One of the more significant announcements to come out of the 2010 AHDI Annual Convention and Expo was the release of the newly revised Healthcare Documentation Quality Assessment and Management Best Practices (PDF) document jointly prepared by AHDI, MTIA and AHIMA. This guide contains some noteworthy changes to the way quality assurance is performed within the medical transcription industry. Highlights include:
– Alignment with the Plan-Do-Check-Act (PDCA) cycle.
– Principles of Quality to include verifiability, definability, measurability, consistency, and integrity.
– A thorough examination of blanks, including valid and invalid causes for blanks.
– Recognition that the transcriptionist is only one of a number of individuals who can affect the quality of a transcribed document. These include the dictation author and facility staff as well as other medical transcription service organization (MTSO) personnel.
– Recommendations for both concurrent and retrospective review procedures.
– Recommendations for a random sampling of 1% per month to assess accuracy levels.
– Recommendation for using the “Error Value from 100” method of QA scoring which assigns an initial value of 100 to every document, regardless of length.
– Recommendation that any document containing one or more critical errors be deemed a failed document.
– Discussion of the need for a Continuous Quality Improvement (CQI) process within the QA workflow.
– Introduction of a new error category: Feedback and Educational Opportunities, defined as errors which “do not change the meaning or have the potential to affect patient care” and for which no point deductions should be taken.
– run-on/fragment sentences
– slang and inflammatory remarks
– inconsequential typos and omissions
– capitalization of drug names
– incorrect word forms (femur/femoral)
I’ll let you ponder the implications of the above for a moment before proffering my opinion that the creation of this new category of errors represents a seismic shift of epic proportions for “old school” MTs. I’ve been a medical transcriptionist for “only” 10 years, but it didn’t take me nearly that long to understand that if there was one thing that defined an MT, it was that we were the “keepers of the flame” for the importance of “correct” grammar and punctuation. The fact that we can and do debate ad infinitum the proper placement of a comma has been a point of pride with us.
Welcome to the brave new world of electronic healthcare documentation!
The fact is that we are now in an era where content takes precedence over form. I know there will be those who will proclaim to their dying breath that grammar and punctuation transcend mere form. But whether we like it or not, a grammatically correct sentence has become far less important to modern healthcare providers than a medical record that contains the essential facts necessary for the delivery of adequate care and the acquisition of timely reimbursement. As structured data becomes the de facto standard for electronic medical record systems, grammar and punctuation become less and less important in the big picture.
Although I have no idea whether or not the authors of the new QA best practices guidelines had this intention in mind, it seems to me that the introduction of this new class of–dare I say it?–“unimportant” errors is a perfect metaphor for the changing role of medical transcriptionists in an EMR era. It would be hard to envision a more emphatic, attention-grabbing declaration to the MT profession that our value must lie somewhere besides our ability to properly place a semicolon. There have been many of us, myself included, who have talked about the importance of “critical thinking skills” for the successful MT, but I’m not sure all of us have had a broad enough view of what those skills must include in today’s healthcare environment. By clearly delineating grammatical-type errors as being relatively insignificant to the overall meaning of the patient encounter, in my opinion the QA best practices authors have provided an unmistakable wake-up call to our profession.
What are your thoughts about these new QA guidelines? Do you think this de-emphasizing of the importance of grammar and punctuation is helpful, harmful, or irrelevant to our industry’s attempts to preserve the use of narrative dictation in healthcare documentation?
Jay Vance, CMT, AHDI Lounge Administrator/Moderator for the AHDI Lounge