March 15, 2014Page | 1
Report to the Joint Commission
on Healthcare Documentation
Objective
To provide further documentation substantiating the need for Joint Commission to adopt dictation and transcription standards in healthcare institutions.
Prepared For
Marion Panagopoulos (Amy)
Daniel Castillo, MD
Mary Brockway
Rachele Zubik
Prepared By
Debbie Schwarm
Contact Information
Website:
Facebook:
Twitter:
Table of Contents
Initial Email
Joint Commission Discussion
Discussion Notes
My Assignment from You
Followup for The Joint Commission
Petition
Open Letter to The Joint Commission
The Juno Case
Proposed Standards
Recommended Industry Standards and Best Practices
Final Comments
Initial Email
From: Debbie Schwarm [mailto:
Sent: Thursday, June 27, 2013 12:04 AM
To: Panagopoulos, Marion
Cc: 'Debbie Schwarm'
Subject: Standards Request
Ms. Panagopoulous:
I am a medical transcriptionist.
I worked in hospital quality improvement for over 20 years prior to this work, and worked closely with JCAH survey preparation in that capacity. Eventually, I began to do medical transcription as a means to provide an income while I pursued a career in website development. I quickly became appalled at the activities going on in this industry. It is my belief that the current behaviors of this professional group are not contributing to quality documentation in the medical record. There is no true quality improvement analysis in this work, there is no required certification or skills analysis of people doing the work, there is no professional organization that regulates transcriptionists or has any leverage in assuring the quality of healthcare documentation; the current organization, AHDI, is an educational organization, but holds no enforcement powers.
By my analysis, this is the only document-producing industry that does not appropriately proofread its work; important documentation that it is. In my own position, my company looks at only THREE of my reports per month. There is a business model now in place which removes the accountability one step further from the hospital; the MTSO (medical transcription service organization). These companies usually ignore labor laws and have few safeguards in place addressing HIPAA mandates. Their focus is monetary, their methods lack quality focus. The institution of them is frequently diluting access to quality further. Rather than continual improvement of the quality of the medical record, each day the industry engages in increasing efforts to save money which results in less focus on quality.
I am near to launch an online medical transcription website (). I also have a community of over 3200 transcriptionists engaging in important discussions on Facebook. As a group, we are beginning to take on these issues with various entities to address rampant labor law violations, for one. We are also interested in finding out how our community might work with the Joint Commission in reviewing the current medical record documentation standards. We believe the current industry trends are not serving this important document and that our insight would prove useful to improve the quality and appropriateness of the medical record.
Because of my personal participation and knowledge of Joint Commission processes, I feel this is exactly the organization that would be interested in working with us to mutually improve the quality of healthcare documentation. I am not afraid to roll up my sleeves and do the important work it will take to ensure these changes and bring a new level of quality to this important healthcare process.
I understand this may be a unique request, but I feel it is important and look forward to hearing from you about what we can do to effect important change in the industry.
Joint Commission Discussion
The discussion of July 23, 2013, between Debbie Schwarm and The Joint Commission officers is described below.
DATE:
July 23, 2013
PREPARER:
Debbie Schwarm, Medical Transcriptionist
Creator: MyMT.me, an online medical transcription community of 3392.
PURPOSE OF DISCUSSION:
To provide an overview of medical transcription industry quality issues to the Joint Commission for the purpose of examining potential opportunities for improvement, to include standards development. There is currently no organization managing and enforcing the dictation and transcription processes.
BACKGROUND:
As a former hospital quality improvement analyst for 20 years (1975-1995), my duties included close work with Joint Commission Survey preparation, to include the development of QA programs from the ground up in five Portland-area hospitals and two military hospitals in Saudi Arabia. In 1995, I made a career change, accepting a position as an operations manager for a high-tech company. Eventually, I came to do medical transcription as an income source, desiring to develop website communities.
I was immediately faced with an unending stream of mistruths, illegal proceedings, almost no evidence of systems management, and an utterly chaotic industry. Not uncommon in the culture, I suffered physical, mental, emotional, and financial fallout doing this work. As technology advances, there continues to be no evaluation of the processes, decisions being made by assumptions, the MT frequently shouldering the financial and quality responsibility for many. I decided to do something about it. It is not acceptable. I currently have 3392 community members (and growing), and we are prepared to begin examining ways to improve the medical dictation and transcription process with intention and organization. My concerns are summarized below, and I am honored to have been given this opportunity to discuss them with you. There is a lot of information contained here. It includes data not specific to Joint Commission functions, but I do believe it all contributes to the quality of the medical record. I believe a global picture of the industry is vital. During today’s discussion, I would like to introduce myself and present a summary of the information to you for your perusal, and to determine future action.
A report that was prepared for this meeting, including perceived problems, discussion, and results of an informal survey, is available here.
Discussion Notes
THE ROLE OF THE MEDICAL TRANSCRIPTIONIST: During the conference call, I clarified the role of the transcriptionist. As a recap, the medical transcriptionist listens to a dictation of events by healthcare providers (usually physicians, but also extenders[LLB1]) in the form of discharge summaries, consultations, histories/physicals, and operative notes, to name a few. The report is typed transcribed by the transcriptionist and uploaded to the facility. Sometimes this is done by transcriptionists working on site. A current trend is to have the work outsourced to an MTSO (medical transcription service organization). These workers transcriptionists generally work from their homes. Some of the work is being offshored to other countries, India being the most prominent location. Of particular concern is that there is currently no body organization that regulates the process by through which dictation and transcription of healthcare documentation takes place. As a result, the rules are as varied as the many companies managing these processes, including and includethe input from vendors of dictation and transcription equipment and software. An example of vendors influencing the standards and processes this can be found here in this excerpt from a manual published by a vendor’s product called Fusion.a Fusion manual.
This resultsVendor influence, which favors productivity, results in the processes often being financially focused as opposed to being quality focused, and the importance accuracy of documentation being determined undermined. by questionable entities.
SPEECH RECOGNITION: We also briefly touched on how speech recognition products enter into this picture, Dragon being the most familiar one to people. In most situations, the healthcare provider dictates a report, a speech engine interprets the dictation, into creating is what is called a "draft." The draft is then usually edited by a medical transcriptionist while re-listening to the dictation along the way, though, and this is important, some facilities are using the draft with no human editor. Instead of typing the report on a “blank canvas,”(as in traditional transcription) the transcriptionist edits the draft that usually contains some rather interesting interpretations. Here is a real partial draft from my own recent work. Training the speech engine is a significant part of this process. This is a poorly trained speech engine, but this is not an uncommon draft output.
"A 42-year-old male who she was HIV positive nodes noted that most actually DC a complaint of continued sac mental left eye pain fall 60feet5inches to 5 to 6 days. He also states some visual loss in the left. There is very beginning on day so that we have been going on fall so this had not been on for a couple of days he decided to have this checked out by Dr.H L and D S on the essentially soft flexible leg edema. The ABI LAD EMS in the left side. He was sent for an followup physician to observation unit for subsequent subsequently had MRI of the brain that showed he had likely of the right feet in the left Celsius and off past medical history is --remarkable for Crohn disease and HIV diagnosed in March of this she year hospital because patient was admitted use of the days of the radius reactive. We also checked at HIV which all of them come back as a 2 week consulted infectious disease on Associates that placement include neuro systole is all plus the right face and diagnosis and was HIV patient was started on 20 fall medial units of penicillin G q. 25 was patient IUs to receive nasal 14 days. This will be completed on December and during his acne showing a cecal line was placed for outpatient therapy. Patient to follow up with their with followup at the HIV Clinic an ID off his office for his labs and also a fall. He has ongoing IV therapy and return for both of her out of the arm was all this is 1 on patient was complaining of pain on his left side affects use the day he stated that the number to be on it and feels 1 to 10HU. The patient denies any more pain on his left knee from his left to right eye lateral signs and was ...... "
The intention goal of utilizing speech recognition products technology is to be quicker increase productivity, resulting in cost savings. It requires a very diligent implementation process, however, to meet those goals. In most many cases, transcriptionists can transcribe reports faster from scratch than from editing errors in computerized drafts. You can view survey results to validate this statement in the Joint Commission Summary I provided. It is important to note once again that there are even some healthcare facilities utilizing speech recognition output with no human editor. Recently, one of my community members offered this as an example of how one hospital is handling their radiology reports:
"Portions of this record may have been created with voice recognition software. Occasional wrong-word or "sound-alike" substitutions may have occurred due to the inherent limitations of voice recognition software. Read the chart carefully and recognize, using context, where these substitutions have occurred."
ELECTRONIC MEDICAL RECORD: I have less exposure and knowledge of the things that are ailing those involved in the electronic health record (EHR) rollout, but I believe its implementation process cannot be ignored in this discussion. It's another entity that is determining how our medical documents are produced as opposed to an entity concerned about patient safety and quality of healthcare. If we are successful in getting your attention to these matters, certainly an in-depth discussion of current EHR implementation issues will be relevant to addressing quality documentation in our healthcare system. I do know that our professional organization's CEO, Linda Brady, attended the High Reliability and Quality at The Joint Commission Liaison Network Forum and reported on the discussion here.
Jill Devrick, President, AHDI, added these comments to my inquiry.
A pertinent article in Forbes can be found here.
My Assignment from You
At the conclusion of the conversation, it was requested that I obtain some data supportive of the claim that I believe some standards development is in order. Please find this information in the next section, Followup for The Joint Commission.
Followup for The Joint Commission
In response to our discussion, I constructed a petition utilizing the online petition platform Change.Org. Here is a link to the petition. ClickHere.
The intention of the petition is to request obtain comments and signatures from other medical transcriptionists who are requesting that The Joint Commission develop dictation and transcription standards. It represents a poll of our then, approximately 3500 Facebook participants, some being reluctant to publicly speak out.
Petition
As medical transcriptionists, we are the only members of the healthcare team who hear the dictation from healthcare providers and translate them into text. We are the front-line, patient-care team member who understands what is unfolding in the healthcare documentation arena. Please hear our concerns.
In a time when we are rapidly advancing in medicine, we have watched an important process be annihilated by ever-anxious speech technology vendors and financial officers pressuring for constant and unsafe cost savings. What has resulted is a fragmented industry operating with questionable practices, little accountability, unmanaged outsourcing and offshoring. The technology CAN be used wisely as a useful tool; however, there is currently no authoritative body overseeing its implementation or the management of other documentation processes.
-We understand the Joint Commission to be a regulatory agency whose task is to assure the American People that our healthcare institutions provide safe, effective and appropriate healthcare.
-We understand the Joint Commission to advocate for the quality and appropriateness of healthcare and to impose regulations for the continual monitoring of patient care, while demonstrating continued improvement with a keen eye for sentinel events. We believe there is evidence of the need for both ongoing monitoring of transcription processes, as well as sentinel events in transcription.
-We understand the Joint Commission to place an emphasis on patient safety in areas directly related to patient care, with less focus on supportive roles, such as medical records and medical transcription, housekeeping, central supply. We believe the documentation role is an extremely important process and is not being managed by specific indicators or quality thresholds.
-We understand the Joint Commission to actively mandate documentation standards, but no standards about the process by which this happens. We believe this is unsafe.
As a community of medical transcriptionists, we petition the Joint Commission to partner with us in developing standards to address the transcription process and how its current evolution is dangerous and has the potential to adversely affect patient care. We are concerned about the lack of process management in domestic and offshoring work, of the over reach and over sell of current speech technology, misapplied by many, in some instances the entire elimination of a human interface.
As our nation embarks on a new technological era in healthcare, to include the mandation of the electronic medical record in some settings, we believe this deserves the most urgent attention. It is our understanding that our professional and educational organization (AHDI) is currently preparing to provide the Joint Commission with some requested data. As an adjunct to this, the medical transcription community also wishes to have a voice.
Petitioners, please comment respectfully to the officers of the Joint Commission and assist our effort with your objective comments and examples. The most useful information for them will be specific examples of issues you encounter as a documentation professional. If you are unsure of the implications of the petition or if you are hesitant to sign for any reason, please feel free to contact me . I am interested in your input.
Petition signatures and comments can be found here.
.
Open Letter to The Joint Commission
Laura Bryan, a respected member of our transcription community provided an eloquent description of industry concerns. Please review her passionateplea here.
The Juno Case
The Juno case represents a sentinel event for the transcription sector. In this case "A documentation error, perpetuated by questionable hospital policies and a series of even more questionable clinical decisions, resulted in the inarguable death of a patient." An article describing the case can be found here.
Proposed Standards
With the assistance of Laura Bryan, I made a list of potential Joint Commission Sstandards, processes, and guidelines for the Joint Commission to considerconsideration:
- Require medical transcription staff to be certified in certain facility types, report typesto perform assigned work.
- Require medical records/transcription departments to have CQI processes in place like other hospital departments in which the quality and appropriateness of services is defined and measured with the aim to identify problems and continually improve processes.
- Determination Establish of proofreading requirements.
- Establish Aan educational process and feedback mechanism tofor dictators to improve dictation quality.
5.Requirements addressing dictation/patient privacy issues[LLB2].
- Requirements addressingAddress the use of outsourcing and offshoring. workers.
- Require the use ofConsideration of Enforcement of AHDI's Book of Style for Medical Transcription.
- Rules delineating acceptation of Establish guidelines for implementing dictator style preferences.
- Establish technology standards (e.g., EHR interfaces, cell-phone usage).
- Require facilities to assure that contracting The use of transcription companies operating operate within wage/hour, work-at-home, OSHA adherence, and other labor laws.
- How to handle Establish guidelines for handling discrepancies, blanks, and the inappropriatenessuse of verbatim transcription, clarification with dictator.
Our professional organization, The Association for Healthcare Documentation Integrity, the professional association representing medical transcriptionists, already has many Best Practices in already in place.