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Editor's e-Note
The nature of truth was brilliantly explored in Akira Kurosawa’s 1950 masterpiece Rashomon, which portrayed a horrific crime from differing viewpoints. The film came to mind when reading this month’s E-News Exclusive, an interesting foray into how documentation differs when viewed through the lens of physicians and coders. Pretty much everyone in the industry knows these two sets of professionals can have quite different ideas on what belongs in the chart. Nevertheless, it’s important that coders learn why physicians document the way they do.

Lee DeOrio, editor
e-News Exclusive
How I Learned to Code Clinically
By Ben Sayabovorn, RHIT, CCS

The more coders are aware of the rationale and motivation behind how and why clinicians document, the more coders can code clinically.

Through conversations with coders, nurses, midlevel providers, and physicians over the years on clinical documentation improvement (CDI) projects, I began to see key differences between how coders and clinicians view documentation and how understanding those differences eventually improved my ability to code. Coders see the medical record as a document that needs to be translated to codes. Clinicians see the medical record as a tool for communication and a data repository for patient information. This article will illustrate examples of some of the differences between the coding and clinical perspectives.

Treatment vs Monitoring
A patient was found to have a sodium level of 130, and no specific treatment (eg, IV fluids) was ordered. Should a query be sent clarifying whether the patient has hyponatremia even though it wasn’t treated?

Full Story »
AAPC Preview
HEALTHCON2017 Heads to Vegas
By Heather Hogstrom

AAPC’s 25th National Conference, HEALTHCON2017, will be May 7–10 at the Rio All-Suite Hotel in Las Vegas. While the city offers plenty of gambling, shows, and shopping, the conference offers its share of education, networking, and products and services.

With 18 CEUs available and more than 90 educational sessions to choose from, attendees can learn about coding, billing, practice management, compliance, auditing, and more. Mike Leavitt, founder and chairman of Leavitt Partners, and former governor of Utah, will present the keynote. Other noteworthy sessions include “Legal Trends and Issues,” a panel discussion addressing health care facilities’ legal concerns; “Codes — It’s Not Always About Payment,” which suggests that as reimbursement models change, so can the use of codes; and “Hashtag, Pound, and Keeping up with the Code-ashian’s” will cover the rapid evolution of health care and how to successfully stay abreast of new ways to conduct business.

Read more »
In this e-Newsletter
Recently in For The Record
The Evolution of Personalized Cancer Care
HIT tools that promote data gathering and analysis are helping researchers better understand how cancer therapy can become more targeted. Read more »

Transcription Shell Game
In an EHR-dominated world, how to measure the cost of producing quality documents can be obtuse. Read more »

The 21st Century Cures Act
Recently enacted into law, the legislation features components that may reshape HIT … in due time. Read more »

Discovery Mission
Is data science the next big job opportunity for HIM professionals? Read more »
Other News
UC Health Denver Pilots ‘Facebook Feed’
for Patient Communication in Its ED

UC Health in Denver tested the CareLoop system, which allows emergency department staff to provide updates on patients’ care via a live feed, according to MobiHealthNews.

Fitness Tracker Clues Woman in
to Life-Threatening Condition

A Fitbit user noticed her resting heart rate was too high, so she called an ambulance and learned she had blood clots in her lungs, reports CNN.
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ACDIS Preview
ACDIS Celebrates a Decade of Dedication to Clinical Documentation Improvement
By Heather Hogstrom

The Association of Clinical Documentation Improvement Specialists (ACDIS) will be celebrating its 10th anniversary at the MGM Grand in Las Vegas, where it’s holding its annual conference May 9­–12. During down time, attendees can take in some of the local entertainment, including museums such as Madame Tussauds or outdoor attractions such as the Hoover Dam.

The conference offers education focused on clinical documentation improvement (CDI) and enables attendees to earn CEUs. Session tracks include CDI expansion, clinical and coding, management and leadership, outpatient and risk-adjusted CDI, physician engagement, and quality and regulatory.

Read more »
Tweets and Facebook Posts From #NCRAConf2017

Gorgeous venue, great agenda ... not much more you can ask for. #NCRA2017 #RMCDS

Anne Auguste‎
Dr. Shulman keynote speaker at NCRA annual conference in DC: the role registrars play in improving quality cancer care.

Deidre Watson‎
Dr. Eisenhauer nailed it (what a registrar might say when asked what we do). Might just be my new motto: “Whatever it takes.”

Read more »
Industry Insight
Orion Health Begins Migration of Patient Records to Amazon Web Services

Orion Health recently announced the company will migrate its Amadeus precision medicine platform to the Amazon Web Services, Inc (AWS) Cloud. Orion Health’s software currently manages more than 110 million patient records globally.

“We are impressed by Orion Health’s approach to developing cloud-based, big data solutions built on modern, scalable technology,” says Steve Halliwell, AWS director of health care and life sciences. “The AWS Cloud gives health care companies a powerful tool to enable new technologies to ingest, analyze, visualize, and store the data, while still improving security and efficiency. We look forward to collaborating with Orion Health as they use the cloud to improve health care delivery for every patient.”

Read more »
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Tech & Tools
Chatham Introduces Master of Healthcare Informatics Program
Chatham University has announced a new Master of Healthcare Informatics, blending health care and technology through a 10-course, fully online professional program designed for working adults in a health-related field, including IT, or business arenas. The courses build on one another, amplifying students’ mastery of technological and managerial skills. The program culminates in a health informatics immersion, carried out under the guidance of an external mentor in the field of informatics. The program includes small classes taught by an engaged faculty and subject matter experts working in the field of health care informatics. Employees of many organizations are eligible for an automatic 20% discount on tuition. Learn more »

Lifetime Patient-Controlled Record Helps Deliver Connected Care
Providing immediate, total interoperability, MedKaz is a mini drive patients carry with them containing copies of all their records from all their providers and the MedKaz application to manage them. The patients simply give it to any provider when they need care. Their providers can electronically search its contents to access specific records and information and coordinate their care. MedKaz blends seamlessly with whatever charting system providers use, saving them time with each patient. It even works during power outages and without Internet access. Providers update it for their patients—and are paid to do so. With MedKaz, providers can access accurate, complete information without having to build expensive technical gateways and networks; patients, caregivers, and diverse teams of providers can coordinate care; and individuals can manage their health information and correct erroneous records. Learn more »

Definitive Healthcare Adds Urgent Care Clinics to Its Provider Databases
Definitive Healthcare, a provider of data, intelligence, and analytics, has added new data on urgent care clinics and urgent care corporations to its product suite. The update includes information on nearly 10,000 urgent care clinics across the country, along with close to 500 urgent care corporations. Each clinic and corporation has an individual profile, offering key data such as locations, affiliations, and relationships, as well as demographic metrics that reveal insightful details about a facility’s service area and population. This update comes just a few months after Definitive first rolled out its clinics database, which includes information on federally qualified health centers, renal dialysis clinics, and rural health centers. With the addition of urgent care companies, Definitive’s clinics database now features robust data on more than 33,000 clinics. Learn more »
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