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The Electronic Health Record (EHR)

The Healthcare Information Technology Revolution

A significant early part of national healthcare reform is focusing on an initiative (being overseen by the Department of Health and Human Services) that will help the nation move toward a truly interoperable health information exchange infrastructure – the goal of which is to move the nation’s predominantly paper-based patient information system into an electronic format that will allow patient health information to be securely exchanged between health enterprises. Consider a future where your entire medical history, from birth to present day, is accurately captured and stored in a way that can be accessed by any health provider or facility anywhere, anytime. Imagine such record being equally accessible to you as a patient and to which you are a participating contributor. It is the hope of both the government and healthcare delivery that such a degree of seamless interoperability between healthcare facilities, physicians, other care providers, nursing homes, pharmacies, etc., will streamline medical care, reduce and/or eliminate redundancy/duplication of care and testing, save time, improve patient care, and ultimately reduce costs for healthcare services in an already fiscally burdened delivery system. The impact of this technology on the healthcare documentation industry is far-reaching.

In response to this national mandate toward EHR implementation, AHDI and CDIA worked collaboratively to address the role of the medical transcription sector in helping to facilitate this goal. In Medical Transcription: Proven Accelerator of EHR Adoption, the associations delivered a powerful message to legislators, healthcare delivery, and industry stakeholders about the importance of the dictation/transcription process in ensuring accurate, comprehensive health data capture – citing dictation and traditional transcription as still the most widely preferred method for capturing patient care encounters and a critical consideration for any integration of EHRs into the way most healthcare enterprises manage health information. The associations have continued to work toward the goal of ensuring an option for complex, codified narrative in the “Meaningful Use” definition for EHR adoption as well as advocating for the role of an analytical knowledge worker in this process.

EHR Readiness Tool Kit

A significant challenge for the clinical documentation sector will be forecasting both the rate of EHR adoption nationwide and the degree to which healthcare documentation roles will evolve and change as a result of this technology. While some things cannot be predicted, most experts agree that the demand for data integrity will only increase, creating an opportunity for the risk-management skill set of the medical transcriptionist. AHDI and CDIA continue to advocate for the tacit knowledge of our workforce and the value that an interpretive knowledge worker can offer in tandem with these enabling technologies. An accurate, complete health record that can be securely stored, accessed, and repurposed within an interoperable delivery system is healthcare’s primary goal for EHRs, and the MT who understands the technology and its objectives can help facilitate high-integrity adoption and integration as well as continue to be an evolving, contributory player in health data capture and documentation.

To that end, AHDI has developed an informational tool kit designed to orient healthcare documentation workers to the electronic health record, what it means to healthcare organizations seeking to adopt an EHR, and what an MT needs to know in order to prepare for that transition as a member of the health information management team. Each downloadable file below will provide MTs with information, resources, and expert opinions on how to navigate this transition:

  • About the EHR: Frequently Asked Questions – A walk through fundamental definitions and explanations of electronic health record technology and how to prepare for the transition.
  • EHR & Technology Abbreviations/Acronyms – A quick reference for the myriad abbreviations and acronyms used in healthcare delivery to denote clinical documentation terminology, standards, technology protocols, and related standards organizations.
  • EHR Major Players – A resource list of major organizations who have a vested interest in and/or regulatory oversight for the development and implementation of electronic health records (including ONCHIT, DHHS, and Health Story Project) as well as an overview of each organization’s role, purpose, and objectives.
  • EHR Implementation Case Studies– Scope, objectives, outcomes, and insights offered by three healthcare documentation professionals with frontline expertise in EHR purchase, adoption, and integration within healthcare organizations.
    • EHR Implementation – Case Study #1 (Everett Clinic): The Everett Clinic is a physician-owned primary and specialty care group with eight satellite offices and two ambulatory surgery centers. EHR implementation for this facility resulted in a staff reduction from 25 MT employees to a staff of 3. Sharon Cordisco, Transcription Manager, describes the implementation and outcomes.
    • EHR Implementation – Case Study #2 (BryanLGH Medical Center): BryanLGH Medical Center, Lincoln Nebraska, is a not-for-profit, locally owned healthcare organization with two acute-care facilities and several outpatient clinics. With EHR implementation, the transcription department did not see a decrease in dictation, but rather an increase. Leigh Anne Frame, CMT, HIM/Transcription Manager, describes the process and impact on the MT staff.
    • EHR Implementation –Case Study #3 (Fletcher Allen Health Care): Fletcher Allen Health Care is a 562-bed, non-profit, academic medical center in Burlington, Vermont. The organization provides care at more than 35 patient care sites and 100 outreach clinics in Vermont and upstate New York. Kelli Provost, CMT, transcription manager, reports that implementation of their EHR has not significantly changed the role of the front-line medical transcriptionist. It has dramatically impacted management job responsibilities and has added a new role – that of monitoring the interface error messages and resolving them.
  • EHR Frontline Focus Groups – AHDI hosted two probative focus groups to generate insight and feedback from individuals and organizations that had already participated in an EHR integration initiative within or in coordination with a healthcare organization. The transcripts for those historical discussions are available below:
    • Business Owners Focus Group (May 27, 2009) – A group of industry business owners met to discuss the integration/adoption experiences, focusing on how transcription service providers best work with clients in implementing EHRs and discussing the impact of EHR integration on cost and service provision.
    • Practitioner Focus Group (May 28, 2009) – A diverse group of 6 medical transcriptionists, managers, supervisors, and QA coordinators were convened to address integration/adoption experience and what role the MT can play in facilitating more efficient, coordinated integration of the technology with the dictation/transcription process.
  • MTs as EHR Facilitators (Flyer) – This one-page flyer is designed to assist MTs in promoting the value of their services as EHR facilitators. An MT who has utilized the tool kit above to prepare for EHR integration can be of significant contributory value to a physician or clinic that is looking at the challenges of adoption. This flyer can be downloaded, duplicated, and distributed to clients, employers, and colleagues to promote this emerging role for MTs.