Health Information Management Students Today

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Hello everyone:   Pardon the quiet the last couple of weeks! I took some time off to enjoy the beautiful Pennsylvania Autumn with hubby and then was off to New Orleans for the MGMA convention – more on that later! A couple of weeks ago, I had the pleasure of speaking to a group of University of Pittsburgh HIM students about what we do at M*Modal and about our perspective on the health information landscape.  I had such a great time!

There was a range of experience there – from students new to the program to final year grad students. But what has been striking me as I’ve talked with these students is how different they are from the students (including me) who took HIM classes back in the days when HIM was called “medical records.”  Not that the students then weren’t as passionate about the subject as they are now, but HIM is now a more technical focus and seems to be attracting students with more technical interests and backgrounds. Or are students in general these days just more technical? As someone who started in medical records when it was all paper, all the time, much of it typed on the old IBM Selectric – it’s hard for me to say for sure.  🙂 It certainly seems as though there are quite a few more young men entering the HIM profession than there used to be – I suspect because of the increased technology focus, though I don’t have any statistics in front of me to support that.

But how exciting are today’s HIM programs and these students?  What better combination of skills could we want in any health information professional than a knowledge of the language of medicine, an understanding of the workings of the healthcare provider organization, knowledge of documentation requirements from a variety of perspectives from patient care to reimbursement to analysis and statistics to medico-legal purposes, IN ADDITION to knowledge of health information systems from a technical perspective?

My only concern is…it seems as though many of today’s HIM students (and I can’t speak for all of them of course!) don’t really want to work in a hospital after graduation. Many of them have hopes of working for an EMR or other HIT company.  I work for a technology company of course – but I hope some of the students reconsider and will spend some time working for a healthcare provider.  Even if the ultimate goal is to work in technology, gaining experience in actual HIM departments, in the trenches where the action really happens, could be invaluable. How better to understand what technology should do, and how it should function, than to have a background as an actual user? To know firsthand about the gaps that sometimes exist between systems and how users actually use them? To understand the pain points and the needs of working HIM professionals and other consumers of health information? And with the increased focus on using health information to provide data for analysis of outcomes and to support evidence-based healthcare, HIM departments may well become one of the most innovative places to be in a hospital!

Some of the Pitt HIM students are going to be doing projects and internships with us here at M*Modal beginning this week, and we can’t wait! It is of course really exciting for us to talk to the students about what we do and to have them work with us – but more importantly – we appreciate having the opportunity to learn from them about what HIM programs are talking about today.

I’ll be sure to share what we learn!

Til next time,

Lynn

ICD-10 and Health Information Technology

Hello all:

I came across one of the most concise explanations of ICD-10 that I’ve seen yet this morning during my usual perusal of incoming tweets. 🙂

FAQ: How will the transition to ICD-10 codes affect health IT?

The article contains general information about ICD-10, what it is, why its coming, and the challenges the conversion will bring, as well as links to more detailed information.

Those of us involved in the creation of health information through dictation and transcription must educate ourselves about this extremely important change and use the information available to find ways to become an irreplaceable part of the HIM process. As I’ve said before, get your hooks in everywhere you can folks  – being knowledgeable about your customer’s challenges and concerns is a must.

I hope you’re all enjoying the beautiful Autumn colors as much as I am!

Til next time,
-Lynn

Clinical Documentation – Friend or Foe

A friend of mine – and friend to all proponents of quality, efficiency and effectiveness – Gary David makes some great points about what “documentation” actually IS in his response to a comment about one of his blog posts. The commenter, ADavis, talked about a previous post by Gary in a HIMSS LinkedIn group discussion making some pretty strong statements about documentation being an inhibitor to progress, not being a collaborative tool – in a nutshell, not being useful.

I’m wondering what he meant – does he mean documentation in its substantive form – the way Gary defines it? Because if so I disagree with him – documentation IS the foundation upon which healthcare performs. It certainly is the tool through which clinicians collaborate. It is how clinicians find out about results of laboratory tests and studies. It is how they prescribe medications and order treatment. It is the source of how providers get paid for what they do. It is what protects the provider – and the patient – during litigation. And it promotes patient care. Imagine healthcare without documentation!

A woman who is very dear to me, someone more active and vibrant than most women half her age, has had a really tough couple of years recently. Ranging from the non-threatening, such as sinus problems and allergies, to more serious total knee replacements, to a very serious heart attack, and then even to cancer, this usually very healthy woman was plagued by health problems – and treated by teams of physicians across different specialties. Does anyone imagine that these doctors all got on the phone every morning and discussed her care? I doubt it. No one can convince me that documentation didn’t play a big part in the collaboration between the physicians that saved her life.

So – I can only imagine that ADavis’ concerns aren’t about documentation in and of itself. Perhaps ADavis is frustrated by the sometimes cumbersome documentation methods, maybe by the regulatory process, by perceived “requirements” for documentation, possibly by LACK of documentation or POOR documentation.

I can’t take credit for the comment Gary makes about me stating that documentation is “substance” and the method through which we “document” is only “form” but that idea comes from someone far beyond my reach.

As much as I would love to aspire to be a true thought leader, alas, what I am is just a fairly outspoken evangelist for the real thought leaders in health information and beyond…

I think it bears re-mentioning my very first posting on my blog where I talk about a quote from Dee Hock (VISA credit card association founder and former CEO):

“Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference. The closest thing to a law of nature in business is that form has an affinity for expense, while substance has an affinity for income.”1

Granted, Mr. Hock was not talking about clinical documentation. But it rings true to me…the useful information that is provided and used by clinicians in the care of patients is the substance of this equation. HOW the documentation is captured, stored, shared, and accessed is only the form….

In a presentation Gary did at our M*Modal headquarters, Gary showed a film of a doctor using a traditional front-end speech recognition product to create documentation. He picked up a document from a fax machine and proceeded to read it into his front-end speech recognition software – he needed to get that information into his EMR. Someone in our audience pointed out that the faxed document could have been scanned and uploaded as a digital file into the EMR. But Gary pointed out – in the process of getting that information into his EMR, the doctor was also READING the information. Sure, someone in the office could have scanned it – but then when would the doctor have become aware of the information in that document?

Back in my physician practice days, I used to have to open the mail, take the typed paper reports sent from other physicians (yep, this was even before FAXING was commonplace), find the patient’s chart, paper clip the report onto the front of the chart, and leave the chart on the doctor’s desk. When the doctor had seen the report, he’d put the chart in the correct pile on MY desk and I’d file it away.

Inefficient? Sure it was – but just like the doctor reading his faxed report into his EMR, it ensured that the doctor SAW the new information.

How do we do this in our electronic world? What good does it do to have all this information available in an EMR if the doctors don’t see it? How do they know something new has been entered into that patient’s electronic record?

Let’s remember that any change we see in the transition from paper to the EMR/EHR is merely a change in form. The “form” is changing now. It will change again. What we need to be concerned with is the preservation of the substance – the information and its usefulness – while adapting to the changes in form.

Hey everyone – we transcription people have been in the documentation workflow management business for a long time. Surely we can use our knowledge and experience to address this type of challenge – to stay relevant into the future?

We need to be part of “preserving the substance of the past by clothing it in the forms of the future.” That is how we remain a vital part of the health information domain.

‘Til next time,
Lynn

1 – Waldrop, M. Mitchell. (October 31, 1996). “Dee Hock on management.” Fast Company. Retrieved from http://www.fastcompany.com/magazine/05/dee2.html , December 18, 2007

Slides from NEMA AHDI Presentation…

Hello everyone:  Once again, thanks so much to NEMA AHDI for inviting me to come to their annual conference – and thanks to all the attendees! It was great fun seeing all of you.

Here is a copy of my slides…If anyone has any questions, you know where to find me! 🙂

NEMA_AHDI_201001009

Help for a Front-end Speech Recognition Nightmare

M*Modal attended the first night of the NEMA AHDI annual conference last night, and we met a couple of MTs with big concerns.

They work at a facility where the ED doctors are forced to use a traditional (read: NOT M*Modal) front-end speech recognition product for their ED notes.  The MTs were removed from the workflow.

The doctors are NOT EDITING their ED notes. NO ONE is editing the dictation.

These MTs are still on staff and see the documentation produced because they still perform filing, transcribe urgent H&Ps, etc. They see numerous horrendous errors in the final, signed-off ED records.

I asked if anyone was performing QA on the documentation and they replied that they were originally, but there was so much, and the workflow is now so cumbersome and inefficient, that administration told them to stop. They are told that the doctors cannot be forced to edit the notes before signing.

I asked what the doctors say, and the MTs state that the doctors are forced to use the front-end speech recognition whether they have time to edit or not and therefore don’t complain. No choice, no options.

This is so NOT the M*Modal way (we believe 100% in OPTIONS and QUALITY) – and if this was an M*Modal user, I’d be on the phone so fast heads would spin. But it is not an M*Modal user so I can’t help there.

These MTs would like to know if they have any recourse – is there anything that can be done to force the facility to review the quality of the documentation and take action?

I know some of you have been in situations where physician self-created documentation methods produced less-than-optimal results when MTs were taken out of the picture. Does anyone have any suggestions for these concerned MTs?

Your help would be appreciated!

-Lynn

HIM – Out of the Basement and into the Forefront

The M*Modal team and I attended AHIMA’s national conference last week and as usual it was a terrific opportunity for us to meet with some of our partners in person (it was great seeing you!) and to meet new friends.

But in addition to that, attending the AHIMA national conference was, as always, a great place to learn about what topics are hot for health information professionals right now. And wow, do they have a lot of hot topics!

The coming ICD-10 conversion, changing and evolving technologies such as computer assisted coding (CAC), continued conversations about RACs, increasing CMS documentation requirements for coding, and of course ARRA and HITECH activities around electronic health records (EHR) have created an over-abundance of change for HIM professionals.

The role of HIM in maintaining and managing the information that every healthcare provider needs in order to function is more obvious than ever. HIM has sometimes been thought of as the medical records folks in the basement…but no more!  Because who is going to be the keeper of the keys to all these changes and new responsibilities? HIM professionals of course.

So this week we are going to be talking about what we heard at AHIMA.

It is increasingly apparent that the medical transcription industry at large must rediscover its HIM roots. The fact that a large amount of medical transcription today is performed outside of the healthcare provider’s facility, and might be performed by an outside service rather than by provider employees, does not mean that medical transcription is no longer part of HIM.  It is our responsibility as providers of transcribed health information to re-forge this connection.

This week we’ll be discussing some of the topics that are important and relevant to HIM professionals.

Let’s re-claim our place in the HIM workflow by showing that dictation and transcription can continue to be of service to the healthcare provider in its quest for useful documentation.

HIM professionals – what are your thoughts?  How can dictated documentation be changed to improve its usefulness to you?

More later,

Lynn

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