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November 18, 2002

CAN YOU HEAR ME NOW?
MTs Speak Clearly on Dictation Guidelines
By Hannah Fiske

An overriding concern on the minds of medical transcriptionists (MTs) is how the quality of dictation affects their ability to offer the first-rate transcription and rapid turnaround required in today’s medical industry. Unfortunately, clinicians pressed for time, dictating on outdated equipment, and surrounded by distractions, often turn in poor-quality dictation that makes it difficult for MTs to perform at their best.

What is the answer to this growing problem? From speech recognition software to providing better education for clinicians about dictation guidelines, health information professionals are exploring every avenue that promises potential improvement.

Although clinicians’ dictation practices have long been of concern to MTs, the issue has recently garnered more attention because of its impact on transcription turnaround and the resulting effect on the reimbursement process, explains Brenda J. Hurley, CMT, FAAMT, director of MT development, MedWare Inc., Maitland, Fla. “There is more of a push to get information turned around quickly, and this is not going to diminish,” Hurley says. “So, suddenly people are wondering why it takes three MTs to review a document. The reason is that it was dictated on a cell phone in the middle of traffic, and it takes three people to listen to see if they can fill in the blanks.”

The impact of poor dictation practices on MTs ranges from psychological stress to diminished income, with an unavoidable effect on job satisfaction. “In most service settings, MTs are usually paid by production,” Hurley explains. “Do poorly dictated notes take longer to transcribe? Absolutely. Are MTs still held accountable for the turnaround time? Yes, but part of their job is taking the time to give it the best effort they can. As a profession, we have accepted this.” Much of the frustration, she continues, comes from good MTs’ innate desire to turn in quality work, despite the fact that they are forced to work with both good and bad dictators. “I don’t know of any transcriptionists who want to do a poor job,” she says. “But, sometimes, we have so little to work with that we are frustrated at not being able to do our best and live up to our own expectations.”

Frustration often results in stress, which can be exacerbated by the intuitive quality of medical transcription, according to Cynthia Richardson, CMT, transcription operations manager, Dictaphone Corporation, Melbourne, Fla. “As transcriptionists, we tend to be very visual so that the clinician’s voice paints a picture in our minds of what was happening in the treatment room,” she explains. “At times, this can be so far-reaching that if the doctor has a lot of nervous energy, the transcriptionist can end up with a terrible headache.”

Listening to a physician’s dictated notes, she continues, can convey the sense of jubilation at the delivery of a perfectly healthy infant to the devastation of losing a patient. By becoming familiar with physicians whose reports they transcribe, MTs can become attuned to the clinicians’ routine and potentially detect errors as well. “I like to think we can be a good resource to prevent physicians from making inaccurate statements about their patients’ care because our job is to document that care,” Richardson says. “We take transcription seriously and believe we play a big part in the quality of care patients receive.”

Because transcriptionists want to produce accurate reports, many are subject to stress caused by dictation practices that hinder their work, agrees Mary Ann Grandonico, CMT, transcription supervisor, Wuesthoff Health Systems, Rockledge, Fla. “We need to make sure quality is the first and foremost concern,” she notes. “We can’t compromise it, whether or not transcription is being done off-shore.” Within the hospital where she works, Grandonico explains that administrators are continuously trying to come up with more creative staffing and scheduling solutions to meet the demand for rapid turnaround. “To meet these demands, it is becoming increasingly difficult to hire people with only two or three years’ experience,” she says. “To survive in this market, new MTs need to get the best training possible to have a strong foundation because we no longer have the time to accept all of the responsibility for their training.”

Turnaround times have become so crucial for hospitals, Grandonico continues, that they no longer have the luxury of training their new MTs, often passing that responsibility on to the larger outsourcing companies. “Ultimately, it is a vicious cycle,” she says. “Everyone wants faster turnaround and needs reports to be available almost immediately. In turn, this also becomes a risk management issue, an aspect I think we need to address more strongly.” Despite the potential for preventable medical errors caused by poor dictation practices, money-conscious hospitals continue to be driven by the bottom line, which may be the only way of finally addressing the dictation problem, Grandonico adds. “In the end,” she says, “money will be the motivating factor in addressing it because it also affects turnaround, which affects billing processes.”

When asked about what constitutes “poor dictation practices,” Hurley, Richardson, and Grandonico agree on a series of contributing factors, including environmental problems, distractions, less-than-satisfactory equipment, and increasing demands upon clinicians’ time. Surprisingly, however, the least effective dictators tend not to be those who speak English as a second language (ESL). “There are many ESL dictators who dictate beautifully,” Hurley says. “They take their time, are organized, and, perhaps because they know they struggle somewhat with the language, they are more precise and contemplate what they are saying.” Others, including many American physicians for whom English is their native language, rush through dictation as they eat lunch or while they commute between their office and the hospital. “I recall having conversations with clinicians when I worked in a hospital, telling them that if they spoke a little slower we could probably hear what they were saying better,” she continues. “Their answer was that they hate dictating and want to hurry up and get it over with. They just don’t have enough time.”

Grandonico agrees that time plays a major role in dictation practices and outcomes. Often, practices grow too large and out of control before a doctor has time to take on a partner, she says. “There are so many demands on their time to perform medical procedures and see a specific number of patients that they have less time to do administrative work,” she notes. “They are simply being stretched to the limit.”

Instead of the situation improving, this case is likely to become more commonplace. “Clinicians now end up dictating in places such as the cardiac cath lab as they try to examine films, with so much going on around them in terms of activity and noise,” Grandonico explains. “It would be much better if the physicians could sit at a telephone with no distractions and be focused; but, with the increasing demands on their time, I can’t see the situation getting better.”

One of the factors that contributes to transcriptionists’ woes is the number of distractions faced by clinicians when they dictate their notes in a hospital environment. “Not only are there background noises that interfere, but physicians are continually interrupted while they are trying to dictate,” Hurley says. A little education would go a long way toward fixing this all-too-common practice, she adds. Simply letting staff members know that when physicians are dictating they are not to be interrupted could make a world of difference to MTs and the quality and timeliness of the final transcribed product.

“Dictating a report may take only approximately five minutes, but it takes a lot longer if the clinician is interrupted,” Hurley adds. “Plus, when they are interrupted, they frequently leave out important pieces of information or say something inconsistent with what they previously dictated because they forget where they left off.” Interruptions occur most often at busy locations such as nursing stations, where a physician is available to nurses, therapists, and others who need his or her time. “It’s unfortunate, but those people need to wait in line because we need their time, too,” she asserts.

The type of equipment used for dictation also plays a part in the final product. In a world where it seems nearly everything is digital, there are physicians who still dictate on cassettes, resulting in a lower-quality product. One limitation is that a tape can only be in one place at a time, as opposed to an electronic or digital record, which can be made available to an unlimited number of people. Also, Hurley notes, tapes tend to wear out before the user notices they need to be replaced. “In the services setting where I used to work, we would simply buy new tapes for the clinicians,” she says. “It was far simpler for us to provide new ones when we noticed a tape was wearing out. They weren’t that expensive, and we benefitted from it in the long run.” Additionally, they often have a high level of static noise in the background and sometimes break in the middle of transcription. “I can’t tell you how many tapes I have repaired in my lifetime,” she laughs. “It can take one to two hours to do this, but if you have 30 minutes of dictation on a tape, the physician will not be happy if he or she has to redo it.” The cost of digital dictation systems, however, has limited the number of facilities currently employing them, despite their convenience and quality.

It should be made clear, Hurley stresses, that MTs have a high level of respect for physicians. “We are not physician-bashing,” she continues. “We understand that the pressure they are under is probably more than that faced by most people. We never meet them, but we can hear this through their voices.” MTs also hear clinicians’ concern for their patients, their fatigue, and often feel a close bond with them from listening to their voices hour after hour. “We don’t know them personally, but we feel the pain they go through.”

To that end—and to ensure the highest levels of both dictation and transcription quality—MTs are working toward finding solutions to the problems surrounding dictation practices. Within medical facilities, for instance, it is important to have health information professionals available to work with physicians who have poor dictation habits, suggests Grandonico. It also helps, she continues, for medical transcription outsourcing companies or departments to be able to develop good working relationships with clinicians, providing them with guidelines and tools to help them dictate more effectively. “Training for both MTs and physicians is becoming an issue,” she notes, adding that doctors should remember that there is always a human being on the other end of their dictation trying to transcribe what they are saying. “Clinicians should be responsible for the dictation they are creating,” she offers. “They should listen and understand that if there is a vacuum cleaner running next to them, someone on the other end of the line will have trouble hearing what they are saying.” Grandonico would also like to remind physicians that speaking faster will not necessarily result in a faster turnaround time. “If it is done right the first time, it will work for everyone.”

Speech recognition software is another possible solution on the horizon, according to Grandonico, who explains that the products are not the threat they were once perceived to be. “Clinicians who are able to dictate in a consistent and audible manner are prime candidates for this new technology,” she explains, predicting that more facilities will soon be implementing it. “Physicians, at first, were unwilling to accept speech recognition software, thinking it would take more time for them to use. In reality, it saves time.”

Perhaps most importantly, ASTM, a nonprofit organization that provides a forum for materials, products, systems, and services, is currently developing a standard guide for data capture through the dictation process. It’s a project with which Hurley is intimately involved and about which she is passionate. “We are trying to develop guidelines for dictation. This will include some of the things to plan ahead, the do’s and don’ts, hints and tips,” she says. “We are trying our best to approach this diplomatically, but clearly this is a partnership. A transcriptionist can only do so much with what we are given.” By providing clinicians with basic guidelines, ASTM members hope to greatly improve the processes of dictation and transcription, which, in the end, will benefit everyone involved.

As they draft the guidelines, Hurley and the other committee members are trying to ascertain what is practicable for most
healthcare providers. “We are taking a positive step in this direction,” Hurley says. “Not only do we have established dictators in the industry, but we also have a new generation coming that is currently in medical school.” This provides ASTM members with the perfect opportunity to educate new physicians about the importance of clear, understandable dictation. According to Hurley, the guidelines will someday be made available to medical schools, as well as to colleges and universities where nurses, nurse practitioners, therapists, social workers, and others in the healthcare industry are trained. “In the future, when medical records are mostly electronic and there is no paper record to write notes, we will have additional healthcare professionals dictating,” she predicts.

The real challenge will come when ASTM presents the guidelines to clinicians to ask for their input and eventually their compliance, Hurley says. “This has not been a secretive project, but we have not had a lot of feedback from physicians,” she says. The reasons for the guidelines continue to motivate her, however, and she is hopeful that the medical community will recognize their value. “We hear so much about medical errors and how important quality of documentation is to quality healthcare,” she says.

The truth, according to most MTs, is that quality transcription and quality of documentation are a direct product of the quality of dictation. Turnaround time is also critical, not only to billing processes, but also to ensure the best patient care. “The longer it takes to produce a report, the longer it takes to get it back on the chart, and that delays availability of medical information,” Hurley says. If a report is dictated correctly the first time, it will be returned more quickly than if two or three transcriptionists need to review it to decipher the language. “This is a big can of worms,” she says, “and one that, now that it’s opened, is unlikely to be closed again.”

— Hannah Fiske is a staff writer at For the Record.

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