September 2018

Transcription Trends: Self-Documentation Challenges
By Delbert L. Arrendale
For The Record
Vol. 30 No. 8 P. 28

If you still believe transcriptionists are sitting in cubicles in hospital basements typing dictation with a headset and foot pedal, think again. In today's world of speech recognition, specialized EHRs, and large health systems, it's providers who are the de facto transcriptionists.

How can we make the transcription process for clinical documentation more efficient while containing costs at all types of health care organizations and delivering an accurate record to facilitate quality care? It is important to recognize three significant industry trends: provider-created documentation, speech recognition advancements, and medical transcription service organizations (MTSOs) replacing facility-employed transcriptionists.

One driver is the more detailed documentation required by ICD-10 and the HITECH Act, each of which impact reimbursement and the bottom line. Accurate documentation is just as essential for physician practices and behavioral health facilities as it is for inpatient acute care hospital stays. Therefore, providers in all fields are affected by documentation trends. It may be a rush to judgment to conclude that eliminating transcription costs—whether they be incurred through a third party or in-house staff—is the best financial strategy for every health care entity.

Taking Action
Innovative MTSOs have responded by employing adjunct services to assist providers utilizing EHR platforms. MTSOs that have embraced EHR technology but also recognize the decline in chart quality—and the decrease in eye contact between providers and patients—focus on contributing to the overall efficiency of creating electronic documents. This approach has a direct positive effect on patient care.

Some organizations have chosen to allow providers to dictate notes and instructions that can be directly entered into the EHR as a draft document by remote scribes to save time for providers and improve overall efficiency. Another option to achieve a more detailed, accurate note is backing up front-end speech recognition with remote scribes to free providers from keyboard entry and proofing.

Many providers turned to front-end speech recognition initially as a means of streamlining document creation. While this may work for some, there are others who struggle to make the appropriate edits and corrections. Even when front-end speech recognition is successful, the chance of missing a critical error is always there.

One way to limit the risk of medical errors from speech recognition is to incorporate an independent MTSO to review and edit selective reports for selective providers.

Working With Technology
It has become common for transcriptionists to type provider narration directly into EHRs instead of into word processing systems that contain specialty tools for efficiency and accuracy. The advantage of direct EHR entry is the elimination of a Health Level 7 interface expense from the transcription platform. However, the actual speed and efficiency decrease with straight EHR typing minus word processing tools.

Additionally, new software has been developed that allows front-end speech recognition files to be copied and made available for quality assurance review after the fact. This software enables an editor to log into the EHR, review the converted text, and correct, edit, and grade in the same session.

"The more savvy MTSOs have developed unique billing methods that allow only the keystrokes used to produce a note inside the EHR to be included in the final billing total," says Buff Groth, director of business development at Medical Technology Solutions of America, which specializes in EHR editing. "These billing methods ensure that the production cost is not only fair to both the client and the transcriptionist or scribe but also keeps the overall production cost down."

Groth continues, "When comparing an MTSO's methods to in-house scribes, there is a substantial cost savings when all factors are considered, such as staffing issues, PTO [paid time off], and insurance. Also worthy of consideration, the MTSO has a stored voice file in place that can be traced if ever needed for potential legal purposes."

For professional transcriptionists, efficiency can be accomplished by utilizing template builders, patient metadata interfaces, auto-insertion of repeated text, speed typing, spellcheckers, internet resources, and more.

Meanwhile, it's unlikely physicians, behavioral health counselors, and clinicians responsible for their own documentation have these tools at their disposal. These professionals must ask themselves whether they're working efficiently. How can clinical documentation be easier and less time consuming, but still include the necessary specificity? Will the addition of speech recognition to the EHR eliminate the need to type notes manually?

Regardless of your role in the health care continuum or how you complete your clinical documentation, the goal is to accurately document without adding provider stress or limiting patient encounters due to time spent documenting.

Documentation Complexities
Depending on the interactions with the EHR and the use of machine and human resources, there are opportunities to make clinical documentation less stressful. In the clinical setting, self-documentation into EHRs backed by workflow and embedded tools—most importantly, speech recognition—can be useful.

In front-end speech recognition, users talk, edit, and sign. However, speech recognition can be fraught with errors. As a result, users who read and correct every word may spend more time on clinical documentation compared with traditional dictation and human transcription.

Other factors add to the complexity of documentation. For example, clinicians, practitioners, and mental health specialists are not always working in a hospital EHR. In fact, many work in more than one EHR. Additionally, clinical documentation can be delayed due to traveling between locations and being away from the desktop.

In these situations, how can documentation be more efficient? Investing in workflow products that are mobile and smart enough to use both front-end and back-end speech recognition is one possible solution. Front-end comes into play when users are sitting at their PC, while back-end with a mobile device allows providers to dictate notes while the encounter is still top of mind.

When incorporating smartphone mobile dictation, providers can dictate notes throughout the day as they work. Encrypted provider voice files travel into the cloud, where back-end speech recognition converts the voice into draft text. When providers return to their desks, they can review, edit, and sign the transcribed notes before moving the reports to the EHR. This is especially beneficial for providers in home health settings and multilocation physician practices.

Some EHR vendors have realized that providers do not want to use speech recognition at all, or at least not exclusively, and have begun to offer integrated transcription services. Providers can choose to use front- or back-end speech recognition, review, edit, and sign, and still have the option to "send to quality assurance," where a transcriptionist can edit selected notes. After all, what is the best use of a provider's time—typing or seeing more patients?

Market Reaction
Recently, vendors have been focusing on a broader base of providers. For example, providers using specialized services, especially in the growing field of behavioral health, are finding EHRs to be both beneficial and problematic.

Mike Perriccio, CEO of C3HealthcareRx and MindHealthy, says technology can help alleviate the challenges these providers face when documenting patient encounters. "While using our EHR, clinicians can easily document their encounter. Moving that documentation into another EHR can be difficult. Not only have we developed workflow that supports the movement of patient notes easily into disparate EHRs, we [also] have incorporated tools into our platform to make it more efficient to create the documentation," he says. "These tools include the use of speech recognition, smartphone apps that include dictation, and cloud services to support our customers when they are away from the office."

As health care professionals spend more time on clinical documentation, IT directors, software providers, and MTSOs must search for better ways to accomplish accurate EHR note creation without causing burnout. Software developers and MTSOs have responded to the trend of provider self-documentation by adding flexibility to their offerings.

To ease individual and organizational stress levels, health care administrators would be wise to focus on their organization's particular workflow. As the number of health care organizations with hundreds and even thousands of providers increases, it's unlikely that a single documentation offering will be a fit for each provider. A more beneficial solution might be a system flexible enough to include front-end and back-end speech recognition, human transcription, and front-end notes edited by a transcription team, working together with the EHR.

— Delbert L. Arrendale is CEO of Arrendale Associates, Inc.