Healthcare Documentation Integrity Week: An Expert’s Guide on What to Know

This year’s Healthcare Documentation Integrity Week (HDI Week) takes place May 16-22, 2021. It’s a weeklong celebration of the contributions healthcare documentation specialists make toward ensuring complete and accurate patient records. Previously known as medical transcriptionist week, it has transitioned to its current title in order to better recognize the wide spectrum of healthcare professionals who contribute to the integrity of the medical record. In an age of increasing digitization and data analytics, this has never been more important.

Modern healthcare runs on data. According to a 2019 World Economic Forum report, hospitals produce approximately 50 petabytes, or 50 million gigabytes, of data per year. The majority of that information comes in the form of clinical notes, lab tests, medical images, sensor readings, genomics, and financial data. But how much of it is accurate? In a field like healthcare, even a small mistake can have enormous consequences.

Healthcare documentation specialists play a crucial role in ensuring the integrity of the medical record, which, in turn, promotes patient wellbeing and safeguards against medical errors. Working in partnership with clinicians and other members of a healthcare organization, they prioritize accurate documentation of health records that accurately reflect a patient’s full medical history.

As healthcare goes increasingly digital, with the inputs of a medical record spread out between so many different platforms and individuals, the case for healthcare documentation integrity is stronger than ever.

To learn more about healthcare documentation integrity, and how healthcare administrators can better incorporate it into their organizations, read on.

Sheila Guston is the interim CEO of the Association for Healthcare Documentation Integrity (AHDI), where she has served on the Board of Directors since 2014.

Over a nearly two-decade career at Spectrum Health, Guston has worked as a healthcare documentation specialist, and most recently a leader of their HIM Document Integrity program. She is a fellow of AHDI and a Certified Healthcare Documentation Specialist (CHDS).

“Today, healthcare documentation is being created in a variety of ways,” says Sheila Guston, CHDS, AHDI-F, interim CEO of the Association for Healthcare Documentation Integrity (AHDI). “Providers are increasingly expected to create their own documentation, previously done by professional healthcare documentation specialists. The EHR has made it possible for them to use a variety of means—straight typing, speech recognition, checkboxes, and drop-down lists, just to name a few. With multiple ways and multiple providers often contributing to the same note, the possibility for error becomes far greater.

For years, the traditional model of healthcare documentation was to have a physician dictating and a medical transcriptionist transcribing. This provided a two-way safety net: if something was dictated wrong, it could be caught by the transcriptionist. If something had been transcribed wrong, it could be caught by the physician.

Today, however, real-time documentation is the goal. Physicians manually enter text or use speech recognition. They select from checkboxes and dropdown lists. If they do not take the time to review and edit as needed, even the smallest error can have significant ramifications. Imagine the consequences for a patient with HIE, for example, mis-documented as having HIV.

“Your medical record follows you for the rest of your life,” Guston says. “Errors that aren’t addressed can result in lifelong consequences and have the potential to impact future care. This is serious. Everyone needs to be reviewing their medical records.”

“Technology keeps evolving, and we have had to evolve with it,” Guston says. “We use the term, ‘healthcare documentation specialist’ because it more aptly recognizes all those who touch the medical record, no matter what role they play.”

The number of people who contribute to the medical record has increased significantly: providers, scribes, coders, therapists, social workers, medical record professionals, and more. The potential for error increases when there is no quality review system in place. This is where clinician-created documentation auditors or analysts come in: they review the records created by providers, identify errors that have the potential to impact a patient’s care, and then flag those for correction.

“Providers have less face-to-face time with their patients today because the onus for documentation has been placed on them.” Guston says. “In the past, they would dictate their notes and an accurate, beautifully formatted document was returned to them for review and signature. Today, they are asked to provide patient care and then create their own document. Efficiencies gained by EHR tools should not be at the expense of quality. We have to find a way to ensure the accuracy of the record and support that provider at the same time.”

“We have to put quality first,” Guston says. “Sometimes doing that means investing in programs, like clinician-created documentation auditing, that don’t generate revenue. But it ensures the quality, safety, and integrity of the medical record. It’s an investment for which the benefits far outweigh the costs.”

In recent years, healthcare administrators have placed a heavy emphasis on data-driven decision-making and data-powered tech solutions. But those tools are only as useful as the quality of the data that powers them. Focusing on the accuracy of the medical record is good for business; it’s also good for the patient and patient-centered care.

“You cannot minimize the importance of the patient’s story,” Guston says. “A complete medical record is far more than just the data elements. It’s that story that gets lost in this data-driven world. The story truly is just as important as some of the big data tools that we’re depending on.”

For Guston, one of the most important advocacy issues in healthcare documentation integrity is empowering and encouraging the patient to take ownership of their own medical record. With patient portals and cloud-based records, it has never been easier to access one’s own medical history.

“Read your record, and stay informed,” Guston says. “If you’re not comfortable with the medical jargon, there are patient advocates out there who can help you with that. But you have to take a vested interest in your own medical record and your own medical care.”

For AHDI, professional certification and continuing education are critical areas for healthcare documentation specialists. While not a requirement to enter the workforce, they are indicative of a person’s commitment to the profession. Especially with the rapidly changing technological and policy landscapes, continuing education isn’t just a nice-to-have: it’s a necessity for staying informed.

“It’s important that everyone continue developing their skills at the same pace that the world around them is developing,” Guston says. “Technology is changing rapidly. Without continuing education, you may be left behind.”

Much has changed since President Ronald Reagan declared the first Medical Transcriptionist Week in 1985. Today, HDI Week applies to not only transcriptionists but clinicians, administrators, scribes, coders, auditors, and patients.

“There will always be a need for someone to ensure the quality of the medical record,” Guston says. “Anybody who interacts with the medical record needs to make quality a priority.”

To connect with the broader community of healthcare documentation professionals, and learn more about healthcare documentation integrity, check out some of the resources below.

• Association for Healthcare Documentation Integrity (AHDI): Established in 1978 as part of an effort to achieve recognition for the medical transcription profession, AHDI has evolved to reflect the broad and extensive responsibilities and services provided in the creation of accurate and comprehensive patient care records. Learn more about their certification options here.
• American Health Information Management Association (AHIMA): A leading voice and authority in health information, AHIMA works at the intersection of healthcare, technology, and business. AHIMA represents health information professionals who work with health data for more than a billion patient visits a year.
• Health Information and Management Systems Society (HIMSS): HIMSS is a global advisor and thought leader supporting the transformation of the health ecosystem through information and technology. Their members include more than 100,000 individuals, 480 provider organizations, 470 non-profit partners, and 650 health services organizations.
• American Healthcare Documentation Professionals Group (AHDPG): Since 1992, AHDPG has been a premier provider of healthcare documentation services, staffing, and training. They were the first employer-owned program to be approved by the Approval Committee for Certification Programs (ACCP), a joint committee established by AHDI and AHIMA.