The Classroom vs Practice in Health Information

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As M*Modal heads out to Salt Lake City today to attend the 2011 AHIMA Convention and Exhibit, I thought it particularly appropriate to kick off the week with a guest posting from a relatively new member of the M*Modal team and graduate from the University of Pittsburgh’s HIM program, Nathan Gibbon. Today’s HIM students spend a great deal of time learning about the benefits of electronic health information and it is interesting to hear about their experiences in the real world after they graduate.

Nathan Gibbon graduated from the University of Pittsburgh’s HIM program in the spring of 2011, after which he was hired as a healthcare implementation business analyst by M*Modal. Before graduation, Nathan did his six-week clinical at M*Modal working on the identification of information for core measures reporting in documentation. Nathan’s senior project, “Using Natural Language Processing to Improve Reporting of Core Measures for Pneumonia,” completed with fellow Pitt student Dino Mascio also at M*Modal, won first prize at Pitt’s 2011 SHRS Student Advisory Board Poster Competition. So, please welcome guest blogger, Nathan Gibbon.

I attended an excellent Health Information Management program at the University of Pittsburgh. I was taught well, and I enjoyed my time there. In my classes we learned about the Electronic Health Record (EHR) and Electronic Medical Record (EMR), and how they have and will revolutionize the healthcare industry. I learned how the electronic systems will provide ongoing documentation of patient information that doctors will be able to access from all over the world.

Fast forward two years later…I am now working for a company which seamlessly integrates its speech recognition and natural language technologies into healthcare documentation workflows, and which helps to increase adoption and usability of electronic health records. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. These acts saw a plethora of electronic health record systems spring up, along with hospitals spending big money to have the systems implemented.

The textbooks provided for my classes went over workflows, systems analysis, waterfall diagrams, Microsoft Access databases etc….all to help an electronic record system be created, implemented, and used effectively. One of the best experiences the program gave me was the Clinical Experience class. We had four individual clinical experience sessions, one per semester. In this class, the students were sent to a hospital, somewhat of our choosing (I picked one close to my house), and were placed in the Health Information Management Department or Medical Records Department. Not everyone’s facility was the same, but for the majority of us, we had similar experiences. I was shocked to see that this hospital was able to run on such little staff, rushing around a basement floor with paper records. Some records were stored on moveable shelves (that I played with frequently when bored), others were stored on random carts, and others were left on the floor of a dark room. The hospital I was assigned to failed to comply with some standards for housing medical records set by the Joint Commission, (formerly JCAHO). Several of my classmates spoke of their clinical sites in the same manner. The facilities simply did not have the room to house all the medical records – not to mention that paper records deteriorate over a long period of time. From that experience I saw the desperate need for the electronic health record in healthcare. All the space, time, and resources wasted on the paper records could be simplified if they were made into electronic format. I was onboard.

For my final clinical experience, CE4, I requested to be placed at a local health information technology company, Multimodal Technologies (M*Modal). The company provides an on-demand Software as a Service (SaaS) business model (in “the cloud”) and their solutions are all based on a standard for information exchange, HL7 CDA. When I first began my Clinical Experience 4, I thought this company was a competitor of the major EHRs in the healthcare world. However, after a talk with the Chief Technology Officer (CTO), Detlef Koll, I learned otherwise. M*Modal can help to increase adoption of the EHRs which might otherwise be cumbersome for healthcare providers to use. Some hospitals implemented major brands of EHR systems which I was surprised to learn do not communicate with other systems because they do not use a standard format for data exchange. This means there is zero interoperability, something we learned from our textbooks that electronic health records would provide.

In conclusion, the way health information management and electronic health records are described in textbooks does not exactly play out in real world scenarios. The information I learned in school was very helpful, and the benefits of EHRs are real, however, the healthcare environment won’t see those benefits when systems cannot readily communicate with adjacent systems. In conjunction with systems being able to communicate and being able to transfer data, systems should be built specific to what the users really need. This will prove to be a long and difficult process. Software vendors will have to spend many hours studying physicians and healthcare providers in order to understand exactly how they are interacting with the system. But until that work is done, systems will continue to be cumbersome for those that interact with them.

Nathan Gibbon
Healthcare Implementation Business Analyst

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!

Response to Questions…

Hello everyone:  Over the past couple of months I’ve been privileged to present at several conferences and to do a couple of webinars. Since then some questions about these presentations have been sent my way (thank you!).

I thought it might be helpful to provide some links to some past articles that might be of interest to anyone who has questions about some of the presentations.

Thanks so much for proving once again how dedicated the people in the health information industry are to providing and producing high-value health information!

As always, questions and comments are most welcome!



Speech Recognition – general

Is Speech Recognition the answer to all your problems?

Speech Rec is here to stay…

MT Compensation and Management

MT Compensation

The Demise of the Career MT

ACE 2010 Presentation – Keeping Transcription Relevant into the Future

What Factors Contribute to MT Career-Mindedness?

Slides from NEMA AHDI Presentation…

Optimization of speech recognition Technology Results

When Metrics Mean Nothing – The Myth of the “Percent Gain”

What does the Medical Transcription Industry Sell?

Narrative Documentation, Standards

Are we Telling the Real Health Story?

A Vision for Truly Meaningful Health Information

Speech Recognition as the Accelerator of Meaningful Clinical Documentation

Hello everyone: Over the last couple of weeks I had the opportunity to attend several conferences. One was the national conference of the Case Management Society of America (CMSA) (more about this visit later) which was held in San Antonio, Texas, (home of the Alamo). Then I had the privilege of presenting to two state HIMA conferences; New Jersey (NJHIMA) in Atlantic City, and then back to Texas (TxHIMA) for their state conference in Dallas.

As always, I really enjoyed meeting with state HIMA members. It is so satisfying to know that wherever you are in the country, HIM professionals have the same passion for safe, high-quality, useful health information. It is also interesting to see that everyone seems to be facing the same challenges with respect to adoption and use of electronic health records. Everywhere I go, I hear the same stories about point-and-click, template-driven EHR systems that are time-intensive and cumbersome for the physician, that don’t provide the necessary information for the HIM, and which cause concerns for the health care enterprise because of costs and questionable ROI.

Needless to say, there is always interest in discussing narrative documentation including how to produce it cost-effectively and efficiently, and how it can be used to generate the discrete data needed for the interoperable exchange of information, to provide data for reporting and analysis, to drive clinical decision support and other automated care protocols, and in general, to realize the benefits that we all expect as we make use of electronic health information.

Some of you have seen these before, but just in case, here are my slides:  NarrativeDocumentation_HIMA_20110629.

In a nutshell:

1. Today’s changing health care environment is setting higher standards for documentation while seemingly making it more difficult for physicians to document patient care. The need for documentation to support Meaningful Use, to drive the communications and reporting necessary for Accountable Care and the Patient-Centered Medical home, to enable the conversion to ICD-10 from ICD-9, and to support the reporting required to monitor quality and outcomes is increasing. It is more apparent than ever that comprehensive, complete, and accurate health information is integral to the functioning of any health care facility. And yet newer methods of documenting patient care are often inefficient and time consuming for the physician and are not intuitive for other consumers of health information.
2. Dictation is still a viable, economical, and effective means of capturing clinical information.
3. In order to be cost- and time-effective, options for clinical documentation must be made available based on the type of encounter being documented and the needs of the user. For some encounters, templated, structured forms are likely sufficient. For others, physicians may do very well with speech recognition and self-editing. For more complex encounters, physician dictation supported by skilled medical transcription might still be the best way to go. The point is – health care providers must have flexibility and options for capturing the complete, comprehensive level of information required to support patient care, coding for billing and reimbursement, research and population health reporting, and all of the other uses for health information.
4. Speech recognition and other technologies, when combined with efficient management practices, can be a cost-effective way to produce high-quality narrative documentation.
5. We cannot continue to look to the best practices that many services and providers have historically followed when implementing speech recognition. In the past the goal might have been to “create cheap documentation fast” – now the goal for clinical documentation MUST be, “create useful documentation efficiently.’
6. Quality is key. We are all hearing a great deal about natural language processing, computer assisted coding, and other technologies that will help us to process and make use of our health information – but if the documentation at the foundation of these technologies is poor – the technology can’t do its job.
7. Efficient management practices are another key component. The percentage of productivity gained does not necessarily reflect the increase in output! Again, technology is no replacement for effective management practices.
8. It is not, as many believe, necessary to eliminate narrative documentation in order to have semantically interoperable electronic information. The Health Story, HL7, IHE Consolidation project is making great strides towards the creation of interoperable standards for the exchange and use of health information which will allow us to have the structured and encoded clinical data that we need to support automated processes, while at the same time retaining the human-readable narrative information that is required for communication and understanding. I personally have always been a big believer in having my cake… and eating it too. 

If you have any questions about the slides or the presentation please let me know. I’d love to hear your thoughts and experiences!

Till 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.

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

Health, Information, and the American Way!

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Good morning everyone!  I am very excited to be heading to Washington, DC to attend the AHIMA Team Talks and Hill day events!


Well, first there is the fact that I’ve always been a little bit of an “advocate” at heart. From the ecology club I started in the 7th grade (sigh – only 4 people joined including me), to the letters I used to write on behalf of multiple causes, to the daughter I raised who once failed a history test because she refused to give the desired answers to questions about Christopher Columbus (because he was a usurper of the indigenous people) and who only a couple of weeks ago kindly rearranged books in Barnes and Noble because books written by and about Frederick Douglass were only shelved under “Cultural Studies” and not under American History where  they belonged, I am appreciative of being allowed to be a part of the democratic process that is the United States of America. After all, we’re only here because of a little effort conducted by a band of “advocates” known as The American Revolution, right?

Second, it is important. Health care in our country is in bad shape and health information and technology can play a big part in helping to improve care and to decrease costs.

What is advocacy? According to Princeton University’s WordNet, (2011) advocacy is the, “active support of an idea or cause etc.; especially the act of pleading or arguing for something.”

Yep, that sounds about right.

But what does that have to do with health information?

I’ve referred to HIM previously as the “keeper of the keys” for quality health information, and AHIMA is the keystone of HIM. According to the paper About the American Health Information Management Association (AHIMA) made available on the AHIMA Communities of Practice Hill Day community, “AHIMA members believe you achieve quality health through quality information” (2011).

Yep, that sounds about right too.

But with so much change happening in the HIM realm including health care reform and its associated Meaningful Use requirements, advances in technology, the coming conversion from ICD-9 to ICD-10, it is easy to lose sight of what “quality information” really means, and what we, as a profession, must do to preserve and maintain it.

AHIMA, as an organization 60,000 people strong, has a big voice in advocating for health information. AHIMA organizes its Hill Day as a means to provide members with opportunities to meet to discuss relevant topics, and then to talk about these topics with our elected officials. In short, AHIMA provides us with a wonderful opportunity for advocacy.

On Tuesday during our meetings with our representatives in the 112th Congress, AHIMA members will focus on the following (AHIMA, 2011):

  • The HIM profession and the AHIMA association – who are we and what do we do? Our strategic focus on key points such as the adoption and implementation of the EHR, health information exchange, guidelines for interoperability including attention to standard terminologies and classification systems, privacy and security of health information, ICD-10, and more.
  • Support for the “Health Information Professions Advancement Act” which will address the need for the HIM profession and shortages of knowledgeable, trained professionals.
  • Protection for HIT and HIM initiatives established as part of ARRA-HITECH including Meaningful Use.
  • A solution for the patient identity challenges encountered as HIT evolves.

I will be blogging and tweeting from DC – so stay tuned as Lynn goes to Washington!

You can find more detailed information about AHIMA’s Hill Day on the AHIMA website.

Of note, AHDI/CDIA has its Advocacy Summit scheduled in DC for May 3-4.

See you on The Hill!!


Director of Health Information Services



Asmonga, D. (2011) About the American Health Information Management Association (AHIMA). Retrieved March 26, 2011 from

Princeton University WordNet. (2011).

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