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Special AHIMA Edition September 2013

Five Challenges Facing Transcription Managers
By Julie Knudson
For The Record
Vol. 25 No. 13 P. 18

Conquer these and department leaders can stay a step ahead.

Transcription departments are deep in the heart of the many changes occurring throughout the health care industry. From EMR implementations to more efficient billing practices, they’re huge players as demand grows for more accurate and timely documentation.

Naturally, the pressure placed on transcription managers has grown along with the demand. A closer examination of the most pressing issues reveals the enormous strain they’re feeling.

Job Security
The Clash may have inadvertently written the transcription department theme song when the band penned the line “Should I stay or should I go?” In today’s environment, many hospitals are debating whether to insource or outsource the transcription function.

“With costs and all the changes in health care, I think budgets have become more critical,” says Karen Davis, president of Atlanta-based Voice One Solutions. “One of the biggest things they have to decide right off the bat is whether it’s more cost-efficient to keep these people in-house or to outsource them.”

While it’s a tough decision for transcriptionists to wait out, it’s also a difficult position for department managers. “I think it’s a huge challenge for them because a lot of them are in smaller or rural facilities, and they don’t want to have to struggle with laying people off,” Davis says.

While this evaluation takes place—the process is rarely swift—the transcription team lives in limbo. Employees have a lot weighing on them: Will they continue to have a job with their current employer? Will they soon be looking for work? Does working for a medical transcription service organization make sense? Should they become an independent contractor?

The situation that played out at Moffitt Cancer Center in Tampa, Florida, is all too common. “Since we first went to speech recognition four years ago, there has been the fear that we would lose our jobs,” says Debra J. Randolph, CMT, Moffitt’s manager of documentation integrity. “We heard from the vendors that we would reduce our staff by one-half within a year, but that did not happen.”

However, the transcriptionists have been informed of the potential for upcoming staff reductions. Randolph couldn’t give them much concrete information, though. “We wanted to let everybody know, but at the same time we didn’t really know what to tell them because we didn’t have a time frame,” she recalls.

Because Randolph wants to limit the chances of dropping a surprise on staff members, she has kept them updated with what little information is available. Thus far there haven’t been any layoffs, but the uncertainty makes managing, motivating, and retaining good workers extremely difficult, leaving transcription managers with the potential for lagging productivity as worried transcriptionists wonder whether they’ll still have a job in a month or a year.

Convincing the C-Suite
As hospitals search for new ways to trim costs and boost revenue, the prospect of eliminating an entire department may be beguiling to those focused on the bottom line. The result is that transcription managers, who often are the last line of defense, must shoulder the effort—and the aggravation—of educating hospital leadership that the transcription function can’t simply vanish.

“A lot of CEOs and CFOs [chief financial officers] believe they can get speech recognition and do away with employee payroll, and that’s just not the case,” says Diana Johnston, BS, RHIA, director of the health informatics programs at Indian Hills Community College in Ottumwa, Iowa.

Part of the problem can be traced to dubious information the C-suite receives from other departments. “The IT groups are convincing the CFOs, ‘I’ll save you money. Bring in speech recognition, and we’ll eliminate all those transcriptionists,’” Johnston explains, adding that for administrators and others to continue supporting HIM efforts at the appropriate levels, they need to understand transcription isn’t going away. “Instead, health care documentation specialists need to be auditors and quality monitors for documentation integrity.”

Even when it’s understood that transcription isn’t being eliminated entirely, documentation groups still are finding their resources dwindling as the relentless drumbeat of cost cutting goes on. Lisa M. Woodley, RHIT, CMT, AHDI-F, HITPro-PW, health information systems supervisor of medical transcription at Seattle’s Virginia Mason Medical Center, believes HIM often isn’t seen as a revenue-generating area for hospitals, a perception that puts it on the chopping block when funding is an issue. “We don’t bring revenue into the hospital, so it seems like it might be a good place to cut costs,” she says.

According to Woodley, this rationale is prevalent not only within her own organization but at hospitals across the country. And even if transcription groups remain in-house, they continue to rank near the bottom when it comes to resource allocations, she says.

Getting Providers and EMRs to Work Together
While physician perspectives on EMRs vary, some transcription managers are discovering that change isn’t something instantly embraced by the provider crowd. At Moffitt, physicians are doing much of the EMR input in real time, though Randolph’s group still performs random audits, proofreading the documents and returning them to providers if corrections are needed. The arrangement has led to new roles for transcriptionists. “It has been a huge change for the providers and a huge change for the transcriptionists,” Randolph says.

One of the adjustments involves converting transcription tasks into an electronic environment. “The system wasn’t designed for us to have access, and it has been a struggle trying to fit the tasks we do into the EMR,” Randolph says. “We’re lucky to have physician liaisons and IT staff that have been willing to work with us.”

Getting physicians to work within the EMR constructs often is a tall task for transcriptionists. Davis says EMR systems generally provide a “semirestrictive” framework, which can make it a difficult transition for everyone. “How do you get the story—the patient narrative—into the EMR?” she asks. “[The EMR] restricts how much physicians can document, but they still need to be able to get the entire narrative into that interface.”

As a result, documentation specialists are increasingly stuck trying to ensure that patient records are thorough and accurate in a workflow that doesn’t always promote such standards.

Staying Involved in Tech Implementations
Across the industry, workflow changes resulting from technology implementations continue to grow at an impressive rate. Unfortunately, the explosion has forced IT groups to conduct their projects in what could best be described as a vacuum. “There are implementations of a lot of computerized documentation strategies made without engaging HIM’s expertise on how it should be implemented and integrated into workflows,” Woodley says.

Systems are being evaluated from an enterprise standpoint without incorporating user perspective. Workflow assumptions are sometimes incorrect or at least incomplete. Outside pressures such as regulatory and turnaround requirements don’t always make it onto the criteria list until late in a project’s life cycle, increasing the likelihood there will be a less efficient workflow forced on documentation specialists at a time when they have more on their plate than ever.

At Moffitt, the HIM director was intent on reaching out to IT at the beginning of the EMR project, and a team of physician liaisons and physician trainers were put in place to act as intermediaries. Randolph says it’s a model for other HIM departments to follow. “Make sure you don’t get passed over when they start having all these project meetings and these steering committee meetings,” she notes. “Be sure you’re involved.”

Randolph says Moffitt’s approach has not only given her group the opportunity to weigh in on how the project moves forward, but it also has helped craft a workable strategy for dealing with any workflow disruptions that may have cropped up during the transition.

HIM directors and transcription managers must take the lead in educating their hospital’s administrative groups, according to Johnston. “Make sure they’re aware of the new regulations and what’s going to be needed,” she says, adding that HIM should take an active role in developing and implementing initiatives related to clinical quality monitoring, meaningful use standards, and clinical documentation improvement. “They need to be seen as a major driver in educating the C-suite, the medical staff, and hospital employees on the evolving skills and process flow needed for these new technologies and regulations.”

Meeting Deadlines
Few things in the transcription realm happen without a deadline. The transition from ICD-9 to ICD-10 and meaningful use are just two pending deadlines presenting a challenge to hospital transcription managers. At the center is EMR implementation. “What I’ve read and what I’ve heard is that some people aren’t totally on board with it,” says Debbie Hahn, RMT, president of the Kansas chapter of the Association for Healthcare Documentation Integrity.

That ground-level pushback may be prompting internal conflicts and causing folks on all sides of the discussion some serious angst, all of which Hahn says does little to change one inescapable fact. “They aren’t sure if they want to [adopt] it or not, but the government has issued deadlines,” she notes, adding that transcription teams often are caught in the middle trying to meet a compliance deadline while battling with those who are still uncommitted.

“We are in an environment now where everybody is being asked to do more with less,” Woodley says. With regulatory mandates, technology project target dates, and the garden-variety deadlines associated with running a department, transcription managers often struggle with figuring out how to meet demands on a limited budget.

When Woodley needs to justify asking for more resources, she highlights HIM’s value to the organization. “I demonstrate to them that documentation is a crucial part of maintaining the patient’s story, of maintaining accurate, timely, and good health records,” she says.

Are Today’s Challenges Really New?
Some of the obstacles facing transcription managers have been around for a while, but the changing health care environment has broadened their scale or made them more urgent. “Technology changes are bringing old issues to the surface in addition to the new technologies’ issues,” Johnston says, pointing to record completion turnaround times and data security as two “oldies but goodies” that have gained renewed focus and placed more pressure on physicians and administration. Meaningful use and the recent HIPAA Omnibus Rule also have ramped up pressure, she adds.

In many cases, the sheer ubiquity of technology has changed the sort of challenges transcription managers face. Concepts such as electronic records have gone from being viewed as newcomers on the hospital scene to being relatively common across the health care spectrum. “EHRs are becoming more desirable as the workforce becomes more mobile,” Hahn says. Today, patients and physicians alike expect to carry medical records around in their pockets.

The technologies transcriptionists use to do their jobs have changed, too. “Front-end and back-end speech recognition are much more common now than they were just five years ago,” Hahn says.

Tomorrow’s Concerns
There are hurdles on the horizon that have not yet made their full impact on the transcription sector. Among them is the shift going on in the workforce’s demographic, which Woodley believes will become a huge challenge in the next several years.

While the team at Virginia Mason boasts decades of experience, Woodley is concerned about how that expertise will be shared with tomorrow’s workers. “How do I take that amazing skill set and amazing amount of knowledge and get it into a new person and get them up to speed and not have it take years?” she asks.

Transcription is increasingly about more/better/faster, so carving out time for experienced, seemingly indispensable workers to step away from their tasks and impart their hard-earned knowledge on the next generation of documentation specialists is becoming more difficult. In addition, a huge segment of the workforce is home based, making face-to-face sharing a hurdle even if departments can find the time to make the arrangements.

As patient involvement quickly moves to center stage, transcriptionists likely will find themselves in the thick of things before long. Stage 2 of meaningful use requires hospitals to provide at least one-half of admitted patients with online access to their medical records within 36 hours of discharge. Johnston believes it’s just one step in the evolving relationship patients will have with the information partly managed by documentation specialists.

“Individuals are going to be getting more involved in their own personal health records,” she says. “They may carry it around on a jump or thumb drive, and I think that’s something we need to be preparing for.”

— Julie Knudson is a freelance business writer based in Seattle.


The Ongoing Debate Over Salary
The pay structure for transcription has been a topic of discussion—and disagreement—for years. Karen Davis, president of Atlanta-based Voice One Solutions, says quality coding and transcription go hand in hand, a relationship that often doesn’t translate into how hospitals pay for their services. “They’re willing to pay $40 an hour for a coder, but they want to pay 7 cents a line for transcription,” she says.

That conversation is becoming more complex as overseas transcription companies increasingly move into the domestic marketplace. Offshore services may claim to provide the lower costs hospitals crave, but questions continue to swirl around the quality and security they can provide. Transcriptionist salaries have been an area of disconnect for some time, says Davis, who speculates that the addition of less expensive overseas vendors is only going to further muddy the waters.

— JK