Sunday, September 23, 2007

Madness Takes Its Toll

Long before Hans Christian Andersen penned The Emperor’s New Clothes, the court jester served an important function in society. Looked to as a source of entertainment while feared for the sting of his tongue, the jester wielded remarkable political power. In their heyday, jesters could inform their employers of impending treachery, mock the other nobles at court, and occasionally utter critical truths which no one else would dare to express in the presence of the ruler.

Whether one turns to the broadly comedic sketches on MAD TV and Saturday Night Live for political satire or reads the biting editorials by social critics like Frank Rich and and Arianna Huffington, today's jesters share one thing in common: In examining the world around them, these people cut through layers of obfuscation to expose the folly and hypocrisy which governs our lives. Whether raging against the machine or calmly detailing their vision for a better world, their insights offer stark examples of how horribly wrong the authorities can be in their assumptions.

Many of today’s jesters find their bitter and angry roots in stand-up comedy. They range from caustic iconoclasts like Bill Maher and Dennis Miller to the truly dyspeptic Lewis Black (a frequent guest on The Daily Show With Jon Stewart). Michael Moore and Maureen Dowd deliver their observations with a potent combination of sarcasm, wit, and a literary stun gun. Often, what they say is incendiary (it’s difficult to read Moore’s Stupid White Men without marveling at his moxie).

A writer’s responsibility is not just to criticize but to offer constructive solutions to age-old problems. Sometimes that means examining the pieces of a complex puzzle and identifying the missing link. Gifted authors like Malcolm Gladwell (The Tipping Point) and James Gleick (Faster) are noted for their skill in dissecting our daily lives in order to better understand the relationships between tiny increments of time, thought, and action.

On October 8, 1994, I committed a major act of heresy. Having been invited to speak at AAMT’s Second Annual Managers and Supervisors conference in Las Vegas, I outlined what (at least to me) had been patently obvious. If medical transcriptionists wanted to have any impact on the medical profession – and if they wanted physicians to respect them for the work they performed – MTs needed to teach doctors how to dictate properly. Stressing that the institutionalized, gender-specific co-dependency rampant inthe medical profession was one of AAMT’s greatest enemies, I proposed a plan whereby the organization’s membership could lobby the American Medical Association so that medical schools would at least teach medical students how to properly create patient documentation.

In my naivete, I had no idea how revolutionary my ideas might be or how much resistance I would encounter. Most MTs were sick and tired of trying to get dictators to clean up their act; others didn’t want to do anything that would upset “the good doctor.” Risk managers were not aware of the problems caused by sloppy dictation habits. Hospital administrators simply wanted to cut turnaround time and labor costs. Nobody wanted to be told that speech recognition does absolutely nothing to improve the language skills of the person who was dictating. And entrepreneurs developing new software applications designed to automate transcription and coding were not interested in talking to transcriptionists. Why not? Because they had already spoken to physicians and claimed to know what the doctors wanted!

No one was willing to admit that the doctors didn’t know what they were talking about. How could they? It was the physicians who were responsible for creating this mess in the first place! Doctors were not interested in hearing that they don’t know what they’re doing -- or that one cannot change or improve the dictation/transcription process without forcing doctors to change their habits. Most important, nobody understood that by dictating more text they might actually increase the level of reimbursement they received from third party payers.

In recent years tremendous amounts of money have gone into building electronic infrastructures to automate processes, yet no one ever has held the medical community’s feet to the fire. As one new software product after another debuts in the marketplace, the message remains: “The doctor can keep dictating the way he always has -- everyone else will just have to change.” So let’s take a good hard look at why the emperor is still wearing no clothes.

Speed kills.

After enough years of transcribing reports, I can tell you that doctors who try rushing through their dictations make more mistakes. There’s absolutely no question about it. They stumble all over themselves, leave out important pieces of data, and frequently contradict themselves in their dictation. Like the March Hare in Alice in Wonderland, one can hear them thinking “I’m late. I’m late. For a very important date. No time to say hello, good-bye. I’m late. I’m late. I’m late.”

Why are they so late? In many cases it’s because they are chronic procrastinators. However, in his brilliant book Faster, James Gleick describes the emergence of a new syndrome he calls “hurry sickness.” Gleick goes into fascinating detail to explain how, in our rush to save tiny increments of time-- especially since the invention of the computer -- we have created huge systems that waste even more time trying to keep track of the time we should be saving. And, to be honest, being able to produce voluminous reports for your clients really doesn’t matter if the work still arrives late and full of mistakes!

Dr. Edward Tenner, the author of Why Things Bite Back: Technology and the Revenge of Unintended Consequences, insists that consumers have only themselves to blame. “Things are needlessly complex because featuritis sells products. People buy [them] for a feeling of control, then complain that they are so hard to manage. But show them something simple and rugged, and most of them will call it boring.”

A simple case in point: One of our clients recently decided to try a web-based transcription service. To his surprise, he experienced a significant drop in the quality of transcription and was shocked to discover how many reports were being lost. After confronting him about his contractual obligations to us, I asked what made him breach his contract and try another service. Did someone dangle a new toy in his face? Was he so desperate to cut costs that he was willing to sacrifice quality? Since he had been a client of long standing, I was curious to understand his motivation.

After some embarrassed hemming and hawing, he confessed that the quality of our work was far superior to the web-based service and that our turnaround times were just as good -- if not better. He sheepishly admitted that it was the idea of being able to track his reports on the web that really interested him. I promptly reminded this surgeon of his chronic tardiness in dictating reports and his constant complaints about not being able to find time to dictate. With so many constraints on his time, what made him think he was going to have the time to track his reports on the web? Was the web page he looked at so pretty?

Further questioning revealed that he had completely forgotten how to use our tracking system to locate reports and that, like many surgeons, he had communications problems -- especially with regard to asking for help. When Ireminded him how our tracking system works -- and that he has always had a user’smanual -- he uttered the words I just love to hear emanating from a physician’s mouth. “Oh, God. I’m an idiot. Please accept my profuse apologies. I don’t know what I was thinking!”

Content Matters.

Physicians constantly bemoan the fact that managed care crimps their style. But isn’t it time sometime slapped these doctors hard and reminded them that their style stinks? Think about it. It’s no secret that doctors hate to dictate. Many think of dictation as an excruciating burden which makes their lives miserable. But their lives could be much simpler if they learned how to dictate properly.

If you want to go to the very root of what is wrong with health information management as we know it, you have no choice but to examine the ways in which doctors document their work. There are the scribblers who leave notes that are totally illegible to nursing staff and consulting physicians. And the procrastinators who can’t understand that their dysfunctional behavior is a roadblock to timely reimbursement from third party payers. There are careless documenters who omit critical data and/or contradict themselves. And some really sloppy physicians who make critical mistakes bordering on medical malpractice.

Eight years after delivering my speech in Las Vegas, nothing has changed. Although transcription and coding have evolved into multi-million dollar industries, physicians still can’t seem to understand that the information they dictate – and the way in which it is dictated – can have a substantial impact on revenue and cash flow. Every time I ask medical students what kind of instruction they receive in such matters, their answers range from a clinical “None” to a confused“Hunh?”

In Stupid White Men Michael Moore goes into excruciating detail to explain the proper use of a toilet to men. He doesn’t do this just for comic effect. He does it so that men -- who seem to have no problems figuring out how to use power tools – can eliminate a constant source of tension with women and, as a result, develop better relationships which will lead to happier lives for everyone (and maybe even more sex).

Medical Records Directors need to take the same approach with physicians by explaining that coding can only be done based on the information which appears in the patient’s record. If the physician fails to give sufficient data, then a coder can only code to certain levels of reimbursement. If, however, more pertinent pieces of data are included in the dictated report, it may be possible to generate a higher level of billing.

If at first you don’t succeed.

Up until now, most of the changes in the medical transcription industry have focused on getting transcriptionists -- not physicians -- to adapt to new ways of working. Huge amounts of venture capital have gone into developing ASP software, greater networking capabilities, and new ways to reduce telephony charges. What folks continue to ignore is how transcription can be used to increase revenue by including more data that can lead to higher levels of coding.

In order to achieve increased levels of reimbursement, physicians must learn how to create reports in such a way that coders have more ammunition with which to bill at higher levels of reimbursement. The extra time it takes to dictate this information is a trivial consideration compared to the potential revenue to be reaped from the process. But in order to put an end to the current madness, doctors will have to change their habits.

Because this is a particularly difficult concept for people who have graduated from medical school to grasp, I’m going to dumb it down as much as possible for the sake of those licensed members of the medical community who “just don’t get it.” So listen up, folks!

Part of the scientific process involves testing hypotheses to see if they can be proven true. If an experiment continually fails to produce satisfactory results, one of the questions to be asked is whether the raw materials being used in the process are of a sufficient grade to make the experiment a success. The most radically dumbed-down version for physicians might read something like “Try adding salt.”

Now, if you bake a cake and put it on display, it will not attract as much attention as another cake that has some decorative icing on it. Why? Because it is the icing that makes the cake more appealing -- not its crust or texture. People will happily pay more for a decorated cake than they will for a plain cake. Oddly enough, the cost differential in preparing the two cakes is minimal. And the extra effort that goes into decorating a cake can be looked upon as giving the cake “added value.” But if you compare the extra revenue to be derived from the sale of a decorated cake (as opposed to a plain cake), you will probably encounter a much heftier profit margin.

Friends of mine who are in recovery are quick to define insanity as doing the same thing over and over while expecting to get different results. The mere fact that someone is a physician does not mean that he knows how to document patient care. In so many unacknowledged and underappreciated ways, that knowledge is the province of coders and medical transcriptionists. Because of their experience -- and their acute awareness of what is missing in their work -- they are the ones who can teach physicians how to properly create patient documentation and lead them to the promised land of richer reimbursements.

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