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Syllabus for Issues in Law Enforcement: Cybersecurity and Public Interest Technology

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This is a syllabus for a course in Issues in Law Enforcement, a criminal justice course. The curriculum is a public interest technology course in cybersecurity. Principally, the federal government handles cybersecurity investigations along with some state governments and the FBI acts as the center for all cybersecurity complaints. The course expands beyond law enforcement and provides a comprehensive background to the field through the following presentations: a history of cybersecurity; an explanation of the Internet; an introduction to cybercrime and cybersecurity techniques; the legal environment, which includes a survey of law enforcement and prosecution departments and agencies, and federal and NY state criminal, civil and privacy laws; a case (Silk Road Market) about a darknet market which demonstrates federal law enforcement in action; and the concept that cybersecurity is an enormous challenge to law enforcement. The course provides two types of student activities: (i) Service learning project in which students present about how to prevent yourself from being hacked; and (ii) Group assignments in which students choose and analyze four types of current cybersecurity cases as a team by answering questions posed by the professor which is presented to the class as a whole.

Material Type: Activity/Lab, Case Study, Full Course, Homework/Assignment, Lecture, Reading

Author: Amy J Ramson

Cybersecurity-The Silk Road Market

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This presentation is about the Silk Road Market, one of the largest cases of illegal drug activity on the dark web, that the federal government has prosecuted. Beyond discussing the case, the presentation adds general facts about the US Department of Justice, the FBI and the DEA, and federal sentencing. The case discussion includes information about: Ross Ulbricht the creator and head of the market; how the Silk Road operated; the involvement of the FBI and DEA; the trial; the fourth amendment violations alleged by the defense; and the sentencing.

Material Type: Lesson

Author: Amy J Ramson

GVL - Ethics and CyberSecurity

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The resource "Ethics and CyberSecurity" is a module in the "Intro to Digital Technology" course. The course is included in the Georgia Virtual Learning resource series available in the open educational resources collection of the NCLOR. This resource is included in the Career and Technical Education discipline with the subject of Technical.

Material Type: Interactive, Unit of Study

Cyber Security Economics

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This economics course provides an introduction to the field of cybersecurity through the lens of economic principles. Delivered by four leading research teams, it will provide you with the economic concepts, measurement approaches and data analytics to make better security and IT decisions, as well as understand the forces that shape the security decisions of other actors in the ecosystem of information goods and services. Systems often fail because the organizations that defend them do not bear the full costs of failure. In order to solve the problems of growing vulnerability to computer hackers and increasing crime, solutions must coherently allocate responsibilities and liabilities so that the parties in a position to fix problems have an incentive to do so. This requires a technical comprehension of security threats combined with an economic perspective to uncover the strategies employed by cyber hackers, attackers and defenders.

Material Type: Full Course

Authors: Dr. Ir. Carlos Hernandez Gañán, Dr. Rainer Böhme, Dr. Tyler Moore, Prof.dr. Michel van Eeten, Prof.dr. Ross Anderson

Reslience

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6. Brave New World - Resilience The trifecta of globalization, urbanization and digitization have created new opportunities and challenges across our nation, cities, boroughs and urban centers. Cities are in a unique position at the center of commerce and technology becoming hubs for innovation and practical application of emerging technology. In this rapidly changing 24/7 digitized world, city governments worldwide are leveraging innovation and technology to become more effective, efficient, transparent and to be able to better plan for and anticipate the needs of its citizens, businesses and community organizations. This class will provide the framework for how cities and communities can become smarter and more accessible with technology and more connected.

Material Type: Lesson

Author: Rhonda S. Binda

Introduction to Healthcare Informatics - 2nd Ed. (2017)

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To access this resource you will need to use your STAT!Ref User ID and Password.  If you need a STAT!Ref User ID and Password speak with your administrator. INTRODUCTION TO HEALTHCARE INFORMATICS - 2nd Ed. (2017) Front Matter Title Page Introduction to Healthcare Informatics Second Edition Sue Biedermann, MSHP, RHIA, FAHIMA Diane Dolezel, EdD, RHIA, CHDA AHiMA American Health Information Management Association® Copyright Page Copyright ©2017 by the American Health Information Management Association. All rights reserved. Except as permitted under the Copyright Act of 1976, 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 AHIMA, 233 North Michigan Avenue, 21st Floor, Chicago, Illinois, 60601-5809 (http://www.ahima.org/reprint). AHIMA Product No.: AB120015 AHIMA Staff: Chelsea Brotherton, MA, Assistant Editor Ashley Latta, Production Development Editor Elizabeth Ranno, Vice President of Product and Planning Caitlin Wilson, Project Editor Pamela Woolf, Director of Publications Cover image: ©teekid, iStockPhoto Limit of Liability/Disclaimer of Warranty: This book is sold, as is, without warranty of any kind, either express or implied. While every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information or instructions contained herein. It is further stated that the publisher and author are not responsible for any damage or loss to your data or your equipment that results directly or indirectly from your use of this book. The websites listed in this book were current and valid as of the date of publication. However, webpage addresses and the information on them may change at any time. The user is encouraged to perform his or her own general web searches to locate any site addresses listed here that are no longer valid. CPT® is a registered trademark of the American Medical Association. All other copyrights and trademarks mentioned in this book are the possession of their respective owners. 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 ISBN-13: 978-1-58426-528-3 ISBN-10: 1-5842-6528-0 Detailed Contents About the Authors… xvii Foreword… xxi Acknowledgments… xxiii Chapter 1. Foundations of Healthcare Informatics… 1 Definitions, Policies, Methods, and Ethics… 2 History of Health Informatics… 4 Core Competencies… 9 Definitions and Terms… 12 Policies… 21 Methods… 21 Ethics… 24 Roles… 25 Health Information Management Professional… 25 CIO, CMIO, and the C-Suite… 27 Physician… 28 Information Technology Specialists… 29 Scribes… 30 Chapter 2. Ethics… 39 Defining Ethics… 40 Values and Morals… 41 Legal Influence… 43 Ethical Standards of Practices… 44 The Ethics Committee… 49 Potential Ethical Issues in Healthcare… 51 Provisioning of Care… 51 Ethical Use of Health Information… 52 Protected Health Information… 54 Health Literacy… 61 Ethical Decision Making… 63 Assessing Potential… 63 Identifying… 63 Evaluating… 63 Deciding on a Course of Action… 63 Preventing Future Occurrences… 64 Chapter 3. Electronic Health Records… 73 History… 75 Components… 82 Inpatient EHR… 90 Ambulatory EHR… 95 Long-Term Care EHR… 96 Behavioral Healthcare EHR… 96 Enterprise EHR… 97 Chapter 4. Information Infrastructure… 103 Using Technology… 105 Computer Concepts… 105 Architectural Models… 107 Assess Systems for Regulatory Requirements… 109 Design and Development… 109 Physical Models… 109 Mobile Computing… 112 Electronic Signatures… 113 Audit Logs… 113 Device Selection Recommendations… 114 Development of Systems… 117 Communication Technologies… 117 Internet Technologies… 119 Evaluate Systems… 122 Systems Testing… 122 Interface Management… 122 Electronic Structure and Relationship of Health Data… 123 Distributed Systems… 125 Evolution of Distributed Systems… 128 Two-Tiered Systems… 128 Three-Tiered Architecture… 129 Web Services Architecture… 130 Collaborative Computing… 131 Cloud Computing… 132 Chapter 5. Data and Information… 145 The Basics of Data… 146 Data Related to Information… 147 Data Format… 148 Data Standards… 150 Standards Development… 150 US Health Information Technology Standards… 152 Data Collection… 158 Structured Data Entry… 158 Unstructured Data Entry… 159 Data Measurement… 161 Nominal data… 161 Ordinal data… 161 Interval data… 162 Ratio data… 162 Data Management… 163 Data Governance… 163 Data Quality… 164 Characteristics of Data Quality… 164 The Data Quality Assessment and Management Process… 167 Data Analysis… 171 Understanding the Data… 171 Cleaning the Data… 172 Imputation… 174 Data Presentation… 176 Tables… 176 Charts and Graphs… 177 Data Visualization… 177 Chapter 6. Understanding Databases… 185 Database Terminology… 186 Types of Databases… 187 Flat Files… 187 Relational Databases… 189 Object-Oriented Databases… 196 Database Management Software… 196 Data Dictionary… 197 Structured Query Language (SQL)… 198 Data Modeling… 202 Data Warehouses and Data Marts… 205 Chapter 7. Introduction to Research… 211 Principles of Research Design… 213 Quantitative Research… 214 Qualitative Research… 214 Mixed Methods Research… 214 Experimental Research… 215 Correlational Research… 216 Quasi-Experimental… 216 Clinical Outcomes Assessment… 216 Steps in the Research Process… 218 Determine Research Question… 219 Define Study Variables and Their Data Types… 219 Identify Sample and Population… 220 Data Collection Methods… 220 Data Collection Instruments… 221 Data Analysis… 221 Reliability and Validity… 222 Select Statistical Analysis Software… 223 Microsoft Excel… 223 SPSS… 223 SAS… 224 R software… 224 Stata… 225 Determine Statistical Formulas to Use or Statistical Tests to Conduct… 225 Compute Descriptive Statistics… 225 Compute Inferential Statistics… 226 Advanced Data Analysis… 227 Trend Analysis… 227 Predictive Analysis… 229 Forecasting… 229 Data Mining… 229 Epidemiological Applications… 230 Data Visualization… 231 Microsoft Excel… 231 SPSS… 231 R software… 232 Dashboards… 232 Data Retrieval… 233 Languages and Tools… 234 SQL: Microsoft Access, Oracle, IBM DB2, SQL Server… 234 SPSS Data Explore Function… 235 Data Reporting… 235 Tables, Charts, and Figures from Statistical Software Results… 236 Reporting Software… 236 Presentation Software… 236 Recommending Organizational Action… 237 Chapter 8. Implementing Healthcare Information Systems… 243 Leadership, Roles, and Strategic Planning… 244 Leadership… 244 Strategic Planning Roles… 247 Development of Leadership Management Plans… 249 The HIT Technology Project… 250 Disaster and Recovery Planning… 251 Systems Development Life Cycle… 252 Planning and Analysis… 252 Design… 254 Implementation… 259 Project Implementation Plan… 259 Support and Evaluation… 261 Maintenance and Evaluation for EHRs, HIEs, and RECs… 263 Transition to a Complete EHR Process… 264 Advantages of Hybrid Records… 264 Challenges When Handling Hybrid Records… 265 Usability… 267 Use Cases… 267 EHR Vendors and Usability… 268 EHR Usability Testing and Assessment… 269 Chapter 9. Healthcare Informatics and Decision Support… 279 Knowledge Management… 281 Administrative Uses of Decision Support Systems… 283 Clinical Decision Support Systems (CDSSs) to Improve Safety and Quality of Patient Healthcare… 286 Disparity in Access to Information for CDSSs… 287 Research about Decision Support Systems… 288 Unintended Consequences of Clinical Decision Support Systems… 292 Quality… 293 The State of the Art… 294 Chapter 10. Health Information Interoperability… 301 Health Information Exchange… 302 History of HIE… 303 Structure and Adoption… 304 Stakeholder Perceptions… 309 Consumer Perceptions… 310 Future Efforts… 311 Aggregating Health Information… 313 Population Health… 313 Public Health… 315 Chapter 11. Using Healthcare Data and Information… 325 Primary and Secondary Uses of Healthcare Data… 326 Natural Language Processing (or Understanding)… 326 Unstructured Data… 328 Textual Data… 329 Nontextual Data… 329 Coded and Structured Data… 331 Healthcare Code Sets… 332 Classification Systems… 332 Clinical Terminologies… 338 Other Data and Information Uses… 341 Metadata… 342 Secondary Data Uses of the Future… 343 Big Data… 344 Chapter 12. Privacy for Health Information… 351 HIPAA Privacy Rule… 352 Focus of HIPAA Privacy Regulations… 353 Basics of the HIPAA Privacy Regulations… 354 Covered Entities and Workforce… 354 Healthcare Transactions… 354 Business Associates… 355 Protected Health Information… 358 Deidentification of Protected Health Information (PHI)… 359 Electronic Protected Health Information (ePHI)… 361 Uses and Disclosures of PHI… 361 Individual Rights Regarding Access to PHI… 362 Uses and Disclosures Permitted by HIPAA… 363 Opportunity to Agree or Object… 363 Incidental Use and Disclosure… 363 Public Interest and Benefit Activities… 364 Limited Data Set… 364 Authorized Uses and Disclosures… 365 Denial of Access… 365 Minimum Necessary Requirement… 366 Other Legal Considerations… 368 Pre-emption of State Law… 368 e-Discovery… 369 Administrative Requirements for Covered Entities… 370 Notice of Privacy Practices… 370 Safeguards… 371 Mitigation… 371 Training… 371 Privacy Official… 371 Accounting of Disclosures: HIPAA and HITECH… 371 Breach Notification Audit Program… 372 Breach Audit Protocol… 373 Individual Rights Regarding Health Information… 373 Genetic Information… 373 Chapter 13. Security for Health Information… 379 Security Rule… 380 Security Risk Analysis… 381 Vulnerabilities… 381 Threats… 382 Risks… 382 Risk Analysis Methods… 383 HIPAA Security Rule Safeguards… 383 Administrative Safeguard Standards… 383 Physical Safeguards Standards… 390 Facility Access Control Standard… 390 Workstation Use Standard… 392 Workstation Security Standard… 392 Device and Media Controls Standard… 392 Technical Safeguards Standards… 393 Access Control Standard… 394 Audit Control Standard… 394 Integrity Standard… 395 Person or Entity Authentication Standard… 395 Transmission Security… 395 Confidentiality, Integrity, and Availability… 396 Confidentiality… 396 Integrity… 396 Availability… 396 Penalties and Enforcement… 397 The Office for Civil Rights… 397 Civil Penalties… 397 Criminal Penalties… 398 Enforcement Activities to Date… 398 Breach Notification… 401 Risk Assessment… 401 Medical Identity Theft… 403 Medical Identity Theft… 403 Red Flag Rules… 406 Operational Recommendations… 407 Disaster Preparedness… 409 Protecting Information Assets… 409 Continuity of Information Services… 411 Overview of Disaster Planning… 412 Considerations for Disaster Planning… 414 Chapter 14. Legal Health Records… 423 Legal Health Records… 425 Setting the Stage for LHRs… 427 Stakeholders for LHR Definition Projects… 427 Paper, Electronic, and Hybrid Health Records… 427 Why Define a Legal Health Record?… 430 LHR Definition Project Steps… 430 Defining the Components of an LHR… 433 Creating a Tailored LHR Definition for Disclosure… 433 The LHR Policy Imperative… 438 Litigation Response Policy and Procedures for Record Custodians… 438 Creating Litigation Response Policies and Procedures… 440 EHR System Attributes That Impact LHR Definitions and e-Discovery… 441 Audit Logs… 442 Authorship and Authentication of Entries and Electronic Signatures… 442 Business Continuity… 443 Business Rules… 443 Data, Document Management, and Nonrepudiation… 443 Retention, Data Permanence, and Migration Plans… 444 Interfaces… 444 Legal Hold… 444 Metadata… 445 Electronic Health Record Output… 445 Rendition… 446 Snapshots and Screen Views… 446 Privacy Attributes… 446 Version Controls… 447 Patient Record Documentation Considerations… 448 Accuracy… 448 Amendments, Corrections, Deletion, and Other Documentation Issues… 448 Patient-Requested Amendments… 448 Corrections… 449 Deletions… 449 Copy and Paste Forward… 449 Late Entries… 450 Resequencing and Reassignment… 450 Templates, Boilerplates, Canned Text, and Structured Input… 451 e-Discovery Overview… 451 Chapter 15. Consumer Health Informatics… 457 Consumer Health Informatics: A Standardized Definition?… 458 Literacy: A Fundamental Skill… 461 Digital Immigrant or Digital Native… 463 Characteristics of the Online Health Consumer… 464 Health Topics of Interest for the Online Health Information Consumer… 464 Getting Connected to the Internet for the Online Health Information Consumer… 466 Consumer Health Informatics Technology… 467 Social Media… 468 Ubiquitous Computing of Online Health Information… 469 Personal Health Records… 472 Blue Button: Access to Health Information… 475 Patient Portal… 476 Validity and Reliability of Online Health Information… 477 Privacy and Security… 478 Chapter 16. Trends and Emerging Technologies… 491 Current and Emerging Trends and Terms… 492 Redefining the Health Informatics Domain… 493 Emerging Technology… 493 Emerging Applications… 495 Expanding Methods of Storage… 495 Expanding Services Geographically… 496 Improved Continuity of Care and Increased Efficiency… 502 Preventive Care… 505 Disease Management… 506 Evidence-Based Medicine… 507 Seamless Care… 507 Health Informatics Workforce… 509 Education… 510 Educational Programs… 510 Demand… 512 Positions and Skills Needed… 513 Genomics… 516 Genomic Information… 516 Use of Genomic Information… 517 Privacy… 519 Ethical Concerns… 520 Cybersecurity… 520 Appendix A. Odd-Numbered Answers for Check Your Understanding Sections… 529 Appendix A. Odd-Numbered Answers for Review Exercises Sections… 535 Appendix B. Case Study: Normalizing Data Tables Appendix C. The RFP Process for EHR Systems Appendix D. AHIMA RFI/RFP Template Appendix E. List of Conditions, Diseases, Treatments, and Laboratory Results Reported to the CDC Appendix F. ICD-10-CM Chapter Titles and Sections of ICD-10-PCS Appendix G. Unintended Consequences Issues Log Workbook Appendix H. Medical Identity Theft Response Checklist and Resources for Consumers Glossary Index About the Authors Lead Authors Sue Biedermann, MSHP, RHIA, FAHIMA, is associate professor emeritus and the former chair of the HIM Department at Texas State University. She has served the Texas Health Information Management Association in various appointed and elected positions including president. At the national level, she has been an accreditation site visitor for more than 15 years with additional past service including the Professional Conduct Committee, Nominating Committee, AOE Strategy Task Force, and project manager for the Professional Resource Task Force. Ms. Biedermann completed the AHIMA Research Institute and was most recently funded by the Texas Higher Education Coordinating Board for a project preparing for HIT students to advance to bachelor's level education. She has been author or coauthor on a number of publications and reports and presents frequently at state and national meetings. During her tenure as a faculty member, she has received the College of Health Professions Faculty Excellence Award and was selected as an Alpha Chi Favorite Professor. Diane Dolezel, EdD, RHIA, CHDA, is an assistant professor in the HIM Department at Texas State University where she teaches informatics, analytics, and data use; healthcare research and data analysis; and quality management to graduate and undergraduate students. At the university, she serves on the faculty student research forum. Dr. Dolezel has published several peer-reviewed research articles on usability of web-based PHRs, data migration for EHRs, metadata, data analysis relational databases, and other informatics topics. She is a frequent speaker at national and regional AHIMA, HIMSS, and TSAHP conferences on electronically stored information, relational databases, and informatics topics. She worked in the information technology field for many years as a senior developer and consultant with significant experience in database programming and systems integration. She has served on the AHIMA Foundation Council for Academic Excellence, Faculty Development Workgroup and was awarded an AHIMA Merit Scholarship as a graduate student. Contributing Authors Juliana J. Brixey, PhD, MPH, MSN, RN, is currently an associate professor at the University of Texas Health Science Center at Houston. She holds a joint appointment with the School of Biomedical Informatics and School of Nursing. Her faculty position entails teaching biomedical and nursing informatics courses. Brixey is also director for the UT Health Center for Interprofessional Collaboration. She previously held the position of operations manager for Outreach and Education for the Gulf Coast Regional Extension Center. Kelly McLendon, RHIA, CHPS, was awarded the 2015 AHIMA Innovation Award. The Innovation Award honors those individuals who are focused on moving Healthcare Informatics/Health Information Management into the future of the healthcare and wellness industry. It honors individuals who have promoted important advances in areas related to HIM practice, quality data, standards development, patient safety, systems development, and any domain where visionary thinking has made a difference. Kelly has been a HIM (medical records) practitioner for over 36 years. Most recently he founded CompliancePro Solutions, a company that has brought the state-of-the-art HIPAA privacy compliance product PrivacyPro™ to the healthcare marketplace. He routinely works with a large network of healthcare providers and vendor business associates. He volunteers his time and expertise to professional associations, such as AHIMA, including serving on their Privacy and Security Practice Council. Kelly is considered an innovator and subject matter expert in HIPAA Privacy and Security, Legal Health Records and is a computer system functional designer. Kelly's career includes many contributions to the migration of HIM into the electronic environment, an effort that has taken decades to achieve. He is a well-known speaker and author and has published a book on the topic of legal health records. He has been recognized with the 2003 AHIMA Visionary Award, the 2008 FAHIMA Distinguished Member, as well as numerous literary awards. Joanne D. Valerius, PhD, MPH, RHIA, is the director of Health Information Management Graduate Programs at the Oregon Health and Science University in Portland, Oregon. Ms. Valerius's interests center on human resource development in healthcare settings and the impact of the electronic health record. Her focus is on a holistic approach to the workplace and how diversity impacts the workplace. Ms. Valerius is a published writer, as well as a national and international speaker. Currently, she serves on the Functioning and Disability Reference Group (FDRG) committee of the WHO for the International Health Information Management Association. She is an educational professional with 40-plus years of experience in HIM; and 20-plus years as a diversity consultant. Susan White, PhD, RHIA, CHDA, is the administrator of Analytics at the James Cancer Hospital at the Ohio State University Wexner Medical Center and an associate professor of Clinical Health and Rehabilitation Sciences in the Health Information Management and Systems (HIMS) Division at the Ohio State University. Dr. White is responsible for the Cancer Program Analytics Department as well as driving the design and implementation of alternative payment models for cancer. In her academic role, she teaches classes in statistics, data analytics, healthcare finance, and computer applications. She has written numerous articles and presented to national audiences regarding the benchmarking of healthcare facilities and appropriate use of claims data. Dr. White has also published articles covering outcomes assessment and risk adjustment using healthcare financial and clinical data analysis, hospital benchmarking, and claims data mining. She is the author of AHIMA's Healthcare Financial Management for Health Information and Informatics and A Practical Approach to Analyzing Healthcare Data. Dr. White received her PhD in Statistics from the Ohio State University. She is a member of AHIMA, the American Statistical Association, and the Healthcare Financial Management Association. Prior to joining OSU, Dr. White was a vice president for Research and Development for both Cleverley and Associates and CHIPS/Ingenix. She has 20 years of experience in the practice of healthcare financial and revenue cycle consulting. Foreword Congratulations! Health information professionals are moving into the field of informatics at warp speed. There are countless articles and quotes saying that this is one of the fasted growing careers. The US Department of Labor Statistics projects that employment in health informatics and related fields will grow nearly 17 percent from 2014 to 2024, much faster than average for all professions (BLS 2015). Informatics involves people, processes, and technologies to produce and use trusted data for better decision making. The difference in our roles of the past, compared to our jobs of today, is that we now share and communicate information via technology rather than through paper records. This allows us to continue providing health information when and where it is needed but through electronic health records and other technology solutions. The mission of the American Health Information Management Association (AHIMA) is to transform healthcare by leading health information management, informatics, and information governance. We believe that informatics will enable us to improve health through trusted information. Our goal is to gain recognition as the professional association of choice and present a widely accepted definition of informatics recognized by the healthcare industry. Sue Biedermann, MSHP, RHIA, FAHIMA and Diane Dolezel, EdD, RHIA, CHDA, wrote and edited this text to inform health information professionals about the major roles associated with the field of informatics. Along with industry experts, they provide a roadmap to understand the foundations of this emerging field and the different competencies needed to succeed. By reading this book, you will begin the journey of leading the healthcare industry into a world where decision making is better and more informed. Introduction to Healthcare Informatics helps the reader to understand the evolution of informatics and covers key issues from standards to clinical decision support. The editors and authors have provided information about computer science, technology, the provision of care, education, and research aspects of medicine. Information management and informatics has never been more important. Only through trusted information will providers be able to continue driving down costs and improving the quality of care. Become part of the evolution to a better, more informed healthcare environment by reading this book and learning about the emerging field of health informatics. Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA Chief Executive Officer American Health Information Management Association Reference US Department of Labor Bureau of Labor Statistics. 2015 (December 8). Press Release: EMPLOYMENT PROJECTIONS—2014-24. https://www.bls.gov/news.release/pdf/ecopro.pdf Acknowledgments I would like to acknowledge the significant contributions of Dr. Susan Fenton in the planning and writing of the first edition of this text and of Diane Dolezel who joined me in this revision. My thanks and appreciation extends to the chapter authors for sharing their expertise with us for inclusion in the text. Recognition should also be given to the many HIM and other related professionals who are making a difference in healthcare with their influence in the healthcare informatics evolution. Last, but not least, thank you to my husband, Jim, and daughter, Amy, for your continued love and support. — Sue Biedermann I want to acknowledge the contributions of Dr. Susan Fenton in the writing of the first edition of this text. I also want to acknowledge the work of Sue Biedermann who guided my efforts in the writing of the second edition of this text. Professionally, I continue to be inspired by Jackie Moczygemba who supports my efforts and provides an excellent role model for this dynamic field. — Diane Dolezel Both authors wish to thank Ashley Latta and the AHIMA Press staff who supported us during the process of writing this book. We hope our fellow faculty and students find this book to be of benefit. AHIMA Press would like to thank the authors who contributed to previous editions of this textbook: • Christopher G. Chute, MD • Susan H. Fenton, PhD, RHIA, FAHIMA • Desla Mancilla, DHA, RHIA • Jackie Moczygemba, MBA, RHIA, CCS, FAHIMA • Kim Murphy-Abdouch, MPH, RHIA, FACHE AHIMA Press would also like to thank Susan H. Fenton, PhD, RHIA, FAHIMA, and Julie Swavely, MHA, RHIA, for their review and feedback of this publication. Copyright ©2017 by the American Health Information Management Association. All rights reserved.

Material Type: Reading

Documentation for Health Records - 2nd Ed. (2017)

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To access this resource you will need to use your STAT!Ref User ID and Password.  If you need a STAT!Ref User ID and Password speak with your administrator. DOCUMENTATION FOR HEALTH RECORDS - 2nd Ed. (2017) Front Matter Title Page Documentation for Health Records Second Edition Lead Author Cheryl Gregg Fahrenholz, RHIA, CCS-P AHiMA American Health Information Management Association® Copyright Page Copyright ©2017 by the American Health Information Management Association. All rights reserved. Except as permitted under the Copyright Act of 1976, 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 AHIMA, 233 North Michigan Avenue, 21st Floor, Chicago, Illinois, 60601-5809 (http://www.ahima.org/reprint). AHIMA Product No.: AB100716 AHIMA Staff: Chelsea Brotherton, MA, Assistant Editor Megan Grennan, Managing Editor Ashley Latta, Production Development Editor Elizabeth Ranno, Vice President of Product and Planning Pamela Woolf, Director of Publications Cover image: ©PeopleImages, iStock Limit of Liability/Disclaimer of Warranty: This book is sold, as is, without warranty of any kind, either express or implied. While every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information or instructions contained herein. It is further stated that the publisher and author are not responsible for any damage or loss to your data or your equipment that results directly or indirectly from your use of this book. The websites listed in this book were current and valid as of the date of publication. However, webpage addresses and the information on them may change at any time. The user is encouraged to perform his or her own general web searches to locate any site addresses listed here that are no longer valid. CPT® is a registered trademark of the American Medical Association. All other copyrights and trademarks mentioned in this book are the possession of their respective owners. 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 ISBN-13: 978-1-58426-554-2 ISBN-10: 1-58426-554-X eISBN-13: 978-1-58426-557-3 eISBN-10: 1-58426-557-4 Detailed Table of Contents About the Lead Author… xvii About the Chapter Contributors… xix Acknowledgments… xxiii Introduction… 1 Part I - Clinical Documentation and the Healthcare Delivery System… 11 Chapter 1. Healthcare Delivery… 13 Framework and History of the Healthcare Delivery System… 14 Legislative Impact… 15 Modern Healthcare Delivery… 19 Healthcare Providers and Facilities… 19 Healthcare Services… 22 Trends in Healthcare Delivery… 23 Hospital-Based Services… 25 Continuum of Care… 26 Clinical Documentation in Healthcare: Moving Toward the Electronic Health Record… 31 Affordable Care Act (ACA)… 31 Personal Health Records… 32 Electronic Health Information Exchange… 36 References… 41 Chapter 2. Clinical Documentation and the Health Record… 43 Clinical Documentation and the Health Record… 44 Purpose and Value of Documentation… 44 Owners of the Health Record… 45 Users of the Health Record… 46 Definition of the Health Record for Legal Purposes… 50 Legal Health Record… 50 Patient-Identifiable Source Data… 55 Administrative Information… 56 Derived Data… 56 Personal Health Records… 57 Types of PHRs… 57 Documentation Guidelines… 59 The Future of Clinical Documentation… 61 References… 66 Part II - Utilization of the Healthcare Record… 69 Chapter 3. Principal and Ancillary Functions of the Healthcare Record… 71 Principal Functions of the Health Record… 73 Administrative Information and Demographic Data… 73 Admitting and Registration Information… 73 Patient-Care Delivery… 76 Patient-Care Management and Support… 77 Quality Management and Performance Improvement… 77 Utilization Management… 80 Risk Management… 80 Billing and Reimbursement… 80 Ancillary Functions of the Health Record… 81 Accreditation, Licensure, and Certification… 82 Biomedical Research… 83 Medical Staff Appointments and Privileges… 85 Risk Management and Incident Reporting… 89 Health Records as Legal Documents… 90 Morbidity and Mortality Reporting… 92 Management of the Healthcare Delivery System… 101 Form and Content of Health Records… 101 Release and Disclosure of Confidential Health Information… 102 Redisclosure of Confidential Health Information… 106 Retention of Health Records… 106 Destruction of Health Records… 107 References… 111 Chapter 4. Documentation for Statistical Reporting and Public Health… 115 Research and Statistics… 116 Public Health Reporting… 117 Centers for Disease Control and Prevention WONDER Database… 117 National Center for Health Statistics… 119 The National Health Care Survey… 120 Vital Statistics… 121 Facility-Specific Indexes… 122 Master Patient Index… 122 Physician Index… 124 Disease and Operation Indexes… 124 Registries… 124 Healthcare Databases… 126 National Practitioner Data Bank… 126 Data Quality Issues… 127 Primary and Secondary Data Sources… 128 Standardized Clinical Data Sets… 128 References… 133 Chapter 5. Clinical Information, Nonclinical Data, and Health Record Design… 135 Electronic Health Record… 136 Data, Information, and Knowledge… 136 Benefits to the EHR… 137 Improved Patient Care… 137 Improved Care Coordination… 137 Practice Efficiencies and Cost Savings… 138 Increased Healthcare Consumer Participation… 138 Improved Diagnostics and Patient Outcomes… 138 Barriers to the EHR… 138 Interoperability… 139 Budget Impact… 139 Project Team Collaboration and Commitment… 139 Completing the Implementation Timeline According to Schedule… 139 Vendor Support… 139 Lack of Healthcare Consumer Awareness… 140 Cybersecurity… 140 Components of the EHR… 140 Specialty-Based EHRs… 142 Federal Policies Driving EHR Implementation… 143 National Infrastructure for the EHR… 143 Providers and the Infrastructure for EHRs… 144 User Access… 144 Documentation Standards… 145 Clinical Decision Support… 145 Data Dictionary… 145 Designing an EHR… 145 Data and Information in an EHR… 147 Nonclinical Information… 148 Demographic Data… 148 Financial Data… 148 Preliminary Clinical Data… 149 Consents and Acknowledgments… 149 Documenting in the EHR… 149 Devices Used to Document in the EHR… 150 Regulating Health Record Content… 150 Clinical Documents in the EHR… 151 Medical History… 151 Report of Physical Examination… 151 Physician Orders… 151 Outpatient Services Provided in Acute-Care Facilities… 154 Specialty-Care Documentation… 155 Discharge Summaries… 155 Autopsy Report… 157 Uses for Abstracted Electronic Data… 158 The Hybrid Health Record… 158 Health Record Storage Systems… 158 HIM Functions in an EHR Environment… 159 Authentication of EHR Entries… 159 Guidelines to Prevent Fraud and Ensure EHR Documentation Integrity… 159 Medical Identity Theft… 160 Authorship Integrity… 160 Auditing Integrity… 160 Documentation Integrity: Automated Insertion of Clinical Data… 160 Corrections in Electronic and Clinical Documentation… 161 EHRs in Health Information Exchanges… 161 References… 164 Chapter 6. Clinical Documentation Improvement… 167 The Importance of Clinical Documentation… 168 Evidence-Based Documentation: The Theory of High-Quality Clinical Documentation… 169 Seven Criteria for High-Quality Clinical Documentation… 169 Operational Considerations of the CDI Process… 174 The CDI Professional… 175 Queries… 179 Concurrent Query… 180 Retrospective Query… 180 Query Format… 183 CDI and the EHR… 184 Translating Clinical Documentation into Coded Data… 185 How a Coding Professional Views an Inpatient Health Record… 185 The Relationship between Clinical Documentation and Coding… 188 Clinical Documentation Analysis and Assessment… 191 Data Review… 192 References… 202 Chapter 7. Information Governance… 205 Quality and Safety of Patients… 206 The IG Principles and Examples for Each in Healthcare… 207 IG and Patient Care… 208 Clinical Documentation Improvement… 208 Meaningful Use Requirements… 209 Coding and Quality Measures… 209 Learning Health System and Quality Improvement… 210 The Role of HIM in Information Governance… 212 Adaptive Leadership and IG… 213 Examples of IG Challenges… 215 References… 220 Chapter 8. Data Analytics… 223 Tools Used in Data Analytics… 224 Microsoft Excel… 224 Tableau… 225 Qlik View… 225 R Studio… 225 Public Data Web Sources… 225 National Initiatives on Big Data… 225 Concepts of Database Management… 226 Data Analytics and the Electronic Health Record… 229 Tools and Best Practices When Conducting Research in an EHR Environment… 229 Clinical Care, Data Analytics, and the EHR… 230 Quality and Population Health and the EHR… 231 Data Governance… 232 References… 236 Part III - Organization and Management of the Health Record… 239 Chapter 9. Federal and State Requirements and Accreditation Guidelines… 241 Federal and State Requirements… 243 Federal Healthcare Statutes… 244 HIPAA… 244 HITECH Act… 248 Federal Patient Safety Legislation… 248 CMS Regulations… 250 Medicare Conditions of Participation… 250 Medicare Compliance Surveys… 252 Telehealth Regulation… 253 CMS Quality Measures… 253 Patient Satisfaction as a Quality Measure… 254 Quality Improvement Organizations… 256 Healthcare Corporate Compliance… 256 Office of Inspector General and OIG Work Plan… 257 Recovery Audit Contractors… 258 Federal and State Protection of Sensitive Health Information… 259 Substance Abuse Records… 259 Behavioral Health Records… 260 HIV/AIDS Records… 260 Genetic Information… 260 State Requirements… 261 Licensure… 261 Medicaid Eligibility and Administration… 261 Medicaid Compliance Programs… 262 Accreditation Requirements for Acute-Care Hospitals… 262 The Joint Commission… 263 Healthcare Facilities Accreditation Program… 266 DNV GL Healthcare… 267 Center for Improvement in Healthcare Quality… 267 Internal Hospital Policies and Procedures… 268 HIM Policies and Procedures… 268 Medical Staff Bylaws… 268 Medical Records Committee… 269 References… 272 Chapter 10. Ambulatory Care Documentation, Accreditation, Liability, and Standards… 275 Ambulatory Surgical Centers… 276 Community Health Centers… 277 Private Practice Providers… 278 Diagnostic Imaging Centers… 278 Missing Clinical Information in Outpatient Services… 279 Ambulatory EHR versus Hospital EHR… 280 MU Criteria for Eligible Professionals… 283 MU for Eligible Providers by Stages… 283 Credentialing and Licensure… 285 State and Federal Regulations… 286 Governmental Regulations of Ambulatory Care… 286 State Governments… 288 Ambulatory Care Accreditation Standards… 289 Types of Ambulatory Accreditation Organizations… 290 The Joint Commission… 291 Accreditation Association for Health Care… 291 The Accreditation Association for Ambulatory Health Care… 291 Association for American Accreditation of Ambulatory Surgery Facilities… 292 American College of Radiology… 292 Commission on Accreditation of Rehabilitation Facilities… 292 Community Health Accreditation Partner… 292 The College of American Pathologists… 292 Commission on Cancer… 292 National Committee for Quality Assurance… 292 Role of the Patient's Primary Care Physician and the Maintenance of Health Records… 293 Document Management and Imaging System… 294 Type of Document Imaging Scanners… 294 Documenting Imaging Best Practices… 295 Risk Management and Liability… 296 References… 299 Chapter 11. Long-Term Care Hospitals… 303 Long-Term Acute-Care Hospital Settings… 304 Regulations… 305 Federal Regulations… 305 State Regulations… 306 Accreditation Regulations… 306 Components of the LTCH Prospective Payment System… 307 LTCH Health Record Content… 308 History, Physical, and Referral Information… 308 Principal Diagnosis… 308 Admission Data… 309 Physician Orders… 310 Progress Notes… 310 Problem Lists… 310 Consultation Records… 310 Reevaluations and Assessments… 310 Advance Directives… 310 Laboratory Reports… 310 Specialty Reports… 311 Flow Sheets… 311 Graphical Data… 311 Care Plans… 311 Education… 312 Procedure Records… 312 Miscellaneous Data… 312 Medication Administration Records… 313 Discharge Documentation… 313 LTCH Policies and Procedures… 313 LTCH PPS Tables… 313 References… 319 Chapter 12. Facility-Based Long-Term Care… 321 Skilled Nursing Facility… 322 SNF Health Record Content… 324 Resident Assessments… 325 Resident Assessment Protocols… 328 Other Documentation… 331 SNF Accreditation Standards and Regulations… 334 Medical Necessity and Medicare Documentation… 335 Physician Certification… 335 Standards Governing Assessments… 335 Medicare Quality Indicators for SNFs… 336 Risk Management and Liability… 336 Real-World Case Study… 337 References… 339 Chapter 13. Home Care and Hospice Documentation, Liability, and Standards… 341 Home Health… 342 What Is Medicare-Certified Home Health?… 343 Certified Hospice… 344 Background… 344 Home Health… 345 Home Health Payment Policy… 345 Standard Core Assessment Tool—OASIS… 345 Hospice Conditions of Participation… 345 Hospice Core Assessment Tool—HIS… 346 Increasingly Complex Organizations… 346 Government Influences… 346 Office of Inspector General Oversight… 347 Comprehensive Error Rate Testing (CERT)… 348 The Medicare Home Care Benefit… 348 Documentation of Eligibility of the Provider… 349 Home Health under the Care of a Physician… 349 Home Confinement (Homebound Status)… 350 Skilled Services Requirement for Benefit Eligibility… 351 First Visit Criteria… 352 Intermittent or Part-Time Nursing… 352 Home Health Prospective Payment System… 352 The Medicare Hospice Benefit… 356 Provision of Care under the Medicare Hospice Benefit and Documentation… 357 Payment System for Hospice… 357 Home Health and Hospice Record Content… 358 Intake/Referral… 358 Home Care and Hospice Assessment Information… 361 Home Care and OASIS… 362 Hospice and Assessment… 362 Home Health Plans of Care… 364 Hospice Plans of Care… 364 Hospice Clinical and Progress Notes… 366 Home Health Clinical Notes… 366 Dietary and Nutritional Information… 367 Bereavement Documentation… 367 Progress Notes and the Discharge Transfer Record… 367 Medicare Home Care Surveys… 368 Quantitative Record Review Guidelines… 370 Home Health Medical Review… 371 Medicare Hospice Surveys… 374 Home Health QAPI… 374 Medical Review of Hospices… 374 Medicare Hospice Quality Assessment Performance Improvement… 375 Physician's Documentation Review… 375 Home Care and Hospice Legal Issues… 376 Patient's Rights… 376 Patient Self-Determination Act of 1990… 377 Do-Not-Resuscitate Orders… 377 Home Health Quality Initiative… 380 Patient Outcome Measures… 382 Accreditation Quality Requirements… 382 CHAP Performance Improvement Standards… 383 The Joint Commission Performance Improvement Standards… 383 General Requirements of Documentation… 383 Communication and Timeliness of Documentation… 383 Consistent and Complete Documentation… 384 Development of Documentation Policies and Procedures… 384 References… 386 Chapter 14. Exploring Other Healthcare Settings… 391 Regulations Common to All Healthcare Providers… 392 Outpatient Private Practitioners or Solo Practitioners… 393 Outpatient Ambulatory Integrated Clinical Settings… 409 Government Healthcare Settings… 419 Veterans Health Administration… 419 Other Military Healthcare Systems… 420 Correctional Facilities… 420 Indian Health Service… 421 Other Healthcare Settings… 422 Blood Banks… 422 Coordinated School Health Programs… 423 University-Based Student Health Services… 424 Veterinary Practices… 424 Critical Access Hospitals… 426 A Note on Health Plans and Insurers… 428 References… 430 Glossary… 435 Index… 469 About the Lead Author Cheryl Gregg Fahrenholz, RHIA, CCS-P, is the president of Preferred Healthcare Solutions, LLC, and has more than 30 years of experience working with healthcare facilities, physicians, and their staff. Her consulting services include revenue cycle integrity management, ICD-10 impact analysis, multispecialty audits related to documentation and coding, Charge Description Master (CDM) reviews, Clinical Documentation Improvement (CDI) audits, operational and financial assessments, coding sessions for physicians and staff, charge capture and charge process redesign, denial audits, risk and sanction analysis, compliance plan evaluations, electronic health record selection and implementation, forensic auditing and litigation support, expert testimony, along with interim or retainer professional support and customized project work. Before establishing her own consulting firm in 1998, Gregg Fahrenholz served as the director of Documentation, Coding and Reimbursement at the Primary Care Networks of Premier Health Network and as the manager of Information Management at Miami Valley Hospital. Gregg Fahrenholz holds a bachelor of science in health information management (HIM) from Bowling Green State University and is an AHIMA-approved ICD-10 trainer. Gregg Fahrenholz is a nationally recognized speaker on the topics of revenue cycle, documentation, coding, and compliance. She has published extensively at the national level through books and peer-reviewed articles on revenue cycle integrity, documentation, and coding. She has co-chaired AHIMA's Practice Councils for both the Clinical Coding and Terminology and Physician Practice. She served on AHIMA's Nominating Committee and Annual Meeting Planning Committee among other volunteer opportunities at AHIMA. She served for numerous years on the Ohio Health Information Management Association board of directors. She received the Triumph Discovery Award from AHIMA and the Distinguished Member Award from the Ohio Health Information Management Association and the Miami Valley Health Information Management Association. About the Chapter Contributors Dilhari R. DeAlmeida, PhD, RHIA, is an assistant professor in the department of Health Information Management at the University of Pittsburgh. She has a master's degree in health information systems and a doctoral degree focusing on documentation improvement in ICD-10. In addition to her volunteer services for AHIMA, she teaches and advises both undergraduate and graduate students in HIM. Dr. DeAlmeida has published on the topic of data analytics, eResearch, and clinical decision support systems. She serves as a reviewer for Perspectives in Health Information Management. Her research interests include electronic health record research and data analytics in healthcare. She is also an AHIMA-approved ICD-10-CM/PCS trainer. Thomas J. Hunt, PhD, RHIA, CHDA, FAHIMA, is an assistant professor at Rutgers University in the School of Health Professions Department of Health Informatics. He previously served as associate dean and professor of Health Information Management at Davenport University. Before transitioning to higher education, he was successful in leadership roles with Sparrow Health System, ProMedica Health System, and Mercy Health Partners. He is a past president of the Michigan Health Information Management Association (MHIMA) and is also a past president of the Lake Huron Michigan Health Information Management Association. Dr. Hunt earned a doctor of philosophy degree in Global Leadership with a concentration in Organizational Management from Indiana Institute of Technology, a master of business administration from Davenport University, and undergraduate degrees from Cleary University and Mercy College of Ohio. He has been a presenter at the International Federation of Health Information Management Associations (IFHIMA) Congress and General Assembly, AHIMA Convention and Exhibit, AHIMA Assembly on Education, as well as the MHIMA Annual State Conference. Ella L. James, MS, RHIT, CPHQ, is the former director of corporate health information management and health information privacy officer at Hospital for Special Care in New Britain, Connecticut. Currently, James is an independent ICD-10-CM coding consultant and auditor for long-term care hospitals across the nation (LTCHs). James is past president of and twice sat on the board of directors for the Connecticut HIMA and was an AHIMA Community of Practice (CoP) facilitator for long-term care. She chaired the coding committee for the National Association of Long Term Hospitals (NALTH). James has presented programs on HIPAA at the state, regional, and national levels and has presented educational programs for coders and physicians on long-term acute-care coding for NALTH. She has consulted on coding and documentation issues for many long-term acute-care hospitals through NALTH. She is the author of Documentation and Reimbursement for Long-Term Care and contributing author of the AHIMA publication Health Information Management Compliance and Documentation for Health Records. Neisa Jenkins, EdD, RHIA, earned her bachelor of arts degree in Health Information Management at the University of Illinois (Chicago), a master of arts in Health Information Management at the College of St. Scholastica and her Doctorate of Education at Walden University. She has over 25 years of experience in Health Information Management. Her professional background includes HEDIS auditing, consulting, quality improvement, utilization management, release of information, EHR-S implementation, HIPAA implementation, ICD-10-CM/PCS, and teaching in higher education. Dr. Jenkins has taught courses in health information management, health service management, and healthcare administration. She has held positions as program dean, faculty chair, visiting professor, and full professor. Dr. Jenkins's teaching philosophy is borrowed from Martin Luther King Jr.: "Intelligence plus character—that is the goal of true education" (Martin Luther King Jr. "The Purpose of Education." 1947). Suzanne Paone, MBA, DHA, RHIA, is an accomplished healthcare executive in academic medicine including awards by the American Hospital Association and Microsoft. She transverses academics with 12 years of teaching and curriculum development in analytics, HIM, informatics, and strategy. She speaks to and advises education, healthcare, and technology companies. Current research includes Transformational Analytics curricula development. Full-time appointment is at Ashford University in HIM and dual appointments include: University of Pittsburgh HIM, Pitt Graduate School of Public Health MHA, and the MBA program at Carlow University. She is the president of Innovation Advising, a cooperative platform for professional services based in servant leadership. Suzanne holds several not-for-profit board positions and is published in technology adoption, eHealth, and health data analytics. Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA, is the director of the health information management and systems program and an associate professor at The Ohio State University. She earned her bachelor of science and juris doctor degrees from The Ohio State University. Her professional experiences span HIM education, behavioral health, home health, and acute care. She has served as an expert witness, testifying regarding the privacy of health information. She has chaired the AHIMA Professional Ethics Committee and has served on numerous AHIMA committees and the Ohio Health Information Management Association board of directors. She is a coeditor and coauthor of AHIMA's Fundamentals of Law for Health Informatics and Information Management; author of AHIMA's Introduction to Health Information Privacy and Security; and a contributing author to numerous HIM textbooks and periodicals. She received the Ohio Health Information Management Association's Distinguished Member Award and the AHIMA Legacy Award in 2010, and she became an AHIMA fellow in 2011. Susan Rossiter, RHIA, CHPS, has over 30 years' experience in a variety of settings within the health information management field. Since 2003, she has been the Health Information Management operations manager for the University of Texas Southwestern Medical Center, a large academic medical center located in Dallas, Texas. Prior to that, she was the Hospital Compliance officer for Terrell State Hospital and has several years of experience in management of HIM departments for acute care, behavioral health, and ambulatory care organizations. Rossiter graduated with honors from Texas Woman's University, where she received the Outstanding Senior Student in the State award from the Texas Medical Record Association and the Dallas Outstanding Senior Student award from Texas Woman's University. In November 2000, she received a Certificate of Recognition from the Governor's Commission for Women as one of the Outstanding Women in Texas Government. As chair for the Executive Women in Texas Government, Dallas Affiliate, she supports and promotes women in leadership service to the state of Texas. Lisa Selman-Holman JD, BSN, RN, HCS-D, COS-C, HCS-O, HCS-H, is the owner of Selman-Holman & Associates, LLC. A 30-year veteran of home care as an RN and as an attorney, she has participated in the writing of home care regulations and has been involved in accreditation surveys, acquisitions, and many regulatory crises. Responsibilities have included risk management, survey compliance, Medicare appeals, Corrective Action Plans, due diligence audits, consulting with agencies, and education of staff. Selman-Holman obtained her JD from University of Houston and her BSN from the University of Tulsa. She is certified as a home care coder and a hospice coder and is certified in OASIS. She is the chair of the Board of Medical Specialty Coding and Compliance and an editor of the Decision Health coding manual. She has served on regulatory task forces and the Quality Improvement Organization for OBQI. Current projects include online programs through CodePro University and outsource coding through CoDR—Coding Done Right. She is an AHIMA-approved ICD-10-CM trainer. Valerie J. Watzlaf, PhD, MPH, RHIA, FAHIMA, is an associate professor in the Department of Health Information Management (HIM) at the University of Pittsburgh. She has worked as a HIM practitioner and consulted in several healthcare organizations in HIM, long-term care, and epidemiology. Dr. Watzlaf has chaired and served on multiple AHIMA committees and boards such as the Board of Directors of AHIMA and the AHIMA Foundation and chair of the Council for Excellence in Education (CEE). Dr. Watzlaf was elected as president/chair-elect of AHIMA starting in 2018. She has coauthored the textbook Health Informatics Research Methods: Principles and Practice. Dr. Watzlaf is also on the editorial advisory board for the Journal of AHIMA and for Perspectives in HIM. She has delivered over 100 presentations and authored over 50 publications and is the recipient of numerous awards and professional accolades including the AHIMA Triumph Award for Research, PHIMA's Distinguished Member Award, and the University of Pittsburgh's SHRS Distinguished Alumnus Award. Acknowledgments Cheryl Gregg Fahrenholz wishes to thank Ashley Latta, production development editor, for her detailed eye and continued guidance with this publication. Additionally, she thanks the contributing authors for sharing their expertise and time in order to produce a comprehensive publication for HIM readers. A special thanks from Cheryl to her husband, Mark, and mother, Pat, for their never-ending support. With all of the challenges in our busy lives, they make it easier to balance professional and family life in order for this publication journey to be a success. AHIMA Press would like to acknowledge the following contributors for their work on prior editions of this textbook. Kathleen Munn, RHIA Diana Warner, MA, RHIA, CHPS, FAHIMA Margaret White, MS, NHA, RHIA, CPHQ AHIMA Press would also like to thank Ruthann Russo, PhD, MPH, RHIT, for serving as a volume editor in the prior edition of this text. Finally, we would like to thank Kathleen M. Kirk, MS, RHIA, CHC, for her review and feedback on this text. Copyright ©2017 by the American Health Information Management Association. All rights reserved.

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