March 2014

Bring It On — MTs Welcome Documentation Roles
By Jill Devrick, MPA
For The Record
Vol. 26 No. 3 P. 6

Although speech recognition and EHR technology have reduced the demand for traditional medical transcription, many health care organizations have decided to retain and repurpose transcription resources by introducing new staff roles to enhance documentation quality in innovative ways.

Last year, the Association for Healthcare Documentation Integrity (AHDI) recognized this trend toward broader roles and endorsed the title of health care documentation specialist (HDS) as an umbrella description for individuals who are involved in any way with the creation and editing of health care documentation.

New roles for HDSs gradually are emerging as health care organizations change the technology and workflows used to capture patient care data and physician narrative. Some HDSs have been quick to seize these opportunities. “Our transcription department managers have been very open with us regarding looking at new roles and preparing for changes happening within the transcription field, so when the new technical position opened up, I applied,” says Sarah Spoelman, a department technical analyst at Michigan-based Spectrum Health. “I felt it was a great way to use my transcription skills and also learn new things that would help me stay active in the health care field while still being in contact with transcription and HIM. I also thought it was a great opportunity to showcase how transcriptionists can fit into other positions because of the skills and knowledge set we bring to the table.”

Lori Pospiech, CHDS, a provider trainer at Spectrum Health, found opportunity in an educational capacity. “With the winds of change long blowing in the field of medical transcription, I was searching for ways to use my knowledge of health care documentation other than traditional transcription,” she says. “I was given the opportunity to try my hand at training providers, which requires that I learn and stay informed about new technology. I now enjoy the best of both worlds. When I’m not training, I still transcribe as well as edit voice-recognized documents.”

Many HDSs continue to transcribe, edit, or provide quality review services while taking on additional roles. Some may take part-time roles assisting the coding department, including data entry (if their organization has transitioned to an online record) or researching claims that need additional information before being submitted. Others have moved to new full-time roles focused on IT support and training, quality assurance (QA) and auditing, and HIM.

Coding is a path that some HDSs are encouraged to pursue because the required knowledge and skills are similar to transcription. Areliz Cruz, CCA, a clinical coder at Lancaster General Hospital in Pennsylvania, recently transitioned from transcription to coding after obtaining additional training and certification. “I found both the health care documentation specialist and clinical coding roles to be a very good fit for my background and skill set,” she says. “As a transcriptionist, you need to have attention to detail and a good understanding of anatomy, pharmacology, and the medical record, all of which have helped me transition to my new coding role.”

Education
Regardless of their role, most HDS pioneers say that seeking additional training and learning more about the applications they’ll be using or supporting is essential. However, HDS knowledge and experience is an excellent foundation.

Dee-Marie Broyles participated in extensive training to become an Epic applications analyst for Oregon-based Asante Health System. “In order to become an analyst and participate in the development of the Epic electronic medical record for Asante, I had to become certified, which entailed traveling to Epic headquarters in Wisconsin for training as well as completing tests and a project,” she says. “I also attended mammography training to learn how to build and maintain the mammography module.”

Julie Staal, CHDS, a speech recognition QA specialist at Spectrum Health, built on her CMT credential to transition to a new role. “I was certified originally, but I have since studied and passed the bridge course through AHDI and now hold the title of certified health care documentation specialist,” she says. “The course was difficult, with testing in the areas of operative procedures and surgical equipment, classification of systems, as well as health care documentation, EHR terms, meaningful use, and front-end/back-end speech recognition terms.”

Many medical transcriptionists (MTs) find that HDS certification is an asset when transitioning to a new role because it serves as validation of their professionalism and competency among colleagues and providers.

Providing Essential Skills
Individuals with a medical transcription background have essential skills beyond keyboarding and understanding medical language. “Medical transcription prepared me with a foundation of excellent critical thinking skills and problem-solving abilities,” says Sarah Barton, CHTS-IM, CCA, an HIM specialist III for Utah-based Intermountain Healthcare. “As a transcriptionist, I learned how to work efficiently while on production pay but also maintain accuracy. That is a skill that is very attractive to HIM employers, especially as we move into the electronic health record.”

Provider organizations are realizing that MTs are a natural fit for EHR documentation roles. With their knowledge of unapproved and dangerous abbreviations, common misspellings, and incorrect medications, terms, and dosages, MTs can play a significant role in finding and addressing documentation issues that can impact patient safety and compliance. “Achieving and maintaining the highest quality of documentation necessitates much problem solving, investigative work, and understanding what factors into the final documentation of a health record,” says Joan VanVels, CHDS, a QA team member at Spectrum Health. “I understand aspects of legality but also aspects of integrity concerning a person’s medical record.”

Kelly Bortzfield, CMT, an HDS at Lancaster General Health, also relies on her transcription background. “The medical knowledge that MTs have gives us the perfect background to perform auditing of self-generated reports by the providers or auditing the work of other MTs for data quality. It also lays a good foundation for a possible move to coding,” she notes.

Beyond the Keyboard
HDSs who have confronted the uncertainty of moving outside of their comfort zones overwhelmingly are positive about their experiences. “It is very exciting and challenging every day, which I love,” Spoelman says. “I have been able to use the transcription and computer skills that I gleaned as a transcriptionist and really build on them. I like being able to work with so many people in so many different departments and show off the skills transcriptionists can bring to the table and what an asset we are.”

The future excites pioneering HDSs, who are both realistic and optimistic. Many cite the need for QA and predict that an emphasis on accurate medical record documentation will become the focus of health information systems as actual transcription and medical editing decrease.

Spoelman is keeping an eye on the movement toward more provider-created documentation. “I have been working closely with HIM and many other groups to bring in my knowledge of how transcription and physician workflows will be affected so that we don’t have any impact to quality patient care or documentation,” she says.

Barton views the redefining of MT roles as an opportunity. “Everything in health care is constantly evolving, and HIM, transcription, and coding are no different. My role will change as we move from a hybrid record system to a traditional EHR. The implementation of ICD-10 may certainly impact my work, though not as directly as it will the coders,” she says. “This is something I love about HIM, though. I love that everything is constantly changing, and there is always something new to learn and a new skill that needs to be mastered.”

VanVels also has a pragmatic view of change: “I made the decision a long time ago to not fight change but empower and educate myself in order to carve my path in this ever-changing field. It is an exciting time with a career that is evolving. I am able to utilize my medical transcription skills but also utilize my strengths, which include understanding what entails accurate and quality-based health care documentation.”

And Staal is happy to be helping shape the future of her profession: “Who better than a transcriptionist who has been certified, trained to be quality driven, versed in HIPAA compliance rules, confidentiality, and all aspects of the medical record? Who better to help form and contribute to our future role?”

— Jill Devrick, MPA, is president of the AHDI’s national leadership board and a product solutions advisor for eHealth documentation solutions at 3M Health Information Systems.