Health Information Chapter 1

American Association of Medical Record Libraries
AAMRL
AAMRL
American Association of Medical Record Libraries
ACS
American College of Surgeons
AHIMA
American Health Information Management Association
AMRA
American Medical Record Association
ARLNA
Association of Record Librarians of North America
CAHIIM
Commission on Accreditation for Health Informatics and Information Management Education
CCHIIM
Commission on Certification for Health Informatics and Information Management
Health information management (HIM)
An allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions; recognized since 1928
Health information management has been recognized as an allied health profession since what year?
1928
This was formed only 10 years after the beginning of the hospital standardization movement
Association of Record Librarians of North America (ARLNA)
What was the Association of Record Librarians of North America (ARLNA)’s original objective?
The association’s original objective was to elevate the standards of clinical record-keeping in hospitals, dispensaries, and other healthcare facilities.
The first annual meeting of the professional organization was held in Chicago in _____
1929
Which organization and the professionals affiliated with it have been advocates for the effective management of clinical records?
The Association of Record Librarians of North America (ARLNA)
The name of the organization has changed several times throughout the years to reflect the changing healthcare environment? Which name has it changed to?
Association of Record Librarians of North America (ARLNA); changed to: American Health Information Management Association (AHIMA)
What is the underlying purpose of (ARLNA) and (AHIMA) that has not changed?
The association’s underlying purpose remains the same: to ensure the quality, confidentiality, and availability of health information across diverse organizations, settings, and disciplines.
____ ___________ must be equally committed to the original goal of “elevating standards for clinical records” as well as fulfilling the obligations of healthcare professionals.
HIM professionals
The HIM director is responsible for
ensuring the quality and availability of health information to facilitate real-time healthcare delivery and critical health-related decision making for multiple purposes across the organization
While the purpose of the functions has remained ___ ____ in the electronic environment, the way in which they are _______ _____ has dramatically _______
the same; carried out; changed
HIM directors now have increased knowledge and skills in what?
The capture, use, and management of information.
HIM skills include:
Terminology mapping
Data modeling
Data governance
Data flow design and improvement
Data mining
Workflow coordination and management
In the virtual HIM department, information is generated at the point of _____ and stored __________
care; stored electronically
_________ ___________has shortened record completion turnaround time
electronic authentication
HIM director at Community hospital supervises:
Several data steward positions that are physically located in departments such as clinical laboratory, radiology, admitting, billing, and dietary management
The virtual HIM department consists of employees who are located remotely away from the organization. Among these are what jobs?
Medical transcriptionists;
Clinical coders
A major part of the HIM director’s work involves what duties?
1. Monitoring and reconciling interfaces
2. Running electronic data integrity audits
3. Attending design sessions for new EHR applications
4. Resolving health information exchange, privacy, and security issues
Among the automated systems that the HIM director and staff works with are:
1. Master patient index (MPI)
2. Healthcare information system (HIS)
3. Clinical information system (CIS)
4. Electronic health record system (EHR), 5. Electronic document management system (EDMS)
6. HIM department information system (HIMIS)
7. Revenue cycle management system (RCM)
8. Voice/text/speech (VTS) system
9. Registry information system (RIS)
Master patient index management is automated by what line of business information system?
MPI is the line of business information system that automates master patient index management
Medical record processing (e.g., chart assembly) is automated by which line(s) of business?
HIS, CIS, EHR, EDMS
Medical record analysis and completion is automated by which line(s) of business?
HIS, EHR, EDMS, HIMIS
Medical record coding and abstracting is automated by which line(s) of business?
MPI, HMIS, RCM
Medical record report dictation and transcription is automated by which line(s) of business?
VTS
Release of information is automated by which line(s) of business?
HIS, EHR, EDMS, HIMIS
Medical record file services is automated by which line(s) of business?
HIS, EHR, and/or EDMS
Medical record data collection and analysisis automated by which line(s) of business?
HIS, CIS and/or EHR, HMIS
Department organization and management is automated by which line(s) of business?
HIS, EHR, EDMS, HIMIS
Registry management is automated by which line(s) of business?
HIMIS and/or RIS
Forms management (format and content) is automated by which line(s) of business?
HIS, EHR, and/or EDMS
Information confidentiality and security is automated by which line(s) of business?
MPI, HIS, CIS, EHR, EDMS, HIMIS
Edna K. Huffman in an article appearing in the March 1941 issue of the Bulletin of the American Association of Medical Record Librarians (Huffman 1941). Three distinct steps influenced development of the HIM profession:
1. Hospital standardization movement
2. Organization of records librarians
3. Approval of formal educational processes and a curriculum for medical record librarians
Before 1918, the creation and management of hospital medical records were the sole responsibility of?
The attending physician
Medical records before 1918 did not contain ________ _______ or _________ _________
graphical records;
Lab reports
Because there was no general management of medical record processes, the incomplete records were often filed as received when?
On discharge of the patient
Hospitals made no effort to ensure that deficient portions of records were _________
completed
Was standardized vocabulary used to document why the patient was admitted to the hospital or what the final diagnosis upon discharge was?
no standardized vocabulary was used to document why the patient was admitted to the hospital or what the final diagnosis upon discharge was
In 1918, the hospital standardization movement was inaugurated by the:
American College of Surgeons (ACS)
What was the purpose of the Hospital Standardization Program?
To raise the standards of surgery by establishing minimum quality standards for hospitals
The ACS realized that one of the most important items in the care of any patient was what?
A complete and accurate report of the care and treatment provided during hospitalization
The Hospital Standardization Program required what?
Accurate and complete medical records [must] be written for all patients and filed in an accessible manner in the hospital
What did the Hospital Standardization Program require for a “complete medical record”?
It must include:
Identification data; complaint; personal and family history; history of the present illness; physical examination; special examinations such as consultations, clinical laboratory, x-ray and other examinations; provisional or working diagnosis; medical or surgical treatment; gross or microscopical pathological findings; progress notes; final diagnosis; condition on discharge; follow-up; and, in case of death, autopsy findings
In order to comply with HSP standards, hospitals recognized that what had to be implemented?
1. New medical record processes had to be implemented;
2. New staff had to be hired to ensure that the new processes were appropriately carried out
3. Medical records must be maintained and filed in an orderly manner and that cross-indexes of disease, operations, and physicians (record clerk came into being)
hospitals recognized that medical records must be maintained and filed in an orderly manner, what job was established as a result?
Job position of medical record clerk was established
Organization of the Association of Record Librarians
35 members of the Club of Record Clerks met at the Hospital Standardization Conference in Boston in 1928
During the close of what meeting was the Association of Record Librarians of North America (ARLNA) formed?
The Hospital Standardization Conference in Boston in 1928
During its first year, the Association of Record Librarians of North America (ARLNA) had a charter membership of how many?
58 individuals
Members of the ARLNA were admitted from __ of the 48 states, the District of Columbia, and Canada.
25 of the 48 states
The ARLNA was the predecessor of what association?
The American Health Information Management Association (AHIMA)
Approval of Formal Education and Certification Programs
Early HIM professionals realized training needed to be implemented; work began on the formulation prescribed course of study as early as 1929
Early HIM professionals understood that for an occupation to be recognized as a profession there needed to be what?
There must be preliminary training; and training needed to be
What did it mean when early HIM professionals thought that “training needed to be distinguished from mere skill”?
This meant that training needed to be intellectual in character, involving knowledge and, to some extent, learning
In what year did the Association of Record Librarians of North America (ARLNA) adopt a formal curriculum?
In 1932
The first schools for medical record librarians were surveyed and approved by whom and in what year?
Association of Record Librarians of North America (ARLNA); 1934
By 1941, __ schools had been approved to provide training for medical record librarians
10
This formal accreditation process of academic programs (brought about by the ARLNA), was the precursor to:
The current accreditation program, which is still sponsored by AHIMA today under the auspices of the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
The Board of Registration was instituted in which year?
1933
The founders of the medical records profession recognized that the existence of unqualified workers in the field did what?
lowered the standards of their profession
AHIMA is under the auspices of which Commission?
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
What did the founders of the medical records profession do to ensure unqualified workers didn’t lower the standards of their profession?
They organized a certification board so that there would be a baseline by which to measure qualified medical record librarians
Who established criteria for eligibility for registration, and developed and administered the qualifying examination?
•The Board of Registration established criteria for eligibility for registration.
•Developed and administered examination
•Currently managed by the Commission on Certification of Health Informatics and Information Management (CCHIIM)
Who is the role of the Board of Registration played by today?
AHIMA’s Commission on Certification for Health Informatics and Information Management (CCHIIM).
Development of the HIM profession coincided with the professionalization of what other jobs?
Other healthcare disciplines such nursing, x-ray technology, and laboratory technology. (All these disciplines established registration and/or training programs around the same time)
Although the names of the association and the credentials have changed several times during the past decades, which fundamental elements of the profession have remained the same?
Formal training requirements and Certification by examination
The medical record association is another name for what group?
Association of Record Librarians of North America (ARLNA)
After Canadian members formed their own organization in 1944, what was the ARLNA name changed to?
The organization was changed to the American Association of Medical Record Librarians (AAMRL) in 1944; and in 1970 became the American Medical Record Association (AMRA); The organization underwent another name change in 1991 to become the American Health Information Management Association (AHIMA)
In the 1970 name change, what term mirrored the work performed by members more accurately than the term “librarian”?
Administrators
AHIMA’s title changes in 1970 and 1991 reflected the changing nature of what?
The roles and functions of the association’s professional membership
In 1991, what did association leaders believe the primary function of the profession in the future would be, rather than the management of records?
In 1991, association leaders believed that the management of information, rather than the management of records, would be the primary function of the profession in the future
The names of the ____________ conferred by the organization changed as the association’s name changed
credentials
In what year did the AHIMA House of Delegates approve a credential name change?
In 1999, the AHIMA House of Delegates approved a credential name change.
One of the credential name changes approved by AHIMA House Delegates in 1999 was registered record administrator (RRA) became what?
Registered record administrator (RRA) became registered health information administrator (RHIA)
Another name change by AHIMA done in 1999 was accredited record technician (ART) became:
Registered health information technician (RHIT).
What does the changing of the organization and credential names say about the profession?
One of the most significant things that it indicates is a major shift in what professionals do and how they fit within their environment
The combined forces of new information technologies and the ______ _____ _____ ________ require the profession to change radically.
Demands for increased, better, and more timely information
The original practice of health information management was based on the:
Hospital Standardization Program, initiated in 1918.
What did the Hospital Standardization Program, initiated in 1918 emphasize the need for?
The program emphasized the need to ensure that complete and accurate medical records were compiled and maintained for every patient
What were accurate medical records needed to support?
Accurate records were needed to support the care and treatment provided to the patient as well as to conduct various types of clinical research
The emphasis on accurate medical records to support the care and treatment of patients and conduct research was fundamental through what year?
This emphasis remained fundamental to the profession through 1990
A review of the professional practice standards published by AMRA in 1984 and updated in 1990 shows a model of practice that was highly ___________ and __________ based
quantitative; department
Further evaluation of the 1990 professional practice standards discloses that the tasks of medical record practitioners at that time involved:
planning, developing, and implementing systems designed to control, monitor, and track the quantity of record content and the flow, storage, and retrieval of medical records
Planning, developing, and implementing systems designed to control, monitor, and track the quantity of record content and the flow, storage, and retrieval of medical records, in other words refer to activities primarily centered on:
The medical record or reports within the record as a physical unit rather than on the data elements that make up the information within the medical record.
in 1990, very few standards “addressed issues relating to:
determination of the completion, significance, organization, timeliness, or accuracy of information contained in the medical record or its usefulness to decision support”
What is at the center of the Traditional Model of Practice?
Medical Record Department
Traditional practice focused on:
The management of medical records as objects.
The Traditional Model of Practice starts with Medical Record Department at the middle, what areas are attached to this?
Record Retrieval
Productivity Monitoring
Forms Control
Record Tracking
Record Storage
Quantitative Analysis
Incomplete Records
The traditional model of practice centering around Medical Record Department would not be appropriate for today’s ____________-intensive and __________ healthcare environment
information-intensive; automated
The traditional model of practice is ___________ focused
department
Tasks in the traditional model are devoted primarily to __________ and ________ records rather than processing and tracking __________
processing; tracking
information
Studies have consistently shown that __ __ __ percent of a hospital’s operating costs are devoted to information handling.
25 to 40%
An information-oriented management model includes tasks associated with a broad range of __________ services
Information
Tasks performed as a health information manager—in contrast to tasks performed as a medical record manager—are information based, “emphasizing data ____________ and information ___________ tasks and focusing on the provision of an extensive range of information services”
manipulation; management
In 1996, AHIMA embarked on an initiative called ______ ____ that identified what?
Vision 2006; many new roles that information managers would likely assume in the upcoming information-focused decades.
What did Vision 2006 demonstrate the difference between?
Traditional practice and information-oriented practice.
Comparison of traditional HIM and Vision 2006 roles; Department based (Traditional HIM) would become ________ ______ in Vision 2006
Information based
Physical records (Traditional HIM) would become what in Vision 2006?
Data item definition
Data modeling
Data administration
Data auditing
Aggregation and display of data (Traditional HIM) would become what in Vision 2006?
Electronic searches
Shared knowledge sources
Statistical and modeling techniques
Forms and records design (Traditional HIM) would become what in Vision 2006?
Logical data views
Data flow and re-engineering
Application development
Application support
Confidentiality and release of information (Traditional HIM) would become what in Vision 2006?
Security, audit, and control programs
Risk assessment and analysis
Prevention and control measures
In the new model, tasks are information based and many of the health information manager’s activities are performed ______ the HIM department as the Theory into Practice example describes
outside
In what other areas do many health information managers today work?
They work in a variety of functional areas, such as quality improvement, decision support, information systems, utilization management, data privacy, data security. Instead of working primarily in hospitals, many work in ambulatory care facilities and other nontraditional settings.
A second important difference is that the traditional model of practice is based on:
creating, tracking, and storing physical records. In today’s information-intense environment, the physical (paper-based) health record is being replaced by the electronic health record
The information in EHRs is created, compiled, and stored in many different areas within the enterprise and is brought together electronically ____ ______ ______.
only when needed
The tasks performed by a health information manager focus on such activities as:
maintaining data dictionaries, developing data models, performing data administration tasks, and ensuring data quality through a variety of auditing tasks.
Another difference between the two models of practice centers on tasks associated with:
data analysis and interpretation
In the traditional model of practice, the tasks involve the __________ and _______of data
aggregation; display
Today’s information world contains more enabling technologies to _____ and _______ data
search; analyze
Thus, the health information manager who works in decision support or quality improvement today uses sophisticated _________-based tools to analyze data from a variety of data sources
computer; analyze
Health information managers find that the tasks they perform are less concerned with paper forms design and focus, but instead on:
instead on developing good user interfaces for electronic medical records.
Tasks in the __________ model of practice were confined principally to issues involving release of information
traditional
In today’s more technologically sophisticated world, release of information tasks are shifting to include what?
Enterprise-wide responsibilities for computer data security and privacy programs as well as functions in health information exchange organizations.
AHIMA’s e-HIM Task Force in 2003 confirmed the information-handling focus of HIM practice where the state of health information is described as:
electronic, patient-centered, comprehensive, longitudinal, accessible, and credible
In the Vision 2006 initiative, AHIMA identified several new _____ as opportunities for health information managers in 2006 and beyond
roles
New roles identified in the Vision 2006 initiative are based on what model?
The information model
In the Vision 2006 initiative, AHIMA identified several new roles as opportunities for health information managers in 2006 and beyond, the first includes:
The health information manager for integrated systems is responsible for the organization-wide direction of health information functions.
The seond role derived from the Vision 2006 initiative:
The clinical data specialist is responsible for data management functions, including clinical coding, outcomes management, and maintenance of specialty registries and research databases.
The third role derived from the Vision 2006 initiative:
The patient information coordinator assists consumers in managing their personal health information, including personal health histories and release of information.
The data quality manager (the fourth) role from Vision 2006 is responsible for which duties?
Data management functions that involve formalized continuous quality improvement activities for data integrity throughout the organization, such as data dictionary and policy development and data quality monitoring and audits.
The information security manager role from Vision 2006 is responsible for which duties?
Responsible for managing the security of electronically maintained information, including the promotion of security requirements, policies, and privilege systems and performance auditing.
The data resource administrator from Vision 2006 is responsible for which duties?
The data resource administrator manages the data resources of the organization, such as data repositories and data warehouses.
The research and decision support specialist from Vision 2006 is responsible for which duties?
The research and decision support specialist provides senior managers with information for decision making and strategy development.
Terminology modeler
(A new and revised job) Creates digital links among various terminologies and classification systems
Personal health record (PHR) liaison or consultant:
(A new and revised job) Assists individuals in compilation of their personal health records
Physician group consultant:
(A new and revised job) Aids in EHR system implementation, auditing documentation practices, or assisting with revenue cycle management
Privacy officer:
(A new and revised job) Expands beyond a single organization or enterprise as health information exchange organizations and health record banks become more widespread
Health record reviewer:
(A new and revised job) Responsible for monitoring quality of health information and reconciling information within health record banks and monitoring records for quality
HIM director:
(A new and revised job) Works with the design, development, and implementation of the HER, monitoring and reconciling interfaces, running electronic data integrity audits, and supervising a staff of individuals in a “virtual” HIM department
Enterprise content and information manager:
(A new and revised job) Manages an organization’s nonclinical paper and electronic documents including developing systems to index and track the location of content and information within the enterprise
Revenue cycle manager:
(A new and revised job) Oversees all of the processes that make up the revenue cycle from documentation, coding, through billing to improve efficiency in the cycle
Health data analyst:
(A new and revised job) Retrieves, analyzes, and reports health data using appropriate software and statistical techniques
Chief information officer (CIO):
(A new and revised job) Responsible for evaluation and acquisition of clinical and nonclinical technological systems that best meet the business needs of the organization
In 2010, health information management (HIM) professionals were working in __ different settings under ___ different job titles, often serving in bridge roles, connecting clinical, operational, and administrative functions
40; 125
The health information management profession began with establishment of the _____ in 1928
ARLNA
A mission describes:
An organization’s distinctive purpose
The Mission of the American Health Information Management Association
To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.
AHIMA Values:
•The public’s right to accurate and confidential personal health information
• Innovation and leadership in advancing health information management practices and standards worldwide
• Adherence to the AHIMA Code of Ethics
• Advocacy and interdisciplinary collaboration with other professional organizations
AHIMA is a _________organization
membership
The majority of AHIMA members are ___________ HIM professionals who work throughout the healthcare industry
credentialed
AHIMA professionals serve the healthcare industry and the public by:
Managing, analyzing, and utilizing information vital for patient care and making it accessible to healthcare providers when and where it is needed.
The primary focus of the AHIMA organization is to:
Foster the professional development of its members through education, certification, and lifelong learning.
AHIMA promotes the development of high-quality information that benefits:
The public, the healthcare consumer, healthcare providers, and other users of clinical data.
To accomplish its mission, AHIMA expects that all its members will follow:
A code of professional ethics
As the Code of Ethics stipulates, all members of AHIMA are expected to:
Act in an ethical manner and comply with all laws, regulations, and standards governing the practice of health information management
As professionals, AHIMA members are expected to continually update their knowledge base and skills through __ and ________ _______
CE and lifelong learning
HITs and managers are expected to promote high standards of HIM:
practice, education, and research; and promote and protect the confidentiality and security of health records and health information
Today, AHIMA has more than ______ members. To accommodate the _________ in membership, the organization has ___ membership categories.
64,000; diversity; two
Active AHIMA membership
•Open to all individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics.
•Active members in good standing are entitled to all membership privileges including the right to vote and to serve in the House of Delegates.
•Active membership provides HIM professionals the opportunity to participate in the organization and to offer input to the current and future practices of the profession.
Student membership
includes any student who does not have an AHIMA credential and has not previously been an active member of AHIMA and who is formally enrolled in an AHIMA-approved coding program or in a CAHIIM-accredited health information management program. The student membership category gives entry-level professionals an opportunity to participate on a national level in promoting sound HIM practices. Student members can serve on committees and subcommittees in designated student positions with voice, but no vote.
Other membership categories include:
New Graduate and Senior Member
The New Graduate membership is for:
AHIMA student members only. After graduation from a CAHIIM-accredited HIT-, HIA-, or AHIMA-approved coding program, AHIMA student members may join as new graduate members at a reduced annual dues rate. This is limited to one year.
In recognition of service to the profession, current AHIMA members 65 and over are eligible for the _______ ________ type.
senior member
AHIMA is made up of two components: a _________ component and a ____ component.
volunteer; staff
The volunteer structure:
establishes the organization’s mission and goals, develops policy, and provides oversight for the organization’s operations
The staff component of the organization carries out:
Operational tasks necessary to support the organization’s mission and goals. The staff works within the policies established by the volunteer component.
As a nonprofit membership association, AHIMA depends on:
the participation and direction of volunteer leaders from the HIM community.
AHIMA’s _______ elect the delegates who serve in the governing bodies of the organization.
members
Which AHIMA body leads the volunteer structure?
AHIMA’s Board of Directors
AHIMA’s Board of Directors has responsibility for managing:
Property, affairs, and operations of AHIMA.
This body is charged with tremendous responsibility.
AHIMA’s Board of Directors
AHIMA’s Board of Directors members include:
The president, the president-elect, the past president, nine elected directors, and the executive director of the organization
Except for the _________ ________, all members of the Board of directors are elected by the membership and serve three-year terms of office
executive director
Members of the Board must be ______ _______ of the association.
active members
In addition to the Board of Directors, which two other groups are elected directly by the overall membership?
•Commission on Certification for Health Informatics and Information Management (CCHIIM)
•Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
The CCHIIM is responsible for:
overseeing AHIMA’s certification process and for setting policies and procedures.
CAHIIM is responsible for:
overseeing accreditation of college programs in health information technology and health information administration and graduate programs in health informatics
The Communities of Practice (CoP) make up a virtual network of AHIMA members who:
communicate via a Web-based program managed by AHIMA
The CoP is open only to:
AHIMA members
The CoP (communities of practice) provides the following benefits:
•Provides opportunities for members to contact other members for quick problem-solving, support, advice, and career-building tips and opportunities. It also makes it possible to share best practices.
•Makes it possible for members to search for other members with similar interests and backgrounds.
•Provides links to other sites that have specialized HIM information.
•Includes a professional library of HIM standards, guidelines, practice briefs, and other resources.
AHIMA’s president appoints the members of the:
association’s national committees, practice councils, and workgroups.
The association’s national committees, practice councils, and workgroups do what?
support the mission of the organization and work on specific projects as designated by the president and the Board of Directors
Examples of the national committees include:
The Annual Convention Program Committee, the Professional Ethics Committee, and the Fellowship Review Committee.
What do the Practice Councils such as those in Clinical Classification and Terminology, Health Information Exchange, and Privacy and Security Practice do?
Advise and provide AHIMA with expertise related to best practice in specific areas of HIM.
AHIMA has several workgroups charged with:
Addressing specific challenges in the HIM field. As an example, the EHR Best Practices workgroup focuses on developing guidelines for e-HIM practice.
The House of Delegates is an extremely important component of the _________ structure.
volunteer
Conducts the official business of the organization and functions as AHIMA’s legislative body.
House of Delegates
The annual business meeting of the House of Delegates is held in conjunction with:
AHIMA’s national convention
Who elects the House of Delegates representatives?
Each state HIM association elects representatives to the House of Delegates to serve for a specified term of office.
How is the House of Delegates similar to the legislative branch of government?
Each state HIM association elects representatives to the House of Delegates to serve for a specified term of office. For that reason, the House of Delegates is similar to the legislative branch of the U.S. government.
Approving the standards that govern the profession, including:
— The AHIMA Code of Ethics
— The guide to the interpretation of the Code of Ethics
is handled by which AHIMA body?
House of Delegates
Electing the members of the AHIMA Nominating Committee, except the chairman and appointed members is a specific power of:
House of Delegates
Other specific powers of the House of Delegates:
•Advising the Board of Directors in the development and modification of the association’s plans
•Levying special assessments
•Approving amendments to AHIMA’s bylaws
•Approving the standing rules of the •House of Delegates
•Approving resolutions
In addition to its national volunteer organization, AHIMA supports:
Component state associations (CSAs), a system of component organizations in every state, plus Washington, DC, and Puerto Rico.
Component state associations (CSAs) provide their members with:
local access to professional education, networking, and representation.
CSAs also serve as an important forum for:
•Communicating information relevant to national issues
•Keeping members informed of regional affairs that affect health information management.
How did most HIM professionals who serve in the House of Delegates or serve on AHIMA’s Board of Directors get their start?
In volunteer services with local, regional, and state associations.
Where are AHIMA’s headquarters located?
AHIMA’s headquarters are located in Chicago.
The _______ _______ of AHIMA is the individual responsible for overseeing day-to-day operations.
executive director
A team of who supports the executive director?
executives, managers, and staff
Examples of the staff departments include, among others:
member services, education, professional practice services, publications, marketing, and policy and government relations
AHIMA has a long tradition of commitment to HIM ________
education
The first prescribed curriculum for the training of medical record professionals was proposed in ____
1929
The first AHIMA educational programs were accredited in 1934. Since that time, the association has developed and maintained:
a rigorous accreditation process for academic programs, continuously developed up-to-date curriculum models, and supported educational programs in a variety of ways.
In 2004, the AHIMA House of Delegates voted to establish an independent accreditation commission (CAHIIM) with sole and independent authority in:
all matters pertaining to accreditation of educational programs in health informatics and information management.
AHIMA house of delegates voted to establish which commission to be responsible for accreditation of educational programs?
CAHIIM (Commission on Accreditation for Health Informatics and Information Management Education)
What is CAHIIM?
The accrediting agency for degree-granting programs in health informatics and information management
Who does CAHIIM serve?
CAHIIM serves the public interest by establishing quality standards for the educational preparation of future HIM professionals.
What does it mean when a program is accredited by CAHIIM?
When a program is accredited by CAHIIM, it means that it has voluntarily undergone a rigorous review process and has been determined to meet or exceed the standards established by the CAHIIM
Accreditation by CAHIIM is a way to do what?
CAHIIM accreditation is a way to recognize and publicize best practices for HIM education program
CAHIIM reviews formal applications from college programs that apply for _________ status
Candidacy
What happens after a successful review of the CAHIIM application documentation?
After a successful review of the application documentation, a program may be deemed a Candidate for Accreditation for up to two years.
Students enrolled in programs that are placed in Candidacy status by CAHIIM approval are eligible to join _____ as _______ members.
AHIMA, student
After a college program becomes a Candiate for Acreditation, what do they need to prepare? And following this, what happens?
•Within an agreed upon time-frame, the college program prepares a self-assessment document and a campus site visit occurs.
•A report of the site visit is reviewed by the CAHIIM Board of Commissioners •And a final determination is made as to the ability of the college program to meet the accreditation standards for curriculum, facility, resources, and other requirements.
Why is the accreditation of educational programs important?
The accreditation of educational programs is important because only those individuals who graduate from an approved program may sit for the national credentialing examinations for registered health information technician (RHIT) or registered health information administrator (RHIA).
What did the founding members of the organization realize early on as a necessity?
The founding members of the organization recognized early on the necessity of setting standards for medical record practitioners.
In 1933, the association organized a certifying board known as what?
The Board of Registration
Why was the Board of Registration (1933) developed?
This board was developed “so that there might be a yard-stick by which qualified medical record librarians could be determined”.
To become a registered record librarian (RRL) in 1940, a candidate needed to:
•Be at least 21 years of age
•Be a graduate of a school for record librarians approved by AAMRL
•Be currently employed in medical records work
•Pass a qualifying credentialing examination
At what point did the association recognized the need to expand its credentialing program?
As the field of health information management became more complex.
Following the realization of the need to expand the credentialing program, what commission was established?
In 2008 the Commission on Certification for Health Informatics and Information Management (CCHIIM) was established
What is CCHIIM dedicated to?
Commission on Certification for Health Informatics and Information Management (CCHIIM) is dedicated to assuring the competency of professionals practicing HIM.
How does CCHHIIM serve?
CCHIIM serves the public by establishing, implementing, and enforcing standards and procedures for certification and recertification of HIM professionals.
What does CCHIIM provide strategic oversight of?
CCHIIM provides strategic oversight of all AHIMA certification programs.
How is the oversight of certification programs standing commission of AHIMA empowered?
This standing commission of AHIMA is empowered with the sole and independent authority in all matters pertaining to both the initial certification and ongoing re-certification (certification maintenance) of HIM professional.
What is re-certification also known as?
certification maintenance
Today, the AHIMA certification program encompasses several different types of credentials, including:
•Registered health information technician (RHIT)
•Registered health information administrator (RHIA)
•Certified coding associate (CCA)
•Certified coding specialist (CCS)
•Certified coding specialist—physician based (CCS-P)
•Certified in healthcare privacy and security (CHPS)
•Certified health data analyst (CHDA)
Each of the credentials (such as RHIT) has specific:
Eligibility requirements and a certification examination.
To achieve certification from AHIMA, individuals must do what?
Meet the eligibility requirements for certification and successfully complete the certification examination.
Because the HIM profession is constantly changing, certified individuals must do what?
Demonstrate that they are continuing to maintain their knowledge and skill base.
To maintain their certification, individuals who hold any of AHIMA’s credentials must:
Complete a designated set of CE credits
What kinds of activities qualify for CE credits?
Activities that qualify for CE credits include such things as attending workshops and seminars, taking college courses, participating in independent study activities, and engaging in self-assessment activities.
What website provides information on the most recent requirements for maintenance of certification?
AHIMA’s Web site provides information on the most recent requirements for maintenance of certification.
What is the AHIMA Fellowship Program?
The AHIMA Fellowship Program is a program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession.
In the AHIMA Fellowship Program, members must have made significant and sustained contributions to the HIM profession, including:
Meritorious service, excellence in professional practice, education, and advancement of the profession through innovation and knowledge sharing.
Individuals who earn fellowship use what designation?
Fellow of the American Health Information Management Association (FAHIMA).
AHIMA Fellowship is open to who?
Fellowship is open to any individual who is an active or senior member of AHIMA and who meets the eligibility requirements.
What are the eligibility requirements to earn Fellowship?
•Fellows must have a minimum of 10 years full-time professional experience in HIM or a related field
•A minimum of 10 years continuous AHIMA membership at the time of application (excluding years as a student member)
•Hold a minimum of a master’s degree and provide evidence of sustained and substantial professional achievement that shows professional growth and use of innovative and creative solutions.
Once conferred, earning fellowship entails:
Is a lifetime recognition, subject to continuing AHIMA membership and compliance with the AHIMA Code of Ethics.
he AHIMA Foundation actively promotes:
Education and research in the HIM field.
In what year was the AHIMA Foundation founded?
the AHIMA Foundation was founded in 1962
What kind of arm of AHIMA is the AHIMA Foundation?
The AHIMA Foundation is a separately incorporated philanthropic and charitable arm of AHIMA.
The HIM profession is based on what?
The HIM profession is based on the belief that high-quality healthcare requires high-quality information.
Historically what has the Foundation AHIMA provided?
The Foundation has provided knowledge, research, and education infrastructure for this industry.
What is the role of the AHIMA Foundation?
Its role is to envision the future direction and needs of the field and to respond with strategies, information, planning, and programs that will keep the HIM profession on the cutting edge.
What are some of the initiatives that have been spearheaded by the Foundation?
Some of the initiatives that have been spearheaded by the Foundation include the Leadership Recognition Program, the benchmarking and best practices research initiative, the legal and regulatory clearinghouse and curriculum, and various faculty support initiatives.
In addition to many initiatives by the Foundation, what else does it administer?
The foundation administers a number of programs, including the scholarship and research programs.
Which branch of AHIMA strives to be the premiere resource for HIM professionals and the leader in advancing the field for the betterment of the HIM profession and healthcare consumers?
The AHIMA Foundation
Members of the Board must be ______ members of the association.
Active
Many large healthcare systems that have multiple hospitals and other facilities over a broad geographic area have _______ complete ___ centralization.
Adopted; HIM
One example of the adoption of complete HIM centralization is:
Parkview Health in Fort Wayne, IN.
Maria Stolze, RHIA, vice president of HIM, has direct:
Responsibility for all HIM functions at the system’s eight facilities.
There are no HIM _________ at the local level.
Directors
Because there are no HIM directors at the local level at Parkview Health in Fort Wayne, IN, who reports to Stolze, the vice president of HIM?
Two directors—of HIM services and transcription, respectively—report to Stolze.
Managers and supervisors who report to the two directors have what kind of responsibility for HIM functions at Parkview hospitals?
Managers and supervisors who report to the two directors have day-to-day responsibility for HIM functions at Parkview hospitals.
The __________ rotate between _________, although at least two are dedicated to the flagship Parkview Hospital because of its size.
Supervisors; facilities
Depending on size, there may be as few as _____ HIM personnel at individual facilities, as coding and transcription are performed ___-____.
Three; [as coding and transcription are performed] off-site.
Why did Parkview in the case study arrive at this model?
Parkview arrived at this model to improve quality and service and to decrease cost, goals it has achieved.
The Parkview approach also has been critical to adopting what?
Uniform HIM policies and procedures.
What is the advantage to the Parkview model? [large healthcare systems that have multiple hospitals and other facilities over a broad geographic area have adopted complete HIM centralization, and where there are no HIM directors at the local leval, but the vice president of HIM, has direct responsibility for all HIM functions at the systems number of facilities]
•This model makes the vp of HIM the ultimate decision-maker [Even if they’re not all in agreement, that’s an advantage of the model]
•Otherwise there might be conflicting policies and procedures between the individual facilities
•You need someone to call it when there are different perspectives
What is the Parkview model?
•Large healthcare systems that have multiple hospitals and other facilities over a broad geographic area that have adopted complete HIM centralization
•There are no HIM directors at the local level
•The vice president of HIM, has direct responsibility for all HIM functions at the systems number of facilities
At the beginning of the organization’s inception in 1928, founding members realized the need to:
Direct the field of medical records toward professional standing.
Directing the field of medical records toward professional standing required what?
The development of a formal organization devoted to establishing standards and best practices for the discipline, including the creation of a prescribed training curriculum and the launch of a formal certification program.
The development of a formal organization devoted to establishing standards and best practices for the discipline, including the creation of a prescribed training curriculum and the launch of a formal certification program was done in what time span?
Amazingly, all this was accomplished in only six short years from the formation of the organization in 1928, to the establishment of a credentialing program in 1933, to the first accreditation of academic programs in 1934.
The association has adapted to the membership’s changing needs, which are:
•Credentialing programs have been expanded to represent the diversity of work tasks in the discipline.
•Accreditation standards for academic programs have continued to become more rigorous, reflecting program outcomes and the growing need for better-trained and qualified graduates.
•Advocacy for confidentiality and patients’ rights continues to be a fundamental objective as AHIMA’s expertise and input are sought in the development of federal policy.
•The role and definition of professional practice have been studied and changed to meet new demands
Evolution of practice
•American Association of Medical Record Librarians
•American Medical Record Administration
•American Health Information Management Association
Former names of credentials
•Registered Record Administrator
•Accredited Record Technician
Current names of credentials
•Registered Health Information Administrators
•Registered Health Information Technicians
Traditional Practice
•Focus was complete and accurate medical records on every patient
•Purpose of record was to support the care and treatment and clinical research
•Activities focused on managing record – not data
Information-Oriented Management Practice
•25 to 40 percent of operating costs goes to information handling
•Information crosses department barriers
•HIM task include data manipulation and information management
Visioning the Future of HIM
•Many HIM professionals work outside of the HIM department
Other departments in hospital
Other settings
•Electronic health record is being implemented
Tasks for visioning the future of HIM:
•Tasks include:
-Maintaining data dictionaries
-Developing data models
-Data administration
-Ensuring data quality
Vision HIM professionals are focused on:
•Data analysis and interpretation
•User interfaces for the EHR
•Privacy and security
Vision 2006 rules:
•Health information manager for integrated systems
•Clinical data specialist
•Patient information coordinator
•Data quality manager
•Information security manager
•Data resource administrator
•Research and decision support specialist
New and Revised Roles:
•Terminology modeler
•Personal health record liaison or consultant
•Physician group consultant
•Privacy officer
•Health record reviewer
•HIM director
•Enterprise content and information manager
•Revenue cycle manager
•Health data analyst
•Chief information officer
AHIMA’s Mission
Membership organization
Majority of members are credentialed
Primary focus is to foster professional development of members
Education
Certification
Lifelong learning
Certification programs set high standards
Provides continuing education for members
Code of professional ethics
AHIMA Code of Ethics:
Members expected to act in ethical manner and comply with all laws, regulations, and standards governing the practice of HIM
Membership:
•Volunteers
-Establishes mission and goals
-Develops policy
-Provides oversight for organization’s operations
•Staff
-Carries out operational tasks to support the mission and goals
Association Leadership
•Members elect delegates who are governing body
•Board of Directors lead volunteer structure
-President
-President-elect
-Past president
-Directors
-Executive director
•Commission on Certification for Health Informatics and Information Management
-Oversee certification process
•Commission on Accreditation of Health Informatics and Information Management Education
-Oversees accreditation of college programs
Communities of Practice (CoP)
•Virtual network of AHIMA members
•Function of CoP
-Method of contacting other members
-Search for members with similar interests
-Links to other sites related to HIM
-Professional library
National Committees
•Members appointed by AHIMA’s president
•Support mission of organization
•Work on specific projects
House of Delegates
•Functions as legislative body
•Members elected by state HIM association
•Responsibilities include:
Approving standards
Electing members to AHIMA nominating committee
Advising Board of Directors
Approving amendments to AHIMA’s bylaws
State and Local Associations
•Component state association in each state plus Washington, D.C. and Puerto Rico
•Provide access to professional education, networking and representation
•Updates members on national issues
•Local associations good way to begin volunteerism
Staff Structure
•AHIMA is located in Chicago
•Executive director responsible for day-to-day activities
•Staff perform duties such as
-Professional practice services
-Publications
-Marketing
-Government relations
Accreditation of Educational Programs
•CAHIIM is an independent accreditation organization
•Establish quality standards
•Accredited programs undergo rigorous reviews
•Graduates are eligible to sit for credentialing examination
Certification and Registration Program
•CCHIIM establishes, implements, and enforces standards and procedures for certification and re-certification.
Current Certifications
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Coding Associate (CCA)
Certified Coding Specialist (CCS)
Certified Coding Specialist – physician based (CCS-P)
Certified in Healthcare Privacy and Security (CPHS)
Certified Health Data Analyst (CHDA)
Fellowship Program
Earned recognition program for AHIMA members
-Significant and sustained contributions to the HIM profession
-Designation of Fellow of the American Health Information Management Association (FAHIMA)
Fellowship Program Eligibility
Eligibility:
•Active or senior member of AHIMA
•10 years full-time HIM experience
•Minimum of masters degree
•Evidence of sustained and substantial professional achievement
•Lifetime recognition subject to AHIMA membership and compliance with AHIMA Code of Ethics
The AHIMA Foundation
•Promotes education and research in HIM
•Philanthropic and charitable arm of AHIMA
•Role is to envision the future direction and needs of the field