August 6 , 2007

Transcriptionville: In Search of Uniformity
By Robbi Hess
For The Record
Vol. 19 No. 16 P. 10

Currently, individual healthcare organizations determine their own format requirements. Learn why it’s important to standardize these documents and how such a change could be accomplished—if at all.

One size fits all may not truly fit everyone, but one size fits many could be a more plausible solution—not only for clothing but also as it relates to standardizing healthcare document formats for transcription.

Brenda Hurley, CMT, FAAMT, writes in “Standardizing Healthcare Formats” that “standardization is important in our professional and personal lives. When we make purchasing decisions for standardized items, we can do so with confidence that they will fit and work for our needs.”

When it comes to format standardization in the medical transcription world, consensus appears light years away, but transcription professionals agree it is necessary sooner rather than later.

Getting on the Same Page
Standardization of “mundane” items such as margins, headers, and footers is not even a practice that professionals can agree on. “There should be a single decision on how a document is supposed to look,” says Jim Lucas, chief operating officer for American Transcription Solutions, Inc. (ATSI).

ATSI CEO David Shepard agrees: “If we had a standardized document, we would be able to standardize the interfaces. With something as simple as an MRI report, we know of four different electronic interfaces that are based on the way the reports have to be formatted for the different groups for which you are transcribing. All transcription companies are faced with writing new interfaces to be compliant.”

While the need for standardization is clear, Roger Kelton, ATSI’s marketing director, says he recently sat in a meeting with 10 radiologists and listened to them argue over the definition of a word. “There is a hodge-podge of forms, and they are all being put together to cater to the unique preferences of the individual doctors,” he explains. “Forms aren’t even the same within the same facility.”

Hurley says there are more than one hundred ways to do a history and physical (H&P). “The MT [medical transcriptionist] needs an encyclopedia of rules to transcribe one simple H&P,” she explains. “If the MT makes a mistake and puts a double space after diagnosis for ‘Dr. Smith’ because his text starts after only one return, the MT bears the brunt and is accused of poor quality work.”

Hurley says standard reports or templates for the radiology department should be easy to institute. However, she cautions, it’s not just about standardizing forms; there should also be standards to provide procedural consistency and proficiency in performance and processes. This would save time and aggravation rather than repeatedly taking resources to “reinvent the wheel.”

“There are standard, routine reports for a normal x-ray, but very few radiologists will agree on the same ‘normal’ chest x-ray. There are too many ways of reporting and storing routine test results,” Hurley says.

To bolster standardization efforts, there are several organizations that focus on healthcare documentation and informatics, including the American National Standards Institute (ANSI) Health Information Standards Board, Health Level Seven, the Workgroup for Electronic Data Interchange, and the American Society for Testing and Materials International. While these organizations have “rules” to follow that are established by the ANSI, the standards often put forth are generally considered “best practices” or guidelines for practice rather than cut-and-dry rules.

Tackling the Problem
There is not a single entity that could—or would—undertake the task of standardization. “To address the problem, everyone would have to be on the same page—or if not everyone, a vast majority,” Lucas says. “It would likely have to be a mandated process.”

Kelton believes it would be a logistical nightmare to take on the enormous task of standardization. “It would have to be on a national level and industrywide in order for it to work,” he says. “Even when the time and money savings of standardization are factored in, it still isn’t enough to get everyone to the table with a solution.”

From an operations standpoint, Lucas says MTs would become more efficient if they knew that report A would always look one way, and report B would always look another way.

The Bigger Picture
Kelton says as the healthcare system moves toward electronic health information systems such as regional health information organizations (RHIOs), it will be necessary to have standardized forms and procedures in place.

“A RHIO is based on the premise that healthcare organizations are trading information back and forth between entities, and to do that efficiently, you need a standardized template,” he says. “As RHIOs grow and build around the country, that may be the catalyst that drives standardization.”

In an increasingly paperless environment, Shepard says it would be ideal to have standardized methods of storing information for easier retrieval.

“Information could be personalized for an individual health system if they want to incorporate a logo, but having the information stored in the same format throughout would make it easier to pass that information between healthcare provider groups and healthcare systems,” he says.

Hurley’s concern is that the many differences in dictation formats hinders patient care. “It is difficult when you consider that items such as vital medications or allergies aren’t even located in the same sections of the report because of the individual doctor or department format preferences,” she says.

What’s Wrong With the Status Quo?
The bottom line is that electronic interfaces within and outside hospital systems interact and store data differently in each location. “These systems increase the overall price of the product to the consumer by causing additional time being spent building and tweaking the various transcription systems because you have to uniquely build formats and forms for each client you are working with,” Kelton explains.

From a sales standpoint, companies point out that healthcare organizations would be more effective and could function more economically if there were “normals” in place for information. “Right now, transcription companies have to tailor and individualize information for each client and that adds to the bottom line,” Kelton says.

“It costs more money and time to have to create hundreds of formats and rule books [instructions] for the MTs to follow the individual physicians’ preferences,” Hurley notes. “Because the MTs don’t have access to the individual dictator, they have no way to discuss their format differences in reports. There is a disconnect, and perhaps the doctors don’t even realize how big of a deal the differences really are.”

Prior to the proliferation of electronic medical records, healthcare facilities relied on preprinted forms, which alleviated some of the issues being faced now. “At one time, the medical record committees would gather input to develop forms. They would work hand in hand with physicians to set up forms and formats. But now it’s electronic, and formats are put together on the fly,” Hurley says. “It’s gone berserk now as it appears that there is no longer a formal process to get a format approved.”

HIM directors and those in charge of hospital finances should recognize the business end of the equation and the costs related to the myriad of formats associated with transcription. “It’s just not cost-effective to maintain all of the preferences required to accommodate each department or physician’s requests,” Hurley says. “HIM departments are looking for better, more efficient ways to deliver communication, ways to improve patient safety, and methods of cutting costs. Simplifying how information and data are exchanged and stored is one step in the right direction.”

Standardization wouldn’t change physicians’ pattern of dictation, Hurley notes. “Dictators could be provided with dictation templates or guidelines and a ‘be sure to include this information’ in a dictation. It wouldn’t really have to change their workflow as the formatting of transcription could be done behind the scenes by the MTs so that it would conform to specific established guidelines,” she says.

Making Standardization Happen
The global issue of nonstandardized forms and formats seems insurmountable when measured against the idea of nonstandardization within a single healthcare system. “Even across internal hospital lines there are disconnects,” Lucas says. “Individuals are fearful of losing their identities.”

It’s all about individual physician and department preference, Kelton says. “One of the things physicians hate is change. They want to see things done the way they have always been done,” he says. “Making changes causes stress. They have become accustomed to picking up a report and knowing where to find certain information, and no one doctor has stepped up to the plate and offered to tackle the problem; it would involve buy-in from all levels of the hospital.”

Mandates from a transcription company or the transcription industry would not be well received by physicians. “They aren’t likely to change their ways unless they are forced to,” Kelton says. “When the industry went from handheld tape recorders to digital recording, we had to literally pry the handhelds from the physicians’ hands.”

It would not only take a Herculean effort to make standardization a reality, it would likely need governmental mandates. Kelton believes if standardization were to happen, it would take years. “It could take anywhere from 18 to 48 months depending on how much buy-in you got from each hospital, clinic, practice, and physician. Without mandates, it would be doomed because it’s not something that will likely be done voluntarily,” he says. “The biggest stumbling block would be simply getting everyone to agree on one format. There would be battles not only between departments but through various regions when you are looking at implementation of RHIOs.”

Hurley agrees that standardization of reports is necessary as the industry keeps moving toward electronic health record implementation. “Imagine how much simpler life would be if information could be shared and stored in a reasonable way so individuals could pull the data necessary,” she says. “Standardization is going to have to be forced on people, but it’s necessary to move in that direction so we can more efficiently exchange data. RHIOs are a prime example of why having reports with standardized formatting and layout [is a good idea].”

Being proactive and moving toward standardization within one’s own healthcare enterprise would also make sense from a coding and billing efficiency standpoint. “Making the reports easy to read and critical information easy to find should be a priority,” Hurley says.

Bottom Line
“As we progress forward with electronic medical record systems, these systems must communicate back and forth, and to do so, there must be a standardization,” Kelton explains. “It’s like having individuals in a room who speak Spanish, French, and English—unless there is a translator, nothing will be understood. Having standardized formats helps translate the information being transmitted between platforms.”

What’s really important, Hurley says, is not that the doctor or transcription manager says the report must be double spaced; rather, it should be about having the correct information within the report. ”The enormity of the rules that the MTs need to follow before they even transcribe the first word is overwhelming,” she says.

Hurley says the healthcare system as a whole can no longer afford inefficiencies. “If there was a reason to keep the status quo [as it relates to the lack of standardized healthcare document formats], I would applaud it. But this isn’t the case,” she says. “The situation doesn’t provide an ounce of better healthcare. It may cause other healthcare professionals to miss critical information located in nonstandard locations within a report. It bogs the MTs down and distracts them from turning around reports faster and emphasizing the quality of the information contained within the report rather than focusing on a multitude of individual format style preferences.”

— Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.

The Value of Conformity
In “Standardizing Healthcare Formats,” Brenda Hurley, CMT, FAAMT, offers several of the key benefits of standardized healthcare documents, including the following:

• facilities sharing information within and among data systems;

• serves as a guide for healthcare providers in the collection of essential data elements;

• promotes greater efficiencies in report generation, no matter how the data is captured;

• expedites the identification and selection of pertinent information needed for communication among members of the healthcare team and for services such as coding and billing; and

• allows for an easier transition to the electronic health record.

— RH