Last week I attended the Association for Healthcare Documentation Integrity (AHDI) conference in Las Vegas, Nevada. This time around I was honored to serve as president, which meant I had the privilege of introducing keynote speaker Ronald Wyatt, MD, the Medical Director within the Division of Healthcare Improvement at The Joint Commission. He kicked off the conference by encouraging the medical transcriptionists and other healthcare documentation specialists to continue supporting clinicians in capturing and editing documentation so that quality is improved and errors are eliminated. He advocated for patient care documentation that is highly accurate, complete and reliable, and asked attendees to do all that they could to build an environment in which a zero error rate (and zero patient harm) is the expectation.
Dr. Wyatt’s keynote was a fitting kickoff to a three-day conference full of education and networking opportunities. On the subject of compliance, Susan Lucci, RHIA, CHPS, CHDS, AHDI-F, presented a session on what transcription service providers and independent contractors need to know about HIPAA. This coincided with the release of AHDI’s new “HIPAA Compliance Guide,” a concise eBook authored by Lucci that outlines everything a transcription organization needs to consider to be in compliance with HIPAA. Another highlight was the QA Summit, in which members of a recent task force on QA of clinician-created documentation presented the best practices that they have developed over the past year.
Throughout the event I was encouraged by the stories and experiences I heard. Many healthcare documentation specialists are being asked or are taking the initiative to create expanded support roles in documentation capture. So now, in addition to medical transcription, speech recognition editing, and QA review, the opportunities include EHR documentation trainer, EHR technician, HIM analyst, and healthcare documentation integrity auditor. Many HDS pioneers shared their stories and encouraged others to diversify and help healthcare providers in whatever way possible to improve documentation quality and promote patient safety.
Although the past several years have been challenging because of the many regulatory and technological changes affecting documentation workflows, the next several years are ripe with opportunity for HDS to collaborate with HIM, HIT, CDI, and clinicians to create optimal processes that help clinicians capture documentation in efficient, yet complete and accurate ways. For healthcare documentation specialists, how we do our jobs is secondary to why we do our jobs – regardless of location or methodology, our mission is to support healthcare practitioners and protect patient safety through precise capture of each patient’s health story.
Jill Devrick, Product Solutions Advisor with 3M Health Information Systems, is current president of the Association for Healthcare Documentation Integrity (AHDI).