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November 2013

Speak Clearly and Carry a Big Credential
By Jennifer Della’Zanna, MFA, CMT, CPC, CGSC, CEHRS
For The Record
Vol. 25 No. 15 P. 6

While celebrating its 35th anniversary during its recent annual conference, the Association for Healthcare Documentation Integrity (AHDI) announced a rebranding of the profession formerly known as medical transcription, as leadership determined “health care documentation specialist” better describes members’ skill set.

The conference spotlighted the great variety of information needed in today’s health care environment and demonstrated how the new credentials of registered healthcare documentation specialist (RHDS) and certified health care documentation specialist (CHDS) would be a perfect fit.

On the whole, the AHDI’s announcement garnered mixed reviews. Allied health care is rife with credentials, so why is the association muddying the waters with yet another set when there’s nothing wrong with the old ones?

The rebranding, complete with new credentials, is a bold move for the embattled AHDI. Although it remains the largest credentialing body for medical transcriptionists, membership has dwindled. Nevertheless, the association, which boasts a long and distinguished history, carries major industry weight. It was in 1978 that a disparate group of “medical secretaries” became a legion of mostly home-based women who used emerging technology to increase the production, quality, and value of clinical documentation. Now, these same professionals are being told that technology advances have made the profession obsolete.

The AHDI begs to differ, as do many of its members. Linda Allard, CHPS, president of New England Medical Transcription, who presented a seminar at the conference’s Educators Summit, “Teaching Your Students to Succeed Beyond the Classroom,” declared, “The industry is not dying; the name is dying.”

The current designations of registered medical transcriptionist (RMT) and certified medical transcriptionist (CMT) denote the two levels of competencies involved in transcription expertise. They indicate training and experience in a skill set that transforms an audio recording to the medicolegal document that stands as an official record of a patient’s health care experience. With the advent of EHRs and front-end speech recognition technology—which MTs have used for years on the back end to increase production times—traditional transcription is indeed much less prevalent. However, that doesn’t mean MTs need to become obsolete.

EHRs and Speech Recognition
It’s no secret that one of the selling points of EHRs is the claim that physicians will no longer need MTs. While there’s no denying that many MT positions are shed when an organization implements an EHR, the AHDI has taken steps to combat this tendency. Over the past few years, the association has offered workshops, lectures, webinars, and papers on how MTs can update and expand their skills. Along with speech recognition editing, MTs are learning about clinical documentation improvement, coding, auditing, and EHR/HIM analysis.

In July, the AHDI and AHIMA collaborated on “New Skills for a New Era,” a survey that found EHRs will not replace MTs but rather are the “key to transcriptionists’ new career paths.” In the report, AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, supported the AHDI’s position: “The skills of a transcriptionist—to listen and be detailed- and research-oriented, with a familiarity of medical terminology and disease process—are still in critical need in HIM departments during this time of healthcare transformation.”

Susan Whatley, CPC, CMT, AHDI-F, a member of the AHDI’s Credentialing Commission for Healthcare Documentation and a program coordinator and the MT instructor at Polk State College in Winter Haven, Florida, helped create the new credentials. As a long-standing member of the educational community, she has seen MT programs transition from HIM to HIT, a shift that “shows me that the industry is not being phased out but merely evolving.”

The Case for Credentials
Until recently, there was only one way to experience documentation: words on a page or a screen. If the document looked good and said what the physician intended, the employer was happy with the MT’s work. But health care documentation is, and will continue to become, more complicated in ways that cannot easily be seen—and may be even more important. “There is such a wide-open potential for opportunity that many [MTs] haven’t realized because of how we work, where we work, and the fact that nothing more has ever been required of us,” Whatley says.

The AHDI has been arming its members with information for years. Now is the time for the next step: credentialing. Whatley says credentialing is the only way health care documentation specialists can stand beside professionals in other allied health care fields. “We already have the skill set, but in the world of coding, medical informatics, quality analysis, information technology, and health information management, credentials are required and respected,” she says.

According to the AHDI, the RHDS exam contains an additional 19 objectives across four knowledge domains that did not exist on previous RMT examinations. The CHDS exam contains an additional 15 objectives across two knowledge domains. The RHDS exam focuses on advanced editing, regulatory compliance, additional clinical medicine, computer fundamentals, and HIT content, while the CHDS tackles topics such as advanced clinical practice, advanced surgical practice, HIT and related standards, and speech recognition technology content and practical application.

The next step for the AHDI and its members is to promote the credentials to industry stakeholders, including employers. The accuracy of patient records is paramount in today’s health care environment, perhaps more than ever. Patients who visit multiple physicians across multiple networks should be assured that a clear and correct medical record will travel along with them.

Audrey Kirchner, CMT, a medical transcription and terminology teacher and the owner of a medical transcription service organization who is active in local and national AHDI committees, coauthored bridge courses that will teach the new competencies to current RMTs and CMTs. “Now more than ever, the need for accuracy and integrity of individual patient records has been brought to light,” she says.

Electronic records are not simply words on a screen instead of a page. The goal of EHRs is for the information to be accessible for treatment, data collection, disease tracking and prevention, and more effective applications of community health. What underlies the visible data will be as important as what providers actually can read on the screen—all of which is now included in what constitutes as health care documentation.

Kirchner says all AHDI members must “heighten their awareness of the critical role that health care documentation specialists play in the present and future compilation of individual health stories.” Nothing is more important than the patient’s story, and because no two patients are the same, each medical record should be as unique as a fingerprint, she adds.

Today’s health care environment requires knowledgeable workers who understand all aspects of creating, maintaining, and guarding the data—and the stories—contained in these records. It’s clear that those with the skill sets confirmed by the AHDI’s new credentials can help lead the industry in this essential role, allowing each patient’s record to speak for itself.

— Jennifer Della’Zanna, MFA, CMT, CPC, CGSC, CEHRS, a medical transcription and coding teacher, regularly writes feature articles about health issues for online and print publications.

Important Links
• Find out more about the credentials and the examinations, and review the exam blueprints at www.ahdionline.org/Certification/RebrandingtheAHDICredentialingExams/tabid/724/Default.aspx.

• The AHDI’s response to AHIMA’s “Vision 2016 White Paper: A Blueprint for Quality Education in HIM” can be found at www.ahdionline.org/Portals/0/downloads/AHIMAVision2016WhitePaperAHDIRESPONSE.pdf.

• Review the AHDI and AHIMA survey “New Skills for a New Era” at www.ahdionline.org/Portals/0/downloads/AHDI-AHIMAAnnounceNewSkillsForaNewEra.pdf.

• Frequently asked questions about the RHDS/CHDS exams and designations can be found at www.ahdionline.org/tabid/725/Default.aspx.