporting relationships between CEO: Chief executive officer IT: Information technology
CFO: Chief financial officer Lab: Laboratory
positions, departments, and employees of an or- CIO: Chief information officer HR: Human resources
ganization. The org chart shows the relation of one CMO: Chief medical officer
department to another and a department org chart Source: ©AHIMA.
AB103118_Ch17.indd 531 2/11/2020 1:35:58 PM

Figure 17.2 Organizational chart for an HIM of the organization. For example, if the mission of
department a healthcare organization includes serving only fe-
male patients, managers will not look at expanding
HIM
director
services to male patients with prostate cancer.
Figure 17.3 provides examples of vision and mission
Coding Discharge ROI statements from various healthcare organizations.
supervisor supervisor supervisor
Policies and Procedures

Data
IP ROI Policies are the principles describing how a depart-
analyst
ment or an organization will handle a specific situ-
OP Clerk Clerk ation or execute a specific process. They are clear,
simple statements of how an HIM department
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will conduct its services, actions, or business; and
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Clerk a set of guidelines and steps to help with decision-
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making. For example, the American Health Infor-
ss
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IP: Inpatient mation Management Association (AHIMA) has a
en
OP: Outpatient
privacy policy on their website stating: “AHIMA
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ROI: Release of information
is committed to honoring the privacy of its mem-
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Source: ©AHIMA.
bers and general users who access the website”
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(AHIMA 2015). The policy goes on to state what
n
the future, and what the healthcare organization
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information is collected and for what purpose.
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believes (McNamara n.d.). Once policies are in place, procedures define the
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Healthcare organizations update their mission processes by which the policies are put into action.
In
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and vision statements regularly as part of the Procedures are written documents that describe the
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strategic planning processes (strategic planning steps involved in performing a specific function.
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is discussed later in this chapter). All employees The procedure could be how to code a health record
an
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of the healthcare organization should know and or how to abstract data. It includes steps taken to
er
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understand the mission and vision of the organi- adhere to the policy. Figure 17.4 gives an example of
e
zation. By understanding the mission and vision, a policy and procedure from AHIMA on the external
th
managers can determine the direction of their Americans with Disabilities Act (ADA) Accommo-
by
20
department and if it fits into the overall strategy dations for taking certification examinations.
20
©
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1. True or false: Planning is a course of action designed to produce a desired (business) outcome.
2. What are the four functions of management that HIM directors use in the day-to-day and long-term operation of the
department to ensure the healthcare organization complies with management of HIM functions?
a. Strategy, controlling, management, planning
b. Planning, controlling, strategy, leading
c. Planning, controlling, leading, organizing
d. Management, controlling, leading, organizing
3. Which of the following is the examination of the future and preparation of action plans to attain goals of the
department or healthcare organization?
a. Controlling
b. Leading
c. Organizing
d. Planning
AB103118_Ch17.indd 532 2/11/2020 1:35:59 PM

4. What is the coordination of all the tasks and responsibilities of a department to ensure the work that needs to be
accomplished is completed correctly called?
a. Organizing
b. Specialization
c. Controlling
d. Strategy
5. What is a written statement that identifies the core purpose and philosophies of a healthcare organization?
a. Vision
b. Values
c. Organization
d. Mission
Figure 17.3 Sample mission and vision statements
n.
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General Hospital Affiliated with a Larger Healthcare System
ss
Lutheran hospital’s mission is to improve the health of the communities we serve by providing
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high-quality services in a responsible and caring way.
en
Our vision is to become the leader in promoting healthy lifestyles in an atmosphere of spiritual
em
support, dignity, compassion, and mutual respect for all.
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Community General Hospital
an
Anytown General Hospital’s mission is to provide quality health services and technology to
M
meet the changing healthcare needs of the people of southwestern Minnesota.
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Anytown General Hospital’s vision is to become the hospital of choice for residents of Polk,
at
Sunny Isle, and Spring counties, a position we strive to strengthen by our long-term
m
commitment to:
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• Teamwork
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• Service excellence
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• Compassionate care
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• Cost consciousness
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• Continuous improvement
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Academic Medical Center

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er
Prairie University Hospital’s mission is to provide the most up-to-date medical and surgical
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services available in the three-state area and to train medical students and graduate physicians
to meet current and future challenges in healthcare.
e
th
Our vision is the achievement of healthy communities and progress toward the future of
by
healthcare for Montana, western North Dakota, and northwestern South Dakota.
20
Specialty Hospital
20
The mission of Women’s hospital of Somewhereville is to meet the healthcare needs of our
©
patients and to exceed their service expectations.

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Our vision is of a hospital:

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• Providing services with compassion and kindness

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• Striving for performance improvement

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• Fostering pride and integrity

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• Aiming for increased cost-effectiveness and productivity

Specialty Clinic within an Academic Medical Center
The mission of the Midwest Asthma Center is to:
• Provide optimal medical care for persons with asthma and related illnesses
• Develop new knowledge about asthma and its management through medical research
programs and materials for our patients, for other healthcare providers, and for
the community
The vision of the Midwest Asthma Center is to provide the highest quality of integrated
comprehensive care for persons with asthma and related illnesses and to be one of the centers
of excellence in the world for asthma treatment, research, and education.
Primary Care Physicians’ Practice
The mission of Coastal Shores Primary Care Associates is to serve the unique needs of
individuals and families by providing high-quality, coordinated, primary care medical services
through and efficient, accessible, and responsive network of caring providers.
Our vision is to be the primary care medical group of choice in the Atlantic County area by
delivering high-quality, individualized, and efficient patient care.
Source: Kellogg 2012, 1086–1087.
AB103118_Ch17.indd 533 2/11/2020 1:36:01 PM

Figure 17.4 Example policy and procedure for ADA accommodations
AHIMA External ADA Policies and Procedures
HOW TO REQUEST TEST ACCOMMODATIONS FOR THE AHIMA

CERTIFICATION EXAMINATIONS
1. The applicant must personally submit a written request.
2. Requests by a third party (such as an evaluator, employer, etc.) will not be considered.
3. If an applicant has a documented disability covered under the Americans with Disabilities Act (ADA) and ADA
Amendments Act (ADAAA) and requires test accommodations, s/he must notify AHIMA in writing each time s/he requests
accommodations.
4. The request should indicate the nature of the disability and the specific test accommodations needed.
5. A qualified professional must provide documentation verifying the disability and explaining the test accommodations that
are needed.
6. Applicants will be notified in writing whether their accommodation request has been approved.
n.
7. The request (application form and documentation) must accompany the AHIMA examination application, and must
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be received by the normal application closing date.
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What to Do:
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• Read the AHIMA Disability Documentation Guidelines carefully and share them with the qualified professional who
em
will be providing supporting documentation for your request.
ag
• Complete the AHIMA Test Accommodation Request form
an
• Attach documentation of the disability and your need for accommodation.
M
• Compare your documentation with the AHIMA Disability Documentation Guidelines to ensure a complete
n
submission.
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at
• Incomplete documentation will delay processing of your request.
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Source: AHIMA 2019.

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Strategic and Operational Planning

by
20
20
The strategic plan of a healthcare or- organization is functioning, will be explored in

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ganization is a map to the future state of the com- more detail in this chapter.
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pany. The plan outlines the outcomes and goals By analyzing the environment every few years
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for the long range. Strategic planning involves (three to five), executive management is able to
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how the organization will react to changes in stay abreast of the changes in regulation, technol-
the external environment in the foreseeable fu- ogy, culture, and direction of the organization. The
ture. Usually the time frame is three to five years strategic plan process helps organizations under-
into the future. In the healthcare environment a stand the environment in which they operate and
strategic plan must take into consideration any identify the plan they will follow to reach their de-
federal, state, and local regulations, laws, and sired future state (Buchbinder and Shanks 2017).
accreditation standards that affect the organi- Operational planning is the specific day-to-day
zation currently and in the foreseeable future tasks required in operating a healthcare organiza-
(Johnson 2017). The steps for creating a strategic tion or an HIM department. The operational plan
plan, which include internal and external analy- is the road map to guide a healthcare organization
sis of the environment in which the healthcare or department toward the goals of the strategic
AB103118_Ch17.indd 534 2/11/2020 1:36:01 PM

plan. The operational plan is a shorter and more determine the strengths of the organization (what
defined time frame than the strategic plan. Depart- the company does well) and the weaknesses (areas
ment managers are involved in creating an opera- for improvement), and establish future opportuni-
tional plan for their departments to propose how ties (and evaluate threats to those opportunities).
to staff and accomplish the work tasks for the An example SWOT analysis performed by an HIM
coming year. Supervisors use operational plan- department found the following:
ning on a daily basis to organize the work of their ●● Strengths. Coders are all credentialed
teams to keep up with department workload.
Healthcare organizations review the inner work- ●● Weaknesses. Staff is not trained in a
ing of the organization to determine strengths and new information system that is being
weaknesses of the business practice and process. implemented within the next three months
This process is an internal analysis. For example, ●● Opportunities. The new information system
n.
an internal analysis of the coding department
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will increase productivity in the department
may reveal that 10 of the coders are credentialed
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by 45 percent
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and have at least 10 years of experience; howev-
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er, the top 5 coders are all leaving their employ- Threats. Some members of the staff are
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●●
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ment within the next three months. An external opposed to change and there is a time delay
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analysis involves exploring the factors outside the with implementing the new information
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control of the organization to determine what is system (Buchbinder and Shanks 2017)
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happening within the same market. The develop-
By exploring SWOT in detail an organization’s
ment of the market assessment determines what n
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management is able to determine what the future
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opportunities and threats to the future of the or-
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state of the organization could and should be. It

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ganization exist. For example, an external analysis

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gives an honest portrayal of the current and future

is performed by healthcare organization A within
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state of the healthcare organization. The strengths

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the service area in which it operates. The analysis

and weakness are usually internal to the organi-
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determines that at healthcare organization B, oper-

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zation, with opportunities and threats being ex-

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ating within the same service area, coders are paid

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ternal (Buchbinder and Shanks 2017). Healthcare

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25 percent more than what healthcare organization

organizations have information management strate-
A is paying. Healthcare organization A concludes
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gic plans to guide the overall enterprise management

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that the reason experienced coders are not apply-

by
of information and information systems.

ing for open coding positions is because they can
20
20
be paid more at healthcare organization B. Health-

Information Management Strategic Plan
©
care organization A has the external analysis infor-

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Information is a strategic asset. A high level of

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mation needed to understand it must increase the

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oversight is required for information to be used

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wages of coders to be competitive within its’ service

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area. An assessment of the market would involve effectively for organizational decision-making,
determining the number of coding positions on performance improvement, cost management, and
the market and the eligible workforce looking for to lower risk to the company. A strategic plan for
work (Buchbinder and Shanks 2017). information management is vital for an organi-
zation to stay within the guidelines of legal and
Developing Strategic and Operational regulatory laws. Strategic information systems
Plans planning is described in the next section.
The process to develop a strategic and operational
plan begins with a SWOT (acronym for strengths, Strategic Information Systems Planning
weaknesses, opportunities, and threats) analysis. Strategic information systems planning is the
In a SWOT analysis, key leadership personnel process of identifying and prioritizing various
AB103118_Ch17.indd 535 2/11/2020 1:36:01 PM

upgrades and changes that might be made in an in research on how health IT can improve
organization’s information systems. The Office for health and care delivery
the National Coordinator (ONC) for Health Infor- ●● Goal 4: Enhance the nation’s health IP
mation Technology released a Federal Health IT
infrastructure (ONC 2015)
Strategic Plan for the years 2015 through 2020.
The four federal health IT goals in this plan are Healthcare organizations should use the ONC
the following: strategic plan in the development of their own IT
strategic plan to ensure compliance with federal
●● Goal 1: Advance person-centered and self- guidelines. The healthcare organization should in-
management health with the objectives to clude representation from all stakeholders who use
empower health management engagement health IT. For example, a laboratory manager may
and to foster partnerships want to implement a new technology that does not
n.
submit data to the EHR to perform lab tests. The
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●● Goal 2: Transform healthcare delivery
HIM manager may want to implement a release
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and community health by improving
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of information software system, but it does not
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healthcare quality and access, supporting
keep an audit trail of releases, which is required
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high-value healthcare, and protecting
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by law. After the strategic and operational plans
public health
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are developed and implemented, a healthcare or-
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Goal 3: Foster research, scientific knowledge, ganization will analyze the workflow and process
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●●
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and innovation by increasing access to and determine ways for improvement. (The ONC
information, accelerating the development n
strategic plan for health IT is discussed in chapter
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of innovative technologies, and investing 11, Health Information Systems.)
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Work Analysis, Change Management, and Project

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Management
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Work Analysis and Design

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The leaders of healthcare organizations must un-

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by
derstand what it takes to accomplish everyday Work analysis involves mapping the steps re-
20
workflow—the process and steps it takes to com- quired to complete a task from start to finish. It
20
plete a task. With new technology and advances in is the technique used to study the flow of opera-
©
healthcare delivery and processes, healthcare man- tions and is sometimes called operations analy-
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agers are required to manage change. Knowledge sis or workflow analysis. Similar to following a
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of the workflow makes needed changes easier to complex recipe while cooking a dish, the work
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identify. Work analysis is the process of gathering analysis for completing a trauma registry for
information about what it takes to get a job done. the state would include many steps, including
For example, a person tracks everything they do running a report on all trauma codes, analyzing
over a period of time, (a week or month), and how the records that belong on the registry, complet-
long it takes to do each task. Analysis of that infor- ing the trauma registry, and sending the report
mation determines what the job responsibilities to the state. A work analysis breaks down the
are. Change management is the formal process of workflow into its component parts. The goal
introducing change, adopting the change, and dif- is to determine if there are areas that slow the
fusing it throughout the organization. This section process of the job task under review. Figure 17.5
will explain work analysis and design, change man- shows a workflow diagram for completing the
agement, and the impact of change on processes. trauma registry.
AB103118_Ch17.indd 536 2/11/2020 1:36:01 PM

Figure 17.5 Workflow diagram trauma registry
• Create report using all the diagnosis codes for trauma

• Use the dates of visit for the prior quarter
Report • Access the records of everyone listed on the report
• Abstract the needed data from the records listed on the report
• Complete the required information on the trauma registry
Abstract
• Send the required trauma registry to the state
Submit
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Source: ©AHIMA.
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After analyzing the workflow, a job description, military uses a change management system called
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job classification, and job evaluation are created. VUCA, which is an acronym for volatility, uncer-
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A job description is a list of duties, reporting re- tainty, complexity, and ambiguity. Volatility means
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lationships, working conditions, and responsi- the situation is not stable and it is unknown how
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bilities for a particular job. Job classification is a io
long it may last. To combat volatility, one should
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method of job evaluation that compares a written be prepared. Uncertainty is not knowing if change
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position description with the written descriptions will or will not happen. The approach to uncer-
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of various classification grades, which make up tainty is investing in information – collecting,

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the formal salary structure of an organization. Job interpreting, and sharing it. Complexity means

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evaluation is the process of applying predefined the situation may have interconnected variables.
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compensable factors to determine their worth. It Resources can be built to manage complexity.

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allows the company to have guidelines and clear Ambiguity is the fact that no precedents exist and
boundaries of the scope of individual jobs; for exit is not known what is not known. The strategy
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ample, education level and credentials. The com- for dealing with ambiguity is to experiment with
by
pany is able to measure the work being done, and different situations and find the best solutions.
20
20
place employees in positions that best fit the needs Healthcare organizations and employers can im-
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of the company. Advances in technology and in- plement these change management strategies to
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formation systems happen quickly. Healthcare help with the fear and resistance to change. The
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workers are constantly changing their processes more information an employee is given the more
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and job tasks due to these advances and need to buy-in they will have in the changes taking place
stay on top of the analysis of their workflow. in their jobs (Butler 2019).
The key to having a smooth transition is in the
Change Management planning. By thoroughly analyzing how change is
Managing change is a challenging yet necessary going to affect the workflow and work procedures,
task for healthcare supervisors. Healthcare rules, the organization will be able to determine the best
regulations, and laws are passed with each con- course of action. Impact analysis is a collective
gressional session in the United States. Changes term used to refer to any study that determines
in payment methodologies, privacy, and security the benefit of a proposed project, including cost-
guidelines and other regulations, as well as up- benefit analysis, return on investment, benefits
dates in technology and healthcare delivery di- realization study, qualitative benefit study, or how
rectly affect HIM professionals regularly. The US change affects workflow.
AB103118_Ch17.indd 537 2/11/2020 1:36:02 PM

Project Management
Project management is a formal set of ●● Phase 4. Monitoring and Controlling:
principles and procedures to help control the activities During this phase, project deviations are
associated with implementing a large undertaking addressed and corrections made based on
to achieve a specific goal (such as an information deliverables. Communication of project
system implementation) that has a definitive be- status is important in this phase. This vital
ginning and end. There is never a shortage of proj- step takes place throughout the project so
ects to manage in healthcare. Projects range from the adjustments can be made as the project is
implementation of a new information system for taking place.
clinical documentation integrity to overseeing the ●● Phase 5. Closing: The team confirms that
n.
meaningful use program. The project management
the project scope and deliverables were met,
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life cycle, methodologies, tools and techniques, and
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including lessons learned and customer
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the project management profession are discussed in
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satisfaction (Eramo 2019). Closure of the project
the following sections.
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is an important tool to help identify areas that
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can be improved upon in future endeavors.
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Project Management Life Cycle
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The project management life cycle is the period Project Management Tools
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in which the processes involved in carrying out
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Project management is made easier by utilizing
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a project are completed, including the definition,
tools to track and analyze the steps and tasks
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planning and organization, tracking and analysis,

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within the project. Tools needed for project man-

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revisions, change control, and communication.

agement include a project plan, Gantt charts, and
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The following is an example of a project manage-

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PERT charts.
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ment life cycle as applied to HIM.

A detailed project plan identifies the individual
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The life cycle of project management includes

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steps to complete the project. Gantt and PERT charts

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the following five phases. Figure 17.6 shows the

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are visual tools used to manage the elements or

life cycle of a project, similar to figure 17.5; how-
steps of a project. A Gantt chart is a graphic tool
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ever, a project has a closing and is not continuous.

used to plot tasks and shows the duration of proj-
by
Phase 1. Project initiation: This phase outlines ect tasks (start and stop dates) and overlapping
20
●
20
an overview of the project, the high-level scope tasks (tasks that can be performed at the same time);
©
and project risks, the charter and support from in other words, it is used as a method to illustrate
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people affected by the project. This phase will the time needed for each task. It also includes who
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have a statement of work, a business plan, and is responsible for the task. A program evaluation
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a contract between stakeholders. and review technique (PERT) chart is a project

management tool that diagrams a project’s time
● Phase 2. Planning: Strategic planning, which
lines and tasks as well as its interdependencies.
is the overall approach of the project, and
Gantt charts focus on the percentage of completion
implementation planning, which is how the
for each task and may show a link between one or
project will be executed, take place during
more tasks with a critical path that identifies the
this phase. Also, a budget is created.
sequence of activities that must happen before
● Phase 3. Execution: This phase involves the next one can start. In the example mentioned
procuring resources for the project, executing earlier, the charts will indicate the time it takes to
tasks, and ensuring the performance of team complete the task of converting the filing system
members. This is the largest phase, where the for records. Figure 17.7 is a display of a Gantt
action takes place and the project is carried out. chart; figure 17.8 is a display of a PERT chart.
AB103118_Ch17.indd 538 2/11/2020 1:36:02 PM

Figure 17.6 Project management life cycle Project Management Professional

A project management professional (PMP) certifica-
tion is a credential offered by the Project Management
Institute (PMI). Individuals with this certification
Project Initiation demonstrate competency in the project manager role
and lead and direct projects and teams. The certifica-
tion examination covers the areas of initiating, plan-
ning, executing, monitoring, controlling, and closing
Planning
the project (PMI 2015). The HIM professional needs
to understand project management to manage the
implementation of new information systems, the
EHR, or new processes mandated by laws; for exam-
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ple, the implementation of the Health Insurance Por-
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Execution
tability and Accountability Act (HIPAA) mandated
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new privacy and security policies for healthcare or-
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ganization. The PMP certification is a highly desir-
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able and valued certification that could benefit HIM
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Monitoring and
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Controlling professionals looking to work as a project manager or
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wanting the knowledge and background of a PMP.
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The PMP credential certifies a person’s skills in
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the five project phases and the tasks associated
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Closing with each phase. The knowledge, skills, and abilities

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of a PMP include communication, human resource,

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finance management, integration, procurement, qual-

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ity, risk management, project scope, stakeholder man-

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Source: ©AHIMA. agement, and time management (Eramo 2019).

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Figure 17.7 Gantt chart

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Implementation of New Coding Software Hospital Wide

by
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6/1–6/7 6/8–6/14 6/15–6/21 6/22–6/28 6/29–7/5 7/6–7/12 7/13–7/19 7/20–7/26

20
Task Start Complete 1 2 3 4 5 6 7 8

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Phase 1 Design
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1.1 Identify Requirements 1 1

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1.2 Acquire Software 2 2

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1.3 Test Software 3 3

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Phase 2 Construct
2.1 Develop Training Program 3 4
2.2 Train Coders 4 4
2.3 Test Application 4 5
2.3.1 Unit Testing 5 5
2.3.2 System Testing 6 7
Phase 3 Pilot
3.1 Implement Software 7 8
3.2 Conduct System Training 7 8
3.3 Support Pilot 8 8
Ongoing Pre / Post Production
Weekly Team Meetings 1 8
Engage Stakeholders 2 8
Source: Najduch 2015a.Used with permission
AB103118_Ch17.indd 539 2/11/2020 1:36:04 PM

Figure 17.8 PERT chart

Implementation of New Coding Software Hospital Wide
Acquire
software Test software
1 week 1 week
Identify Implement
Test system
requirements system
Start Finish
1 week 1 week 1 week
Develop training
Train coders Audit
program for coders
1 week 2 weeks 1 week
Source: Najduch 2015a. Used with permission
n.
tio
ia
oc
ss
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en
em
1. What is a useful general tool for guiding day-to-day decisions?
ag
a. Operational plan
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b. SWOT
M
n
c. Strategies io
at
d. Strategic plan
m
r
2. What analysis shows the honest portrayal of the current and future state of the healthcare organization?
fo
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a. External analysis
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b. Workflow analysis
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c. Supply management analysis

an
d. SWOT analysis
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er
3. True or false: Values are a process by which the policies are put into action.
Am
4. What is the formal process of introducing change, adopting the change, and diffusing it throughout the
e
th
organization?
by
a. SWOT
20
b. Change management
20
c. Supply management
©
ht
d. Workflow
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5. Which of the following is the management and control of the supplies used within an organization?
op
a. Work analysis
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b. Staffing
c. Supply management
d. Strategic plan
Financial Management
Financial management is the mecha- for financial management with input from de-
nism that all businesses use to fully comprehend partment leaders. Knowledge of accounting and
and communicate their financial activities and sta- budgets is important for those tasked with the fi-
tus. Top-level executives are usually responsible nancial management of an institution.
AB103118_Ch17.indd 540 2/11/2020 1:36:05 PM

Accounting in a remote village in Alaska may use cash ba-

sis accounting for healthcare services rendered
Accounting is the process of collecting, recording,
because they do not bill health insurance and
and reporting an organization’s financial data in-
patients pay for services as they are delivered.
cluding the assets, expenses (defined later), and li-
Accrual accounting involves recording known
abilities of the company. It is important for the HIM
transactions in the appropriate time period before
professional to understand accounting methodol-
cash payments (receipts) are expected or due. A
ogies and budgets so they are prepared to manage
company records the revenue when it is earned
a department. The viability of a healthcare orga-
and records expenses as the transactions happen,
nization relies on financial management and the
not when it receives the cash or makes a payment.
revenues that enter the institution rely heavily on
For example, a large rehabilitation center will
the functions of the HIM department (for example,
write on their books the exercise classes that they
correct coding for reimbursement). Assets include
n.
provide, even if they have not been paid for those
tio
the human, financial, and physical resources of
classes yet. In healthcare, most organizations use
ia
an organization such as the employees, financial
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accrual accounting where cash or revenue reflects
ss
holdings, and physical buildings owned by the
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the amount the organization expects to receive for
organization. Expenses are the amount of money
en
the services provided. The HIM department may
charged as a cost to the organization, such as the
em
use the accrual accounting system for the release
ag
cost of utilities. Liabilities include the amounts the
of information function, charging for the service
an
organization owes to others, like loans.
M
of copying records, with revenue reflecting the
The financial stability of the healthcare orga-
n
io
amount expected from the patient.
at
nization depends on the ability to understand
m
the revenue and overall expenses each year. Rev-

r
Budgets
fo
In
enue is the recognition of income earned and the

A budget is a plan that converts the organization’s
lth
use of appropriated capital from the rendering of

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goals and objectives into targets for revenue and

services during the current period (CMS 2018),
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spending. A comprehensive organization master

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while expenses are the amounts charged as costs

ic
budget includes forecasted revenue (amount of

er
by an organization to the current year’s activities

Am
money expected for the year) and forecasted ex-

of operation. Revenue is earned through coding
penses (cost of doing business for the year). In reali-
e
th
and billing for healthcare services. Management

ty, the budget of a healthcare organization is several
by
must consider that they will not receive the entire

budgets, each addressing a specific need. For ex-
20
amount billed for services due to adjustments to

20
ample, the budget for an HIM department includes

claims. An HIM manager may choose to hire an in-
©
what is needed to staff and manage the required

ht
dependent coding consultant who can audit Medi-

ig
functions of the department. The HIM department

yr
care claims, which can result in higher revenue for

op
manager can use the budget to provide informa-

the organization. Expenses are either variable or
C
tion that allows her to forecast success or difficulty

fixed costs, with variable costs including resources
for the department by analyzing the projected staff
that change like supplies, while fixed costs remain
available to work during the upcoming holiday
constant like rent, wages, and equipment rental.
season when many employees are requesting time
There are two ways to record the transactions
off. There are many types of budgets, including the
in the financial books—cash basis accounting and
following operating, cash, and capital budgets:
accrual accounting. Cash basis accounting is reg-
istering the transaction when it occurs, meaning ●● Operating budget. This budget summarizes
when money is received for services provided, or the anticipated expenses for the day-to-day
paid for expenses incurred. This type of account- routine operations
ing is usually used in small businesses, because it ●● Cash budget. This is the forecast of expenses
is easier to manage. A small health clinic operating and revenue for one year; it includes the
AB103118_Ch17.indd 541 2/11/2020 1:36:06 PM

expenses predicted, the revenue forecast, Supply management

cash outflow and inflow, and the ending Supply management is the management and con-
cash on hand trol of the supplies used within an organization.
●● Capital budget. This budget refers to the It can be physical goods, services, information,
long-term plans for facilities and equipment or any resources needed to run the organization.
(Buchbinder and Shanks 2017) Knowing the supplies needed to run the healthcare
organization vastly improves and helps in manag-
Budget management involves the process of
ing a successful organization. In an HIM depart-
maintaining financial viability by ensuring op-
ment it is important for the manager to anticipate
erating revenues for the year are sufficient to
and include in the budget the costs that the de-
cover the operating expenditures (Harrison and
partment incurs with supplies, pens, paper, copy
Harrison 2013). Managers control their budgets
costs, coding books, and regulation documenta-
throughout the year by making adjustments or
n.
tion requirements.
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amendments when needed. A budget adjust-
ia
oc
ment is the approval to move funds from one
ss
budget to another. For example, an HIM depart- Staffing
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ment manager has a coding employee vacancy
en
Staffing is the managerial function that involves
em
for a period of time. The amount of money bud- proper and effective selection, appraisal, and
ag
geted to pay for that employee is not used, so a training of personnel. The HIM manager must be
an
budget adjustment could be made to move the
M
aware of (and budget for) the staffing needs of the
n
unused money into a different fund to cover the department and take into consideration employee
io
at
cost of something else such as overtime pay for paid time off, leave, and illness. When it comes to
r m
employees who are covering for the unmanned

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staffing, the manager should keep the following in

In
position. A budget variance is a difference in mind:

lth
the budgeted revenue or expense amount; for

ea
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instance, an HIM manager budgeted $10,000 ●● Staff recruitment and selection

an
for training coders during the current year and

ic
●● Performance management
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training actually cost the department $11,500.

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●● Staff retention
Therefore, the department has a negative budget
e
Employee relations and fair treatment

th
●●
variance of $1,500. Ideally, a positive variance
by
occurs when the projected revenue is higher or ●● Staffing planning and scheduling
20
the expenses are lower than projected, meaning Productivity

20
●●
©
the expenditures are within or below the amount ●● Training and development
ht
that was budgeted. Part of the budgeting process

ig
yr
involves supplies and staffing management. The For additional information on staffing and the
op
C
planning includes maintenance of contracts and managerial functions of staffing, see chapter 20,
services, utilities, and employee salary increases. Human Resources Management.
Management of Resources and Allocation

Healthcare organizations have limited budget includes an amount of money to be used
resources. Resources include money, people, tools, for information systems and the manager must
and technology. Resource allocation is a process decide between purchasing a software system
and strategy of deciding where resources should be to help with clinical documentation integrity
used to achieve the mission, values, and goals of the or an information system to track information
organization. For example, the HIM department needed for various registries because there is
AB103118_Ch17.indd 542 2/11/2020 1:36:06 PM

not enough funding for both. The manager must must have the current coding guidelines each
prioritize the needs of the department with legal year and cannot work with outdated codes; thus,
and regulatory issues that may affect the choice the department must purchase updated code
of resources. For example, the coding department books each year.
Management of Vendors and Contracts

A vendor is a company outside the a legal document that details the relationship
healthcare organization with which an HIM de- between two entities—for instance, between

partment conducts business; for example, coders the contracted coders and the HIM department.
may use an encoder that is owned and operated In this case the vendor is outside the coding
n.
by an external company (vendor). A contractor is department and the HIM department manager is
tio
ia
an outside company or individual who provides contracting with the vendor for coding services.
oc
or performs a service for the HIM department; Choosing a vendor or contractor includes iden-
ss
tA
for example, the coding functions could be con- tifying the need, designing the system, submit-
en
tracted to a company that specializes in coding. ting a request for information (ROI), analyzing
em
HIM professionals must understand the process the ROI, submitting a request for proposal (RFP),
ag
an
for selection, implementation, and managing of and establishing a contract for services with the
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outside vendors and contractors. A contract is chosen vendor.
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at
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Enterprise Information Management

In
lth
ea
Enterprise information management content for managing information as a corporate

H
an
(EIM) ensures the value of information assets, asset that ensures data quality, safety, and ease
ic
er
requiring an organization-wide perspective of of use (Johns 2014). With executive-level man-

Am
information management functions; it calls for agement decisions relying on the data and infor-
e
explicit structures, policies, processes, technolo- mation found within the organization’s health
th
by
gy, and controls. It also includes the infrastructure information systems, the importance of accurate,
20
and processes to ensure the information is trust- complete, and quality data becomes clear. Man-
20
worthy and actionable. EIM is the set of functions agement of information from the entire enter-
©
ht
used by organizations to plan and organize, and prise perspective is vital to quality patient care
ig
coordinate people, processes, technology, and and business viability.

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Management of Mergers
Mergers are business situations where A merger may entail a consolidation where two en-
two or more companies combine—one of them contin- tities combine to form one new entity (the surviving
ues to exist as a legal business entity while the other(s) entity), or it may be an acquisition where one entity
cease to exist legally and their assets and liabilities be- acquires part or all of the assets of the other; or it may
come part of the continuing company. Mergers com- be a stock acquisition where one entity acquires the
monly occur in healthcare with healthcare providers stock of the other entity. All organizations must deter-
and organizations attempting to streamline their mine the licensure, regulatory, and accreditation require-
operations and improve their competitive positions. ments before the operational issues of a merger.
AB103118_Ch17.indd 543 2/11/2020 1:36:06 PM

The HIM professional understands the operation- ●● Merging of department employees

al issues related to the management of information ●● How the master patient index (MPI) will
and the functions of the department and how they be handled (MPI information is found in
will be affected by the merger. Operational issues chapter 3, Health Information Functions,
for the HIM manager include the following: Purpose, and Users)
●● Single or multiple locations for HIM ●● How release of information will be handled
functions
The function of the HIM department must be re-
●● Integration of information systems viewed to guarantee compliance with state licensure
●● Completion of health records and regulatory requirements (AHIMA 2012).
n.
Management of Corporate Compliance
tio
ia
oc
and Patient Safety
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en
Corporate compliance is the process of establish- return for services and will tell their friends and
em
ing an organizational structure that promotes the family about their experience.
ag
prevention, detection, and resolution of instances
an
Risk Management and Risk Analysis
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of conduct that do not conform to federal, state,
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or private payer healthcare program requirements io
Risk management is a comprehensive program of
at
nor to the healthcare organization’s ethical and activities intended to minimize the potential for
r m
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business policies. In HIM, compliance includes injuries to occur in a healthcare organization and
In
managing a coding or billing department accord- to anticipate and respond to ensuring liabilities
lth
ea
ing to the laws, regulations, and guidelines that for those injuries that occur. Risk management
H
govern it. A compliance officer is a designated includes the processes that are in place to iden-
an
ic
individual who monitors the compliance pro- tify, evaluate, and control risk, defined as the or-
er
Am
cess at a healthcare organization. (Compliance is ganization’s risk of accidental financial liability.

discussed in more detail in chapter 16, Fraud and A healthcare organization as a whole has a risk
e
th
Abuse Compliance.) The HIM manager is responsi- management director or department to evaluate
by
ble for knowing and obeying laws that govern the and manage the potential for injuries that hap-
20
20
management of HIM functions including coding pen during the course of doing business—for ex-
©
and billing. A formal compliance program plan is ample, patient falls, patient infections occurring
ht
ig
the process that helps a healthcare organization ac- while being treated, or surgery on the wrong body
yr
op
complish its goal of providing high-quality health- part. HIM managers must handle risk in terms of
C
care and efficiently operating a business under coding and billing fraud and abuse (discussed in
various laws and regulations. The plan will include chapter 16, Fraud and Abuse Compliance). Managers
internal controls that promote adherence to appli- must know the laws and regulations governing
cable federal and state guidelines. Improving the HIM functions and educate staff on those items.
quality and safety of healthcare delivery should be Risk management programs is discussed in more
a goal of all healthcare organizations; risk manage- detail in chapter 10, Data Security.
ment and analysis determine how the healthcare Risk management begins with a risk analysis,
organization is reaching the goal of quality health- which includes identifying weaknesses in an or-
care and safety of patients. Customer satisfaction ganization’s operations and determining how
is critical to the health of an organization—when likely it is that any given threat may occur. An
customers are not happy, the organization will not HIM manager performs a risk analysis of the
stay solvent because unhappy customers will not HIM functions and procedures (such as coding
AB103118_Ch17.indd 544 2/11/2020 1:36:06 PM

and billing) to ensure the functions are being epartment, the manager may want to assess cus-
d
performed properly. tomer satisfaction with the process of attaining cop-
ies of patient immunization records. Customers can
Customer Satisfaction be considered internal or external based on their
Customer satisfaction is important to the healthcare relationship to the service. An internal customer
organization and to the HIM department. Custom- needing a copy of immunization records could be a
er satisfaction is a measurement of a customer’s surgeon who works for the healthcare organization.
expectations, either by falling short, meeting, or An external customer might be a parent who needs
exceeding the expectations. Customer satisfaction their child’s health records so the child can play
is usually determined using surveys that measure baseball at the local community center. A sample
satisfaction with services provided. In an HIM satisfaction survey is displayed in figure 17.9.
n.
tio
Figure 17.9 Customer satisfaction survey
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Customer Satisfaction Survey
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City Community Hospital
en
123 Main Street
em
Your City, ST 00111
ag
800-555-5555
an
M
Who received services at City Community Hospital? How would you rate how well the staff worked together on
n
□ Me your behalf?
io
at
□ My dependent □ Excellent
m r
□ Very good
fo
Were your important questions answered regarding your

In
condition or treatment by your healthcare providers □ Good

lth
(physician, nurses)? □ Fair

ea
□ Yes, always
H
□ Poor
an
□ Yes, sometimes Overall, how satisfied were you with the treatment and care
ic
er
□ No you received at City Community Hospital?

Am
□ I didn’t have any questions □ Excellent

e
□ Very good
th
Were the answers you were given presented in a way that you
by
could understand? □ Good

20
□ Yes, always □ Fair

20
□ Yes, sometimes □ Poor

©
□ No
ht
Overall, how satisfied were you with your provider?

ig
□ I do not have any questions □ Excellent

yr
op
How would you rate the skills of our staff in meeting or □ Very good
C
exceeding your expectations?

□ Good
□ Excellent
□ Fair
□ Very good
□ Poor
□ Good
Would you recommend City Community Hospital to your
□ Fair family or friends?
□ Poor □ Yes, definitely
□ Yes, probably
□ No
If no, why not?
Comments:
Source: ©AHIMA.
AB103118_Ch17.indd 545 2/11/2020 1:36:06 PM

HIM Roles
The roles for HIM professionals in cycle management, and enterprise information
terms of management are varied and vast. HIM management.
professionals understand the principles of manage- Healthcare organizations are concern about
ment as well as the delivery of healthcare across compliance with regulatory agency policies as well
the continuum of care. With the understanding as patient safety. The process improvement and
of the technology and systems used in a health- patient safety department of healthcare organiza-
care setting the HIM professional is uniquely tions address quality standards for care, for which
qualified to work in many settings, not only HIM professionals are able to understand, moni-
directly in healthcare but in related fields, for tor and correct processes that need to be changed
example insurance claims management, revenue within the work flow of patient care.
n.
tio
ia
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ss
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en
em
ag
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1. What process should an organization use to see if there are resources available to help accomplish the mission,
M
values, and goals of the organization?
n
io
at
a. Measuring
m
b. Process improvement
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fo
In
c. Resource allocation
lth
d. PERT chart
ea
2. What is a formal set of principles and procedures that help control the activities associated with implementing a large
H
an
undertaking?
ic
a. Resource allocation
er
Am
b. Project management
c. Project improvement
e
th
d. Financial management
by
20
3. What project management tool focuses on the percentage completion of a task and may show a link between one or
20
more tasks?
©
a. PERT chart
ht
b. Project management
ig
yr
c. Planning and design

op
C
d. Gantt
4. Which of the following is the process that all organizations and businesses use to fully comprehend and communicate
financial activities and status?
a. Financial management
b. Cash basis accounting
c. Budgets
d. Resource allocation
5. The process of maintaining financial viability by ensuring operating revenues for the year are sufficient to cover the
operating expenditures is called what?
a. Budge adjustment
b. Budget management
c. Budget variance
d. Accrual accounting
AB103118_Ch17.indd 546 2/11/2020 1:36:06 PM

6. Which of the following are amounts charged as costs by an organization to the current year’s activities of operation?
a. Budgets
b. Accrual accounting
c. Revenue
d. Expenses

Central Community Hospital hired review nurse who is responsible for ensuring that
Susan Davis as the new manager to work in the reimbursement authorizations are in place and
health information management (HIM) depart- managed. When Susan asked Intake why they
n.
tio
ment. One of the first items Susan reviewed was sent the documents to HIM, the answer was “be-
ia
oc
the workflow process for how documents were cause that’s how it has always been done.” When
ss
handled between the intake department and HIM. thinking about other ways the situation could be
tA
The intake department is responsible for assuring handled, Susan came up with the following ideas:
en
em
all documentation needed for a new admission to
Have Intake scan the documents into the
ag
●●
the hospital is received from the clinic that is ad-
an
mitting the patient. She noticed that the two de- electronic health record (EHR), and then
M
hand the copy to the utilization review
n
partments were managing a lot of the same work, io
nurse, leaving HIM out of the process; or
at
which created duplicate documents in the health
m
r
record. Intake would scan documents and then Once Intake is done with the document,
fo
●●
In
send them to HIM. HIM would receive the doc- instead of scanning it into the EHR, hand it
lth
uments and scan them as well. HIM would also directly to HIM, and continue with the rest
ea
H
copy the documents to send them to the utilization of the process.

an
ic
er
Am

e
th
by
The HIM department of a small criti- the project and discovered within a few weeks
20
20
cal access hospital in Alaska purchased telehealth that the director didn’t have the skills needed to
©
technology to allow the hospital to communicate manage the project. The supervisor sent the direc-
ht
with providers from across the state and the nation. tor to training in project management applications
ig
yr
The HIM director indicates that she has the skills and processes. The director was able to use proj-
op
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needed to manage the new telehealth project from ect management tools and resources and gain the
start to finish. Her supervisor asked her to manage skills needed to complete the project successfully.
References
Association. 2019. Register Health Information Association. 2017. Pocket Glossary of Health Information
Administrator Candidate Guide. AHIMA External Management and Technology, 5th ed. Chicago: AHIMA.
ADA Policies and Procedures. American Health Information Management
American Health Information Management Association. 2012. Identifying issues in facility and
Association. 2015. Privacy Statements for AHIMA’s provider mergers and acquisitions. Journal of AHIMA
websites. http://www.ahima.org/privacy. 83(2):50–53.
AB103118_Ch17.indd 547 2/11/2020 1:36:06 PM

Butler, M. 2019. Weathering the storm: How to lead BSC-Basics/Blog/ArtMID/2701/ArticleID/1119/

through the chaos of change. Journal of AHIMA Strategic-Planning-in-the-Healthcare-Industry.
90(1):12–15. Kellogg, D. 2012. Principles of Organization and Work
Buchbinder, S.B. and N.H. Shanks. 2017. Introduction to Planning. Chapter 18 in Health Information Management
Health Care Management, 3rd ed. Burlington, MA: Jones Technology: An Applied Approach, 4th ed. Edited by N.B.
& Bartlett Learning. Sayles. Chicago: AHIMA.
Centers for Medicare and Medicaid Services. 2018. McConnell, C. 2019. The Effective Health Care Supervisor.
https://www.cms.gov/apps/glossary/. Burlington, MA: Jones & Bartlett Learning.
Eramo, L. 2016. HIM, meet project management, why McNamara, C. n.d. Basics of Developing
project management is a skill growing in importance Mission, Vision, and Values Statements. https://
for HIM. Journal of AHIMA 87(1):20–23. managementhelp.org/strategicplanning/mission-
Harrison, C and Harrison, W. 2013. Introduction vision-values.htm.
to Health Care Finance and Accounting. Delmar, Office of the National Coordinator for Health
n.
Cengage Learning. Clifton Park, NY. Information Technology. 2015. Federal Health IT
tio
Strategic Plan. https://www.healthit.gov/sites/
ia
Johns, M.L. 2015. Enterprise Health Information
oc
Management and Data Governance. Chicago: AHIMA. default/files/9-5-federalhealthitstratplanfinal_0.pdf.
ss
tA
Johnson, T. 2017. Strategic Planning in the Healthcare Project Management Institute. 2015. PMI Certifications.
en
Industry. https://www.balancedscorecard.org/ http://www.pmi.org/certification.aspx.
em
ag
an
M
n
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at
m
r
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In
lth
ea
H
an
ic
er
Am
e
th
by
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20
©
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yr
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AB103118_Ch17.indd 548 2/11/2020 1:36:06 PM

Chapter
18
Performance Improvement
n.
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Darcy Carter, DHSc, MHA, RHIA
tA
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Miland N. Palmer, MPH, RHIA
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Learning Objectives
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•• Examine performance measurement principles •• Apply the elements of a quality assessment
n
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•• Examine quality improvement principles program
at
m
•• Discuss various performance improvement tools •• Identify major organizations that publish clinical
r
fo
and techniques used to facilitate communication, quality standards and guidelines

In
identify root causes, and collect, analyze, and report •• Articulate ways in which healthcare organizations
lth
ea
data manage the prevention and occurrence of adverse

H
•• Verify the fundamental principles of continuous events

an
performance improvement •• Examine the management of quality and

ic
er
•• Examine formal performance improvement performance improvement principles

Am
activities •• Discuss the importance of collecting and analyzing

e
•• Verify team-based performance improvement process data for performance improvement

th
principles •• Verify clinical quality management initiatives in

by
•• Explain team-based performance improvement healthcare

20
processes •• Explain the role of utilization management in

20
•• Examine the concept of quality and its importance regard to performance improvement
©
ht
in healthcare •• Identify the various process improvement

ig
•• Correlate the importance of patient safety and methodologies used in healthcare to improve
yr
op
national patient safety goals quality and patient safety

C
Key Terms
Accountable Care Organization Checksheet DNV GL Healthcare
(ACO) Claims management External customers
Affinity grouping Clinical practice guidelines Financial indicators
Agency for Healthcare Research Clinical protocols Fishbone diagram
and Quality (AHRQ) Common-cause variation Flow chart
Benchmark Customer Force-field analysis
Brainstorming Dashboards High Reliability Organization
Cause-and-effect diagram Data abstracts (HRO)
549
549
AB103118_Ch18.indd 549 2/6/2020 5:52:42 PM

Incident or occurrence report Outputs Run chart

Inputs Patient advocacy Scorecards
Internal customers Performance improvement (PI) Sentinel event
ISO 9001 certification Performance indicators Six Sigma
The Joint Commission Performance measurement Special-cause variation
Lean Potentially compensable event Standard
Lean Six Sigma Process indicators Statistical process control chart
Medication Reconciliation Process measure Statistics-based modeling
Multivoting technique Process redesign Structure indicators
National patient safety goals (NPSGs) Productivity indicators Structured brainstorming
Nominal group technique Quality indicators Systems thinking
Opportunity for improvement Risk Time ladders
Outcome indicators Risk management program Unstructured brainstorming method
Outcome measures Root-cause analysis Utilization management (UM)
n.
tio
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Throughout history and continuing today, there everyone involved at every level of the process.
ss
tA
are many individuals involved in the provision of In the US, the healthcare system needs improve-
en
healthcare services who are trying to improve the ment, achievement, and success. A death due to a
em
way services are provided, thereby enhancing out- medical error should never happen and healthcare
ag
an
comes or improving performance. Performance organizations are always finding ways to improve
M
improvement (PI) is the continuous study and ad- the way processes occur to prevent errors and
n
io
aptation of a healthcare organization’s functions tragedies in the future. This can be accomplished
at
m
and processes to increase the likelihood of achiev- through continual growth and progress guided
r
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ing desired outcomes. To be successful, these im- by quality and process improvement both depart-
In
lth
provement activities require the participation of mentally and system-wide.

ea
H
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ic
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Performance Measurement and Quality

Am
Improvement
e
th
by
20
Performance measurement is the process of com- (Meisenheimer 1997). Performance is measured

20
paring the outcomes of an organization, work unit, using one or more performance indicators—a
©
or employee against pre-established performance measure used by healthcare organizations to as-

ht
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plans and standards. Performance measurement sess the quality, effectiveness, and efficiency of
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is one of the most important concepts in the in- their services. Examples include financial indica-
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troductory discussion of quality improvement. tors and productivity indicators. Financial indi-
Healthcare professionals struggle with where to cators are a set of measures designed to routinely
focus their resources for quality improvement be- monitor the current financial status of a health-
cause there are so many areas in need of process care organization or one of its constituent parts.
improvement. According to the theoretical writ- An example of a financial indicator would be the
ings of general industry quality masters, the key to average cost per radiology exam compared to the
improvement rests in the measurement of the im- average insurance reimbursement amount received.
portant characteristics of individual organizations. Productivity indicators are a set of measures de-
Performance is “the execution of an activity or signed to routinely monitor the output and quality
pattern of behavior; the application of inherent of products or services provided to an individual,
or learned capabilities to complete a process a healthcare organization, or one of its constitu-
according to prescribed specifications or standards” ent parts; used to help determine the status of a
AB103118_Ch18.indd 550 2/6/2020 5:52:42 PM

productivity bonus. An example of a productivity high-volume, or problem-prone (such as discharge

indicator would be the number of patients seen not final billed [DNFB], coding compliance, or pa-
per physician per day. It is important to measure tient safety issues). Outcomes of care, customer
the aspects of performance that reflect quality and feedback, and the requirements of regulatory
point conclusively to the aspects of performance agencies are additional areas that healthcare orga-
that require improvement. The traditional perfor- nizations consider when prioritizing performance
mance improvement process and sentinel events measures. Once the scope and focus of perfor-
will be discussed in the next sections. mance monitoring are determined, the data collec-
tion requirements for each performance measure
Traditional Performance Improvement are defined (Shaw and Carter 2019).
Process As shown in step 2 in figure 18.1, measuring
Although a number of terms and acronyms represent performance depends on the identification of per-
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the PI concept (for example, continuous quality formance measures for each service, process, or
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improvement [CQI] and total quality management outcome determined important to track. A perfor-
ia
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[TQM]), this chapter uses PI. The key feature of mance measure is a quantitative tool (for example,
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a rate, ratio, index, or percentage) that provides an
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PI as implemented in today’s healthcare organiza-
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tions is that it is a continuous cycle, starting with indication of an organization’s performance in re-
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identification of the measures, performance meas- lation to a specified process or outcome. A perfor-
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urement, analysis and comparison, opportunities mance indicator is one measure and performance
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for improvement, and ongoing monitoring as dis- measures include multiple indicators that would
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played in figure 18.1. io
be looked at to measure performance. Monitoring
at
selected performance measures can help an orga-
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A logical starting point is to identify areas to mon-

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itor performance including important organiza- nization determine process stability or identify im-
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tion functions, particularly those that are high-risk, provement opportunities. Specific criteria define the
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Figure 18.1 Organization-wide PI process

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2. Measure
performance
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3. Analyze and compare

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internal/external
by
data
20
20
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Start
here 1. Identify
performance
measures
4. Identify
improvement
opportunity
5. Perform ongoing
monitoring
Source: ©AHIMA.
AB103118_Ch18.indd 551 2/6/2020 5:52:43 PM

organization’s performance measures. Compo- Number of incomplete health records that

nents of an effective performance measure include exceed the established standard
a documented numerator statement, a denomina-
Average monthly discharg es
tor statement (such as an error rate in coding with
the number of correctly coded health records as the Tracking this outcome allows the hospital to con-
numerator and the total number of health records tinuously monitor its deficiency rate or percentage
coded as the denominator), and a description of the of delinquent health records. If the health record
population to which the measure is applicable. In delinquency rate exceeds the hospital’s estab-
addition, the measurement period, baseline goal, lished performance standards (an internal com-
data collection method, and frequency of data col- parison) or nationally established performance
lection, analysis, and reporting must be identified standards (external comparison), an opportunity
(Shaw and Carter 2019). An example of this would for improvement has been identified (step 4 of
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be managing the DNFB report. A measurement figure 18.1). Corrective action must be taken when
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period is set monthly with a baseline goal of the a healthcare organization fails to meet a perfor-
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DNFB being under a specific dollar amount (such mance indicator.
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as $500,000). Data collection would occur weekly Step 5 is a culmination of the prior steps. Moni-
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and include the value of the charges on the out- toring performance based on internal and exter-
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standing health records. The health information nal data is the foundation of all PI activities. Each
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management (HIM) professional may then ana- healthcare organization, using its mission, scope
an
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lyze (step 3 of figure 18.1) the DNFB weekly and of care, and services it provides, must identify and
report both weekly and monthly averages to the n
prioritize which processes and outcomes (in other
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chief financial officer (CFO). Based on the DNFB words, which types of data) are important to mon-
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data, performance improvement activities may itor. For example, a healthcare organization would
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be initiated if a pattern of high DNFB is observed. monitor its performance on patient satisfaction
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The sum total of the performance measures ap- using both internal data that have been collected
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plicable to a healthcare organization make up the from patients regarding their level of satisfac-
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performance measurement system required in the tion and external data from other organizations
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hospital accreditation processes. to compare their performance with that of similar

Accreditation organizations such as The Joint organizations.
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Commission, Healthcare Facilities Accreditation Performance monitoring is data driven. The key
by
Program, and DNV GL Healthcare (defined later to successful monitoring is the appropriate analy-
20
20
in this chapter) are examples of external resources sis, display, and application of measurement data.
©
used to establish the performance measures for a This is accomplished efficiently with dashboards.
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healthcare organization. If a healthcare organiza- A dashboard is the “display of the most important
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tion fails to meet the accreditation organization’s information needed to achieve one or more objec-
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standards, site surveyors will cite the healthcare tives that has been consolidated… so it can be moni-
organization with a requirement for improvement tored at a glance” (Few 2013, 26). A dashboard can
if the threshold for the measurement is exceeded. be disseminated in either electronic or paper format.
The monthly delinquent health record rate is The organization’s leadership uses the information
one important outcome hospitals are required to displayed on the dashboard to guide operations
monitor continuously. To establish this perfor- and determine improvement projects. Having
mance measure, the following criteria and formula real-time data in an easily accessible format like
are used. The monthly delinquent health record a dashboard allows leaders to keep track of high-
rate is calculated by taking the number of incom- impact, high-risk, or high-value processes and
plete health records that exceed the established make adjustments on a daily basis if needed. For
standard and dividing it by the average monthly example, a dashboard can show the DNFB at differ-
discharges. ent healthcare facilities within an organization.
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Additional information on data presentation is in are better able to address situations that may lead
chapter 13, Research and Data Analysis. to an adverse patient outcome.
Every department in a healthcare organization
should continuously monitor its key performance Sentinel Events
indicators. The following are tips for identifying The Joint Commission requires healthcare organi-
and monitoring key performance indicators for zations to conduct in-depth investigations of oc-
HIM functions: currences that resulted—or could have resulted—
in life-threatening injuries to patients, medical
●● Collect information at the appropriate level
staff, visitors, or employees. The Joint Commission
of detail needed to monitor performance
uses the term sentinel event for such occurrences.
●● Monitor the overall performance of the A sentinel event, therefore, describes an occur-
department using a number of indicators rence with an undesirable outcome usually hap-
appropriate for the size and complexity of
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pening only once. The occurrence, however, points
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the department to serious issues involved in care processes that
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●● Divide the department into the units where must be resolved so this does not happen again.
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specialized work is performed
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Examples of sentinel events include medical er-
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●● Find measures that describe the unit’s rors, explosions and fires, acts of violence, removal
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performance over time, recording on a daily of the wrong body part, and obstetric death. When
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basis and reporting on a weekly basis these occur, the healthcare organization is required
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Design a report that can track data over to prepare a detailed report of its investigation
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●●
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to explain the root cause of the event in order to
time, including percentage measures to
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identify problem areas avoid recurrence of similar events in the future.

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The Joint Commission issues sentinel event alerts

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●● Design a dashboard that can be used to

when it detects a pattern of similar events report-
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monitor key indicators in real time

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ed by the healthcare facilities it accredits and uses

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When all departments in a healthcare organiza- its sentinel events data as a basis for its National
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tion continuously monitor their performance, they Patient Safety Goals.

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Quality Dimensions of Performance Improvement

by
20
20
There are three types of quality indi- including patient and family satisfaction
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cators, or standards against which patient care is (Donabedian 1988).

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measured to identify a level of performance for

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that standard. Quality has both a technical and an interperson-

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al dimension. The technical dimension recognizes

1. Structure indicators measure the attributes that caregivers must have the knowledge and judg-
of the healthcare setting, such as number ment to arrive at an appropriate strategy for pro-
and qualifications of the staff, adequacy viding service and the technical skills to execute it.
of equipment and facilities, and adequacy The interpersonal aspect recognizes that caregivers
of organizational policies and procedures. must have the communication skills and social at-
2. Process indicators measure steps in a tributes necessary to serve patients appropriately.
process and tasks people, or devices do, from The interpersonal aspect of quality recognizes the
conducting appropriate tests, to making a importance of empathy, honesty, respectfulness,
diagnosis, to carrying out a treatment. tactfulness, and sensitivity to others. It is far easier
3. Outcome indicators measure the actual to measure quality’s technical dimension than its
results of care for patients and populations, interpersonal dimension (Donabedian 1988).
AB103118_Ch18.indd 553 2/6/2020 5:52:45 PM

Contemporary Approach to Process Improvement

The contemporary approach to process depends on the pharmacy to provide the medica-
improvement is much more proactive tions needed to fill the physician’s orders for his or
than the traditional quality management approach. her patients. As the importance of the perceptions
Although process improvement uses several tra- and requirements of external healthcare customers
ditional quality management techniques such as becomes clear, the need for a standardized compa-
quality indicators, most often its primary focus rable way to measure their perceptions and opin-
is on continually making small, targeted changes ions is apparent.
for improvement that over time lead to significant The Centers for Medicare and Medicaid Services
overall improvement. Process improvement is a (CMS) and the Agency for Healthcare Research
mindset that, when adopted into organizational and Quality (AHRQ) collaborated to develop the
n.
culture, can produce significant and continuous Hospital Consumer Assessment of Healthcare
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improvement. Process improvement is a proactive Providers and Systems (HCAHPS) survey. This
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cycle that ensures key processes, products, and was the first standardized survey used to compare
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services are performed efficiently and within set hospital performance and quality at the national
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quality standards. One key to successful process level. Hospitals are required to administer and
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improvement is proactively measuring, monitor- participate in this survey if they provide services
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ing, and improving indicators before the process to Medicare patients. The results from this survey
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or indicator is considered broken or unacceptable. are informative to process improvement projects
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An example would be putting an effective coding io
within hospitals as hospitals can use these results
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compliance plan in place that includes measuring, to identify areas that need improvement. Consum-
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monitoring, and improving the coding in the fa- ers may also access the results of the surveys at
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cility before a negative outside audit or noncom- the US Department of Health and Human Services
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pliance fine is assessed and the in-house auditing (HHS) website and use the information to make
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process or coding product is determined to be informed decisions about which providers and
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unacceptable. Opportunities for improvement are hospitals they would like to use. Depending on the
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identified by gathering and analyzing data on an indicators used by the hospital and the informa-
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ongoing basis. Process improvement assumes that tion needs to measure those indicators, organiza-
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organizations should continuously and systemati- tions may use supplemental survey tools to gather
by
20
cally identify and test small, planned changes in that information. Often, contractors or consultants
20
processes and systems. design and administer the surveys; only approved
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As process improvement practices have contractors can administer the HCAHPS survey.
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evolved, an important focus on the opinions of Another means by which customers can see how
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customers has developed. Many organizations a healthcare organization performs is through the
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and quality experts define quality as meeting or ex- publication of scorecards. As discussed earlier, qual-
ceeding customer expectations. External custom- ity has many dimensions. Healthcare leaders cannot
ers are those people outside the organization for just focus on one aspect of quality (such as financial
whom it provides services. For example, the exter- measures) without also considering other aspects
nal customers of a hospital would include patients, (such as patient satisfaction or clinical quality) or
third-party payers, and the department of health. they miss the whole picture. Scorecards are tools
Organizations also have internal customers such that present metrics from a variety of quality aspects
as employees. The employees receive services in one concise report. They may present measures
from other areas in the organization that make it of clinical quality (such as infection rates), financial
possible for them to do their jobs. For example, a quality, volume, and patient satisfaction. Several
nurse in an intensive care unit would be an inter- sources, including healthcare organization as well
nal customer of the hospital pharmacy; the nurse as local and national agencies provide scorecards.
AB103118_Ch18.indd 554 2/6/2020 5:52:45 PM


1. The administration at Community Hospital has received several complaints about food services from patients recently
discharged from the hospital. Administration has decided to review the patient responses to the survey they provide
to patients upon discharge in order to monitor the performance of food services at the hospital. In this example, which
of the following is driving the performance monitoring?
a. The mission of the organization
b. The process improvement team
c. Data
d. Experts
2. Which of the following provides real-time process measure metrics in a consolidated format?
n.
a. Structure indicator
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b. Outcome indicator
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c. Dashboard
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d. Time ladder
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3. Fifty percent of the HIM staff has a nationally recognized credential. This is an example of which type of indicator?
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a. Outcome
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b. Process
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c. Structure
d. Internal
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4. The focus of PI should be on which of the following?
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a. Interpersonal skills
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b. Customers
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c. Financial stability of the organization

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d. Employees
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5. University Hospital tracks the number of patients that are diagnosed with a urinary tract infection that was not present
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when the patient was admitted to the facility. This is an example of a(n):
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a. Financial indicator
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b. Outcome indicator
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c. Process indicator
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d. Structure indicator
20
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Fundamental Principles of Continuous Performance

Improvement
The fundamental principles of performance im- ●● Staff and management must be involved in
provement include the following: the process
●● The problem is usually the system ●● Setting goals is critical
●● Variation is constant ●● Effective communication is important
●● Data must support PI activities and decisions ●● Success should be celebrated
●● Support must come from the top down These principles are discussed in detail in the
●● The organization must have a shared vision sections that follow.
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The Problem Is Usually the System Variation Is Constant

Problems in patient care and other areas of the Every system has some degree of variation built
healthcare organization are usually symptoms of into it. No system produces the exact same out-
shortcomings inherent in a system or a process. A put every time. It is desirable to reduce varia-
system is a set of related and highly interdepen- tion within systems as much as possible so that
dent components that are operating for a particular system output can be more predictable, better
purpose. Every system has inputs or data entered controlled, and the system can be more relia-
into a hospital information system (for example, ble (Omachonu 1999). Variation that is inherent
in the hospital’s Admission Discharge Transfer - within the system is common-cause variation.
Registration (ADT-R) system, the patient’s knowl- For example, when a nurse takes a patient’s
edge of his or her condition, the admitting clerk’s blood pressure, she may believe she is per-
knowledge of the admission process, and the com- forming the procedure in exactly the same way
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puter with its admitting template are all inputs). every time, but in practice she will get slightly
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The system processes the inputs and eventually different readings each time. Although the blood
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produces outputs, or the outcomes of inputs into pressure cuff, patient, and nurse are all the same
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a system (for example, the output of the admitting inputs into the system, variations can occur. For
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process is the patient’s admission to the hospital). example, the cuff may be applied to a different
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One system’s outputs may then become inputs place on the patient’s arm. The patient may have
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for another system. Healthcare organizations are a slightly different emotional or physiological
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large systems; each department in a healthcare or- status at the time of the measurement. The nurse
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ganization is a system with numerous subsystems. may have a different level of focus or concen-
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The admitting department in a hospital is a tration. Any one of these (or other) factors can
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system that exemplifies inputs, outputs, and the affect the values obtained. However, they are
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interrelationship between processes. When a pa- potentially present in every single episode of blood
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tient enters the hospital, he or she presents to the pressure measurement in every single patient.
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admitting clerk. The clerk uses a computer to col- It is important to recognize not every variation is
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lect data for the ADT-R system. This information a defect. The variation may just be an example of
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system collects data on patients admitted to the common-cause variation.

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healthcare organization. The process begins with Factors outside of the system may cause varia-
by
the clerk asking for the patient’s address, insur- tions. This type of variation is special-cause varia-
20
ance coverage, and reason for admission, as well tion. If the special cause produces a negative effect,
20
as the patient’s responses. The output of the proc- identify the special cause and eliminate it, if possi-
©
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ess is the patient’s admission to the hospital and ble. If the special cause produces a positive effect,
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a completed face sheet (which includes patient reinforce it so this positive effect will continue and
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information, demographics, insurance information, perhaps be expanded into the processes of others
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emergency contact) for his or her health record. in the organization. An example of this type of
These outputs are viewed as inputs into the next variation occurs when a patient is diagnosed with
system which in the hospital is the EHR. hypertension and the physician prescribes a blood
Systems thinking is a vital part of PI and is an pressure medication for the patient. After the pa-
objective way of assessing work-related ideas and tient takes the blood pressure medication, there is
processes with the goal of allowing people to un- a substantial drop in the blood pressure measure-
cover ineffective patterns of behavior and thinking ment. All the factors (diet, exercise, stress, family
and then finding ways to make lasting improve- history) have remained unchanged demonstrating
ment. This requires individuals to think about pat- that the medication caused the decrease in blood
terns and interrelationships between work units in pressure values, which is considered a special
the organization. cause. In this situation, the variation is intentional
AB103118_Ch18.indd 556 2/6/2020 5:52:45 PM

and desired. In other situations, the variation may potential areas for improvement efforts as well as
produce an undesirable and unintentional effect. the success of changes already implemented.
For example, if a patient is upset about a phone PI activities must identify the best method for
call he received just before the nurse came in to obtaining timely, accurate, and relevant data. Ex-
take his vitals, his blood pressure may register examples of data collection methods and instru-
ceptionally high. The change in values occurred ments include retrospective health record review
due to a special cause (phone call) and resulted with specific quality criteria, surveys, direct obser-
in a blood pressure reading much higher than vation, and individual or focus group interviews.
expected. Electronic health records (EHRs) have allowed
Similar examples of special-cause variation healthcare organizations to implement and auto-
exist in HIM operations. For example, common- mate data collection. Data collection alone is not
cause variation can be observed in the number of enough. Careful data analysis is required to build
n.
health records that can be coded each day. On a knowledge and inform process improvement
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day when one of the regular coders is out sick, the efforts.
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number of health records coded might drop signif-
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icantly because the coder will have no productive Support Must Come from the
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Top Down
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work time while home sick leaving the team short
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staffed. This would be an example of special-cause PI must become a part of the healthcare organiza-
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variation. Ideally, the goal is to remove special
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tion’s culture. It is vital that the executive leaders
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causes if they create an undesirable effect. When of the organization believe in its value for it to per-
trying to control and reduce variation in a process n
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meate the entire organization. Leaders must also
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it is important to remember there are staff with dif-
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ensure their management teams are well versed

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fering levels of expertise and patients with diverse in the principles and techniques of continuous
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levels of severity.
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PI. More information on organizational culture is

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in chapter 21, Ethical Issues in Health Information

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Data Must Support Performance Management.

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Improvement Activities and

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The Organization Must Have a

Decisions
Shared Vision
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PI activities should be guided and driven by data

by
The organization’s executive leaders and board of

in order to ensure an informed process. PI activities
20
directors are responsible for developing and com-

20
conducted without the use of reliable data are just

municating a clear vision of the organization’s
©
a guess. In the burgeoning era of big data, organi-

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future. The organization’s vision, mission, and

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zations and teams must be careful not to become

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values set its direction and support the norms it

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overloaded with data. Data, transformed into in-

considers important. These statements guide em-
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formation through proper analysis, are a key tool

ployees as they make their own contributions to
to the success of PI activities. Collection and anal-
the organization in fulfilling their professional
ysis of appropriate data will provide a solid foun-
responsibilities. See chapter 1, Health Information
dation for PI activities and improve the chances of
Management Profession, for more information on
success (Strome 2013). Before PI was a generally
mission and vision.
accepted practice, healthcare organizations relied
on unsupported assumptions about which pro-
cesses were functioning well and which ones were Staff and Management Must Be
not. However, objective and accurate assessment Involved in the Process
cannot occur without concrete data. Collecting PI depends on everyone in the organization ac-
and analyzing data provides information about tively seeking to meet the spoken or anticipated
the current processes, their effectiveness, and their needs of internal and external customers. This
AB103118_Ch18.indd 557 2/6/2020 5:52:46 PM

is particularly important for employees who Effective Communication Is Important

have direct contact with external customers as
Effective communication is essential for the PI
they may be in the best position to recognize
process to work. Communication must exist at all
when customer needs are met. Often employ-
levels of the organization and in all directions.
ees offer helpful ideas for improvement. Staff
Openly identifying and discussing problems is not
should be empowered to make a difference for
always comfortable or easy. However, an organization
their fellow employees and the patients they
that is committed to serving its customers must view
serve.
problems as opportunities for improvement. Two-
way communication is effective and requires clear,
Setting Goals Is Critical
articulate, and tactful speaking. More importantly, it
All PI programs must have established goals or requires careful, attentive listening and u
nderstanding.
targets the organization strives to achieve in a giv- Organizations need to listen to their customers—both
n.
en PI program year. Each goal should be specific
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internal and external—so they can hear informa-
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and define measurable end results. For end results tion about which services need improvement.
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to be measurable there must be data collection and
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evaluation of that data. An example of an organ-
Success Should Be Celebrated
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izational goal might be: To provide high-quality
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patient care that is cost-effective. Although PI demands healthcare organizations focus
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After establishing goals, specific, measurable on identifying and addressing problems, it also must
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objectives that can be completed within a certain celebrate the organization’s successes. A celebration
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time frame should be identified. An objective asso-
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of success communicates to everyone the partici-
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ciated with the previously mentioned goal might pants’ efforts are applauded, success can result from
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be: By the end of the year, a high-quality, cost- such efforts, and others should be encouraged to par-
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effective care program will be designed for the ticipate in PI initiatives. The people involved in im-
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management of diabetes patients. proving the process are recognized and appreciated.
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Formal Performance Improvement Activities

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Managers should feel empowered to data, or uses data from similar external organiza-
by
monitor all processes within their supervision and tions, it helps establish an organizational bench-
20
20
responsibility, making small adjustments where mark. A benchmark is a systematic comparison of

©
necessary, and identifying when a more in-depth, one healthcare organization’s measured character-
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formal approach is appropriate. Daily monitor- istics with those of another similar organization
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ing and minor process adjustments performed or with internal, regional, or national standards.
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by a single manager are informal and more of a For example, an HIM department will track their
maintenance activity. Once a manager identifies health record deficiencies on a monthly basis and
an issue through the monitoring process, it re- compare their deficiency rate to that of similar
quires a structured, formal PI intervention. The sized facilities. Often, further study or more fo-
scope of the process, complexity of the problem, cused data collection on a performance measure is
and involvement of other systems or departments warranted when data collection results fall outside
should influence how formal the process should the established benchmark. This is the “monitor-
be and who should be involved. ing and improving customer satisfaction” process
Data collection and analysis is a vital part of PI; (Shaw and Carter 2019, 114). Opportunities for im-
and benchmarking is an important PI data analy- provement are often discovered when unintended
sis tool. When an organization compares its cur- events and patterns are observed during continu-
rent performance to its own internal historical ous monitoring. This technique is best represented
AB103118_Ch18.indd 558 2/6/2020 5:52:46 PM

as the “team-based performance improvement monitoring where data is collected on each patient
process” (Shaw and Carter 2019, 28–30). The inter- from the health record and recorded in the speci-
dependency and interrelation of these processes fied fields of an abstract on paper or electronically.
is important and will be discussed later in this
chapter. Time Ladders
PI initiatives use a number of tools and tech- Time ladders support the collection of data that
niques. Some of the tools facilitate communication must be oriented by time; they specify intervals of
among employees while others help people de- time necessary to address the problem under con-
termine the root causes of performance problems. sideration listed down the right side of one, two,
Some tools indicate areas of agreement or consen- or three columns. Then, as the data collector ob-
sus among team members. Others permit the dis- serves, he or she records events next to the time of
play of data for easy analysis. occurrence. For example, a receptionist could re-
n.
cord on a time ladder when a patient arrives at his
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Checksheets
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or her workstation and then record again on the
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A checksheet is a data collection tool that records same time ladder when the patient goes to an exam
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and compiles observations or occurrences. The room. To visualize how the receptionist’s other du-
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checksheet consists of a simple list of categories, ties have an impact on his or her interactions with
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issues, or observations on the left side of the health patients, he or she could also be asked to record
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record and a place on the right to record incidenc- timing of phone calls, provider requests for assis-
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es by placing a checkmark (see figure 18.2). When tance, and other competing tasks. Collecting time
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the data collection is finished, the checkmarks are
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ladder data over an appropriate period develops a
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counted to reveal any patterns or trends. A check- detailed, clear picture of the workflow or process.
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sheet is a simple way to obtain a clear picture of Another example is a time ladder created from
In
lth
the basic facts. After data are collected, other tools computer-based data. For example, the EHR could
ea
may be used to display the data and help analyze be used to generate a report documenting the
H
an
them more easily. time of arrival for patients without appointments.

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Using this data from a substantial period of a month

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Data Abstracts or more, clinic management could anticipate the

e
Data abstracts are a defined and standardized set need to keep a specific number of appointment slots
th
by
of data points or elements common to a patient available for walk-ins. Figure 18.3 shows an exam-
20
population that can be regularly identified in the ple of a time ladder.

20
health records of the population and coded for

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use and analysis in a database management sys-

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tem. The data abstracts are used in clinical process Figure 18.3 Time ladder
yr
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Patient #1 arrived 9:00 3 calls from patients

Figure 18.2 Checksheet Request to make call from clinician
Patient #2 arrived 9:15 4 calls from patients

Coders Patient #3 arrived Print forms for patient #1
Issue Observed 1 2 Total Patient #1 to exam room 9:30 3 calls from patients
Print forms for patient #2
Missing Request for specialist consult patient #1
9
documentation Patient #4 arrived 9:45 5 calls from patients
Patient #2 to exam room Print forms for patient #3
Missing Patient #5 arrived Print forms for patient #4
5
authentication Patient #3 to exam room 10:00 1 call from patient
Patient #4 to exam room Print forms for patient #5
Physician query
8 Patient #5 to exam room 10:15 Schedule appointment for patient #2
required
Source: ©AHIMA. Source: ©AHIMA.
AB103118_Ch18.indd 559 2/6/2020 5:52:48 PM

Statistics-Based Modeling Techniques of how a process is performing and whether an

With increased implementation of EHRs, the improvement effort has worked.
amount of data collected by and available to health- A statistical process control chart looks like a
care facilities is growing exponentially. The best run chart except that it has reference lines indicat-
way to use and apply this data is through statistics- ing the upper control limit (UCL) and lower con-
based modeling. Statistics-based modeling is the trol limit (LCL) drawn horizontally at the top and
use of analytical and graphical techniques to assist bottom of the chart. The upper line represents the
in the display and interpretation of raw data. Two UCL, and the lower line represents the LCL. In fig-
common statistical-based modeling techniques ure 18.5, the middle line represents the mean and
are run charts and process control charts. A run the line above represents two standard deviations
chart displays data points for a specific time frame above the mean. The line below the mean repre-
to provide information about performance (see sents two standard deviations below the mean. Re-
n.
tio
figure 18.4). In a run chart, the measured points member, two standard deviations from the mean
ia
of a process are plotted on a graph at regular time statistically include 95 percent of the observations
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intervals to help team members identify whether of a process and three standard deviations include
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there are substantial changes in the numbers over 99 percent (see chapter 13, Research and Data Analy-
en
time. For example, suppose an HIM professional sis, for more information on calculating statistics).
em
ag
wished to reduce the number of incomplete health Like the run chart, the statistical process control
an
records in the HIM department. He or she might chart plots points to show how a process is per-
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first plot the number of incomplete health records forming over time. However, the two control limit
n
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each month for the past six months. Based on an
at
lines permit the evaluator to use the rules of prob-
m
analysis of the health records process, he or she ability to interpret whether the process is stable (in
r
fo
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then might enact a change designed to improve other words, predictable and within the bounds of
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the process. The data collection should continue probability) or out of control (many points of data
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after the change is made to determine its effect on

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outside the second or third standard deviations).

an
the process. If the run chart then indicated that the The statistical process control chart makes it
ic
er
number of incomplete charts had decreased post- possible to see whether the variation within a
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change, the HIM professional could attribute the process is the result of a common cause or a spe-
e
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decrease to the improvement effort. A run chart is cial cause. It lets the PI team know whether the
by
an excellent tool for providing visual verification team needs to try to reduce the ordinary variation
20
20
©
Figure 18.4 Run chart

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Measurement
Time
Source: ©AHIMA.
AB103118_Ch18.indd 560 2/6/2020 5:52:49 PM

Figure 18.5 Statistical process control chart
Incomplete Charts
60
55
+2 SD
50
45
40
–2 SD
35
30
25
January February March April May June
n.
Source: ©AHIMA.
tio
ia
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occurring through common cause or to seek out that would stay within the two or three standard
ss
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a special cause of the variation and try to elimi- deviations of the mean, whereas a special-cause
en
nate it. Removing the variation will bring the up- variation is more likely to produce patterns that
em
per and lower control limit lines closer together. will exceed the limits of chance of the two or three
ag
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Common-cause variation would produce patterns standard deviations.
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at
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ea

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1. The type of variation caused by factors outside a system is a(n):

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a. Input or output
er
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b. Processes
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c. Common-cause variation
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d. Special-cause variation
by
20
2. Which tool displays performance data over time?

20
a. Benchmark
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b. Run chart
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c. Checksheet
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d. Time ladder
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3. Community Hospital has reviewed their nosocomial infection rate for the past quarter and found that it is 0.2 percent.
Community Hospital then compares their rate with that of a similar hospital across town and finds that the other
hospital has a rate of 0.3 percent. This is an example of which of the following?
a. Checksheet
b. Data abstract
c. Run chart
d. Benchmark
4. Lisa is a coding auditor at a local hospital. As part of her coding review process she is tallying each instance that a coder
incorrectly assigns the discharge disposition for a patient. Which of the following data collection tools is Lisa using?
a. Checksheet
b. Flow chart
c. Time ladder
d. Fishbone diagram
AB103118_Ch18.indd 561 2/6/2020 5:52:50 PM

5. A set of related and highly interdependent components that are operating for a particular purpose is called a:
a. System
b. Benchmark
c. Statistics-based model
d. Run chart
Team-Based Performance Improvement

The combined cognitive ability of teams related to the process need to be explored and
can be an important tool in PI because of the com- established. The team can then work toward
plex issues faced in healthcare. Team-based PI modifying the process to meet the customers’
n.
tio
begins with the assembly of the team. Staff with requirements.
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knowledge and background in the process un-
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der examination should be included. In addition, Documenting Current Processes and
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staff members accept change and transition easier Identifying Barriers
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when they have been part of the decision-making The process improvement team members work to-
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process. gether to discuss and document current processes
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The team’s success depends on the following
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and identify barriers to establishing successful
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nine elements: io
processes. For this step, the team’s knowledge is
at
m
1. Establishing ground rules for the team vital because members must answer the following
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(described in chapter 19, Leadership) questions:

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2. Stating the team’s purpose or mission What is the current process?

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●●
(described in chapter 19)

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Where are the start and end points of the

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●●
3. Identifying customers and their requirements process?
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4. Documenting current processes and

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●● What are the inputs, outputs, and

identifying barriers interdependencies?
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5. Benchmarking
by
●● What is the potential for error in the process?

6. Collecting current process data
20
What are the barriers to the process?

20
●●
7. Analyzing process data
What are the gaps to meeting the customer’s
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●●
8. Process redesign
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needs?
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9. Recommendations for process change

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Benchmarking
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Except where noted, these team-based perfor-

mance elements are discussed in detail in the sec- Benchmarking compares an organization’s perfor-
tions that follow. mance against that of external standards. Health-
care organizations routinely use benchmarking as
Identifying Customers and Their a way to measure their performance. When bench-
Requirements marking for PI, a healthcare organization compares
The PI team must identify the customers associ- its performance data with that of a similar health-
ated with the processes under discussion. Keep care facility and uses the findings to determine areas
in mind customers are both internal (for example, that need improvement. Benchmarking also increas-
the healthcare organization’s business office) es motivation to improve processes and outcomes
and external (for example, third-party payers). through comparison to potential competitors and
Once customer groups are identified, their needs similar departments.
AB103118_Ch18.indd 562 2/6/2020 5:52:50 PM

Collecting Current Process Data Figure 18.6 Flow chart
Once performance monitoring identifies an im-

Start
provement opportunity, the first task of the PI pro-
cess team is to research and define performance
expectations for the process targeted. For example,
performance monitoring of coding productivity Process
identifies that coding staff is consistently not meet-
ing previously set productivity standards.
PI teams have a variety of tools they employ,
such as flow charts, brainstorming, diagramming, No
Decision
and force-field analysis (described in the following
sections) that make it easier to gather and analyze Yes
n.
tio
information; and they help team members remain
ia
focused on PI activities and move the process
oc
Process
ss
along efficiently. The PI team should also use any
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information from routinely monitored processes
en
as relevant to the targeted process.
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No
Decision
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Flow Chart Current Process
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A flow chart is a graphic tool that uses standard
n
io Yes
at
symbols to visually display detailed information,
m r
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including time and distance of the sequential flow Process

In
of work of an individual or a product as it pro-

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ea
gresses through a process. A flow chart should be

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created to illustrate the current process used be-

an
No
cause the team must first examine and understand
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Decision
er
the current process before making improvements.

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Each team member has a unique perspective on Yes

e
th
and significant insight into how a portion of the

by
Stop
process works. Flow charts help all the team mem-
20
20
bers understand the process in the same way (see Source: ©AHIMA.
©
figure 18.6).
ht
The work involved in developing the flow chart for identifying a number of potential process steps
ig
yr
allows the team to understand every step in the that may benefit from improvement efforts and for
op
generating solutions to specific problems. It helps

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process as well as the sequence of steps. The flow

chart provides a visual picture of each decision people to begin thinking in new ways and involves
point and event in the process. It exposes places them in the process. It is an excellent method for
where there are redundancies and complex and facilitating open communication. There are a num-
problematic areas. ber of approaches to brainstorming, including the
following:
Brainstorm Problem Areas ●● The unstructured brainstorming method
Brainstorming is a technique used to generate a results in a free flow of ideas. The team
large number of creative ideas from a group. It leader or facilitator writes the ideas on a
encourages PI team members to think outside the chart or board when presented. This allows
box and offer original ideas to address problems everyone to see the list as it forms. There
in the process. Brainstorming is highly effective should be no discussion or evaluation of the
AB103118_Ch18.indd 563 2/6/2020 5:52:51 PM

ideas at this point. The goal of brainstorming Finally, label the natural groupings that
is to encourage creativity and generate many emerge. An example of an affinity diagram
ideas. is in figure 18.7.
●● In structured brainstorming, the team ●● Nominal group technique is a process
leader or facilitator asks team members used to reach consensus about an issue
to create their own list of ideas. Team or an idea that the team considers most
members can work by themselves or in important. Each team member ranks each
small groups for a specific amount of time. idea according to importance. For example,
Then, the team members take turns offering if there were six ideas, the most important
a new idea. The process may take several idea is ranked with the number six (giving
rounds. As team members run out of new it six points); the second most important
ideas, they pass; the next person then offers idea is ranked the number five, and so on.
n.
an idea until no team member can produce After each individual team member has had
tio
ia
a fresh idea. a chance to rank the list of ideas, the scores
oc
for each idea are totaled. The nominal group
ss
Affinity grouping allows the team
tA
●●
to organize similar ideas into logical technique demonstrates where the team’s
en
priorities lie.
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groupings. Write ideas generated in a
ag
brainstorming session on sticky notes. ●● The multivoting technique is a variation
an
Without talking to each other, each team of the nominal group technique and serves
M
n
member reviews the ideas on the notes the same purpose. Instead of ranking each
io
at
and places each in natural groupings that issue or idea, team members rate issues by
r m
seem related or connected to each other. marking them with a distribution of points.
fo
In
Each member is empowered to move In weighted multivoting, a team member

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the ideas in a way that makes the most distributes his or her allotment of points
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sense. As team members shift the ideas or among as few or as many issues as he or
an
place them in other groupings, the other she wants. For example, the team member
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team members consider the merits of might give 13 out of 25 points to one issue
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the placements and decide what further of importance, 3 points each to four other
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action to take. The goal is to have the team issues, and no points to the remaining issues.
by
become comfortable with the arrangement. After the voting, the sum of the numbers
20
20
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Figure 18.7 Affinity diagram

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Human Policy Physician Software

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Resources Issues
Need additional Need physician Poor Coding system is

coders response deadline documentation slow
New coders need Physician suspension Slow query System flow

RHIT or CCS policy needs update response optimization
Current coders Establish coding Incomplete

need training standards reports
Higher pay for Improve physician

staff retention relations
Source: ©AHIMA.
AB103118_Ch18.indd 564 2/6/2020 5:52:52 PM

given to each issue determines the issue line (or backbone). Each box contains a different
with the highest priority. Thus, the team category of information.
will be able to see which issue emerged as The categories may represent broad classifi-
particularly important to the entire team. cations of problem areas. For example, possible
categories include people, methods, equipment,
Cause-and-Effect Diagram materials, policies, procedures, environment, or
One of the common quality improvement tools measurement. The team determines how many
used for risk management purposes is the cause- categories it needs to classify all the possible
and-effect diagram. A cause-and-effect diagram, sources of the problem.
also known as fishbone diagram because of its After constructing the diagram, the team brain-
characteristic fish shape (see figure 18.8), is an in- storms the possible root causes of the problem.
vestigational technique that facilitates the identi- Brainstorming continues until all the team’s ideas
n.
fication of the various factors that contribute to a about causes are exhausted. The purpose of this tool
tio
problem. It facilitates root-cause analysis, or the is to permit the team to explore, identify, and graph-
ia
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analysis of an event from all aspects (human, pro- ically display all of the root causes of a problem.
ss
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cedural, machinery, material), to identify how each
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contributed to the occurrence of the event and Force-Field Analysis
em
to develop new systems that will prevent recur- Force-field analysis is another tool used to display
ag
rence. The problem or reason for the quality im- data generated through brainstorming. Force-field
an
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provement exercise is written clearly in a box on analysis identifies specific drivers of and barri-
n
the right side of the diagram. A horizontal line is io
ers to an organizational change, so that positive
at
m
drawn and diagonal lines resembling ribs connect factors can be reinforced and negative factors re-
r
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the boxes above and below the main horizontal duced (figure 18.9). Team members brainstorm the
In
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Figure 18.8 Fishbone diagram

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Technology People
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Coders cannot track queries

by
Unresponsive physicians
20
Physicians do not get notice of queries Inexperienced coders

20
Old charts are not flagged Management not engaged

©
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Deficiencies are hard to identify Unresponsive IT programmers

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List of DNFB accounts is not accurate High turnover of coders

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High DNFB
Documentation policy is for paper based records Poor communication/physician liaison
No monitoring or reporting policy No guidance for improvement actions
No policy to reward staff for progress Reports are not well distributed
No policy on coding timeliness standards Reports are inconsistent
Outdated physician suspension policy No regular data collection
Policy Management
Source: ©AHIMA.
AB103118_Ch18.indd 565 2/6/2020 5:52:53 PM

Figure 18.9 Force-field analysis ●● Create a flow chart of the redesigned

process.
Drivers Barriers
(+) (–) ●● Develop policies and procedures that
support the redesigned process.
$ Profit Cost of materials
Lack of trained personnel
●● Educate involved staff about the new
Market niche Initial investment process including justifications for the
change.
Source: ©AHIMA.
Recommendations for Process
reasons or factors that would encourage a change Change
for improvement and those that might create bar- The process improvement team is responsible
riers. The team leader places the factors in the ap- for putting the outcome of its work in a report
n.
format, along with recommendations for improv-
tio
propriate column on the chart.
ia
Force-field analysis enables team members to ing the process. Determine the recommendations
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ss
identify factors that support or work against a pro- after receiving and analyzing all data. The data
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posed solution. Often the next step after force-field include findings from the appropriate tools and
en
analysis is to develop ways that would eliminate techniques discussed previously. The recommen-
em
dations should consider anything that might have
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barriers or reinforce drivers.
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an impact on the organization, including the
M
Analyzing Process Data following:
n
io
at
Following the collection of data, it is important Utilization of staff
m
●●
r
for the team to consider the data in a meaningful

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Effect on the budget

In
●●
way. Again, PI tools and techniques can assist
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the team by providing meaningful documents ●● Change in productivity

ea
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from which conclusions can be drawn. Teams ●● Effects on customer requirements

an
can use bar graphs, histograms, scatter dia-

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Recommendations are viewed by the appropri-

er
grams, and Pareto charts to better analyze the

Am
ate manager or administrator, considered by the

data. For additional information on these tools leadership group and top management for an or-
e
th
and techniques, refer to chapter 13, Research and ganization-wide problem, or by the management
by
Data Analysis. group heading the HIM department if the prob-

20
20
lem is confined to only that unit.

©
Process Redesign After implementing the new process, the team

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Following in-depth examination of all the data, continues to measure performance against cus-
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policies, procedures, and interviews, the team tomers’ expectations and established performance
C
must determine whether the process will receive standards to determine if there is a need for fur-
minor adjustments or a major restructuring to ther improvement (refer to figure 18.1). When
make it meet customers’ expectations. If the solu- measurement data indicates the improvement
tion is process redesign, the following are the next is effective (for example, error rate dropped by
steps. 50 percent), ongoing monitoring of the process
resumes.
●● Incorporate findings or changes identified The team disbands at this point in the cycle,
in the research phase of the improvement and routine organizational monitoring of the
process performance measures resumes. Figure 18.10 il-
●● If necessary, collect focused data from the lustrates the relationship between organization-
prioritized problem areas to further clarify wide performance monitoring and team-based PI
process failure or variation processes.
AB103118_Ch18.indd 566 2/6/2020 5:52:54 PM

Figure 18.10 Organization-wide and team-based PI model
2. Measure
performance
3. Analyze and compare
internal/external
data
4. Implement
process/education 5. Document and
communicate
findings
TEAM PI
Start PROCESS 2. Research and
here define
1. Identify
performance
n.
performance
tio
expectations
measures 3. Design and redesign
ia
4./1. Identify
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process/education improvement
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opportunity
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en
ORGANIZATIONAL
em
PI PROCESS
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5. Perform ongoing
n
monitoring io
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Ongoing organization-wide PI monitoring Team-based PI processes

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Source: Shaw and Carter 2019.

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ea
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an
ic

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th
by
1. A PI team has been tasked with improving the patient admitting process because the hospital has received patient
20
complaints. Before creating a new process, the team has diagrammed the current process. Which of the following
20
tools would the team have used to when they diagrammed the current process?
©
a. Flow chart
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b. Force-field analysis
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c. Unstructured brainstorming
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d. Structured brainstorming
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2. Which of the following is used to compare an organization’s performance against that of external standards?
a. Affinity grouping
b. Benchmarking
c. Scorecards
d. Brainstorming
3. Which of the following is an investigational technique that facilitates the identification of the various factors that
contribute to a problem?
b. Cause-and-effect diagram
c. Force-field analysis
d. Nominal group technique
AB103118_Ch18.indd 567 2/6/2020 5:52:55 PM

4. In what technique do team members rate issues by distribution of points?

b. Nominal group technique
c. Multivoting technique
5. Kevin is the HIM Director at University Hospital. He is looking for ideas on how to improve the process for requesting
employee vacation time. In their monthly staff meeting, Kevin asks each employee to create a list of ideas. Each team
member has an opportunity to share their ideas with the group. When the team has no more ideas to share, this
process ends. What team-based performance improvement tool is Kevin utilizing?
b. Nominal group technique
c. Multivoting technique
n.
tio
ia
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ss
Managing Quality and Performance Improvement
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HIM professionals must manage qual- iscussed previously in this chapter, shared vision
d
ag
ity and the PI process to ensure these activities ac- is one of the cornerstones of a successful PI pro-
an
M
complish the important and vital changes needed gram. A shared vision puts everyone—including
n
by the organization’s internal and external cus- io
the governing board, upper management, and
at
tomers. Traditional management functions such employees—on the same path to organizational
m
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as planning, organizing, leading, and controlling success. Changing to a shared leadership envi-
In
should be applied to PI initiatives. See chapter ronment can create a new organizational culture
lth
ea
19, Leadership, for information on management of shared vision, responsibility, and accountabil-
H
functions. External entities should be considered ity. Because every employee is a vital part of this
an
ic
during a healthcare organization’s quality delib- shared leadership, this type of environment helps
er
Am
erations, discussions, and decision-making. Exter- to increase employee motivation and empower-
nal entities include agencies that offer voluntary ment. For more information on change manage-
e
th
accreditation services, are involved in the reim- ment, please refer to chapter 17, Management.
by
bursement cycle, administer licensure services, In addition to an enterprise-wide vision, a

20
20
and offer national quality policy and direction. shared leadership framework is essential for
©
In order to meet a healthcare organization’s goals implementing PI. Shared leadership essentially
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and mission, all relevant agencies must be factored means that organizations ensure all their employ-
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into their approach to achieving superior quality. ees participate in an integrated, continuous PI pro-
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Components of PI activities include organiza- gram. When various organizational frameworks

tional factors, standards of organizational quality, or structures are developed, it encourages shared
utilization management, and risk management. leadership by encouraging employee participa-
tion and instilling ownership.
Organizational Components of PI Large healthcare organizations are complex
To be successful in implementing PI programs, both in size and in geographical location requiring
healthcare organizations may have to restruc- focused effort to standardize and facilitate neces-
ture and create a new culture to accommodate sary changes. The organizational structures and
the vast changes and competition that exist in processes that constitute a PI program need to be
today’s healthcare environment. PI is most suc- accomplished across the entire healthcare organ-
cessful in organizations that have an interdiscipli- ization, meaning that every location and depart-
nary and participative management approach. As ment within the organization takes part in the PI
AB103118_Ch18.indd 568 2/6/2020 5:52:55 PM

program. To be effective, the organizational unit A standard is a written description of the ex-
responsible for PI must be able to communicate pected features, characteristics, or outcomes of
with all areas of the healthcare organization and a healthcare-related service. Standards provide
foster interdisciplinary cooperation. Many health- a minimum level of performance. Four types of
care organizations have created a PI department standards relevant within the context of clinical
to help the organization pursue its quality efforts. quality assessment are addressed in the following
Many PI departments assume leadership in the as- sections:
sessing and tracking of organizational compliance
●● Clinical practice guidelines and clinical
with accreditation standards, focus areas, and pa-
protocols
tient safety goals.
The following are the basic responsibilities of ●● Accreditation standards
the PI department: ●● Government regulations
n.
Licensure requirements
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●● Helping departments or groups of ●●
ia
departments with similar issues to identify The sections that follow will discuss each of
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potential quality problems these standards in detail.
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Assisting determination of the best methods
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●●
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for studying potential problems (for Clinical Practice Guidelines and Protocols
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example, survey, chart review, interview Standards of clinical quality include both clinical
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with staff, or data mining) practice guidelines and clinical protocols. Clinical
M
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●● Participating in regular meetings across the protocols are detailed, step-by-step instructions
io
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organization as appropriate, and training used by healthcare practitioners to make knowl-
m r
edge-based clinical decisions directly related to

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organization members on quality and PI

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methodology, tools, and techniques patient care. The Agency for Healthcare Research
lth
and Quality (AHRQ) is an agency within HHS.

ea
A permanent multidisciplinary committee should

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AHRQ’s mission is to improve the quality, safety,

an
coordinate the program and ensure the unifor- efficiency, and effectiveness of healthcare for all
ic
er
mity of clinical quality assessment (QA) processes Americans. Clinical practice guidelines are de-
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throughout the organization. The committee should veloped to standardize clinical decision-making.
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include representatives of the medical staff, nursing

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As the word guideline suggests, clinical practice

by
staff, and infection control team. Consult represen- guidelines are not meant to be inflexible and do
20
tatives from other areas as needed. not apply in every case.

20
©
In contrast to clinical practice guidelines, clin-

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Standards of Organizational Quality ical protocols are treatment recommendations

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in Healthcare based on guidelines. They are specific instructions

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A number of private and government entities de- for performing clinical procedures established by
velop and maintain standards of organizational authoritative bodies, such as medical staff com-
quality for healthcare. These entities include agen- mittees, and intended to be applied literally and
cies and departments of the federal government, universally. One example of a clinical protocol is
accreditation organizations, private for-profit or- the step-by-step description of the accepted proce-
ganizations, and not-for-profit organizations such dure for preparing intravenous solutions at a spe-
as medical societies and organizations dedicated cific acute-care hospital.
to research on a specific disease or condition.
Standards of quality include descriptive state- Accreditation Standards
ments known as standards of care, quality of care In the US, many different organizations monitor
standards, performance standards, accreditation
the quality of healthcare services and offer accredi-
standards, and practice standards. tation programs for healthcare organizations. These
AB103118_Ch18.indd 569 2/6/2020 5:52:55 PM

programs base accreditation on a data collection a process to mark the surgical site and involve the
and submission process followed by a comprehen- patient in the marking process.
sive survey process. Participation in accreditation The data collected are used to help focus the
programs is voluntary. (See chapter 3, Health In- accreditation survey on patient safety and high-
formation Functions, Purpose, and Users, for a dis- quality patient care and to select specific patients
cussion of accreditation.) The Joint Commission, to “trace” during the on-site survey. This ap-
DNV GL, and other voluntary accreditation orga- proach, known as tracer methodology, consists of
nizations are addressed in the following sections. following (tracing) a few patients through their
entire stay at the hospital to identify quality and
Joint Commission The Joint Commission (dis- patient safety issues that might indicate quality
cussed in chapter 8, Health Law) emphasizes PI problems or patterns of less than optimum care.
in their accreditation standards. All hospitals and A trace of a surgical patient, for example, might
n.
long-term care facilities are required to report out- reveal a missing updated history and physical
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come measures. Outcome measures document (H&P) on the patient’s health record within 24
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the results of care for individual patients as well hours before surgery. Following this lead, the
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as for specific types of patients grouped by diag- surveyor might discover that the healthcare or-
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nostic category. For example, an acute-care hos- ganization is having an ongoing problem with
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pital’s overall rate of postsurgical infection is an H&Ps in general; a problem with obtaining the
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outcome measure. Process measures focus on required updated H&P within 24 hours before
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a process that leads to a certain outcome, mean- surgery, or perhaps a problem with just one par-
ing that a scientific basis exists for believing that n
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ticular physician.
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the process, when executed well, will increase the
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probability of achieving a desired outcome. An ex- DNV GL and Other Voluntary Accreditation
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ample is the percent of stroke patients receiving Organizations DNV GL Healthcare is a voluntary
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appropriate medication (Tissue Plasminogen Ac- accreditation organization that has operated in
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tivator [TPA]) within the appropriate time frame. the US since the late 1800s but is relatively new to
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Outcome and process measures have evolved into healthcare. The organization is recognized by CMS
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quality measures now called accountability meas- to have deemed status, which means healthcare or-
ures. Accountability measures focus on four main ganizations accredited by DNV GL are recognized
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components: research, proximity, accuracy, and as meeting the Medicare Conditions of Participa-
by
adverse effects. These measures are the key to im- tion, which are the administrative and operational
20
20
proving patient care and quality, thus improving guidelines and regulations under which health-
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patient outcomes. The Joint Commission scores care organizations can take part in the Medicare
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healthcare organizations on compliance with spe- and Medicaid programs. Medicare and Medicaid
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cific National Patient Safety Goals (NPSGs). The are discussed in chapter 15, Revenue Management
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NPSGs outline the areas of organizational prac- and Reimbursement.

tice that most commonly lead to patient injury or Other voluntary accreditation organizations in-
other negative outcomes that can be prevented clude: Healthcare Facilities Accreditation Program
if standardized procedures are used. For exam- (HFAP), which focuses accreditation activities on
ple, an NPSG requires the healthcare provider to general acute-care specialty hospitals and long-
eliminate wrong-site, wrong-patient, and wrong- term acute-care hospitals; The National Commit-
procedure surgery. To accomplish this, healthcare tee on Quality Assurance (NCQA), which focuses
organizations must create and use a preoperative on health plans and outpatient provider organiza-
verification process, such as a checklist, to con- tions; and The Commission on the Accreditation
firm the patient’s identity and that appropriate of Rehabilitation Facilities (CARF), which focuses
documents (for example, health records, imaging on long-term and mental health rehabilitation
studies) are available. They also must implement facilities.
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Government Regulations and Licensure ●● Improve quality of care for Medicare

Requirements beneficiaries
Various agencies and departments of the fed- ●● Protect the integrity of the Medicare Trust
eral, state, and local governments also review the Fund by ensuring Medicare only pays for
quality of services provided in healthcare orga- services that are reasonable, necessary, and
nizations. However, government regulations and appropriate
licensure requirements are compulsory rather
●● Protect beneficiaries by addressing complaints
than voluntary.
Medicare Conditions of Participation. To par- QIOs use medical peer review, data analysis,
ticipate in the Medicare program, healthcare and other tools to identify patterns of care and
providers must comply with federal regula- outcomes that need improvement. They then work
tions known as the Conditions of Participa- cooperatively with facilities and individual physi-
n.
tion. The CMS develops the Conditions of cians to improve care. CMS established a compre-
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hensive program in which QIOs use a data-driven
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P articipation.
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Quality improvement organizations. Quality approach to monitoring care and outcomes and a
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improvement organizations (QIOs) are re- shared approach to working with the healthcare
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sponsible for monitoring the quality of care community to improve care.
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provided to Medicare patients. CMS and the State and local licensure requirements. To maintain
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its licensed status, each healthcare organization
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QIOs collaborate with practitioners, benefi-
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ciaries, providers, plans, and other purchasers must adhere to the state regulations that govern it
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of healthcare services to achieve the following
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such as quality of care. For additional information,
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key functions: refer to chapter 8, Health Law.

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1. Which of the following is a written description of the expected features, characteristics, or outcomes of a healthcare-
20
related service?
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a. Flow chart
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b. Standard
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c. Pareto chart
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d. Ground rules
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2. Midtown Hospital is currently under construction in an urban area. The administration is planning to treat Medicare
patients at this new facility. In order to participate in the Medicare program and treat these patients the facility must
comply with which federal regulation?
a. Conditions of Participation
b. National Patient Safety Goals
c. Clinical Practice Guidelines
d. Utilization Management Review
3. QIOs use peer review, data analysis, and other tools to:
a. Evaluate whether or not a healthcare facility is meeting standards for accreditation and licensing
b. Calculate reimbursement
c. Penalize healthcare organizations
d. Identify areas that need improvement
AB103118_Ch18.indd 571 2/6/2020 5:52:55 PM

4. The NPSG scores organizations on areas that:

a. Commonly lead to financial stability of the organization
b. Affect customers
c. Affect compliance with state law
d. Commonly lead to patient injury
5. Which of the following is a voluntary accreditation organization that is relatively new to healthcare?
a. DNV GL
b. AHRQ
c. The Joint Commission
d. ACO
n.
Utilization Management Risk identification and analysis
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●●
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Loss prevention and reduction
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Utilization management (UM) is composed of a ●●
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set of processes used to determine the appropriate- Claims management
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●●
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ness of medical services provided during specific
The sections that follow will discuss each of
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episodes of care. In most hospitals, UM programs
these healthcare risk management programs in
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perform three important functions—utilization re-
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detail.
view, case management, and discharge planning.
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Utilization management is an important part of
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Risk Identification and Analysis
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quality patient care as it helps to ensure necessary The role of the risk manager is to collect and an-
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and appropriate care, effectiveness of the services alyze information on actual losses and potential
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provided to the patient, and timely and safe dis- risks and to design systems that mitigate potential
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charge of patients. See chapter 15 for a complete losses in the future. Risk managers use informa-
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discussion on utilization management. tion from a variety of sources to identify areas of

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risk exposure within the organization. The fol-

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Risk Management
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lowing are some sources for risk management in-

In healthcare, risk is any occurrence or circum- formation:
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stance that might result in a loss. Loss includes any

by
●● Incident reports (sometimes called

damage to an entity’s person, property, or rights,
20
occurrence reports or occurrence

20
including physical injury, cognitive injury, emo-

screens)
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tional injury, wrongful death, and financial loss. In

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Current and past liability claims against the

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this chapter, the focus is on how risk management ●●

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organization
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relates to quality. For additional information about

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risk, refer to chapter 10, Data Security. ●● Performance improvement reports

The purpose of the risk management program ●● Internal inspections of the organization’s
is to link risk management functions to the related physical plant and medical equipment
processes of quality assessment and PI. The aims ●● Reviews conducted by the organization’s
of the program are to (1) help provide high-quality insurance carriers
patient care while also enhancing a safe environ-
●● Survey reports from state and local licensing
ment for patients, employees, and visitors, and (2)
agencies
minimize financial loss by reducing risk through
prevention and evaluation. ●● Survey reports from accreditation
The basic functions of healthcare risk manage- organizations
ment programs are similar for most organizations ●● Reports of complaints from patients, visitors,
and including the following: medical staff, and employees
AB103118_Ch18.indd 572 2/6/2020 5:52:55 PM

An incident (or occurrence) report is a struc- differently depending on the size and type of
tured tool used to collect data and information organization. Accordingly, the role of the risk man-
about any event not consistent with routine oper- ager in managing claims varies. Many organiza-
ational procedures, such as a wrong-side surgery tions place the entire process in the hands of their
or foreign body left in following surgery. In the liability insurance vendors. In such cases, the risk
language of risk management, the documentation manager may act as the healthcare organization’s
of these events is used to identify potentially com- liaison with the insurance company. However,
pensable events. A potentially compensable event some healthcare organizations are self-insured,
is an occurrence, such as an accident or medical meaning that they establish a dedicated fund for fi-
error that may result in personal injury or loss of nancing future liability settlements. Organizations
property to patients, staff, visitors, or the health- manage claims and risk by incorporating patient
care organization. advocacy, incorporating regulatory and accredita-
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Incident reports are prepared to help healthcare tion requirements, and having an organizational
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organizations identify and correct problem areas incident response mechanism in place.
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and prepare for legal defense. An incident report
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documents the event for operational purposes
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Patient Advocacy
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and is not used for patient care, so it is considered Many large healthcare organizations such as
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an extremely confidential document that is never acute-care hospitals have instituted patient advo-
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filed in the health record and should not be pho- cacy programs. In such programs, a patient rep-
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tocopied or prepared in duplicate. The healthcare resentative (sometimes called an ombudsperson)
provider should never document that an incident n
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responds personally to complaints from patients
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report was completed. Incident reports are not
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and their families. Often, patients and their fami-

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part of the legal health record and are not discov- lies are looking for nothing more than an expla-
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erable in event of legal action (Farenholz 2017). See

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nation of an adverse occurrence or an apology for

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figure 18.11 for an example of an incident report. a mistake or misunderstanding. Patient repre-
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sentatives can handle minor complaints and seek

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Loss Prevention and Reduction

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remedies on behalf of patients. They can also rec-

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The risk manager is responsible for developing ognize serious problems that need to be forwarded
systems to prevent injuries and other losses within
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to performance improvement or risk management

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the organization. Performance improvement ac- personnel.

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tions are often initiated in response to suggestions

20
20
offered by the risk manager. Education also is an Accreditation Requirements for Risk
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invaluable tool in risk management and some- Management in Acute-Care Hospitals

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times is the only activity required to prevent po- Anything that undermines patient safety is a
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tential safety problems. risk issue. According to accreditation standards,

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Risk managers in many healthcare organi- all hospital activities must be evaluated as to the
zations are responsible for developing policies potential risk to the patient or the organization.
and procedures aimed at preventing accidents Leadership is responsible for ensuring adequate
and injuries and reducing the organization’s resources for patient safety.
risk exposure.
Incident Response Patient safety should be of
Claims Management utmost importance to healthcare organizations
Claims management is the process of managing and all employees within the organization. Health-
the legal and administrative aspects of the healthcare organizations need to create a culture of
care organization’s response to injury claims (in- safety within their facilities in order to focus on
juries occurring on the healthcare organization’s error elimination. Steps must be taken to ensure
property). Claims management may be handled patient safety and adequate response to an adverse
AB103118_Ch18.indd 573 2/6/2020 5:52:55 PM

event occurring within the organization. Health- a dverse events. Once the situation has been appro-
care organizations must be equipped to recognize priately resolved, the organization should initiate
an adverse event and then have a plan and proto- a PI process to identify what improvements and
cols in place to care for the affected patient and to changes to the systems and processes are needed
mitigate the situation in order to prevent further to prevent future adverse events.
Figure 18.11 Partial example of incident or occurrence report (including the necessary data elements
for this incident)
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©
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continued
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Figure 18.11 Partial example of incident or occurrence report (including the necessary data elements for
this incident) (continued)
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by
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©
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continued
AB103118_Ch18.indd 575 2/6/2020 5:52:56 PM

Figure 18.11 Partial example of incident or occurrence report (including the necessary data elements for
this incident) (concluded )
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20
©
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Source: Shaw and Carter 2019.
Clinical Quality Management Initiatives

Initiatives and processes seeking to en- menced. Stemming from the Institute of Medi-
sure high-quality care and patient safety became cine (IOM) 1999 and 2001 reports on the quality
a focus in healthcare as the 21st century com- of healthcare in America, a consensus developed
AB103118_Ch18.indd 576 2/6/2020 5:52:56 PM

around the need to use information technology as gether to coordinate and improve care for patients
both a methodology and a pathway for managing with Medicare. This coordination of care includes
and improving healthcare quality. sharing patient information among providers to
The beginning of the 21st century witnessed eliminate duplication of tests and prevent med-
an increased link between clinical quality and re- ical errors. Participation in an ACO is voluntary.
imbursement for health services. Pay-for-perfor- ACOs focus on improving the quality of care of
mance initiatives by the federal government, Joint patients and decreasing healthcare spending. As
Commission, and private payers began rewarding ACOs meet the requirements of the model, they
organizations for quality outcomes. These incen- share in the savings. Patients who receive care
tives, such as Meaningful Use, encouraged health- from an ACO maintain all of their rights as a Med-
care providers to invest in technology that will icare beneficiary (CMS 2018). For more informa-
improve patient care and safety. For additional in- tion on the Affordable Care Act and ACOs, refer to
n.
formation on these topics, refer to chapter 15. chapter 2, Healthcare Delivery Systems.
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In recent years, CMS has become an advocate
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Robust Process Improvement
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for pay for performance within the Medicare
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program. One of its efforts requires hospitals par- Methodologies
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ticipating in the Medicare program to collect and As discussed earlier, benchmarking is an impor-
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report on proven clinical hospital quality mea- tant quality tool in healthcare quality programs.
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sures. To qualify for full inpatient prospective However, some healthcare organizations have
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payment the hospital must report on all measures begun to benchmark against other industries
required by CMS. Those that do not report data on n
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(for example, a hospital’s handoff from surgery
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these measures face a payment reduction per case.
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to intensive care compared against the race-car

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Medicare expects hospitals to compare their own industry’s handoff during a pit stop) and are se-
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data to national and regional averages in order to lecting models that may be adapted to the health-
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identify areas for quality improvement. care industry. These methodologies can be used
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The early part of the 21st century witnessed in healthcare as part of the PI process. Some of
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new and creative efforts to encourage medical these are Lean, Six Sigma, Lean Six Sigma, and
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error reporting. The Patient Safety and Quality high reliability.

Improvement Act of 2005 allows for the volun-
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tary reporting of medical errors, serious adverse Lean

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events, and their underlying causes (HHS 2017). Lean is a process improvement methodology fo-
20
20
Subsequent emphasis by The Joint Commission on cused on eliminating waste and improving the
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patient safety issues has resulted in voluminous re- flow of work processes. Healthcare organizations
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search and new programs sponsored by The Joint have found ways to apply the Lean methodology,
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Commission to assist its accreditation customers such as eliminating waste in processes by stream-
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in improving this important area of healthcare or- lining workflow and tasks to remove time-con-
ganization functioning. suming and unnecessary steps. Healthcare has a
Accountable care organizations, PI methodolo- growing burden to improve the quality of patient
gies, ISO-9001 certification, and medication rec- care while also decreasing and controlling costs.
onciliation are key components of clinical quality In many ways, Lean is a good fit for healthcare
management. organizations and many of the principles of Lean
are transferrable from its origins in the automotive
Accountable Care Organizations industry to other industries, including healthcare
Accountable Care Organizations (ACOs) are (Meyer 2010). Because of the complex nature of
a part of the Affordable Care Act (2010). ACOs healthcare, there are abundant opportunities to in-
are a network of physicians, hospitals, and other corporate Lean methodology to reduce waste and
healthcare providers and suppliers working to- improve efficiency.
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Six Sigma efficiencies within healthcare organizations—

Six Sigma uses statistics for measuring variation improving both product and process.
in a process with the intent of producing error-
free results. Sigma refers to the standard deviation High Reliability Organizations
used in descriptive statistics to determine how High reliability organizations (HROs) are orga-
much an event or observation varies from the esti- nizations that focus on creating an environment
mated average of the population sample. Six Sig- that eliminates or minimizes error. HRO method-
ma was chosen as a target statistic because even ology comes from the airline, wildland firefight-
two or three standard deviations would not be ac- ing, and nuclear power industries and is now
ceptable in certain scenarios. A 2.5 percent error being used in healthcare. HROs are concerned with
rate for making correct change at a movie theater noticing weak signals in order to prevent a poten-
may be acceptable, but that error rate in healthcare tial negative outcome, and these weak signals re-
n.
can be catastrophic. Even one preventable adverse ceive a substantial response within this model. In
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healthcare, as with other types of industries, there
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event or death should not occur. Therefore, it is
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important to keep this PI approach in proper per- are often small signals that are ignored. Health-
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spective when applying it to healthcare. The Six care organizations can become HROs by paying
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Sigma measure indicates no more than 3.4 errors attention to these small signals. For example, a
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per 1 million encounters (Pyzdek and Keller 2018). housekeeper may notice a problem with a patient.
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Within an HRO organization, that housekeeper
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Consider the challenge of achieving no more than
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3.4 errors per 1 million prescriptions, surgeries, would be empowered and motivated to report this
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or diagnoses. In certain areas, this standard may
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concern to a clinician. An important part of this
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seem unattainable; and in others, it may not be rig- model and one way that HROs notice weak sig-
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orous enough. nals is mindfulness—a keen awareness and a nec-

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Deploying Six Sigma in healthcare requires the essary characteristic for all employees of an HRO.
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identification of elements of a product line that When employees are mindful and focused on their
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duties, there is less room for error. For example,

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are critical to quality, or CTQs. The healthcare or-

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ganization should conduct focus groups or inter- a distracted physician may be more prone to
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views of customers to elicit the CTQs. Typically, in error. Organizational reliability is improved, and
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healthcare the customers will be the patients and errors are reduced when sources of distraction are
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the providers or physicians. All others involved— eliminated and mindfulness is emphasized within
by
20
the corporations, payers, accreditors or licensers— a healthcare organization. HROs are preoccupied
20
are identified as stakeholders, entities with an with failure and use these failures as learning ex-
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important interest in the product that do not have periences to improve processes and quality in or-
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consumer relationships to it. Supporting the CTQs der to eliminate error (Weick and Sutcliffe 2015).
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are elements critical to process (CTPs). Techniques

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such as focus groups or interviews help to deter- ISO 9001 Certification

mine the CTPs. If healthcare organizations expand into global
entities, they are required to deal with the same
Lean Six Sigma issues other industries face when doing business
Combining Lean and Six Sigma is a way to combine outside the US. ISO 9001 certification is part
elements from both techniques into an integrated of a PI system required to conduct business
program to improve process flow and quality in certain foreign countries. The International
(Sperl and Ptacek 2013). This Lean Six Sigma meth- Organization for Standardization in Geneva,
odology utilizes elements of elimination of waste Switzerland, first published ISO 9001 standards
from Lean and critical process quality characteris- in 1987. ISO 9001 sets specification standards for
tics from Six Sigma. Using these tools in a combined quality management with regard to process man-
format allows for quality improvement and overall agement and product control. In the healthcare
AB103118_Ch18.indd 578 2/6/2020 5:52:56 PM

setting, product control is quality control of pa- utside healthcare organization, there is potential
o
tient care activities. Companies that document for missing medication dosages, omitted medi-
and demonstrate compliance with ISO 9001 stan- cations, or information on drug interactions and
dards can receive certification by independent allergies. All of these factors put patients at risk
ISO auditors (Rakhmawati et al. 2014). for adverse drug events. Medication reconcilia-
tion, such as ensuring that the patient is receiving
Medication Reconciliation the right dose of medication, is the process that
Medication adjustments and changes often occur monitors and confirms that the patient receives
during patient encounters with health services, as consistent dosing across all healthcare facility
patients are admitted, discharged, or transferred transfers, such as on admission, from nursing unit
to another hospital unit or to another health- to surgery, and from surgery to the intensive care
care organization. Healthcare providers may not unit. Healthcare organizations use the medication
n.
have access to a listing of current medications reconciliation process to eliminate medication er-
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the patient was taking prior to admission or en- ror and improve care for the patient. Medication
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counter with health services. As the patient trans- reconciliation is also part of the Joint Commis-
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fers within the healthcare organization or to an sion’s NPSGs.
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HIM Roles
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Healthcare organizations use measures io
Consumers rely on information regarding quality,
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to determine their level of performance on qual- such as Hospital Compare data, to make healthcare
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ity and safety. These measures focus on outcomes, decisions. This information is an asset and should
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the structure of the healthcare organization, pa- be governed with accountability (Kloss 2015).
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tient surveys, and organizational systems; and are Health information management professionals
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used by healthcare organizations, private payers, are uniquely qualified to practice in the field of
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and accrediting organizations to ensure they pro- performance improvement. They understand the
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vide exceptional care. Organizations use internal practice of collecting, analyzing, and interpreting
measures as quality standards for their organiza- performance data for healthcare organizations.
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tion. External measures are used by accrediting or- HIM professionals understand where and how
by
20
ganizations and private payers for payment based data is collected throughout a patient’s encounter
20
on performance as well as value-based purchas- with a healthcare organization, which allows them
©
ing initiatives. Payment for healthcare services is to help organizations achieve quality clinical out-
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linked to quality measures. As more and more incomes. HIM professionals also understand data
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formation is collected and analyzed in relation to quality, data analysis, and other aspects of data
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quality, the information must maintain integrity. management.

1. Which of the following is a basic function of a healthcare risk management program?
a. Claims management
b. Discharge plan
c. Time ladders
d. Workflow analysis
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2. Which of the following is a group of processes that determine the appropriateness of medical services?
a. Utilization management
b. Incident management
c. Case management
d. Risk management
3. John is currently a patient at Community Hospital. He is dissatisfied with the care he is being provided. He addressed
this concern with his nurse; however, the care did not improve. Who should the patient contact at the hospital to
discuss his concerns about his care?
a. Utilization review coordinator
b. Risk manager
c. Patient representative or advocate
d. Discharge planner
4. A woman dies in labor and delivery. The Joint Commission would call this type of outcome a(n):
n.
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a. Sentinel event
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b. Clinical protocol
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c. Screening criteria
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d. Occurrence screen
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5. Fred is a patient at Community Hospital. He fell out of bed during his second day at the facility. Which of the following
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steps should now occur?
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a. Review conditions of participation
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b. Conduct a continued stay utilization review
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c. Perform claims management functions io
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d. Complete an incident report

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Memorial Hospital has been under- cases they are working on. Gina is the coding
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going significant growth over the past few years. manager at Memorial Hospital, and she has
by
20
After the hospital implemented their new elec- been reviewing the last two quarterly coding
20
tronic health record (EHR) system, the HIM audits of her team. She finds that the coding
©
department scanned the paper health records quality has dropped over the past six months.
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that were being stored in the filing room and Performance indicators on productivity have
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the filing room was no longer needed to store also dropped during this period. Using bench-
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health records. Because of the growth within the marking, Gina compares her coding team’s pro-
healthcare facility, the filing room was recently ductivity and quality metrics with similar-sized
transformed into a space for the clinical docu- hospitals within her organization. As she antici-
mentation integrity (CDI) team. This space is pated, her facility’s coding quality and produc-
directly adjacent to the coding area. The prox- tivity are below that of other healthcare facilities
imity of the CDI team to the coding team has in her organization. Gina conducts a root-cause
facilitated significantly increased interaction analysis to help identify the cause of the decline in
between the two groups. The CDI team often ap- both the productivity and quality of the coding
proaches members of the coding team regarding being performed by her team.
AB103118_Ch18.indd 580 2/6/2020 5:52:56 PM


A large acute-care hospital located in A PI team was assembled with representatives
the US was plagued with a poor reputation, high from the surgery service, housekeeping, nursing,
readmission rate, and weak profitability. As a last infection control, and HIM. The team meticulously
resort, the hospital board of directors fired the evaluated and improved each of the procedures
CEO and conducted a national search for a re- related to the new surgical suite. Continued mon-
placement. The new CEO selected by the board itoring only demonstrated minor improvements
had been running a very successful hospital in in postoperative surgeries. Having exhausted the
a different part of the country. This new recruit expertise and ideas of the internal PI team, the
was skilled and knowledgeable in PI. She had CEO contacted external experts and assembled
first-hand experience with methods like Lean a team to come and consult with the internal PI
n.
Six Sigma and HROs. She came on board and team. Both teams were put into a small confer-
tio
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immediately initiated training and much-needed ence room and given five hours to review the col-
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culture changes. Hospital-wide PI teams were as- lected data and the changes that had been made
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sembled to assess and prioritize the improvement with little to no results. The external view of the
en
needs of the hospital. Taking each of the highest outside experts, along with a detailed decomposi-
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priority issues, following the process of identify- tion of the processes related to the suite, pointed
ag
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ing measures, measuring performance, analyzing to the construction process. Pulling the specifica-
M
data, identifying the improvement opportunity, tions and reports from the construction process,
n
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and continually monitoring performance they the team had questions for the construction con-
at
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were able to make drastic changes in every depart- tractors about the grade of materials used in the
r
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ment. Through this transition process and over room. Specifically, they were concerned that the
In
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the course of a year the new CEO realized sizea- walls and flooring were too porous to be properly
ea
ble cost savings. Through the PI process, priorities sterilized. The contractor confirmed the suspicion
H
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for new equipment and infrastructure were set. and came up with a solution to recover the walls
ic
One high priority item was a new surgical suite and floor with appropriate materials. Monitoring
er
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with updated technology. The board approved infection rates closely, the suite reopened for use.
e
the construction of the new suite and purchase of Weekly dashboard reports were given to all stake-
th
by
the new equipment. Because of the implemented holders and showed no postoperative infections.
20
PI processes and monitoring, one month after At a review meeting at one month, the postoper-
20
the surgical suite opened the hospital epidemi- ative infection rate had dropped to a level lower
©
ologist noticed a spike in postsurgical infections. than before the new surgical suite was opened.
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References
American Health Information Management Donabedian, A. 1988. The quality of care: How can it
Association. 2017. Pocket Glossary of Health Information be assessed? Journal of the American Medical Association
Management and Technology, 5th ed. Chicago: AHIMA. 260(12):1743–1748.
Centers for Medicare and Medicaid Services. 2018. Farenholz, C. 2017. Documentation for Health Records,
Accountable Care Organizations. http://www.cms.gov/ 2nd ed. Chicago: AHIMA.
Medicare/Medicare-Fee-for-Service-Payment/ACO/. Few, S. 2013. Information Dashboard Design: Displaying
Department of Health and Human Services. 2017. The Data for At-a-Glance Monitoring, 2nd ed. Burlingame,
Patient Safety and Quality Improvement Act of 2005. CA: Analytics Press.
https://www.hhs.gov/hipaa/for-professionals Institute of Medicine. 2001. Crossing the Quality
/patient-safety/statute-and-rule/index.html. Chasm: A New Health System for the 21st Century.
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Washington, DC: National Academies Press. Rakhmawati, T., S. Sumaedi, and N. Astrini. 2014.
Institute of Medicine. 1999. To Err Is Human: Building ISO 9001 in health service sector: A review and future
a Safer Health System. Washington, DC: National research proposal. International Journal of Quality and
Academies Press. Service Sciences 6(1):17–29. http://doi.org/10.1108
/IJQSS-12-2012-0025.
Kloss, L. 2015. Implementing Health Information
Governance: Lessons from the Field. Chicago: AHIMA. Shaw, P. and D. Carter. 2019. Quality and Performance
Improvement in Healthcare: A Tool for Programmed
Meisenheimer, C. 1997. Improving Quality: A Guide to Learning, 7th ed. Chicago: AHIMA.
Effective Programs, 2nd ed. Burlington, MA: Jones &
Sperl, T. and R. Ptacek. 2013. The Practical Lean Six
Bartlett Learning.
Sigma Pocket Guide for Healthcare. Chelsea, MI: MCS
Meyer, H. 2010. Life in the “lean” lane: Performance Media.
improvement at Denver Health. Health Affairs
Strome, T. 2013. Healthcare Analytics for Quality and
29(11):2054–2060.
Performance Improvement. Hoboken, NJ: John Wiley &
n.
Omachonu, V. K. 1999. Healthcare Performance Sons.
tio
Improvement. Norcross, GA: Engineering and Weick, K. and K. Sutcliffe. 2015. Managing the
ia
Management Press.
oc
Unexpected: Sustained Performance in a Complex
ss
Pyzdek, T. and D. Keller. 2018. The Six Sigma Handbook, World. Hoboken, New Jersey: John Wiley
tA
5th ed. New York, NY: McGraw-Hill. & Sons, Inc.
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mr
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In
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ea
H
an
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e
th
by
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20
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Chapter
19
n.
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Leadership
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•• Compare different leadership theories •• Examine the fundamentals of team leadership

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•• Differentiate among leadership styles •• Examine the process to execute and facilitate team
In
•• Identify the impact of change management on meetings

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processes, people, and systems •• Examine business-related partnerships

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•• Examine critical thinking skills •• Identify leadership roles

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•• Examine the difference between leadership and •• Summarize health information-related leadership
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management roles
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Key Terms
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by
Active listening Distal attributes Referent power

20
Authoritarian leadership Emotional intelligence (EI) Reward power

20
Behavior theory Empathy Self-awareness

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Benevolent autocracy Expert power Self-regulation

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Bureaucracy Exploitive autocracy Situational leadership

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Business-related partnerships Great Person theory Social skill

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Change management Laissez-faire leadership Team building

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Chief executive officer (CEO) Leader–member relations Team charter

Chief financial officer (CFO) Leadership Team leader
Chief information officer (CIO) Leadership criteria Team member
Coercive power Leadership grid Team norms
Conflict management Leading Theory X and Y
Consensus building Leading by example Timekeeper
Consensus-oriented decision- Legitimate power Trait theory
making model (CODM) Managing Transactional leadership
Consultative leadership Motivation Transformational leadership
Contingency theory Participative leadership Transitional model
Critical thinking Power and influence theory
Democratic leadership Proximal attributes
583
583
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Leadership is a process whereby an individual in- Figure 19.1 Blake and Mouton’s leadership grid
fluences a group of individuals to achieve a com-
mon goal (Northouse 2019). Leading is one of the
CC TL
four functions of management (others are planning,
organizing, and controlling) in which people are di- Concern
for M
rected and inspired toward achieving specific goals. People
Leaders should not be confused with managers, be-
cause managers have people who work for them, IM A
whereas leaders have people who follow them. This

Concern for
concept will be explored throughout this chapter. Production
Yet, while leaders provide direction, they must also Source: ©AHIMA.
use the skills of a manager to guide their followers
n.
to successful results in an effective and efficient way. The first style is impoverished management (IM)
tio
By inspiring others, creating a vision, and mapping where a leader has a low concern for people and
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out what needs to be done, a leader can ensure that a low concern for production (near the zero point
ss
everyone in the group or team is successful. on a graph). The country club (CC) style shows that
tA
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Former President Dwight D. Eisenhower once a leader has a high concern for people and yet still
em
said that “leadership is the art of getting someone has a low concern for production. The authoritarian
ag
else to do something you want done because he (A) leadership style reflects a very low concern for
an
M
wants to do it.” How a person perceives himself people and a very high concern for production. The
or herself as a leader may be different than an em- n
team leader (TL) style has a very high concern for
io
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ployee’s view of that person as a leader. There are people and also a very high concern for produc-
m
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numerous definitions for leadership with multiple tion. Finally, the middle of the road (MR) leadership
In
approaches to identify and explain the multifac- style produces medium results with a medium
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eted factors that shape leadership and how it is concern for both people and production (Blake
H
accomplished. These theories evaluate the rela- and Mouton 1964).

an
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tionship of the leader to others and examine styles This chapter will discuss the various leadership
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of leadership, adding to the general knowledge of theories, styles, patterns of leadership, and trans-
leader behavior and effectiveness. formational leadership, as well as characteristics
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Though created over 50 years ago, Robert Blake of leaders who create, motivate a group of people,
by
and Jan Mouton’s leadership grid is still one of and deliver an inspiring vision of the future. Also
20
20
the most used tools to determine leadership style discussed are change management, critical think-
©
and presents five different personal leadership ing, and identifying the executive level of man-
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styles that depend on a person’s concern for peo- agement. The chapter concludes with discussions
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of teams including team leadership and business-

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ple (plotted on the y-axis) versus their concern for

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production (plotted on the x-axis) (see figure 19.1). related partnership and holding meetings.
Leadership Theories
There are four major theories on leader- inherited set of traits and not learned.
ship. Each theory defines a different way in which A leader is born a leader and is not created
a person is perceived as a leader. Each theory is by education or training.
discussed in the following sections. 2. Behavior theory. Leadership can be learned.
1. Trait theory. Originally called Great Man 3. Contingency theory. Leadership is based on the
theory, the belief is that leadership is an situation and context.
AB103118_Ch19.indd 584 2/6/2020 5:53:35 PM

4. Power and influence theory. Leadership can be individuals who were born into a leadership role.
based on position and title. The difference between great leaders and good
ones isn’t their intelligence or technical abilities
Each of the four theories is discussed in the fol-
it is their emotional intelligence (EI). There are five
lowing sections.
skills that allow leaders to capitalize their perfor-
mance and their employees’ performance. They
Trait Theory
are the following:
Trait theory is one of the earliest leadership theo-
ries, sometimes referred to as the “Great Person 1. Self-awareness. The ability to know oneself
Theory,” which states that some people have in- in terms of strengths, weaknesses, desires,
nate leadership skills that are not due to training values, and impact on other people.
and exercises but, rather, to their natural abil- 2. Self-regulation. The ability to change and
ity. Leadership is considered a unique property control moods and impulses in oneself.
n.
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of extraordinary people that cannot be learned 3. Motivation. The general willingness to
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(Galton 1869). achieve what one desires to do or be.
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Traits can be divided into three divisions: distal 4. Empathy. The ability to understand other
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attributes, proximal attributes, and leadership cri-
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people.
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teria. Distal attributes—such as personality, cog- 5. Social skill. The ability to build relationships
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nitive abilities, motives, and values—are traits and rapport with people.
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that surround the leader as a person. Proximal
M
attributes—such as problem-solving skills, social Contingency Theory
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appraisal skills, and expertise and tacit knowl-
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Contingency theory states leadership exists be-

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edge—are derived from the distal attributes and

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tween persons in social situations, and persons

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are part of a leader’s operating environment. From who are leaders in one situation may not neces-
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these proximal attributes, a leader possesses lead-

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sarily be leaders in other situations (Stogdill 1948).

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ership criteria—leader emergence, meaning they The first contingency approach, in terms of team
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are developing into a leader, leader effectiveness,

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performance, to leadership stated that leadership

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meaning they are a successful leader, as well as ad-

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effectiveness depends on the relationship between

vancement and promotion. Criticisms of the trait the leader’s task motivations and certain aspects
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theory are that it is too simplistic –perceptions of of the situation. Task motivation is a leader who
by
leaders by their followers does not necessarily re- set goals and structures responsibilities to be
20
flect the effectiveness of the leader, the context of

20
measurable outcomes. This model postulates

the leader’s position is not considered, and it fo-
©
that the leader’s task motivations are dependent

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cuses too much on personality traits and not on

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on whether he or she can control and predict the

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social skills and problem-solving ability.

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team’s outcomes. Whether those outcomes are in

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alignment with the situation (context) depends

Behavior Theory on three calculations: (1) whether the leader per-
A group of researchers, in response to the trait the- ceives supportive relations with team members
ory advocates, proposed the behavior-based the- (leader–member relations); (2) whether the task is
ory to better define what makes a leader. Whereas highly structured with standardized procedures
the proponents of the trait theory believe leaders and measures of performance (task structure); and
are born with these characteristics, the behavior- (3) whether the leader’s position of authority is
ists determined leaders can be made and that suc- harsh or satisfying to the team members (position
cessful leadership is based on definable, learnable power) (Fielder 1964).
behavior. Many contingency theories have defined
The behavior theory opened the door to lead- leadership effectiveness in terms of team per-
ership development rather than looking for those formance or satisfaction. However, a decision
AB103118_Ch19.indd 585 2/6/2020 5:53:35 PM

model created by Victor Vroom and Arthur Jago influence a person has over others based on their
emphasized that situational factors are more im- skill and ability to influence others.
portant than leadership behaviors (Vroom and Positional power is divided into legitimate pow-
Jago 1995). The model relies on decision-making er, reward power, and coercive power. Legitimate
to determine leadership style. Five different de- power is afforded by a person’s position or status
cision-making strategies range on a continuum within the organization such as the department di-
from directive to participative decision-making. rector. The team leader expects the team members
These strategies include two types of autocratic to follow their orders and their status allows the
styles, in which one person has complete con- leader to act as a liaison between the team and up-
trol and decision-making authority (type A1: the per management. Use caution when relying too
leader decides alone, and type A2: leader collects much on legitimate power as it is only effective
information from followers and then decides in situations in which the team believes the team
n.
alone), two types of consultative styles (type C1: leader has the right or power to influence them.
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leader consults followers individually and then Reward power is based on the leader’s ability
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decides alone, and type C2: leader consults fol- to give rewards to team members for outstanding
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lowers as a group and then decides alone), and work such as letters of recommendation, addi-
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a group decision-making option (group consen- tional training or responsibilities, and additional
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sus). Figure 19.2 illustrates the relationships be- compensation for working on the team. Reward
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tween the leader and followers. power and legitimate power go hand in hand as
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the leader can only provide rewards if they are in
Power and Influence Theory n
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a position of power.
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Finally, coercive power, considered the oppo-
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The power and influence theory of leadership

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takes a different approach in that there are vari- site of reward power, occurs when the team leader
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ous ways leaders use authority, control, and their uses threats and punishments to get their way.
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influence on others to get things done. Perhaps For example, the team member may be threat-
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the best-known of these theories is the model that ened with termination. Extensive use of coercive
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social psychologists John R. P. French Jr. and Ber- power should be avoided as many leaders abuse
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tram Raven proposed listing five forms of power this power and use it inappropriately (French and
(French and Raven 1960). Positional power is the Raven 1960).
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authority a person has because of their position in Personal power is divided into referent power
by
the organization’s structure. Personal power is the and expert power. Referent power (also known
20
20
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Figure 19.2 Vroom and Jago’s decision-making strategies

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Leader
C
Autocratic Consultative
Group
consensus
A1 A2 C1 C2
Individuals Group
Followers
Adapted from: Vroom and Jago 1995.
AB103118_Ch19.indd 586 2/6/2020 5:53:36 PM

as charismatic power) is the ability of the team and should acknowledge the expertise of other
members to identify with leaders who have desir- team members (French and Raven 1960).
able resources or personal traits. This may come Two additional power and influence theories
from the leader’s energy, endurance, empathy, are transactional leadership and leading by ex-
toughness, humor, or charm. Expert power refers ample. Transactional leadership assumes that
to leaders who are experts in their field or have the team members will accept and complete their
knowledge or skills that are in short supply. Team responsibilities for no other reason than to receive
members tend to listen to those who demonstrate rewards. Therefore, leaders need to design a task
expertise. A person does not have to be in a posi- and reward system to ensure the team’s work
tion of power to have expert power. A team leader progresses at a satisfactory pace. Leading by ex-
can take maximum advantage of expert power ample places the leader in a role model position,
by using their knowledge to offer guidance and which allows a person to display, through their
n.
support to the team to motivate them. A leader actions, how they would expect others to act. If
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should not be a know-it-all and must listen to the the team members see the leader assume respon-
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concerns of the team members to create credibil- sibilities and complete them on time, then the
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ity and respect. The team leader does not have to team members are likely to do the same (French
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have all the knowledge and expertise in the group and Raven 1960).
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Leadership Styles
n
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After all leadership styles are evaluat- and creates a shared vision. The negative aspects
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ed, they can be divided into three basic groups: of the democratic style is that it is not particularly
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authoritarian, democratic, and laissez-faire. Au- effective when decisions have to be made quickly
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thoritarian leadership is a domineering style of and the group feels the leader is not leading but,
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leadership in which decisions are made at a dis- rather, depending too heavily on the group. This
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tance from the workers they affect. Rulemaking, style is difficult to use when there is little commu-
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task assignments, and problem-solving are done nication and the group is comprised of inexperi-
solely by the leader and enforced through pun- enced people. A type of leadership style included
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ishment, threats, demands, orders, and regula- in the democratic method is value-based leader-
by
20
tions (Lewin et al. 1939). A result to this type of ship—an approach that emphasizes values, ethics,
20
leadership is that the decisions are made by one and stewardship as central to effective leadership
©
person and usually not allowed to be questioned. (Lewin et al. 1939).

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A disadvantage is the team members are often The third leadership style is laissez-faire lead-
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afraid of the leader and the consequences of mak- ership (also known as delegative leadership). This
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ing of mistake and being punished. style reflects a leader who holds a title and respon-
The democratic leadership style is participative sibility but is strictly hands-off and has everyone
and supports collective decision-making by offering else perform the work. This style is commonly as-
others in the group choices and then empower- sociated with negative outcomes though it can be
ing group members by facilitating group delib- highly effective if the group members are already
erations and encouraging and rewarding active highly accomplished and motivated. Some of the
member involvement. The leader gains authority negatives associated with laissez-faire leadership
by taking personal responsibility for the group’s include some group members may need direction
outcomes and accepts accountability for the re- and guidance, some group members may be inex-
sults. The pluses for this type of leadership style perienced and struggle with the task at hand, and
are that it builds consensus of the group mem- the leader may appear to be uninterested. A type
bers, encourages creativity, builds commitment, of leadership style associated with laissez-faire is
AB103118_Ch19.indd 587 2/6/2020 5:53:36 PM

path–goal leadership, which emphasizes the role best under supervision that involves close control,
of the leader in removing barriers to goal achieve- centralized authority, authoritarian practice, and
ment but otherwise having a hands-off attitude af- minimal participation of the group members in the
ter the group is established (Lewin et al. 1939). decision-making process. The leader feels that the
team is lazy, has no motivation, and will do noth-
Patterns of Leadership ing productive if not overseen closely. In t heory X,
Leadership can be defined as a continuum of six dis- leaders are pessimistic about the team members
tinct styles (see figure 19.3). On one side of the contin- and the quality of their work, and assume the av-
uum is exploitive autocracy—the harshest form of erage person dislikes work and must be forced to
leadership, as the leader wields absolute power and accomplish the group’s goals. This theory may
uses the team to serve their own personal interests. be self-fulfilling because if the leader believes the
This is followed by benevolent autocracy where the team members are lazy, they may, indeed, become
n.
leader also wields absolute power but is generally lazy (McGregor 1960).
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kind and sincere in the use of the team for the good Theory Y relates to participative leadership
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of the organization. Subsequently, in a bureaucracy where the team leader believes team members are
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eager to do well, have the motivation to perform
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the leader relies primarily on rules and regulations
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but sometimes those rules and regulations become their best, and are capable of doing so. In theory Y,
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more important than the team’s purpose. Next is leaders are optimistic about the team members and
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consultative leadership where the leader remains expect great results from their work. The Theory Y
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open to input from members of the team but still leader assumes that work is not avoided, self-mo-
n
retains full decision-making authority. Situational io
tivation and inherent satisfaction will work toward
at
the benefit of the group, and each group member
m
leadership involves the leader who changes the ap-

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proach based on the needs of the team and situation. seeks responsibility. Leaders will delegate tasks
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At the most lenient end of the continuum is partic- and responsibilities as much as possible and open
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ipative leadership where plans and decisions are communication is encouraged (McGregor 1960).
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made by the team and the leader is there to provide While the reality is that neither of these theo-
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advice and assistance (McConnell 2018). ries is used exclusively by leaders, there are ele-
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Leader–member relations—the acceptance of ments of each that reflect how people anticipate
and confidence in the leader by the team members, working with others. As an example of Theory X,
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as well as the loyalty and commitment they show some people may dread being placed on a partic-
by
toward the leader—is vital for any leadership style ular team feeling they will have to do all the work
20
20
because the lack of acceptance and confidence in a because other members of the team will not carry
©
leader by the team will cause the leader to fail. their weight. However, there are some groups for
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Douglas McGregor investigated the theory that which people volunteer either because they know
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leadership styles may be related to a leader’s phi- other people in the group or believe the work is
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losophy about the members in a group or team, worthwhile. In this theory Y example, leaders
and his research resulted in Theory X and Y. The- rarely have to threaten, punish, or look over the
ory X is pure authoritative leadership, in which shoulders of the team members because the mem-
the team leader believes team members perform bers enjoy being a part of that group.
Figure 19.3 The continuum of leadership styles

Harshest Most lenient
Exploitive Benevolent Consultative Situational participative

Bureaucracy
autocracy autocracy leadership leadership
Source: ©AHIMA.
AB103118_Ch19.indd 588 2/6/2020 5:53:37 PM

Transformational and Transactional followers. Finally, leaders challenge their follow-

Leadership ers to be innovative and creative, referred to as in-
Leaders who inspire and motivate a group of peo- tellectual stimulation (IS).
ple, and create a vision of the future exemplify Transformational leaders recognize many of
transformational leadership. The leader becomes today’s problems cannot be solved with the same
a role model who coaches and builds a team of solutions of the past. New problems require new
committed members. The leader identifies a need- answers. Therefore, transformational leaders need
ed change, creates the vision of how to accomplish to think outside of the box for new and innovative
this change, and aligns the group members with solutions and inspire their group members to do
tasks that will not only achieve the goals and ob- the same.
jectives of the vision but also enhance the perfor- The theory of transactional leadership assumes
mances of group members. people are motivated by reward and punishment,
n.
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There are four common components of trans- such as monetary rewards or disciplinary actions
ia
formational leaders. First, leaders serve as a role as punishment. The understanding of the worker
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model to the group, referred to as idealized influ- is that they are there to do a job and be told what
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ence (II). Second, leaders have the ability to in- to do, with a clear chain of command. The transac-
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spire and motivate their followers, also known as tional leader operates as if performance to a certain
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inspirational motivation (IM). Third, leaders dem- standard is expected and clear from the beginning.
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onstrate individualized consideration (IC), or a There is no need to praise or correct unless expecta-
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genuine concern for the needs and feelings of their tions exceed or fall below the standards for the job.
n
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1. In which of the following theories would a leader feel that they can trust group members and do not have to micromanage?
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a. Theory X
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b. Theory Y
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c. Transformational leadership theory

20
d. Participative leadership theory

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2. The belief that a person may be a leader in one situation but not in another is the basis of what leadership theory?
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a. Trait
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b. Behavioral
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c. Contingency
C
d. Power and Influence

3. True or false: Leading is one of the four management functions in addition to planning, consolidating, and controlling
4. According to Vroom and Jago’s decision-making strategies, the “c” stands for which of the following?
a. Chief
b. Clinical
c. Consultative
d. Coordination
5. What is the type of power given to leaders who are authorities in their fields or have knowledge or skills that are in short supply?
a. Expert
b. Referent
c. Legitimate
d. Influence
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Change Management
Managing change in a healthcare setting organization (see table 19.1) (Kotter 1995). An ex-
is a constant responsibility for leaders and is often ample of this method of change management in
impacted by internal and external forces outside health information management (HIM) is the im-
of their control. Within an organization, change plementation of a new electronic system in the ra-
generally occurs when there is a need for a proc- diology department for physician orders. A new
ess or procedural improvement. It is the role of the system may change the way the HIM department
leader to influence and guide others through the processes physician orders for radiology tests. The
change so the group feels the change was worth- manager of the HIM department could follow
while and they are not threatened by the final re- Kotter’s eight-step method to alleviate the anxiety
sult—whether by loss of employment, change in caused by the required change.
n.
work responsibilities, or reduced income.
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Lewin’s Change Management Model
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Methods of Change Management
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Kurt Lewin, one of the first researchers in social
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Change management is a controlled method to psychology, proposed an alternative model of
en
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ensure change can be managed smoothly. The un- change management by advocating that orga-
ag
derlying tenet is all human beings prefer doing nizations must first unfreeze, or disrupt, current
an
things that have the most meaning for themselves. processes, meaning the organization’s existing
M
mindset is interrupted. Often organizations con-
n
When people believe change is going to be harm- io
at
ful to themselves or their careers, they are resist- tinue using the same work processes believing the
m
“if it ain’t broke, don’t fix it” adage. However, the

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ant to change. To overcome this resistance, leaders

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need to patiently sell the idea of change by educat- organization’s recognition that change must occur
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ing and training their team and carefully dissemi- is the unfreezing of current work processes. This
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nating information. The following sections explain stage can lead to employees and management
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various methods of change management: Kotter’s having feelings of denial and anxiety that must be
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eight-step method to leading change, Lewin’s overcome before the organization can move on to
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change management model, and Bridge’s transi- the second stage.

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tional model of change. The second stage—create the change—occurs

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when people resolve their uncertainty and look for

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new ways to do things. This is typically a period

20
Kotter’s Eight-Step Method to Leading Change

©
While a professor at Harvard’s Business School,

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John Kotter developed an eight-step method of Table 19.1 Kotter’s eight-step method of leading
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leading change within an organization. The eight change

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steps to creating a climate of change within an

Engage and
organization include the following. A climate of enable change
change starts with establishing a sense of urgency, Create a climate in the whole Implement and
of change organization sustain change
building a team to guide change, and developing
1. Establish 4. Generate short- 7. Consolidate
an informed vision and strategy to deal with the a sense of term wins gains
change. To engage and enable change in the en- urgency
tire organization or within a department includes 2. Build a team to 5. Empower a 8. Anchor changes
generating short-term wins, empowering broad- guide change broad-based in organizational
action culture
based action, and communicating the change vi-
3. Develop vision 6. Communicate
sion to all employees. To implement and sustain and strategy vision to all
change includes consolidating gains and anchor- employees
ing the new approaches within the culture of the Source: Kotter 1995.
AB103118_Ch19.indd 590 2/6/2020 5:53:37 PM

of confusion and even anger and fear as they real- to acknowledge the directive if they understand
ize change must occur. There is usually resistance the purpose behind the change. A better-informed
as the change is not clearly defined yet; however, employee is more likely to accept the change.

the organization is beginning to move in a positive However, do not provide too much information as
direction. this may result in the leader spending excessive
The final stage is refreezing the environment, time clarifying the minute details rather than fo-
so the change is integrated into the processes cusing employees on the bigger picture.
and procedures within the organization. The
change now becomes the status quo and produc- Bridge’s Transitional Model of Change
es a positive impact in the organization (Lewin William Bridges, a management consultant, fo-
1947). An example of using Lewin’s model with- cused his research on transitional process rather
in an HIM department is the implementation of than change implementation. He created a transi-
n.
a new reimbursement methodology in the US. tional model that defines three stages: (1) ending,
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Unfreezing would involve preparing for the losing, and letting go; (2) the neutral zone; and
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implementation date. Transition and refreez- (3) new beginnings. Each stage identifies chang-
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ing would involve getting all staff and teams
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ing emotions employees experience as their daily
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comfortable with the change and then getting work is either changed or replaced. The emotions
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productivity back up to where it was prior to associated with stage 1 are fear, denial, anger,
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unfreezing. sadness, disorientation, frustration, uncertainty,
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It is not the change itself that leads to misun- and a sense of loss. In stage 2 people may expe-
derstanding, it is the manner in which a change n
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rience resentment toward the change initiative;
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is introduced. Leaders should introduce and
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low morale and productivity; anxiety about their

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conduct training for the change well in advance role, status, or identity; and skepticism about the
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of the change’s implementation so employees

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change initiative. Finally, in stage 3 employees

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can adapt to and learn the idea, consider the may experience high energy, openness to learn-
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implications, and ask questions for more clarifi- ing, and renewed commitment to the group or
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cation. Involving employees in change manage- their role in the organization (table 19.2). Un-
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ment will reduce their uncertainty and potentially derstanding what a member of a group is feel-
increase their acceptance rather than them feel-
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ing during the change process will help a leader

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ing the change was thrust upon them without anticipate potential issues and allow the leader
by
their input.
20
to better guide the employees to a successful res-

20
When providing the information and direc- olution (Bridges 2016).

©
tives of how the change will occur, a leader must

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consider the types of employees impacted by the Table 19.2 Bridges’ list of feelings for a
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change, the work situation where the change will transitional model
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occur, and how supervisors will work with their

Stage 1 Stage 2 Stage 3
staff—including their attitudes toward their staff
Fear Resentment High energy
members. Care must be given to how the directive
Denial Low morale and Openness to
for change is presented to the staff. For example, productivity learning
directives should be reasonable, intelligible, word- Anger Anxiety about role, Renewed
ed appropriately, compatible with the desired end status, or identity commitment
result of the change, and indicate that the change Sadness Skepticism
can occur within a reasonable time frame. Disorientation
Presenting the directive for change takes a great Frustration
deal of forethought on the part of a leader and is Uncertainty
not to be rushed into without considering how Sense of loss
the staff will react. Employees will be better able Source: Bridges 2016.
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Mergers Electronic Record Systems

Mergers involve the joining of two or more com- Another major source of change is the develop-
panies into one; this is a major source of change ment and implementation of the electronic health
management as hospitals and other healthcare record (EHR) in a healthcare organization. Tradi-
organizations are combined. During and after the tionally, HIM has been very labor intensive with
merging of two healthcare organization, employ- people whose sole job is to move paper; from pa-
ees will wonder if there will be duplication or re- tient care sites, to analysis and assembly, to in-
placement of positions. Will the new entity need complete files, to coding, and then to permanent
two HIM directors or can one position handle both files—not to mention moving paper for disclosure
departments? Perhaps the healthcare organization of information and off-site storage. However, with
will create a corporate HIM position and only have the creation of the EHR most document movement
supervisors at each location. The employee might is handled electronically, thus reducing staffing
n.
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wonder if their pathway to advancement has been levels previously necessary in HIM departments
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lost as a result of a change in the organizational (see chapter 3, Health Information Functions, Pur-
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culture. One entity may have an organizational pose, and Users, for more information about change
tA
culture that encourages promotion from within within the EHR environment. This change is sig-
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while another entity may see the benefit of bring- nificant and affects all employees as the physi-
em
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ing in professionals from outside the healthcare cal size of the department may be reduced since
an
organization. Which entity will dominate and thus there is less paper to be stored and used for patient
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offer an advantage to that company’s employees? care. It is a leader’s duty to explain the benefits of
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Will one entity’s staff be given preference over the the change to staff and set a vision of where the
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other? Mergers can create unsettling times but by department needs to transform; and clarify that
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being prepared for a leadership role an individual while some jobs may be eliminated (file clerks)
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can provide extra security as either an asset in the new jobs may be created (scanning). A leader must
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new entity or by moving to another healthcare or- feel comfortable with their role and convey that
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ganization that can better appreciate their leader- sense of job security to the other employees in the
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ship abilities. department.

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Leadership
20
20
©
The difference between leading and to explore leadership competencies, emotional in-
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managing is sometimes hard to distinguish and telligence, and leading others.

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the terms are often used interchangeably. It is im-

Leadership Competencies
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portant to understand the difference, especially

in terms of leading an organization, department, The main competencies for effective leaders in-
or team of employees. Managing is the process clude being emotionally stable, having the ability
of planning, controlling, leading, and organizing to get the job done, being a good communicator,
activities. Managing is a process and it includes being unafraid, being credible, having the ability
leading. Leading refers to a person’s ability to un- to develop committed followers, and exhibiting
derstand and influence situations, and motivate charisma. The first competency of being emotion-
and encourage others, while intervening when ally stable can be learned and developed by under-
necessary, toward success or to a desired end goal. standing emotional intelligence, discussed next.
More information on managing can be found in The ability to get the job done includes providing
chapter 17, Management. To better understand direction, expectations, and standards of what is
how to become an effective leader it is important expected. Communication is key to providing
AB103118_Ch19.indd 592 2/6/2020 5:53:37 PM

clear instructions and making sure that everyone with others to motivate them in a desired direc-
who needs to know the directions understands tion. Humans communicate in many different
them. The ability to be unafraid means leaders ways using both verbal language and body lan-
take responsibility, take risks, and keep fears to guage. Some cultures have different acceptable so-
themselves. Credibility means being truthful and cial interactions, for example eye contact or body
keeping commitments. The ability to develop proximity. Leaders need to understand the cul-
committed followers happens with leaders who ture of the people they are working with to ensure
are willing and able to help out wherever they their behaviors are socially acceptable in a partic-
are needed and who care about those who are fol- ular culture. Developing and practicing those
lowing them. Charisma, which is the charm that skills are important for a leader (Bradberry and
inspires others, can be learned, especially by mak- Greaves 2009).
ing a point of recognizing people doing the right
Leading Others
n.
things for the project (McConnell 2018).
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The ability to be a leader and to lead others can
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Emotional Intelligence be learned and developed through education
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and practice of leadership skills. Leading is the
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Emotional intelligence (EI) includes five skills
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good leaders try to master to maximize their ability to analyze and understand the situation,
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performance and the performance of their team. project, or department and what needs to be ac-
ag
These skills are: self-awareness, self-regulation, complished; for example, leading a department
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motivation, empathy, and social skill. Self-aware- through the change needed for implementation
n
of a new computer system. The leader is respon-
ness is the ability to know one’s self, to under- io
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sible for energizing and engaging others and
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stand one’s strengths and weakness and personal

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values and the effect that has on others. For exam- intervening where needed to get the best out of
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followers and team members (Kansas Leadership

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ple, a leader knows that she gets very angry when

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a team member is late for a meeting; knowing this Center 2016).

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she is able to control that anger. She can develop

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Critical-Thinking Skills
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the skills to prevent herself from getting angry or

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change the start time of the meeting to combat her HIM leaders are continuously confronted with a
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own anger. Self-regulation is the ability to control changing profession, whether it is in reimburse-
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or direct impulses and moods. Expanding on the ment, technology, or disclosure of protected health
by
20
same example, the leader may consider the pos- information. One of the most useful tools an HIM
20
sible reasons the team member is always late and leader can possess is to think critically. Critical
©
may explore solutions with them. Motivation is thinking is a disciplined process of actively and
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a person’s desire to do something, the thing that skillfully conceptualizing, analyzing, synthesiz-
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compels a person. For example, a leader should ing, applying, and evaluating information. The
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consider what motivates them as a person as well information can be gathered from or generated
as what motivates their team members. People are by observation, experience, reflection, reasoning,
motivated by different things including money, or communication, and used as a guide to belief
success, mentoring, learning something new, a job and action (The Foundation for Critical Thinking
well done, or being a part of a team. Empathy is 2018). Through analysis and evaluation of an is-
the ability to understand another person’s emo- sue one is able to create an understanding of the
tions. For example, a coworker recently lost his fa- issue. Critical thinking involves the examination
ther and is therefore distracted from the project at of the purpose, problem, or question; any assump-
hand. Empathy is the ability to imagine how that tions, concepts, reasoning leading to conclusions,
may feel and what can be done to help this team implications and consequences, or objections from
member through this difficult time. Finally, social alternative viewpoints, and a frame of reference.
skill is the ability to build and maintain rapport Critical thinking has two components—belief
AB103118_Ch19.indd 593 2/6/2020 5:53:37 PM

enerating and processing skills, or the habit of

g financial officer (CFO). It is important to note these
using those skills to guide behavior (The Founda- executives report to the board of directors and the
tion for Critical Thinking 2018). decisions they make affect the subordinate levels
Critical thinking varies according to the indi- in an organization. More information about hos-
vidual’s underlying motivation. When used for pital structure and the board of directors can be
selfish purposes, it is often revealed as the skillful found in chapter 2, Healthcare Delivery Systems. At
handling of ideas for the personal interest of an this level of management, technical and functional
individual or group. When used in good faith, it expertise matters less than leadership skills and a
is seen as ethical and perhaps idealistic, especially strong grasp of business fundamentals. The lead-
by those with other agendas. Critical thinking of ership skills discussed earlier in this chapter are
any kind is never universal—everyone is subject vital for an effective CEO.
to episodes of undisciplined or irrational thought.
n.
The quality of critical thinking is a matter of de- Chief Executive Officer
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gree and dependent on, among other things, the The chief executive officer (CEO) is generally
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quality and depth of experience in a given domain accountable solely to the board of directors (see
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of thinking or with respect to a particular class of
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chapter 2 for more information about the board of
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questions. The development of critical-thinking directors). The major responsibilities of the CEO
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skills is a lifelong endeavor as no one thinks criti- are to develop and implement high-level strategies;
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cally in all situations (The Foundation for Critical set a vision; make major organizational decisions;
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Thinking 2018). manage the overall operations and resources of a
The list of core critical-thinking skills includes n
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company; build culture; set the budget to be pre-
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observation, interpretation, analysis, inference,
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sented to the board of directors for approval; and

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evaluation, explanation, and metacognition (The act as the main point of communication between
In
Foundation for Critical Thinking 2018). There are the board of directors, the corporate operations,
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tools that can be used to help with critical thinking and the public (SHRM 2018). The CEO position
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in a group. These include brainstorming, nominal requires strong communication and collaboration
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group technique, and Ishikawa diagrams. Brain- skills, approachability, transparency, and the abil-
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storming is the aggregation of ideas from a group, ity to transform an organization (Hanke 2018).
where no response is considered bad and the goal
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is to generate quantity, not necessarily quality. Us- Chief Information Officer

by
ing the nominal group technique, the group writes The chief information officer (CIO) is responsi-
20
20
down their suggestions anonymously and then ble for leading, planning, budgeting, resourcing,
©
votes on which ideas are the most appropriate and training the information technology (IT) staff.
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for the context of the discussion. This technique The CIO needs to know how to create business
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focuses on finding a communally acceptable solu- models and make rigorous decisions based on the
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tion. An Ishikawa diagram (also referred to as a analysis of the return on investment for addition
root-cause diagram) is used to determine the root of purchasing technology for the organization.
causes of a problem by constantly asking, Why? Healthcare organizations are continually purchas-
ing technology to improve the way they conduct
C-Suite business. In addition to a deep understanding of
The HIM department reports to administrators in technology and the interoperability of electronic
the C-suite (also referred to as the C-level). The records, the CIO needs a good understanding of
C-suite is a slang term for the uppermost man- change management.
agement level in an organization and refers to the
executive titles that start with the letter C, refer- Chief Financial Officer
ring to the word chief as in chief executive officer The chief financial officer (CFO) typically re-
(CEO), chief information officer (CIO), and chief ports to the CEO or board of directors and is the
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chief financial spokesperson for the organization. and accounting principles. A healthcare orga-
Most CFOs have a master’s in business adminis- nization’s CFO has the added responsibility of
tration (MBA) or are a certified public account- understanding healthcare reimbursement meth-
ant (CPA). Along with leadership skills a CFO odologies and the organization’s cost reports. A
must possess a strong understanding of corpo- cost report contains information on the costs and
rate finance methodologies, cash management, charges of an organization.

Match the emotional intelligence terms with the definitions.
n.
1. Self-awareness
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2. Self-regulation
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3. Motivation
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4. Empathy
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5. Social skill
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a. Controlling or redirecting
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b. Managing relationships
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c. Knowing one’s self io
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d. Being driven
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e. Considering others
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Team Leadership
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HIM professionals often work with team leader possesses the qualities of compassion
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other healthcare professionals (such as nurses, and integrity, which can be developed through
by
information technologists, informaticists, thera-

20
training (Scott 2018).

20
pists) throughout the organization. As such, they A team leader must project certain leadership
©
should be a part of any team within an organi- traits and qualities to the team members to ensure
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zation where their expertise is needed. By assem- the team’s objectives are met. These include the
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bling a diverse group of people with technology following:

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knowledge as well as users and stakeholders,

●● Communication. This is an essential function
teams provide a valuable asset to the future of any
to ensure all the members of the team are
healthcare organization. It should be noted that
aware of and understand their role and
teams and committees are not the same; teams
responsibilities.
have a relatively short life span, whereas commit-
tees are part of the formal organizational struc- ●● Organization. This skill allows the team to
ture. The team leader is someone who provides perform at the optimal level by maintaining
leadership, instruction, and direction to a team order to meet goals and objectives.
for the purpose of achieving a set goal or objec- ●● Confidence. Through their actions, the team
tive. It is the team leader who is responsible for leader must show the team that they are
the team’s outcomes and ensuring everyone on confident not only in their abilities, but also
the team contributes in a meaningful way. A good in the abilities of the team members.
AB103118_Ch19.indd 595 2/6/2020 5:53:37 PM

●● Respectful. All members of the team have to trying to achieve a moving target. Leadership is
be shown respect for their input and who ineffective when there is no clear decision maker
they represent on the team. in the group and the lack of leadership results in
●● Fair. All members of the team must be conflicts between team members as they struggle
treated equitably and no favoritism shown to understand and take ownership of the process.
because of title or relationship to the team As with all new initiatives, support from the up-
leader. per levels of management is essential for a team to
accomplish its targeted goals. The support is often
●● Integrity. The team’s leader must not appear
in the form of a team charter, providing a team pur-
to change or waiver when difficulties occur
pose, help with team member selection, and cre-
but rather keep a constant viewpoint and
ation of team norms. Without executive support,
direction.
the team loses its champion to defend the team be-
Influential. The team leader must be able
n.
●●
fore the other top executives and the board. Exec-
tio
to bring the team to a consensus when utive support also ensures the team will have the
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differences of opinion occur to achieve a
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resources (time, personnel, and money) needed to
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common outcome. complete the team’s objectives successfully.
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●● Delegation. The team leader cannot do it
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all; therefore, various tasks and objectives Team Charter
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should be delegated to different team
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The team charter, provided by upper manage-
members.
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ment, is the document that explains the issues the
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●● Facilitator. When disagreements occur io
team was created to address, describes the team’s
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among the team members, it is the team goal /or vision, and lists the initial members of
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leader’s responsibility to keep everyone on the team and their respective departments. A team
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task and focused on the projected outcomes.

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must understand their purpose and direction to

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Negotiator. When a stalemate occurs be successful. A clear charter helps define the pur-
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●●
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on the team’s decision regarding the pose for the members (Heathfield 2018).
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final deliverable, it is the team leader’s

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responsibility to work toward a common Team Purpose

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agreement (Scott 2018). The main purpose for creating teams is to provide
th
by
a formal framework so its members can participate

Factors that contribute to the success of a team
20
in planning, problem-solving, and decision-mak-

20
include a team leader and team members who ing to better serve the organization. Therefore, the
©
have effective and excellent communication skills

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team purpose needs to be well defined by the team

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and all roles and responsibilities of members being charter. When everyone knows the team’s objec-
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clearly defined. When there is disagreement among tives then the team will not waste time with un-
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members, it needs to be productive disagreement necessary or unproductive communication.

instead of accusations; and when decisions are
made, all parties must agree to support those deci-
sions. Next, the team needs to have strong external Team Selection
relationships with not only executive management Once management determines a team should be
but the other stakeholders who have an interest in formed to accomplish a set of specific goals and
the team’s goals and objectives. Finally, the team objectives and a person has been delegated as
needs to perform a routine self-assessment to de- the team leader, it is time to appoint the team
termine what worked and what were the bottle- members. Every team should have the input and
necks to finding the end result. expertise of people from different parts of the or-
Teams that fail often have unclear goals or ganization who have direct relationships to the
changing objectives so the team is constantly outcomes associated with the goals and objectives
AB103118_Ch19.indd 596 2/6/2020 5:53:37 PM

of the team. Membership should include people (a professor at The Ohio State University). Re-
with technical expertise, knowledge of the proc- ferred to as Tuckman’s model of forming-storm-
ess under consideration, employees who work ing-norming-performing, this four-stage model is
with the process after the changes have been inte- a simple way to determine where a team dynamic
grated, as well as other people who may affect or is at any given point. Forming is the process of
be affected by the outcomes of the team. Effective putting the team together. This is the first expo-
teams have good interpersonal communication sure of the team members to each other and mak-
skills and understand the roles of each member of ing first impressions that are either on target or
the team. off base from reality. These first impressions will
The size of the team depends on the scope of color a person’s viewpoint of other team members
the outcomes required. For example, in a large or- throughout most of the team’s existence. Storm-
ganization strategic planning may have as many ing is the phase when personalities clash as team
n.
as 100 members who are then placed on teams and members are trying to find their role on the team
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subcommittees to work on specific objectives. On and attempting to establish their position in the
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the other hand, deciding what documents need to team dynamics. During this time the leader may
ss
be scanned in an HIM department may only need have to institute conflict management, which fo-
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five or six members to accomplish the task. cuses on working with individuals to find a mu-
em
tually acceptable solution (Tuckman 1965). For
ag
Team and Member Participation more information on managing diversity and con-
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Comprising a team of diverse members is a risky flict management, see chapter 20, Human Resources
n
venture that can prolong the desired outcomes of io
Management. Norming is the phase where conflicts
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are reduced, everyone knows their positions and
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the team. This is especially true if the team mem-

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bers do not know each other, each member’s area responsibilities, and actual work to achieve the
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of expertise, or the task ahead. It can also occur goals and objectives can begin. Finally, performing
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when multiple managers are placed on one team is the phase where actual results are obtained as
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as each might try to take control from the team the team is productive and reaches its final out-
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leader. Ideally, the team leader should be clearly comes and deliverables.
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known to team members and should start by lead- Each of these phases can exist for different times
ing the team in team building exercises at the be- depending on the composition of the team and
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ginning of the process so the members can learn people’s personalities. For example, if a team is
by
to work as a group rather than individually. An comprised of members who have worked before
20
20
example of a team building exercise is dividing on other teams, then the storming phase can be
©
the team into groups of three to five members and shortened. However, if the team is comprised of
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having them use toothpicks and 3 x 5 cards to de- members that have never met or are representing
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sign a boat that will float for one minute without different departments that have not traditionally
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falling over or sinking. worked well together, than the storming phase
Diversity of team members is vital to ensure the can take up a lot of time that could otherwise have
members are examining all the facts and r emain objec- been productive (Tuckman 1965).
tive. Diversity allows members to understand their Eventually team members must work together
own biases, perspectives, and decision-making pro- to reach the common goals and objectives of the
cesses (Rock and Grant 2016). Diversity includes team. Each member must take the responsibility
not only team members from different departments to communicate not only with the team leader
but also cultural differences. More information on but with each other, not blame others but support
cultural competence can be found in chapter 21, group members’ ideas, leave the egos at the door
Ethical Issues in Health Information Management. and not brag, use active listening (a communica-
Each team goes through group dynamics that tion method that requires the listener to provide
often take the form proposed by Bruce Tuckman feedback to the speaker), and get involved by
AB103118_Ch19.indd 597 2/6/2020 5:53:37 PM

eing a participant, not a bystander. The four rules

b and which need to be retooled. The establishment
for active listening are: (1) seek to understand be- of and adherence to team norms helps build team
fore you seek to be understood; (2) be nonjudg- discipline and trust among team members, and
mental; (3) give your undivided attention to the supports a safe environment.
speaker; and (4) use silence effectively (Depart- Some norms that are common to most teams in-
ment of State 2018). clude the following:
Team Norms ●● Meetings will start on time.

Team norms help determine acceptable and un- ●● Members will listen and not interrupt.
acceptable behavior for a team. Team norms may ●● Everyone will be able to speak.
be explicit as in rules and regulations or unwritten ●● The team leader will moderate the
behavior that is formed over time or through peer discussion.
n.
pressure. Most newly created teams start out with
tio
●● Members will avoid cultural humor.
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a preliminary set of norms that will be reviewed
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and modified frequently as conflicts or disagree- Members will speak respectfully.
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●●
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ments among team members occur. Some teams ●● All members’ concerns will be addressed to
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review norms at the beginning or end of each come to consensus (Berea College, Brushy
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meeting and discuss which are working effectively Fork Institute 2018)
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Team Meetings
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Once the team has been formed, a leader Conducting Effective Meetings
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has been selected, team members have established

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Everyone on the team must be ready to partici-

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their roles on the team, and a charter has been pre-

pate and be an active member on the team. This
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sented by upper management, it is then the team

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means members coming prepared for the meeting

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leader’s responsibility to set an agenda, schedule

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by reading any material issued beforehand, being

meetings, conduct the meeting, build consensus,
ready to discuss the material, and understanding
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and handle any follow-up tasks required to ensure

what will be covered in the meeting. Often team
by
the next meeting runs smoothly. The frequency of

members represent a division or unit within the
20
meetings is determined by the time constraints

20
organization, so the team member should collab-

given in the team charter. Some teams may meet
©
orate with other people in their department and

ht
once a month while others need to meet weekly or

ig
bring their collective views to the meeting. This

yr
more often to reach a goal within the time frame

op
will provide a richer discussion as a single person

given. For example, moving the HIM department
C
might not have considered all of the nuances that

to an off-site location may require teams meeting
someone else from the department might have ob-
more infrequently when compared to implement-
served and shared with the team member repre-
ing computer-assisted coding.
senting the unit.
Prior to the meeting, the team leader should
Scheduling of Meetings send requests to team members for input on meet-
One of the most difficult parts of organizing and ing agenda items. This is not to say everything
running a team is the scheduling of meetings. The suggested will be included, but it is a starting
greater the number of team members, the more point and indicative of what members feel are
difficult it is to arrange a meeting. Ensure team important issues that need discussion. The team
members are informed in advance of the meeting leader controls the amount of information and dis-
to reduce scheduling conflicts. cussion presented in the meeting to a reasonable
AB103118_Ch19.indd 598 2/6/2020 5:53:38 PM

amount so the meeting does not exceed its allot- c oncerns expressed by the group to form a list of
ted time. The agenda and any other materials to conditions for possible proposals to address; tak-
be read should be sent to the members well in ad- ing turns in a unified attempt to shape each idea
vance (four to five days) of the meeting so they into the best possible proposal before choosing
have enough time to review and prepare for the among them; and using empathy in the closure
meeting. stage to address any unresolved feelings from the
The team leader must start the meeting on process.
time to be cognizant and respectful of the mem- The six CODM steps include the following:
bers’ schedules. The meeting should begin with a
1. Discussion
review of the agenda and ask for any additional
comments before continuing. A team member 2. Identify the emerging proposal
delegated to be secretary will take notes (min- 3. Identify unsatisfied concerns
4. Collaboratively modify the proposal
n.
utes) during the meeting. It is also helpful to have
tio
a member be a timekeeper to ensure the meet- 5. Assess the degree of support
ia
oc
ing stays on track without too many digressions. 6. F
inalize the decision or circle back to the
ss
When confronted with numerous tasks to com-
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first steps (Hartnett 2018)
en
plete in a limited amount of time, the team leader
em
must delegate several tasks and responsibilities Consensus building is needed so the team is in-
ag
to the team members, which allows everyone to clusive and not limited in their perspective. The
an
team members represent diverse backgrounds,
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share in the decision-making process.
n
At the end of the meeting, the leader should con- and everyone should be encouraged to participate
io
at
duct a review of what was discussed and remind and all voices should be heard. Team members
m r
need to collaborate for further development of

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everyone who is responsible for individual tasks

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for future meetings. Be sure to end the meeting on ideas into final results. Consensus building seeks
lth
to have everyone reach a common agreement so

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time or even a little early; the team members will

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appreciate the thoughtfulness behind an efficient that implementation of the team’s deliverables
an
will be acceptable to all parts of the organization.

ic
meeting. Finally, once the secretary has completed

er
It also results in more informed, collaborative de-

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their notes, they should be distributed to the team

members for review and clarification, if needed. cisions and outcomes as everyone on the team
e
th
has ownership of the results and can relay them

by
Consensus Building to their counterparts in their respective organiza-

20
tional units (Hartnett 2018).

20
When a group of people converge from diverse

©
backgrounds to search for a solution to a problem,

ht
Communication
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conflicts and differences of opinion often occur. It

yr
op
is the responsibility of the team leader to use con- Communication is vital for a leader to be effec-
C
sensus building—a decision-making method that tive. Direct communication with team members
seeks consent of all participants to resolve those is important so they understand everything that
differences so an acceptable result can be found. concerns their work on the team. Communication
Note that a successful result does not mean it is can take different forms, whether through the use
favored by all, but only that it is acceptable to the of meetings, minutes, reports (a summary of the
members of the team. data collection, conclusions, and recommenda-
The consensus-oriented decision-making mod- tions of the team at a specific period of time), and
el (CODM) presents a six-step progression that storytelling (which is used to summarize an en-
allows groups the flexibility to come to a consen- tire project using words, pictures, or graphs in a
sus by approaching important topics with open fashion that permits listeners to grasp the team’s
discussion rather than presenting a preformulat- accomplishments and to understand its specific
ed proposal; gathering a list of all the needs and application).
AB103118_Ch19.indd 599 2/6/2020 5:53:38 PM

Figure 19.4 Stages of communication
Noise
Concept of
Sender Encoding Medium Decoding Receiver
message
Noise
Source: ©AHIMA.
n.
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Most forms of communication use the same not only the concept of the message but
ia
process shown in figure 19.4. They follow the six also the encoding, medium, and decoding.
oc
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stages below Surrounding the entire message is the
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background noise, those things that are
en
Stage 1: Determine the concept of the
distracting to the receiver when interpreting
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message (ideation). This is the most difficult
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the message being received; for example, the
part of the process as the message must be
an
tone of voice and mannerisms of the person
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clearly and concisely formulated prior to
attempting to communicate.
sending the message to the receiver. n
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at
It is also important to know that while much
m
Stage 2: Designate the sender. It is usually

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the team leader who communicates to of the communication a team leader oversees is
In
verbal, there is a great amount of nonverbal com-

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people outside of the team and ensures the

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message is sent to each team member. munication that adds to the message. Nonverbal
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communication is both written (text and graphs)

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Stage 3: Encoding. The message is put into

ic
and visual (behavior, body language, clothing,

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a format that is clear and understandable

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and intentional and unintentional signals). Team

to everyone. For example, when
leaders who are successful communicators adapt
e
communicating with a person who is not

th
to the intended receivers’ learning styles. Those

by
an HIM professional, it would be important

learning styles include sensory (people who learn
20
not to use jargon (specialized language for a

20
by doing), personality (some people prefer to

group) and acronyms that HIM professionals
©
work at night and sleep during the day), informa-

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use such as Master Patient Index, ROI, or

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tion processing (reading and writing out notes),

DRG.
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social interaction (forming study groups), and in-

Stage 4: Select the medium by which the
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structional and environmental preference (some

message should be sent—via email, letter, people prefer to learn in a classroom rather than
text, telephone or face-to-face conversation, online).
or posting on the organization’s intranet. Last, there are barriers to effective communica-
Each type of medium has a specific intimacy tion. The first is selective perception, which means an
for the receiver that may not be appropriate individual will tune out information if it does not
depending on the circumstances. meet their preconceived ideas or conclusions. The
Stage 5: Decoding. The receiver acquires the next is information overload. Healthcare profession-
message and must internalize the message als are constantly being presented with an excess
accurately, so the meaning is not lost. of information and data, often much more than
Stage 6: The communication process is they need to accomplish their jobs. Having too
understood by the receiver. This impacts much information slows down the c ommunication
AB103118_Ch19.indd 600 2/6/2020 5:53:39 PM

process by making it difficult to distinguish what the message may be c ompletely different than the
is of value and what is not. Emotions often interfere original intent, and the true intent of the message
with the coding and decoding of a message. Atti- may not be received. Finally, the actual presentation
tude will determine if the receiver is receptive to a of the information may create a barrier. Many times,
message presented by the team leader. In the US a clearer message can be received better visually
today, language can be a barrier to effective com- rather than through a narrative format. For exam-
munication. Many hospitals in western states are ple, this paragraph is over 300 words long. Many
now looking for bilingual employees to speak with people would grasp this information better in the
employees and patients whose primary language form of bullets, as the following:
is Spanish. Silence can be used effectively as a com-
munication tool (namely, waiting until someone ●● Selective perception
responds to a message) or as a barrier (indicating ●● Information overload
n.
the receiver is either ignoring or in disagreement
Emotions
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●●
with the message). Some people have communica-
ia
Attitudes
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tion apprehension and do not like to speak in front ●●
ss
of a group or present ideas that conflict with the Language
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●●
en
group’s opinion. Sometimes differences in gender ●● Silence
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can result in a single message having multiple in- Communication apprehension
ag
●●
terpretations based on the gender of the receiver.
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●● Differences in gender
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Another barrier to communication is political cor-
n
rectness where the intent of the message may be ●●io Political correctness
at
skewed so as to not offend the receiver. In this case, Presentation of information
m
●●
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In
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ea
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er
Match the terms with the descriptions

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1. _____ Team building

e
th
by
2. _____ Team charter

20
3. _____ Team leader

20
4. _____ Team member

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5. _____ Team norms

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a. The rules, both explicit and implied, that determine both acceptable and unacceptable behavior for the group
C
b. The process of organizing and acquainting a team and creating skills for dealing with team processes
c. Responsible for championing the activities of the team
d. Explains the issues the team was initiated to address, and describes goals and vision
e. Responsible for participating in the team
Business-Related Partnerships
Often it is beneficial for people in lead- can be internal or external to the healthcare or-
ership positions to make business-related part- ganization, is an agreement between two parties
nerships. A business-related partnership, which to cooperate for the advancement of their mutual
AB103118_Ch19.indd 601 2/6/2020 5:53:39 PM

interests and the entity’s strategic goals. To create HIM department are the billing office, compliance,
a successful partnership, each party must agree on and information services. Internal relationships in
a shared vision and mission and ensure each part- HIM are discussed in chapter 3, Health Information
ner’s needs and expectations will be met. It is im- Functions, Purpose, and Users.
portant to identify the strengths and weaknesses
of each partner so the tasks and accountability can External Business Partnerships
be assigned to each partner appropriately. External business-related partnerships often oc-
cur with the various vendors providing services
Internal Business Partnerships to HIM professionals, whether they are HIM con-
Within a healthcare organization, business part- sultants, EHR providers, or off-site storage compa-
nerships can exist between individual managers nies. With external business partnerships, areas of
or across entire departments. This is necessitated responsibility as well as how success is evaluated
n.
by the need to share resources, whether it is project and measured for both parties must be determined
tio
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funding, capital equipment, knowledge, expertise, beforehand. It is imperative that the HIM profes-
oc
or personnel. The main advantage of developing sional assume a leadership role so the vendor will
ss
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a partnership within an organization is that two provide what the organization needs, not what is
en
heads are often better than one—sometimes great easiest for the vendor to provide, or what is the
em
ideas can be generated with input from and the bare minimum from the vendor. Often projects fail
ag
an
perspective of two people. Also, high-caliber em- because vendors want to install what they have
M
ployees can be made partners to compensate for a already developed rather than meet the deliver-
n
leader’s areas of weakness. However, when two
io
ables required by the healthcare organization. It is
at
m
or more people are brought together the poten- important that HIM professionals exert their leader-
r
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tial risk of disagreement and its resolution may be ship capabilities for the betterment of the organiza-
In
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problematic. Common business partners for the tion as well as their own professional development.
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er
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Leadership Roles
e
th
While leaders may be managers, not in the past and has experience in correcting the
by
all managers are leaders. A leader can be any-

20
errors.
20
one in a department or organization who may While titles do not necessarily guarantee
©
or may not have an organizational title. For ex- a leader, it does give a person a platform to
ht
ig
ample, Ben works in a large HIM department develop and exhibit leadership qualities. The
yr
op
where he rarely sees the HIM director, who is titles available to HIM professionals listed in
C
often in meetings in another part of the medical the following section are taken from the inter-
center. The department is transitioning to com- active Career Map published by the American
puter-assisted coding software and Ben is run- Health Information Management Association
ning into an issue with the software accurately (AHIMA). The Career Map lists the different
assigning the right codes when the physician job titles at various levels of mastery of the
does not articulate the proper documentation HIM profession and divides the jobs into dif-
required by ICD-10-CM/PCS (International Clas- ferent career paths; for example, coding and
sification of Diseases, 10th revision, Clinical Modi- revenue cycle, informatics, data analytics,
fication/Procedure Coding System). Rather than go and information governance. The following
to the department director (who has the title) he jobs listed are at the advanced and master
instead turns to Emily, the coder who sits next level—those that best show leadership potential
to him, who has experienced the same problems (AHIMA 2018).
AB103118_Ch19.indd 602 2/6/2020 5:53:39 PM

HIM Roles
There are many opportunities for de- of data quality were identified—accuracy,
veloping leadership skills in the HIM profession. accessibility, comprehensiveness,
Health information management professionals are consistency, currency, definition, granularity,
instrumental in compliance and risk management, precision, relevance, and timeliness
education and communication, informatics and (AHIMA Task Force on Data Quality
data analysis, information technology and infra- Management 1998).
structure, health information administration, and ●● Health information administration. To
revenue cycle management. These roles are the run an efficient department, managers
following: must also lead. Traditional leadership
Compliance and risk management. HIM roles are the director and assistant
n.
●●
director, manager and supervisor, and
tio
professionals already hold the positions of
ia
compliance auditor, compliance officer, and regional director of HIM who oversees
oc
multiple healthcare organizations. In
ss
chief compliance officer. Other positions
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include chief privacy officer and business addition, HIM professionals with special
en
skills in certain areas have taken the
em
analyst. These positions are becoming
lead by becoming consultants who aid
ag
increasingly important as payers are
an
connecting reimbursement to successful organizations with their expertise; for
M
outcomes. example, an HIM professional skilled in
n
io
auditing may offer consultative services
at
HIM education and communication.
m
●●
in auditing.
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Professionals with advanced degrees

In
can teach the next generation of HIM ●● Revenue cycle management. HIM professionals
lth
have a unique position within any

ea
professionals what they need to start a

H
career in addition to the skills needed five healthcare organization as the claim for
an
years in the future. These positions include services cannot be sent to an insurer until
ic
er
the different ranks of professor, program the HIM medical coder has analyzed the
Am
director, or department chairperson. In patient chart and assigned both diagnosis

e
th
addition, healthcare organizations are and procedure codes prior to submission

by
seeking knowledgeable people to train to the billing department. As such, HIM

20
professionals have an opportunity to

20
their employees in coding as well as

demonstrate leadership in positions like
©
compliance, the EHR, and privacy and

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security. director of coding, coding manager, revenue

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yr
cycle manager, and reimbursement and

op
●● Informatics and data analysis. HIM

insurance manager.
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professionals with additional training

and knowledge in project management, All these positions offer HIM professionals
data analytics, and mapping between an opportunity to demonstrate leadership to
nomenclatures are highly valued. These are their organization by understanding the organ-
leaders who can forecast future needs and izational strategic plan and ensuring their staff
see a job through to a successful conclusion. will provide support. However, a title does not
●● IT and infrastructure. Data quality managers guarantee leadership, so HIM professionals
are needed to ensure the data collected must constantly seek out opportunities by vol-
throughout the healthcare organization unteering for assignments that will provide ad-
(not just diagnosis and procedure codes) ditional leadership skills and build a network of
conform to the Data Quality Management professionals both internal and external to the
Model of AHIMA where 10 characteristics organization.
AB103118_Ch19.indd 603 2/6/2020 5:53:39 PM

●● Chief learning officer. This position is the EHR and the federal government’s
dedicated to the training of employees Meaningful Use initiative. Not only must
so their learning is in alignment with this individual understand the information
the organization’s mission, goals, and technology aspects of the EHR but also the
objectives. Another responsibility of this regulatory and healthcare reform issues
position is identifying what manpower the that are focused on payment based on
organization will need in the near future performance.
and ensuring that organizational resources ●● Practitioner consultant. This position works
are used strategically and applied to achieve closely with clinicians and IT specialists
maximum results. to develop and provide solutions that
●● E-MPI manager. This position is dedicated have both a clinical and financial impact.
to resolving issues with the master patient The practitioner consultant needs to be
n.
indices (MPIs) when an enterprise decides to well versed in medical terminology and
tio
ia
combine the MPIs from various healthcare nomenclature, disease processes, and the
oc
organizations into an electronic format. The billing and revenue cycle.
ss
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e-MPI manager works with registration ●● Research and development scientists. This
en
to reduce duplicates and changes, and position helps support the development of
em
contributes to the design of the e-MPI to solutions for health IT as well as being part
ag
an
ensure coordination with local healthcare of the educational system to help train future
M
organization leadership through the IT professionals. This position normally
n
use of improved practices. It is highly
io
requires a PhD (doctorate).
at
m
recommended that this person has extensive

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Vice president of coding. This position is

fo
●●
information system programming skills as
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responsible for managing the different

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well as HIM departmental experience.

coding divisions in facilities , establishing
ea
Information governance officer. This position

H
●●
performance guidelines, forecasting
an
is dedicated to developing an organization- the needs of the organization and its

ic
er
wide framework for managing information employees, and participating in process

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throughout the information’s life cycle and improvement opportunities. Since the
e
ensuring the information collected supports

th
organization is dependent on well-trained

by
the organization’s strategic plan and and knowledgeable medical coders, this
20
initiatives. This position requires knowledge position is vital for the financial health of the
20
of all of the health information systems as organization.

©
ht
well as data analytics.

Vice president of security. This position
ig
●●
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Meaningful Use specialist. This position provides a workforce focused on the

op
●●
is focused on end-user issues, workflow

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protection of information security focused

processes, and issues with the EHR, and not only on the EHR but also on the patient-
requires an overall understanding of the centered health record as typified in patient
issues related to the implementation of portal access.

Changes in healthcare are impacting all Act), and the integration of the health record from
healthcare organizations. The HIM professional is a paper to an electronic format. Because of an in-
desired for their expertise in reimbursement, HIPAA creased demand on the HIM professional’s time,
(Health Insurance Portability and Accountability leaders need to delegate to staff within the department.
AB103118_Ch19.indd 604 2/6/2020 5:53:39 PM

Jonathan is the director of the HIM department and and can successfully complete this assignment. He
is also a member (or leader) of additional commit- also needs to be aware that even though he is fo-
tees within his medical center. His workday is now cusing his time on other issues and meetings, he
9 to 10 hours long due to his day-to-day duties and is also ultimately responsible for any task that he
the additional committee work. Therefore, Jona- delegates to someone else. While Jonathan may be
than has decided to delegate his oversight of the delegating a task to Mary to relieve some of his
release of information unit to Mary, a credentialed work pressure, this is also a great opportunity for
member of the HIM department workforce. Jona- him to test Mary for future assignment of duties
than needs to feel confident that Mary is responsible and, potentially, promotion.
n.
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Kaleb has been working at Valley Hos- himself and what skills he needs to improve to be-
ia
oc
pital for four years as a clinical informaticist and come a leader. He continually volunteers within his
ss
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wants to further his career by developing his skills department and the hospital to serve on teams and
en
and eventually taking on more responsibilities committees. After a year of self-exploration, team-
em
for leadership opportunities within the hospital. work, and training, Kaleb was promoted to depart-
ag
He begins by exploring his emotional intelligence ment manager and continues to explore ways to hone
an
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and leadership competencies to better understand his skills and abilities to continue to be a great leader.
n
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lth
ea
H
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Hanke, S. 2018 (May 30). Five top skills for CEOs to

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em
ag
an
M
n
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at
m
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In
lth
ea
H
an
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Am
e
th
by
20
20
©
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Chapter
20
Human Resources
n.
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Management
ss
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en
em
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Valerie S. Prater, MBA, RHIT, FAHIMA
an
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n
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Learning Objectives
at
m
•• Identify human resources management roles and •• Analyze performance of employee productivity and
r
fo
responsibilities performance standards

In
lth
•• Identify major provisions of employment laws •• Identify management actions that promote positive
ea
•• Apply ethical principles to human resources communication and fair handling of workplace
H
management responsibilities disputes

an
•• Examine workforce planning •• Apply labor law to supervision in a union

ic
er
•• Analyze the role of job analysis in the employee environment

Am
recruitment and selection process •• Recommend training methods for workplace

e
•• Examine management practices used to organize scenarios

th
and schedule work •• Create an employee career development plan

by
20
20
Key Terms
©
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Adverse impact Career development Distributional errors

ig
Age Discrimination in Employment Civil Rights Act of 1991 (CRA 1991) Downsizing
yr
op
Act of 1967 Classroom-based learning Dysfunctional conflict

C
Americans with Disabilities Coaching Employee engagement

Act (ADA) of 1990 Collective bargaining Employee relations
ADDIE model Comparison system Equal Employment Opportunity
Authorization cards Competencies Commission (EEOC)
Autonomy Compressed workweek Equal employment opportunity law
Bargaining unit Contingent or contract work Equal Pay Act of 1963
Behaviorally anchored rating Critical incident method Exempt employees
scale (BARS) Development Exit interview
Benchmarking Disciplinary action Fair Labor Standards Act
Bias Discrimination (FLSA) of 1938
Bona fide occupational Dismissal Family and Medical Leave Act
qualification (BFOQ) Disparate treatment (FMLA) of 1993
607
607
AB103118_Ch20.indd 607 2/6/2020 5:54:15 PM

Flextime Negligent hiring Selection

Forced distribution New employee orientation Selection test
Full-time equivalent (FTE) Nonexempt employees Serial work division
Genetic Nondiscrimination Occupational Safety and Health Act Sexual harassment
Act (GINA) of 2008 Occupational Safety and Health Simulation
Graphic rating scale Administration (OSHA) Staffing
Grievance process Offshoring Strike
Halo-horns effect Onboarding Taft-Hartley Act
Harassment Online learning Telecommuting
Hostile work environment On-the-job training Termination
Human capital Outsourcing Termination at will
Human resources Parallel work division Title VII of the Civil Rights
management (HRM) Part-time employee Act of 1964
Job analysis Performance appraisal Training
n.
Job description Performance management Turnover
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Job interview Performance measurement Union
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Job sharing Pregnancy Discrimination Act Validity
ss
Job specifications Process Variance
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Justice Progressive penalties Work measurement
en
Layoff Protected class Worker Adjustment and Retraining
em
Line authority Quid pro quo Notification (WARN) Act
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Mentoring Reasonable accommodation Workflow analysis
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National Labor Relations Act (NLRA) Recruitment Work distribution analysis
M
n
National Labor Relations Board Reliability io Workforce planning
at
(NLRB) Right-to-work laws Wrongful discharge
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In
The healthcare industry is the largest employer meet the needs of a variety of internal and external
lth
in most states in the United States—a dramatic customers, all while facing competition.
ea
H
change from 1990, when manufacturing was dom- This chapter begins with an introduction to
an
inant, and from 2003 when retail was the largest human resources management, a foundation in
ic
er
employer (BLS 2014). The Bureau of Labor proj- employment law and ethical principles. Next,
Am
ects 19% overall growth in healthcare sector em- human resources management functions and the
e
th
ployment through 2024, with the Medical Records importance to healthcare organizations and to the
by
and Health Information Technicians occupation health information management (HIM) profes-
20
category expected to grow by 13% through 2026; sion are presented. These include workforce plan-
20
©
drivers of growth include aging of the US popula- ning and job analysis, recruitment and selection,
ht
tion (AHIMA House of Delegates 2017). staffing and performance management, retention
ig
yr
With employment growth and opportunity come and employee relations, and training and devel-
op
C
workforce challenges. The healthcare industry is opment. Principles of fairness and respect are
complex and continues to experience rapid change, applied across topics. Focus is on the roles and
including advances in technology. Healthcare orga- responsibilities of HIM supervisors and manag-
nizations must deal with pressures to reduce costs, ers. Intended as an overview, the chapter is not
demonstrate evidence of quality and safety im- a comprehensive review of all aspects of human
provement, manage a growing volume of data, and resources management.
Human Resources Management

Human resources management (HRM) attending to their labor relations, health, safety,
is defined as “the process of acquiring, training, and fairness concerns” (Dessler 2016, 2). The need
appraising, and compensating employees, and of to fill positions with qualified candidates and
AB103118_Ch20.indd 608 2/6/2020 5:54:16 PM

effectively manage human resources has never There are many HIM manager roles with line
been more important in healthcare than it is to- authority across all types and sizes of healthcare
day. Despite increased emphasis on technology, organizations; examples of titles include HIM
healthcare remains a service industry with peo- Director, Disclosure of Information Manager,
ple as the most important and valuable asset. In and Coding Supervisor. The HRM functions per-
financial accounting terms, discussed in chapter 17, formed by these managers can vary, but typically
Management, an asset is something of value to an include direct, day-to-day involvement in one or
organization that appears on the positive side of all of the areas addressed in this chapter—from
the financial statement. The human assets of an or- recruitment and staff selection to performance
ganization are often referred to as human capital, management and training. With more work today
the sum of the knowledge, skills, creativity, and done in teams and dependent upon collaboration,
problem-solving abilities of the workforce (Momand all employees, regardless of management title, can
n.
2018). While employee salaries are shown on the benefit from having HRM knowledge and skills
tio
financial statement as costs to an organization, it is (Fried and Fottler 2018).
ia
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noted that organizations have a greater chance of Healthcare organizations, unless very small, have
ss
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success when people are managed as assets to be a human resources department with a human
en
grown and developed versus as costs, or liabilities resources manager. The human resources depart-
em
(Momand 2018). Human resources management ment serves line managers in an advisory role, sup-
ag
is crucial as healthcare organizations seek to improve porting performance of HRM functions. In a large
an
M
financial and quality performance. healthcare system, the human resources department
n
io
typically includes employees who specialize in
at
Roles and Responsibilities recruiting, compensation, training, or other areas;
m r
fo
Health information management leaders can con- these staff assist both individual employees and
In
tribute directly to effective and efficient manage- line managers. The human resources department is
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ment of an organization’s human resources. They responsible for organization-wide functions such
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support the organization’s mission and financial as human resource strategic planning, payroll, and
an
ic
health by helping to make the organization a place benefits administration, and for compliance with
er
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where people want to work and can grow profes- personnel policies and procedures consistent with
sionally. It is said that that all managers are hu- the organization’s mission. In a smaller healthcare
e
th
man resources managers, and therefore the HRM business, a single human resources manager may
by
handle all human resources responsibilities. A co-

20
concepts are relevant to all managers (Fried and

20
Fottler 2018). Managers who have line authority operative relationship among the organization’s
©
in an organization are those who supervise one or human resources manager, departments, and line
ht
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more employees, can give orders, and are respon- managers is essential for effective overall HRM in
yr
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sible for getting work done by directing the work an organization. Key roles and responsibilities for
C
of others (Dessler 2016). HIM line managers are explored across the chapter.
Employment Law and Ethics

As a basis for HRM responsibilities, ma- certain characteristics such as race if unrelated to a
jor federal laws addressing the employer-employee job, and labor law outlining rules for the employer-
relationship in the US are reviewed in this section. employee-labor union relationship. While state law
Addressed are equal employment opportunity is not reviewed here, managers should be aware
law, efforts to ensure equal access to employment that most states have laws in one or more of the
and fairness in employment without regard to areas noted. A basic understanding of employment
AB103118_Ch20.indd 609 2/6/2020 5:54:16 PM

law is important for supervisory and middle-level resources management. Discrimination refers to
managers for the following major reasons: treating a person differently based on individual
characteristics, such as race, or group membership,
●● Compliance is ethically the right thing to do
such as religious affiliation; if in violation of a law,
●● People want to work where they are treated it is illegal. To support legal concepts and ethical
fairly, consistent with law principles, managers should “…avoid making
●● Managers have responsibility to employment decisions on the basis of personal
communicate organizational policies based attributes, characteristics, or behaviors unless they
on law to staff can be shown to be directly related to job perfor-
●● Violations of law can result in significant mance” (Filerman et al. 2014, 192). Discrimination
legal and financial liability for the and its relationship to job performance are dis-
organization cussed below from a legal perspective in present-
n.
ing Title VII of the Civil Rights Act of 1964 and the
tio
Ethical principles are introduced in this section Age Discrimination in Employment Act of 1967.
ia
and referenced throughout the chapter as related
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In each section of this chapter, consider spe-
ss
to HRM. Chapter 21, Ethical Issues in Health Informa- cific ways a manager can uphold the ethical prin-
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tion Management, discusses ethical principles in
en
ciples of justice and autonomy, and avoid illegal
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more detail discrimination, in effectively carrying out HRM
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responsibilities.
an
Ethical Principles
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Fair Labor Standards Act of 1938
Ethics refers to the formal, intentional process used
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io
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to make clear and consistent decisions involving Amended several times since its passage, the
mr
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personal and professional values (Harman 2006). Fair Labor Standards Act (FLSA) of 1938 sets the
In
Ethical principles, combined with employment law, minimum wage requirements for overtime pay,
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ea
provide guidance to support managers in making and child labor standards; it is administered and
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fair and respectful decisions when supervising enforced by the Wage and Hour Division of the US
an
employees. The two ethical principles that stand out

ic
Department of Labor (DOL) and applies to most

er
as particularly applicable to human resources man-

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US work settings (DOL 2014).

agement in the healthcare field are the following: Employees are classified as nonexempt or exempt
e
th
based on job title, duties, and salary level; nonex-

by
1. The principle of justice recognizes the impor-

empt employees are covered by FLSA minimum
20
tance of treating people fairly and applying

20
rules consistently. wage and overtime provisions, exempt employees

©
are not covered (Dessler 2016). Examples: top execu-

ht
2. The principle of autonomy, or respect for

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tive salaried positions are exempt, clerical jobs paid

yr
an individual’s voluntary choice, recognizes

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hourly are nonexempt; managers who are expected

that employees need a voice in what happens
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to work hours as needed to keep operations running

to them in the workplace (Beauchamp and
are typically exempt. Administrative, professional,
Childress 2013).
and technical positions must be carefully analyzed
The American Health Information Management in consultation with the human resources depart-
Association (AHIMA) Code of Ethics obligates HIM ment to determine if FLSA minimum wage and
professionals to demonstrate actions that reflect overtime pay rules apply. Current definitions of
ethical principles, including to “respect the inher- exemption are published online by the DOL.
ent dignity and worth of every person” (AHIMA
2019). Showing respect for employees without Equal Pay Act of 1963
favoritism or discrimination is consistent with The Equal Pay Act requires that men and women in
the AHIMA Code of Ethics, the intent of equal the same workplace receive equal pay for perform-
opportunity laws, and is essential to ethical human ing equivalent work. Comparison of job content,
AB103118_Ch20.indd 610 2/6/2020 5:54:16 PM

rather than job title, is used to determine whether in figure 20.1, who are protected by law
one job is substantially equivalent to another based on past history of employment
(EEOC n.d.a.). The Equal Pay Act covers essen- discrimination affecting these groups
tially all employers and all forms of pay including ●● Disparate treatment. Illegal employment
salary, overtime, bonuses, vacation and holiday discrimination based on intentional unequal
pay, benefits, and reimbursement for business treatment of an individual who is a member
travel expenses (EEOC n.d.a). of a protected class
●● Adverse impact. Unequal discriminatory
Title VII of the Civil Rights Act of 1964 effect of an employment practice (for
Title VII of the Civil Rights Act of 1964 and its example, requiring a passing score on a test
amendments represent perhaps the most impor- that does not cover job-related knowledge
tant and sweeping of the federal antidiscrimina- or skills) on members of a protected class
n.
tion laws. Commonly referred to simply as Title (Gomez-Mejia et al. 2016)
tio
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VII, this act applies to employers with 15 or more
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Hiring managers and supervisors should be
employees and prohibits employment decisions,
ss
aware that employment discrimination based on
tA
including those involving hiring, compensa-
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a characteristic associated with a protected class,
tion, dismissal, or working conditions, based on
em
such as a racial or ethnic group, is illegal unless the
an individual’s race, color, religion, sex, or na-
ag
characteristic can be shown to directly interfere
an
tional origin (Gomez-Mejia et al. 2016). Unlawful
with job performance; for example, where cultural
M
employment practices as defined in this law are
n
dress impacts ability to meet a job safety stand-
io
shown in figure 20.1.
at
ard (EEOC n.d.c). In very narrowly interpreted
m
Title VII established the Equal Employment

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situations, employers may be able to defend as a

Opportunity Commission (EEOC) as the federal
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bona fide occupational qualification (BFOQ) the

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agency with responsibility to administer and

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use of an otherwise discriminatory characteristic

enforce equal opportunity employment laws, inves-
H
in making an employment decision if the charac-

an
tigate complaints, and file discrimination charges

teristic is directly related to business necessity; for
ic
in court.
er
example, preference for a particular religious affil-

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The following definitions are important to human

iation for teaching at a religious-affiliated school
e
resources management developed from Title VII

th
(Dessler 2016). Job analysis, discussed later in the

by
court cases:
chapter, must be used to justify job-related quali-
20
20
●● Protected class. Identified groups of fications for a position. Amendments to Title VII
©
people, with characteristics as described that address issues surrounding harassment and
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Figure 20.1 Title VII of the Civil Rights Act of 1964: unlawful employment practices
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C
From the text of Title VII of the Civil Rights Act of 1964 (Pub. L. 88-352) (Title VII)
Unlawful employment practices SEC. 2000e-2. [Section 703]
(a) Employer practices
It shall be an unlawful employment practice for an employer—
(1) to fail or refuse to hire or to discharge any individual, or otherwise to discriminate against any individual with
respect to his compensation, terms, conditions, or privileges of employment, because of such individual’s race,
color, religion, sex, or national origin; or
(2) to limit, segregate, or classify his employees or applicants for employment in any way which would deprive or tend
to deprive any individual of employment opportunities or otherwise adversely affect his status as an employee,
because of such individual’s race, color, religion, sex, or national origin.
Source: EEOC n.d.b.
AB103118_Ch20.indd 611 2/6/2020 5:54:16 PM

pregnancy discrimination in the workplace are Pregnancy Discrimination Act of 1978

described in the sections that follow. Title VII was amended with the Pregnancy Discrim-
ination Act of 1978 to protect women from sex dis-
Harassment crimination based on pregnancy, and conditions
Harassment, including sexual harassment, is cov- related to pregnancy or childbirth (EEOC n.d.e).
ered as a form of illegal discrimination under Title This act further specifies that women should be
VII. Harassment involves unwelcome workplace treated the same as other employees with respect
conduct based on an individual’s race, color, reli- to eligibility for health plan benefits and with
gion, gender, national origin, age, disability, or regard to their ability to work.
genetic information (EEOC n.d.d). To be considered Supervisors and managers who are responsi-
illegal, enduring the offensive conduct becomes a ble for staff selection, scheduling, or performance
condition of the individual’s continued employ- appraisal (addressed later in the chapter) should
n.
ment, or is severe enough to create a hostile work be familiar with the major provisions of this leg-
tio
environment (EEOC n.d.d). A hostile work en-
ia
islation, and with all other equal opportunity
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vironment is a setting in which intimidating and employment laws.
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abusive workplace conduct that interferes with
en
an employee’s job performance takes place; the un- Age Discrimination in Employment
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wanted conduct goes beyond a minor or occasional Act of 1967
ag
annoyance. Examples of such unwanted conduct
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The Age Discrimination in Employment Act of
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by a supervisor, coworker, or nonemployee include 1967 prohibits age discrimination against job appli-
n
telling offensive jokes, name calling, and acts in- io
cants or workers age 40 and older, making hiring,
at
m
volving physical threat or insult (EEOC n.d.d). compensation, and other employment decisions
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A type of harassment based on sex is sexual ha-

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based on age illegal (EEOC n.d.f). Age presents

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rassment; this may include verbal comments, un- an area of legal risk for managers and supervisors
ea
wanted physical contact, sexual advances, or requests particularly in the candidate selection process or
H
for sexual favors (EEOC n.d.d). Sexual harassment

an
when a staff layoff is necessary. To avoid violation

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complaints can arise based on a hostile work envi-

er
of this law, hiring and continuing employment

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ronment where repeated and unwelcome sexually decisions should focus on job requirements and
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oriented conduct makes a workplace uncomforta- performance standards. Retaining qualified expe-
th
ble or may be based on direct quid pro quo advances

by
rienced older workers can help maintain stability

20
where sexual favors are requested in exchange for a within an organization’s workforce.
20
job benefit or continued employment (McWay 2016). In narrowly defined situations, employers may
©
Sexual harassment can apply to workers regardless

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be able to defend age as a BFOQ if they can show

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of gender and can be committed by supervisors, co-

yr
that age is directly related to job performance

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workers, or nonemployees. In a real-world example, based on job analysis. An example based on job
C
a hospital employer paid a court-ordered financial safety is the age 65 requirement for mandatory re-
settlement in a case brought by a group of women tirement of airline pilots (FAA 2012).
who alleged sexual harassment by a physician dur-
ing employment-related medical examinations; the Occupational Safety and Health
hospital had received complaints, but had failed to Act of 1970
take action (McNair et al. 2007).
The Occupational Safety and Health Act of 1970,
The best management strategies to address
as amended in 2004, states as its purpose the
workplace harassment focus on prevention, fea-
following:
turing clear policies, open communication, and anti-
harassment training. Supervisors should inform To assure safe and healthful working
employees of the organization’s complaint proce- conditions for working men and women; by
dure, take all complaints seriously, and document authorizing enforcement of the standards
prompt follow-up action. developed under the Act; by assisting and
AB103118_Ch20.indd 612 2/6/2020 5:54:16 PM

encouraging the States in their efforts to as courts rule on complaints. In a complaint, a

assure safe and healthful working conditions; disabled individual alleges that an employer
by providing for research, information, failed to provide a reasonable accommodation,
education, and training in the field of or workplace adjustment that does not present an
occupational safety and health (OSHA 2004). undue (significant) hardship to the organization,
and that this failure interfered with the qualified
This legislation created the Occupational Safe-
individual being hired or with his or her ability
ty and Health Administration (OSHA) agency
to perform a job. In order to comply with this law
within the DOL to administer and enforce the law
and demonstrate fair employment practices, man-
and provide education on workplace safety. Em-
agers should have an appreciation of the key ADA
ployers are expected to provide a physically safe
terms and concepts explained with examples in
work environment and to report all job-related
figure 20.2 and work closely with the organization’s
illnesses, injuries, and fatalities. Supervisors and
n.
human resources department.
managers should be mindful of potential workplace
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safety hazards, knowledgeable of OSHA injury
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Civil Rights Act of 1991

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n.

AB103118_FM.indd 1 2/11/2020 1:38:48 PM

Kimberly Wilson, Production Development Editor

James Pinnick, Vice President, Content and Product Development

Rachel Schratz, MA, Assistant Editor

Cover image: sollia ©Shutterstock

results directly or indirectly from your use of this book.

American Health Information Management Association

AB103118_FM.indd 2 2/11/2020 1:38:48 PM

Leslie L. Gordon, MS, RHIA, FAHIMA

AB103118_FM.indd 3 2/11/2020 1:38:51 PM

About the Volume Editors and Chapter Authors xxvi

Part II Data Content, Structures and Standards 91

Chapter 4 Health Record Content and Documentation 93

Megan R. Brickner, MSA, RHIA

Chapter 5 Clinical Terminologies, Classifications, and Code Systems 123

Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA

Chapter 6 Data Management 153

Danika E. Brinda, PhD, RHIA, CHPS, HCISPP

Chapter 7 Secondary Data Sources 197

Marcia Y. Sharp, EdD, MBA, RHIA

Part III Information Protection: Access, Disclosure and Archival,

Privacy and Security 221

AB103118_FM.indd 5 2/11/2020 1:38:51 PM

Part IV Informatics, Analytics, and Data Use 319

Chapter 17 Management 527

Leslie L. Gordon, MS, RHIA, FAHIMA

Chapter 18 Performance Improvement 549

Darcy Carter, DHSc, MHA, RHIA

Miland N. Palmer, MPH, RHIA

Chapter 19 Leadership 583

Leslie L. Gordon, MS, RHIA, FAHIMA

Chapter 20 Human Resources Management 607

Valerie S. Prater, MBA, RHIT, FAHIMA

Chapter 21 Ethical Issues in Health Information Management 655

Misty Hamilton, MBA, RHIT

Appendix A Check Your Understanding Answer Key 679

Appendix B Glossary 715

AB103118_FM.indd 6 2/11/2020 1:38:51 PM

About the Volume Editors and Chapter Authors xxvi

Information-Oriented Management Practice 6

The Future of HIM 7

Today’s Professional Organization 8

AHIMA Mission and Vision 9

AHIMA Structure and Operation 10

State and Local Associations 12

Accreditation of Educational Programs 13

Certification and Registration Program 13

AHIMA Support of Training and Education 14

AHIMA Career Map 15

AB103118_FM.indd 7 2/11/2020 1:38:52 PM

Chapter 2 Healthcare Delivery Systems 21

Accountable Care Organizations 40

Private Medical Practice 41

Hospital-Based Ambulatory Care Services 41

Community-Based Ambulatory Care Services 41

Public Health Services 42

Home Healthcare Services 42

Delivery of Long-Term Care Services 44

Biomedical and Technological Advances in Medicine 45

Electronic Health Records and Health Data 46

Policy Making and Healthcare Delivery 48

AB103118_FM.indd 8 2/11/2020 1:38:52 PM

Tax Equity and Fiscal Responsibility Act of 1982 56

Part III Information Protection: Access, Disclosure and Archival,

Paper Health Record – Serial-Unit Numbering System 85

Part III Information Protection: Access, Disclosure