May 12, 2008

Times Are Changing
By Selena Chavis
For The Record
Vol. 20 No. 10 P. 18

A collaborative between MTIA and the AHIMA, the report provides guidelines for the timely delivery of transcribed reports.

In April, a joint task force created through the Medical Transcription Industry Association (MTIA) and the AHIMA released the findings of its anticipated Turnaround Time for Common Document Types (TAT 4 CDT) study. Born out of an ongoing initiative between the two groups to address the need for standards in healthcare documentation, the task force has a white paper pending final approval that provides definitions and findings for TAT and demonstrates how the complexities and elements that go into TAT affect clinical decision making.

“The evolution towards the EHR [electronic health record] seems to be driving the need for faster turnaround times,” says Susan Lucci, president-elect of the Association for Healthcare Documentation Integrity and a TAT 4 CDT task force member. “Our research revealed that there is a wide range of TAT in the industry, which equates to everybody doing their own thing.”

The completion of the study comes as the second part of a three-pronged effort to define key industry standards, with the hope that the findings will provide a framework for useful dialogue regarding future best practices and benchmarks for quality documentation.

“There really have been no standards in place,” notes MTIA President and Webmedx Chief Operating Officer Jay Cannon. “Really what this task force desired to do was provide a recommendation … to have a starting point for dialogue. I think we are going to have a document here that is a useful tool to improving clinical documentation.”
According to Lucci, the study revolved around the TAT experiences of HIM directors and managers of healthcare facilities, as well as supervisors and managers of medical transcription service organizations (MTSOs)—specifically, whether the current state of the industry meets their needs.

The task force also sought to gain a better understanding of challenges facing the medical transcription industry, including financial concerns, the offshoring movement, and the electronic healthcare delivery movement.

Industry statistics reveal that TAT can range from an almost immediate response to 72 hours. Contributing factors include the use of domestic and offshore talent and the implementation of new and evolving technologies such as automatic speech recognition software. With so many variances in delivery and no clear standard, Cannon says it has become increasingly difficult for providers to have intelligent, TAT-related dialogue.
Through the delivery of the TAT 4 CDT white paper, the task force hopes to improve that dialogue. Findings from this study have revealed based on weighted averages that major work types range from 24 hours for a discharge summary to four hours for a radiology report. (See Time Tables sidebar for more details.)

“The TAT 4 CDT effort is specific to define appropriate TAT requirements based on the needs for providing care. It will allow the industry to say what reasonable expectations are,” says Dale Kivi, MBA, head of business development for California-based FutureNet Technologies, who adds that in an industry facing rapid changes, the TAT 4 CDT findings will hopefully level the playing field between providers to some degree.

Two Down, One to Go
To understand the need for TAT 4 CDT, Kivi believes it’s important to understand the broader scope of what MTIA and the AHIMA are trying to accomplish from a standards perspective. Pointing out that there are three major components contributing to success in the industry—cost-effectiveness, TAT, and quality—Kivi notes that initiatives have been launched to address all three.

“[TAT 4 CDT] will be the second white paper jointly released by AHIMA and MTIA,” he says, pointing to the visual black character (VBC) white paper released last year that recommended a standard for character measurement and costing.

The 2007 white paper, “A Standard Unit of Measure for Transcribed Reports,” recommended the VBC method for medical transcription with the hopes of providing a costing model that could be applied to all types of medical reports and various technologies.

“There’s been a significant improvement in the clarity of volume measurement [due to last year’s study],” Kivi says.

Regarding the need for these standards, last year’s white paper says that “success in developing a standard adopted by all players in the industry and universally applied by all would result in improved business relationships between healthcare organizations and medical transcription companies. It would provide transparency for the industry thus allowing for more objective decisions concerning medical transcription based upon better understanding of costs and cost comparisons. It would also enable buyers of medical transcription to focus on improved value propositions and to better differentiate between medical transcription suppliers once the cost has been easily determined.”

In much the same way, Kivi says the industry is hoping to improve patient care and revenue stream by also addressing TAT and quality. And with the TAT 4 CDT report now under final review, a study is currently underway that will provide recommendations for more definitive standards for measuring quality and addressing related issues, Kivi says.

Cannon believes the joint task force was able to leverage its experience in developing the VBC white paper to bring about a useful document with TAT 4 CDT. “This is a topic that could have very easily turned into an academic exercise that could have resulted in no finite conclusions,” he says.

Lucci adds, “[TAT 4 CDT] is going to create an environment that improves understanding of the impacts that influence TAT and the framework by which healthcare facilities can implement a project to improve TAT based on their own unique organization’s needs.”

Efficiency at What Cost?
While task force members and proponents of TAT 4 CDT are quick to point out that the goal of the TAT 4 CDT effort was to improve dialogue for addressing healthcare documentation needs, Cannon acknowledges that current struggles within the industry over some unrealistic expectations for TAT have fueled the need for an industry standard.

“What we saw in the industry was a demand for more rapid TAT,” Cannon says, adding that increased efficiency often equates to higher production costs to maintain quality standards. “Everybody would like to have more rapid TAT, but the reality is that costs are getting higher.”

Kivi agrees, noting that “both overseas talent and speech recognition have added increased competition in the industry,” which leads to “increased expectations from providers for decreased cost and TAT.”

Suggesting that the entire decision falls into a value proposition, Cannon says the discussion comes down to finding the balance for acceptable quality at a reasonable cost. “The [task force] established a correlation between cost and the performance standards that currently face the industry,” he says. “I think what this is going to do is increase dialogue between the provider and consumer.”

Kivi says there are three major areas that a national TAT standard will help improve: patient care, Joint Commission expectations, and revenue stream. As for the financial aspect, he notes that TAT specifically has a direct correlation to discharged not final billed (DNFB) in hospitals.

“TAT for transcription can positively or negatively impact DNFB,” Kivi says. “Industry pressures to look at this issue will provide [Joint Commission] standards to measure by, and it has the added effect of ensuring DNFB does not become a problem.”

Lucci says it should also provide some leverage for HIM professionals, presenting the opportunity to raise the bar for improvement. “It often depends on your facility’s needs,” she suggests, offering that the study reveals that wide variances in TAT are often directly linked to environment. “Is it urgent care or are you a smaller community hospital where the urgency just simply isn’t what it is in a big metropolis? [Establishing TAT standards] can provide validation for whether you are doing well or not.”

Kivi adds that variances in TAT between healthcare organizations and MTSOs are often driven by the HIM director’s experiences and physician expectations. “It might be 24 to 48 hours in one facility. In another, it might take six hours for the same work type,” he says. “That doesn’t make either side of those bookends of expectations right. TAT 4 CDT helps to identify what’s appropriate.”

Unchartered Territory
Setting the course for this study was no small challenge, according to Lucci, who recalls a process that built on itself as issue after issue surfaced. “Once you start peeling back the onion on the topic, our onion kept getting bigger instead of smaller,” she notes. “What we found when we set out to do this was how very little data and research were available.”

Comprised of seven AHIMA representatives and six MTIA members, the task force included key leadership from major transcription and HIM associations, transcription technology and service vendors, hospital HIM directors, and a student intern. Alongside representation from the task force, the TAT 4 CDT recommendations have also been sent for review to The Joint Commission and the American Medical Association.

Applauding the makeup of the task force, Cannon says, “We were very intentional about looking at the current environment that exists.”

Lucci concurs, pointing out that an environmental scan of HIM professionals and MTSO leadership was key to getting the process off the ground. “The first thing we wanted to do was establish a survey. We asked a lot of fact-finding questions to determine similarities and differences,” she says, adding that the task force was then able to discuss the active role of healthcare documentation. “What’s the workforce situation? It’s not a static number—the number of patients, reports, and users is constantly changing.”

In an effort to understand the complexities of the healthcare industry, Lucci says the task force tried to consider all the groups impacted by TAT and balance those needs against the needs of the financial departments and administration. “Whether in-house or outsourced, there are still some high costs involved,” she notes, adding that differing requirements among different types of healthcare environments also created a need to establish steps for implementing best practices at a “particular facility.”

“We want you to be able to read through this and come away with a basic framework of understanding and then be able to have a meaningful dialogue,” Lucci says, emphasizing that the findings are a first step toward standards. “Here’s your frame of reference that fits the model. Now, individualize it for your specific purposes.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

Time Tables
Along with more detailed best-practice provisions, the Turnaround Time for Common Document Types white paper pending approval by the AHIMA and the Medical Transcription Industry Association Joint Task Force on Standards Development provides recommendations for turnaround time by major work types. Their findings from research and survey data compiled based on a weighted average formula are as follows:

History and physical	8 hours
Operative report	8 hours
Discharge summary	24 hours
Inpatient progress note	8 hours
Consult	12 hours
Radiology	4 hours

Behind the Recommendations
According to Susan Lucci, president-elect of the Association for Healthcare Documentation Integrity and a Turnaround Time for Common Document Types (TAT 4 CDT) task force member, a number of findings from the study were key to the development of the TAT white paper. Some of these findings include the following:

• Medical transcription, including the editing of draft reports created with speech recognition technology, is currently the dominant and preferred method of creating narrative documentation in the U.S. healthcare system and is likely to remain a critical practice for at least 10 years.

• In many instances, fluctuating (unpredictable) dictation workloads and a critical shortage of skilled transcriptionists are factors affecting TAT.

• The evolution of the health record in emerging systems, such as electronic health records and personal health records, will increase demand for quicker TAT of patient information to achieve desired financial and clinical benefits.

• Speech recognition technology, which is expected to become more prominent in the documentation solutions marketplace, can enhance TAT under certain circumstances.

• Medical transcription production will continue to expand globally, which can improve TAT in some cases.

• Faster TAT on transcribed reports in cases where skilled workers are critical to the process will likely increase overall costs.

• Market adoption of TAT 4 CDT in which expectations are properly set and managed will improve patient care and safety and provide a more efficient healthcare operation.

• TAT 4 CDT must be readily and easily implemented, given today’s market realities, without compromising the future market’s demands.

• The dynamics of change in the marketplace require healthcare documentation standards to be reviewed no less than every three years, and more frequently if hospital organizations demand it.

• In all cases, regular dialogue between all constituents affected by documentation TAT will result in a better and more consistent outcome.

— SC