The Value of MTs in Healthcare Documentation Production?

Transcription

1 The Value of MTs in Healthcare Documentation Production? Gary C. David, PhD Associate Professor of Sociology Bentley University, Waltham, MA 2009 Spring Fling Michigan AHDI Chapter Frankenmuth, MI

2 The Value of MTs in Healthcare Documentation Production-? Project Description: Examination of how medical records are created Medical Transcription Based Traditional dictation-transcription Back-end speech recognition Healthcare Practitioner Based Front-end speech recognition Direct Entry Blended approaches 2

3 Project Data Collection Survey Total of 3807 respondents Interviews Over twenty one-on-one interviews with MTs Thirteen one-on-one interviews with MTSO management Focus Groups Five MT focus groups, with over twenty total participants Committee Work Serving on SRT special committee, and working with BP in quality assurance committee Site Visits Numerous site visits to New England regional transcription facilities, as well as MTSOs in India. Other East Coast site visits planned. 3

4 Project Outputs - Presentations 2008 An Exploratory Study of the Challenges of Medical Transcription Outsourcing in India. Gary David, Anjanee Sethi, Donald Chand, Shymali Rathore, Angela Cora Garcia. International Smart-Sourcing Conference. Hyderabad, India. August 8-9, Academic Perspectives on Industry Practices: Preliminary Results from the MT Project. Association for Healthcare Documentation Integrity Annual Conference and Expo. Orlando, FL. August 8 th Offshore Transcription: Myths and Realities. Medquist INPUT Leadership Summit. Atlanta, GA: May QA Best Practices in Medical Transcription Panel Medical Transcription Industry Association Annual Convention. Long Beach, CA. April Medical Transcription Research Project: A Business Owner s Perspective. Medical Transcription Industry Association Annual Convention. Long Beach, CA. April Contemporary Issues in Medical Transcription. American Sociological Association Annual Meetings. Boston, MA. August 2 nd Finding the Place of Technology in Medical Transcription. American Sociological Association Annual Meetings. Boston, MA. August 3 rd Discovering the Work of Medical Transcriptionists. With Angela Garcia. American Sociological Association Conference. New York, NY: August. 4

5 Project Outputs - Publications Submitted Listening to What is Said Transcribing What is Heard: Understanding the Work of Medical Transcription. Sociology of Health and Illness. With Angela Cora Garcia and Donald Chand. Submitted The Work of Medical Transcriptionists: Sense-making and Interactional Competence in the Production of Medical Records. Journal of Contemporary Ethnography. With Angela Cora Garcia (first author) and Donald Chand Rethink EHR Implementations. For the Record, January Survey of Medical Transcriptionists: Preliminary Findings. Preliminary.pdf Further Examining the MT Study. Advance for Health Information Professionals, August Getting in Tune New Survey Spotlights the MT s Role in Healthcare. For the Record, 20(15):p.14. July 21 st. 5

6 Project Outputs - Webinars 2008 Results from the Medical Transcriptionist Survey. Webinar to joint members of Association for Healthcare Documentation Integrity and the Medical Transcription Industry Association. June Crafting Value Proposition for Medical Transcription. Webinar for Sales and Customer Service Employees of Medquist. July Balanced Scorecard for Medical Transcription Industry. Webinar to Medical Transcription Industry Association. April The Challenge of Measuring Performance. Webinar to joint members of Association for Healthcare Documentation Integrity and the Medical Transcription Industry Association. November 16. With Donald Chand 6

7 Cover Stories! January 19, 2009 July 21,

8 Dominant Perceptions of Healthcare Documentation Creation Typists, not transcriptionists Transcription is a commodity What doctors dictate is accurate Transcription is a cost, and does not add value The more technology (and faster the delivery), the better the documents (and process) MT interpretation is problematic and source of error (issue of verbatim) Gary C. David 8

9 Problem of Message Framing Our research has demonstrated that the medical transcription industry has a messaging problem Customers and analysts have been able to frame the industry and its value, thereby devaluing the industry and its product. Gary C. David 9

10 Perception Setting: What is medical transcription Our principal research question involves examining what it is that medical transcriptionists do Through an ethnographic study of work, we are discovering that: Medical transcription is the process of transforming dictated voice files into a format that is recognizable and usable to a range of user constituencies Who does this include: Allied Healthcare Professionals Claims processors Researchers Coders Audit Contractors Patients Gary C. David 10

11 Transcription Typing Listening to what is said; transcribing what is heard Typing is a physical act that (almost) anyone can and does do Transcribing is a professional act that calls upon a range of professional sense-making abilities rooted in experience and training Gary C. David 11

12 What generates revenue? Doctors do not generate revenue; documents generate revenue It is not the specific act of the doctor that generates revenue. Rather, it is the representation of that act in a document that generates revenue. Anything that puts the integrity of that document at risk similarly puts at risk the revenue stream of the healthcare provider. Gary C. David 12

13 MS-DRGs and the Revenue Stream Diagnosis-related group (DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use, developed for Medicare as part of the prospective payment system. DRGs are assigned by a "grouper" program based on ICD diagnoses, procedures, age, sex, and the presence of complications or comorbidities. DRGs have been used since 1983 to determine how much Medicare pays the hospital, since patients within each category are similar clinically and are expected to use the same level of hospital resources. (Wikipedia) Example of reimbursement ranges MS-DRG 291 Heart Failure with MCC $7,200 MS-DRG 292 Heart Failure with CC $4,960 MS-DRG 293 Heart Failure without MCC/CC $3,544 Courtesy of Amy Bowman, Jordan Hospital Gary C. David What is dictated, or can be gleaned from the system, can have a major influence on the reimbursement 13

14 What Doctors Dictate A study based on a sample of 220 dictated medical records totaling 9,726 lines of transcription found 27% of the 96 more-serious flaws were attributed to the speaker, typically a physician, and not the transcriptionist. Twenty of 38 critical flaws (53%) and six of 58 major flaws (10%) were traced to the speaker (Conn 2005). Doctors have a reputation of being poor dictators, and the work of the MT is done DESPITE doctor dictation, not because of it. If you assume that doctors are not necessarily correct in their dictation, then the work of the MT becomes framed much differently than if you think doctor dictation is inherently correct and complete. Gary C. David 14

15 The Question of Verbatim ver ba tim (vər-bā-təm) - in the exact words: word for word Function: adverb Etymology: Middle English, from Medieval Latin, from Latin verbum word Date: 15th century Work that is done verbatim negates the expertise and training of the MT When customers ask for verbatim, they do not actually want the literal definition. This creates the problem of determining what they actually mean. Gary C. David 15

16 The issue of interpretation Saying that MTs interpret creates the impression that they are placing their individual judgment regarding what a dictator says in terms of a medical procedure A better way of putting it is that MTs recognize that a dictator is trying to say or demonstrate Or, put differently, MTs listen to what is said, and then transcribe what is heard Gary C. David 16

17 The role of technology Hospitals and other healthcare providers need to think in terms of strategic technological use Just because you can do something with technology does not mean you should Role of the industry to help providers understand what technology should be used where The need to provide an analysis and assessment of technological impact across a range of qualitative and quantitative metrics Gary C. David 17

18 Central Findings of Project Shifting the perception of MT: From manual labor to knowledge work From individual and isolated to collective and collaborative. From passive recipient to active participant 18

19 Collaborative Nature of Transcription Examination Dictation Sign-Off Transcription QA 19

20 Workflow Models of Healthcare Documentation Production Practitioner- Patient Encounter Practitioner Non-Dictation Practitioner Dictation Electronic Medical Record Self- Composition Speech Recognition Technology Traditional Transcription Front-end Back-end Medical Transcriptionist / QA Dictator Sign-Off Secondary QA Document Use Practitioner Practitioner n Reimbursement Agents Coders Researchers Patients 20

21 Traditional Transcription 21

22 Transcribing versus Editing Assumptions are: It is less work It is faster It can be more accurate Rests on two beliefs Transcription is more like manual labor than knowledge work Technology automatically makes things better. 22

23 Back-End Speech Recognition: Editing versus Transcribing 23

24 Direct Entry: Front-end Speech Recognition Images Omitted for Distribution 24

25 Direct Entry: Electronic Medical Records Beginning examination of MDs using EMRs Initial concerns are Impact of computers on exams Comparison between dictated and direct entry records Generating useful information 25

26 National Health Information Technology Infrastructure Lower Health Care Costs by Investing in Electronic Information Technology Systems: Use health information technology to lower the cost of health care. Invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standardsbased electronic health information systems, including electronic health records. (whitehouse.gov) Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives. President Obama, Address to Joint Session of Congress Tuesday, February 24th, 2009 What if the information in the electronic health records is not accurate? 26

27 Dissemination of Inaccurate Records 27

28 Medical Transcription challenges Integration of the distributed worker Knowledge sharing Mentoring Occupational community development Demonstration of Value Documenting the Dictator Verbatim versus Professional Sense-making The role of MTs in PHRs 28

29 Challenges Moving Forward Ultimately, demonstrating value becomes a matter of documenting activity: Documenting Dictator Error Documenting improvements to records Documenting the nature of the work (in its various modes) Documenting the impact when that work is removed 29

30 And finally