Capturing America’s Healthcare Story

Transcriptionists must get involved and advocate for every patient.

By Karen Fox-Acosta, CMT, AHDI-F, Written for Advance

Everyone likes a well-told story. Stories pass through the ages, sometimes through voice, sometimes through text, but not necessarily through bits and pieces of compartmentalized data. I believe we all can agree that computerized data is extremely useful, but it falls short of telling a meaningful story. As we move into the future of meaningful use and how it applies to healthcare documentation, the best patient story is captured through a unique blend of narrative and computable data.

Recently on the Association for Healthcare Documentation Integrity (AHDI) Lounge, Laura Bryan gave an excellent synopsis of the advancements that have been made with the Health Story Project in her blog titled: Health Story Project Update: ONC gets on Board. “The goal of the Health Story Project is to marry the best of both worlds — discrete data and narrative text — to create a rich source of information that is easily understood by clinicians and computers and easily exchanged between care providers.” Laura goes on to say how the Office of the National Coordinator (ONC) has agreed to work with the Health Story Project to incorporate the work they are doing and consolidate these standards into a single, easy-to-use guide. “The fact that the ONC is actively involved in this work signals their intention to include these implementation guides in the electronic health record (EHR) certification guidelines. This means that the ONC recognizes the value of both discrete data and narrative information in the “meaningful use” of an EHR.”

In healthcare, it is the comprehensive story combined with meaningful, accurate data and the direct correlation to patient safety and risk management that remains the focus of the advocacy efforts of AHDI and the Clinical Documentation Industry Association (CDIA). We invite you to join us as we converge on Capitol Hill for our 6th annual Advocacy Summit on May 4, 2011, and as we build strategic alliances throughout the years. Having a completely robust electronic health information process that captures the patient’s encounter as told by the clinician, creating an information-rich full narrative that contains data in the background that is computable, with the story being captured in such a way that the reader (the clinician, the patient, the patient’s family, the consulting physician, the insurance provider, the legal defense team) can build a complete picture of the health processes of the patient, ideally documented from birth to end of life. Just think what that could look like, patients with their entire life’s healthcare history captured in a cohesive, portable way. Dewey Square Group will be working with our advocates on the Hill, providing strategic meetings with key legislators as we continue to build champion relationships and share why what our profession does matters to America’s healthcare story, meaningful yet practical use.

With at least 1.2 billion patient reports created in the U.S. every year, health information documentation professionals, medical transcriptionists and medical transcription service providers, and our allies are poised as the greatest voice to advocate for the patients we may never meet. Stories like the one Jennifer Lyons told during her Hill visits of a day in the life of a young boy who came to the hospital where she worked and how she documented his hospital encounter, from ER visit to admission history and physical to discharge summary. Or Kat King quoting from our dictation error abstract and asking which potential errors in their own health records (or their parents or children) would our legislators want to remain and, exponentially, be repeated with an interoperable EHR. It is these well-told stories that have grown through individual, local, state and national volunteer advocacy efforts that have changed the minds of decision-makers. As AHDI and CDIA ramp up our advocacy efforts, as we work hard to connect with our health information management and health information technology peers, as we develop alliances with local and state healthcare practice and patient safety organizations, as we build public awareness, and as we promote credentialing as a benchmark for working in this field, I reach out to all our allies in healthcare delivery and ask that you join us in advocating for every single patient our healthcare records represent, and yes, I’m here to recruit you to become a voice for America’s healthcare story.