Wednesday, September 19, 2007

Fantasy Versus Reality

Imagine Jerry Seinfield doing standup comedy about medical transcription. As he leans into the microphone, he says “And whatare these two letters under my name? ‘CC’? I mean, what’s with that?”

As technology keeps bringing rapid changes to the world of medical transcription, the cultural iconography of our profession has undergone a shocking transformation. Symbols which were once universally understood have either lost their meaning or are fading into oblivion. The strong sense of ethics once deemed to be a cornerstone of our profession is headed for extinction. To veteran MTs, this all seems to be happening in the interests of mass production, cutting costs and increasing profits.

Computers have changed the way we work in so many ways that when the letters“cc” appear under someone’s name, no one in their right mind expects to see a carbon copy being generated on tissue paper. Granted, there are still some of us who can remember using carbon paper (as well as chalk and razor blades). But these days, you just tell the computer to print out an extra copy of the report. Not only does the end product look like an original copy, it is free of smudges and your fingers aren’t covered with carbon particles.

Suppose we tackle another sacred cow -- the issue of putting one’s initials at the bottom of a report so that whoever reads the report can know by whom it was transcribed. Some 40 or 50 years ago, typing the letters “DNR/gh” might indicate that a report had been dictated by David Norman Roberts and transcribed by George Heymont. In an era when secretaries (and transcriptionists) were very closely linked to their bosses, one’s initials on a document indicated that the document was error-free, ready for distribution, and that any questions could be directed to the secretary who had prepared the document (in this case “gh”).

Today, thanks to more complex tracking systems and the frequent use of "code signatures” (designed to prevent a doctor from trying to establish direct contact with a medical transcriptionist who might be an employee or independent contractor with a third-party MTSO), one’s personal seal of approval either appears automatically as part of a pre-formatted template or is not visible at all. Yet one can still hear medical transcriptionists huffing and puffing about how they “wouldn’t feel comfortable putting their initials on such a sloppy piece of dictation.”

As if anyone even cared!

When confronted with the clash between the sacred fantasies and illusions that drive many medical transcriptionists toward higher standards of performance and the harsh realities which exist in the medical transcription and healthcare industries, it becomes obvious that the culture built around medical transcription has suffered a severe and irreparable disconnect. In theory, we are told that turnaround time on certain documents can seriously affect a patient’s hospital course.

  • But if surgeons didn’t procrastinate on dictating admitting histories and physicals for their patients, they wouldn’t risk losing their time slot in the surgical suite because they failed to submit the required documentation on a timely basis in order to gain authorization to operate.

  • Surgical reports must be dictated within a time span mandated by the JCAHO. While it is important for many in-house surgeries that this report get into the chart, it is equally important for come-and-go surgeries. Why is it so important if the patient has already left the hospital? Because the real urgency is to get the transcribed report to billers and coders so that the healthcare facility can submit the appropriate documentation to third party payers and be reimbursed on a timely basis.

  • What about discharge summaries that are late? The theory used to be that a discharged patient could be readmitted to the hospital several days later and need to have that documentation in his chart. But since we all know of physicians who are several months delinquent in dictating their reports, there has to be another reason for such urgent turnaround. That reason is cash flow.

Even if MTs struggle to increase productivity and speed, does that really mean that a transcribed report is getting into a patient’s chart any faster? I sincerely doubt it (especially if you’ve ever spent time in a medical records department during the swing or graveyard shift). What we see instead are industry pressures creating a false sense of urgency which can be used for (a) competitive bidding on contracts and, (b) goosing up the speed at which reimbursements from third party payers flow into a hospital’s coffers.

As long as we’re talking about money, let’s look at what’s happening to MTs in today’s economy. I recently had lunch with two gay physicians and listened in silence as one of them bemoaned the fact that “today’s doctors and lawyers have become the new middle class while all these little kids are the ones getting rich.” His colleague clucked in agreement, adding “Spoken of course by you, who has everything.”

What are medical transcriptionists getting out of today’s booming economy? Not a whole lot of spending power. Veteran MTs, who expect to be rewarded for their years of experience and accumulated wisdom, are often making as much or less per line than they did 10 or 20 years ago! Newbies who invest several thousand dollars in a curriculum which promises to prepare them for a career as a medical transcriptionist are discovering that they might not earn quite as much as they had hoped to. And then, of course, there are the costs of computer maintenance, web access, software upgrades, etc.

Recently, I was contacted by a rather snotty administrator from a local multi-physician practice that was shopping around for a new transcription service. Was there anything wrong with the turnaround time they were receiving or the quality of transcription? “No,” she replied, “we have a typist who picks up tapes but she’s very expensive and our doctors don’t dictate very much because they’re so sensitive to the cost. They really feel they should be paying less for transcription.”

It quickly became obvious that this woman was (a) not computer literate, (b) not willing to deal with reality, and (c) definitely not the kind of client I would ever want. I politely explained that she was paying her current transcriptionist for quality service and that the rate she was paying was quite in line with today’s market. I emphasized that California is enjoying a very healthy economy and good medical transcriptionists are extremely hard to find. “But we still feel we should be paying less,” she insisted.

I paused for a few seconds and replied “Then I’d suggest you tell your doctors to eat at McDonalds five days a week. Have a nice day.”

In an industry where price and turnaround time are valued so much more than quality or accuracy, the sad truth is that mediocrity -- not excellence -- is what is ultimately rewarded. The more market share an MTSO can claim, the more venture capital it can pump into its technology. It often seems as if hospital administrators and service owners are screaming “Faster, pussycat! Faster!”with little understanding that their demands for increased speed are bound to result in a higher percentage of errors.

Not allowing sufficient time for MTs to produce an accurate document can lead to severe compromises in the level of patient care. And God forbid anyone suggest that the real source of the problem lies with physicians who can’t think clearly, dictate a coherent report, or understand the need to create accurate documentation.

No matter how you look at the situation, it’s time to stop wallowing in fantasy and face the music. Haste makes waste. Sloppy dictation (combined with a fetishistic desire for faster turnaround time) does absolutely nothing to improve the quality or accuracy of documentation in a patient’s chart. Faster, cheaper and harder is not necessarily better.

At a certain point, medical transcriptionists must take a good hard look in the mirror and ask themselves if they are truly typing as fast as they can to save a patient’s life? Or if perhaps they’re being forced to act like faceless whores with keyboards -- data input workers who are paid to turn specialized tricks with their medical vocabulary in what is rapidly becoming a global electronic brothel (gentler souls may prefer to call it a sweatshop).

No comments: