Medical Considerations

Dictation Considerations

.It is no secret that the busiest Specialty practices communicate with the patient’s Primary Care Physician. This communication has a twofold purpose of informing the Primary Care Physician of their Assessment and Treatment Plan – it is also a powerful marketing tool which encourages more referrals.

What does 98-99% Accuracy Mean?

When you consider that most services guarantee 98-99% accuracy, many people never reflect on what that means – at 12 to 15 words per line, it means that they will do better than 1 or 2 mistakes every 9 lines which implies the need to spend extra time to edit. This is why 99% accuracy is unacceptable to us – it is not good enough. Our QA consists of nurses that proofread every file for medical accuracy. We enjoy an excellent reputation because of our attention to quality. This full service support alleviates your in-house people from performing these functions which reduces the staffing needs and associated costs.

Speech Recognition and Dictation

We have seen many situations where EMR/EHR salespeople have encouraged practices to invest in these systems and justified the investment by eliminating transcription costs. It should be noted that dictation is a productivity tool that allows the Physician to leverage their revenue opportunity against the cost of transcription. By their own admission, the EMR/EHR salespeople are acknowledging that this technology will reduce the Physician’s productivity by a conservative 15% which means 7.5 hours a week (1.5 hours per day) in a 50 hour work week.  This reduced productivity is directly tied to the documentation requirements of this “technology”.  Only you can calculate the lost revenue stream of 1.5 hours less patient visits per day for your practice. When you consider that transcription costs no more than $50 per day in busy, heavy and thorough dictation users, it is a clear business decision to continue using transcription with the EMR/EHR.  All of these systems have document import capabilities for externally generated transcription which are not overtly discussed if not requested by the prospective customer.

Prepopulated Templates and Dictation

Prepopulated Templates are typically generic in nature and do not reflect the presentation and unique characteristics of each patient’s illness.  In referral situations, templates do not reflect the expertise of the Specialist. Unless the user is of the ‘Instant Messaging’ generation, there is a significant productivity issue with the Physician manipulating the mouse from one field to the next to complete these templates.  Finally, the structured data does not provide the detail necessary to defend malpractice claims.

What about Medical Scribes?

The recent development of Medical Scribes is a response to the severe Doctor productivity decline from EHR/EMR implementation.  For cost justification purposes, these EHR/EMR products were promoted with the practices using Speech Recognition or Templates and eliminating the practice’s transcription costs.

Some practices are transitioning to Medical Scribes.  An advantage is the instantaneous nature of the report.  There are several disadvantages to using Medical Scribes, though.  The major disadvantage is cost – the average Medical scribe earns $35,000.  Add to the $35,000, the cost of benefits, payroll taxes (including unemployment insurance) – at a conservative 25% of salary (usually calculated by consultants at 50%) makes it an additional $8,750.  Finally, you are contending with human resource issues including hiring, motivation, training, interpersonal relationships and dealing with vacation and unplanned sick time, not to mention where to put another body.  Transcription is a much more cost effective method for handling documentation – it is a fraction of the $43-50,000 annual cost of a Medical Scribe.

These Medical Scribes are trained medically but not necessarily for clerical skills of inputting the data.  Even if they were very fast at inputting, for a good transcriptionist, there is a 3 to 1 relationship between transcription time and dictated time – in other words, it takes 3 times longer to type than it does to say it, which is why transcriptionists have footpedals to stop the playback so they can catch up.  You would be hard pressed to find a scribe (or transcriptionist) able to keep up and capture everything that is stated in real time.

By logical sequence, if the scribes are unable to capture all of the information, you will have less comprehensive documentation which have billing implications.  Of lesser consideration but some importance is the malpractice significance and trying to support/defend your cause in such a scenario.

There is a tremendous irony that EHR/EMR’s which ideally were supposed to save time and increase productivity have had the opposite effect and now are requiring expensive workarounds in order to use effectively.

In-house or Outsourced Transcription

It is counter intuitive to transcribe in-house, because many people think that they are paying extra for a middleman when they outsource. However, it is a more cost effective strategy. Essentially, there are two models of transcription productivity; Hourly/Salary model and Incentive/Piecemeal model. In the Hourly/Salary model, a transcriptionist will output 600 to 800 lines per day. In the Incentive/Piecemeal model, a transcriptionist will output 1500 to 3000 lines per day. This means that a part-time transcriptionist costs 15-18¢ per line without benefits and a full time transcriptionist costs 18-30¢ per line with benefits. For predominately financial reasons, most of the hospitals and practices have outsourced their transcription.

The major benefit to outsourcing the transcription is to take advantage of this productivity increase and cost savings. Equally important, outsourcing eliminates the headaches of Personnel Management (hiring, training, motivating, managing sick/vacation days and personalities).

With the implementation of the EMR/EHR, some practices are bringing the transcription in-house to facilitate the technology. However, it is not difficult to setup the necessary interface with the IT and programming resources at our disposal.

The Case for Transcription

While fulfilling Government mandated Meaningful Use

The average physician spends 33 seconds dictating an established office visit and 92 percent of all office visits are established. If the average physician sees forty patients a day (orthopedic practice example), total dictation time of 30 minutes plus time to search for the data – (40 X 92% x 33 seconds) + (40 x 8% x 125) = < 30 minutes per day.

Using a traditional EHR application, the same number of patients would require 140 minutes of data entry time. (above cited data courtesy of Mark R. Anderson, FHIMSS, CPHIMS, CEO, AC Group). The monetary cost to a clinician with average earnings of $200 per hour would be approximately $360 per day or $8,000 per month vs. the fractional cost of transcription.

Meaningful Use under the HITECH Act requires ever-increasing amounts of structured and codified data in Electronic Health Records (EHRs). Such data facilitates Health Information Exchange (HIE), and supports Clinical Decision Support. Conversely, the important details of patients’ medical circumstances are far more complex and useful than can be adequately represented by encoded information.

In addition, these details provide a basis by which providers recall prior encounters and humanize patients. Moreover, the voice of the patient is not lost in the process. The details even enable better medical decisions, by better showing patients’ unique circumstances, preferences, and values. It’s one thing to know that a patient is experiencing side effects from a medication, and quite another to know what those side effects are and how they feel about those side effects.

Automated extraction of data from natural language introduces a class of errors that are unacceptable for the care of individual patients. How can we reconcile the need (and mandate) for standardized, machine-interpretable data with the need for thorough information about patients? How can we enable the science of medicine to leave room for the art of medicine?

Another consideration which is not being factored into the equation, beyond the Government mandated meaningful use requirements, how do we provide the comprehensive documentation necessary to successfully defend medical malpractice claims while maintaining the physician’s productivity?

Given the Government mandate for meaningful use, the best possible solution is a hybrid arrangement where the Physicians utilize templates for Review of Systems, objective and assessment information and dictate a narrative for the subjective and plan using dictation markers. While not necessarily maximizing the Physician’s productivity, this arrangement would facilitate a more comprehensive and significant Patient record while complying with the meaningful use mandates in the most productive manner given the constraints.

In conclusion, communication between patient and Physician initiates the key information that aids in diagnosis, treatment planning and evaluation of outcomes. The ability to document this information as “the patient says it” and as “the Physician interprets it” would make the patient record more individualized and comprehensive and as such, a more inclusive and useful document.

Off-shore Transcription

If you are like most practices, you are frequently being solicited by offshore companies that offer appealing transcription rates. Despite the offshore assurances about local quality assurance effort, there are ongoing issues with the transcription quality. Most practices that have outsourced to save money have returned dissatisfied because the work product required extensive editing time. Additionally, offshore services that outsource to India are vulnerable to societal instabilities including catastrophic acts of God, power interruptions, political problems or war.

Prior to starting this service in 1993,  Casey O’Rourke spent 10 years consulting with Hospitals and Clinical Practices for Dictaphone Corporation.  Mr. O’Rourke has the expertise in Productivity models including Time and Motion studies.

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