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What did I do today?


What did I do today?   Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...

A United Approach


A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...

HHS Proposes Significant Changes to Patient Access Rules


In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...

What is a Legal Hold and e Discovery Anyway


Whether I am assisting clients or presenting, I am often asked about legal holds and e-discovery. The transition from paper to electronic records, which include emails, computer faxes, protected health information ("PHI"), personally identifiable information ("PII") and documents that are created, received, maintained or transmitted in an electronic format created...

FHIR Revisited


Like a moth to a flame, we periodically have to take a close look at FHIR. As mentioned in the March 26 blog post, interoperability was the hot topic at HIMSS, and FHIR is at the blazing edge of interoperability...

Health Information Exchange and Trusted Exchange Frameworks


Despite progress in health IT, Health Information Exchange (HIE) remains squarely in toll booth mode, with gated stops and slowdowns that may or may not permit information to move forward. ...

Mobile Health: Growing Engagement and New Responsibilities


This week I'm blogging about an M-word. Not MACRA or MIPS, but Mobile Health or mHealth....

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