See the "For the Record" article Unfinished Business here.

I maintain this will continue to be an issue as long as there are no proper and enforced quality management standards related to the healthcare documentation process.  In my opinion, sorting out and pointing out doctors creating documents being an issue?  That is a guess on our part.  The EHR is here to stay, as it should be.  Doctors have to document, they just do.  They are either going to dictate, write a handwritten note, or use a computer platform.  There is no value in talking about the "EHR" as a whole as a bad thing for clinicians to be using.  Rather, quality management procedures help documentation experts objectively identify when and how and why different scenarios make sense and how to assure the quality in those settings.  The EHR has amazing value.  We are never going to be invited to that party if we speak from 10,000 feet saying it's all bad.  Rather, what we want to do is, same as traditional and speech-recognized transcription, paper charting, and scribing....identify when these different procedures make sense, how to implement processes that check quality, identify when a transcribed report makes sense versus the clicking and pointing data (really great medication systems in EHR platforms), how do we manage the quality in all of them?  Why are we spending time criticizing the manner in which clinicians do their initial documentation?  Whether they speak it, write it, type it, click it, all of it requires proofing and quality management.  There is no one system that works for "once and done" in this important documentation.  All other industries employ better editing and proofreading than we do in the medical industry.  The argument about which human makes less errors in what setting?  This is not arguable.  The question is, how do we assure the human errors of doctors, nurses, pharmacists, and medical transcriptions (yes, the wonderful perfect transcriptionist who has the ability to see and correct all medical errors and makes none themselves...ugh...what a burden we have on our shoulders).

As my mom used to say when we tattled on each other, "You just take care of Debbie.  That's a full-time job."   I propose when the medical transcription industry cleans its own act up, we can venture out into other neighborhoods to share our wisdom.  Our own industry is the remains of a bloody massacre, the issues still ignored and the plight of our industry blamed on anyone and everyone but ourselves.  Medical transcription messes were/are made by medical transcriptionists (MT workers, MT owners, MT managers, MT leaders).

But, the article points out something interesting to me and something I have pointed out to Dr. Baker at The Joint Commission, that is, TJC studies and publishes findings about accreditation failures in medical records, but apparently doesn't marry the connection that there the professionals managing this part of the healthcare process, are not schooled in and required to use, what they, themselves espouse, "You can't fix what you don't measure."  Is it a big mystery that one of the most failed aspects of hospital accreditation is in an area that is not required too perform ongoing quality management?  Is this rocket science?

I will keep pushing on there, The Joint Commission, because when they mandate that our industry properly learns how to manage quality, now we can get somewhere.

1 Comment

  1. Lynne Martin Veilleux - June 29, 2016, 10:37 am

    This part of the article I very much appreciate: “Providers are simply not documentation specialists. We need them to focus on providing top-notch care, and leave top-notch documentation to the health care documentation specialists,” she says. Some providers are very good at documentation. However, we tend to not see our own errors. When providers prepare their own reports, their work should be verified by a second set of eyes. The possibility of missing an important detail or making a critical error is lessened by a second set of eyes. This should in no way be a punitive process. When providers dictate their reports, there would need to be more collaboration between the dictator and those transcribing to ensure a better record. When you work remotely, you are often not even allowed to contact the dictator for clarification, simply leaving an edit note. There seems to be a lot of stigma with leaving blanks or notes for clarification. It is for the good of the record that this is done, and it does not happen nearly enough. The production-based pay of transcriptionists also does not lend itself to more collaboration as that would lead to more unpaid work. As we progress, it would be important to provide medical documentation specialists with hourly pay to help address the issues that fail to be addressed under the status quo.

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