EMR Implementation and Protecting Patients

EMR implementation is happening everywhere we turn. This is a definite step in the right direction but there are problems with this (this is not a productivity post).  Next up is voice recognition, speech understanding technology, SR, VR, whatever you're calling it. Hospitals, clinics, physicians are saving big money (are they?) by the changes happening, but who is thinking about the quality of the patient record in all of this?

This is my business....Transcribing patient reports and being a patient myself, this is hot topic. All the pointing and clicking leaves little to not only the patient's narrative but also the doctor's voice. Then, there are the doctors' speech who could never, in their lifetime, be recognized and plopped into a patient's record without editing of some sort (or a complete re-type).  

One lesson that has stuck with me from a mentor of mine is when transcribing, we should not be messing with the doctor's voice.  Yes, we edit (according to client preference of course) and fix glaring grammatical errors, but a good transcriptionist will NOT mess with the doctor's voice. He speaks how he speaks, and we need to respect that.

To answer my earlier question -- there are some driving forces in our business who are interested in fighting for clinical documentation quality assurance. Kathy Nicholls put together a study that is so incredibly interesting I wish more folks would take notice.  See her blog post about it at Identifying Errors, Protecting Patients Report.  There are the all-to-common R/L discrepancies, medication dosage errors (mostly on account of SRT), lab values, etc., but check out these numbers:

In looking at the types of errors, here’s what we see:

• Dictated left/right inconsistencies: 1.92% of total
• Discrepancies/inconsistencies: 7.93% of total
• Lab value errors: 2.64% of total
• Medication Error in dosage: 2.88% of total
• Medication Error in name of drug: 3.13% of total
• Patient Demographics/
• Incorrect Information: 11.78% of total
• SRT Errors 69.71% of total

Now, with these percentages one must look at the larger scale of this, and Kathy said it best in her comment on the blog:

.....those percentages seem small, until you extrapolate it to the bigger picture. The reports from the CDC show a total of 34.4 million inpatient admissions per year, 109.9 million outpatient visits per year, and 123.8 million ER visits per year. If you assume (loosely) that each inpatient visit generates 3 reports of some kind (I’m thinking history and physical, procedure note of some kind, and a discharge summary) and each of the other types each has one report, that equals 336.9 million reports per year. Now that 1% becomes 3.37 million with errors, 2% 6.74 million, and 3% 10.1 million. It puts a new light on that for sure. And you’re also right, no one wants that 1% to be their family member or their personal record.

I think the point is that we have to find ways to share this information with the RIGHT people. It’s not about saying we don’t want the technology as it does bring some good things. It IS about calling for initiatives that put a quality check in place for information that goes into the EHR before it harms a patient.

Here's a sampling of the errors found:

• Penicillin listed as an allergy and then prescribed as a discharge medication.
• Metoprolol 500 mg
• “SPECT myocardial infarction” instead of “SPECT myocardial perfusion.”

Errors from SRT

• “Informed consent was obtained” became “informed consent for suicide was obtained.”
• Glyburide became Namenda. These two aren’t even close in sound, and so the patient with diabetes ends up getting treatment for Alzheimer’s.
• Tramadol became Trileptal. Clearly a medication for epilepsy isn’t going to help this patient’s rheumatoid arthritis very much.

This is very troubling and I hope those in the clinical documentation field (including EMR vendors) will not take this lightly. Do we risk harming patients just to save facilities money?  And, to that end, how much are they truly saving when you add in malpractice, EMR implementation productivity loss, and all the other "consequences" that come along with it?  

There are transcription companies (us, for one) who offer an alternative which is a perfect solution in my opinion. If the EMR allows structured data, a doctor can dictate the visit, which we all know is the quickest way to document the encounter, and our software plugs the dictation into the appropriate areas of the EMR. We  are checking and double checking patient record QUALITY!  Without quality checks (by folks who actually know what to look for) of some sort the facilities, offices, clinics WILL lose patients one way or the other.

If you're a patient, REQUEST your record, find out about WHAT QUALITY CHECKS are in place in handling YOUR record -- it's YOUR right.

Have you or a loved one had an issue with your medical record AND how it was handled?  I would love to hear from you!   

If you're interested in our services, please contact us through our website Just My Type Transcription or at info (at) justmytypetranscription(dot) com.

Medical Transcription Resources

A medical transcriptionist is only as good as the resources she keeps. Here are the resources I use on a daily basis to assist in the art of transcribing medical reports accurately and efficiently.

Benchmark KB Online - This is a great tool for transcriptionists. There are many facets of this resource in that there are specialty-specific and searchable word books and contains the Holy Grail of our business the Book of Style in a handy searchable format. There are also QA alerts for terms/phrases that need to be changed to avoid confusion in medical reports. The best part is there's a searchable physician database that is constantly updated.  This is a MUST for all transcriptionists.

Wheeless' Textbook of Orthopaedics - Great orthopedic specialty information. Just a great and detailed site.

American Medical Association - I use this to look up past practicing physicians and if I can't find what I'm looking for in Benchmark KB Online.

OneLook Dictionary Search - This is a one-stop shop for dictionaries -- medical, general, translations, etc.

Google - The All Mighty Google scores again! This is the quickest way to information, but a good medical transcriptionist will not take the sites listed in Google's word for it and absolutely must verify, verify, verify!

Skullcandy INK'd Headphones - Every transcriptionist needs a great set of headphones, ear buds, etc., and I blogged about these. They are of great quality, reasonable price, comfortable and can be worn for hours on end.    

Below is my single, most used and most coveted asset for medical transcription.

*** Drum Roll Please ***

Instant Text - Without this, I could not be successful. Well, that's not totally true, but it would take me a heck of a lot longer to get there without it.  Instant Text is a text expander.  Actually, this is not JUST a text expander. It's the most feature-rich, easiest to use and amazing text expander I have found. The possibilities are limitless with this program. No memorizing shortcuts = super easy to use. I have a command glossary for common tasks used in Word and/or other programs. For example, if a physician dictates a sentence and then goes on to dictate a compound sentence, I have a command that will go back and insert the comma + and.   My hands rarely move from my keyboard. I've made a drug database with brand name drugs, generics and dosing schedules.  This program also offers me a "compile" feature. I save reports and later can run the program and IT pulls the common phrases, words, etc., from the reports. The productivity potential is incredible! They now offer a free trial, and believe me, it is truly the best thing since sliced bread.

So....that wraps up my list of key resources for medical transcriptionists. If you're not using these resources, you really need to be. There are many others that I use, but these are the ones I use consistently.

-- Company plug to follow --

If you're looking to increase physician productivity while retaining the documentation capture capabilities of EMR / EHR, look no further! Hire us today to realize the savings in time AND hard dollars! You will NOT be disappointed with our service!  

Just My Type Transcription takes great pride in producing high-quality patient documentation. We treat your patients as if they're our family. Your patients' documentation is safe, accurate, and we of course are a HIPAA compliant service organization. We do NOT offshore any transcription and/or transcriptionists.  EVER.   

We're able to save new clients up to 40% on transcription costs with various options.  We know time is money, so call us at 847-890-0560 or email us to set up a quick demonstration of our web-based software which we provide to all customers as a service (no investment in software).  

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Just My Type Transcription was born

My willingness to go off on my own in the world of medical transcription is in part due to the ridiculous wages for transcriptionists and even more so QA personnel.  It's frustrating to have a great MT who is more than willing to take his/her time, do the research, not focus on production as much as quality to be paid less than minimum wage.  We do need to pay the bills, some are single parents who can't hold a job outside the home due to a child's illness, or the ludicrous amount of school days off - institute day, conference day, blow your nose day.

Being a QA for an MTSO, I have seen some of the poorest quality reports generated from a renown (in their own minds) school who is all about the Benjamins. I am appalled by this. Someone did not do the research when they heard/typed 'celiac screw' and KEPT that in the report. Rookies make mistakes, yes, but I have also seen 'seasoned' MTs whose output is horrid, terrifying even. I personally have no idea how or why and MTSO would want to keep them. Again, low wages. They can't afford NOT to keep them. Sad but true.

This leads me to why I went off on my own. I believe everything happens for a reason. I believe I took this job with the MTSO to further my education in the 'real world or transcription.' Of course, I didn't see this at the time. The good, the bad, and the ugly. I actually love this MTSO. I have learned a great deal from the 100+ doctors I have on the account I type for. I most definitely have a clear view of the company I want run and hopefully that will sustain me.

Just My Type Transcription