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October 2014

Transcription Gaps Pose Problems
By David Yeager
For The Record
Vol. 26 No. 10 P. 16

Are health care organizations paying proper attention to the caliber of their transcribed documents?

Although medical record privacy is always a concern, some patients may be surprised by who isn’t looking at their files. Most consumers probably expect that their medical records are reviewed for accuracy, but that’s not always the case.
For example, Jane (not her real name) has filled numerous roles, including supervisor/coordinator in acute care transcription, for more than 15 years. Over the past several years, she’s become troubled by the lack of transcription quality assurance (QA) at her workplace, a large, university-affiliated medical center in the Midwest.

Formatting errors are one of the major problems Jane has encountered, as well as omitted dictation from speech recognition-generated reports. She also has found frequent errors related to patient demographics, dates of service, provider names, and medications. When Jane expressed concern to a supervisor, he discouraged her from talking about them any further. While it’s unknown how many other health care organizations eschew QA, failure to do so can affect quality of care.

“That’s truly my concern because nobody is talking about quality assurance,” Jane says. “There are patient care errors on nearly every report; I never see a 100% accurate report. I can’t believe that it’s gone on this long without the doctors screaming.”

You Say QA, I Say…
As more health care organizations implement EHR systems, document quality becomes more important than ever, especially with doctors’ reports, which are often shared among multiple providers. Whether the reports are produced by back-end transcription or front-end voice recognition software, providers and patients depend on these documents to be relatively error free. Yet adequate QA of medical documents is far from universal. Why doesn’t it get more attention?

“I think the problem is that it’s somewhat inconsistent,” says Jill Devrick, MPA, president of the Association for Healthcare Documentation Integrity (AHDI) and a product solutions advisor for 3M. “There have always been QA processes in place in those health care organizations that have in-house departments, and the transcription service organizations that provide transcription services to hospitals have always had some sort of QA so that they could evaluate their transcriptionists and ensure that they’re doing the best possible job. However, the standards behind those QA processes have been different because every company or even every department could develop their own standards to define quality documentation.”

Although many facilities have instituted clinical documentation improvement programs, they only address the translation of a patient’s clinical status into coded data. A QA program is needed to completely review a patient’s narrative and demographic data. To assist the process, AHDI and AHIMA released a QA resource kit in July offering standards for measurement, reporting, and documentation improvement.

As far back as July 2010, AHDI, AHIMA, and the now-defunct Medical Transcription Industry Association released a report on QA best practices for health care documentation, which was updated in March 2011. But being aware of best practices doesn’t guarantee that people will follow them. Jane has witnessed this disconnect at her facility.

“We have always said that we follow AHDI, but every time I brought corrections to [my supervisor], he just lost it,” she says. “It was frustrating to me because I don’t understand where he’s coming from or why [he’s resistant].”

Unfortunately, there’s no validated data to determine how much QA is actually being done. Devrick says AHDI is trying to generate support for a benchmarking survey of all the health care organizations in the United States to determine how many have their own transcription departments, how facilities handle QA on outsourced documents, and how much QA is being performed on physician documentation. AHDI hopes to learn what types of programs and professional skills are needed, and how to update certification programs to reflect the needs of health care providers, she says.

In the meantime, what can providers do to ensure they’re producing the best possible documentation? The key is to be proactive, says Patti Swire, the director of client services for Precyse, a provider of HIM technology and consulting services. She says, in many cases, certain types of QA can sometimes be done more than necessary, but not always performed efficiently.

“Preventing errors before they happen should be the overall goal of a good program. When errors are made, it’s important to understand the root cause of any quality problem so that you can get underneath it. This often starts with the dictator,” Swire says. “Otherwise, what I’ve seen happen in a lot of settings is that repetitive errors may be frequently found and reported because the root cause of the issue has not been identified and addressed.”

To prevent wasted time and effort, she says the QA process must begin when medical transcriptionists (MTs) are hired. Support newcomers to make sure they’re meeting quality standards and streamline the process so MT questions are routed and answered in the most effective manner. In addition, open communication with the client is essential so that any dictator-related error that may cause a quality concern, at the point of transcription, can be addressed whenever possible. Swire says less than 10% of any MT’s work should need to be routed through a concurrent review process, if no other reason is found to do so, adding that retrospective review of 5% or 10% of the work isn’t necessarily any more effective than reviewing the industry standard 1%.

Industry standards also recommend that each health care organization perform QA in relation to their departmental budgets for software, personnel, and resources. To get the most out of a QA process, Swire recommends that organizations emphasize results, reduce the process’s subjectivity, and standardize procedures. All these factors can improve the value of QA.

“I think that if the organization looks for ways to standardize the entire process as much as possible, those standardized processes produce the best possible quality outcomes on a consistent basis,” she says. “For example, if an MT is making a mistake or a group of MTs are making the same type of mistake, a robust error resolution process and feedback program that addresses the quality error at the root cause will ensure that those recurrent issues are addressed quickly.”

Effective QA extends to outsourced documentation as well. With many facilities either outsourcing completely or contracting to handle overflow, this is a significant consideration. To improve efficiency, smart providers will make every effort to provide complete information to their transcription company.

“When we don’t receive information, we do end up having to send blanks back to the customer,” says Criss Spoto, the operations technology and QA manager for Amphion Medical Solutions. “When we can’t be sure of something, we leave it blank and send it back for the customer to clarify.”

Any time there’s a blank space, it’s possible that important information won’t be included in the care document. Outsourcing contracts usually have strict stipulations and many vendors have strong QA programs, but that doesn’t mean providers don’t have to worry about errors. In fact, it’s recommended they perform their own QA on outsourced documents.

“If you use traditional dictation methods, you definitely need a good QA program, especially if you don’t have in-house transcriptionists,” says Walter Houlihan, MBA, RHIA, CCS, the director of HIM and clinical documentation at Baystate Health in Springfield, Massachusetts, and the president of AHIMA’s Massachusetts chapter. “Anything you outsource, whether it be transcription, coding, or anything else, you should have an internal QA program in your department and not rely on the transcription company’s QA. You need to QA their work or QA their QAs. I think that’s critical.”

Which End Is Up?
Baystate Health, a three-hospital medical system with nearly 80 ambulatory sites, is in the process of transitioning to front-end speech recognition software. Houlihan sees it as an evolutionary step in a process that began 15 years ago. When he first arrived, there was minimal standardization in the dictation and transcription processes at Baystate Health sites. Standardizing the work across the inpatient and ambulatory sites assisted with transcription quality, turnaround time, and expense. Now, Baystate Health is switching to front-end dictation.

Front-end dictation is often touted as a means to reduce transcription costs. Houlihan expects to recoup Baystate Health’s investment in about two years, but believes there’s even greater value in front end users’ ability to immediately see and edit, as needed, their dictation, which contributes to faster report turnaround times and completion of the signed document. In an era of increasing regulation, timely documentation is becoming a necessity. One way for health care organizations to improve in that area is to have physicians edit their own reports. This allows the reports to go immediately into the EHR.

“The industry should be going in the direction of putting more control in the dictator’s hands, which is one option to avoid gaps in transcription,” says Houlihan. “Unfortunately, with back-end transcription, there might be providers who sign without completely reading the entire document, due to being very busy with direct patient care. They might not read everything that comes from the transcriptionists, and that could affect patient safety and the continuity of care.”

A common criticism of front-end speech recognition, however, is that it adds to the workload of already overburdened physicians. Making them responsible for their own QA has the potential to create a backlash. Houlihan says the majority of Baystate Health’s providers recognize the importance of making the switch and are on board with this important systemwide initiative.

Often, front-end dictation still goes through an MT, but the technology often limits the ability to make corrections. Because the speech engine needs to adapt to the user, MTs sometimes are forced to leave incorrect information in the document. Devrick says she’s heard this complaint quite a bit.

“I do know that there’s a lot of frustration among transcriptionists,” she says. “If the doctor misspeaks and the transcriptionists know what correction needs to be made in the document, they’re basically being told to correct it based on what the doctor says and not what’s correct. There are a lot of folks out there who feel like they’re very well trained to be able to assist the physicians and support them in making corrections to the content in the document so that the next person doesn’t have to, but they’re not being allowed to do that because the speech engine will be confused.”

Whether front-end dictation results in significant QA changes remains to be seen. While it’s true that cutting out the middleman—MTs—saves time, it also reduces the number of opportunities to catch errors. For now, it appears many facilities are preserving the status quo. “Right now, I don’t believe things have changed much at all because when they’re on a front-end solution, a lot of times they’ll still call us in to take a second look,” says Spoto.

Front-end/back-end issues aside, one way to get better value from QA may be to allow MTs to put their knowledge to better use by mentoring new hires and participating more actively in the editing process. For a time, Jane worked part time in a QA capacity for the transcription company that serves her facility. Rather than allowing her to assist the other MTs with formatting or questions related to the medical center’s physicians—many of whom she knew well—Jane was only allowed to QA documents that came into her queue. After six months, she quit in frustration.

Jane feels that time constraints and a lack of communication are hindering quality documentation. She says some transcription companies don’t allow enough time to research documentation questions, and some health care organizations don’t communicate style changes to transcription companies in a timely manner. Jane believes greater patient access to medical records eventually will drive QA improvement but, in the meantime, some providers may be skimping.

“It’s such a changing field; hospitals have to keep up with the technology and all of the changes that are being put on the board,” she says. “So I know they’re spending a fortune for everything, but you still cannot sacrifice quality.”

— David Yeager is a freelance writer and editor in southeastern Pennsylvania.

AHIMA/AHDI QA Resource Kit

QA Best Practices for Healthcare Documentation