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The Final Frontier

Note: Today’s post is a guest post! Ava Marie George, CMT, AHDI-F, AHDI Director, works as a professor at Davenport University in Lansing, Michigan, and as an Independent Contractor for Covenant Healthcare in Saginaw, Michigan. She lives in Haslett, Michigan with her husband, three children, and two dogs. (P.S. – What she did not include here is that she is a brand new CMT, and she was also recently elected as AHDI’s President Elect, an office she will assume in August!) Thanks, Ava, for doing this and for giving us lots to think about.

Be vocal, be involved, and be heard!

When it comes to the role that we play in clinical documentation, where you were is where you are and where you’ll always be.  Now, if you’re a positive person, this is an affirming statement. It confirms our role in providing accurate and complete documentation that is meaningful to our patients first and to our profession second.  America is currently engaged in passionate conversation with respect to healthcare reform.  The critical and pivot point is in the discussion of “meaningful use” of EHRs with the technology companies vying for the moniker of “America’s EHR provider.”  There has never been a time in our history when we, the documentation specialists and transcription industry, need to work together to keep the conversation directed towards the importance of the patient’s healthcare story within and despite technology.

Preservation of the narrative must be included in the meaningful use rule especially with respect to the EHR.  Consider this…more than 1.2 billion clinical records are produced in the United States each year and of those, 60% are documented using traditional dictation to transcription method.  The technology available today including check off, point and click, pull down, and other stripped forms of templated documentation do not adequately capture the critical patient information that is needed to treat, communicate, code, or bill. There is no other form of data capture that expresses the complex patient story better than narrative dictation.

So, how do we participate?  We join and actively participate in our association.  We align ourselves with other associations who are just as vested in the healthcare story.  We build those bridges and partnerships between associations and begin to speak for ourselves with larger, louder voices.  We step out of our comfort zones, from behind our keyboards, take off our headsets, and involve ourselves directly in the conversation wherever we can.  We no longer ask to be invited to the table.  We need to impress upon those in Washington the fact that physician-driven data entry is costing health care time and money.  Ask the question:  Why is the government promoting using our highest paid physicians, who do not have the expertise in documentation and data capture, to input clinical data?  Our physicians, nurses, and other specialists are better deployed in frontline care rather than burdened with capturing the patient story within an EHR.

Healthcare documentation specialists are critical to effective capture of health information because we understand the diagnostic process and the complex story-telling of patient care.  We provide risk management support and oversight to ensure health encounters are captured accurately and are able to identify error/inconsistency in the record as well as support pay-for-performance goals through documentation improvement measures.  We know how to apply data capture standards that ensure health information is available at point of care for clinical decision-making.  We integrate documentation seamlessly with data capture technologies, such as EHRs and speech recognition technology (SRT) solutions because we have used these technologies for years and are the experts in the field.  We partner with physicians to document care encounters in a way that frees up providers for hands-on patient care.

The technology of the future is beginning to arrive on the scene.  We are not at the level depicted in science fiction, but we can use the documentation technology tools we have now in the most effective and professional manner.  It is up to us to protect the patient through our expert clinical documentation, collection, and oversight of the clinical record.  Happy Medical Transcription Week 2010!

MT Puzzler: Today’s prizes will be a Stedman’s Orthopedic Word Book and one registration for the HIPAA for the IC course at HIPAA4MT. Remember, to be eligible to win, you must make a comment here on the post, and post it to your Facebook, Twitter, or other place online and invite other MTs to join us. Good luck and happy hunting!

What disorder in its advanced stage gives the cranium a “hair-on-end” appearance on radiography?

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Filed under: Medical Transcriptionist Week • Professional Development

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