January 2016

TAT — The Hydra of Health Care Documentation
By Jay Vance, CMT, CHP, AHDI-F
For The Record
Vol. 28 No. 1 P. 8

According to Greek and Roman mythology, the Hydra was a terrifying beast with many heads, deadly breath, and poisonous blood. If one of its heads was cut off, two more grew back. Killing the Hydra was one of the 12 Labors assigned to Hercules, and it was no easy feat to accomplish.

In many respects, meeting transcription turnaround time (TAT) deadlines is indeed a Herculean task. The obstacles are myriad, and as the clinical documentation process has become more complex and new technology has come into play, the challenges to meeting TAT seem to multiply. However, there are strategies available to ameliorate the impact of these challenges to some degree.

As a 15-year veteran of the health care documentation and HIT fields—the first several of those years spent in the trenches as a production transcriptionist—I like to think I have a fairly decent grasp of the obstacles to meeting TAT deadlines. But to provide additional input, I created an online survey specifically designed to elicit feedback from health care documentation specialists (HDSs) regarding the factors they feel have the greatest impact on their ability to meet TAT deadlines. The survey was publicized in a number of popular online transcription communities and, at the time of this writing, had garnered 192 responses. Clearly the survey and its results are strictly informal and not necessarily scientifically significant in a broad sense, nor were they intended to be. But the responses do provide some valuable insights into the real-world factors which working transcriptionists deal with on a daily basis in their attempts to meet TAT deadlines. (The survey's complete results, including comments, can be viewed online at https://goo.gl/zkbJg1.)

Survey Findings
The survey provided respondents with a list of potential influencing factors that could be graded from zero (no impact) to 10 (high impact). Respondents were also given the opportunity to add comments and identify additional factors not explicitly included in the survey. The influencing factors specifically listed in the survey were the following:

• length of dictation;
• type of report;
• ability to understand dictation (not related to audio quality);
• technology usability;
• working on multiple accounts simultaneously;
• unrealistic TAT requirements;
• unpredictable work volume;
• high work volume;
• workplace or personal distractions;
• level of familiarity with account and/or physician requirements; and
• audio quality.

Of the above factors, the scores for all but two were weighted heavily toward the high end; only "type of report" and "workplace or personal distractions" were rated predominantly five or less. The factors identified by respondents as having the greatest impact as measured by the number of "10" ratings were "audio quality" (54.7%), "ability to understand dictation (not related to audio quality)" (51%), and "unpredictable work volume" (35.9%). Following closely behind were "unrealistic TAT requirements" (29.7%) and "high work volume" (27.6%).

There were several additional factors influencing TAT compliance identified by survey respondents, including the following:

• physician dictation habits;
• transcriptionists' level of experience and expertise;
• unrealistic quality assurance (QA)/quality control expectations;
• time spent searching for missing patient names, account numbers, dates of service, etc;
• poor workflow planning by managers;
• job dissatisfaction and lack of incentive due to low pay;
• inferior speech recognition drafts requiring heavy editing;
• dictation not received from clients in a timely manner;
• lack of after-hours support from IT, QA, clients, etc; and
• high percentage of difficult dictations sent to specific transcriptionists.

Comments from survey participants provided specific examples of some of the influencing factors. By a large margin, the most often-cited obstacle to HDSs' ability to meet TAT deadlines centered around poor physician dictation habits or environmental conditions primarily controlled by dictating providers. Examples included the following:

• "the party/fire alarm/screaming child in the background;"
• "sitting half a room away from your speakerphone and shuffling papers [and] slamming doors while you speak;"
• "dictating while you ride the elevator to your parking level, locate your car, drive out, merge into traffic, and zoom down the freeway with your windows down, while you lose your train of thought multiple times and lose track of what you have corrected previously;"
• "having to change or assign report type, long pauses, dictators talking to others during recording;"
• "the assumption that I automatically know the places of business and the doctors you reference as if I lived in the same town (I have to Google them all);"
• "the doctor's fatigue level;"
• "the ability of the dictating provider to speak English;"
• "physicians failing to provide required patient demographics or other critical information;"
• "poorly organized dictation and dictation requiring multiple edits due to dictator corrections;"
• "doctors entering every job as STAT even when they are not;"
• "errors by the dictator that require excessive research to solve;"
• "doctors who can't complete a sentence without changing their mind 10 times;"
• "doctors who should never be on voice recognition;" and
• "the dictator keying in the wrong work type code with a lower priority level."

Overall, the survey results, although informal and unscientific, paint a fairly accurate portrait of how HDSs regard TAT requirements. Furthermore, based on personal experience and observations, many of these concerns are valid to a significant degree. It can be reasonably concluded that the factors affecting TAT compliance that transcriptionists and editors can control are greatly outnumbered by the processes and behaviors over which the HDS workforce has little or no influence.

Digging Deeper Into the Results
As president of the Association for Healthcare Documentation Integrity and as a production coordinator for a national transcription service provider, it's easy to sense and understand the frustration and low morale experienced by many in our workforce. They are under tremendous pressure not only to meet tight TAT deadlines but also to maintain a high level of accuracy while watching their compensation rate decline steadily. In short, the HDS workforce has several valid reasons for feeling frustrated and discouraged.

That being said, it's also true that no individual, regardless of job title or role in the clinical documentation process, can be expected to be aware of or fully appreciate all the factors impacting TAT compliance. This is true for physicians, facility administrators, HIM directors, CEOs of transcription service organizations, production managers, and hard-working HDSs.

In this labor force, just like workers in other fields, there is a natural tendency to blame outside forces for problems and minimize the impact of factors over which the workforce has some control. This is reflected in the responses to the survey question about how much workplace and personal distractions impact the ability to meet TAT requirements. A whopping 69% of respondents rated this factor a five or lower.

With all due respect to my fellow HDSs who work at home, if they were to objectively take into consideration all the interruptions encountered in a typical day—not to mention the lure of Facebook—I suspect we would find that workplace and personal distractions represent a much greater challenge to productivity (and consequently to meeting TAT deadlines) than indicated by the survey answers.

Taking all of the above into consideration, there can be no denying that there are factors affecting TAT compliance which should be and can be addressed by all parties involved in health care documentation. But as the medical transcription industry faces ever-increasing pressure to meet ever-decreasing TATs, the impact of this burden on the individuals whose well-being and livelihood are most affected—the HDSs laboring in the trenches—cannot be ignored or minimized by physicians, facility administrators, service owners, or production management.

The front-line guardians of quality medical documentation face the Hydra of TAT deadlines every day; these battle-scarred warriors deserve the respect they have earned.

— Jay Vance, CMT, CHP, AHDI-F, is president of the Association for Healthcare Documentation Integrity.