As the healthcare system changes under pressures from governmental, regulatory, and third-party payer sources, the educational standards for the professions of healthcare must change as well. Healthcare documentation - also called medical transcription - is no different. For this reason, the Association for Healthcare Documentation Integrity (AHDI) recently announced changes to its model curriculum and its education approval program, which is the process that ensures that healthcare documentation schools and colleges meet certain standards.
Model Curriculum, 5th Edition
The Model Curriculum is the cornerstone of educational approval for healthcare documentation specialist programs. AHDI's Approval Committee for Certificate Programs (ACCP) has been revised to require schools to follow the AHDI Model Curriculum for Healthcare Documentation, 5th edition, which was released earlier this year. Certainly the most obvious change in the Model Curriculum is that of the profession's name, from medical transcription to healthcare documentation. The new name was chosen to reflect the broader core knowledge of today's professional, which still encompasses high levels of medical terminology and anatomy and physiology expertise but now adds documentation security and additional editing skills.
An example of a new competency in the Model Curriculum is one from the Medicolegal Aspects of the Healthcare Record course, which requires students to "understand general documentation concepts related to optimizing reimbursement." This means that students should know what is needed in the document to ensure reimbursement - not that students must learn to code.
eSource for Healthcare Documentation Instructors
The volunteers who revised the Model Curriculum were so enthusiastic about its new courses and standards that they created a virtual teachers' manual and electronic community for healthcare documentation educators. The eSource includes not only sample lesson plans and tests but also access to an online community of healthcare documentation teachers who share ideas and strategies for improving student skills. For more information on this subscription-based product, see the eSource for Healthcare Documentation Instructors: A Vital Resource for Users of the AHDI Model Curriculum.
Educational Program Approval
The ACCP program has been improved from an administrative standpoint to better evaluate programs for compliance with AHDI educational standards. Schools applying for approval must complete a self-study, which is submitted for peer review by ACCP reviewer representatives. Perhaps the biggest ACCP change is the new requirement for an annual report from approved schools. In this, schools must report any changes in their curriculum and staff, such as a different dictation product or new instructors.
Importance of Well-Educated Healthcare Documentation Specialists
As the national impetus to adopt electronic health records has accelerated, the role of healthcare documentation specialists has changed. While the dictate-transcribe model is alive and well, the healthcare industry needs us now more than ever to ensure accurate content in healthcare documentation.
Where an inaccurate record, perhaps a front-end speech-recognized radiology report, once stayed within a paper chart or electronic health record at a single institution, that information now can follow patients not only within a given hospital system but throughout healthcare via health information exchanges and other record-sharing technologies. Dr. Annette Johnson detailed problems that ensued for a patient when a front-end speech-recognized radiology report ruled out deep venous thrombosis (DVT) in a patient, yet the word "no" was left out of the report. The patient underwent several surgical procedures to prevent progression of the non-existent DVT before the error was found.
Because the primary cause for errors in front-end speech-recognized reports is a breakdown in the proofreading process, and because studies show that healthcare documentation specialists do a better job at proofreading than do radiologists, the need for a well-educated, well-prepared workforce is as strong as ever.
The goal of the Model Curriculum and Education Approval process is that graduates of approved schools will be ready to pass the RMT exam, which is the entry-level credential for the profession. Credentialing is an important step for a professional. It indicates to the public - the consumers of the healthcare industry - that healthcare workers have met national standards of competence set by their professions. A professional credential is not a license but rather a certification gained by passing a nationally standardized examination. One of the beauties of certification compared to licensing is that it travels with you no matter what state you work in.
Professional credentials open doors for healthcare professionals. Some professions require credentials to work, but in healthcare documentation, the credential is optional. The fact that it is optional, however, gives you a great opportunity to distinguish yourself from the masses who claim proficiency in our profession. Whether it be the RMT or the CMT, attaining a credential in your chosen profession will have positive effects for you and your career, perhaps in tangible pay-related increases and perhaps, even more importantly, in intangible factors such as confidence, professional pride, and increased knowledge. Similarly, healthcare documentation service owners with credentialed workforces have the edge over other organizations when answering an RFP.
It can be a little scary to consider taking a high-stakes exam like a credentialing exam. One of the best ways to allay pre-exam anxiety is to be well prepared. If you are considering taking a credentialing exam, you should already have the knowledge, be it from school or years of work experience. You just need to polish your skills and get used to the way exam questions are written. Practice materials are invaluable for this. AHDI offers study groups and ample exam prep materials. Additionally, AHDI plans to release online credentialing practice exams by the beginning of 2013. Finally, bulk pricing breaks are available for schools and companies that are interested in helping their students and employees attain credentialing.
Susan D. Dooley is professor and program manager of healthcare documentation/HIM (medical transcription) at Seminole State College of Florida in Altamonte Springs, Fla. She is an at-large director of the AHDI National Leadership Board. She also received AHDI's 2012 Educator of the Year award.