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June 2021 Connect with us Facebook Twitter Sign up  |  Archive  |  Advertise
Editor's e-Note
Despite the prevalence of EHRs, paper records still exist. Naturally, they must be safeguarded. Plus, documents printed from the EHR must be protected from nefarious characters.

This month’s E-News Exclusive offers tips on how to accomplish this old-school task and best practices for secure storage.

Lee DeOrio, editor
e-News Exclusive
Properly Storing HIPAA Documents
By Raymond Rangel

HIPAA applies to two types of organizations: covered entities and business associates. Covered entities include treatment, operations, and health care payment organizations. Business associates include institutions that process patient data in the course of performing services for covered entities. Organizations within these categories are required to have HIPAA-compliant storage.

The main consideration with HIPAA storage is the Security Rule, which includes administrative, technical, and physical protections that should be used to prevent unauthorized access. Compliance with the Security Rule requires organizations to take the following steps:
  • Verify that the health records they produce, receive, store, or send are all strongly available, with their integrity and privacy maintained.
  • Establish defenses against threats to the documents that are reasonably anticipated such as security issues and fire and water damage.
  • Establish protections to prevent use or disclosure that is forbidden and reasonably foreseen.
  • Ensure employees are following compliance guidelines.
Full story »
Products & Services
Junum Announces MalnutritionCDS Integration With Epic EHR
Junum’s MalnutritionCDS solution is now available on Epic’s App Orchard. Through the App Orchard program, Junum’s solution integrates with the Epic EHR system to help hospitals better identify malnutrition, deliver exceptional patient care, and maximize revenue capture. Malnutrition is a common, complicated, and costly problem for hospitals. When care teams can diagnose malnutrition early, they can intervene sooner to help improve patient outcomes and capture the appropriate reimbursements. Junum provides the tools needed to accurately diagnose malnutrition within a hospital’s existing EHR workflows and improve revenue capture accordingly. Learn more »

Tool Organizes Health Records
Therap’s EHR is now available and affordable for individuals and families to maintain their medical histories in an easily accessible web-based EHR system. Therap’s EHR tracks medical, dental, and other professional appointments and the results of those appointments with robust records of vital signs, intake and elimination, blood glucose, height/weight, immunizations, infection tracking, lab test results, menses, skin/wounds, and seizures. The EHR has health tracking reports that can be used to prepare for and take to appointments. Therap’s Medication Administration feature identifies medications with detailed descriptions of general usage and side effects, when the medications are scheduled, and whether they’re administered on schedule. Therap’s EHR also records diagnoses history and detailed descriptions of allergies, and has a section for Advance Directives and Individual History with summaries and attached documents. Therap’s Life Records for Families and Individuals can be viewed and updated from devices with browsers, allowing staff and family to share documentation and communicate in real time. Learn more »

VaxAtlas App Stores and Shares COVID Vaccination Records
VaxAtlas, a software and vaccine management platform, has launched the VaxAtlas app, available for iOS and Android. The VaxAtlas app provides consumers with a digital and portable solution to securely store vaccination cards, organize vaccination records, receive alerts and booster notifications, then verify and share with any verification pass or organization when needed. For employers, the app offers access to reports and tools to manage employee vaccinations, information on return to work, COVID disease hotspots, and preparedness for future outbreaks. Through the VaxAtlas app, users can scan paper records, easily retrieve digitized vaccination cards, and access a lifetime storage solution. Through a combination of vaccination information, claims data, and national records, VaxAtlas prevents fraudulent records by verifying vaccination records as well as the user. Learn more »

Oneview Healthcare Launches Cloud-Based Care Experience Platform
Oneview Healthcare launches CXP Cloud Enterprise for enhancing the patient care experience within health systems. Deployed on Microsoft Azure with Samsung tablets, this cloud-based platform helps health systems quickly adopt technology for engaging patients, reducing nonclinical demands on care teams, and optimizing clinical and operational effectiveness. CXP Cloud Enterprise gives patients and their families the ability to communicate virtually with health care teams, along with access to education and health information. It provides full functionality on a secure, reliable cloud deployment with patient education, meal ordering, patient service requests, apps and digital services, virtual rounding, visitation, and translation services. Key features of CXP Cloud Enterprise include bedside telehealth consultations from offsite care team members; rounding questionnaires and a digital work list; clinician screencasting to help patients understand their condition, treatment, and goals; automated service requests that help nurses reduce call button distractions; targeted patient educational resources; meal ordering customized for their dietary needs; on-demand entertainment; video chat to connect with friends and family; and simple integration with current systems for a single, secure platform hosting the latest apps. Available as a tiered product offering to meet individual hospital requirements, Oneview CXP Cloud Enterprise is available in the Azure Marketplace. Learn more »
Ask the Expert
Have a coding or documentation question? Get an expert answer by sending an email to

This month’s selection:
Would “no qualifying data available” satisfy the family history element?

Diane C.

Since we now have varying guidelines, this question must have varying answers.

When using the code set 99202–99215, we are now using the new 2021 American Medical Association evaluation and management documentation guidelines, which no longer require that we “score” history elements. Therefore, the answer in this scenario would be yes, it would satisfy based on the new rules.

When treating in patients in alternate places of service that require us to use 1995/1997 documentation guidelines, we are then required to count the history elements, and of course family history becomes much more imperative with the exception of the emergency department place of service.

The Centers for Medicare & Medicaid Services, our gold benchmark standard, indicates that a statement such as you have mentioned could imply that the provider did not query the patient on their family history. Any element within past, family, and social history should be documented to validate that the patient was queried regarding specific concerns within their history that, if pertinently positive or negative, could impact the episode of care.

I guess that is a long way to answer—no, it is not.

Keep in mind that the provider can document unobtainable history, and for lack of family history due to adoption—inclusion of this information will validate the history component.

— Shannon O. DeConda, CPC, CEMC, CEMA, CPMA, CRTT, is an AAPC-approved instructor, partner of DoctorsManagement, and president of NAMAS (National Alliance of Medical Auditing Specialists).
In this e-Newsletter
Recently in For The Record
Medical Records—Everybody Wants ’Em
As medical record requests reach new levels, HIM departments are looking for ways to relieve the pressure. Read more »

The Quest for Clean COVID Claims
With denials management already a thorn in the sides of providers, the virus only exacerbated problems. Read more »

Can HIT Salvage the Nation’s Pandemic Response?
The haphazard construction of vaccination efforts has spotlighted an overall deficiency in the public HIT infrastructure. Read more »

Cancer Registry, Care Coordination Go Hand in Hand
The work of cancer registrars propels interoperability efforts and helps define treatment options. Read more »
Other News
Age, Race May Determine Whether Cancer Patients Access Their EHRs
A JAMA Oncology study found that patients in their 80s were less likely to enroll in a patient portal to access their EHRs than 18- to 29-year-olds, and Black patients were less likely to enroll than white patients, according to Cancer Therapy Advisor.

Machine Learning Is Booming in Medicine. It’s Also Facing a Credibility Crisis
Artificial intelligence is growing in popularity, but its accuracy is in question, reports STAT.
Industry Insight
Iodine Software Acquires Physician Engagement Platform Artifact Health

Iodine Software, a health care AI company, has acquired physician engagement platform company Artifact Health. The acquisition brings together two industry leaders and expands Iodine’s clinical predictions and insights platform beyond clinical documentation improvement teams to directly engage physicians through Artifact’s HIPAA-compliant mobile platform.

Iodine experienced rapid growth over the last decade by applying its CognitiveML Engine to solve mid–revenue cycle leakage—a problem that costs health care systems billions in lost revenue due to resource-intensive, highly manual clinical documentation workflows. More than 500 hospitals and health systems using Iodine report significant improvements to quality scores and increase earned-revenue capture. This acquisition announcement signals Iodine’s commitment to expand its machine learning technology to broader health care workflows.

Read more »
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