Beyond Transcription: New Roles for Healthcare Documentation Specialists

In my last post, I described how the role of the medical transcriptionist is evolving beyond traditional dictation and transcription to a broader role of “healthcare documentation specialist.”  I have seen firsthand that it is possible for healthcare organizations to scope out and engage in new document creation roles while maintaining the status quo.  The lovely folks at Spectrum Health in Grand Rapids, Michigan, (AHDI’s 2011 “Employer of the Year”) are doing just that.  In addition to bumping up their transcription productivity using back-end speech recognition in the past few years, they are also very involved in the implementation of provider-initiated document creation methods such as template-driven workflows and front-end speech recognition.

Are they experts in every new role that they have attempted?  Maybe, maybe not.  At this stage, I think it’s more important that they are pioneers rather than experts, and that’s what I hope for the entire healthcare documentation industry:  more pioneers.

So how do we become pioneers?  Well, first of all, people don’t become pioneers when they are pushed into doing something.  Pioneers are trailblazers, leading the way into unknown or unclaimed territory.  With all that is going on in health care right now, healthcare documentation specialists have many opportunities to share their expertise in clinical documentation while creating expertise in uncharted roles.

AHDI’s mission is to “set and uphold standards for education and practice in the field of health data capture and documentation that ensure the highest level of accuracy, privacy, and security for the U.S. healthcare system in order to protect public health, increase patient safety, and improve quality of care for healthcare consumers.”  That’s a pretty tall order compared to the broad assumption that medical transcriptionists turn clinical dictation into documentation and that is all.  So healthcare organizations should think more broadly about how healthcare documentation specialists can assist in improving accuracy, privacy, and security of healthcare documentation.

In my conversations with transcription managers, I have learned that many healthcare organizations are being challenged by increasing documentation requirements and the move to the EHR, and many specialty departments could use some input and support from a documentation expert who understands how to build templates or what makes a good dictator.  But I am also hearing that IT analysts and other individuals who do not necessarily have specialized training in healthcare documentation are being tasked with creating templates, training physicians, etc.  As a result, the new technology is often implemented less optimally than it could have been with a medical language expert involved.  Therefore, I encourage healthcare organizations to utilize the expertise in their transcription department and create some new roles to enhance the quality of the overall document creation effort as it moves beyond traditional transcription.

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