As I write this, our CEO Peter Preziosi, our board member and treasurer, Sherry Doggett and MTIA board member, George Catuogno are presenting at the annual HCCA conference in New Orleans, LA. With nearly 1000 in attendance, this is a huge conference with 8 or more educational tracks each day in the area of Healthcare Compliance. Next week, many of us will meet in Long Beach, CA for the annual MTIA conference. This 3-day event marks the second where MTIA and AHDI have been partners working together on initiatives that make our two organizations stronger because of our singular focus on healthcare documentation making it the best it can be.
In Mid-May, nearly every state in the US is expected to be represented in Washington, DC as we visit with senators and legislators to remind them (yes we’ve been there before) what we do and how our knowledge makes a difference in the quality content of healthcare documentation.
These are the things that your fellow members and leaders are working on. We are opening new doors to those people in healthcare who are dedicated to topics like compliance, reduced risk, patient safety and better patient outcomes. These are the things that matter most in healthcare delivery and as MTs, we are on the frontlines of ensuring patient safety every single day with every report we transcribe.
Recently, I had an opportunity to visit and view an electronic health record system that is fully operational. It was amazing and in the HIM Department I visited, there were NO paper charts. Not a single one, and believe me, I was scouring the department in search of paper. Finally, I found some paper and ran over to see what it was. Somewhat disappointed, I must tell you it was an email printed out – nothing to do with patient care. Then I thought to myself, “Wow, they’ve really done it – a completely paperless HIM department.” And the reality of that change hit me like a freight train.
So as I visited further, as I learned about what this meant to the hospital in terms of improvements, I also learned that there were things that weren’t all positive. Workflow issues are magnified. While there is an electronic system, the master patient index (MPI) issues of duplicate patient records still exist and are even more difficult to identify. There are issues of physicians entering their own progress notes and reports – many of which have been identified with quality issues or reports that lack complete required content, according to medical staff bylaws. Coders are finding many of the CPOE errors and are bringing them forward for clarification and correction.
Where gains have been made in reducing dictation, most of these gains have been made at the clinic level, and there are still challenges of content there. There is inconsistency in documentation practices from clinic to clinic and although guidelines have been established, it is not easily enforced.
The takeaways are many. The EHR is becoming more prevalent and this will continue. The EHR doesn’t eliminate the need for dictation, and in fact at this hospital, the same number of MT employees are there that were there before the installation. What is no longer in place is outsourcing as most of what the outsource company did was the clinic work, which is mostly completed by the physicians now. In fact, there is a potential need to grow the inhouse MT staff at this hospital and to implement a QA process. It might be a good idea to extend the random QA review to include all records to help ensure that the quality of all documentation meets the QA standard established. This may open a few more doors and opportunities if someone were to ask me !?!?!
All of this said to point out that AHDI is working on many fronts to bring into clear focus what your professional association is doing to bring recognition to the value proposition that experienced MTs bring to healthcare documentation. Also to let you know that figuratively speaking, I have actually been to the EHR Mountain for a first glance and I have seen its potential! I have learned a bit about the value it brings and better, how MTs absolutely fit into the future picture. I will return to the “mountain” soon and gather even more information and share more insights here on my blog. So stay tuned.
So for now, please remember that the expertise you have as a trained, experienced and with more credentialed MTs entering the workforce, we have a huge potential to bring better patient outcomes because of our knowledge. It is the quality grounding we have that will help us to remain important and required team players in the future! Being involved with your professional association is the way to stay informed, keep your saw sharpened and evolve with the technology that we employ! Let me know what you think? Would love to get your perspectives!