that of the 1. 2 billion clinical documents produced in the US Notes
each year, approximately 60 percent contains information 1. Cannon, Jay and Susan Lucci. “Transcription and EHRs:
trapped in unstructured documents—unavailable for clinical
Benefits of a Blended Approach.” Journal of AHIMA 81, no.
use, quality measurement, or data mining. By re-evaluating the
2. February 2010: 36-40.
clinical documentation process and implementing innovative 2. Jamoom E., Beatty P., and A. Bercovitz et al. “Physician
technologies and processes, HIM professionals unlock impor-
adoption of electronic health record systems: United
tant data and make transcription truly actionable. HIM pro-
States, 2011.” NCHS Data Brief. no. 98. National Center for
fessionals are also encouraged to evaluate NLP in conjunction
Health Statistics. 2012.
with their EHRs and other clinical documentation technologies 3. Jones, Spencer et al. “Unraveling the IT Productivity Para-mentioned above.
dox-Lessons for Healthcare.” New England Journal of Med-
As more and more documentation moves to a template-based
icine. June 2012. http://www.nejm.org/doi/full/10.1056/
approach, HIM professionals should carefully evaluate their
medical transcriptionist labor pool and conduct frank discus- 4. Ayra, Rajiv et al. “Impact of Scribes on Performance Indica-
sions on future opportunities. While human eyes and ears will
tors in the Emergency Department.” Society for Academic
still be required to ensure quality and accuracy, new technolo-
Emergency Medicine, 2010. https://www.scribeamerica.
gies will streamline processes and open the door for new roles
in producing clinical documentation.
5. Duszak, Richard et al. “Physician Documentation Defi-
All efforts put forth by HIM professionals to re-evaluate tran-
ciencies in Abdominal Ultrasound Reports: Frequency,
scription technology, processes, and job descriptions should
Characteristics, and Financial Impact.” Journal of the
ensure that each patient encounter is effectively documented
American College of Radiology 9, no. 6. June 2012: 403-408.
and that quality information is maintained regardless of how it
Some of these emerging roles are available in facilities now,
while others are to come in the near future. All will require some Michael Carnrite ( firstname.lastname@example.org) is executive vice president,
additional training and fine-tuning of the core medical tran- transcription services, and Susan Sumner ( email@example.com) is ex-
scriptionist knowledge set. ¢
ecutive vice president, ambulatory services at Accentus, Inc.
Visit us at AHIMA Booth #107!
8/17/12 8: 44 AM