Working Together for Greater Outcomes

Sharing documentation best practices is a win-win for healthcare stakeholders.

By Bonnie Bakal for Advanced Healthcare for Health Information Professionals

One of my all-time favorite song lyrics is from Josh Groban’s You Raise Me Up and goes:
“I am strong when I am on your shoulders, You raise me up to more than I can be.”

This conjures up numerous possibilities when considering the importance and benefits of organizational alliances working together to achieve a greater goal outcome. Organizations seek out groups to ally with for various reasons – exchanging information and strategies, holding joint meetings, brainstorming, and solving shared problems.

AHDI’s annual meeting in August 2015 in Washington, DC, was in partnership with AHIMA’s CDI Summit. Both organizations are dedicated to accurate health records. This venue gave both the benefit of each others’ health care documentation concerns, past experiences, current activities, innovative solutions to often shared issues and future goals, and the memberships of both associations benefitted from this alliance effort and exposure to the challenges of each. AHDI’s membership attended AHIMA’s workshops and lectures and gained insight into handling healthcare documentation issues in different ways and were exposed to work place issues and concerns that they do not encounter on a daily basis.

Through the years AHDI has worked with several Healthcare Associations: AHIMA, HCCA, WEDi, and HL7 just to name a few, and more recently HIMSS and TJC. All of them voice a crucial need for accurate and concise healthcare documentation, and its importance for quality and continuum of care and patient safety. Innovative technology is a big factor in achieving these goals, and the importance of quality training and monitoring effective usage are at the core of successful, effective and accurate documentation outcomes.

Recently there has been a lot of conversation over the internet regarding offshoring/technology/quality measures/financial implications. Although many key figures in the standards arena have been kind, and listened to the concerns of invested healthcare documentation specialists, there is the constant ‘pat on the head’ and moving on to bigger concerns, most involving finances, placing patient continuity of care through unregulated healthcare documentation at risk. The Joint Commission published an article that stated that documentation by dictation, transcription, speech recognition technology, provider input, use of templates or another method needs to be reviewed to protect patients from injury or death. Dr. Ronald N. Wyatt with the Joint Commission was asked if there were any national standards related to medical transcription, and the short answer was that there are no standards for quality improvement for healthcare documentation, other than timeliness issues and some content requirements. When AHDI offered to be a resource to TJC regarding patient safety and the importance of regulated healthcare documentation, the response cooled.

While researching information for this submission, I came across the website for the Association of Clinical Documentation Improvement Specialists (ACDIS). This organization encourages healthcare providers to document the understanding of the patient’s conditions and choose and articulate the best treatment options for patients’ and thereby select the best outcomes which can be accomplished most reasonably financially.

ACDIS’s mission is “to serve as the premier healthcare community for clinical documentation specialists, providing a medium for education, professional growth, program recognition, and networking. AHIMA’s mission is “advance professional practice and standards.” AHDI’s Advocacy and Alliance Building mission is to “advocate for standards in education and practice in healthcare documentation to ensure the highest level of accuracy, privacy, and security in order to protect public health, increase patient safety, and improve quality of care for healthcare consumers.” Sounds like these associations and currently gaining national recognition scribes all have very similar goals and could benefit from the areas of each others’ expertise to command more attention for the benefit of the highest quality healthcare documentation to benefit the patient, the treating physicians, and our healthcare facilities in a win-win sharing environment that would enable us to become enough of a force to be reckoned with that the accrediting agencies in healthcare would place an overdue emphasis on the importance of the highest quality medical documentation product.

The dictionary defines “alliance” as a relationship forged between two or more individuals or groups that works as a positive for both parties and creates a bond. As AHDI looks to the future and to promoting accurate, timely and concise healthcare documentation, the association will continue to encourage beneficial alliance opportunities.