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AHDI Conference News

Documentation Experts Address Pressing Issues
By Susan Lucci, RHIT, CHPS, CMT, AHDI-F

The Association for Healthcare Documentation Integrity (AHDI) recently celebrated its 35th year, with its annual conference kicking off on Wednesday, July 31 with the national leadership board meeting and leadership summit where attendees were provided with an update on the association’s key focus areas.

The AHDI is launching a rebranding of its credentials from registered medical transcriptionist (RMT) and certified medical transcriptionist (CMT) to registered health care documentation specialist (RHDS) and certified health care documentation specialist (CHDS). The CMT is not being retired, and those who currently have that credential may keep it if they wish.

Professionals wishing to update their credential to reflect a broader scope of content will be able to take a bridge exam beginning this fall. Registration for the new bridge content and exam opens in September. Individuals who have successfully passed the two-part credential-qualifying exam (CQE) since it was launched in January 2011 will automatically receive the updated credential titles of either RHDS or CHDS. Check the AHDI website for more information and details.

On Thursday, August 1, the three days of educational programs began with Dalia Al-Othman, Esq, presenting the keynote address. Her inspirational speech on her experiences first as an attorney and then as a patient who overcame several challenges was uplifting and provided insight to developing a patient advocacy organization. Health Care Navigators is dedicated to helping patients through all aspects of their care. The organization provides support while a patient is in the hospital and after he or she returns home.

During her presentation, Al-Othman stressed the growth in this field and that health care documentation specialists may be well suited for roles in this expanding arena. She mentioned the expertise that health care documentation specialists have in medical language ideally suits them to help patients understand the difficult terminology used in health care.

During “Transcription & Technology in the New EMR Era,” Nick Mahurin, CEO of Infraware, provided an update for attendees regarding the Health Story Project. The recent alliance with HIMSS places key emphasis in the technology sector and a path for adopting the Health Level Seven International-approved consolidated CDA language for patient reports as required by meaningful use stages 2 and 3.

Mahurin made a key point in sharing with the audience the dynamics and importance of the intersection of patient engagement, which also is part of meaningful use and current complexity, and the sometimes overwhelming content in electronic records. Templates are rigid in format and may fall short in allowing providers to capture unique complexities in patient care. Narrative notes provide an easy process for providers to capture this information, and the Health Story Project helps bring structure to narrative records.

Julie Dooling, RHIA, director of HIM solutions for AHIMA, provided an educational session on the status of health information exchanges, some of the driving forces behind the initiative to share health information across the nation.

Next to the ICD-10-CM transition slated for October 2014, probably the next most important focus for compliance is HIPAA. Brenda Hurley, CMT, AHDI-F, provided an update on the HIPAA Omnibus final rule, which became effective in March with full compliance by September 23, 2013. The HITECH Act of 2009 proposed extended requirements to business associates, and the final rule upheld all of those proposed regulations. There are many requirements that must be met by all business associates. Hurley provided information on the need to update policies and procedures, get all workforce members trained on HIPAA, and ensure business associate agreements are updated and executed.

In another session, “Is There Life After Transcription?” I presented on the emerging alternative roles for health care documentation specialists in areas such as data analysis. Some specialists are finding their transcription jobs are being eliminated because of technology advances, and some are actively looking for an alternative career choice. Big Data requires many different aspects of data analysis, and the need for professionals skilled in analyzing data in various forms is definitely on the upswing.

To close the educational sessions on Sunday, Lea Sims, CMT, AHDI-F; Joe Weber; and I participated in a panel discussion on the “The Juno Case: A Sentinel Event for the Transcription Sector.” An administered fatal dosage of medication was the result of a transcription error in the patient's medical record. The $140 million medical malpractice judgment was the first of its kind to be found against both a hospital and a medical transcription service organization. The focus of this presentation was on the opportunities that have been identified for health care organizations to keep in mind that health care documentation errors can have serious consequences. This case stresses the importance of maintaining good quality practices and perhaps reexamining internal policies and procedures to ensure best practices in patient safety.

The future for health care documentation specialists was a common theme throughout this year’s 35th anniversary convention. Some older traditional jobs are going away but, as with many progress innovations, opportunities arise. New career paths are emerging. Preparing for these fledgling roles is an important step to plan for now. Gaining further education and securing new credentials may be necessary to enter these new roles.

There also is a growing concern that, once the industry moves into ICD-10-CM, more documentation may be needed through the narrative process, and there may not be enough qualified, experienced health care documentation specialists to fill that need since fewer individuals are entering the profession and many are nearing retirement age.

Of course, the importance of maintaining standards and having clear, updated policies and procedures as well as good quality practices in place is now, perhaps more than ever, an important responsibility for medical transcription companies.

— Susan Lucci, RHIA, CHPS, CMT, AHDI-F, is consultant and chief privacy officer of Just Associates and an editorial advisor to For the Record.