Documentation and Coding Burdens

Medical economics published a great article "The Perfect Storm" and Peter Basch provided some additional commentary on this article and how the perfect storm should mean the end to E&M coding. As he points out prior to 1995 physicians were not paid for documentation but paid for services rendered. The main driver in recent years has been generating sufficient documentation to support the E&M Billing code.

Fear of failing a coding audit has made many senior physicians unlearn documentation skills developed over decades, regardless of whether they handwritten notes, dictate, or use an EHR.

The process of delivering care has been hijacked for the purposes of creating billing codes. In fact diagnostic coding systems can be traced back to King Henry VIII reign and the adoption of ICD coding in the early 1900's for morbidity and mortality. The codes were designed to track reasons for death and have been hijacked in attempt to fulfill a range of other purposes.

Multiple calls for scrapping what is an unfair burdensome system have occurred

In 2002, the Department of Health and Human Services convened a committee that concluded almost unanimously that the E&M system should be scrapped. Among its conclusions: The E&M system was not a fairer way of judging physician effort than the previous self-attestation method, it failed to add any new value, and it added an unreasonable burden to an already overburdened healthcare system

The Medicare Modernization Act of 2003 recommended to the Secretary of HHS that pilots of alternate payment systems be conducted

Unfortunately we remain locked into a process that adds little or no value to the process of caring for patients. There is an opportunity to focus on the value of clinical documentation to contain useful information that helps in the care and treatment of patients.

This is the right time for the Centers for Medicare & Medicaid Services to reissue its call for pilots of payment and documentation schema without E&M coding requirements. This is the right time for physicians to reject the shameful organizing metaphor of E&M coding—"it's not what you do, it's what you document"—and replace it with a renewed focus on what our patients deserve: better healthcare

He's right - for the longest time the call to documentation has been about the coding and billing. We have an opportunity to demonstrate the value of rich meaningful clinical documentation. Instead of asking our clinicians to be data entry clerks filling in forms for the purposes of coding use existing technology and solutions to allow for the capture of rich detailed clinical content that includes the narrative but is computer interpretable. It is possible today - we have technology, solutions and a whole industry of medical knowledge workers that delivers much of what is required already. We can create the additional information necessary to feed the data hungry EMR as part of that process and as a residual benefit this information can feed a new payment system focused on delivering high quality efficient healthcare

Physicians Morphing into Data Entry Clerks

There is something wrong with the general positioning of technology in healthcare especially when you consider it relative to other industries. In no other industry do the most highly paid, skilled knowledgeable workers become data entry clerks. You don't find technology vendors working on optimizing the stock tracking systems to allow the CEO of Merrill Lynch to enter stock data in his financial tracking program.........

So, why oh why in healthcare do we spend enormous amounts of energy finding ways to make doctors more efficient in capturing data and entering that information into electronic medical records systems?

Philips Dowd, a former clinical associate professor of medicine at Brown University and an internist and hematologist suggests that these systems are not ready for prime time. The iHealthBeat site features a review of an opinion piece written by Dr Dowd for the Providence Journal: "Physician Says EHR Systems Turn Doctors Into 'Clerk-Typists" that places EHR's "where cell phones were at in the 1980s: primitive, proprietary and expensive".

Wrapped up in this piece are two major issues:

• Capturing the data
• Communicating the data

The capturing of data represents an ongoing challenge and the data hungry EHR's need to be fed. In fact much of the drive towards electronic records is being fanned by insurers who see this as a path to

reduce their billing costs and increase control over denials and prescription services

But as he rightly points out

patients found the [EHR] disrupted what had been a fluid, meaningful dialogue....the system offered little assistance and increased the time required to complete and record a patient visit

The process of interacting with a patient is an integral part of the clinical decision making and diagnostic process. Questions, answer and observation (dramatized to an extreme but not widely removed from reality in the clever series House on TV). Electronic systems have yet to facilitate this process and disrupt was has been meaningful and important element of patient clinical interaction. Dowd's summary brings this point home:

I see the [EHR] as the final stage in the forced metamorphism of physicians from thoughtful professionals to clerk-typists from the Katherine Gibbs School of Medicine

This is true and I heard in a recent discussion with a physician that his clinical interaction and the questions he asks has been changed as a result of the implementation of a structured EHR and data entry systems. With experience using the system he discovered that anything that was not covered in the "standard" replies available in the system cost him much more time......inevitably in a time pressured world he found himself not asking questions fearing a non-standard response from his patient and requiring a complex and time consuming additional data entry. The change from the widely used open ended questions to closed simple yes/no interactions is not likely to elicit more information or add greater value to the diagnostic clinical history taking.

Facilitating this data entry and voice enabling the capture of structured meaningful clinical documents cannot come fast enough. Technology can and already does automate some of this using Speech Understanding which understands words and their underlying context and meaning and output structured and meaningful clinical documents in Clinical Document architecture (CDA) format - or put another way The Full Healthstory that encompasses both the detailed narrative alongside the structured and encoded clinically actionable data necessary to drive the EHR and decision support systems. In addition the delivery of these structured documents are already available from many of the medical transcription service organizations (MTSO) who capture and produce CDA Healthstory documents. The Medical Transcriptionist is the knowledge based worker here to support and enable the clinicians to capture the information quickly, accurately and effectively. Right now many customers elect to receive text or word output but the rich meta data is available and health systems, doctors offices and physician practices should be asking for the Full Healthstory form their MTSO provider.

The challenge of communicating the data Dr Dowd rightly pointed out what every patient knows through the nauseam of multiple form filling activity in clinical offices

My brand can't speak to your brand or group or hospital

There is no sharing of data and information is repeated, recaptured and fails to be shared effectively between clinical teams. Walk into any clinical office and the first thing they do is ask you to fill in YAPF (Yet Another Paper Form) that contains much of the data you know is in multiple systems around the various clinical offices they have visited (an average Heart Failure patient visits 23 different providers per year). You can bet they fill out 23 or more different forms!

Once again the CDA concept allows for easy adoption and sharing of the full Healthstory. The standard encompasses all the elements necessary for good patient care, administration, reporting and research and importantly includes the narrative. You can download the Healthstory Q1 business update here (warning ppt download) and you can find out more about joining here. Everyone, patients, clinicians, hospitals, insurers and healthcare facilities should all be insisting on the full Healthstory

Speech Recognition and MT Compensation

Speech Recognition and its relationship to compensation took on a life of its own over at the MTChat message board in this thread titled MT Exchange: MTs and "Speech Wreck". There were strong words and a concerted attack on Julie Weight....Yikes! The confusion that ensued linking and even blaming a technology with poor business practices and in particular poor compensation models that appeared to be unfair missed the point.

But it was the posting by Jay Vance of XY Files in an MT World who posted a thoughtful response to some of the criticism being leveled at Speech Recognition in this posting "Is Speech Rec Wrecked" that even featured actual data (thanks for sharing this!) from a survey he conducted in 2006 of Speech Recognition editors. In fact the data presented was helpful in assessing the actual benefits (back in 2006 - a long time ago in technology terms!) that even then showed:

a total of 51% of respondents - saw an average increase in productivity of between 25% and 50%. This confirms the anecdotal information I had collected via informal conversations with MTs working as SR editors in a variety of situations on a variety of SRT platforms.

I don't think it is a stretch to assume that this must have gotten better and productivity has improved beyond this and for a greater proportion of editors. The survey included some review of compensation changes (there was a reduction in rate but hard to determine if this was a real reduction or represented a reduction in rate that was offset by increased productivity) and a final question on satisfaction with the technology:

31% said they were somewhat satisfied
26% said they were very satisfied. These two categories totaled 57%

Not great but better than average. Overall

there is a wide spectrum in terms of the impact of SRT on productivity, compensation, and overall satisfaction among MTs working as SR editors. Consequently, I don't believe there is enough objective evidence to conclude that speech recognition has proven to be a widespread disaster for the MT working class. As with any scenario involving people, technology, and money, mileage is going to vary widely. In my experience, there are simply too many factors that can influence productivity, compensation, and overall satisfaction with speech recognition technology to draw hard and fast conclusions about the impact SRT is having on working MTs on the whole.

And this was in part the point that Julie Weight was trying to make on the MTChat board - there are many factors and there is no use trying to stall the implementation of Speech technology - that trains has left, like outsourcing.

Both Jay and Julie make the point that this technology is in use and although I probably am a stronger advocate and believer in the Speech technology I think the overriding point here is that this can and should be a good thing for the industry. Reducing the labor intensive element of producing a report has to be a good thing....freeing up the medical editor to add value to the clinical information as part of the process of review, editing and validation.

Recognizing this is old data this gives us a good reason to update this information and there is a survey currently ongoing from MTIA that can be taken here and I would encourage you to participate. This is an extensive survey and needs input but if you don't have the time I put a 4 question survey here that. If you can spare the time please take the full survey, but if not I'd welcome hearing your responses.

Integrating Knowledge bases into Training Environments

Changing training is as much a part of the process of improving health care as is the implementation of technology. In many respects it can have more of an effect since influencing the upcoming generation of workers early, before they become set in the ways of the existing methods, will ease and promote transitions to new and more efficient tools and work process. This is a longer term strategy but one that will have a more persistent effect.

So the news that "Career Step" is integrating the BenchMark KB (Knowledge Base) into their training package for clinical documentation specialists bodes well for increased standardization and the provision of technical support tools to help with the process of verification of facts, clinical terminology, names of drugs and other elements of clinical documents.

The resulting output of trained clinical documentation knowledge workers (some 10,000 expected to be enrolled this coming year) will be fully fluent in using these resources and many others and be catapulted into the workforce equipped and more importantly experienced in using the latest tools for improved efficiency and accuracy of clinical documentation.

There is no doubt that new tools and technologies are going to change the way we practice and deliver health care. Providing access and incorporating this into training programs is a big step to moving our health care system forward along the path of improved, more efficient delivery of safer more cost effective medicine.

Medical Transcription the EMR and Speech Understanding

The Medical Records institute e-Newsletter from September contained an article by Claudia Tessier from the Medical records institute titled: "Medical Transcription and EMRs: Opportunity Lost?" that discussed the relationship between medical transcription and the electronic medical record (EMR). As the Claudia says:

...medical transcription offers a bridge to EMR adoption

But the idea that

the EMR offers the best opportunity yet to get rid of transcription and its concomitant headaches

Misses the opportunity for medical transcription and valuable data that is lost with the push towards the structured form based hunt and click style documentation. In a recent discussion with a clinician he lamented the loss of "the beauty and descriptive nature of medical language that has been used to describe medical conditions and image findings". Instead as he put it "we have turned detail rich clinical information into dumbed down fill in the blank cookie cutter reports" which do not reflect the richness of the information he wants to provide to his colleagues.

To date medical transcription is estimated to constitute 60% of the input into current EMR systems but that input is in the form of text blobs and not clinical data. The article goes on to suggest that:

...EMR vendors should ramp up their cooperation to create uniform integration. Let every one of the 300+ EMR systems allow dictation and let the market determine whether the related turnaround time, quality, costs, etc. (see below) are acceptable. Let users dictate on cell phones and dictation devices, or through laptops and tablets—whatever their preference.

Is spot on - the systems work and with better integration and more choices for input we open the doors to capturing input from our clinicians caring for patients and struggling to document for the benefit of communication with others members of the team as well as capturing sufficient information to be paid for the services they are delivering to their patients.

But this input is still not resolving the necessity to feed EMR's with clinical data which is essential for computer based systems to understand the information and be able to act on it. There are existing standards to hold and transmit this information including the Continuity of Care Record (CCR) which is "....working in collaboration with HL7 on the expression of ASTM's Continuity of Care Record content within HL7's CDA XML syntax and the seamless transformation of clinical and administrative data between the two standards.” - Rick Peters, MD

Transcription companies are already offering xml-based solutions that support structured output and the significant value this brings to EMR's is that this structured data has been checked and reviewed by medical transcriptionist/editor with expertise and knowledge to validate that content relative to the original dictation input of the clinician. More value from the validated data output from Medical transcription will make the transcription industry more of a partner and even more important in their contribution and ongoing role in the delivery of high quality healthcare.

So where does Speech Understanding come into all of this - unlike the traditional speech recognition technology which Hollywood conditioned us to expect far more comprehension on the part of the engine as captured in this classic clip from Star Trek IV - the voyage home where Montgomery Scott (Scotty) of the original series of Star Trek fame is trying to interact with a computer circa 1980.....

But his experience is typical of traditional speech recognition systems and a typical response either visually or verbally would be "Directions unclear - please repeat request"

Speech Understanding is the next generation of the technology, crossing the chasm between the need and desire of physician to dictate using all the richness and expressivity of language but that is recognized and understood and not only creates an accurate representation of the free form text but also produces a structured and encoded document. Structure is captured and stored in native CDA format and encoding is achieved using clinically relevant encoding systems such as RadLex for radiology, RxNorm for drugs, Universal Medical Language Systems (UMLS) and SnoMed for clinical terminology etc

You can have the best of both worlds and Medical Transcription will be around for years to come - albeit in a updated MTv2.0 form where the transcriptionist is a knowledge based worker proofing, editing and validating clinical data......so in the words of Spock: "Live Long and Prosper"