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Editor's e-Note
Physician advisors can offer valuable assistance to clinical documentation improvement (CDI) programs, from answering queries to championing the program, while improving data accuracy and patient care.

In this month’s E-News Exclusive, Jon Elion, MD, FACC, points out that he’s often asked questions by conference attendees who don’t have physician advisors available to them at their organizations. Consider the qualities that make a good liaison and the benefits of having a bridge between the CDI team and the medical staff.

Lee DeOrio, editor
e-News Exclusive
A Physician to Lean On
By Jon Elion, MD, FACC

The clinical documentation specialist looked a little tentative stepping up to the microphone to ask her question. I had just finished a talk where I shared stories about clinical documentation improvement (CDI) from the point of view of a practicing physician. As her question unfolded, the reason for her hesitancy became clear.

“The medical director of our surgical ICU says we should document and code for malnutrition for our open-heart surgery patients, since we give them intravenous albumin postoperatively. He said that treatments are used to treat something. Since albumin treats malnutrition, he says we need to document and code for that. We are not comfortable with this—what should we do?”

Full Story »
AHDI Preview
AHDI Offers Medical Record Motivation
in Milwaukee

By Heather Hogstrom

Health care documentation specialists, HIM and HIT professionals, medical scribes and transcriptionists, and more can benefit from the Association for Healthcare Documentation Integrity’s (AHDI) Annual Conference, taking place in Milwaukee August 4-6. Along with information and inspiration that will enhance attendees’ knowledge and job performance, the conference provides the opportunity to earn continuing education credits, learn more about current tools and technology such as EHRs and speech recognition, and network with vendors and fellow professionals.

Full Story »
Lessons on Reinvention
From HFMA ANI in Las Vegas

By Dan Ward

With HIMSS having been in Las Vegas only four months prior, many HFMA attendees could be forgiven for believing it was déjà vu all over again. But far from being a mere reboot, HFMA’s ANI represented a timeless Las Vegas theme: reinvention.

Recent rebranding and renaming initiatives, for example, solidified new identities through their presence at the conference. Beyond this straightforward form of reinvention at ANI, there was a clear trend that speaks directly to a shifting health care landscape, namely: vendors moving firmly beyond traditional core competencies and into aspects of health care financial management previously only orbiting their foundational identity.

This specific form of reinvention was evident throughout the conference—within the booths, in the sessions, and throughout the halls and hotel lobbies.

Naturally the question is, why now? Why are so many organizations traditionally associated with a specific and sometimes narrow aspect of our industry investing significant time and resources in this type of reinvention?

Full Story »
In this e-Newsletter
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Dive Into Data, Save Lives
Analysis of EHR documentation can provide insights to help improve patient outcomes. Read more »

Coding and the Third-Party Option
More health care organizations are hopping on the outsourcing bandwagon. Read more »

Unfinished Business
Nearly one-half of the hospitals surveyed by The Joint Commission fail to demonstrate complete and accurate medical records. Read more »

Informatics Poised for Job Growth
The future is bright for anyone interested in joining the ranks of this expanding field. Read more »
Other News
Medical Economics Asks
Why EHR Use Is Falling

Physician office EHR use has decreased by nearly 4% over the last year, due in part to reduced productivity, reports Medical Economics.

Hospitals Partner to Create
‘Virtual Safety Net’ for Patients

Six hospitals in the California East Bay area are using a secure data sharing platform to share patient health records in real-time, according to H&HN.
Featured Jobs
The nation's top employers and recruiters of HIM talent advertise in For The Record magazine and post their job openings on Check out the most recent opportunities that have been submitted by employers across the country!

Inpatient Coder
University of Florida Health
Tech & Tools
Edifecs Automates the Complete Episode Administration Lifecycle
for Hospitals

The Edifecs Episode Administration for Providers, a solution for managing the complete episode payment lifecycle, combines episode analytics with management and workflow tools for episode bundling and administration to maximize revenue for integrated delivery networks, hospitals, hospital systems, physicians, and postacute care providers under bundled payment programs. Clinically integrated networks and hospital systems can use the solution to model, administer, and optimize bundled payments to reward providers for delivering better medical outcomes for their patients at a lower cost. Learn more »

Consulting Firm Jumps Into Health Care
JDR Consulting is launching a new channel, JDR Healthcare Solutions. The firm will be providing its core services, as well as its new flagship service specific to the health care side, Physicians Practice Assessment. Physicians Practice Assessment will evaluate a physician’s practice to understand whether its revenue is performing as expected. An assessment is conducted of the entire physician practice—which includes all aspects of the business—from the way a receptionist greets the patient through the billing/collection process. Learn more »
Ask the Expert
Have a coding or transcription question? Get an expert answer by sending an e-mail to

Re ICD-10-CM code for Diabetes Type 1B: We are getting conflicting information on whether to code this as Type 1 diabetes mellitus since there is not always a need for insulin. Is other specified diabetes mellitus more appropriate? What do you recommend?

Nancy Deemer, CCS
Fort Myers, Florida

Type 1B is a very specific diabetes mellitus. Type 1B diabetes mellitus is where the patient may experience a “high blood sugar emergency” and their need for insulin may wax and wane over a period of time. So their use of insulin may not be long term; however, it is recommended that you do use the Type 1 diabetes mellitus code.

— Cynthia Keith, Clinical Content Manager, Alpha II

DM is diabetes mellitus or juvenile onset. Diabetes type 1 is insulin dependent, and type 2 is more appropriate for medication, diet-controlled and sometimes use of insulin.

— Belinda Gilchrist, Senior Clinical RN, Alpha II
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Industry Insight
Study Finds EHRs Taking a Toll
on Physicians

The growth and evolution of the electronic environment in health care is taking a toll on US physicians. That’s according to a national study of physicians led by Mayo Clinic, which shows the use of EHRs and computerized physician order entry (CPOE) leads to lower physician satisfaction and higher rates of professional burnout. The findings appear in Mayo Clinic Proceedings.

“Electronic health records hold great promise for enhancing coordination of care and improving quality of care,” says Tait Shanafelt, MD, a Mayo Clinic physician and lead author of the study. “In their current form and implementation, however, they have had a number of unintended negative consequences including reducing efficiency, increasing clerical burden, and increasing the risk of burnout for physicians.”

Read more »
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Coming up in our August issue is our Education Resource Guide. Contact sales for more information. is the premier online resource to recruit HIM professionals. Post your open positions, view résumés and showcase your facility's offerings all at!