Production Pay and Revenue Cycle Management

AHDI has published a position paper that was released at the annual convention in Indianapolis earlier this month.  In this paper, the association presents the current state of healthcare documentation and why it is essential to consider a more flexible compensation model that takes into account the many other duties of the professional medical transcriptionist. 

In a recent article published in For The Record, Sherry Doggett, President of AHDI states "There are many things that medical transcriptionists perform in many scenarios in the work envionment that really are not conducive to production pay."  Additionally, healthcare documentation specialists (MTs) are often asked to move from one computer to another, a different transcription platform or system, work back and forth between straight transcription and speech recognition, work multiple accounts and different doctors through a single shift.  All of these transitions are counter productive.  

Take into consideration different account specifics that vary within a single account to accommodate different physicians' style and add the numerous queries and flags MTs notate throughout the day, the corrections they must make to errors during dictation.  These things take time - uncompensated time and you have the makings of upheaval that may erode the future of this important sector.  When allied health professionals consider their work to be of decreasing value and say they work in a "sweatshop for minimum wage," it is beyond time to pay attention to the type of comments seen here.  

Year after year, healthcare documentation specialists have been asked to do more for less while the commoditization of this profession has been squeezed from every angle.  It is considered a cost center when there has been a failure to recognize the value of this knowledge-based field.  Consider coding.  How can coders code without the documentation that tells the unique patient's story and is the basis for coding?  How is it we will be able to move successfully into ICD-10-CM/PCS without better and more specific documentation?  

It is interesting to observe the conflicting opinions about whether or not front-end speech is better for quality patient care.  On the topic of front-end speech, Jeffrey Linder, MD believes that "physicians are more likely to see and respond to alerts if they are using an EHR."  While the AJR published a study that revealed a 23% error rate in front-end speech compared to 4% in dictation/transcription reports.      

In all the efforts to employ technology to improve healthcare, the technology advances absolutely have their place and merit in moving us away from paper.  That said, providers are faced with more demands, larger case loads and in truth they need choices that suit their preferences that will lead to efficiencies.  Forcing any one solution on multiple providers will be met with resistance and will not accomplish the goals of patient safety and better outcomes.  Rather, in a current article, Nick vanTerheyden, MD states "The most appropriate means of documentation is the one that is most effective and productive to a physician's workflow.  It will take a combination to deliver the highest clinican satisfaction."    

When all is said and done, it seems that in order to get more information, meet the needs for the clinical documentation improvement required for ICD-10-CM/PCS, and achieve meaningful use goals, healthcare organizations that intentionally keep dictation and transcription as well as other options will come out on top.  Looking at creative compensation methods for the professionals behind the scenes that help produce these quality documents from which coding and billing take place must move higher in priority in order to keep them engaged.  Many have left the profession already due to poor compensation and we cannot afford to lose any more at a time when the language of medicine is a premium concern.  We must value these hard-working professionals and look at other areas for controlling costs in the revenue cycle.     

Smart Moves for Smarter EHRs

In a couple of recent articles that are not connected, there is an underlying connection.  One, in "For the Record" discusses The Hazards of Note Bloat and the unintended consequences of having a lot of information that doesn't truly say much about the complexity of the patient's condition, not to mention that it is "difficult to view, notes lengthen and errors accumulate."  But wait, aren't EHRs supposed to reduce errors?  The article goes on to explain how narrative (dictation/transcription) notes have been reduced, but not completely eliminated.  It also discusses speech recognition and its implementation this month. 

The next article talks about the value of outsourcing as a cost-savings process to reduce costs and how this is happening in a big way in Canada.  This model has been shown again and again to be cost effective and many hospitals across the US have already embraced this practice to help reduce costs.

In yet another article, 3 major healthcare groups were identified as having caught the financial flu and are not doing particularly well at this time. 

In reviewing the 3 unrelated articles, it became apparent that there may be a myopic view of how to balance reducing costs with optimal EHR utilization.  Consider this.  EHRs are here to stay.  We need them and the value they bring to healthcare overall.  What we don't need is documentation that doesn't improve the quality of the patient encounter.  We need streamlined, content-rich, not bloated notes that drone on endlessly with what the previous note stated.  We need to optimally enable physicians so they have the time to see a growing patient population, not spend endless hours doing their own data entry.  We also must get the level of detailed specificity now that will be needed as the ICD-10 date edges ever closer.  Healthcare organizations must be fiscally healthy enough to provide care and continue to be viable as baby boomers get to Medicare age.  So yes, they do absolutely need to cut costs in the right places but keep those that enhance their revenue capabilities. 

Here's the conundrum in summary.  If healthcare organizations and hospitals focus only on reducing costs at the expense of eliminating medical transcription/editing, they are using a tunnel vision approach that will reduce costs but will simultaneously fail to optimize reimbursement.  Complete, detailed documention renders optimal coding, which leads to appropriate and optimal reimbursement.  If this process becomes muddy through "note bloat" or abbreviated input from extremely busy clinicians, the revenue cycle process may breakdown and the endless cycle of trying to reduce costs and not optimize documentation will continue. 

Stop the broken cycle of cost-cutting measures as the only option.  It's time to see the bigger opportunity and realize the value gained in the outsourced model of quality dictation/transcription and speech editing process to capture all the details needed for ICD-10 today.  This can get healthcare organizations over the financial flu and on the road to recovery. By adopting a practice of excellent documentation practices, these 3 unrelated items can become related in a way for long-term success with the EHR and improve patient outcomes as one of the most important goals.          

EHR Process: Speak Your Preference

EHRs and meaningful use (MU) are getting so much publicity. There is the carrot (financial incentive) and stick (reduced reimbursement) approach to get them in place by 2014 with the promise of reducing costs, improving patient outcomes and patient safety. Through all of this publicity, seems we haven't heard enough from the chief care giver - the physician.

Many of the EHRs that have been approved by CCHIT don't include a dictation/transcription option. CCHIT may not ultimately be the approval body. Interestingly enough, MU definitions haven't been finalized. So there are goals to meet that haven't been fully defined and timelines that associations like the AMA and AHA along with a host of other national groups that have spoken clearly about how the all or nothing MU criteria plan is ill-advised. They agree that the timeline is not realistic.

We probably all can agree that EHR implementation without meaningful use doesn't get us to the goals promised. And we understand that it is a given to migrate away from paper records. However, the rush to get it done seems to put physicians and a practical improved approach to healthcare delivery in the system that we have, in the backseat.

Let's look at this from an objective perspective. Now we have healthcare reform. That's great news for so many who don't have healthcare today. It means that an additional 32 million (estimated) Americans will have access to healthcare who previously did not or did if their conditions became critical enough for them to present to the ER. What will healthcare reform do to physician case loads? To hospital census? Let us not forget that we have an aging population with baby-boomers approaching retirement. Do we have enough physicians for all this increased volume?

Now let's look at how many EHR systems approach healthcare documentation. They are designed for the physician to become the data entry clerk - and in truth, many are operating this way today. VA's VISTA system, Kaiser Permanente, and there are a host of EHRs designed for ambulatory settings and physician office practice that utilize the same approach.

Here's a thought. Do you see the president of a bank entering deposits and counting out cash at his bank? No, so why would we ask our most highly educated member of the healthcare delivery team to become a data entry clerk?

Currently 1.2 billion patient reports are created by expert medical transcriptionists who have trained and many have become credentialed in their field. Narrative dictation captures the unique circumstances of each individual patient. No two patients are alike in their history and even presenting symptoms. And to leave out important details of the patient's additional illnesses can most certainly impact hospital and physician revenue. So why would we A. slow physicians down entering the detail and B. risk lower reimbursements?

The purpose of this blog post is just simply this. Consider: The physicians who are mostly going to be time and resource-impacted by EHR implementation need to speak out in favor of the ability to continue to document patient encounters in the most efficient and complete way. Physicians' voices must be heard in this evolution to electronic records. What EHR systems must do is provide an avenue for physician choice in documentation practices.

If physicians want to self-enter - then that should be an option. However, for those physicians with a patient case-mix that is complex and those with multiple medical problems, their option to continue to dictate will mean the difference in their ability to increase the demand on their time as patient loads increase.

Physicians - please speak up - be sure that you have options in how you document patient encounters. You are the CEO of the healthcare delivery team and the process needs to provide better patient safety and ensure that your time is optimized while ensuring appropriate reimbursements for all you do.

The EHR in Prime Time

Did you happen to catch CBS Sunday Morning yesterday, 9/13/09? Well if you didn't here's a link but the lead story was the EHR and all its benefits. David Blumenthal, MD, National Coordinator, spoke and others who are leading the charge. The move to the EHR is part of President Obama's healthcare reform initiative, Title XIII of ARRA that was signed into law in February. And we need to get this done.

There is little doubt that the improvements that a fully integrated and nationally linked healthcare system can bring to us as a country. Improved outcomes, less waste, faster information available when every minute counts - all of these are crystal clear, valid and important to achieve. My only concern is that we don't want to fail to capture the critical details of the patient's unique set of circumstances at the risk of getting it done faster.

There have been plenty of articles written about some of the shortcomings of new systems as well as the merits of others. This is a decision that cannot be lightly made nor should it be made hastily without all the considerations a decision of that magnitude should receive.

I am confident that these decisions will be well-made and that meaningful use will help ensure that these goals are optimally met. We do need to utilize enabling technologies like Health Story project to preserve the details of every patient's story and include this through technological solutions so that no critical issues are overlooked or left out. Physicians have so many pressures on their time with increasing patient loads. Allowing them to continue to document in this manner will help them continue to focus on the work they do best - and that is diagnose and treat their patients. You can have transcribed reports that are fullyl minable in an EHR.

Check out the story on CBS Sunday Morning and tell me what you think.

Changes in Healthcare, Changes in Medical Transcription

Let’s talk about change for a minute, shall we? Change is something that happens in every aspect of our lives – we get older (dang it!), our kids do, we move and relocate, we get new cars, we utilize better technologies, we have way more than 3 or 4 channels on TV, we don’t have to wash dishes by hand, we have energy efficient appliances that do more, cost less to use and in general improve our efficiency.

All change is not bad – but change is a fact of life. Let’s face it, many of us used to transcribe on typewriters with carbon paper or at the very least white out. We have seen various renditions of voice capture hardware. Long distance used to cost hundreds and hundreds of dollars on even modest plans. Now most everyone gets unlimited long distance for about $25 or perhaps even VOIP for a flat rate.

This industry has witnessed many changes and evolutions. We must embrace change – many of us should be change-agents by now because of the many changes we have witnessed, been through or otherwise led changes.

Most of you know what kind of crisis healthcare is in. And you also know that we have a President who vows to fix healthcare so everyone can have access. The debate is long and volatile about how to exactly get it done the best way, however, we know that the “status quo is not an option on the table,” as stated by Barack Obama. We have already been impacted in many ways by healthcare reform.

The drive to push costs down is being driven by a huge number of reasons. MS-DRG changes, ICD-10 upcoming, RAC audits nation-wide, POA (present on admission) to name a few and with 54% of the nation’s hospitals operating in the red and 80% of those with 500+ beds in the red, our healthcare system must change and is changing - now. That means we must evolve with this change.

I know many people like their present routines and don’t want to change, but the EHR is shrinking our market share. That’s simply the truth. Those with the best skills, the most differentiators and the willingness to change and evolve as our sector does will never worry about a job.

Did you know that people who are optimistic about change, even life-altering change live longer than those who are not? These people have the secret recipe of not only making lemonade with the lemons that come their way, they are also constantly seeking out enough lemons to make lemon meringue pie! Be creative and keep a smile close at hand.

We are not witnessing an end-game strategy, it is an evolving shift - and as Darwin said, “it’s not the strongest or the largest of the species that survives, but the one most adaptable to change.” So please everyone know what’s going on in our profession, be the best you can be – make yourselves indispensible to your employer! Be flexible and know what the drivers are in what’s taking place here and let’s move forward together and succeed!

Happy Memorial Day Weekend!

MT Relevance in Healthcare's Future

There is a lively discussion taking place here not just on the topic of mandatory credentialing but also the facts around MT relevance and our place in healthcare documentation's future. There are a number of great issues being presented and the burning questions seem to be larger than life.

Read this and more below:

For the purposes of history, very few professions willingly seek regulation and credentialing. AAMT/AHDI has always known we would have our work cut out for us by going down this road. But history has also shown that professions that are unwilling to self-regulate will either be (a) forced into regulation by the government or (b) forced out of relevance by technology and automation. Any unregulated, noncredentialed profession that can’t demonstrate a significant value-add is bound for marginalization. And unless you’re completely isolated from what’s going on in our industry right now, that is exactly what’s happening to our profession

Here is a final excerpt from that final post made by Lea Sims regarding what our choices are when faced with the reality of what is happening and why we need to engage this entire sector. We must face the facts of the transformation that is taking place - thought provoking:

...So…it’s really up to every MT, not to AHDI. How long can you count on your behind-the-scenes, no-credential, no-accountability, low-visibility role to sustain you in healthcare? Most experts say that within the next 5 to 10 years, a great deal of what you are doing will be automated (if you don’t believe that, you should be attending HIMSS) and all healthcare might need an MT for is to capture some complex narrative at the acute care level. All “normals” will give way to automation. All “templates” will give way to automation.

What value will you demonstrate to healthcare of the future? What cost-saving solution can you demonstrate? What ability to protect the patient can you market? What assistance with clinical decision-making can you offer? Instead of arguing with me here about what you are NOT, how much time are you spending thinking about what you ARE? You can say “no” to “risk management” as a value-add role, but what are you willing to say “yes” to? That’s all healthcare is going to listen to, folks.

When it comes to the art of this profession, at the end of the day, is our role to simply document what is dictated or is there an element of critical thinking involved? I have to say that some of the many MTs I know make sound decisions and corrections every day, many times a day - because they have the skill to do so. There is compelling information here that we all need to consider as those who would suggest that our role is clerical and therefore potentially just an expense that systems and technology can replace or do we choose to validate our skills and evolve them to the next wave in healthcare reform?

The issues around AHDI and what we do in support of MTs is substantial. That too, has evolved. Yes it is true that AAMT was different in earlier years, but as all things must, we had to change our mission and direction because frankly our members needed more. In order to provide membership with relevant and meaningful offerings, we too had to evolve with healthcare. Membership in AHDI is substantive and provides value in many forms. Through the Knowledge Base (KB), advocacy, credentialing, continuing education, leadership development, standards of practice, networking and more.

Will end this here but would ask that our members start speaking up and share what you think. And don't just tell us - tell those who are hearing misinformation. What is AHDI doing that we need to do more of? What aren't we doing that we should? And what do you think about some of the comments that have been made on this post? Do you agree or disagree? What further points need to made. We are listening - and your thoughts matter.

The Health Story Project

Have you heard of the Health Story Project? Have you heard about CDA4CDT? Perhaps you have heard about the +20 billion dollars (and likely more) set aside for health IT as part of the stimulus package for economic recovery and healthcare reform? Maybe you have heard that the EHR is targeted for nationwide implementation by a goal date of 2014? If you answered yes to any of these questions, then every MT will want to learn more about the Health Story Project. Here's why.

One of the objections to narrative text in the EHR is that it is not searchable or minable for data research. Because currently, it is in free-form without an established standards and formats it does not lend itself well to easy tagging for search processes (more). A shift to templated systems or point and click technology alone cannot capture the relevant details and unique circumstances of each patient admission. Something that we can all agree on is that the potential to improve patient care, reduce costs, eliminate redundancy in testing and to gain efficiencies via e-prescribing absolutely exists by migrating to electronic records. The best way to do that and keep the details present, to ensure that DRGs continue to be optimized and to ensure that patient safety comes first, Health Story provides that process.

The Health Story Project by way of CDA4CDT (clinical documentation architecture for common document types) is a process that allows narrative text to be translated in the EHR as searchable, retrievable text. Since more than 80% of physicians prefer dictation and transcription as the method of choice for documenting patient encounters, this process is the way to ensure that the continuation of dictation and transcription will be able to deliver the structured text research outcomes while providing a level of granularity and detail that can only be captured through the dictation medium.

What you can do? Urge your MTSO employer to join the Health Story Project and the many MTSOs who are using this process to enable full functionality of hospital EHR systems while still allowing physicians to record patient encounters in the method that is their preference and the one that allows them more patient care time. Don't work for an MTSO? No problem, talk about it at your hospital - and if your hospital outsources any of their work, ask them to include a request for CDA4CDT in their RFPs.

The time has come for us to take an active role in our future and beginning to have conversations about relevant strategies to help ensure your success and career are here today. Click here to learn more from a physician's perspective.