Article on Medical Mistakes (sm)

December 8, 2008

A New Day Rising
By Selena Chavis
For The Record
Vol. 20 No. 25 P. 10

Medical transcription, long the mainstay for healthcare documentation among providers, is forging into unknown territory as the industry redefines its role in the framework of EMRs. 

Like many facets of the healthcare industry, the transcription field is evolving around the electronic movement. Many questions have been raised about how medical transcription will be integrated into electronic medical records (EMRs) as the industry looks toward the future. While there are varying opinions about what the future holds, most experts agree that, at some point, the role of the medical Transcriptionist will be redefined.

“I think the case is it will morph … and potentially be replaced … or evolve in a way that is different from what it is today,” says Claudia Tessier, RHIA, vice president of the Medical Records Institute. “I and others have the perspective that it will be encroached on unless it adapts and morphs.”

With the promise that EMRs bring to scaling healthcare costs and improving quality of care, Tessier points out that many in the healthcare industry see an opportunity to eliminate the practice of dictation and transcription in its current form. Gone would be the days of feverish typing from handheld dictation devices; the new era would have clinicians input their own documentation directly into patient records via the convenience of cell phones, pull-down menus, and point-and-click and free-text keyboard entry methods.

Add to those efficiencies the promise that many believe speech recognition technology holds, and Tessier says two questions about medical transcription emerge: When will direct data entry options have a significant impact on medical transcription, and what is medical transcription’s role in the transition to EMRs and computer-guided care?

But are potential changes to the process well thought out? Susan Lucci, RHIT, CMT, AHDI-F, director of transcription operations with TRS Transcription and president-elect of the Association for Healthcare Documentation Integrity (ADHI), believes that healthcare documentation is too complex to ever fully integrate into a point-and-click system.

“I think we’ll see a dramatic shift in the kind of work we receive—more severe, less physician office,” she says, pointing out that, in some situations, documentation requires a narrative from the physician. “I think that we can all agree that no two patients are the same. The drawback would be if we ever took it [narrative dictation] out entirely.”

Then, there’s the fact that some areas of the country are lagging behind in the electronic movement. Miriam Wilmoth, CMT, AHDI-F, a member of the ADHI’s electronic health record team and president of the Tennessee Association for Medical Transcription, notes that many providers in her region are still using paper records. “We still have that dichotomy in Memphis,” she says. “Some of the trends that are hot in other areas of the country take a while to trickle down here.”

Going forward, Tessier believes the key to success is providing choice and flexibility with multiple options available, including traditional transcription, computer entry, and speech recognition. “There are all of these options. What’s important is that clinicians be given these options,” she says.

Adapting the Process
No one can fully predict the long-term effect of the electronic movement on the transcription industry or how the role of transcription will evolve over time, but many contend that it will not see its demise anytime in the near future.

“The reality is that the transcription industry is so big that the impact of EMRs and HIT are longer term,” Tessier says, adding that many in the field may become complacent under that belief. “To a great extent, there continues to be a belief that because it is still big, it will continue to be big.”

Currently, the Medical Records Institute estimates that 90% of information capture is dictation and transcription compared with less than 3% front-end speech recognition and about 6% direct physician input by keyboard, stylus, touch screen, and other methods. Alongside those numbers, the AHDI estimates that global medical transcription expenditures are between $12 billion and $20 billion annually, with the largest share of that occurring in the United States.

Tessier points to industry frustrations over the high cost of medical transcription alongside a demand that currently outweighs the supply of medical transcriptionists. Add to that concerns about turnaround time and quality, and many are seeking ways to improve the process.

Change is coming, Tessier says, suggesting that “it’s not an ‘either/or.’ It’s more an ‘and … and … and.’ It’s not being replaced by EMRs—it’s being integrated.” It also means that adjustments are coming, and professionals need to adapt their skill sets. “Everyone would be a lot more comfortable if they knew change means X, Y, Z,” she adds.

Take speech recognition technology, for instance. When it was first introduced, Tessier points out that many in the industry predicted the demise of transcription. Now, 20 years later, the industry is bigger than ever, but at the same time, speech recognition has come a long way and is expected to continue on that track.

Lucci believes there are many opportunities to create efficiencies. “There is a clear evolution to much more speech recognition editing,” she notes. “We’re seeing increases in requests from our clients to use speech recognition.”

Improvements in speech recognition technologies have been steadily expanding the capabilities of computers to understand voice commands, and the benefits achieved through increased productivity cannot be denied. Statistics reveal increases in productivity that equate to upward of 50%.

Wilmoth points to a Memphis hospital where speech recognition technology was implemented in the radiology department. Radiology transcriptionists were given notice that the organization was unsure of the technology’s long-term impact.

However, the end result was that 17 radiology transcriptionists were no longer needed. “The technology worked fine. They [the hospital] only have enough traditional transcription to keep one [transcriptionist] busy,” says Wilmoth, who adds that she envisions voice recognition being a tool that is specialty specific. “I don’t think it will take off as quickly with HIM transcription.”

Raising the bar for efficiencies within an EMR will be the integration of speech recognition with the Clinical Documentation Architecture for Common Document Types, a system for interoperable healthcare reports that conform to standards for information exchange. The standardization and adoption of these electronic documents are expected to enlarge and improve the flow of data, including narrative documentation, into the EMR.

In this case, transcription’s role morphs into an editing function, opening up the need for an expanded skill set from medical transcriptionists, suggests Wilmoth, where listening skills must be adapted, and more critical thinking approaches must be used.

Alongside efficiencies created with speech recognition, many are looking to direct entry from clinicians as an answer to transcription costs associated with traditional dictation, but Lucci says it is unrealistic to expect that dictation will be completely replaced for the long term, especially in the hospital setting. Pointing to statistics that suggest narrative dictation is faster than narrative computer entry, she says that in the acute care setting, few physicians can perform all their required tasks and then have the additional burden of the time required in a computer-entry model.

“I think hospital dictation will not change a whole lot for a while yet,” she says.

Lucci also doesn’t believe that it will make sense to convert certain types of critical patient information to a point-and-click method. “One thing for sure is the history of present illness,” she says. “That is uniquely the situation that caused the patient to present in the first place. It requires narrative input.”

The Readiness Factor
Wilmoth concedes that most EMRs currently have dictation and transcription integration ability where documents are either uploaded into the system or copied and pasted into the record. With that capability in mind, how ready and willing are physicians and clinicians to take on the task of direct entry?

Clearly, statistics reveal that traditional medical transcription is still the choice of many physicians, although trends with younger, more computer-savvy physicians suggest that the tide will continue to turn toward more direct computer-entry models. Wilmoth says the concept of choices should be paramount going forward, and physicians should be kept in mind, especially in the hospital setting where technological choices that are not embraced by clinicians and physicians can often equate to higher costs due to a lack of use or incorrect use.

Wilmoth mentions a comment she recently overheard from a radiologist who was opposed to changing dictation practices to computer entry, who said, “I did not go through 12 years of school to be a secretary.”

“It’s not an elitist attitude. Their skills lie elsewhere,” Wilmoth says. “Taking the dictation option out is certainly going to frustrate some and potentially affect patient care.”

Computer-entry models will likely be embraced more in the physician office setting, Lucci says, where the need to create efficiencies and reduce overhead is becoming more urgent. Statistics from the Medical Records Institute suggest that transcription costs per physician range from several thousand dollars to more than $25,000 annually, making technologies such as speech recognition and point-of-care documentation more attractive.

Alongside resistance to change from some physicians is the question of how a transcription workforce already diminishing in numbers will adapt to its role being redefined. Acknowledging that as more EMRs enter the physician office setting, the need for transcriptionists will continue to decrease, Wilmoth says many transcriptionists are not prepared to “morph” into the editing roles that will be required to complement speech recognition technology.

“It’s a different skill set,” she says. “I think there are some that can transition into editors … some will ride it out and retire … and some will refuse to embrace technology and will go do something else.”

Then, there’s the compensation issue. Presently under notable debate is how to create a fair and equitable system to pay medical transcriptionists for “editing” work, especially in the training phase when production levels dip. Alongside that scenario is the fact that they “will have to edit twice as much as transcribed to make as much money,” according to Wilmoth.

Is Accuracy a Factor?
Consider the following differences between dictated instructions and what medical transcriptionists were able to catch and clarify as potential errors in physician-entered documents. According to Lucci, the following variances were just a few of nearly 150 errors one transcriptionist found in just two months’ time:

1. Dictated: Will resume Altace and metoprolol, but will hold if the systolic blood pressure is less than 10 or the diastolic is less than 60.
   Typed: Will resume Altace and metoprolol, but will hold if the systolic blood pressure is less than 100 or diastolic is less than 60.

2. Dictated: Zosyn 3.375 mg q eight hours IV X 7 days.
   Typed: Zosyn 3.375 grams q eight hours IV X 7 days.

“Physicians have entrusted transcriptionists to do their documentation for well over 30 years,” Lucci says, pointing to the fact that, in many ways, physicians have limited their own ability to document accurately because it has not been their day-to-day practice. “Is accuracy an issue? If you look at clinician-entered information as compared to dictated and transcribed reports, I think you would be surprised to see that the quality isn’t as good. A well-trained [medical transcriptionist] will catch errors in dictation and speech recognition.”

Issues associated with accuracy may be compounded in that physicians may not have the time to be as thorough as they need to be if left to enter their own documentation directly into an EMR.

“Not only is accuracy an issue, but completeness is a bigger issue to telling the patient story,” Lucci says.

Wilmoth tells the story of a patient whose visit to a physician amounted to no more than a series of questions and answers. She notes that the physician pointed and clicked his way through the exam on the computer without ever “laying a hand” on the patient and then proceeded to bill for a complete exam.

“The questions then become, was he attempting to overbill, or did he not understand the documentation system?” she asks. “The other scenario is that they may underdocument to save time.”

It appears certain that traditional dictation and transcription practices are evolving. As they do, the EMR’s impact is by most accounts a change for the better in healthcare documentation. What is perhaps not completely certain is how exactly that transition will take place, to what extent, and when it will happen.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

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