The Fortune Cookie Message

The fortune cookie is always the highlight of a Chinese dinner. Dining out with my hosts tonight at a Chinese restaurant in Desert Hot Springs, California, one of our fortunes read "Integrity is doing the right thing, even if nobody is watching." An appropriate message for how we lead our lives and for the responsibilities we have in the medical transcription and clinical documentation sector. This past week we had the privilege of presenting at the Healthcare Compliance Association convention in Chicago and our message to compliance officers was similar to the fortune cookie message -- wake up to the sloppy dictation and documentation practices going on in healthcare facilities around the country. Not only is it the right thing to do, but poor dictation and documentation habits in an electronic health environment will increase the number of medical errors to exponential proportions, threatening the integrity of the information captured and exchanged within the broader system.

Cathy Baughman, CMT, FAAMT, 2007 AHDI President, showed errors that went unchecked from the Children's Hospital Radiology Department in St. Louis, Missouri, following implementation of front-end speech recognition and self editing from the radiologists. This example is not confined to radiology at Children's Hospital in St. Louis, it is rampant in the healthcare industry because quality data standards are non-existent. Policy makers and architects of the National Health Information Infrastructure hope to one day see consumers access their health information similar to using an ATM card to access their banking information. The ability to exchange healthcare information that is usable, relevant, and accurate is critical to this goal. Look forward to a legislative agenda from AHDI and MTIA promoting these important principles.

In the meantime, AHDI and MTIA, along with AHIMA and M*Modal are working on implementation guides using HL7's clinical documentation architecture for common narrative reports beginning with tags that will enable the History & Physical to be exchanged across healthcare systems. However, even with the proper computer tagging and taxonomy in place, if the information going into the system to begin with is inaccurate, it will remain inaccurate. We still must address the issue of good dictation and documentation hygiene. AHDI recently released a Dictation Best Practices Tool Kit, generously sponsored by MedQuist, to assist clinical authors in becoming more efficient and effective with their dictation. We have widely distributed this tool kit at several national conventions and through AHDI local and state/regional components to assist dictators in doing the right thing.

429 miles driven today