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Software, People Combo a Hit
By David Strite

Driven by the implementation of the HITECH and Affordable Care acts, as well as the ICD-10 coding initiative, the medical documentation industry has undergone unprecedented growth. While these new regulations are changing health care's landscape, providers are struggling to figure out how to work within their parameters, implement EHRs, and ready themselves for an influx of new patients—as many as 30 million—entering the system through the Affordable Care Act.

Hospitals and large medical practices may look to tap software solutions to help them make it through the transition. However, technology alone can't solve all of health care's growing pains nor can it guarantee high-quality documentation.

Evolution of Transcription
Over the past 30 years, medical transcription technology has advanced from tape recorders and couriers to digital dictation, smartphone apps, and even cloud-based platforms. Improvements in speech recognition technology have enabled automated voice collection. Thanks to the Internet and new cloud software, physicians, nurse practitioners, and others can create documentation quickly and easily on their tablets, smartphones, or laptops from nearly anywhere. Integrating clinical documentation with EHRs and other HIT systems increases the chances of leveraging electronic medical information quickly and easily.

However, transcription software hasn't been a panacea for documentation ills; EHRs still must begin with quality transcription. After all, the stakes are higher than ever to ensure that all of the information captured in the patient record is accurate.

Documentation errors can have a wide range of effects, from the clinical, such as delayed diagnosis, misdiagnosis, medication errors, and even death, to the financial—the resulting coding and billing errors may lead to lower reimbursement and malpractice litigation.

While software in combination with new electronic devices plays a key role in keeping pace with the demand for faster and more accurate documentation, even the best technology won't be a cure-all. There are some errors that only HIM professionals can recognize.

The Pendulum Swings
Quality documentation begins with a comprehensive approach that brings people back into the equation. Assembling a team of experienced and dedicated documentation professionals is the first step to ensuring compliant recordkeeping. A foundation built on best practices, including establishing a core set of policies and procedures, gets the project off on the right note.

When dealing with hospitals and physician practices, transcription service providers must develop a personalized approach. Each practice and hospital is different—from their physician mix and physical location to the type of medical services they provide. Cookie-cutter approaches derived from templates don't work, especially at specialty practices.

Highly specialized medicine uses specific terminology that can be recognized only through training and experience. That being the case, certification, experience, and continuous training must be a fundamental consideration in these settings. Selecting and staffing a team trained in the organization's specialty contributes to transcription quality. For example, cancer-related practices and hospitals benefit from having a team of dedicated medical transcriptionists (MTs) who can quickly recognize various oncology-related terms, including those found in anatomy, diagnostic, and imaging procedures, and pharmacology and laboratory values. Further, assigning MTs to specific physicians will help them recognize and adjust quickly to idiosyncrasies such as speech patterns.

Any quality assurance (QA) process must include opportunities for continuous improvement. For example, regular feedback, auditing, and testing help ensure quality standards are maintained. It also is important that trained QA support staff interact regularly with MTs to stay aware of any documentation issues.

The Association for Healthcare Documentation Integrity (AHDI) has established quality scores that weigh varying degrees of error against the length of a report. The AHDI recommends the following quality goals: 100% accuracy with respect to critical errors, 98% accuracy with respect to major errors, and 98% accuracy with respect to all errors in the report. Many service level agreements are based on the transcription service provider's ability to meet these criteria.

MTs Diagnosing Errors
Blanks and misinterpreted speech recognition pose major quality concerns and can lead to missing, incorrect, or questionable information. Such errors can impact patient care and revenue cycle management. Common causes of blanks include the following:

• the inability to verify terminology;

• incomplete or missing physician thoughts;

• discrepancies in dictated details;

• author-requested blanks (information to be filled in after transcription);

• faulty equipment, including audio file distortion, and clipped or incomplete dictation;

• the inability to identify a person or a place; and

• preexisting blanks within text that have been copied forward.

As part of best practices, smart providers will implement procedures for inspecting the validity of blanks. In the event an error is suspected, MTs or QA editors can intervene proactively to resolve any issues. Because software doesn't necessarily recognize blanks, this process becomes even more important.

In some cases, transcription quality is affected by the dictator's ability to speak clearly. The inability to organize thoughts into coherent dictation and idiosyncrasies such as rapid speech or a heavy accent also can disrupt dictation.

Remind physicians regularly about their responsibility to create the best dictation possible. Posting notes and issuing other reminders can help alert physicians to speak at conversational rates, differentiate sound-alike terms, and spell or enunciate clearly difficult terminology, drugs, equipment, names, and places.

Optimizing Success
It's important to make the dictating environment as optimal as possible. Despite technological advancements, some dictators prefer familiar equipment, making it a good strategy to have traditional options such as phones readily available. Still, don't ignore new technology, including smartphones and tablets, for more ambitious physicians.

From the start of the documentation cycle, everything must be in working order. If physicians are expected to produce viable dictation, they must be provided with a quiet, HIPAA-compliant environment and the proper equipment. Also, the equipment—whether it be a digital recorder, phone, tablet, or smartphone—must be reliable and monitored regularly.

Further, both online and smartphone dictation software must be audited regularly to ensure quality. Health care organizations must be prepared to act in the event software or hardware runs afoul or needs to be updated. Additionally, security must be top of mind at all times. In an increasingly electronic environment, health care organizations face numerous threats, including malware, viruses, and hackers.

Ensuring Quality Documentation
Today's clinical documentation environment is complicated. New advances in software and related hardware have improved documentation, but only to a point. Producing accurate, timely, and compliant medical records still falls mostly in the hands of HIM professionals, who monitor and plug holes during the documentation process. This diligence remains a staple in any successful health care organization.

— David Strite is senior vice president of operations at iMedX.