January 2015

The Critical Role of MTs in EMR Documentation
By Susan Whatley, CMT, CPC, AHDI-F
For The Record
Vol. 27 No. 1 P. 6

What is your medical record worth? How important is the content? Does its accuracy matter? The answers to these questions would seem to be self-evident, but these are strange times in the health care industry.

The use of electronic documentation and the processes involved to capture and record a patient's story have taken the profession by storm. Now that the dust has settled a bit, the door for discussion has opened across the HIM arena: What have we gotten in exchange for our efforts to go paperless? What must we do better?

Certainly, medical transcriptionists (MTs) and health care documentation specialists (HDSs) are asking questions because their livelihoods have been impacted. In addition, there's interest from EHR vendors looking to sell products, transcription companies hoping to turn a profit, and health care facilities reevaluating tight budgets. It seems everyone has a financial stake in creating medical records.

More importantly, the quality of medical records is not what it should be. In fact, in a report identifying the most challenging requirements of the first half of 2013, The Joint Commission found 55% of hospitals did not maintain complete and accurate records for each patient.

As electronic processes were infiltrating the scene, the idea was birthed that doctors, nurses, and other care providers make better documentation specialists than those trained to perform the task. As a result, provider-created documentation was born. This strategy emphasizes speed and the bottom line rather than quality and patient safety.

Medical records are designed to tell each patient's unique, individual, and detailed story—they're not supposed to be point-and-click duplicates. Critical thinking, training, and quality must not be trumped by the belief that faster is better.

While there are benefits to electronic records, they should not come at the expense of patient safety. Expedient documentation and fast turnaround times are noble goals, but they must not sacrifice the accuracy and quality of the information being entered in the chart.

Firsthand Accounts
An office manager at an orthopedic clinic who requested anonymity believes most physicians should not be documenting in the EMR. "These doctors have been sold a bill of goods," she says, noting that the physicians are spending more time documenting onscreen than interacting with patients. The physicians who choose to focus more on the patient are then forced to document the day's encounters after office hours. She estimates the EMR's value is low for physicians, and even lower for patients.

A nurse practitioner who has worked in various health care settings, from clinics to acute care facilities, throughout her 30-year career is also disenchanted with EMR documentation. "I have yet to find an electronic record I like," she says. "They leave out the details, and it's the details that make the record personal to the patient."

Medical records are not one-size-fits-all, she adds, noting that cookie-cutter templates limit a provider's ability to uniquely describe each patient's medical story.

For example, the nurse practitioner, who requested anonymity, says EMR templates are unable to record a detail such as a patient missing the fifth digit on the left foot. In these cases, free-text entry is required, she notes, adding that should the provider skip that step, the record will not accurately reflect the patient's actual state.

One of the most troubling aspects of provider-created documentation is that many MTs—the professionals who have long been the guardians of patient records—have been dismissed from hospital settings. A devastating consequence of this misplaced trust in technology is that MTs are being forced to leave the industry, mostly because they can no longer make a living wage. As hospitals decide that it is more profitable to close their medical transcription departments and outsource their entire workload to transcription service companies, MTs lose more than job security and stability. They also lose their hourly pay and any prior incentive programs, instead working at a piecework rate that often earns them less than 50% of their salary at the hospital, which sometimes equates to less than minimum wage.

Underappreciated Skill Sets
No medical transcription department exists to make a profit. Its primary function is to partner with the facility and providers to ensure patient safety. In other words, transcription has the backs of the providers, the facility, and, most importantly, the patients. Outsourcing documentation may cut costs for the facility and add to the coffers of the transcription vendor, but it also may be a detriment to patient safety.

The perception that transcription is an expensive, expendable step in the documentation process has been fueled in part by transcription service companies and health care organizations. For example, in 2012, a jury awarded a $140 million verdict when it was ruled that a typographical error on the doctor's discharge summary resulted in the death of a 59-year-old woman. In an effort to save two cents per line, the hospital outsourced its transcription to India and then failed to review the summary for accuracy before issuing medication orders.

The landmark ruling helps to further debunk the idea that transcription is a clerical support service and that transcriptionists simply type what they hear and no skill or knowledge is required to do the job.

Transcriptionists don't just sit in a chair all day performing clerical services. Each and every dictation requires focused attention on the task at hand. MTs incorporate anatomy, terminology, and pharmacology training with critical thinking skills to detect errors and protect patients as well as providers and facilities.

MTs have been pushed aside for technology and software, which are now considered the experts. Tools such as front-end speech recognition may speed the documentation process in settings such as the emergency department, but the process works on the assumption that the provider entering the information and editing the document will not make any errors.

If it's recognized that time constraints often prohibit providers from reading transcribed documents completely before signing off on them, how will reviewing their own documents be any different? Will there now be more time to go back and carefully proofread the document that was just created? If there is no time to read a transcribed report, how will there be time to proofread one created electronically? There's not more time; it's just divided differently as the provider now becomes both the creator and the proofreader. On the assumption that there will be no errors, that proofreading step likely will be circumvented to save time. Removing transcription from the documentation process removes an extra pair of trained and professional eyes along with a crucial opportunity to spot and correct errors before they enter a patient's record.

Industry Associations Collaborate
Last August, the Association for Healthcare Documentation Integrity (AHDI) and AHIMA identified the need to review provider-created documentation for errors and incompleteness. In a press release, AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, said, "Having a QA [quality assurance] program is an essential component to ensuring patient safety. AHIMA and AHDI urge health care organizations to reinstate QA programs as part of a comprehensive plan that focuses on quality health information."

The release also states, "CDI [clinical documentation improvement] and QA are different—a CDI program facilitates the accurate representation of a patient's clinical status that translates into coded data, while a QA program is the complete review of the narrative and demographic data to protect the patient, caregiver, and the organization's documentation integrity."

The skill sets of MTs and HDSs make them ideal candidates to fill these new QA roles.

Why Not Work Together?
Recently, an industry trend has emerged in which coders work with CDI specialists and nurses to help improve documentation. Each group brings its respective knowledge bases to the table to create a well-rounded team. The documentation process should involve documentation specialists who understand the importance of capturing accurate patient information.

Why ask nurses to code or coders to be nurses? Joining forces seems to be a better option. In a similar vein, why ask clinical providers to be documentation specialists? A more sound strategy would likely be to allow health care professionals to serve patients where their skills best fit: Coders review records and assign codes, nurses tend to patients and document care, and MTs and HDSs review provider-documented details and/or create documents. All three groups boast highly specialized areas of expertise, but at the same time depend on each other to provide their organizations with the best chance of meeting patient safety, reimbursement, and risk management goals.

As a vital part of the HIM team, MTs and HDSs work quietly behind the scenes to care for patients. For years, these professionals have preserved the integrity of medical records through careful attention to detail and taken pride in their behind-the-scenes contribution to patient safety.

As more health care organizations adopt HIT and move to paperless environments, it would be unwise to devalue and disregard the contributions of MTs. Rather, their skills should be celebrated and incorporated into high-tech settings.

— Susan Whatley, CMT, CPC, AHDI-F, has spent more than 20 years in the transcription and coding industries as an independent contractor, lead transcriptionist in an acute care setting, and an educator. She has served the Association for Healthcare Documentation Integrity at the local, state, and national levels and currently teaches coding and transcription at two state colleges.

— Carole J. Gilbert, RHIT, CHTS-IM; Paula Goode, CMT; and Betsy Ertel, AHDI-F, contributed to this article.