Friday, September 28, 2007

Till There Is A Cure

We’ve all heard of PMS. Will someone please tell me why no one wants to talk about PJJ syndrome? PJJ occurs on a regular basis in hospitals throughout America. Most medical records personnel anticipate the onset of PJJ months in advance. The pre-JCAHO jitters can have a devastating impact on workplace stress, staff morale, employee health, and productivity. But no one has found a way to tame this bizarre form of administrative seizure activity which precedes an audit by the Joint Commission for the Accreditation of Healthcare Organizations.

While the folks in IT and other departments have no trouble understanding the classic GIGO formula (garbage in, garbage out), risk managers, Chiefs of Staff and physicians on the Medical Records Committee seem to suffer from an occupational blind spot. If nurses and medical transcriptionists can easily identify the chronic conditions which provoke PJJ, why can’t those with medical licenses diagnose the problem? As Bill Maher (the host of TV’s Politically Incorrect) would say, it’s like watching people trying to ignore a 500-pound pile of elephant dung located smack in the middle of their living room!

If a patient required treatment with antibiotics, anti-inflammatories, antacids or a change of diet, everyone would know what to do and the problem would quickly be solved. So let’s not kid ourselves. The “garbage in” factor can often be traced to known sources. The culprits can often be quickly identified.

Why can’t the pre-JACHO jitters be avoided? To answer the question, let’s look at certain news stories which are guaranteed to appear every year. Will there be stress at the nation’s airports over Thanksgiving weekend? You’d better believe it. Will the first baby born in the New Year make it onto the local news? Without a doubt. Will everyone wonder if Punxsutawney Phil sees his shadow on Groundhog Day? Easy story to cover.

Come April 15th, will the news media have their cameras out as taxpayers rush to the post office to file their returns before the midnight deadline? You can bet money on it. Planning a story about people who wait until the last minute to do their taxes is a no-brainer for news editors. It makes for good copy and touches a universal fear button. The story is a sure shot for the 11 o’clock news because there’s always some poor schmuck who will wait until the last minute to file his tax returns.

But what about the story that does not get written? What about the millions of people who file their tax returns on time because they were doing what they should have done all along? I’m not just talking about people who are employees, but also about those freelancers and business owners who maintain the financial discipline necessary to track their income and expenses using programs like Quicken and/or Quickbooks.

These people dutifully log all transactions, balance their checkbooks, and deliver reliable financial data to their accountants in plenty of time to meet each year’s April 15th deadline. Whether running a hospital or a restaurant, they pay their employer’s taxes on time. Their W-2 forms are delivered to employees and their 1099 forms appear in contractor’s mailboxes on time.

Not only do these people understand the responsibility to store and maintain data so that they are ready to print W-2 and 1099 forms by mid-January, they also know that other people are expecting these forms to arrive on time in order to prepare their taxes and avoid any penalties for late filings.

That seems pretty straightforward, doesn’t it? It’s the kind of process that someone with a medical degree should be able to understand. And yet, when it comes to creating valid clinical documentation, too many physicians think that their patient’s right to a clear and concise medical record has nothing whatsoever to do with the timeliness and quality of a physician’s dictation.

Suppose we compare maintaining a patient’s medical record to handling a company’s accounting functions. In the financial world, data has to be clean. If you make the kind of mistake that moves a decimal point three digits to the right, it can have stunning economic repercussions. If, for some bizarre reason, you decide not to record any transactions that occur on Fridays, how can you know how much money you have in the bank? How can you plan a budget without sufficiently solid data to forecast income and expenses? How many people in your accounts payable department are allowed to issue blank checks?

No one in the business world can tolerate that kind of ineptitude when profit margins are tight and management needs to maintain a desperate grasp on reality. But look at what we tolerate in the world of medical transcription. There isn’t a hospital in this country that doesn’t have at least one doctor whose dictated reports contain enough blanks to look like a piece of Swiss cheese. Or a handful of physicians who are notorious procrastinators. Not to mention the doctors who don’t bother to read their transcribed reports in order to check for errors and/or make corrections.

When people don’t know how much of a mess has been made – or don’t care – there’s good reason for the person in the hot seat (usually the Medical Records Director) to get a bad case of the pre-JCAHO jitters. Suddenly, there is a heightened awareness of the need for quality control in transcription. Like a bolt out of the blue, there is a demand for perfect transcription with no blanks in any reports. Extra employee hours must be devoted to making sure that past records are complete and can withstand the scrutiny of the JCAHO’s auditors. As the pressure starts to build and employees are asked to work longer hours, management’s expectations become more and more unreasonable.

Like someone who has “found” religion, a clinic or hospital that once wasn’t very concerned about quality assurance suddenly executes a 180-degree turnaround in policy and procedures. With a JCAHO audit looming on the horizon, there is a newfound urgency for all charts to look pristine and complete. Is this any more of a joke than the stereotype of the stewardess who, on April 14th, shoves a box full of receipts at her accountant and says “I don’t know what these are for, but I saved all of my receipts this year. Just make sure you get my taxes done on time, Buster.”

While working in the arts, my friends and I used to compare the long-term health of large dysfunctional nonprofit institutions to that of problem drinkers. In many cases, the management and staff of these institutions resembled adult children of alcoholics who desperately kept trying to “make their parents get better” without being able to face the horrid fact that their parents didn’t want to get better. Is there a corollary between a hospital’s pre-JCAHO jitters and an alcoholic’s delirium tremens? You tell me.

The people at the bottom of the ladder are not fools. Nurses know which doctors make sloppy, illegible entries into patients’ charts. Medical transcriptionists know which doctors are continually contradicting themselves while dictating because they’re lost in space, dictating so fast that they can’t help but make errors, or are simply too pooped to pay attention to what they’re doing. Accountants know who’s been doing a responsible job of tracking expenses. Even Santa Claus knows who’s been naughty or nice.

But in the medical field, everyone keeps dancing around the truth about doctors like a bunch of co-alcoholics who are terrified to perform an intervention. God forbid someone should nail a physician to the wall, tell him he has sloppy work habits and force him to sober up and learn the proper techniques for creating a coherent medical record. That might require people to risk losing their jobs by accusing a doctor/alcoholic figure of not doing his work properly and being a hazard to those around him. Even worse, it might mean that in a medical peer review, doctors might actually have to accuse their colleagues of being incompetent slobs whose poor work habits continually jeopardize the accuracy of their patients’ medical records.

So what happens? Each year, we see the same news stories on television and witness the same song and dance in the HIM industry. The variations are easy to spot from one year to another. In one instance, a hospital installs a new piece of software which is supposed to guarantee that physicians follow certain procedures for templating their reports. In another, hospital administrators decide that by outsourcing transcription to India they can get faster turnaround with a lower price per line. With new advances in Internet technology, ASP entrepreneurs trumpet claims that they have solved all the problems of creating and maintaining an electronic medical record.

Larry Abernathy, the President of Digital Voice, Incorporated, claims that “Philips speech recognition technology is being married to our dictation system, to give birth to DVI SpeechPower. Without changing physicians’ dictation behavior, we can run their DVI VoicePower dictations through the speech engine, produce a draft text report, and then provide this text – along with a synchronized voice playback – to a ‘medical editor.’ We anticipate dramatic improvements in productivity since correcting a small number of mistakes will be considerably faster for your transcriptionists than transcribing the entire document. And it also expands the pool of personnel from which you can recruit, since fast keystroking is no longer a required skill.”

Abernathy’s statement blithely ignores the fact that fast keystroking is not the issue which keeps bringing medical transcriptionists to their knees. The problem is the incoherent garbage spewing forth from the mouths of physicians with absolutely no intention of improving the quality of their dictation.

In its mission statement, the American Society of Tests & Measurements (ASTM) claims to be the foremost developer and provider of voluntary consensus standards, related technical information, and services having internationally recognized quality and applicability that:

"promote public health and safety, and the overall quality of life; contribute to the reliability of materials, products, systems and services; and facilitate national, regional, and international commerce."

In recent years, an ASTM committee supervised by AAMT’s Claudia Tessier has been hard at work developing new standards for medical transcriptionists to follow. Although doctors initially said they wanted to be told how to dictate, it soon became obvious that the transcriptionists would have to make all the adjustments in their work habits.

It’s interesting to note that some 85 years after the Titanic disaster, analysis of the wreckage retrieved from the ocean floor helped scientists determine that the use of a cheaper grade of steel (which became brittle at low temperatures) was a major factor in causing the ship’s hull to buckle when the Titanic collided with an iceberg. Will ASTM, which supposedly sets standards for raw materials used in the manufacturing process, insist that doctors deliver a higher quality of dictation (the basic raw material that transcriptionists must process in order to create a coherent patient record)?

The reason it will be a cold day in hell when that happens is best articulated by Robert I. Field, the director of the graduate program on health policy at the University of the Sciences in Philadelphia. In his comments about the challenges faced when two or more hospitals try to merge, Field notes that basically “you have a large number of prima donnas who are used to taking orders from no one."

In her superb essay in the New York Times entitled Teaching Old Dogs New Medicine Can Be Some Trick, Dr. Abigail Zuger explains that the wealth of important new information offered to doctors during continuing medical education sessions is often forgotten soon after physicians settle back into their professional routines. And so the dance of denial continues. It doesn’t matter that the good doctor drools, has two left feet, and keeps stepping on his partner’s toes. He’s not going to change.

Which means that you’ll just have to keep dancing with the folks what brung you (and try to avoid stepping in that 500-pound pile of elephant dung in the middle of the dance floor). Think about that the next time you attend a conference sponsored by AHIMA, AAMT, HIMSS, MTIA, or any other healthcare information management-related organization. Because once you go back to work, you’re going to face the same old problem.

Garbage in, garbage out.

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