I hope that the new coders that are just coming into the career field do not have to go through what I went through to learn coding and to transition to DRG’s. I know now that I was hired because of all my pre-nursing education and my on the job training in respiratory therapy. I can still remember when they offered me the job as a coder. I was so excited to be offered a job in the medical field that was full time days. The administrator told me upon hiring me that they did not have a medical records director in place. After working for about two weeks, they sent me to a workshop in another city to learn everything I needed to know about coding and DRG’s. I really relied upon my medical background to grasp everything that I needed to know. I kept all kinds of medical books, surgical books, dictionaries open in front of me as I coded the diagnosis and the procedures. If there was something I didn’t understand I would try to ask a question of the physician on the case. The physicians came to the medical records department on a regular basis to complete their records. It was acceptable for coders and physicians to discuss cases in the dictating room. I can still remember the other people in the department and how they related to me as a new person and in my new role. They were like, Oh she is the one that works with and talks to the doctors, ooooh. Most of my coworkers acted like they were all scared to even say hello to the physicians when they came into the department. I became very comfortable with working with physicians early on in my career. Before I knew it I was asked to join them in their committee meetings and take notes

Finally the day came when I was introduced to my new boss. She was young and pretty and single.
She was fresh out of college. After working with my new boss after about three months and DRG’s was coming closer to being fully implemented in our state, I can remember asking her a question about a particular case that I was working on. I was having a challenging time trying to really grasp the concepts of all the DRG’s and how to map them. I approached my director with a question. She tried to explain it the best she could. I still did not get how she arrived at her choice. I sat the record to the side and thought I would try again tomorrow. I approached her again the next day and she explained to me again what the DRG should be. I asked her why that particular DRG and she got very upset with me.. I got upset when she changed her tone of voice and she ended up saying to me, do I need to draw you a picture? I was so hurt by that comment. I shouted back to her, “I guess you do and left her office”. I finally assigned the DRG that she suggested and submitted the claim but I realized that I had a lot of work to do to really understand the concepts behind how to select the best code and the best DRG’s.

In reflection, I think about how hard it was to learn and apply new concepts and I think about how hard it is going to be for some of these hospitals when they need to train their staff on coding for ICD-10 and really start implementing the system. I think about the coders themselves and the countless hours of sleep they are going to lose when they try to implement this new mandate. Are hospitals going to hire a pretty little thing, right out of college and think that she can do the job of implementation by herself? Are administrators and Health Information Managers (HIM) going to send people to a one day workshop and think they can learn it all there? What about productivity rates? Are hospitals going to only hire people with years of experience? There is definitely going to be a learning curve? Who is going to pay the price?

RECs are funded by the Economic Stimulus Bill of 2009, or more specifically, the HITECH Act. This program has received funds of $677 million so far. Their mission is to help 100,000 providers become “meaningful users” of electronic health records in 24 months. Each individual REC is required to help at least 1,000 providers achieve “meaningful use” status. Will RECs deliver on their mission?

Software Advice is hosting a poll with this same question. They want to know if you think RECs will reach their objectives. To participate, visit the poll here.

Their poll also ties in with a blog post titled, “5 Reasons RECs are RECkless.” One of their main concerns with RECs is the short timeline. RECs funded in February of this year have just 17 months to reach their goal; the others funded in April have 19 more months. So, if their goal is to help 1,000 providers in this short time frame, they will need to work with 50 to 60 providers a month. Do they really have enough time and reosurces to support this demand? Where are they going to find enough staff?

To participate in their poll and read more from their article, visit: http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/

If you are not keeping up with and tracking your own health information then you are in the dark. I am advocating that we all take action now and start to compile, track and store our own health information. Our health information is scattered and the average American has over 5.5 medical records. We need to take care of our health care information. We need to know what is inside our medical records. We have the right to make an amendment. We have the right for a copy of it. We have rights. Let’s use them. To learn more follow my blog.

Most auditors are trained professional and they have written criteria or standards to go by. Most generally, auditors can not walk into your facility and ask to review something without your knowledge of what it is that they want to look at. You must know or someone at your facility must know what the standard is in which they are reviewing you on. There needs to be a policy in place on how your company works with auditors and the auditing process. It is up to each facility or practice to make sure that they keep up with the criteria or the standards that govern their business. The standards are usually made available by the company that is reviewing your site or they are available on government websites.

The reason that I have chosen to write this article is that I am an independent Health Information Management (HIM) consultant and I am seeing a rise in the number of nursing personnel that are entering into this type of work. There are many types of nurse auditors out in the field today. Nurse auditing is on the rise. The Nurse auditor that I am most familiar with and that I would like to share with you about is an individual who reviews clinical information for a company, usually an insurance company. They review and interpret clinical information and make sure that it matches criteria provided by the company they work for. They spend many hours inside of an office with their noses peered inside the medical record. Sometime they bring along a laptop and enter data into it for their company. They are usually meticulous to detail. They are usually independent contractors meaning that they work on a contract or project basis. They are usually self-employed and self managed. They usually do not have any health benefits but their pay is usually higher than what a regular facility will pay you for your time. As an auditor, you have a flexible schedule whereby you can choose the days and times you want to work. This person usually is requested to travel, it can be local and sometime more extensive than that. For the most part, the auditor must have a reliable car, car insurance along with a cell phone. Most auditors will have their own computer; sometimes the company will supply them. Each contract is different.

Have you thought about this as a career field for yourself? Do you know of someone that would like to work in the filed? Does this sound exciting? Are you self motivated? Do you like to work independently? Do you have solid computer skills? Read on for some additional information before you make a decision.

Here is some reason why this type of work may not be for you. If you need a steady income this type of work might not work for you. Most companies work on a project basis and they do not guarantee hours or an income. If you are not able to follow-instructions verbally and need to have someone show you with a hand on approach, this might not be the type of work that you are suitable for.

I am not advertizing for any job or position, this article is meant for educational purposes only. The field is truly exciting. I have worked along side many LPN and RN’s. If you are a new nurse entering the field or a seasoned nurse needing a break, I hope that you will consider the possibilities or nurse auditing.<a href="http://positiveresourceconsulting.com

The second category of engaging patients and families is long overdue. I think if I have read correctly that the committee is wanting to:

• Provide patients with an electronic copy of or electronic access to clinical information per patient preference
• Provide access to patient specific educational resources
• Provide clinical summaries for patients for each encounter

I think that education is the key here. The American Health Information Management Association (AHIMA) has taken an active role in trying to educate consumers and empower them to take more responsibility for their health care information. More needs to be done in this area. Here again I go back to my own personal experience. I have to track my health information so that I can ensure that I receive good quality care. I believe everyone should have access to their personal health information at all times. I really feel that each physician should give the patient a summary of his/her condition after each encounter. This doesn’t have to be in paper format. It could be sent to a flash drive and every patient would have one with their personal health information on it. Of course training would need to be done on how to use a flash drive. (Believe me there are a lot of people who do not even know about them or how they work) The flash drives today are becoming more sophisticated and technically secure. A person can purchase one with password protections, or biometrics. I feel very secure using a flash drive to carry my information to and from my doctor’s appointments. As a consultant, I am also very involved with training the health care providers about the importance of sharing information with their patients. I am also involved with training different health support groups on how to approach their providers when they need information. Training is the key here.

I hope this gave some insight to my thoughts on the term meaningful use. When you look at the term meaningful use one really has to ask themselves who is the end user. Who is the consumer of this information? To me the answer is -we all are.

To find out more on how I am involved please go to my website. www.healthcaretracker.org

At each new doctor’s visit, I can remember my mother telling each physician that I saw all about my medical history. Sharing my medical history over and over again with each new physician and also sharing my current concerns with my physicians is still something that I do today. In fact, we probably all have shared our health care information with a health care provider or two or three at some point. You can probably relate with me because I am sure you know the drill when you go to a new physician and you sit in the waiting room and complete that health care questionnaire. We all know that it is a must needed step but what a time consuming process.

Sharing complete accurate health care information with our health care provider is a very important first step. In fact it is the first step in the health care process. It is very time consuming and a hassle to recall all our health care services and medications while we are waiting in a waiting room but it is one that is essential for quality care.

As I grew older, I realized that I wanted to do something in the medical field but I really did know what exactly. I went down the career path to be a registered nurse but soon found that it was not the right path for me. I later heard about a career whereby I would be responsible for all of the medical records and making sure that what each health care provider did each day along with their staff would be documented and available for years to come. Yes, that is right I became what use to be known as a medical records librarian, today we are called Health Information Management Specialist.

On a personal note, I have been trying to keep track of my own health care information along with my family’s information for years. I am also a mother of two grown children. I also enjoy writing as a past time but that experience in itself really hasn’t prepared me for tracking health care information. For example, in order for me to track my own health care information I have since found out that the hospital where I was born is no longer in existence. Most records were destroyed in a fire. Most of my physicians from my childhood are no longer around. Even as an adult some of my physicians that I have built a good report with are no longer on my insurance plan. This fact in itself has forced me to choose different physicians for my health care. Let’s face it, health care information is a challenge to capture and store.

I decided since I have both the professional and the personal experience of tracking health care information that I would develop a company called Positive Resource Health Care Industry Consultants. (Positive Resource for short) In 2007, I decided to develop a product that is easy to use by both the health care provider and the health care patient/consumer. I decided to call the product the Health Care Tracker. The health care tracker comes with forms and these forms are easy to use and the health care tracker allows you a portable way to use information when you need it most. The health care tracker was developed in 2007 and has been used by thousands and by assisting others with tracking their health care information.

I don’t want to stop there; I want to find out what products really work to track or monitor health care information and make them available to health care organizations and to the public. Health Care organization’s need guidance on selecting and implementing the EHR from an expert, someone who understands records, I want to help with the training and the transition. We all need a good thermometer, blood pressure device in our house but which of these is the right tool for tracking your health care information when you are sick? Do you know? Today, we have the ability to track many different aspects about our healthcare.

I am taking my disability and using it to the best of my ability and helping others. The term for meaningful use has a whole new point. I think everyone should track their health care informmation and have a personal health record. Thank you for allowing me to share with you!