Monday, September 17, 2007

The Big Lie

My nephew recently found himself in a peculiar predicament. Having earned a few too many speeding tickets, he was informed that he had enough “points” against him that one more speeding ticket would cause him to lose his driver’s license. Even if you’re a young man with lots of testosterone and a heavy foot on the gas pedal, living and working in suburbia -- where you must drive everywhere to get anywhere -- that means you’d have to be a total fool to misjudge the gravity of the situation. When push came to shove, the State of New Jersey was not interested in cutting my nephew any slack or listening to his theories about why laws against speeding are stupid and shouldn’t apply to him. One more speeding ticket and his driving days would be over.

What does this have to do with medical transcription? I’ll be happy to tell you. Thanks to a nagging herpes simplex infection in my left eye, I was recently referred to Dr. K, a corneal specialist. During our initial chat I informed Dr. K that I own a medical transcription service and asked how he was handling his dictation. Dr. K was very happy with his little handheld microcassette recorder and made a point of dictating a letter while in my presence to Dr. M, the ophthalmologist who had generated my referral. His dictation was clear, crisp and easy to understand. He sounded like an ideal client.

Unfortunately, Dr. L (my primary physician who very much wants to know what the hell is going on with his patient’s eye) never received a copy of Dr. K’s letter. So, during a follow-up visit, I convinced Dr. K to send Dr. L a copy of his letter to Dr. M. At this point, Dr. K re-read the letter in my presence as he made some corrections. “This transcriptionist always misses something,” he muttered, “but I guess 95% accuracy really isn’t too bad.”

“Let me ask you a question,” I interjected. “Would you go to a surgeon who didn’t know how to make an incision?” Dr. K. was a little taken aback by my comment and admitted that he would not want to do that. Perhaps to compensate, he said “Normally I wouldn’t explain what’s happening with the eye in such detail to most patients, but since you’re a professional I’ll explain it to you like I would to another professional.”

“I appreciate that very much,” I responded. “But I’m also a patient and I want you to explain this to me like I’m a ten year old.” As we reviewed the contents of his letter, I noticed four words in block caps at the bottom of the page:


With a very calm voice, I explained to Dr. K. that those words do not get him off the hook from a risk management standpoint. “Oh, I know that,” he chuckled. That’s why I pay for medical malpractice insurance. In fact, I consult to several malpractice companies.”

A subscriber the Yahoo Groups KAMT-LIST recently asked what might happen if MTs delivered a pile of blank reports that had the following words in block caps at the top of each page:


Not a pretty picture, huh?

A sad fact of American society is that far too many people are loathe to take responsibility. Whether they whine, wheedle, or threaten to sue, their problems always seem to be someone else’s fault. If the situation looks very different to those who are in recovery (or who have friends in recovery), it’s because they have learned through various 12-step programs that responsibility lies at the core of leading an honest life.

The crisis surrounding medical records data abuse is no different from the crises surrounding alcohol and substance abuse. An army of “enablers” routinely cover for data offenders. And by doing so, they help to perpetuate “the big lie.”

Last year, America’s “big lie” was all about sex in the Oval Office. The big lie in medicine is that doctors can’t and shouldn’t be expected to deliver quality patient documentation. And that physicians who are too lazy, too sloppy or too inept to create a clear and concise patient record should be forgiven and let off the hook simply because they’re too busy or think they’re
too important to have to worry about such things.

At whose risk?

In recent years, AHIMA and AAMT have struggled with the challenge of getting doctors to produce quality documentation. In-house transcription supervisors have tried such lame consciousness-raising activities as baking a cake to celebrate Medical Transcription Appreciation Week or giving gold stars to the doctors deemed to be their best dictators. Meanwhile, physicians have demonstrated quite clearly through their actions that they have little or no desire to learn proper documentation techniques.

They really couldn’t care about the issue. How do we make them care?

Recently, while cruising an AOL chat room, I came across the answer. I was reading someone’s user profile and noticed that the favorite quote was listed as “Carpe denim” (Seize My Jeans) rather than the old standard, “Carpe diem.” And I realized that that’s exactly what needs to be done in the HIM industry if we are ever going to turn this situation around. We need to grab doctors by the seat of their pants and give them a sense of urgency about their need to learn proper documentation techniques and apply those techniques to their work.

To date, we’ve had frighteningly little success in this arena. The new E31.22 work group formed by the American Society of Tests & Measures (ASTM) is currently pursuing a course of action which is not just professionally irresponsible, but extremely dangerous. From a business perspective, it is also doomed to failure. Its stated goal is to create a series of standards which will allow doctors to keep dictating any way they please on the assumption that an army of medical transcriptionists -- who have widely varying degrees of editorial talent and transcribing skill --- will be able to listen to their garbled dictation and then, as if by magic, accurately intuit how each doctor wants his dictation to be formatted.

I don’t know what planet these people are living on, but somehow the leadership of ASTM’s E31.22 work group is foolish enough to believe that MTs will universally be able to understand and interpret the context and meaning of a doctor’s misspoken words, edit the flow of data to make it medically correct and then meticulously fashion the results so that they conform to ASTM’s standard formats. When one considers the number of doctors who do not even read their own transcribed reports, it becomes obvious that -- if put into effect -- ASTM’s methodology would result in some frighteningly inappropriate editing that could easily jeopardize patient care.

Why is ASTM hell bent on pursuing this treacherous course of action? Because, like many people in the medical industry, the leaders of the E31.22 work group have bought into the healthcare industry’s big co-dependent lie. They still believe that:

· Doctors are too busy to learn proper documentation techniques (especially if doing so would require them to sacrifice some time on the golf course).

· Doctors should not be held responsible for the care they provide to patients (after all, that’s what medical malpractice insurance is for).

· The core competencies of every medical transcriptionist include advanced powers of clairvoyance that can relieve a doctor of the need to properly document a patient’s care.

As they say in many 12-step programs, denial is not just a river in Egypt.

And yet hope springs eternal. With all the hoopla surrounding the Y2K issue, I am convinced that the current crisis in patient documentation can be remedied on a timely basis by taking a radically different approach to the situation.

· Treat the solution as a product rollout, with a timed schedule of goals and sales that must be accomplished by certain dates.

· Make sure that the incentive for physicians to comply is so critical to their well being that they cannot afford to ignore it (much like the State of New Jersey’s stance with regard to my nephew’s driver’s license).

· Keep in mind that the only two forces able to strike fear into the hearts of practicing physicians have been hospital risk managers and the threat of a visit from the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) to perform an audit of their hospital’s medical records.

With those thoughts in mind, how do we get physicians to start creating quality documentation? It’s a lot simpler than most people think. Instead of the impotent triumvirate of ASTM, AAMT and JCAHO, a task force is assembled that can actually have some impact on the HIM industry. This task force should include representatives from (in alphabetical order)

  • ACHE American st1:placetype>College of Healthcare Executives)

  • AHIMA (American Health Information Management Association)
  • AMA (American Medical Association)
  • ASHRM (American Society of Hospital Risk Managers)
  • JCAHO (Joint Commission for the Accreditation of Healthcare Organizations)
  • MTIA (Medical Transcription Industry Alliance)
  • USDHHS (U.S. Department of Health and Human Services)

This task force is then given nine months to develop, test and refine the contents of a full-day seminar devoted to proper techniques of patient care documentation so that doctors can use this seminar to earn Continuing Medical Education (CME) credits. Once the curriculum is finalized, the task force is given 90 days to “train the trainers.” If done properly, the product will have been researched, developed and be ready to launch at the end of one calendar year.

The second year is spent out in the field, teaching the syllabus to physicians. Just as software trainers are hired on a contractual basis, these trainers can be contracted by organizationswhich offer courses for CME credits to physicians. Who are these organizers and/or organizations?

  • Hospitals
  • Medical schools
  • State and local medical societies
  • Drug companies sponsoring physician retreats.
  • Vendors at medical trade shows.
  • Event planners for medical conferences.

Here’s how to implement the program: The task force sets a target date (the end of Year 2) by which time every licensed physician must complete this course. Each physician must keep a copy of the certificate of completion on file with the Medical Records Director of any hospital where that physician has professional privileges. If a physician fails to obtain certification by the target date, the hospital suspends that physician’s staff privileges until proof of certification is tendered to the Medical Records Director.

Starting with the target date (end of Year 2), the JCAHO representatives visiting any hospital on a medical records audit must be presented with proof that each and every physician with staff privileges has a certificate of completion on file that is no more than two years old. Physicians who are not current are given 60 days to acquire or “refresh” their certificate to avoid placing the hospital’s accreditation in jeopardy.

How would this scheme play out with regard to time?

· If a task force was appointed by June 1, 1999 and completed the development of a syllabus by February 1, 2000, then trainers would be ready to go out into the field by June 1, 2000.

· By January 1, 2001 a reasonable amount of physicians could be expected to have achieved certification.

· By June 1, 2001, every physician in America would have been required to complete the syllabus.

They say it can’t be done?

Think again. If a hospital risks losing accreditation, you can rest assured that its management will haul ass to be in compliance with the JCAHO. And if physicians must acquire these CME credits in order to retain their staff privileges (which is how they take care of their patients and earn a living), doctors will magically find a way to make time on their calendars to get certified.

Like the seatbelts we all learned to use while driving, quality documentation can save the lives of patients and reduce the number of medical malpractice lawsuits. So from a documentation standpoint, a little bit of preventive medicine goes a long, long way. The bottom line is that we can no longer afford to have doctors behaving like drunk drivers on the information superhighway. Either they learn how to deliver quality documentation when documenting patient care or else they sacrifice a certain level of professional freedom.

Like my nephew who has too many speeding tickets, I’m sure that many doctors will feel as if they are being persecuted. They’ll grumble and complain that the certification process is a ridiculous waste of their time and an unnecessary professional burden. But trust me on this one: If they want to earn a living and continue to support their families and employees, they’ll take the damned course.

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