Ambulatory EMR adoption is an endemic national concern. According to a survey conducted by the New England Journal of Medicine only 4% of respondents have a fully functional EMR (with order-entry and clinical-decision support capabilities) and 13% have a basic system.
The U.S. healthcare system initiative to develop a national electronic health record (EHR) infrastructure by 2014 aims to successfully share and exchange health information and support personal health records for all Americans. When ambulatory healthcare organizations are unsuccessful in adopting electronic medical records (EMR) technology into their practices, interoperability for health information exchange (HIE), personal health records (PHR) and a national EHR will be limited.
In a recently published Speech Recognition Adoption White Paper written by the Medical Transcription Industry Association (MTIA) and the Association for Healthcare Documentation Integrity (AHDI, formerly AAMT), a great deal of emphasis was placed on the role medical transcriptionists must continue to play in driving a successful national EHR. In summary, the paper indicated that though many EMR and Speech Recognition technology providers have taken aim at medical transcriptionists (MTs) as being a costly and obsolescent part of healthcare documentation, the limits of EMR and speech recognition technology (SRT) are being significantly complemented by the work of MTs in cases where solution providers and savvy healthcare organizations have recognized the value of the relationship between technology and MT “knowledge workers”.
The white paper further offers a state of affairs in the world of speech recognition and compares frontend speech recognition (FESR) with backend speech recognition (BESR). FESR is the process whereby speech-to-text translation occurs real-time with the creation of a narrative dictation, typically for concurrent correction by the dictator. BESR is the process whereby the speech-to-text translation occurs subsequent to the creation of a narrative dictation, typically for later correction by a third party (such as an MT).
When comparing FESR with BESR it was found that enterprise healthcare organizations experienced significant success with BESR by routing work translated through a speech recognition engine to an MT for later correction. This method supported clinicians’ ability to narratively dictate without changing their habits and therefore was widely accepted as an effective documentation method. Further, because cost savings were generally realized, CFOS supported BESR adoption. Typically 80% of clinicians were adaptable to BESR with no change in dictation habits, and higher for certain specialties like radiology. With MTs typically producing 1.5 to 2 times the volume over that of conventional transcription, BESR has proven to be an effective option for documenting health records. The accuracy of speech-to-text translation using BESR improves over time by comparing the corrected reports to a dictator’s speech patterns thereby improving the translation algorithms over time.
FESR has also made strides in the past decade. Gone are the days of sitting in front of a computer and recording thousands of words to train the recognizer. Like BESR, FESR learns and improves with repetition and can “learn” from completed, corrected documents. The trouble with FESR that many clinicians find objectionable is the need to interact with the process to make real-time corrections, thereby causing a change in dictation habits and slowing the clinician down. Although there is an upside (real-time documentation means immediate completion for the chart) in most situations that value is diminished by the extra time it takes the clinician to compete the record, the associated costs of that clinician time, and the fact that turnaround time (TAT) via a backend process is usually adequate.
According to Claudia Tessier, VP of Medical Records Institute, in her article, Medical Transcription and EMRs: Opportunity Lost? FESR represents less than 3% of clinical documentation. On the other hand, back-end speech recognition (BESR) has made significant gains in clinical documentation this decade with hospitals and major healthcare systems effectively deploying the technology enterprise-wide.
If clinician documentation habits are relevant to adoption, it’s no surprise then that ambulatory EMR adoption has delivered such abysmal results. According to the American Medical Association (AMA), the cost of an ambulatory EMR per clinician averages $30,000. If cost is not enough of a barrier to adoption, then usability certainly is. Next time you visit your primary care physician and have your medical record manually documented into an EMR by your physician while seeing you, ask how much he/she likes the process. If you are a clinician, then you understand. Though many EMR technologies are impressive, the documentation process is not well-embraced when it distracts from the intimacy of the patient encounter or slows the documentation process down to the point that fewer patients can be seen.
In an article by Peter Waegemann, CEO of Medical Records Institute and Chair of the TEPR Conference, despite a national initiative to have complete adoption of EMR technology by the year 2014, the above-referenced findings by the New England Journal of Medicine study clearly reflect that something is “drastically wrong”, that “it is time to stop and have a hard look at what needs to be changed”, and that “it is time for all the committees, associations, and others who are touting EMRs to confront this dismal picture” and find ways to help “correct [several] areas in our national strategy”.
The areas Mr. Waegemann identifies as problematic? Cost, Information Capture, Legality, Functionality, Information Exchange, Continuity of Care. Regarding Information Capture, Mr. Waegemann states, “Another main hurdle is the process of getting information into the computer”, continuing by noting that “electronic documentation is disruptive, may take a little longer, and requires a change in habits.”
Clinician behavior is unlikely to change if the pressure of time and efficiency continue to drive the culture of healthcare. If EMR usability also continues to challenge clinicians, then the role of the MT may, in fact, be extremely relevant in helping to meet the current EMR adoption challenges. As noted by the American Health Information Management Association (AHIMA) in a Practice Brief entitled Speech Recognition in the Electronic Health Record, “MTs are poised to evolve into clinical data, data quality, and decision support specialists.” The challenge to MTSOs, Healthcare Provider organizations and EMR providers is to work cooperatively to develop and promote solutions that match this charge.
In her article, Friend or Foe, published in For the Record, Robin Daigh, a VP at MD-IT, aptly addresses that it is the blend of technology and service solutions needed to meet the present EMR adoption dilemma. In this article Ms. Daigh notes that of the three documentation options (direct data entry, FESR and narrative dictation) that “many EMR vendors with whom we’ve spoken [indicate] dictation is the preferred choice of 80% of doctors.”
Ms. Daigh continues with a relevant illustration about documentation time and costs, noting the example of a typical outpatient visit to an internist and indicating that it takes about one minute to dictate a note for an established patient and costs about $4.30 versus 5 minutes and cost of about $13.50 to document the encounter directly into an EMR:
“By contrast, many EMRs use [direct] structured data entry as the primary method for entering clinical notes, in which physicians point and click their way through drop-down menus. The time required is at best equal to that of a transcribed note, and physicians often report it takes 8 to 10 minutes to complete a note using structured data entry, meaning the indirect cost to physicians is anywhere from $13.50 to $27.” states Daigh. “Indeed, physicians may ‘save’ $1.60 in outsourced transcription expense but at the cost of their valuable time. In our experience, this loss of productivity with [direct] structured data entry is the single biggest barrier to physician EMR adoption. By contrast, transcription customers are delighted to learn they can continue to dictate and let the transcription service deliver the clinical note to their EMR.”
Medical Transcription (with or without SRT) is relevant to documentation because it is the companion of narrative dictation, and narrative dictation holds a key advantage: the documentation of complete and accurate records. In another New England Journal of Medicine publication, Off the Record – Avoiding the Pitfalls of Going Electronic the article authors note that template-based documentation may distract from the important cognitive work of providing care, limiting thoughtful review and analysis. “Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue.”
In its traditional form Medical Transcription still services a significant percentage of the industry; coupled with speech recognition (BESR), it enables scalable deployment across enterprise healthcare; with HL7-based integration it feeds enterprise EMR systems with unstructured data health records; with emerging BESR technologies it feeds those same systems with structured data health records, leading to improved decision support; and in response to the endemic ambulatory EMR adoption problem it offers a bridge to acceptable usability.
Medical Transcription in fact holds a relevant role in documentation and in helping solve the ambulatory EMR adoption dilemma, vital to the future of healthcare interoperability and the national EHR initiative. Moving forward, organizations that are focused on providing integrated solutions that leverage both technology and service offerings will lead to an increase in EMR adoption and ultimately improved patient care.
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