Beyond Transcription: Evolving Roles for Healthcare Documentation Specialists

I have never been a medical transcriptionist myself, but I have spent most of the past seventeen years working as a consultant for medical transcription departments in healthcare organizations.  Over the past few years, medical transcription has been in an identity crisis of sorts.  With all of the activity around the HITECH Act, migration to electronic health records, ICD-10, and meaningful use, a lot of people are asking questions about how medical transcription fits into the future health care landscape, and even whether it is still necessary.  But the Association for Healthcare Documentation Integrity (AHDI), formerly known as American Association for Medical Transcription (AAMT), is speaking up about how transcription and other document creation roles enable quality health care.

As my friend and fellow AHDI board member Susan Lucci observes in her blog, “Year after year, healthcare documentation specialists have been asked to do more for less while the commoditization of this profession has been squeezed from every angle.  It is considered a cost center when there has been a failure to recognize the value of this knowledge-based field.  Consider coding.  How can coders code without the documentation that tells the unique patient’s story and is the basis for coding?  How is it we will be able to move successfully into ICD-10-CM/PCS without better and more specific documentation?”

The evolution of medical transcription has been widely discussed by AHDI for the past several years.  At AHDI’s Annual Conference and Expo in early August they launched a new position paper entitled “Statement on the Roles and Value of Healthcare Documentation Specialists and Equitable Compensation Practices.”  In this paper, AHDI:

• Supports widespread adoption of EHRs
• Introduces the umbrella term of “healthcare documentation specialist” which includes medical transcriptionists, speech recognition editors, QA reviewers, etc.
• Supports physician choice of document creation methodology based upon workflow and environmental needs to enable more complete and accurate documentation without sacrificing quality of patient care or personal time
• Recommends the presence of a “human interface” (in the form of a healthcare documentation specialist) to maximize the quality of the data and narrative necessary for optimal performance of EHR technology
• Focuses on patient safety and outcomes—not productivity—as primary goal of all healthcare documentation functions
• Advocates rethinking production-based compensation and developing compensation models that recognize healthcare documentation specialists as knowledge workers that add quality and value to health information technology
• Encourages strategic use of healthcare documentation specialists throughout all healthcare organizations

In my next blog, I will go into how healthcare documentation specialists are trailblazing new roles and responsibilities for themselves as their positions within the industry continue to evolve.

Jill Devrick is a Product Solutions Advisor with 3M Health Information Systems.