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January 9, 2006
Getting
a Bead on Transcription Melding transcription with technology can accelerate feedback to referring physicians, thus streamlining processes, enhancing referring physician/customer satisfaction, and saving money. Children’s Memorial Hospital (CMH) in Chicago is a large specialty hospital with two affiliated medical clinics. More than 1,000 physicians offer pediatric care in 70 specialties; more than 12,000 surgeries are performed; and physician outpatient visits exceed 250,000 per year. However, CMH had received feedback from its referring physicians that the facility was failing to promptly and reliably communicate about its referred patients, so it undertook an initiative to correct the perception. Kara Hollis, RHIA, CMH’s HIM director, says, “The goal of the project was to improve the method of dictating, transcribing, delivery and storage of clinical information focusing on discharge summaries, operative reports, and physician office notes and letters. We wanted to standardize our process, have one database feeding the EMR [electronic medical record], and have the ability to monitor the process from dictation to document delivery. For our physicians and office staff, we wanted to reduce the manual paper processing and enhance their ability to communicate timely with our referring physicians. We set a target of having 90% of all notes sent out within seven days of associated patient visits.” To track the myriad paths followed from patient visit to managing dictation and transcription and physician approval, a facility must call on its IT department for help. CMH’s goal of more timely communication brought attention to the manual processes that supported the distribution of more than 1,000 reports per day to specialty clinics and their referring physician base. To achieve its goal, CMH measured and established accountability for every interval in the transcription cycle—including knowing which visits required dictation, proactively measuring dictation delays, ensuring appropriate transcription turnaround times, efficiently managing the process of report refinement, shortening the physician approval process, and automating distribution of reports on completion. Lew Altman, senior vice president of sales and marketing for Axolotl, says there were three elements to the project: replacing the outsourced transcription vendor and providing a transcription platform for some of the house typing, centralizing and standardizing transcription for CMH’s specialty clinics, and streamlining processes to efficiently get documents completed, signed, and routed through distributed printing, faxing, and EMR integration. To streamline routing documents to these clinicians, the project team armed the transcriptionists with a CC function so they can take a dictated request to copy a clinician, select that clinician from a list, and once that report is approved by the dictating physician the report is automatically distributed to referring clinicians via CMH’s EMR, distributed printing, faxes and, for a small percentage of physicians, printed and mailed. Merlene Rodgers, RHIA, vice president of HIM operations with Axolotl, says if there are critical pieces of information—such as date of service—missing, they are noted in the transcription and sent back to be completed. “The note goes back and forth electronically until it’s complete and then it’s sent [either electronic, or via hard copy or fax] depending on physician preference and CMH’s rules,” Altman explains. “Rather than a potential two- or three-day lag as in the former paper-based process, the notes are signed and immediately distributed upon completion. “The initial investment in changing the way in which the transcription is handled and tracked is returned in later years,” Altman continues. “I think Children’s will reap gains now and will see a bigger harvest in future years.” Separating Technology From Transcription “Take the technology away from the transcription provider and have a third-party vendor host the platform,” he explains. Also, with a third-party vendor, the hospital doesn’t have to interrupt cash flow to purchase equipment or hire IT staff. “Find a vendor that offers the technology platform but doesn’t offer the typing service as it would compromise the integrity of the service offered,” he says. By using a third-party vendor, Revis says, a facility can contract with typists, enabling them to leverage the strength of the transcription company without obscuring the value they are offering. Does this technology work better in some hospitals than others? Revis explains the major difference a facility will see is in terms of technology platforms. “A very large healthcare organization or a multisite facility would likely be more inclined to license a technology platform themselves while a smaller hospital would take advantage of a third-party vendor as opposed to having to buy its own servers and utilizing IT resources,” he says. “A larger facility would probably have the infrastructure in place and would likely have more flexibility to control and manage a system.” Any changes to the transcription and dictation process, Revis says, is all about transparency. He says to track or compare pricing on transcription, an HIM director must understand exactly what they are being charged for. What role does the HIM manager play in the process? In terms of separating technology from service, HIM plays a significant role in any changes made because they, along with the chief financial officer and chief information officer, are the main stakeholders in managing the technology. “The HIM manager is in the trenches —they manage the people and are in charge of turnaround and the budget for the department. A lead transcriptionist would also likely be involved in any changes,” Revis says. “The HIM manager would get feedback from the ground troops and feed it back to the IT department. A serious evaluation of the whole network would have to be undertaken. “When an HIM department is charged with cutting costs, they need to have a dashboard benchmark so they can see how fast they are going, how much gas they are using. If they are relying on a single service provider, that information won’t be forthcoming,” Revis explains. According to Revis, another advantage for hospitals and HIM departments, is that if a facility controls the technology and tells the transcriptionists to type on its platform, it can see who is doing the best work and can address it with the provider. “You can offer constructive criticism to the provider and that should be considered an advantage by the provider,” he says. “A transcription company will probably fight tooth and nail to not separate the technologies. The company will say they are a one-stop-shopping platform and it’s easier for them to provide the equipment and services from soup to nuts but that’s a smoke screen,” Revis says. “They would argue it’s not a good approach but I think it’s unavoidable. The leading HIMs in the industry are saying they have to control the technology to control the costs and the workflow.” However, Altman explains that combining integration and technology with transcriptionist behavior was a key contributor to CMH reducing cycle time. To address dictation delays on the front end, the transcription platform introduced place holders showing that a dictation is expected for an event, and that requirement is automatically satisfied when a dictation is received by the transcriptionist. On the distribution end, because they are equipped with the CC function, most transcribed reports are automatically routed to physicians according to CMH rules without requiring manual intervention. Rodgers says the processes were implemented one piece at a time. “The clinics had the underlying technology, but the templates had to be rebuilt to match their EMR templates in order to capture the information,” she notes. In addition to melding the new transcription processes with the daily routines of the facility, Altman says there are cultural aspects that come into play when any changes are implemented that may disrupt normal workflow. “The new process changed how work was done in the clinic and now the HIM department is taking responsibility for the routing of documents,” he says. “There are the normal political challenges that come with working with clinics that are separately owned entities.” “An electronic signature was implemented by work type,” Rodgers says. “Physicians can choose to have selected populations of transcriptions electronically signed. Also, to get the document back to the referring physician we built in an electronic ‘carbon copy’ function that sends the completed note upon electronic signature.” Timelines For CMH to successfully gain control over its transcription turnaround timelines, it looked for a new, technology-based transcription vendor to shorten every interval in the cycle. By reducing manual processes, significant cost savings have been realized. Also, advanced technology provided patient registration interfaces, automatic reconciliation of visits with dictations, exception reporting for deficient transcribed documents, electronic signature integrated into physician workflow, and automated distribution of approved reports, according to Axolotl. Because of the changes, CMH has made substantial progress toward its seven-day turnaround goal and has reported successes both at the operations and management levels. HIM directors can easily view the cycle and compliance times of their transcription vendor, physicians, and their own department. HIM also has the tools to monitor the absence of dictation, status of a transcription, average turnaround time for each physician to dictate a report, views of reports needing completion or signature, and an automated process to fax a report to the referring physician the moment it is signed. Rodgers says a report was pulled from CMH that indicates the facility is at 80% of getting its reports delivered within the targeted seven-day timeframe. “They can now go back and evaluate their processes. They can see if the lag time is starting at the transcription level or if it is taking the physicians several days to sign the notes once they receive them,” she explains. “You can look through every part of the process and pinpoint specifically where the process snags and address it at that point with specific information in hand.” Prior to the new tracking of the transcription path, HIM managers were able to have a delinquency list in hand, but the report couldn’t quite pinpoint where the process stumbled on its way toward completion. “With the new report, the HIM departments have more dimension to see what the real issue is with completion and they can obtain better compliance when they can show with credibility where the lapse is occurring,” Altman explains. CMH, Altman says, is a real innovator in reaching an important milestone in managing referral communication. The facility has unified the way information is captured, completed, and shared. Transparency
in Transcription What is your facility’s initiative? “When looking to get transcription services, prices, and turnaround times under control, the ultimate goal should be improvement in the quality of patient care,” he explains. “With everyone under pressure to improve patient care, it makes more sense to devote time to patient care vs. spending millions of dollars on typists. It isn’t helping those patients who are waiting for three days longer than necessary to get a report back. It also doesn’t help if the report comes back with errors.” Revis says it’s common for a major hospital to spend more than $1 million annually on transcription costs. He says a facility should examine what it is paying for transcription and the level and quality of returned work. “Right now, those tools aren’t available to me. How can I acquire those tools?” he asks. “[Perhaps] the only way to uncover the information you need is to separate the technology from the transcription platform where the HIM director would go and say, ‘I want to be more efficient and want to improve costs but I need a dashboard and transparency.’ If any hospital undertakes this effort, they will save money—perhaps significant money.” Revis says Nuance offers a transparent transcription workflow platform that uses speech recognition technology to turn transcriptionists into editors rather than typists. “If a hospital adopts this technology platform, they can adopt speech technology and can go from 15 cents a line to 8 cents a line as the transaction is only acting as an editor,” he says. Revis says the MedQuist scandal involving alleged shady billing practices has brought attention to the problem of overbilling. “Since that scandal brought visibility to the process, there has been an increased interest in separating the platform and the technology,” he says. “Imagine if the hospital controls the system that the doctors use to monitor time and all you do with the transcription company is to have them type into our system. It puts the hospital in a position to run a report and see how fast the following transcriptions were turned around and see how many lines have been run through the system and then be able to easily compare it to the invoice.” The auditability and verifiability of reports has always been an issue, Altman says. “One of the things that CMH has with the new platform is, once the report is delivered, the line counts and the individual cost for that report are included. The reports are easy to audit, read, and verify.” Revis gives an example of a scenario by which an HIM department has to examine its operation by explaining, “Look at the first part—which is to better manage transcription services. HIM directors are most concerned with turnaround time of transcription, cost of transcription, and quality of transcription. These are the things they are most concerned about and they are also the things the HIM director has the least control over. They rely on third-party vendors to supply them with it. The minutiae involved with this leaves them in the dark as to whether they are being charged properly or if they are being given the transcription in the correct amount of time. There is a paradigm that has existed which is that [both] the technology and services are provided to the hospital by the same company. When the technology and transcription are separated, the HIM director gains some control over the process.” Rodgers says HIM managers become concerned when they notice a marked change in transcription volume or if their invoice suddenly goes up or down. Because the reports CMH receives are delivered as Word documents, and the platform displays the reports’ line count and price, they are easily verifiable at the report level, Altman says, providing the HIM director with the assurance of accurate billing. “If you get a credit card bill and it was all one line item that said you owed $1,000 but didn’t have any detail behind it, you have no way to verify the purchase,” Altman explains. “Our premise is to offer a level of itemization to the hospital so they can verify what they’ve paid for—it’s a service a facility should look for in its transcription vendor.” Rodgers, a former HIM director, says that, in that role, she was frustrated by a lack of tools. “I couldn’t truly audit or validate the work being done. I had to operate on blind faith,” she says. Now, however, she says HIM directors have more weapons at their disposal. “Finding software where every piece is visible from the time the doctor hangs up the phone to the time the note is electronically signed is bringing light to the HIM department that they never had before.” —
Robbi Hess, a journalist for more than 20 years, is a writer/editor
for a weekly newspaper and a monthly business magazine in western
New York.
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