April 14, 2008
The secret’s out. If facilities are serious about improving documentation quality, it’s imperative that they stress the importance of proper dictation methods.
Just how difficult is it these days to capture physician documentation? “Our hands are held behind our backs, and we’re asked to catch the ball” is how one transcription manager describes the challenge of deciphering poor dictations while at the same time being expected to provide accurate reports.
“Challenges with physician dictation have been a dirty little secret in transcription forever, and as we’re squeezed for turnaround time and limited to the number of blanks we are allowed to leave, dealing with poor dictation practices can be very frustrating. We have to meet unreasonable expectations, but we have no control to make it happen,” says Brenda Hurley, CMT, FAAMT, director of industry relations and compliance at Medware, Inc. and past president of the Association for Healthcare Documentation Integrity (AHDI) who has helped the organization create a Dictation Best Practices toolkit (available at www.ahdionline.org/scriptcontent/DBP.cfm).
Michael Clark, senior vice president of operations at MedQuist, notes that poor dictation practices create an interesting challenge because the transcriptionist’s role is to interpret what he or she believes was said, and that has always been a challenge in terms of physicians articulating what they want to convey in their dictation.
“There is a lot more responsibility on the dictator today than in the past, and the responsibility carries over to the transcriptionist. We need to help physicians know why they should use best practices and why those are more encompassing today than in the past,” says Clark. He adds that transcriptionists must deal with dialects, slang, intent, and other factors that inhibit a clear message. If a note is dictated using best practices, it is much easier to transcribe, and it provides more certainty that the information in the draft is appropriate for the physician’s review, signature, and, ultimately, the patient’s record.
Tools of the Trade
To address the documentation problems stemming from poor dictation, the AHDI undertook an initiative in 2006 to highlight dictation best practices based on the American Society for Testing and Materials’ standard E2344, which is a basic standard to improve the quality of healthcare documentation through the dictation process.
“It’s an item we all deal with as medical transcriptionists. We don’t have direct contact with dictators who maybe don’t have a clue about bad habits because they haven’t learned and they are not aware of the consequences of their poor dictations,” says Hurley. So rather than focusing on the poor dictations, the AHDI is addressing the issue from a compliance standpoint. “The message to physicians is, ‘If you are serious about quality, use these dictation guidelines,’” she says.
The AHDI created the best practices tool kit to assist facilities with the adoption and implementation of policies and training practices that promote high-quality dictation and ensure the best documentation outcomes. The kit includes Dictation Best Practices: A Guide for Physicians, a self-running audiovisual presentation, and a PowerPoint presentation with handouts for a live seminar. In addition, the kit includes the rationale for promoting better dictation practices and “Dictation 101,” recommendations for instructing dictators in good dictation habits.
The tool kit was first introduced and available on the Internet. Then MedQuist took an interest and sponsored the necessary funds to produce the information on a CD for distribution, with the AHDI presenting the CDs at the 2006 AHIMA conference.
Many of the suggestions in the toolkit seem to be common-sense approaches to ensuring that a dictation is clear, but Hurley identifies dictation environment, speed, volume, and organization as the most common areas where physicians can improve.
Location, Location, Location
One of the most common problems encountered is the poor dictation environment. For example, at nursing stations, they are often interrupted and background noise can be overwhelming.
Fairy Miller, CMT, RHIT, director of transcription at Caldwell Memorial Hospital in Lenoir, N.C., who took part in the AHDI’s initiative, tried much of the information available on the Internet to determine its effect.
At Caldwell Memorial, dictations done at nurses’ stations are particularly problematic. To mitigate the problem, a memo regarding the issue was sent not only to the physicians but also to the nursing directors, notifying them that everything they are talking about at the nurses’ station is heard in transcription. “Once people become aware of the problem, they understand the importance,” says Miller.
She finds that the approach taken in communicating the importance of good dictation can influence physician buy-in. “If you can show them how it’s important to them personally—that the process supports them, billing, and even potentially supports them legally, if necessary—they have a better understanding that high-quality dictation is for their own good,” says Miller.
What Was That?
The dictation speed and volume are two other components that can make or break good dictation. “Doctors are quite busy and often rush through the dictation to get on with patient care. Even with digital technology, it is still very fast, and there is only so much clarity you can get with a fast dictation,” says Hurley.
Volume issues usually involve a dictator who whispers, likely because of confidentiality concerns. “We instruct them to dictate like they are talking to their kids. The information might be confidential, but whether you whisper or speak loudly, transcriptionists are going to and need to hear it either way,” Hurley says. “The bottom line is transcriptionists can’t get what they can’t hear, and the report won’t be as high in quality if there is too much background commotion distracting the dictator.”
If one of the seven transcriptionists at Caldwell Memorial encounters a physician whose dictations are difficult to understand, Miller finds it is most effective to have a one-on-one conversation with that particular dictator. In addition, Miller will sometimes attend a medical staff meeting to address any problems and hear any concerns the physicians may have.
Stay on Track
Lack of organization is another key factor that often affects dictation practices. Hurley says that when physicians are unorganized in reporting on a case, they are likely to leave something out, especially if they are interrupted. She gives an example of one operative report in which the dictator reported out of sequence, and, as a result, failed to mention closing the incision.
Putting the Tools Into Practice
Sherry Doggett, CMT, FAAMT, director of corporate transcription services at Health Alliance, a multihospital integrated delivery system in Cincinnati, says it is critical to have a process in place to encourage successful dictation practices, as well as to deal with dictators who need assistance in improving their practices.
Thanks to its affiliation with the University of Cincinnati Medical Center, there are usually more than 600 residents at any given time at the University Hospital, part of the Health Alliance system. “Every year when the new residents come on board, we have an avenue to present dictation best practices at a formal inservice that is part of orientation,” Doggett says. She presents materials and handouts highlighting dictation practices and giving residents the name of a person from the transcription department to contact should they need support.
Doggett says it’s important to take the right approach when attempting to get physicians to improve dictations. “Our transcription report coordinator coordinates workflow and acts as a liaison for improvement between transcription and physicians. If transcription is having a problem with a particular physician’s dictations, she will meet with them and work with them to improve their process,” she says.
Physicians are usually receptive to Doggett’s “how can we help you help us?” approach. By using that strategy and providing immediate positive feedback, she has seen enormous gains among physicians looking to boost their dictation skills.
Lee Starling, a transcription/file retrieval manager at Shands at the University of Florida, has also seen her share of great and not-so-great dictators. Because it’s also a teaching facility, Shands’ orientation of new residents gives her the opportunity to highlight the importance of good dictation and provide new physicians with information regarding best practices.
She says her physicians generally do a good job with their dictations. If, however, one of Starling’s staff encounters a difficult transcription, she contacts the physician directly to address the specifics of the problem, a technique the physicians usually respond to very well.
Measure of Success
Some facilities are able to track their best—and worst—dictators through various technologies. At Health Alliance, the transcription department maintains a log that records documentation problems and enables them to track and trend any physician issues.
“In the past, we might have received a complaint about a particular physician’s dictating habits, but everything came in piecemeal with two or three people from various departments handling it independently. By having a defined process in place like we do now, we no longer have that problem,” Doggett says.
Shands can measure its physicians’ success through automated speech recognition reports. As a user of MedQuist’s back-end speech recognition technology, Shands is given a report every quarter ranking their physicians in terms of correction effort, which provides another level of measuring their success as dictators. “The report is sent to the division chair then distributed to each division. And physicians know exactly where they stand in relation to how they are dictating,” says Starling.
Barriers to Change
A poorly dictated report requires greater attention and more time to decipher. It usually goes through multiple levels of review, which increases turnaround time. Even then, the end product is not as good as it would be if the dictation started in a good environment.
“It’s about habits, and changing them is key,” Hurley says. “Nobody likes criticism. Healthcare providers are a stressed group and have a lot of pressure, so dictation is an area where they can cut corners but still feel confident that their report will come out well. So we have to put emphasis on what needs to be done with dictation.”
Like others in her position, Doggett sees physician resistance as the biggest barrier to implementing dictation best practices. “We’ve built a really good relationship with our doctors. They see that we are quality oriented and are doing this to improve the final result,” she says. “Because we’ve been able to show them that, it has created a positive process improvement.”
Doggett’s best advice? “Get them when they come in the door. Use the ‘how can we help you help us?’ approach and give feedback immediately. Stop inappropriate dictating behavior as soon as it is noticed,” she recommends.
Being a small, rural hospital, Caldwell Memorial faces a constant battle with physician turnover. When new doctors join the facility, they are given an inservice to learn about the dictation system, best practices, and what to expect from transcription concerning such things as turnaround time. “But it seems that just when someone is up to speed on their dictation, they move on to another facility,” says Miller.
Implications for Speech Recognition
As the industry transitions to speech recognition to increase quality and productivity, good dictation habits come full circle, with physicians who dictate according to best practices having the greatest opportunity to succeed in the speech recognition arena, according to Clark.
Clark believes two things motivate physicians to change: time and cost savings. “Time is extraordinarily valuable, and any time physicians can save time, that in itself is a motivation for change,” he says. “Cost is the second thing, as time is money. If speech recognition is used to lower cost and increase quality, physicians are usually interested, but they will not see the best results if they aren’t using best practices.”
If a facility is moving to speech recognition, Hurley says that good vendors will recognize the need for using basic dictation principles to make the technology as effective as possible. “It is unfortunate that a facility must invest millions in speech recognition before dictation practices come to the forefront when they could already see their return on investment by using dictation best practices and standardization of documents. The vision is still quality documentation, so why not start now?” Hurley says.
“Medical transcriptionists really want to get the report right, and if they have to leave a blank because of poor dictation, it becomes very frustrating,” she adds. “We have the skills and education and know the anatomy, so it is very difficult because you want to do a great job on every report. We take it very seriously, as if it was our family’s case we were transcribing.”
— Annie Macios is a freelance writer based in Doylestown, Pa.
Basic Elements of Good Dictation
1. Organize your data before dictating.
2. Dictate in a secure, quiet area.
3. Speak clearly and loudly.
4. Always state your name and the name of the patient you are documenting care for. Include at least one other identifier (eg, birth date). Take care to spell the patient’s name correctly (especially important with common names or unusual names).
5. Clearly state the work type. Remember that facility work types change from organization to organization.
6. Do not rush. Dictate at an even pace throughout the report so the medical transcriptionist can hear every nuance of a vowel or consonant in a word.
7. Give hints in areas that could be misunderstood, such as ABduction or ADduction, hyPERtension and hyPOtension, one-five for 15, five-zero for 50.
8. Never use abbreviations unless stating what it stands for at least once in the report. Make sure the abbreviations you use are approved by the facility you are working in. Most approved abbreviations are facility-specific.
9. When listing medications, never abbreviate. Spell any uncommon drugs. Many drugs sound alike, so be very clear (eg, Endal, Inderal, MiraSept, Mircette). Try to dictate dosage instructions consistently (in the same sequence) throughout. If you rush anywhere, this is NOT the place to do it. Medicine errors cause deaths.
10. Delineate lab values. While you are reading them and they make perfect sense to you, it can be very confusing to sort out what part of a number goes with what when you are just listening to a bunch of numbers. The transcriptionist cannot always tell where one value stops and the other begins. For example, the value “133.6” could be a single value, but it could also represent two separate values where a dictator fails to indicate a new lab test. Thus, a sodium of 130 and a potassium of 3.6 can sound like “133.6” if the dictator merely provides back-to-back values without a test indicator by dictating “130, 3.6….” and so on.
— Source: “Dictation 101”(www.ahdionline.org/ScriptContent/Downloads/DBPDictation101.pdf)