Discrete Data Elements – Is That All We Need?

Seal of the United States President's Council ...

Image via Wikipedia

There can be no doubt that the ability to share and access useful health information is integral to improving healthcare in the United States. However, can we break down all of the information necessary to collaborate on  the care of the patient into discrete data elements? How do we create interoperability and access without losing the value of narrative documentation?

Read guest blogger Detlef Koll’s (CTO of M*Modal) thoughts on the subject at Excellence in Health Information.

Part 2 coming next week from HIMSS 2011.

Transcription Quality Redux

QA Cycle

Image via Wikipedia

Hello everyone: We’ve had a number of comments on the blog and through email about the post Quality Health Information – a Transcription Wake-up Call and it is certainly a topic that deserves attention.

I am hearing more in recent months about a practice that some companies use to decrease the amount of work sent to secondary QA levels before delivery to the provider. Companies select a threshold for how much work can be sent to QA – usually a percentage of total work transcribed or edited – and the MT is paid a lower line rate for work sent to QA that exceeds that threshold.  Balancing the push for productivity with quality is a difficult balancing act. Pushing an MT for  higher productivity (especially if line rates have already been decreased as speech recognition was introduced) does increase the temptation for an MT to send jobs to QA. How does an MT balance the need for speed with the amount of time she should spend researching a term?

I cannot comment on the specifics of this practice since I do not know what all of these companies do to support the MT otherwise, but I do have some questions.

  1. Does the MT have resources available to help complete the terms she isn’t able to make out or find through research? Is there someone available to lend a second ear or to answer questions?
  2. Is the QA person able to provide comment? In other words – can the QA person say, “yes, sending this job to QA was indeed reasonable” so that the MT can be paid the full line rate for those jobs?
  3. Has the company provided sufficient training to the MTs? Does it provide supplemental training for ESL authors or unfamiliar specialties or work types?
  4. Does the company provide reference materials, samples for specific, difficult doctors, and other tools to help MTs?
  5. Does the MT receive feedback on the documents she sends to QA? Does she receive corrected copies?
  6. Is work assigned to MTs such that they are able to become familiar with difficult doctors and unfamiliar specialties?
  7. Are particularly difficult doctors exempted from the threshold?
  8. How is the QA threshold selected? Is it one arbitrary percentage across the company? Are less experienced MTs expected to meet the same threshold as experienced MTs? Is there a higher threshold for known difficult authors or more difficult specialties or work types? Are all MTs held to the same threshold regardless of the level of difficulty of the work?
  9. Is sufficient QA performed on final documents to ensure that quality isn’t suffering as a result of this practice?
  10. Are MTs rewarded financially for consistently high quality work?

My hope is that a company that penalizes MTs for sending work to QA provides the tools and support to MTs to help them to create a high-quality document.  I also hope that if MTs are punished for sending work to QA, that they are also rewarded for producing consistently high quality documents.

My fear is that companies expect to push productivity and decrease QA without taking the measures required to ensure quality… I hope my fears are not justified!

All my best as always,



AHDI and the Medical Scribe Question

A medical record folder being pulled from the ...

Image via Wikipedia

There is an interesting conversation going on right now on AHDI Lounge about the role of the medical scribe in the documentation of patient clinical encounters.

Something that bothered me about AHDI ACE last summer was that rather than discussing what should be done to preserve dictation and transcription as a viable means of documenting patient care (and there is much that can be done to do this!), the focus of some of the AHDI leaders seemed largely to be on, “how do we turn MTs into something else?”

These “something else” positions often support exactly the form of documentation that we previously stated as contributing to the degradation of the quality of clinical information.  But those forms of information capture seem to be ok as long as the MT is doing the work.

Remember the conversations about needing to preserve the “patient story” in the medical record, and needing to make that story available in the EMR? Do you think medical scribes are creating narrative around the physician – patient encounter? No. They are capturing clinical facts. They are following the template in the EMR. They are not capturing the physician’s intuition and thoughts about that patient visit.

Worse – they are often in the position of determining what information to capture in the patient record, and how. They are interpreting the physician – patient encounter. Does anyone else besides me find this to be alarming? Yes they do.

I was at a healthcare provider site several weeks ago – a very prestigious one – who stated flat out, “we want scribes gone” for that very reason.  They see the scribe’s interpretation of the encounter as a major risk to the quality of information, to the organization, and to patient care. Unlike an MT, who transcribes what the physician dictates – those scribes with their limited clinical backgrounds and experience are interpreting the physician-patient interaction and deciding how to document the encounter.

AHDI previously expressed concern that eliminating dictation and transcription as a form of information capture because the physician can perform direct-data entry into the text boxes of an EMR would cause the degradation of the quality of health information – would cause us to lose the patient story.

So why then are these same methods of information capture just fine as long as we are transitioning MTs to be the person doing the work instead of the doctor? Why is it ok to lose the “patient story” as long as it is an MT performing the direct data entry?

My point is this – AHDI claims its vision is: To direct the evolution and ensure the integrity of healthcare documentation and data capture.

AHDI has always had a credibility issue. It has never been taken seriously by many in healthcare when compared, for example, to AHIMA. This latest conversation is a good example of why this is. AHDI is largely looked at as only trying to save transcription for the sake of saving transcription. They are not looked to as authorities on health information.  Wavering on its stance about how a particular method of information capture contributes to the quality and usefulness of health information will only contribute to that perception.

Making MTs aware that there are other opportunities out there and helping them to find information and training is one thing. But embracing the medical scribe profession as part of AHDI is another thing entirely. It changes what the organization is.

Are you AHDI – in support of the integrity of health information? Or are you in support of anything that provides jobs for MTs regardless of the method used to capture the information?

Each of those is fine. Each is even admirable. But you can’t be both.

If the core value of AHDI is to “ensure the integrity of healthcare documentation” then that must be the guiding principle behind all of its decisions.

All the best as always,

Jay Vance – Guest Blog on Excellence in Health Information

Little airplane

Image via Wikipedia

Hello all:  It is my great pleasure to host Jay Vance as a guest blogger on Excellence in Health Information.

Jay’s presents his insight on the challenges facing medical transcription and healthcare in general, and how we can face these challenges.

Please join me in welcoming Jay and we invite you to participate in the discussion.

All the best,



Thoughts on Patient Access to Health Information?

The Doctor, by Sir Luke Fildes (1891)

Image via Wikipedia

Hello everyone:  In a post on open.source.com, Lori Mehen asks “Will reading your doctor’s notes make you healthier?”

You probably remember the Seinfeld episode she recounts in her article:

‘In an old Seinfeld episode, Elaine visits her doctor  and manages to sneak a peek at the physician’s notes. She sees she’s been labeled “difficult.” The doctor grabs the notes from her and after a confrontation, jots down more notes. Later, Elaine convinces Kramer to try to get access to her chart, but he walks out empty-handed only to report, “they’ve now created a chart on me.”‘

She goes on to talk about a study named OpenNotes which asks:

‘”The OpenNotes project aims to improve communication and transparency between doctors and patients,” says Dr. Tom Delbanco, the lead investigator of the study. “We have one simple research question: After a year, will the patients and doctors still want to continue sharing notes?“‘

My question to all of you out there in the HIM space is – what do you think? You have transcribed and coded and QA’d and abstracted countless physician notes.

You are also patients and consumers of healthcare. It is one thing for engineers and developers of software to speculate – and even a subgroup of physicians who want the transparency between them and their patients – but I’d like to hear from those of you who listen to and read physician documentation day in and day out.

Do you think the average physician documents in a way that can be understood by the patient? Do you think he or she should have to? Will physicians be inclined to leave information out of documentation that might be worrisome to a patient? Is there information a doctor might be unwilling to present for patient viewing because of legal concerns?

How will this impact documentation in support of ICD-10 and quality measures which require a higher level of specificity in the documentation? Does the need for a record to be understood by a patient conflict with the need for a higher level of documentation?

I think everyone would agree that better communication between physicians and patients would be beneficial to the patient. Is open access to physician documentation the answer? Are there pieces of the HIM workflow that can help to create a patient-facing summary? Um – hint – MTs? Or would that be frowned up?

Would love to hear your thoughts!




Mehen, L. Retrieved February 4, 2011from http://opensource.com/life/11/2/will-reading-your-doctors-notes-make-you-healthier

OpenNotes. Retrieved February 4, 2011 from http://www.myopennotes.org/

Transcription People are Special

happy valentines day - pink gerbera with a hea...

Image by Vanessa Pike-Russell via Flickr

Hello everyone:  I wanted to take a few minutes in between conference calls to tell you all how happy I am to be part of this industry.

My post from last week Quality Health Information – a Transcription Wake-up Call could have generated lots of tomato-throwing at me.

But instead, I’ve received so many comments and emails from people in the industry who, rather than taking offense, are willing to accept the fact that we do have challenges – and face those challenges head-on. I’ve heard about lots of interesting solutions these people are using to address quality issues –  everything from improving training and education, to reviewing compensation, to looking into more effective management and QA processes, to enhancing technology and more…

I’ve heard from people from hospitals and physician practices, from MTSOs, from AHDI, and from AHIMA. I’ve heard from MTs and managers and directors and QA personnel.  All of them dedicated to the production of quality health information.

We have a lot of passionate people in the health information domain – regardless of whether or not they work for a healthcare provider or for a service or for a technology company – and I’m proud to be part of it.

Thank you everyone for reminding me 🙂

All my best as always,

%d bloggers like this: