Wednesday, September 19, 2007

Faith-Based Transcription

I am constantly amused at how so many people assume that medical transcription simply “happens” and how physicians assume that if anything is wrong with a report it must automatically be the fault of the transcriptionist! While watching Jean Stapleton’s poignant performance as “Eleanor Roosevelt: First Lady of the World,” I couldn’t help but chuckle when the First Lady’s frustrated assistant tried to find a polite way to warn Mrs. Roosevelt that she couldn’t possibly handle a trip to Europe by herself. Eleanor, of course, insisted that she would have no need of a secretary during her travels. Thrusting a sample of the First Lady’s obtuse notes (scrawled in her distinctively cryptic penmanship)under Mrs. Roosevelt’s nose, the assistant demanded to know “And just who is going to be able to understand that?”

As much as we wish to believe that we are living in what Voltaire called“the best of all possible worlds,” a few brushes with reality can leave one with a very different perspective on what’s happening in the day-to-day routine of processing transcribed reports. As some readers may know, I recently underwent surgery to implant an Ahmed valve in my left eye in a pre-emptive strike against uveitic and steroid glaucoma. As one way of minimizing anxiety about my upcoming surgery, I decided to treat the experience as a chance to see what really happens when a medical transcriptionist travels down the delicate path to the operating room. So, while discussing my surgical options, I asked my treating ophthalmologist if he should be informing my primary care provider about my impending surgery. “Well, if you want to, I can either call him or sendh im a letter. But if you only see him every one or two years, I don’t think it matters,” he replied. Aha, I thought. Here’s a chance to see if the system really works.

After requesting that my ophthalmologist send a letter to my internist, Iwaited to see what would happen. Several weeks later, on a follow-up visit to the ophthalmologist, I asked if the letter had been sent. As he leaned out the door to the examining room, he asked one of the residents “Didyou dictate that letter to Mr. Heymont’s physician?” Of course he hadn’t.

Why wasn’t I surprised? Because this was business as usual. However, a little bit of humiliation can go a long way. After a few poignant moments of physician education --during which I explained why patients have to be so aggressive about making sure their doctors follow through on their promises -- my ophthalmologist assured me that he would personally dictate the letter to my internist and make sure it went out that day.

One small step for mankind. One giant step for my medical record.

Prior to surgery, I was scheduled to meet with an anesthesiologist who would perform a preoperative history and physical. This was my first opportunity– as a patient – to watch a physician use a template-driven program to enter and record a patient’s vitals, review of systems, past medical history and add any necessary comments in the fields provided by the software. Let me assure you that the experience is quite different from a vendor’s demonstration.

Although I was quite impressed with the templating program’s ability to keep the anesthesiologist on track and make sure she filled in all the appropriate fields, it was obvious that between her splitting headache, the number of interruptions due to a shortage of examining rooms, and the fact that she was having trouble filling out some other forms, there was no editorial safeguard to ensure that her report was accurate. This became all too evident as I watched her try to type by hunting and pecking keys. On two occasions I had to correct her spelling.

But why should I be concerned about spelling errors? After all, I’m only the patient. And although I’m having surgery in an ambulatory care center, it’s only my medical record that’s involved!

On the day of the operation, I reminded my surgeon of his promise to be sure that I receive a copy of my operative report. When the anesthesiologist entered the examining room with a medical student in tow, we chatted briefly as he prepared to knock my lights out. As soon as I mentioned that I own a medical transcription service, the medical student gasped “God, I don’t know how you people do that kind of work. I mean, I listen to doctors dictating reports and just can’t imagine how you guys deal with all those accents and vocabulary and everything!”

Even with a needle in my arm, I couldn’t let this opportunity slip by. I asked the medical student if he and his friends had received any instruction in how to dictate reports. Needless to say, they had not. “Then you need to do me a favor. You need to go to the Dean of Studies at this medical school and tell him that you’re not getting the preparation and training you need in order to function properly in the workplace,” I insisted. “Tell him that this medical school needs to have dictation and medical documentation become an integral part of its curriculum. Why? Because maybe– just maybe -- if he hears it from his students he’ll get the message.”

The medical student diligently promised to follow through. Then I blacked out and was wheeled into the surgical suite.

That same medical student reappeared during one of my follow-up appointments with the eye surgeon. “Do you remember what you promised me on the day I underwent surgery?” I asked. He remembered, but had not yet taken any action because of a hectic schedule. Once again, he swore that he would contact the Dean of Studies at UCSF. Do I believe in Santa Claus? Yeah, right.

Meanwhile, upon further questioning, the surgeon assured me that when he dictated my operative report, he had indicated that a copy should be mailed to me. As we all know, op notes usually get a 24-hour turnaround. Yet, two weeks later, I had still not received a copy of my operative report. Gee whiz! Who woulda thunk it? When I returned for another follow-up appointment I asked my surgeon what had happened. “Well, I didn’t give them your address when I dictated because I always just assume that if I tell them to send someone a copy, they have the address right there,” he replied.

That opened up another opportunity for physician education (after which the surgeon merrily retrieved my chart, personally Xeroxed a copy of my operative report for me, and brought it back into the examining room). Sure enough, the report indicated that a copy should be sent to me. But, as expected, only my name was on the report. My address was nowhere to be found and so, in all likelihood, a medical records clerk had probably just stuck the report in the chart and moved on to the next chore.

The point I’m trying to make is a simple one. Key parts of the dictation/transcription process are based on faith. Faith that the doctor knows what he’s saying and is coherent enough to properly communicate his thoughts to a medical transcriptionist. Faith that the medical transcriptionist has sufficient language skills and reference resources to do an accurate job of converting voice to text. Faith that medical records personnel are paying attention to the reports they process. And last, but certainly not least, faith that the system truly works.

Does it? Although people make many promises, they often fail to follow through on their word. That’s why the exact point at which a glitch in communication aborts the process that is supposed to achieve our ultimate goal is something that we really need to start worrying about. All too often, the single event which aborts the process has absolutely nothing whatsoever to do with the quality of transcription. It usually involves an element of inconvenience, illegibility, laziness and/or computer illiteracy.

This means that we need to take a closer look at what’s happening at ground zero. Far too many of us have been frustrated by e-mail requests thatwere never answered, tech support calls that got nowhere, and some of the useless customer service options we have encountered in voice mail hell. So, instead of watching “Survivor” or “Big Brother,” suppose we venture out into the brave new world of reality-based medical transcription to see what’s going on. Let’s try this event for starters.

One night I received a phone call at around 10:30 p.m. “Good evening, Alert & Oriented Medical Transcription Services. How may I help you?”I asked.

“I need an ID,” replied a voice on the other end.

Since physicians are not always famous for connecting the dots, I waited 10 seconds before asking “Would you like to tell me who you are?” Following a cough and grumble, I learned that I was talking to Dr. Smith. “We have several Dr. Smiths among our clients. Can you please be a little more specific so that I can try to help you?”

Mind you, I wasn’t trying to be rude or sarcastic. I just needed some basic information which, to no one’s surprise, the good doctor had a great deal of trouble communicating. Why should something as simple as identifying yourself over the phone become such an obstacle? Because our work habits have become so egocentric (especially with the use of cell phones) that many people assume the world operates with full knowledge of what is going on in their minds. You would not believe the number of times I have had to explain to people calling from a client’s office that we receive many phone calls during the day and, as a result, need them to identify themselves before anyone can begin to help them!

After you’ve answered enough of these calls you can’t help but laugh every time you hear talk about the patent a doctor has on a new piece of software that will revolutionize medical transcription without requiring any change in physician behavior. What these people continually fail to realize is that you cannot begin to revolutionize medical transcription until you get physicians to change their behavior!

I recently tried explaining this to a plastic surgeon whose real passion was engineering. He had read some of my articles and agreed that changing physician behavior was the key to any success in improving the quality of dictation. He just couldn’t understand why it was so hard to accomplish this goal. He was convinced that if each physician knew the person who transcribed his reports, the simple knowledge of what that person looked like would make the physician want to do a better job. After 30 minutes on the phone, I realized our conversation was going nowhere. This man remained convinced that, in their heart of hearts, physicians would want to go the extra distance to improve their dictation simply to help the person on the other end of the line do a better job transcribing their reports. Why, he asked, hadn’t I made it my life’s work to go out there and make this happen?

“Have you ever tried to tell a Jewish mother something she really doesn’t want to hear?” I asked. Of course, he replied. He had a Jewish mother! At that point I knew I had him where I wanted him. “So let me ask you something: If the message came from another physician, would you listen?”

Sure, he would.

“And if you had to attend an all-day seminar about learning how to dictate properly, would you listen?”

Now he wasn’t so sure.

“What if you had to pay $350 an hour in consulting fees to the fat lady down in Medical Records who transcribes your reports? That’s $350 an hour until you learn how to do it right. Then would you listen?” I asked.

He would do no such thing – especially if it meant paying that kind of money to someone who was nothing more than clerical personnel.

“Well, then you need to wake up and smell the coffee,” I warned,” because that’s the person who can help you. And until you’re willing to pay her what she’s worth for the information you need to learn how to do your job properly, you’re not going to make any progress whatsoever.”

“But I still don’t understand why it wouldn’t work if the doctor knew the transcriptionist personally,”he whined. (This man obviously had not bothered to read Malcolm Gladwell’s superb book, “The TippingPoint.”)

I had no choice in the matter. I had to make this doctor confront the truth. “The reason you don’t understand is because you’re living in a dream world,” I told him. “A physician’s dream world. And it’s time for you to snap out of it.”

You know, at first I didn’t put much stock in faith-based programs. But I swear to God, when I hung up that phone, I felt as if I had been born again!

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