As I mentioned in my previous two blogs, a lot is happening in healthcare surrounding creating new roles for healthcare documentation specialists. So how can you start to put these ideas into action? Here are some thoughts on how your transcription organization can use the change management process to implement new document creation roles.
- Put yourself out there: Look for opportunities to share your expertise towards resolving documentation challenges. Ask to be involved in discussions about clinical documentation improvement to ensure you are doing all you can upstream (when creating each document) to avoid corrections and questions downstream (during coding and billing). Offer to observe clinician workflow and provide suggestions. Enlist organizational champions such as tech-savvy physicians or administrators who understand the value of your role and can introduce you to situations where you may be of assistance. Partner with technology vendors to recommend solutions when possible.
2. Map out existing workflows: Visit areas that need assistance to see and discuss workflow, even areas where medical transcription has never been involved before. Work with the staff there to map out and understand workflows such as:
- Creating a dictation for traditional transcription or back-end speech recognition editing
- Provider initiation of documentation through templates, direct typing, or front-end speech recognition
- Handling multiple contributors or drafts of a document
- Signature and addendum processes, especially when multiple providers are involved
- Provider notifications about completed documents and the distribution process
- How data is shared across systems, such as ADT records, order information, and completed documents.
3. Look for areas of improvement: Are there ways that healthcare documentation specialists can assist with some of the challenges discovered during process mapping? You may be able to offer assistance in a variety of ways, including:
- Providing traditional or back-end speech recognition editing of document types not previously handled by transcription
- Assisting with template building and fine-tuning
- Assessing quality of provider-originated documentation in the EHR or other systems
- Coaching or training of clinicians on best practices for dictation, front-end speech recognition, or template completion
- Standardizing terminology, templates, field selections, etc.
- Rethinking print distribution needs in an EHR world
- Recommending methods of data sharing that would lead to improved efficiency and accuracy.
4. Set proper expectations: Most issues can’t be resolved overnight. Spending time and resources on training and technology configuration up front can save a lot of time and headaches downstream. Involvement in new roles will take resources from traditional roles, at least temporarily. The time frame could range from hours to weeks to long term. You may want to dedicate full-time resources for a short-term project, part time resources for a long term project, or some other combination.
In my next blog, I’ll hit on some additional thoughts on how your transcription organization can use the change management process to implement new document creation roles.
Jill Devrick is a Product Solutions Advisor with 3M Health Information Systems.