admin on June 1st, 2010
By, Lea M. Sims
With our nation engaged in dialogue around health care reform, and health care delivery engaged in discussions around what “meaningful use” of EHRs will look like, there has never been a more important time for the health care documentation sector to stand up and demonstrate its contributory value to these critical issues. This means aligning our key messages with health care’s goals and demonstrating why we matter to the health data capture process, both now and in the evolving EHR.
What is health care delivery telling us?
More than anything, health care needs cost-effective, technology-centric solutions that ensure quality of care, eliminate redundancy and inefficiency, and improve the quality and accessibility of patient information within and between health care enterprises. When it comes to our sector, the health care system is looking for the right solutions to securely and accurately capture, consume and repurpose health information. It needs partners and advocates who will advance its EHR adoption goals, facilitate reliable data exchange, and deliver robust health encounter information that allows providers to make real-time clinical decisions. And out of the evolving debate around “meaningful use,” a new concern is also emerging-How much of the EHR documentation burden should be shouldered by the physician?
How can our sector respond to those challenges?
The Association for Healthcare Documentation Integrity (AHDI) and the Medical Transcription Industry Association have been delivering a core message to legislators, policymakers and health care stakeholders around the ability of the health care documentation sector to meet these evolving needs for managing health information. Our key messages around EHR adoption have focused on the following points:
1. Preservation of narrative capture is critical to meaningful use of EHRs because:
- More than 1.2 billion clinical records are produced in the U.S. every year.
- 60 percent of all clinical records are documented via traditional dictation/transcription.
- No documentation method captures complex patient stories better than narrative dictation.
- Dictation/transcription is still the preferred method among U.S. physicians for documenting patient encounters.
- Point-and-click templates cannot adequately capture a comprehensive, complete patient story.
- Physician-driven data entry is costing health care time and money; physicians are better deployed in frontline care than burdened with clerical capture.
2. Health care documentation specialists are critical to effective capture of health information because we:
- Understand the diagnostic process and the complex story-telling of patient care.
- Provide risk management support and oversight to ensure health encounters are captured accurately.
- Are able to indentify error/inconsistency in the record as well as support pay-for-performance goals through documentation improvement measures.
- Know how to apply data capture standards that ensure health information is available at point of care for clinical decision-making.
- Integrate seamlessly with data capture technologies, such as EHRs and speech recognition technology (SRT) solutions.
- Partner with physicians to document care encounters in a way that frees up providers for hands-on patient care.
How can you promote this campaign in 2010?
Be an advocate. First and foremost, our sector needs you to promote the concepts above to your providers, clients, health care facilities and legislators. Be proactive in advocating for your current and future value in advancing health care’s goals for EHR adoption. Download the MT Week flyer/poster-Capturing America’s Healthcare Story: Why We Matter to Health Care-at www.ahdionline.org and share it with your professional contacts.
Be ready to deliver. The value proposition we’re making to health care is predicated on the assumption that our workforce can facilitate EHR adoption by being an extra set of eyes on the health record, well-oriented to the diagnostic process, and capable of recognizing error and inconsistency in health information. This will require MTs to embrace professional development, continuing education and credentialing. Position yourself well for evolving and future roles by seeking additional training in new roles/technologies (receive $100 off the cost of our SRT training course if you register in the months of April/May for May/June courses), obtaining your certified medical transcription (CMT) or registered medical transcription (RMT) credential, becoming an AHDI member to stay in the stream of cutting-edge information, and embracing long-term continuing education.
Above article publish on http://health-information.advanceweb.com/Columns/AHDI-Track/Why-We-Matter-to-Health-Care.aspx
admin on July 17th, 2009
Should doctors be taken word-for-word?
By Cheryl McEvoy
A run-on sentence. A misspelled drug. A superfluous comma. Heck, maybe even a split infinitive. Dictation errors can irk word-wary MTs, but should they be forced to overlook such grammatical offenses? Thus begins the debate over verbatim transcription, a contractual item that makes MTs withhold all judgment — medical, grammatical or otherwise — and simply type what the dictator says. The controversial practice pits risk management against quality assurance (QA), but MTs’ reputations and patient care are what’s on the line.
While traditional transcription lets MTs correct punctuation, misspellings and dictation errors at their discretion, verbatim transcription requires MTs to transcribe notes exactly as dictated. The practice is usually based on the client’s preferences; if a doctor doesn’t want his words altered, the MT is expected to transcribe word-for-word. There are arguments for and against the no-edits approach, but most MTs aren’t thrilled about it.
The running joke is, “If you want verbatim transcription, I will put in every ‘uh,’ ‘ah,’ ‘oh’ and ‘um’ that you have dictated,” said Barb Marques, CMT, AHDI-F, president-elect of the Association for Healthcare Documentation Integrity (AHDI).
In reality, it’s no laughing matter.
Risky Business
Doctors can make mistakes, so risk managers champion verbatim transcription as a way to keep MTs from taking the fall, according to Donna Brosmer, CMT, AHDI-F, NREMT-B, quality officer, Spheris. If the document ends up in court, an MT can claim no culpability because the doctor requested the dictation be transcribed word for word. If the MT changed any words, he or she might be held accountable for the error – a mark hospitals and medical transcription service organizations (MTSOs) don’t want on their hands.
But many say verbatim transcription neglects the value a skilled MT can bring to the table. With knowledge of diseases, diagnoses, treatments and medical terminology — not to mention, a knack for grammar and punctuation — MTs can serve as the first line of defense against errors, according to Brosmer. “You have a group of very intelligent people creating these reports, transcribing these reports,” she said.
For example, a good MT would know the difference between Xanax and Zantac and could correct the mix-up if a doctor misspoke, Brosmer said. MTs are also trained to notice when a doctor switches between left and right.
“If he said ‘right foot’ five times in the report and he gets down to the bottom and says ‘left,’ 99.9 percent [of the time], he really does mean the right foot,” Marques said.
Errors like that are becoming more common as good dictators become few and far between. With doctors able to dictate from their Blackberrys and iPhones, MTs are struggling to hear over the background sound of gyms, pools and oncoming traffic, Brosmer said.
Physicians are also getting more lax. Marques said today’s rising doctors do not speak in complete sentences, making it harder to understand the report. While a skilled MT would have the confidence to edit and make corrections without delaying the report, with verbatim transcription, the MT would have to query the physician or flag errors in hopes he would re-examine his work.
Making matters worse, many doctors don’t review their transcribed reports, according Lesli McGill, director of U.S. operations, SPi Healthcare. McGill hails from the “old school” of transcription, where she learned to edit as she transcribed. She recalled the “rubber stamp” method physicians used to approve reports — simply passing it on without so much as a glance. In today’s electronic environment, that stamp has been replaced with a click of approval, making it even easier to overlook flagged items.
Employee Pride
What the controversy boils down to is quality. MTs pride themselves on delivering a timely and accurate record, so they loathe initialing a document that isn’t up to par — especially if that document is hauled into court. “[MTs] want people to understand they did the best job they could with that document,” McGill said. “It reflects badly on them if it’s a verbatim account and you’ve got a bad dictator.”
The squabble isn’t likely to end soon, the experts said. The topic was among discussions at the Medical Transcription Industry Association (MTIA) Convention last April, and it’s expected to be on MTs’ minds at the AHDI conference later this month. In health care, quality isn’t something to take lightly; a mistake that slips through the cracks could mean the difference between life and death. MTs are supposed to be the first defense against errors, but amid the skirmish of lawsuits and legal liability, some fear verbatim transcription will push patient care to the wayside.
Cheryl McEvoy is an editorial assistant with ADVANCE
Above article published on
http://health-information.advanceweb.com/editorial/content/editorial.aspx?cc=202692
admin on June 4th, 2009
This is the first in a series of quarterly articles that will focus on technologies relevant to medical transcription. Hopefully, maybe even those MTs who are techno-phobic will find some of the topics enlightening, stimulating and/or of value in making career decisions. But maybe not. To challenge that hope, I’ve started off with everyone’s favorite technology: speech recognition. If you want to really stimulate a transcriptionist, just say “speech recognition.” Or, better yet, assert that “speech recognition will forever change the process of converting physicians’ thoughts and utterances into text.” Then run for cover.
Every transcriptionist out there has heard some form of that assertion. Their reactions range from dismissal to fear to anger. So what’s the truth? What does the future hold? Well, at some point in the future, there will be no medical transcription. Physicians will dictate into a PC or portable device; their speech will be converted to text; and the dictator will make any necessary corrections to finalize the report. No transcription expense. No transcription delay. But that future is at least 3 years off. Just kidding. It’s way more than that. However, there is a future closer than that, related to speech recognition, which has some major implications for this industry.
Doctors hate doing anything that they believe is below their stature or slows down their ability to generate revenue. So we will not see “front-end” recognition-where they correct their own mistakes as described above-in most environments for many years. But there’s a new game in town. It’s called “back-end” speech recognition. Physicians don’t change a thing in their dictation behavior. They continue babbling into telephones or some other dictation device just like they always have. But their voice files are now run through a server-based recognition engine, a draft is produced, and a medical editor corrects the errors both in recognition and dictation.
This technology is truly beginning to get some traction. Physicians love innovation, but they hate change. So this suits them just fine. In fact, they typically don’t even know it’s going on. The goal of back-end speech recognition is to at least double the productivity of transcriptionists. And to do it for about a penny a line. Most implementations are not quite there yet. Speech recognition talk has always been ahead of speech recognition technology. Nonetheless the handwriting is on the wall. This technology will begin to transform transcription in the coming years. So it seems wise for MTs to learn more about it and perhaps even to embrace it.if they like what they learn.
Currently, it is prohibitively expensive for an independent transcriptionist or small transcription company to purchase a recognition server. However, there are a number of ASPs popping up, which charge by the line to produce a draft. I could tell you a lot more groovy stuff about this rather exciting technology, but I’m just about out of my allotted space. So tune in next quarter for the second Watch article, which will explain more about how it works and what it means for medical transcriptionists. Unless, of course, I feel like writing about something else.
Above article published on
http://health-information.advanceweb.com/editorial/content/editorial.aspx?CC=49562
