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|Electronic Health Records|
The Electronic Health Record (EHR)
The Healthcare Information Technology Revolution
Please note: As of April 2015, this page is currently under review.
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:
7/13/2017 » 7/15/2017
2017 Healthcare Documentation Integrity Conference