Response to Questions…

Hello everyone:  Over the past couple of months I’ve been privileged to present at several conferences and to do a couple of webinars. Since then some questions about these presentations have been sent my way (thank you!).

I thought it might be helpful to provide some links to some past articles that might be of interest to anyone who has questions about some of the presentations.

Thanks so much for proving once again how dedicated the people in the health information industry are to providing and producing high-value health information!

As always, questions and comments are most welcome!

Lynn,

M*Modal

Speech Recognition – general

Is Speech Recognition the answer to all your problems?

Speech Rec is here to stay…

MT Compensation and Management

MT Compensation

The Demise of the Career MT

ACE 2010 Presentation – Keeping Transcription Relevant into the Future

What Factors Contribute to MT Career-Mindedness?

Slides from NEMA AHDI Presentation…

Optimization of speech recognition Technology Results

When Metrics Mean Nothing – The Myth of the “Percent Gain”

What does the Medical Transcription Industry Sell?

Narrative Documentation, Standards

Are we Telling the Real Health Story?

A Vision for Truly Meaningful Health Information

Speech Recognition as the Accelerator of Meaningful Clinical Documentation

Hello everyone: Over the last couple of weeks I had the opportunity to attend several conferences. One was the national conference of the Case Management Society of America (CMSA) (more about this visit later) which was held in San Antonio, Texas, (home of the Alamo). Then I had the privilege of presenting to two state HIMA conferences; New Jersey (NJHIMA) in Atlantic City, and then back to Texas (TxHIMA) for their state conference in Dallas.

As always, I really enjoyed meeting with state HIMA members. It is so satisfying to know that wherever you are in the country, HIM professionals have the same passion for safe, high-quality, useful health information. It is also interesting to see that everyone seems to be facing the same challenges with respect to adoption and use of electronic health records. Everywhere I go, I hear the same stories about point-and-click, template-driven EHR systems that are time-intensive and cumbersome for the physician, that don’t provide the necessary information for the HIM, and which cause concerns for the health care enterprise because of costs and questionable ROI.

Needless to say, there is always interest in discussing narrative documentation including how to produce it cost-effectively and efficiently, and how it can be used to generate the discrete data needed for the interoperable exchange of information, to provide data for reporting and analysis, to drive clinical decision support and other automated care protocols, and in general, to realize the benefits that we all expect as we make use of electronic health information.

Some of you have seen these before, but just in case, here are my slides:  NarrativeDocumentation_HIMA_20110629.

In a nutshell:

1. Today’s changing health care environment is setting higher standards for documentation while seemingly making it more difficult for physicians to document patient care. The need for documentation to support Meaningful Use, to drive the communications and reporting necessary for Accountable Care and the Patient-Centered Medical home, to enable the conversion to ICD-10 from ICD-9, and to support the reporting required to monitor quality and outcomes is increasing. It is more apparent than ever that comprehensive, complete, and accurate health information is integral to the functioning of any health care facility. And yet newer methods of documenting patient care are often inefficient and time consuming for the physician and are not intuitive for other consumers of health information.
2. Dictation is still a viable, economical, and effective means of capturing clinical information.
3. In order to be cost- and time-effective, options for clinical documentation must be made available based on the type of encounter being documented and the needs of the user. For some encounters, templated, structured forms are likely sufficient. For others, physicians may do very well with speech recognition and self-editing. For more complex encounters, physician dictation supported by skilled medical transcription might still be the best way to go. The point is – health care providers must have flexibility and options for capturing the complete, comprehensive level of information required to support patient care, coding for billing and reimbursement, research and population health reporting, and all of the other uses for health information.
4. Speech recognition and other technologies, when combined with efficient management practices, can be a cost-effective way to produce high-quality narrative documentation.
5. We cannot continue to look to the best practices that many services and providers have historically followed when implementing speech recognition. In the past the goal might have been to “create cheap documentation fast” – now the goal for clinical documentation MUST be, “create useful documentation efficiently.’
6. Quality is key. We are all hearing a great deal about natural language processing, computer assisted coding, and other technologies that will help us to process and make use of our health information – but if the documentation at the foundation of these technologies is poor – the technology can’t do its job.
7. Efficient management practices are another key component. The percentage of productivity gained does not necessarily reflect the increase in output! Again, technology is no replacement for effective management practices.
8. It is not, as many believe, necessary to eliminate narrative documentation in order to have semantically interoperable electronic information. The Health Story, HL7, IHE Consolidation project is making great strides towards the creation of interoperable standards for the exchange and use of health information which will allow us to have the structured and encoded clinical data that we need to support automated processes, while at the same time retaining the human-readable narrative information that is required for communication and understanding. I personally have always been a big believer in having my cake… and eating it too. 

If you have any questions about the slides or the presentation please let me know. I’d love to hear your thoughts and experiences!

Till next time,
Lynn
M*Modal

Physician Heal Thyself – A Letter to My Doctors

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Hi all:  Do you remember a while back when I blogged about a visit to my doctor where she was so busy inputting information into her EMR – that she forgot to examine me?  I sat on the exam table while she sat with her back to me interviewing me according to the EMR template.

I experienced another interesting doctor’s visit just last week.  Read my Letter to My Doctors on Excellence in Health Information.

All my best as always,

Lynn

M*Modal

Too Expensive to Fix

I recently came across a 2003 issue of Journal of Healthcare Information Management that is almost entirely devoted to measuring the ROI of HIT investments and I was struck by this quote from Richard Lang, EdD in his Editor’s Introduction.

“Although an ROI may predict how long it will take a capital investment to return anticipated savings via cost reductions or new revenue, it lacks a suitable measurement for the “qualitative” aspects that can contribute heavily to the realization of strategic objectives” (Lang, 2003)

I have worked with or talked to so many providers over the last year who realized they made a mistake in the way they planned to realize, or in how they measured, the ROI of their EMR systems.  One health system executive said he knows his organization made a mistake in their plans for EMR implementation and he admits they made incorrect assumptions about where they would see the return on their investment.  But he asked – how do you get an entire organization to admit that that it made a mistake? Even if it does, what can they do about it after spending many millions of dollars? Start all over? Not likely. And they are not alone.  Currently several of these providers are coming to my employer, M*Modal, looking to augment the capabilities of their EMR in hope of achieving the strategic objectives they expected to see upon EMR implementation.

One of the most common mistakes seems to come from the assumption that point-and-click data entry and structured EMR forms are a better way to capture health information than narrative dictation.  Many in fact incorrectly believe that direct-data entry into structured reporting is the only way an organization can get the discrete data they need to drive automated clinical decision support, to enable population reporting, and to attain the holy grail of electronic health information – semantic interoperability.

One of the primary contributors to ROI that these providers expected to see was the elimination of dictation and medical transcription costs.  After all, since the doctors can point-and-click their way through a structured form, why should they need to dictate?  Since many of these facilities spend millions of dollars every year on dictation and transcription, the cost benefit seems like a no-brainer.  And let’s face it; many of the decision-makers aren’t accustomed to looking at the aspects of health information which can only be measured qualitatively.  They are accustomed to looking at FTE expense and productivity units.

However, they found several things:

  • Point-and-click methods of information capture can be time-consuming, cumbersome, non-intuitive, and significantly add to the physician’s documentation time, even sometimes causing a decrease in the number of patients physicians see in a day.
  • The information captured is not as usable for clinical care and some HIM functions as narrative forms of documentation.  As one physician told me, “I like that I have access to all the patient vitals, but I can’t tell how the patient feels today compared to how he felt yesterday.”
  • The quality of the documentation is often degraded as well.  Physicians copy and paste in order to save time and end up with duplicate, extraneous, or contradictory information.  They enter information into the miscellaneous text boxes because they can’t find a place for the information they wanted to capture in the drop-down menus and structured fields.  And in the traditional EMR world, information captured in the plain text boxes = no structured data = information that is lost in the computer and can’t be reused by the EMR.  As one IT manager said, “we have several thousand physicians using it, but that doesn’t mean they are using it correctly.”

So getting back to the quote at the top of this post, in counting on the elimination of narrative documentation, and thus dictation and transcription, as an expense that can be eliminated, providers often forget about the cost of the physician’s time and about the cost of degraded quality of information.  In the organization’s quest for structured data, they forget about the clinician’s need to use health information as a means of communication. They forget that one of the benefits to be gained as a result of the implementation and use of electronic health information is the improved health of the patient. That is, some of the benefits will not be realized by the provider but rather will be felt by the recipients of the improved, more efficient care.  This type of return on a technology investment is not as easily measured as number of FTEs or productivity units per hour.

At M*Modal, we’re working with several providers now who have realized that they can give physicians the option to document patient care using narrative dictation AND still get the structured data they need. They’ve realized that their objectives for truly useful and cost-effective documentation can only be achieved if the system offers options and flexibility for capturing health information.  Is the solution always optimal? No – because EMRs with their proprietary data formats aren’t eager to open up to accept readily-exchangeable data standards.  Some organizations are beginning to look to capabilities available outside of their EMRs as the solution to their problems.  But what happens to the providers who cannot afford to look to complementary solutions that will help them to realize the benefits they expected to get from their EMRs?

Though the government-driven efforts to encourage the adoption and use of electronic health information through the ARRA, HITECH, and Meaningful Use certainly have increased interest in HIT, one negative result is that providers might place so much emphasis on the financial incentives that they don’t look at the benefits of health information that can’t be measured in cost per FTE or in CMS incentive payments.  I hope that providers who are only now in the decision-making process take note of the lessons-learned by others before they too end up with a problem too expensive to fix.

Food for thought,

Lynn

Originally appeared at Excellence in Health Information

Reference:

Lang, R. (2003).  ROI and IT:  Strategic alignment and selection objectivity.  Journal of Healthcare Information Management.  Volume 17, number 4. Fall 2003.

AHDI – M*Modal Continuing Management for Modern Medical Transcription Series – Webinar

US medical groups' adoption of EHR (2005)

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Hello everyone:  It was my very great pleasure today to be the presenter for an AHDI webinar as part of the M*Modal – AHDI Management for Modern Medical Transcription series.

Today’s presentation was titled, “The Continuing Relevance of Medical Transcription in Health Care.”  Here is a pdf of the slides. AHDIWebinar_Transcription_Relevance_20110517

Key points:

Medical transcription:

  1. Is part of HIM.
  2. Can support Meaningful Use, ICD-10 coding, and computer assisted coding (CAC).
  3. Must provide documentation that is valuable and useful.
  4. Must emphasize quality of content over print format and cost.
  5. Supports options and flexibility for increased adoption.
  6. Can be cost-effective without sacrificing MT pay.

Back in the earlier days of speech recognition (and in fact many health care facilities and transcription companies  still follow these practices today), the best practices for speech recognition were much more limiting than they are now.  They tended to be directed at productivity – not towards the cost-effective creation of useful documentation.

Unfortunately, the emphasis on productivity and cost savings caused us to lose sight of what it is that we do – create high-quality, accurate, clinical documentation – and who creates it – the highly skilled, knowledgeable, Career-Minded, Medical Transcriptionist.

I myself stood up in front of a roomful of people at the 2006 AHIMA national conference and gave recommendations such as:

  • Select physicians carefully
  • Select MTs carefully. You will have plenty of volume left for traditional transcription.  Leave your high-producers in transcription and move your low- to mid-range producers to speech rec.
  • Have your MTs perform “as dictated” editing as much as possible.
  • Encourage physicians to adopt best practices for speech recognition.

That was before I came to M*Modal and realized that the right technology allows us to view documentation from a different perspective.  It allows us to get the real value and use out of clinical documents rather than only using them to check off a requirement on a chart completion list.  Luckily even the most stubborn of us can learn fast when we want to.  🙂

Today that list would look more like:

  • Bring on the doctors – let the technology sort out which result in quality sufficient for editing and which do not.
  • Train all of your MTs to edit.  Advanced speech recognition technology will cover a significant portion of the transcription volume.  Transcription IS editing.
  • Pay your highly-skilled, highly productive transcriptionists appropriately as they move into speech.  You cannot deliver the quality of documentation necessary to support requirements for meaningful use, ICD-10, or computer assisted coding, without them.
  • Create the requirements for documentation according to usefulness and quality.  “You get what you say” does not result in documentation that consistently adheres to content or quality needs.
  • The “average % productivity gained” is not the correct metric to use to measure the results of speech recognition; nor is it the correct means to determine a compensation plan.
  • Get your cost savings through a combination of effective use of the technology and workforce and performance management.  Understand that cost benefits come from increased output from fewer staff members – not a high average % increase.  Your increased output will allow you to take on more volume without increasing staff.  If your output increases enough that you can decrease staff, get rid of the “hobby MTs” and reward your Career-Minded MTs for making you more efficient.

Medical transcription must be about delivering high-quality, comprehensive, useful information – not cheap documentation – if it is to stay relevant as an enabler of health information technology.

All the best as always,

Lynn

M*Modal

Throw Away Everything you Thought you Knew About Speech Recognition and Medical Transcription

Fort Lauderdale, Florida

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Hello everyone:  What better way to roll into National Medical Transcriptionist Week than with a trip to lovely Fort Lauderdale to meet with the even lovelier folks of AHDI – Florida!

As always, a visit to this lively, engaged group of dedicated professionals resulted in more discussion than there was time!  And to cap it all off, I had the pleasure of meeting two luminaries in the health information domain, Pat Forbis and Claudia Tessier.  I was greatly humbled to have been part of a speaking schedule that included two women who have been such leaders in our field. I even got to share a bench with Claudia, both of us “iPadding” away.  Very cool to “ipad” sitting next to the leader of the mHealth Initiative!

The theme for AHDI-Florida’s annual meeting was the “Winds of Change”, so what better topics to discuss than the emerging technologies which are having such an impact on our industry, on health information, and on how health care itself is delivered.

The point I most wanted to make in my presentation is that changing technologies do not mean the end of medical transcription.  In fact, if we keep sight of the fact that medical transcription is about the accurate and high-quality creation of meaningful, useful clinical documentation – not the “cheap” creation of something someone only uses to check off requirements on a chart completion list, then transcription can actually be an important enabler for electronic health information.

Unfortunately, the focus in recent years has sometimes been on the wrong things.  We’ve focused so much on cost, on print formats, and on providing customized requirements, that we’ve lost sight of the real value we provide to the health care provider.  Worse, we’ve allowed them to lose sight of our value too.

So let’s throw away everything we thought we knew about transcription, slides here –  Florida_AHDI_20110514 , and look at it in an entirely new light.  Let’s look at it as a way to provide high-quality, comprehensive documentation to support increasing demands for information….produced in a way that happens to be cost-effective.

What can we do?

  1. Make sure everyone knows about the Health Story project, particularly the Health Story, IHE, HL7 Consolidation project.  Learn about it, and share your knowledge with your employer, your customers, your vendors, and your representatives in the U.S. Congress.
  2. Remember how important your highly skilled, highly productive, career-MTs are if you are to be a provider of information that can be used to support Meaningful Use, computer assisted coding, the coming ICD-10 conversion, and the other increased demands for health information that are coming our way.  Feel free to refer here for links to other articles about this topic.
  3. Focus on quality.  Without quality, the rest can’t happen.

Thank you as always to AHDI-Florida for being such gracious hosts and such passionate supporters of high-quality clinical documentation.

And don’t forget to visit Misty and Bethany at M*Modal’s Always Understanding blog for activities all week in honor of National Medical Transcriptionist Week!

All my best as always,

Lynn

M*Modal

A Vision for Truly Meaningful Health Information

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This article comes on the heels of the AHDI – CDIA Advocacy Summit in Washington, DC, where members of AHDI and CDIA worked together to speak to members of Congress about the value of narrative health information and the part that medical transcription plays in helping to preserve the patient story.  This article is a joint effort from Liora Alschuler, CEO of Lantana Consulting and me, and also appears on Excellence in Health Information.

Physicians have long used narrative documentation as an effective means of information capture.  Dictation in particular is a widely used method of creating clinical reports such as history and physical documents, operative reports, consultation reports, discharge summaries, and progress notes.  In addition to serving as important communication tools, these documents are an excellent source of the information used by providers for HIM, medico-legal, and administrative functions.  These documents can contain the subtleties of the physician thought process in addition to important clinical facts. They contain a level of expressiveness that cannot easily be captured using other methods of information capture.  According to the Health Story Project, the amount of the nation’s total clinical information captured as narrative documents is approximately 60%, with 1.2 billion documents produced in the United States every year (2011).1

Now that it is accepted that electronic health information will lead to more efficient and effective health care, the belief that information must be captured as discrete metadata-tagged elements in order for the data to be semantically interoperable has led to the assumption that narrative forms of documentation are no longer of value.  When physicians lose the option to dictate narrative notes, they typically are asked to enter the data into the EHR manually, using “point-and-click” methods to capture clinical data. But adoption of electronic health records has been slow, largely because of the increased level of effort and time required to enter information into the EHR, and also because care givers do not find the clinical facts available to them through EHR templates to be a sufficient representation of the patient’s health and clinical history.

The Health Story Project (originally CDA4CDT) was founded for the purpose of creating implementation guides for the electronic exchange and use of health information captured in narrative clinical documents.

The Health Story guides address content requirements for the most common document types and create data standards for exchange of information captured within the original “primary source” documentation of the delivery of care. They represent the original capture of key observations and results, as well as data elements required for the electronic record. The component parts are described through CDA templates, the reusable building blocks of Clinical Document Architecture, most of them developed initially for the HL7 Continuity of Care Document (CCD).

Meanwhile, IHE and HITSP were also developing CDA implementation guides which enable and facilitate Meaningful Use requirements, but which led to some duplication and disconnects with the Health Story guides.

A new initiative, the HL7/IHE Health Story Consolidation Project, joins the two efforts. This project creates a standard which provides the ability to capture and encode discrete data elements while also structuring narrative information such that its value is persisted in the electronic health record.

The collaboration between Health Story, IHE, and HL7 will:

  • Republish all eight Health Story guides for the original common document types plus the related/referenced templates from CCD in a single source.
  • Update the templates to meet the requirements of Meaningful Use, augmenting the base CCD requirements to meet the requirements of HITSP C32/C83.
  • Reconcile discrepancies between overlapping templates published by HL7, IHE and HITSP.

This collaboration is a volunteer effort hosted within the ONC’s Standards and Interoperability (S&I) Framework.  If widely adopted, a standard for health information exchange based on this project could resolve many current challenges by enabling the capture, exchange, and use of clinical data in the EHR in a way that is also meaningful and understandable by human caregivers.

The resulting implementation guides will facilitate meaningful use of electronic health information by:

  • Increasing adoption by allowing physicians to document patient encounters using methods that are efficient, effective, and convenient.
  • Improving the usefulness of the data by increasing the likelihood that the required level of specificity and comprehensiveness will be provided.
  • Enabling the expressive information that is relevant to the documentation of patient care but which does not accommodate entry by point-and-click methods of information capture.

This project gives us the best of both worlds by enabling the exchange and use of clinical facts tagged as discrete data elements without losing the narrative information which still remains the most effective tool for communication and collaboration between the human members of the patient care team.

Dr. David Blumenthal, in his introduction to the ONC’s Federal Health Information Technology Strategic Plan 2011 – 2015, refers to electronic health information as the “’lifeblood’ of modern health care” (2011).2 This collaboration between the Health Story, HL7, and IHE take us one step closer to that vision.

All my best as always,

Lynn

M*Modal

1 – Health Story Project.  (2011).  HL7/IHE Health Story Consolidation Project.  Health Story

Project: Integrating narrative notes with the EHR. http://www.healthstory.com/standards/sec/consolidate.htm

2 – Office of the National Coordinator. (2011).  Federal Health Information Technology Strategic

Plan: 2011 – 2015.  David Blumenthal, MD, MPP.  Retrieved April 21, 2011 from http://healthit.hhs.gov/portal/server.pt/document/954074/federal_hit_strategic_plan_public_comment_period

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