Health Information – the Exciting Road Ahead!

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Hello everyone:

I have been privileged over the past couple of weeks to visit some of the most prestigious health care providers in the country and to hear their thoughts about the state of health information today.  I can tell you that we in the health information field are in for some exciting times ahead!  Whether we work for HIT or HIM companies or for health care providers, the changes occurring in health care mean that our roles in serving health care are changing too.  So there could be no better time to pick up our conversations again on Excellence in Health Information.

See the rest here…Health Information – the Exciting Road Ahead!

Til next time!

Too Expensive to Fix

I recently came across a 2003 issue of Journal of Healthcare Information Management that is almost entirely devoted to measuring the ROI of HIT investments and I was struck by this quote from Richard Lang, EdD in his Editor’s Introduction.

“Although an ROI may predict how long it will take a capital investment to return anticipated savings via cost reductions or new revenue, it lacks a suitable measurement for the “qualitative” aspects that can contribute heavily to the realization of strategic objectives” (Lang, 2003)

I have worked with or talked to so many providers over the last year who realized they made a mistake in the way they planned to realize, or in how they measured, the ROI of their EMR systems.  One health system executive said he knows his organization made a mistake in their plans for EMR implementation and he admits they made incorrect assumptions about where they would see the return on their investment.  But he asked – how do you get an entire organization to admit that that it made a mistake? Even if it does, what can they do about it after spending many millions of dollars? Start all over? Not likely. And they are not alone.  Currently several of these providers are coming to my employer, M*Modal, looking to augment the capabilities of their EMR in hope of achieving the strategic objectives they expected to see upon EMR implementation.

One of the most common mistakes seems to come from the assumption that point-and-click data entry and structured EMR forms are a better way to capture health information than narrative dictation.  Many in fact incorrectly believe that direct-data entry into structured reporting is the only way an organization can get the discrete data they need to drive automated clinical decision support, to enable population reporting, and to attain the holy grail of electronic health information – semantic interoperability.

One of the primary contributors to ROI that these providers expected to see was the elimination of dictation and medical transcription costs.  After all, since the doctors can point-and-click their way through a structured form, why should they need to dictate?  Since many of these facilities spend millions of dollars every year on dictation and transcription, the cost benefit seems like a no-brainer.  And let’s face it; many of the decision-makers aren’t accustomed to looking at the aspects of health information which can only be measured qualitatively.  They are accustomed to looking at FTE expense and productivity units.

However, they found several things:

  • Point-and-click methods of information capture can be time-consuming, cumbersome, non-intuitive, and significantly add to the physician’s documentation time, even sometimes causing a decrease in the number of patients physicians see in a day.
  • The information captured is not as usable for clinical care and some HIM functions as narrative forms of documentation.  As one physician told me, “I like that I have access to all the patient vitals, but I can’t tell how the patient feels today compared to how he felt yesterday.”
  • The quality of the documentation is often degraded as well.  Physicians copy and paste in order to save time and end up with duplicate, extraneous, or contradictory information.  They enter information into the miscellaneous text boxes because they can’t find a place for the information they wanted to capture in the drop-down menus and structured fields.  And in the traditional EMR world, information captured in the plain text boxes = no structured data = information that is lost in the computer and can’t be reused by the EMR.  As one IT manager said, “we have several thousand physicians using it, but that doesn’t mean they are using it correctly.”

So getting back to the quote at the top of this post, in counting on the elimination of narrative documentation, and thus dictation and transcription, as an expense that can be eliminated, providers often forget about the cost of the physician’s time and about the cost of degraded quality of information.  In the organization’s quest for structured data, they forget about the clinician’s need to use health information as a means of communication. They forget that one of the benefits to be gained as a result of the implementation and use of electronic health information is the improved health of the patient. That is, some of the benefits will not be realized by the provider but rather will be felt by the recipients of the improved, more efficient care.  This type of return on a technology investment is not as easily measured as number of FTEs or productivity units per hour.

At M*Modal, we’re working with several providers now who have realized that they can give physicians the option to document patient care using narrative dictation AND still get the structured data they need. They’ve realized that their objectives for truly useful and cost-effective documentation can only be achieved if the system offers options and flexibility for capturing health information.  Is the solution always optimal? No – because EMRs with their proprietary data formats aren’t eager to open up to accept readily-exchangeable data standards.  Some organizations are beginning to look to capabilities available outside of their EMRs as the solution to their problems.  But what happens to the providers who cannot afford to look to complementary solutions that will help them to realize the benefits they expected to get from their EMRs?

Though the government-driven efforts to encourage the adoption and use of electronic health information through the ARRA, HITECH, and Meaningful Use certainly have increased interest in HIT, one negative result is that providers might place so much emphasis on the financial incentives that they don’t look at the benefits of health information that can’t be measured in cost per FTE or in CMS incentive payments.  I hope that providers who are only now in the decision-making process take note of the lessons-learned by others before they too end up with a problem too expensive to fix.

Food for thought,


Originally appeared at Excellence in Health Information


Lang, R. (2003).  ROI and IT:  Strategic alignment and selection objectivity.  Journal of Healthcare Information Management.  Volume 17, number 4. Fall 2003.

AHDI – M*Modal Continuing Management for Modern Medical Transcription Series – Webinar

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Hello everyone:  It was my very great pleasure today to be the presenter for an AHDI webinar as part of the M*Modal – AHDI Management for Modern Medical Transcription series.

Today’s presentation was titled, “The Continuing Relevance of Medical Transcription in Health Care.”  Here is a pdf of the slides. AHDIWebinar_Transcription_Relevance_20110517

Key points:

Medical transcription:

  1. Is part of HIM.
  2. Can support Meaningful Use, ICD-10 coding, and computer assisted coding (CAC).
  3. Must provide documentation that is valuable and useful.
  4. Must emphasize quality of content over print format and cost.
  5. Supports options and flexibility for increased adoption.
  6. Can be cost-effective without sacrificing MT pay.

Back in the earlier days of speech recognition (and in fact many health care facilities and transcription companies  still follow these practices today), the best practices for speech recognition were much more limiting than they are now.  They tended to be directed at productivity – not towards the cost-effective creation of useful documentation.

Unfortunately, the emphasis on productivity and cost savings caused us to lose sight of what it is that we do – create high-quality, accurate, clinical documentation – and who creates it – the highly skilled, knowledgeable, Career-Minded, Medical Transcriptionist.

I myself stood up in front of a roomful of people at the 2006 AHIMA national conference and gave recommendations such as:

  • Select physicians carefully
  • Select MTs carefully. You will have plenty of volume left for traditional transcription.  Leave your high-producers in transcription and move your low- to mid-range producers to speech rec.
  • Have your MTs perform “as dictated” editing as much as possible.
  • Encourage physicians to adopt best practices for speech recognition.

That was before I came to M*Modal and realized that the right technology allows us to view documentation from a different perspective.  It allows us to get the real value and use out of clinical documents rather than only using them to check off a requirement on a chart completion list.  Luckily even the most stubborn of us can learn fast when we want to.  🙂

Today that list would look more like:

  • Bring on the doctors – let the technology sort out which result in quality sufficient for editing and which do not.
  • Train all of your MTs to edit.  Advanced speech recognition technology will cover a significant portion of the transcription volume.  Transcription IS editing.
  • Pay your highly-skilled, highly productive transcriptionists appropriately as they move into speech.  You cannot deliver the quality of documentation necessary to support requirements for meaningful use, ICD-10, or computer assisted coding, without them.
  • Create the requirements for documentation according to usefulness and quality.  “You get what you say” does not result in documentation that consistently adheres to content or quality needs.
  • The “average % productivity gained” is not the correct metric to use to measure the results of speech recognition; nor is it the correct means to determine a compensation plan.
  • Get your cost savings through a combination of effective use of the technology and workforce and performance management.  Understand that cost benefits come from increased output from fewer staff members – not a high average % increase.  Your increased output will allow you to take on more volume without increasing staff.  If your output increases enough that you can decrease staff, get rid of the “hobby MTs” and reward your Career-Minded MTs for making you more efficient.

Medical transcription must be about delivering high-quality, comprehensive, useful information – not cheap documentation – if it is to stay relevant as an enabler of health information technology.

All the best as always,



Throw Away Everything you Thought you Knew About Speech Recognition and Medical Transcription

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Hello everyone:  What better way to roll into National Medical Transcriptionist Week than with a trip to lovely Fort Lauderdale to meet with the even lovelier folks of AHDI – Florida!

As always, a visit to this lively, engaged group of dedicated professionals resulted in more discussion than there was time!  And to cap it all off, I had the pleasure of meeting two luminaries in the health information domain, Pat Forbis and Claudia Tessier.  I was greatly humbled to have been part of a speaking schedule that included two women who have been such leaders in our field. I even got to share a bench with Claudia, both of us “iPadding” away.  Very cool to “ipad” sitting next to the leader of the mHealth Initiative!

The theme for AHDI-Florida’s annual meeting was the “Winds of Change”, so what better topics to discuss than the emerging technologies which are having such an impact on our industry, on health information, and on how health care itself is delivered.

The point I most wanted to make in my presentation is that changing technologies do not mean the end of medical transcription.  In fact, if we keep sight of the fact that medical transcription is about the accurate and high-quality creation of meaningful, useful clinical documentation – not the “cheap” creation of something someone only uses to check off requirements on a chart completion list, then transcription can actually be an important enabler for electronic health information.

Unfortunately, the focus in recent years has sometimes been on the wrong things.  We’ve focused so much on cost, on print formats, and on providing customized requirements, that we’ve lost sight of the real value we provide to the health care provider.  Worse, we’ve allowed them to lose sight of our value too.

So let’s throw away everything we thought we knew about transcription, slides here –  Florida_AHDI_20110514 , and look at it in an entirely new light.  Let’s look at it as a way to provide high-quality, comprehensive documentation to support increasing demands for information….produced in a way that happens to be cost-effective.

What can we do?

  1. Make sure everyone knows about the Health Story project, particularly the Health Story, IHE, HL7 Consolidation project.  Learn about it, and share your knowledge with your employer, your customers, your vendors, and your representatives in the U.S. Congress.
  2. Remember how important your highly skilled, highly productive, career-MTs are if you are to be a provider of information that can be used to support Meaningful Use, computer assisted coding, the coming ICD-10 conversion, and the other increased demands for health information that are coming our way.  Feel free to refer here for links to other articles about this topic.
  3. Focus on quality.  Without quality, the rest can’t happen.

Thank you as always to AHDI-Florida for being such gracious hosts and such passionate supporters of high-quality clinical documentation.

And don’t forget to visit Misty and Bethany at M*Modal’s Always Understanding blog for activities all week in honor of National Medical Transcriptionist Week!

All my best as always,



A Vision for Truly Meaningful Health Information

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This article comes on the heels of the AHDI – CDIA Advocacy Summit in Washington, DC, where members of AHDI and CDIA worked together to speak to members of Congress about the value of narrative health information and the part that medical transcription plays in helping to preserve the patient story.  This article is a joint effort from Liora Alschuler, CEO of Lantana Consulting and me, and also appears on Excellence in Health Information.

Physicians have long used narrative documentation as an effective means of information capture.  Dictation in particular is a widely used method of creating clinical reports such as history and physical documents, operative reports, consultation reports, discharge summaries, and progress notes.  In addition to serving as important communication tools, these documents are an excellent source of the information used by providers for HIM, medico-legal, and administrative functions.  These documents can contain the subtleties of the physician thought process in addition to important clinical facts. They contain a level of expressiveness that cannot easily be captured using other methods of information capture.  According to the Health Story Project, the amount of the nation’s total clinical information captured as narrative documents is approximately 60%, with 1.2 billion documents produced in the United States every year (2011).1

Now that it is accepted that electronic health information will lead to more efficient and effective health care, the belief that information must be captured as discrete metadata-tagged elements in order for the data to be semantically interoperable has led to the assumption that narrative forms of documentation are no longer of value.  When physicians lose the option to dictate narrative notes, they typically are asked to enter the data into the EHR manually, using “point-and-click” methods to capture clinical data. But adoption of electronic health records has been slow, largely because of the increased level of effort and time required to enter information into the EHR, and also because care givers do not find the clinical facts available to them through EHR templates to be a sufficient representation of the patient’s health and clinical history.

The Health Story Project (originally CDA4CDT) was founded for the purpose of creating implementation guides for the electronic exchange and use of health information captured in narrative clinical documents.

The Health Story guides address content requirements for the most common document types and create data standards for exchange of information captured within the original “primary source” documentation of the delivery of care. They represent the original capture of key observations and results, as well as data elements required for the electronic record. The component parts are described through CDA templates, the reusable building blocks of Clinical Document Architecture, most of them developed initially for the HL7 Continuity of Care Document (CCD).

Meanwhile, IHE and HITSP were also developing CDA implementation guides which enable and facilitate Meaningful Use requirements, but which led to some duplication and disconnects with the Health Story guides.

A new initiative, the HL7/IHE Health Story Consolidation Project, joins the two efforts. This project creates a standard which provides the ability to capture and encode discrete data elements while also structuring narrative information such that its value is persisted in the electronic health record.

The collaboration between Health Story, IHE, and HL7 will:

  • Republish all eight Health Story guides for the original common document types plus the related/referenced templates from CCD in a single source.
  • Update the templates to meet the requirements of Meaningful Use, augmenting the base CCD requirements to meet the requirements of HITSP C32/C83.
  • Reconcile discrepancies between overlapping templates published by HL7, IHE and HITSP.

This collaboration is a volunteer effort hosted within the ONC’s Standards and Interoperability (S&I) Framework.  If widely adopted, a standard for health information exchange based on this project could resolve many current challenges by enabling the capture, exchange, and use of clinical data in the EHR in a way that is also meaningful and understandable by human caregivers.

The resulting implementation guides will facilitate meaningful use of electronic health information by:

  • Increasing adoption by allowing physicians to document patient encounters using methods that are efficient, effective, and convenient.
  • Improving the usefulness of the data by increasing the likelihood that the required level of specificity and comprehensiveness will be provided.
  • Enabling the expressive information that is relevant to the documentation of patient care but which does not accommodate entry by point-and-click methods of information capture.

This project gives us the best of both worlds by enabling the exchange and use of clinical facts tagged as discrete data elements without losing the narrative information which still remains the most effective tool for communication and collaboration between the human members of the patient care team.

Dr. David Blumenthal, in his introduction to the ONC’s Federal Health Information Technology Strategic Plan 2011 – 2015, refers to electronic health information as the “’lifeblood’ of modern health care” (2011).2 This collaboration between the Health Story, HL7, and IHE take us one step closer to that vision.

All my best as always,



1 – Health Story Project.  (2011).  HL7/IHE Health Story Consolidation Project.  Health Story

Project: Integrating narrative notes with the EHR.

2 – Office of the National Coordinator. (2011).  Federal Health Information Technology Strategic

Plan: 2011 – 2015.  David Blumenthal, MD, MPP.  Retrieved April 21, 2011 from

Important Step for Narrative Documentation – Must-Attend Webinar!

Hello everyone: Please see below for an invitation to attend a webinar that explains how to participate in the HL7 ballot cycle for the HL7/IHE Health Story Consolidation Project implementation guide.

For those who are not familiar, the HL7/IHEHealth Story Consolidation Project is an important and very exciting initiative. It brings together efforts from the Health Story, which created HL7 CDA implementation guides and content standards for the electronic exchange of information contained in the most commonly used clinical document types, with IHE and HITSP implementation guides. This is exciting news since the two efforts sometimes duplicated each other, and there were some disconnects and discrepancies created along the way, but both initiatives made important progress towards the goal of accessible, interoperable, and useful health information.

With the consolidation of these two projects, these disconnects and duplications will be eliminated. The previously released Health Story guides will be republished in a single source along with updated versions of the Continuity of Care Document (CCD), and all will be updated for compliance with Meaningful Use and also to meet the requirements of HITSP C32/C83.

This is a very exciting effort which, if widely adopted, could resolve so many of the challenges presented by capturing, exchanging, and using clinical data electronically in a way that is also meaningful and understandable by human caregivers and the patient. With so much conversation underway about the adoption of a useful standard for the exchange and use of truly meaningful health information, this seems a huge step towards the solution we have all been waiting for.

If you are passionate about meaningful health information and also about having this information made available in a safe, secure manner in the electronic environments which we all agree are necessary to cut health care expenditures and improve patient care, then please attend this important session.

All the best,

Lynn – M*Modal

Dear Members and Friends of the Health Story Project

You are invited to participate in an education session to encourage participation in the current HL7 ballot cycle for the HL7/IHE Health Story Consolidation Project implementation guide. Please register using the link below, and forward as you wish to colleagues who may have an interest.

Webinar: HL7/IHE Health Story Consolidation Project: How to Participate in the HL7 Ballot

When: Wednesday, April 13, 4-5 PM eastern

Register for Webinar:

The HL7 International data standards organization will soon open a ballot for an important package of standards for health information exchange. The Health Story Project is hosting a webinar to show those unfamiliar with the process how to participate in the ballot.

The HL7/IHE Health Story Consolidation Project has harmonized exchange standards for eight common types of clinical documents along with the HL7 Continuity of Care Document (CCD) standard and the HITSP C32 requirements for Meaningful Use into one single implementation package. ONC’s Office of Standards and Interoperability (S&I) is hosting the effort within its S&I Framework and is facilitating the project. Within HL7, the project is sponsored by the Structured Documents Work Group.

Development of the original eight implementation guides for History & Physical, Discharge Summary, Operative Note, Consult Note, Progress Note, Procedure Note, Unstructured Documents and Diagnostic Imaging Reports was supported by the Health Story Project through an associate charter agreement with HL7. The project has harmonized these with complementary IHE Profiles and will result in a series of corresponding change proposals to IHE and updates to templates required for Meaningful Use.

The HL7 Ballot is open to all. This webinar will review all administrative, documentary and technical steps needed to cast your ballot and to participate in the ballot reconciliation process.

Holistic Health Information

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Hello everyone: As springtime finally settles on us (we had a warm day yesterday here in Pennsylvania), I notice the yearly onslaught of neighborhood walkers and runners all out getting some air and some exercise – with the goal, no doubt, of improving their health. Many of these people are taking a holistic view of health, knowing that health must come from an all-around approach and not from any one source.

And of course, being me, thoughts of health lead to thoughts of health care which of course lead to thoughts of health information – specifically – of holistic health information.

No, I’m not going to tell you where to find information about aromatherapy or acupuncture – but I would like to talk about the need for a real discussion about the whole of health information – about the usefulness of health information in the care of the patient and all of its related parts.

What do I mean by that?

According to, the word holism means:

“the theory that the parts of any whole cannot exist and cannot be understood except in their relation to the whole; “holism holds that the whole is greater than the sum of its parts”; “holistic theory has been applied to ecology and language and mental states”1

If you ask me, this definition applies perfectly to health information and in fact M*Modal’s CEO (and in the spirit of full disclosure, my boss), Michael Finke, has for years now referred to the “health information ecosystem” in his discussions.

Why bring that up now?

I’ve had occasion over the past couple of weeks to talk with people from several organizations, all concerned with the state of health information for a variety of reasons. And again it strikes me that our conversations about health information tend to become as silo-ed and disconnected as the health information systems we lament. We talk about the pieces that affect us personally, losing our view of the whole.

While that is natural and understandable, it is time that we begin to talk about health information as a “whole that is greater than the sum of its parts.” Its parts might be HIT, transcription, the EMR, coding and billing, privacy and security, or whatever – but at the end of the day, ‘the parts of any whole cannot exist and cannot be understood except in their relation to the whole.’

Think about that.

  • Discrete data points have no meaning without surrounding context
  • Coding can’t be accurate if the documentation is not
  • Transcription is meaningless if it doesn’t make it into the patient record
  • The EMR is worthless if it doesn’t give a whole picture of the health of the patient
  • HIT has no value if systems and technologies don’t talk to each other
  • Privacy and security doesn’t protect anyone if information can’t shared between caregivers and the patient
  • Core measures and other quality reporting will not result in better patient health if the information used to drive the reporting isn’t complete and accurate
  • The list could go on and on…

These are all parts of the one holistic ecosystem of health information. Can we “fix” any of these separate parts if we don’t consider their relationship to the whole? No, not in a way that’s meaningful. How do we know if a particular topic is part of the ecosystem? Easy – can you trace it back to improved care of the patient?

So does effective coding for billing go back to care of the patient? Yes – healthcare ain’t free and it is necessary to know that payers are being billed and providers compensated appropriately. Does the ability to share information collaboratively amongst members of the patient care team connect back to the care of the patient? Of course. That’s a no-brainer. Do customized section headings on a printed document connect back to care of the patient? Nope. Does forcing the doctor to use documentation methods that cause him to spend more time documenting and less time focusing on the patient connect back to improved care of the patient? Well, not in my opinion though others might disagree.

Within the transcription audience in particular, I’ve recently been struck by the disconnectedness between groups when I’ve talked about AHDI and CDIA (formerly MTIA) coming together to work on certain projects collaboratively. I hear comments about this being for transcriptionists and that being for inhouse transcription and something else being for transcription service providers and something else again being a problem caused by this group of service providers or by that particular company.

My fear? That if we don’t realize that we all need to be of one mind in understanding the role of transcription in the creation of quality health information, regardless of who is producing it and where it is produced, that the arguments will be moot in a few years…

There are certain truths about the use of medical transcription in the production of quality health information that are real regardless of whether or not the work is transcribed by an inhouse MT or a service MT, by an MT in India or an MT in Bismarck, North Dakota, by an MT working in a small physician practice, or an MT working for a huge global transcription service provider. Some of these are:

1. The documentation produced must be of high quality. It doesn’t matter if the work is produced in Oklahoma, in India, or on Mars. Without quality – the rest of the arguments for transcription fall apart.
2. The method of producing the work must be cost effective and efficient for the group performing the work – no matter who it is.
3. The work must be cost-efficient for the end user, whether it is a healthcare provider customer of an MTSO or the physicians in a practice with an on-site MT.
4. The work must provide value to the provider beyond being a typed document. If it’s only value is that it looks pretty on a printed page – then the work will disappear faster than you can say “customized formatting requirements.”
5. The process must be efficient for doctors from dictation to editing and review to sign-off.
6. The work must be completed quickly enough to be useful for patient care and HIM purposes.
7. We must understand the world of electronic records and the realities of how we can be a part of that world.
8. We must – and this is a biggie – produce the evidence that shows that transcription is a valuable part of health information. If we sound as though we are trying to preserve our businesses rather than trying to preserve health information that has value to the provider, then we lose credibility.

Is anyone interested in all of the various health documentation related groups coming together to promote, educate, and communicate about the things we must know now to remain a viable part of the health information ecosystem? If so, tell them about it. With AHDI/CDIA Advocacy Day coming soon, we must come together as one voice in support of the preservation of holistic health information.

Of note, CDIA’s national conference is coming up this week. Conferences are often a venue where the organization asks its constituents to listen to its leaders and speakers. But there is no better time to ask them to listen to you.

CDIA (formerly MTIA)

All the best,

1 Retrieved April 11, 2011 from

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