October 29, 2007
A June research report touted the effectiveness of this workflow design, but opponents say it’s a flawed approach.
For proponents of a once-and-done (OAD) transcription model, the future can’t come quickly enough, and they believe it’s already here just waiting to be implemented.
For others, the OAD model is seen as being light years away from practical implementation in terms of technological advances and physician acceptance. Some have even called it a once-and-do-over model.
Believers and Skeptics
According to Barry Hieb, MD, a healthcare research director at Gartner, Inc., the lack of efficiency and the money that leaks through transcription cracks have always been issues in the healthcare industry. In June, Hieb authored “The Evolving Model of Clinical Dictation and Transcription,” an industry research paper in which he discusses how the “role of dictation and transcription in clinical documentation is evolving in response to new technologies and new functional requirements...”
The report finds that “traditional dictation and transcription are giving way to ‘editor-based’ approaches and that once-and-done dictation will eventually be adopted in the majority of situations.”
“Transcription and dictation is a big industry, and millions and millions of dollars are spent on transcription,” Hieb explains. “We, both as an industry and as physicians, aren’t happy when we dictate something and send it to an MT [medical transcriptionist] and in a best-case scenario, it will come back in a couple of days. When it comes back, I, as a doctor, have to remember that particular case, look at it, and make changes. Then it goes back to the MT for changes, comes back to me, and I sign off. It could be four days to a week before that information shows up in a chart. That’s a fairly labor-intensive and expensive process.”
Hieb believes medical dictation and its associated transcription activities have moved into the second phase of a three-phase evolution because of the emergence of mature speech recognition capabilities. He writes in his report that “because speech recognition makes increased productivity and associated cost savings possible, it is now an integral part of most new dictation and transcription contracts.”
The OAD dictation model, Hieb explains, will take longer to unfold but will be driven by the need to provide value back to physicians at the time they are dictating reports.
On the flip side, “The reality today is that you have physicians that don’t even sign off on charts even though they are legally liable for the content. My concern is that when we look at building a national healthcare information infrastructure, it will be that much more critical to ensure the accuracy and completeness of information,” says Peter Preziosi, PhD, CAE, CEO of the Medical Transcription Industry Alliance and executive director of the Association for Healthcare Documentation Integrity (AHDI).
Preziosi says with information being exchanged across an enterprise, if there is an error in a record, it would be relatively contained. “But in an enterprisewide system [such as a regional health information organization or information sharing between connected sites], that error is multiplied,” he says.
Preziosi says the onus of chart accuracy must be on the clinician, not the MT, making the need for clinician sign-off imperative.
Can the Industry Do Better?
Enter speech recognition, Hieb says. “While speech recognition isn’t perfect, it is evolving,” he notes. With back-end speech recognition, the physician’s completed dictation gets fed into a “recognizer.” While Hieb agrees that the first pass isn’t perfect, the dictation then goes to an MT.
“We will be calling MTs editors rather than transcriptionists because their job won’t be to work from the raw data but to go back and correct the places where it looks like the speech recognizer got confused,” Hieb says.
Using speech recognition technology cuts significant costs from the entire transcription cycle, he says. “The editors can crank out 50% to 100% more copy a day and, as a result, the hospital gets charged less money. But the downside is there is still a two-day turnaround time, and the hospital is still paying for both transcription and dictation costs,” Hieb says.
The advantage to the editor mode of transcription is that the doctor is not being asked to change the way he or she operates, and the report is turned around faster. “Presumably, the editor is happier, is doing more work, and is being more productive. And from a documentation standpoint, you are telling the physician that the report will be back more quickly, but you still have to look at it, revise it, and sign off on it,” Hieb explains.
The OAD model, he says, carries with it a good news/bad news scenario: The hospital can save money and enhance performance, but the doctor has to change his or her dictation routine.
“Doctors are hesitant now because we will be telling them, ‘You will be dictating at a computer, but you can see what you are dictating’,” Hieb says. He acknowledges that some doctors are poor dictators, but with OAD, they can receive direct feedback and make edits as they go, while the patient information is fresh in their minds.
According to Preziosi, the key to good transcription is a well-trained workforce. “As an industry, we need to look at what our customers are telling us. And if we need to build up a more substantial infrastructure and workforce to meet those needs, then we need to retool and reshape,” he explains. “We need to look at how we can ensure public trust in the workforce that we are developing, and we do that with credentialing. We shouldn’t always assess on production; we need to look at the MTs’ understanding of critical thinking and problem-solving skills.”
Production isn’t the be-all and end-all of transcription, Preziosi cautions. “We aren’t just talking MT productivity levels; we [the industry] need to make certain the information being provided in the charts is relevant, usable, and placed in the proper area of the records,” he says.
In clinical circles, Preziosi says OAD is dubbed once-and-do-over. “When clinicians take on a speech recognition technology engine and are using it in real-time in the front-end, it is almost a matter of garbage in, garbage out. If the physician doesn’t have the time to do the self-editing, you don’t get an accurate document,” he says. “OAD has to do with the clinician handling the entire document from start to finish. … Does the average clinician have time to do this? It’s likely they don’t. OAD is an interesting concept, but it’s not realistic.”
Hieb believes that one of OAD’s benefits is that when the clinician dictates, edits, and signs off on the record, it’s ready to go into the electronic chart. “The turnaround time has dropped from four days to two days [with back-end speech recognition] to two minutes, and now any doctor can see that report as soon as the physician signs off on it,” Hieb explains. “That turnaround time brings nothing but benefits and better care to the patients.”
Although a hospital would have to invest in the software and hardware technologies necessary to implement an OAD system, Hieb says those expenses would pay off in the long run. “There will be set-up and maintenance fees, but they will be nowhere near the costs of the money spent on dictation and transcription,” he explains. He agrees, though, that getting doctors to change their behavior will be the largest hurdle to overcome.
Hieb says analyses of the time and effort required when a doctor performs raw transcription and dictation rarely take into account the extra steps of having to go back and look at the first draft, examine the corrected draft, and eventually sign off.
“With OAD, there is no subsequent time added to that chart, little hassle, and minimal risk of error,” he says. “The single best defense against malpractice is good documentation, and with once-and-done, you have given the doctor the chance to do the reports and be done with it.”
Speech recognition software has generally improved over the years, a critical factor in whether a doctor performs front-end or back-end dictation. Today, it is estimated that speech recognition picks up close to 90% of the doctors’ dictation accurately.
“If a doctor is a good speaker, that accuracy will go even higher,” Hieb says. “Doctors are surprised to see that they can save time and money. If they spend a little bit of time up front ‘training’ the system, they are reaping dividends in time and money saved.”
Cathy Baughman, CMT, FAAMT, manager of transcription services and president of the AHDI, says front-end speech recognized documentation and/or utilization of point-and-click technology for creating reports are only as good as the author providing the input.
“In my 29 years of experience in the healthcare industry, I’ve learned that physicians and other care providers choose medicine as their career because they want to participate in the care and treatment of patients to help improve the quality of life for the individuals. Creating patient care documentation is quite necessary but certainly not the first love of any care provider I know,” she says.
Baughman says when a physician has to pay more attention to interacting with a software program than interacting with patients, the patient experience starts to suffer.
Nevertheless, Hieb says OAD is being accepted more readily in private practices. “That is where the technology is really making inroads because the doctors see they can save time and money, and if they have an electronic copy of the record, the staff isn’t busy chasing down records. In fact, they may be able to reduce the amount of staff they are paying,” he says. “The OAD knows to file the record in Susie Smith’s chart, and the general trend in medicine is toward more clinical automation.”
Initially, Hieb says some doctors felt they were taking on secretarial responsibilities; education and peer endorsement helped OAD gain physician acceptance. “If we tell them it’s in their own best interest and that if you spend a little extra time editing, you will save time and money in the long run, they quickly see the benefits of OAD.”
As with many speech recognition technologies, OAD integrates more easily into radiology and pathology, but Hieb says it can also be effective in the emergency department (ED), where time is of the essence.
“In the ED, the real benefit is getting that data out there and into the chart instantly. The more quickly and effectively the information is captured in the chart, the more quickly the physicians have access to that data,” Hieb says.
According to Baughman, she has observed many radiology reports derived from front-end speech recognition that contain gross critical errors and many nonsensical entries that physicians fail to correct in their speech-recognized documentation.
“These errors get uploaded to the EMRs [electronic medical records] and distributed to referring physicians and can impact the overall view of the hospital from which they are sent,” she says.
For Hieb, the reason to embrace OAD is because the goal of the healthcare system is to help sick people get well and healthy people stay healthy. “We are entering an age when information is a critical component of achieving these two goals, and once and done is a better, more efficient way to capture that information,” he says.
Preziosi says the concept is not feasible in today’s marketplace, even with the enabling technologies that will be seen in the future. “Given the cost restraints, the persistent labor shortages, and the increased demands on the healthcare system, I don’t see OAD as being realistic,” he explains. “I think the clinical documentation sector needs to listen to the concerns of the consumers of our services and adapt our service offerings to meet their ever-evolving demands.”
Baughman believes the industry needs to embrace technologies that will make healthcare more productive and efficient and doesn’t believe OAD fits that description.
“When one evaluates who the highest paid individuals are in healthcare, it is the physician. So why would we have him or her spending precious, costly time with extensive editing?” she questions. “It makes more sense to me to utilize the skills of a professional medical language specialist to edit the speech-recognized documentation to ensure that it is as accurate as possible before the physician signs off and the report is distributed.”
— 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.