Health Information Management

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Health Information
        Management
Concepts, Principles, and Practice

             Second Edition




    Kathleen M. LaTour, MA, RHIA, FAHIMA
 Shirley Eichenwald Maki, MBA, RHIA, FAHIMA
                   Editors
Copyright 2006 by the American Health Information Management Association. All rights reserved. No part
of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher.

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here that are no longer valid.



ISBN 1-58426-142-0
AHIMA Product Number AB103306



AHIMA Staff:
Claire Blondeau, MBA, Project Editor
June E. Bronnert, RHIA, CCS, CCS-P
Jill Burrington-Brown, MS, RHIA
Michelle L. Dougherty, RHIA, CHP
Melanie A. Endicott, MBA/HCM, RHIA, CCS
Susan Fenton, MBA, RHIA
Kathy Giannangelo, RHIA, CCS
Beth Hjort, RHIA, CHPS
Susan Hull, MPH, RHIA, CCS, CCS-P
Karen Kostick, RHIT, CCS, CCS-P
Elizabeth Lund, Editorial Assistant
Donald T. Mon, PhD, FHIMSS
Carol Ann Quinsey, RHIA, CHPS
Harry Rhodes, MBA, RHIA, CHPS
Dan Rode, MBA, FHFMA
Rita A. Scichilone, MSHA, RHIA, CCS, CCS-P, CHC
Mary H. Stanfill, RHIA, CCS, CCS-P
Melissa Ulbricht, Production Editor
Maggie Williams, MA
Ann Zeisset, RHIT, CCS-P, CCS
Kenneth Zielske, Director of Publications




                          American Health Information Management Association
                                233 North Michigan Avenue, Suite 2150
                                     Chicago, Illinois 60601-5800

                                                    ahima.org
                                                                                  Contents



About the Editors and Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Part I          Informatics and Health Information Management
                Chapter 1              Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
                                       Shirley Eichenwald Maki, MBA, RHIA, FAHIMA, and Kathleen M. LaTour, MA, RHIA, FAHIMA
                Chapter 2              Healthcare Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
                                       Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, CPHQ
                Chapter 3              Informatics in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
                                       Deborah Kohn, MPH, RHIA, CHE, CPHIMS, FHIMSS, and Pamela Oachs, MA, RHIA
                Chapter 4              The Health Information Management Profession. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
                                       Sandra R. Fuller, MA, RHIA
                Chapter 5              Data and Information Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
                                       Frances Wickham Lee, DBA, RHIA
                Chapter 6              Information Systems Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
                                       Karen A. Wager, DBA, RHIA

Part II         Development of Healthcare Information
                Chapter 7              Healthcare Information Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
                                       Kathleen M. LaTour, MA, RHIA, FAHIMA
                Chapter 8              Paper-Based Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
                                       Mary Cole McCain, MPA, RHIA
                Chapter 9              Electronic Health Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
                                       Margret Amatayakul, MBA, RHIA, CHPS, FHIMSS
                Chapter 10             Legal Issues in Health Information Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
                                       Lynda A. Russell, EdD, JD, RHIA, CHP, and Rita K. Bowen, MA, RHIA, CHPS
                Chapter 11             Ethical Issues in Health Information Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
                                       Laurinda B. Harman, PhD, RHIA

Part III Aggregate Healthcare Data
                Chapter 12             Secondary Records and Healthcare Databases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
                                       Elizabeth Bowman, MPA, RHIA
                Chapter 13             Clinical Classifications and Vocabularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
                                       Susan H. Fenton, MBA, RHIA, and Matthew Greene, RHIA, CCS
                Chapter 14             Reimbursement Methodologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
                                       Anita Hazelwood, MLS, RHIA, FAHIMA, and Carol Venable, MPH, RHIA, FAHIMA


                                                                                                                                                                                                 iii
iv         Contents

Part IV Comparative Data
                Chapter 15            Healthcare Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
                                      Carol E. Osborn, PhD, RHIA
                Chapter 16            Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
                                      Elizabeth Layman, PhD, RHIA, CCS, FAHIMA
                Chapter 17            Clinical Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
                                      Vicki L. Zeman, MA, RHIA

Part V          Knowledge-Based Healthcare Data and Information
                Chapter 18            Biomedical and Research Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
                                      Carol E. Osborn, PhD, RHIA
                Chapter 19            Expert Systems and Decision Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
                                      J. Michael Hardin, PhD
                Chapter 20            Knowledge Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
                                      Kam Shams, MA, and Mehnaz Farishta, MS

Part VI Management of Health Information Services
                Chapter 21            Principles of Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
                                      David X. Swenson, PhD
                Chapter 22            Leadership Theory and Change Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
                                      David X. Swenson, PhD
                Chapter 23            Work Design and Performance Improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
                                      Madonna LeBlanc, MA, RHIA, and Andrea Weatherby White, PhD, RHIA
                Chapter 24            Human Resources Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
                                      Shirley Eichenwald Maki, MBA, RHIA, FAHIMA
                Chapter 25            Training and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
                                      Karen R. Patena, MBA, RHIA
                Chapter 26            Financial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
                                      Nadinia Davis, MBA, CIA, CPA, RHIA, FAHIMA
                Chapter 27            Project Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
                                      Patricia B. Seidl, RHIA, CCDM
                Chapter 28            Strategic Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
                                      Linda L. Kloss, MA, RHIA, CAE

Appendices, Glossary, and Index
                Appendix A            Sample Documentation Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 803
                Appendix B            Sample Position Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839
                Appendix C            Sample Notice of Health Information Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841
                Appendix D List of AHIMA Practice Briefs, Standards, and Position Statements . . . . . . . . . . . . . . . . . . . . . . 845
                Appendix E            Web Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851
                Appendix F            AHIMA Code of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
                Appendix G Answers to Check Your Understanding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
                              About the Editors and Authors




Kathleen M. LaTour, MA, RHIA, FAHIMA is an assistant             Margret K. Amatayakul, MBA, RHIA, CHPS, FHIMSS,
professor and chair of the department of healthcare informat-    is president of Margret\A Consulting, LLC, in Schaumburg,
ics and information management (HIIM) at the College of St.      Illinois, a consulting firm specializing in computer-based
Scholastica in Duluth, Minnesota. She is an active member        patient records and associated HIM standards and regula-
of the Minnesota Health Information Management Associa-          tions, such as HIPAA. She has more than thirty years of expe-
tion, where she was selected as the Distinguished Member in      rience in national and international HIM. A leading authority
1992. She has served as chair and member of many AHIMA           on electronic health record (EHR) strategies for healthcare
councils and as a member of AHIMA's Board of Directors           organizations, she has extensive experience in EHR selection
from 1993 to 1997. She participated in the development of the    and project management, and formed and served as executive
AHIMA Model Curricula for both bachelor's- and master's-         director of the Computer-based Patient Record Institute (CPRI).
level programs. She has authored several articles and recently   Other positions held include associate executive director of
contributed a chapter to Health Information Management Tech-     AHIMA, associate professor at the University of Illinois, and
nology: An Applied Approach, second edition, a textbook          director of medical record services at the Illinois Eye and Ear
published by AHIMA in 2006. She was awarded fellowship           Infirmary. She is a much-sought-after speaker, has published
in AHIMA in recognition of sustained contributions to the        extensively, and has earned several professional service
field of HIM and, In 2004, was corecipient of AHIMA's            awards. Amatayakul also serves as an adjunct faculty mem-
Legacy Award.                                                    ber of the College of St. Scholastica and the University of
                                                                 Illinois at Chicago.
Shirley Eichenwald Maki, MBA, RHIA, FAHIMA, is an
assistant professor in the department of healthcare informat-    Rita K. Bowen, MA, RHIA, CHPS, has nearly thirty years
ics and information management at the College of St. Scho-       of experience in healthcare information management. She is
lastica in Duluth, Minnesota. She also serves as project         currently the privacy officer for the Erlanger Health System
director for The ATHENS Project (css.edu/programs/athens),       in Chattanooga, Tennessee, and has previously held posi-
a health sciences EHR curriculum model project funded by a       tions as director of health information services, director of
grant from the U.S. Department of Education, Title III pro-      medical records, marketing director, and medical records
gram. She is the 2001 recipient of the College of St. Scholas-   consultant at various hospitals and medical services com-
tica's Max H. Lavine Award for Teaching Excellence. A            panies throughout the United States. Bowen has an MA in
former president of AHIMA, she was awarded the associa-          health information management technology from the Col-
tion's Distinguished Member Award in 1998. In addition, she      lege of Saint Scholastica and earned her bachelor's degree
coauthored with Merida L. Johns, PhD, RHIA, AHIMA's              in medical science from Emory University in Atlanta. She
White Paper on the Health and Well-being of HIM Educa-           has a continuous history of activities with AHIMA and the
tion. She has held the position of director of education and     Tennessee HIMA.
accreditation at AHIMA and has served as an HIM consul-
tant with Pyramid Health Solutions and Quadramed's HIM           Elizabeth Bowman, MPA, RHIA, is a professor in the HIM
Division. Finally, she was awarded fellowship in AHIMA in        program at the University of Tennessee Health Science Cen-
recognition of sustained contributions to the field of HIM       ter in Memphis. She has been an HIM educator for more than
and, in 2004, was corecipient of AHIMA's Legacy Award.           twenty-five years. She received a bachelor's degree from


                                                                                                                              v
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