TECHNOLOGY and MEDICAL TRANSCRIPTION

A Bridge to Electronic Medical Records

Claudia J. Gordon, BS, BME

Christopher C. Gordon, CPA

May 2007

 

Physicians at a large family practice clinic in KS decided to purchase an expensive electronic health records system (EHR).  While this clinic had an inhouse IT department and a transcription supervisor who had managed their medical records for many years, input from them was not considered.  As a result, within months after implementation, at least two major components of the system were not in use due to the fact that the doctors "didn't like using them" or they were not cost effective.

 

Everyone has heard similar stories as medical facilities make hurried or unwise choices about moving into new technology.

 

Even though the use of electronic health records appears to be imminent, the US Department of Health and Human Services reports "About 25 percent of physicians use some form of electronic health records, but only 1 in 10 doctors practice with a fully operational system."¹

 

 

CHANGES IN TECHNOLOGY

Overview

The EHR is comprised of modules which can record statistics like lab values and vital signs, but the most complex portions are the required narratives (clinical notes, discharge summaries, etc).  These can be facilitated by speech recognition technology (SRT), the process whereby the physician speaks into a computer or other digital equipment, whose software engine generates a written text of what it has "recognized."

 

SRT does have the potential to enhance clinical documentation and physician productivity subject to a number of factors: 

 

1.         Accuracy/Quality

Aside from the inherent inaccuracy of the SRT engine, quality is often overlooked due to a lack of specified requirements.  In theory, SRT should be held to same standard of accuracy prevalent in producing narratives for the medical record today.  In practice, clinicians are willing to accept certain errors in exchange for the benefits.²  However, if clinicians develop an over dependence on the SRT and do not have the work verified, the potential errors impacting patient care, billing, and risk management could cost them far more than might be saved by utilizing the SRT.

 

2.         The Dictator

The factor having the greatest impact on the accuracy of the transcript is one that neither hardware, software nor editor can improve:  the quality of the dictator's speech and the organization of the dictation.  No SRT can produce optimal accuracy and productivity without requiring some adaptation on the part of the dictator.  Therefore, "standards for ensuring accuracy with documents produced using SRT call for third-party editing."³

 

3.         Editing

The amount of editing required depends upon what is generated by the computer.  Optimally, the editor is not the dictator but someone else who can bring interpretive medical knowledge and technical skills to the process.

 

 

Summary

While there are predictions of widespread use of the EHR in the near future, there remain many issues to be resolved before this happens, including:

 

1.         EHR as an emerging technology

2.         The number of EHR vendors, variety of applications and disparate features offered by them.

3.         A relatively low number of installations.

4.         Many different situations in which these technologies are used.

5.         Human factors affecting implementation, training, and retention.²

 

 

ONE SOLUTION:  A BRIDGE

The goal of Physicians' Choice Transcription Service, Inc. (PCTSI) is to provide a bridge toward technology implementation, while enabling clients to work within their resources to streamline processes and cut transcription costs.

 

PCTSIs new system offers the following technical advantages toward bridging the gap:

• Dictation can be done over the telephone, into handheld digital recorders, or into PC microphones (Phillips, Sony, and others)
• Document management server built into the dictation system
• Secure database-driven repository of transcribed documents
• Document distribution system for secure file transfer, fax, email, remote print, etc.
• Job tracking from beginning of recording to return of finished document to the client site in one easy-to-manage screen
• Bi-directional HL7 interface and RIS and PACS integration to most major brands of medical records software
• Electronic signature
• 128-bit encryption for HIPAA compliance
• Web site access to transcribed documents

 

Making SRT technology available.

Our document management system can serve clients at any point on the technology spectrum.  This technology bridge can be as flexible as any given client needs it to be.  It provides HL7 for interfacing of documents to client's EHR and imports patient demographics into our system, thereby increasing accuracy, which can reduce client labor costs.  While SRT is available for our document management system, based on our current assessment of the maturity of SRT in general we have elected not to acquire it at this time.  Through our ongoing evaluation of the technology, its cost benefit and our client needs, a determination can be made to obtain SRT when it makes sense to do so.

 

The Role of Medical Transcriptionists:  It's not the fingers…it's the brain.

Recently, the American Association of Medical Transcriptionists changed its name to the Association for Integrity of Healthcare, to recognize the capabilities of the medical transcriptionist.  MTs are evolving into clinical medical language/data specialists, data quality managers, and decision support specialists, as envisioned by AHIMA (American Health Information Management Association).²

 

While it may be a decade before widespread electronic capabilities can be achieved, in the interim MTSOs (medical transcription service organizations) will continue to play an important role.  Even after widespread adoption and implementation has been reached, there will be some physicians who prefer not to use electronic systems in their practices but instead will continue their use of manual transcription as the method for converting their records into digital format.¹   Therefore, transcription professionals who deliver high-quality, accurate, timely and cost-effective services will continue to play an important role. 

 

Risk Management factor.

Technology advances coupled with our trained and experienced transcriptionists become a vital tool in risk management  Our periodic monitoring of employees' work gives them continued feedback and education.  They are encouraged to leave blanks if a phrase is intelligible or does not make sense within the context of the report.  They continue to do their own research on new medications.  And, they sometimes flag a phrase within a report as being a possible contradiction to something else contained therein.  The continued honing of these skills prepares them to serve as third-party editors in any given SRT scenario.

 

 

SUMMARY of SOLUTIONS

For Providers:

Change in the creation of patient medical records is rarely implemented without some negative impact upon the physicians and the facilities involved.  When that change is too drastic or too swift, the results can cause havoc within the facility and can actually affect patient care. 

 

Rarely is there a financial return on this type of technological investment, regardless of what software vendors say.  Research is necessary to identify the costs of future upgrades, maintenance costs, optional enhancements such as networking, hand-held devices and the system's ability to integrate with the facility's central system to provide upgraded tools such as e-sign and auto-fax.  "Essentially, the use of the technology  holds no guarantee that cost savings will automatically be recognized." ⁴

 

With regard to the required research, a recent article in Advance for Health Information Professionals gives the following suggestions for facilities:

1.         Define your needs, based on how your medical records department runs now.

2.         Study the selection process, and find someone who will guide you.

3.         Read everything you can find about what software is being used elsewhere and what is working well.  Then, take time to really look at the vendors and their software.

4.         One single vendor may not be able to fill all your needs.  "No one vendor can do everything.  It is a disciplined architecture process, and you have to start with understanding your organization, where you are today and where you need to wind up."

5.         The selection team should consist of representatives from HIM, IT, risk management, nursing informatics, ancillary areas, patient financial services, the business office, medical staff and administration.

6.         Do not leave up to the vendors the re-engineering of the way things are done in HIM.  Look to outside consultants and to others who can help with the transition.

 

One wonders if there would have been a different outcome of the investment made by the large family practice clinic we cited at the beginning of this piece if similar research guidelines had been followed.  Investing in a system that does not become fully used may be worse than making the decision not to apply the technology at all.⁴

 

Regardless of the technology implemented, the effectiveness of any technology is predicated upon the people utilizing it.  While technology may improve or enhance many processes, as with SRT, human input (such as editing dictated patient records) will always play vital role in quality health care and risk management.

 

 

For PCTSI:

While change will be on the horizon for several years, the practicality of implementation is still a challenge.  As we pursue our contribution as a bridge to the new technology, our goal is to work with current and prospective clients within our market niche, providing processing alternatives with newer technology, working together as teams to reach their individual facility goals within the timeframes allowed by their resources. 

 

By moving our employees ahead and continuing to train them to edit their own work, they are being positioned to use their interpretive medical knowledge and technical skills to benefit our clients and are actually changing their own job descriptions.

 

We are, above all, an organization which provides service along with its product.  In an age when customer service is a lost art, PCTSI will continue to provide the individualized attention which meets the needs of health care facilities and their patients.

 

 

 

FOOTNOTES:

1                     Advance for Health Information Professionals, November, 2006

2                     American Medical Informatics Association 2004, "Impacts of Computerized Physician Documentation"

2                     JAMA May 24/31, 2006, "Copy and Paste," Robert Hirschtick, MD

3                     American Health Information Management Association (AHIMA) "Speech Recognition in the Electronic Health Record" 2003