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For other articles and previous issues click here. July 29, 2002 Transcription
Turnaround: Heading in the Right Direction Speed and accuracy are the buzzwords
in the medical transcription field as facilities aim to improve
patient care and maintain financial solvency. Medical transcription turnaround reliability is one of the greatest challenges faced by many health information managers across the country. According to David Iwinski Jr, CEO of Acusis LLC, a Pittsburgh, Pa.-based medical transcription firm, the medical transcription industry, with estimated annual revenues of $12 billion, exists primarily as in-house services. He adds that only approximately 35% of facilities have contracted with outsourcing companies for transcription services. “There are tremendous savings to be had,” he says, “but hospitals are often concerned that, even if good quality transcription could be provided, their own in-house service would be faster and allow more immediate access to their medical charts.” The emphasis on speed, Iwinski explains, is due to the fact that a rapid turnaround allows hospitals to maintain more timely coding and billing procedures. “When we talk to potential clients who do their transcription in-house, they are not only concerned about quality, but also insistent upon a 24-hour turnaround.” Unfortunately, he adds, many facilities have encountered outsourcing vendors whose ability to provide rapid turnaround—combined with consistent quality—is somewhat inconsistent. “Some companies always get the job turned around, but they are very expensive,” he says. “Our clients have reported that, with others, a turnaround of 48 to 72 hours is not uncommon.” Turnaround is also affected, Iwinski continues, by seasonal fluctuations that occur in many parts of the country. “Many healthcare organizations and smaller transcription companies do not have the added capacity to handle spikes or short-term increases in transcription volume,” he explains. These increases occur, for example, during the winter in Florida when the state becomes the destination of hundreds of thousands of tourists hoping to escape the bitter cold of northern winter climes. “When regional increases occur, local firms that have just enough staff to handle their expected volumes often find they can no longer support a 24-hour turnaround,” Iwinski says. “They just don’t have the physical capacity.” For this reason, he notes, many large facilities choose to contract with larger transcription outsourcing firms that, compared with in-house services and smaller firms, are better able to manage production and maintain rapid turnaround. Healthcare administrators generally agree that rapid medical transcription turnaround combined with high-quality transcription can be difficult to find. But what is the real effect of this challenging situation? Beyond the headaches and sleepless nights it may cause health information managers and other administrators, transcription turnaround also impacts physicians’ daily schedules, patients’ medical experiences, coding and billing processes, hospitals’ revenue flow, and perhaps even preventable medical errors, according to William Keena, vice president of operations for EDiX, a San Diego, Calif.-based medical transcription outsourcing company. “Hospitals have to compete for physicians, so it is important to have the ability to offer them well-transcribed reports quickly, which helps the physicians provide better care more efficiently.” There is also an impact on patients, he adds, who could be lying on a gurney in a crowded emergency department, waiting to be either discharged or wheeled into surgery. An increased emphasis on speed, however, could potentially translate to an increase in preventable medical errors, Keena warns. “Turnaround is defined by the healthcare industry in terms of how quickly a hospital gets a report back,” he explains. But simply getting a report back from a transcription company within 24 hours is no longer enough because healthcare professionals are also insistent on accuracy. “Accuracy is a very important issue when you are talking about patient care,” he says. “If the transcriptionist types ‘left’ when the physician dictated ‘right,’ it could have a huge impact on a patient’s life as well as the hospital’s liability.” Historically, Keena continues, the emphasis in medical transcription was on pure speed. A recent focus on the number of medical errors that occur within the industry—fueled by reports issued by the Institute of Medicine—has resulted in a deeper understanding of, and commitment to, accuracy combined with speed. In addition to enabling physicians
to work more efficiently and effectively, and potentially impacting
patients’ quality of life, medical transcription turnaround
also affects the financial health of medical organizations. “A
24-hour time frame is barely adequate for billing and coding purposes,”
Iwinski explains. “Most hospitals are under tremendous monetary
pressures these days. Budgets are very tight, there is less governmental
funding available, and insurance companies are increasingly stringent
about reimbursement.” There are a variety of factors that influence the quality and speed of medical transcription, whether it is performed in-house or by an outsourcing firm. Accuracy, according to Iwinski, depends less upon time allocated for transcription than on the quality of the individual transcriptionist, the department’s or outsourcing company’s quality assurance/quality control process, and on the capacity of the company to handle influxes of records. “It is essential to have qualified transcriptionists and editors who have been rigorously tested, quality assurance and control strategies based on well-founded methodologies, and adequate capacity within your transcription team,” he explains. “When the staff is not working at their full-out rate, there is no question that you can offer 24-hour turnaround with superb quality.” On the other hand, Iwinski continues, some experienced and capable medical transcriptionists (MTs) are required to work too many hours in environments not governed by rigorous quality control processes. “When there is an influx of files for some reason, they have no choice but to do one of two things: work faster or sacrifice quality.” It is crucial that administrators maintain an optimum schedule of transcribing and editing among their staff, he says. Like any intellectually demanding task, medical transcription, if performed for too many hours a week or for too long a time on a given day, will result in a decrease in quality. “An MT who transcribes for six or seven hours will have a certain level of alertness, and probably, at the end of that standard shift, a diminished intensity,” he notes. “If that same transcriptionist is suddenly given a 20% increase in workload, he or she will be forced to work either 20% more hours or 20% faster.” That is not to say that hospitals demanding records within a 24-hour turnaround should be expected to accept less accurate reports, however. A well-developed strategy on the part of a medical transcription team or outsourcing company, along with its processes and ability to absorb an influx of files, will influence the quality of its product. “If it is possible to establish a dispersed network so that you can shift resources around, an influx may not present any problems at all,” Iwinski adds. “If your capacity shows signs of strain, though, quality may be an issue. Whether you work faster or longer, the stress will have an effect.” Health information managers, however, have several solutions they can apply to help prevent an accounts receivable backlog and other dysfunctional issues related to transcription turnaround. Keena explains that a facility’s ability to handle its own records depends on the size of its staff. He also recommends that healthcare organizations begin an improvement process by taking time to identify and assess any major errors that have occurred within their medical transcription department. “Most hospitals have very limited auditing capabilities,” he adds. “Usually, auditing is performed by an HIM supervisor, but in this case, I would recommend they spend the money to have an independent source perform the audit.” Secondly, he suggests developing a plan based on the outcome of the audit. This plan may include extensive MT training, offering regular and structured feedback, holding MTs accountable for their work, and rewarding them for quality combined with accuracy. Facilities may also find it beneficial to upgrade medical transcription systems to ensure compliance with new privacy requirements and to develop and supply a full range of templates and other resources their MTs may require. “Reference tools can help transcriptionists do a better job in a shorter time frame,” Keena explains. One of the primary challenges faced by hospitals, however, is maintaining an adequate number of full-time MTs on staff. “Whether you employ 20, 40, or 60 transcriptionists, it is difficult to manage workloads because the volume of files comes in unevenly,” he continues. “If you experience a high-volume day or if an MT calls out sick, there may be no way to ensure the turnaround because the deadline is not a matter of days, but of hours.” For this reason, many facilities opt to contract with an outsourcing firm that has the ability to balance its workload among thousands of MTs nationwide. “It is very difficult to guarantee 24 hours or less when you have a limited population,” Keena notes, explaining that no organization possesses the ability, or for that matter the desire, to make 20 or 40 employees work 24 hours a day every day of the year, and most do not possess the financial ability to offset this limitation. “Medical transcription turnaround is absolutely, critically, tied to a facility’s revenue cycle,” Keena stresses. “Many chief financial officers are realizing that if they do not have reports back within a certain amount of time, they cannot code and bill for those services.” Because of concerns about accuracy, however, they also realize that it is necessary to look at the entire process, from the MTs themselves to information systems and resources to even physicians’ dictation styles and equipment. Keena and Iwinski both agree that medical transcription turnaround and quality is, to an extent, dependent on the quality of the dictated records supplied by physicians. Iwinski adds that the environment in which a physician dictates a record plays as much a part in the eventual quality of the recording as his dictation abilities. “For example,” he says, “imagine a doctor working in a quiet office, on a high-quality microphone or digital recorder equipped with good noise suppression technology, speaking directly into the microphone with an appropriate pace of speech, paying close attention to the file.” Most MTs, he explains, could transcribe such a file rapidly and error-free, requiring very little editing. “That is a factor of the doctor’s training and technique, as well as the quality of his or her equipment and environment.” On the other hand, Iwinski has encountered physicians’ reports that—out of necessity—were dictated in a busy emergency department, while the speaker ate lunch, continuing to talk as he or she turned away from the microphone to drink soda. They also frequently use low-quality microphones plugged into the back of personal computers, he adds. “In a case like that, the combination of low-quality equipment, a noisy environment, and poor technique all combine to make transcription extremely difficult.” Whether on-site or outsourced, MTs have limited control over the product they are supplied. They also understand that physicians often need to perform dictation whenever, wherever, and however it is most convenient. “Additionally, we understand that hospital budgets are tight and often don’t permit top-of-the-line dictation equipment, which can be very costly if you are looking to supply an entire organization,” Iwinski continues. “That money is usually better spent on medical equipment related to patient care. As much as we would love physicians to have quiet space to do dictation, typical utilization of square footage in a hospital simply won’t allow for that on a regular basis.” Regardless of the quality-control processes a medical transcription company or department has in place, the last round of defense to ensure accuracy of medical records is for physicians to carefully review the transcribed files, Iwinski explains. “We are not doctors and we don’t participate in medical care, so we can only be as good as the raw material we are given,” he adds. “The responsibility of turning that dictated text into a medically reliable file that other doctors can use for diagnosis and treatment rests ultimately with the doctor who performed the initial dictation.” Iwinski stresses, though, that most physicians he encounters take dictating and reviewing their files seriously, and provide feedback to their transcription providers to enable them to improve their performance. Iwinski believes that perhaps the best
solutions to concerns about medical transcription turnaround and
quality are the development of effective MT training and transcription-related
quality-control processes by healthcare facilities and outsourcing
firms. Combining these measures with a commitment to hiring dedicated
and adaptable transcriptionists who, if possible, are designated
to work with a limited number of doctors, is the best defense against
transcription backlogs and inaccuracies. “At a very prosaic
level, we are simply in the business of typing,” Iwinski says.
“At a deeper level, though, the money we save hospitals has
a direct impact on the quality of medical care, research, and quality
of patients’ lives.” |
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