Thursday, September 27, 2007

The Road To Verbatim

If, as the old saying goes, the road to hell is paved with good intentions, then there can be little doubt that the road to verbatim transcription has been arrogantly plowed by corporate venality. This point was made clear to me while watching a re-run of the South Park episode in which Squeak tries to convince his friends that gnomes are coming into his bedroom every morning at 3:30 a.m. to steal his underwear. Those familiar with the plot will recall that a huge chain of coffeehouses named Harbucks is trying to muscle its way into South Park. Having been saddled with the assignment of preparing a presentation on local current events, Stan, Kyle, Kenny, Cartman, and Squeak follow the gnomes to their underground headquarters and learn all about the corporate takeover process. Phase 1 is clearly labeled “Steal Underwear.” Phase 3 is boldly defined as “Profits!” Unfortunately, none of the gnomes can explain what Phase 2 involves.

While there have been numerous threats to the integrity of medical transcription, the most vile dangers come from people who really do not understand what the process of medical transcription involves. The reason they don’t understand is quite simple. They haven’t had much experience doing it. Some of these people may be MBAs who -- with a bloodthirstiness that defies imagination -- are determined to squeeze every last penny out of the process. Some are software engineers who are so in love with technology that they remain clueless about what happens during the course of real transcription. And some are just greedy fools who want to do the least possible work and make the most possible money without any concern for whose life might be endangered by their behavior.

By trying to slash labor costs in pursuit of bigger profits, these people have not hesitated to trample the collective conscience of the medical profession. In an age of technical wizardry where hopes remain high for artificial intelligence, these people have no understanding that A.I. cannot and will not eliminate basic problems of human clumsiness and stupidity. In their eyes, short-term gain is far more important than the patient’s health.

As someone who has transcribed for both court reporters and physicians, let me explain the inherent values and dangers of verbatim transcription. First let’s examine the legal justification. In a deposition or trial setting, a court stenographer is present to record every word that is said. That person has the power to stop the proceedings at any moment if, for instance, more than one person is speaking at the same time or if the court reporter needs to fix a mechanical problem. The presence of a court reporter to record every stuttering exclamation – every “Errrr, “ "Ummmm,” "Aaaagh,” “Maybe” – as well as every sentence that begins with a false start becomes extremely important when the plaintiff or defense is trying to impeach a witness’s testimony. It doesn’t matter whether you’ve gone to law school or have graduated from the Perry Mason School of Legal Drama. A lawsuit can be scuttled on legal technicalities and one of the surest ways to weaken an opponent’s case is to impeach the testimony of the other side’s witnesses.

Now let’s examine the environment in which medical transcription takes place. Unlike the court reporter, the medical transcriptionist has no power to stop a doctor in the middle of his dictation and tell him that he is failing to communicate his thoughts because his dictation is rambling, incoherent, contradictory, garbled, inaudible, or is being drowned out by such peripheral noises as radios, televisions, beepers, crying children, flushing toilets, vomiting patients, overhead announcements, traffic noises, jet engines, squawking parrots, and barking dogs. No, I am not kidding. I once had to listen to an Emergency Room doctor dictate reports while he had the Act II “Triumphal Scene” from Verdi’s Aida playing in the background!

Unlike the court reporter, the medical transcriptionist does a tremendous amount of editing on the fly by (1) changing words like “didj” to “digoxin,”(2) changing units of measurement so that the patient’s blood pressure is not measured in Fahrenheit degrees, (3) changing grammar so that the physician doesn’t sound like an illiterate thug, (4) changing the patient’s gender so that the patient does not get diagnosed as a hermaphrodite, (5) unscrambling lab results that have obviously been transposed by the dictating physician, and (6) changing crucial dates, such as when a physician tries to describe yesterday’s date of surgery as taking place three years into the future. All this and so much more editorial/secretarial work is done with two basic goals in mind. First, and foremost, to protect the patient. Second – and of growing importance in an extremely litigious society – to protect the physician from his own carelessness and stupidity in the event that a patient’s medical record is ever entered into evidence in a legal proceeding.

Unless you’ve been raised by wolves, you already know that the handwriting of most physicians is barely legible and does not stand up well in court. If you’re a physician who is in love with the sound of your own voice, you might even doubt that you could contradict yourself while dictating medical reports. But if, as a patient, you’ve been admitted to a hospital, you can only hope and pray that someone doesn’t let a mistake (that could kill you at some point in the future) enter your medical record.

What kind of price should we put on medical malpractice mistakes that are a result of documentation errors? You tell me! What price would you attach to a fatal allergic reaction that the patient suffered because someone wasn’t paying attention -- not during the actual hands-on patient care, but during the crafting of the patient’s medical record? What compensation would you offer for the wrongful loss of an arm, a leg, or an eye, because the surgeon said “left” when he should have said“right” and that single stupid error was not caught but was instead allowed to metastasize throughout a patient’s electronic medical record? What’s it really worth to you as a doctor, nurse, medical transcriptionist, MTSO, medical records director, or risk manager? Is your healthcare organization really willing to consign such costs to a budget line item labeled “collateral damage”?

For some unscrupulous hospital administrators and MTSOs, the risk of jeopardizing patient care by insisting on a contract that calls for verbatim transcription can be easily rationalized if reducing labor costs will increase profit margins. My guess is that these people have never worked as medical transcriptionists themselves because, if they had, they would know better. I’m also willing to bet that some of these people are trying to fashion a legal loophole so that, if they seek to cut labor costs by processing all of their dictation through a back-end speech recognition engine,they cannot be held accountable for mistakes that were dictated but not caught.

There is a perverse genius to this approach. The more labor costs you eliminate with computers, the more money you can make. The more money you make,the more you can invest in new technology or better yet, pocket in the form of a performance bonus. Onceyou’ve gotten rid of medical transcriptionists, you can hire them at half the price as “correctionists”(real medical editors want too much money). That, of course, was the panic scenario which coursed through the medical transcription profession several years ago.

The truth has proven to be quite different. Several months ago, a leading business magazine reported that speech recognition was not living up to expectations in call centers and other business applications. Do medical records directors really think that physicians (who do not always read their transcribed documents carefully to check for errors) are going to want to work twice as hard because the verbatim transcripts they receive are filled with errors? Do they really think that the wealth of contradictions that will appear in verbatim transcription will offer a clearer picture of the patient’s condition? What about all those times that doctors dictate “Oh, go back to where I said so-and-so and change that.......”? What if a healthcare provider who is quickly skimming through a patient’s medical record doesn’t read that far and moves forward with the wrong information?

Some doctors have been furious over the poor quality of reports they receive. My company recently landed a client whose previous service had either used speech recognition or sent his work overseas. The physician was beside himself -- not just because of all the time he had had to spend correcting documents – but because it seemed as if no one ever made the changes he requested.

Qualified medical transcriptionists provide the safety net that protects the integrity of a transcribed document. And, while speech recognition may improve beyond our wildest imagination in the next few years, I sincerely doubt that the medical profession will see any measurable improvement in the quality of dictation. Until that miracle comes to pass, anyone who signs a contract for verbatim transcription is making a grave mistake that could dramatically jeopardize the quality of patient care.

To sanction verbatim transcription in a medical records environment opens a Pandora’s box filled with crises of ethics, accountability, and liability. If a physician’s credo is to “First, do no harm,” why should we allow a business associate involved in the creation of a patient’s medical record to be held to a lesser standard?

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