Vol. 14 •Issue 14 • Page 26
Controlling Quality Control in Medical Transcription
Twenty-five years ago, medical transcription quality control (QC) was an ad hoc process. Twenty-five years ago, I typed “Krone’s disease,” and Dr. Krone, a gastroenterologist on staff at the medical center where I was training, sent me back a polite note that the well-known intestinal malady was not, in fact, named after him, but after one Dr. Burrill Crohn, a late-19th century American physician. This was QC as education. In those days, a medical transcriptionist (MT) went to work for a hospital, clinic or physician, and over time became very proficient in the particular vocabulary, syntax, formats and other eccentricities of her client/employers. Given at least a minimum level of commitment to the job, the quality of that MT’s work was good and always improving.
Twenty-five years ago, transcription outsourcing was usually a desperation measure. The medical records director, finding herself with an insurmountable backlog, sent work out to an individual or group of individuals. These individuals would return a transcribed record, the quality of which was always suspect. It was axiomatic among hospital MTs that work coming back from contractors would have a lot of errors. However, the work got done. And, of course, there was an element of defensiveness in the hospital MTs’ evaluation of outsourced work. But the fact remained—and remains—that the more familiar an MT is with the dictation habits and vocabulary of dictators, and with facility preferences regarding format, the higher the quality of the transcribed document will be. This is a law of the universe, like the laws of gravity or quantum mechanics. Let us give it a name, in honor of that courteous gastroenterologist who instructed me so many years ago: Krone’s Law of Medical Transcription.
Many things have changed in transcription during the past 25 years. The technology and structure of the business are unlike what most of us would have imagined in 1977. Today, outsourcing is no longer a stopgap measure. It has become the primary solution for medical transcription in many health care facilities. And over the past few years, discussions of quality—what it is and how to achieve it—have come to the forefront, along with a range of theories, standards and practices that attempt to achieve quality in the transcribed record. It is no coincidence or accident that QC has become a hot-button issue concomitant with the rise in outsourcing. As outsourcing has increased, QC has become a more problematic aspect because Krone’s Law, like the law of gravity, is still in effect.
Medical offices, clinics and hospitals that retain in-house MTs are generally less penalized by Krone’s Law than are medical transcription service organizations (MTSOs) because turnover can be minimized and MT familiarity with dictator habits, vocabulary and format rules will be high. Within the MTSOs, QC is a more problematic issue, as will be seen in the following discussion. But the consequences and cost of QC affect everyone concerned with transcription including medical records managers, MTs, dictators and ultimately, of course, patients.
It should be noted that what follows applies to transcription from any source, including offshore transcription. Except for relative fluency in English (which may be more problematic than many health information managers realize), the realities of offshore and U.S. medical transcription QC are the same.
QC Today: Out of Control?
Contrary to what some in-house MTs might have been muttering 25 years ago, there is nothing inherent in outsourcing that reduces the quality of the transcribed document. What reduces the quality of the document is a lack of MT familiarity with the producers/consumers of the document, their habits, vocabulary and formats.
For a variety of reasons, MTSOs have had difficulty maintaining stable relationships between their MTs and their clients. For example, ever-tightening turn-around-time (TAT) requirements by clients are a major factor, given the inevitable fluctuation in work flow. The MTSO that “staffs up” to meet heavy demand and short TATs then finds itself with MTs sitting idle when work.diminishes. This creates financial issues for the MTs, most of whom are paid for production, and possibly legal issues for the MTSO, who may in effect be asking MTs to be “on call” (waiting for work) without being paid for their “call” time. The impetus is to put those MTs to work on other clients with heavier volume, whether or not the MT is familiar with those clients.
Flexibility in MT assignment may be a desirable goal, and an achievable one, up to a point. But beyond that point, a high level of familiarity with clients is going to be impossible. We don’t currently know what the limits to flexibility are; can an MT become truly familiar with 1,000 dictators? (Some research to answer this question would be of great interest.) Needless to say, the providers of medical transcription are just as eager as their clients are to maintain quality in the transcribed record. But the operation of Krone’s Law dictates that quality will go down as MT congruence with clients goes down.
Enter the QC department. Now, because of the high number of “new” MTs on any given client at any given moment, the MTSO must have a group of people whose main responsibility is to review the work of other MTs. This is an expensive proposition for the MTSOs. The expense creates pressures in several directions, promoting, for example, depression of MT wages and price increases for clients.
In addition, quality itself has come to have new meanings that make QC even more expensive. A lot of people sitting around thinking about quality has led to a lot of tinkering with the concepts and practices of quality. Today, in addition to concern with such quality essentials as accurately reflecting the dictator’s intentions and correct medical spelling, we now see rather long discussions about the correct placement of commas and semicolons, whether “gastroenterology” should be capitalized when referring to a department, RBC vs. rbc, and so forth. The cost-benefit ratio for time spent on these issues needs to be carefully evaluated.
Another problem facing everyone concerned with quality in medical transcription is that the originators of the medical record—the dictators—are themselves not subject to any QC. Pursuing quality in medical transcription, one MTSO hired an expert in the famous QC program known as “Six Sigma.” This was a noteworthy attempt to bring to medical transcription the principles of this very successful approach to quality in manufacturing. But to try to apply Six Sigma to transcription, with no means of controlling the quality of dictator input, is probably impossible. Transcription being done from poor dictation is like an assembly line in which the materials coming down the line are defective before anyone on the line lays a hand on them. The Six Sigma expert may have been astonished to discover that while program principles could be applied to MTs, they could not under any circumstances be applied to the raw-material providers, the dictators.
This in turn brings us to a current attempt at QC currently finding favor with some MTSOs and health care administrators: “verbatim” transcription. If the purpose of QC in medical transcription is to produce a document that accurately reflects the dictator’s intentions and correctly spells medical terms, then “verbatim” transcription is a direct blow to transcription quality. If we take the concept of “verbatim” transcription literally, an MT hearing “potassium 134, sodium 3.5” must transcribe it exactly so, because that is what was dictated, thus both nullifying the benefit of the MT’s training and experience, and impeding the production of a high-quality medical document. It is true that the dictator is ultimately responsible for what he or she says. It is also true that everyone makes mistakes, and one of the benefits of a team approach to any task is mutual QC. Finally, it often turns out that when clients request “verbatim transcription,” they don’t really mean “verbatim” (numerous exceptions will usually be enumerated), which is fortunate in some ways, but creates a chaotic situation for MTs, QC personnel and dictators.
To review, we now have a situation in medical transcription QC where:
1)outsourcing has produced heightened concern with quality at the same time that,
2)the congruence between MT and client/dictators is weakening, with the inevitable negative impact on quality as predicted by Krone’s Law, and
3)the understanding of what is required to maintain quality and the definition of quality have become muddled, with the result that
4)a great deal of time and money are being spent on “quality” without necessarily achieving true quality.
In short, QC in medical transcription is currently threatening to go out of control.
Solutions: Controlling QC
The first essential element in controlling QC and achieving true quality in the dictated medical record is to respect Krone’s Law. MTSOs must make strenuous efforts to maintain MT-client congruence. This presents difficulties, but it is highly likely that whatever the costs of such efforts, they will be less expensive over the long run than current QC programs. Correlatively, MTSOs should carefully review their QC programs in the light of Krone’s Law. They might consider, for example, that a blanket QC program applied to all MTs, regardless of experience and longevity with a given client, is unnecessarily costly. The American Association for Medical Transcription (AAMT) has suggested the following for QC review programs on its Web site (www.aamt.org/scriptcontent/qualityassurance.cfm?section=professional).
“Reports transcribed by MTs who are new to an organization should undergo review on a regular basis until competency and judgment have been consistently demonstrated. At that time, random review by periodic sampling of transcribed reports should be performed to ensure ongoing compliance with quality standards. AAMT recommends selecting a 3 percent to 5 percent sampling of documents for the period being reviewed, although the sample could be larger or smaller depending on (a) whether there have been quality or accuracy issues with the particular MT in the past; and (b) how much time has elapsed since the MT’s most recent review.”
Respecting Krone’s Law, health care clients will logically request that their transcription work be done by a consistent team, and at the same time they will be willing to work with the MTSO to help facilitate that arrangement. It would be helpful if clients, for example, recognizing the inevitable fluctuations in transcription workflow, could allow some flexibility in TAT wherever possible, under certain circumstances and for certain work types.
Second, QC as education must be emphasized. This is an investment in the future. One barrier to this is the trend among MTSOs to pay QC personnel by “the line” for reviewed or edited reports, as if the QC person’s ability to educate the MT were of no importance. That is, any time spent providing feedback to the MT is in effect unpaid time. The importance of QC as education has been well-stated by AAMT as follows:
“Ongoing feedback, education and performance improvement should be the goal of any quality assurance program. The scope of the program should not be limited to merely the correction of errors, but should focus on developing an MT’s experienced judgment, including the ability to discern client/chart-ready documents from those that could benefit from additional review. Attention to quality must also include a commitment to the ongoing professional development and continuing education of the MT as a means of ensuring overall continuous quality improvement.” (www.aamt.org/scriptcontent/qualityassurance.cfm?section=professional).
Third, all parties to the creation of the transcribed record must recognize what the essence of quality is: fidelity to the dictator’s intentions and correct spelling/usage of medical terminology. Other considerations (including document format) are simply not worth the time and money currently being spent on them.
Finally, attempts must be made to raise dictator awareness of their role in the quality of the dictated/transcribed medical record and to assist them to maintain quality in their dictation. I personally favor a class in medical and nursing schools—perhaps in the form of a short seminar given to students when they first enter the hospital environment—that will teach some principles of narration and dictation. It should be noted that when the electronic medical record is a reality, and speech recognition technology is a practical tool, these dictation and narration skills will be more important than ever.
As a corollary to this last point, I want to say a few words about blanks. Some health care providers and facilities consider blanks to indicate a lowering of quality. They stipulate that their transcribed documents will contain “no blanks.” This stipulation creates a serious dilemma for the MTSO; is very costly; and like “verbatim” transcription, it actually threatens to compromise quality. A “no blanks” policy sends into the QC process documents that are otherwise of impeccable quality but that would have contained blanks, such as the potassium-sodium example above, or a name not spelled by the dictator. In some circumstances, it forces an MT to make a choice between her paycheck and the quality of her transcription, if she is penalized for sending reports into the QC process (another growing trend). It provides an impetus for guessing, always the bane of quality. And it eliminates the possibility of educating the MT through feedback. Clients should acknowledge the necessity for occasional blanks, and MTSOs should ensure that there are no more blanks than absolutely necessary.
So, is QC important in medical transcription? Of course. Even in an ideal world of perfect MT-client congruence, there would be a need to monitor quality because the world of medical dictation is highly dynamic. Medical vocabularies are ever-changing, and there are always new dictators. But at the moment, QC programs threaten to become a costly juggernaut that will have unintended consequences for the whole MT industry. A fresh look must be taken at QC programs by everyone concerned in the process.
Rebecca A. McSwain holds a doctorate in anthropology and has been a medical transcriptionist since 1977.