A day without transcription

By Lea M. Sims, MT, AHDI-F
Advance for Health Information Professionals

What would be the impact on patient care if transcription were no longer a resource option?

Among the many lessons health care delivery learned from Hurricane Katrina was how important it is to protect “critical systems” in the event of any emergency or disaster, the presumption being that certain systems and processes are so vital to the protection of human life and/or continuity of care that they cannot stop functioning under any circumstances.

While most facilities would include patient care documentation near the top of that priority chain, where would transcription, specifically, fit on that list of critical systems?

Is Transcription Going Away?

With 1.2 billion health records produced in the U.S. each year, 60 percent of clinical notes captured via the dictation/transcription process every year and providers still demonstrating a strong preference for dictation as the method for entering health encounters,1you might think the answer to that question is obvious. Yet, EHR systems continue to overlook the interface solutions that will ensure narrative capture, electronic medical record vendors continue to hypnotize physicians with fancy template systems and the dazzling promise of eliminating transcription costs, and most in health care are operating under the ill-informed assumption that speech recognition technology (SRT) is going to completely automate the documentation process pretty soon anyway.

If you listen to some in health IT and HIM, you might be inclined to believe that transcription is simply an expendable clerical support system. It seems everywhere you turn these days, you hear someone saying, “Isn’t transcription going away?” What no one is asking, of course, is what a health care delivery system without transcription would really look like. What would be the impact on patient care if transcription were no longer a resource option? To explore that question, we have to consider how heavily dependent health care (especially the acute care sector) truly is on transcription services, and to do that, we have to take a more granular look at those 1.2 billion health records.

On Jan. 20, 2010, a normal day by all accounts, 2,949 health records were dictated by providers at Baptist Health System, a 5-site hospital system in Northeast Florida. A day without transcription for this busy facility would mean relative paralysis of communicated health information. The most significant impact would have been felt in the absence of its 246 admitting History & Physical exams (H&Ps), which are required on the chart for any treatment or diagnostic intervention, and on all the document types upon whose availability ongoing clinical decision-making and coordinated care is so vitally dependent.

Consider just the 1,674 X-rays dictated. While some of those undoubtedly represent routine or normal findings, a significant number represent clinical findings that will inform the diagnosis and treatment plans of a physician awaiting those results. Likewise, a fair portion of the 285 pathology reports dictated on Jan. 20 represent pending cancer and disease diagnoses.

“The impact to Baptist Health would be the potential impact to patient care with procedures being delayed, canceled or rescheduled due to the lack of an H&P on the chart before the procedure could be done and the possible financial impact due to delays in available documents necessary for coding and billing purposes,” noted Sherry Martin, CMT, transcription manager for the Baptist system. “Also, if transcription was unable to be performed, this would create a need for handwritten documentation by the physician, decreasing the time available for patient care.”

A Vital Contribution

No one would likely argue the importance of a readily available health record, particularly in an acute care facility, though some might contend that while documentation of those 2,949 records was critical, the importance of having them captured through transcription/editing is still debatable. Those who would suggest that transcription isn’t a vital contribution must believe that Baptist Health System would have been as well served by having its 2,949 records entered by its physicians, because every other potential scenario involves an already overburdened health care provider having to: a) hand-write those notes, b) edit his own speech-recognized draft, or c) point-and-click his way through a complex maze of “customized” choices that may or may not accurately capture the unique care encounter of his patient. Arguably none of these is as quick, efficient or cheap as transcription.

If EHR vendors and those pushing front-end SRT are successful in convincing facilities to abandon the notion of transcription/editing, it will happen because those facilities are not considering the long-term risks associated with dependence solely on technology for documenting health records. Aside from the significant quality concerns inherent in removing an editorial eye from the data capture process, there is also the issue of how patient care will be documented when those technology-dependent systems fail. Not likely, you say?

Transcription Is a Priority

Sherry Doggett, director of corporate transcription services for Health Alliance, would beg to differ. Her multi-hospital integrated delivery system in Cincinnati learned first-hand just how important transcription resources become in a time of crisis. In September 2008, wind storms in Cincinnati caused a city-wide power outage that left 600,000 people without power for nearly 7 days and required her hospital system to operate on generator backup for a significant portion of that time. While some generated power was allocated to their dictation and SRT system (Health Alliance considers documentation systems a “tier 1” priority), their own home-based MTs and SRT editors were without power. For a hospital system that produces more than 11,000 documents per day via dictation and transcription/editing, this was more than an inconvenience. It was an emergency.

“At least a third of those documents were needed for immediate patient care,” Doggett said. “Thankfully, we had an established partnership with an outsourced transcription service that stepped in immediately to rescue us. I can’t even imagine how we would have kept documentation moving during that time without transcription resources.”

Transcription is woven into every level of the Health Alliance plan for ensuring seamless and uninterrupted documentation of patient health records. If their sophisticated SRT system fails, their editors can be redeployed to frontline transcription. If frontline transcription resources are cut off (in this case by loss of power), they turn to their outsource partner. In other words, transcription is the failsafe plan in every scenario. Consider the alternative. If Health Alliance believed transcription could be fully replaced by technology, not only would it have to figure out how to dump an 11,000-records-per-day data entry load back on its providers, it would be without any backup when those systems are offline or fail.

Elimination Is Not the Answer

Baptist Health System and the Health Alliance are not rare exceptions in acute care. They represent thousands of hospital systems that rely heavily on integrated solutions that include transcription/editing.

Even in the private practice and clinic sectors, where the pace of operations and the simplicity of documentation are prompting providers to dump transcription in favor of template EHRs, no one is really evaluating the efficacy of these so-called “solutions”-where physicians are reporting increased time in data entry and frustration with compromised care. A day without transcription in those facilities now means a day when providers see fewer patients as a result of having to spend more time documenting-a day spent “pointing and clicking” on a laptop, relationally disconnected from patients who wonder why they no longer have their physician’s undivided attention.

Despite all of this anecdotal evidence that transcription/editing may still be the most efficient, quality-focused and cost-effective means of getting America’s health stories accurately captured, many continue to declare that it must be “going away.” One wonders if, like the proverbial emperor’s new clothes, health care is just buying into a prevailing sentiment that on closer inspection may be devoid of substantive value. Any discussion of what meaningful (or more importantly, practical) use of an EHR system should look like needs to be mindful of these complexities. A health care system that moves in haste toward complete dependence on automation may very well “repent at leisure.”

Reference

1. National health statistics reports no. 5, 2006 National Hospital Discharge Survey; no. 3, National Ambulatory Medical Care Survey-2006 summary; no. 4, National Hospital Ambulatory Medical Care Survey-2006 outpatient department summary; no. 7, National Hospital Ambulatory Medical Care Survey-2006 emergency department summary; no. 12, Ambulatory Surgery in the United States; Hyattsville, MD: National Center for Health Statistics. 2008.

Lea Sims is director of professional programs for the Association for Healthcare Documentation Integrity (AHDI) and oversees AHDI’s communications, best practices, credentialing and education programs.