Healthcare Documentation: Is Integrity Important?

For the past year, I have served on the National Leadership Board of the Association for Healthcare Documentation Integrity (AHDI). AHDI may not be familiar to you, but it may ring a bell when I tell you that they were formerly the American Association for Medical Transcription (AAMT). AAMT became AHDI about six years ago when the association broadened its mission and vision beyond traditional healthcare documentation roles. Now AHDI’s focus is on the integrity of healthcare documentation, regardless of where it originates or is ultimately stored.

I think AHDI was smart to include the word “integrity” in its new name because it reminds us that the documentation accompanying patient care must adhere to standards of consistency, accuracy, and completeness. Integrity is important in all aspects of healthcare delivery, from the patient/caregiver relationship through coding and reimbursement practices.

Are Docs On Board with Clinical Documentation Improvement?

This February, I participated in the first of four 3M Data Integrity webinars, where a polling question was asked of the audience: Are your physicians actively engaged in documentation improvement?” Here’s how the participants answered:

• 59 percent said that their physicians were actively engaged in documentation improvement
• 36 percent responded that their physicians were NOT actively engaged in documentation improvement
• 5 percent were not sure or did not know

Documentation and Compliance Risk: Top Areas to Watch

As the country moves to automated record-keeping in health care, there are certain areas that need to be scrutinized prior to assigning codes for billing. Compliant coding is of utmost importance, not only for healthcare providers, but also for government auditors. While new technologies are being introduced daily, the government has warned that it will not tolerate providers who try to “game the system.”

The top areas that must be evaluated by providers in determining how to use technology include:

EHRs and the Perils of Copy and Paste

Guest blog by Connie Tohara, Director of Health Information, University of Utah Hospital

The national election is over, and the implications for healthcare are many.  However, rapid change is not just on the horizon—it has been a part of the everyday life of the HIM professional for longer than we care to remember.  Over the years, we have had the introduction of DRGs, MS-DRGs, APR-DRGs, RACs, MACs, MICs, and ICD-10, just to name a few.  The core product that we work with—the medical record—is changing as well.  We find ourselves in a transitional world.  We’re dealing with the additional requirements of hybrid records and scanning. Workflows must change and productivity is always taking a hit from one new problem or another.

The latest problem to raise its ugly head came with a letter to hospitals released on September 24th under the signatures of Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS), and Eric Holder, Jr., Attorney General for the U.S. Department of Justice.  In part, it states:

…there are troubling indications that some providers are using this [EHR] technology to game the system, possibly to obtain payments to which they are not entitled…. These indications include potential “cloning” of medical records in order to inflate what providers get paid…A patient’s care information must be verified individually to ensure accuracy:  it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments.

Using Change Management to Create New Document Creation Roles – Part 2

In my previous post, I went over how your transcription organization can use the change management process to implement new document creation roles. Here are some additional thoughts on getting the ball rolling with this process.

1.  Start small.  Allocate one transcriptionist to work with one provider for consultations, training, or coaching and branch out from there into a pilot group.  Don’t try too much too soon so that new ventures are manageable along with existing responsibilities.  As you or others find success in new roles, it is likely that word will get out and demand for your services will increase.  You should create a list of expectations, goals, and processes for all temporary or recurring roles, and these will evolve over time, maybe even into a full-blown job description (or two or three) someday.

The Windy City is the Next Stop to Innovation at the 2012 AHIMA Convention & Exhibit

Starting tomorrow, Chicago will be abuzz as HIM professionals from around the nation stream into the Windy City for the 2012 AHIMA Convention & Exhibit. Here is a look at some of the speakers, sessions, events, and happenings going on at the Convention (Twitter hashtag: #AHIMACon12).

The watchwords at this year’s Convention are education and innovation, and with a full docket of educational sessions and tracks, there is ample opportunity for attendees to experience both. Download the AHIMA Convention & Exhibit brochure to read more. AHIMA is also paving new ground with the debut of the Health Information Innovation Leadership Conference, to be held concurrently with the AHIMA Convention & Exhibit.

Using Change Management to Create New Document Creation Roles – Part 1

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.

1.  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.

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.

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?”

HIMagine That! A back-and-forth take on the real world of HIM

Coding and documentation veterans Sue Belley and Donna Smith take a break from hospital visits and client consultations to trade tales about coding mishaps, ICD-10 enigmas, the latest regulatory twists, and why it’s nearly impossible to get physicians to document diagnoses in correct coding terminology. A back-and-forth take on the real world of HIM.

Sue:    So Donna, I’ve been doing some investigating….

Donna:   Here we go again.

Sue:    I’ve been thinking about the coder having to identify the type of contrast agent used in cardiac caths and other fluoroscopic procedures for ICD-10-CM coding.

Donna:   (places hands over ears) La la la – I can’t hear you!

Sue:   This is no time to be burying your head in the sand!  I remember all the caths we did when I was a coding manager. The type of contrast used wasn’t in our cardiac cath report, and besides, coders don’t have to worry about contrast in ICD-9.  If coders spend a lot of time looking for a relatively miniscule thing in the whole scope of coding, it’s going to be bad for productivity!

Donna:   So what do you think would fix this, Sue?  It sounds like a documentation issue, but it’s not the sort of question you take to the physician. Contrast is usually documented in the procedure flow note, which coders don’t need to review today. Rather than querying the physician or searching through the note, we need a way to bring the contrast type into the cardiac cath report.