By Julie Knudson for For The Record
It bears repeating: Poor dictation habits can severely affect quality of care and timely reimbursement.
For years, physicians have been dictating their patient reports and for years, transcriptionists have been trying to figure out what they’re saying. But as the health care system evolves, technology such as EHRs and speech recognition are turning difficulties during the transcription phase into serious downstream challenges. Helping physicians ditch their bad habits has become more than a part-time hobby for administrators—for many, it’s an all-out mission.
Various habits contribute to poor dictation, and even normally well-spoken dictators can occasionally fall victim to one or more of them. Add in a busy physician’s workload and go-go-go schedule, and the quality of the dictation can fall dramatically.
Joyce Smith, manager of transcription services at Spectrum Health System in Grand Rapids, Michigan, says some transcription groups suspect their physicians paid their way through medical school moonlighting as auctioneers. “They can dictate so fast!” she marvels.
The tendency to multitask also can detract from dictation quality. “They may eat while they’re talking, so they mumble, or they’re tired and they yawn,” Smith says. And occasionally, they simply forget there is a human at the other end of the process who must determine exactly what is being said.
The more physicians in a health system, the greater the range of poor dictation excuses. Melissa Campion, RHIA, CHDA, CHPS, CMT, an eHIM senior systems analyst for transcription at a large integrated health system in Melbourne, Florida, says her team has encountered several doozies. “They dictate on speakerphones in the car with the top down or with five of them in the room—and I can hear all five of them,” she says.
Foreign accents, which many may assume present a significant hurdle for transcriptionists, aren’t always a challenge. “The accents are actually easier to deal with because most of the doctors with a heavy accent are aware of it and try harder to make it clear,” Campion says, adding that her team struggles more with dictation from physicians from the Deep South who may be unaware of how their accents come through in the reports.
Poor dictation isn’t all about accents, background noise, and speech patterns (although mumbling often is the first issue transcriptionists mention when discussing dictation problems). Kathy Lengel, manager of transcription services at Lancaster General Health in Pennsylvania, says relaying accurate and complete data in an efficient manner also can significantly impact the quality and timeliness of the final report. “Poor dictators are very inconsistent in the format they use,” she explains. “They don’t provide good patient information, and some of our poor dictators enter no patient demographic information. … They jump all over the place. They have no rhyme or reason to how they’re dictating.”
The quality of patient care and safety are primary concerns when dictation troubles come into play. Both timeliness and accuracy are factors. “Our institution has taken the stand that we are not to guess,” Lengel says of the instances when her team can’t understand what a physician is saying. “If we aren’t 100% sure of something, we are not to fill it in.”
Incorrect dosages could be catastrophic. Because treatment decisions are based on information in the chart, accuracy is crucial. When it comes to difficult dictators, the report often must be sent to another person—typically a lead within the transcription team—to try to complete the report. “That obviously holds up the patient care end of things,” Lengel says. In some cases, her group may require three or four leads to listen to the dictation before they can construct a complete and accurate report.
Linda Allard, CHPS, president of New England Medical Transcription, instructs her team not to guess if something within a report is unintelligible. When sound quality or dictation are poor, she says timeliness is affected immediately. “Turnaround time will be affected because in our case, we’re going to send the report to our editors so they can try a second time to figure out what was missed,” she notes.
If that fails, the report is forwarded to a point person within the client organization for further action. “That means that instead of going directly into the patient’s chart right away, it goes to the hospital where somebody has to manually go in and fix it,” Allard says.
Financial pitfalls also can plague health care organizations with too many poor dictators. If coding can’t be completed because of missing information in a record, Campion says a bill hold could ensue. “Every week there are usually a handful of reports that have too many blanks,” she explains. “If we have to fax it to the physician for clarification, it can delay reimbursement.”
While patient safety is a top priority, some institutions don’t realize that patient satisfaction also may suffer. “Sometimes we have patients coming in wanting copies of their report,” Campion says. “I have to tell them that I can’t give it to them because it isn’t done yet. It sets a bad customer expectation, and it can damage the relationship between the physician and the patient.”
Teach and They Shall Learn
Education often is the best way to improve physician dictation practices. Allard says her team begins every new technology implementation with an eye toward resolving issues and helping physicians learn how the system works. “We provide dictator cards that the doctors can carry around in their pockets,” she says. “We start from the beginning by being very proactive.”
Once dictators understand that entering the correct numbers at the beginning of a dictation session will pull up the correct work type and patient demographics—thus ensuring the document is returned faster and with fewer questions—they’re usually more willing to make the effort to use the system correctly and efficiently. “Certainly doctors are busy doing what they do best, but they may not understand exactly how important it is to use the right numbers or say the right things,” Allard says.
Lengel says explaining workflow to physicians has been instrumental in eliminating several recurring dictation problems. “We explained to them that if they enter the incorrect work type, the report won’t flow to the transcriptionists who are better equipped to handle that work type,” she says. The physicians didn’t realize how the process worked once they finished their portion, but most were eager to contribute to an efficient and accurate system once they knew how their actions affected downstream workflow. Detailing how incorrect formats impacted the timely return of reports and discussing ideas on how to adapt dictation habits also proved to be productive.
Depending on the organization, incentives and penalties may be tools to boost dictation practices. At Campion’s health system, the senior leadership team receives weekly turnaround time reports that identify outliers. “[The reports] actually help us out with pulling the docs in and trying to help them get better,” she notes.
While educational sessions have been helpful, a motivated administration can take steps to make noncompliance unattractive. If particular physicians continue to cause turnaround issues or other problems, Campion says the organization can use financial incentives, such as withholding bonuses, as a way to promote improvement.
Highlighting the fact that good dictation is an integral part of quality of care is another effective approach. “The medical staff need an administration who can continually stress the importance and positive impact that good dictation has on quality patient care, improved reimbursement, and minimized liability,” says Cynthia Vogt, vice president of A+ Network Transcription Services. “Doctors need to be held accountable for the quality of the dictation they provide, just as they are for all other facets of the patient’s care.”
Some transcription groups have discovered they can tap into physicians’ innately competitive nature as a way to boost dictation quality. At Spectrum Health System, transcriptionists nominate and vote for Outstanding Dictators of the Year, with the winners recognized in the physician newsletters. It’s an honor that doesn’t go unnoticed among the physicians. “We asked one physician to speak at one of our meetings, and he said, ‘Will that guarantee I’ll win outstanding dictator next year?’” Smith recalls.
Even those who excel at dictation often will try to better their skills if they understand there’s room for improvement. “We have back-end speech recognition here, and we’ll send letters to dictators to let them know what their recognition percentage is,” Smith says. “It’s amazing. Even if they get a letter complimenting them on their high percentage, they always want to try to increase it.”
To be a satisfactory dictator takes several qualities, not the least of which is being aware of the fact that someone on the other end must be able to make sense of the dissertation. “The ideal dictator is attentive, consistently articulates, speaks with proper grammar, and is considerate of the person listening to their dictation,” Vogt says, adding that medical transcriptionists aren’t expecting physicians to speak in slow motion, spell every word, or exaggerate enunciations. In addition, avoiding other activities while dictating—eating is mentioned frequently—is highly recommended for a clear and concise rendering.
Beginning a dictation session with adequate patient identification also is extremely helpful. Besides keying in the medical record number, Campion encourages physicians to state the number during the dictation to ensure their keystrokes and the stated information match. “They should collect their thoughts before they start dictation or learn how to use the pause feature instead of saying ‘Um’ or ‘Let me think,’” she says.
Saying numbers clearly is essential for patient safety reasons. In that vein, digits that are easily confused when spoken (50 and 15, for example) should be spelled for clarity’s sake.
When selecting honorees for the outstanding dictator award, Smith’s team targets “someone who consistently dictates in a clear and concise manner, includes all necessary data at the beginning of each report, takes the time to spell difficult terms, medications, equipment, and consulting physician names or specialties and, most importantly, is courteous to the transcription staff.”
Dictators who organize their work into a structured format are a blessing, Smith says. “They can eliminate time-consuming practices such as constantly saying, ‘Go back up and add this,’” she notes.
Other Steps to Pursue
Education and competition aren’t the only strategies to improve dictation. Health care organizations may have additional options if they’re willing to make some internal changes. Campion says it’s important to note that physicians often are doing the best they can with what they have. “We sit down and try to hear both sides of the story,” she explains. “We can complain that it’s bad listening to a doctor who always dictates in a noisy area, but maybe in that unit we didn’t provide a quiet place for them to dictate.”
Campion recommends providing physicians with the proper tools—whether it’s a quiet environment or a physician assistant to help with workload—to maximize their dictation efforts.
On occasion, slightly more drastic measures may need to be taken. For example, in a previous organization, Lengel encountered a resident from another country who had tremendous difficulty dictating. “We talked to the director of the residency program, and he actually sent the resident to some English classes,” she recalls.
The effort paid off. The resident was able to make better word choices and construct sensible sentences. “It made a huge difference in his dictations,” Lengel says. Because the resident was eager to invest the time to hone his skills and improve his dictation, the cost of the class proved to be a worthwhile investment for the hospital.
Should You Put It in Writing?
Medical transcription service organizations (MTSOs) may want to consider including contract language that addresses dictation issues. Cynthia Vogt, vice president of A+ Network Transcription Services, says it makes sense, given that transcriptionists’ earnings can be directly affected by poor dictation. “With medical transcriptionists being paid on a production basis, having to struggle through reports by difficult dictators slows down productivity and thus negatively impacts their income potential,” she explains.
A transcriptionist could spend several hours working on a report generated by a poor dictator and as a result make less than minimum wage. “If difficult dictators are unwilling to improve the quality of their dictation, the MTSOs should be able to charge more and pay the medical transcriptionists more for transcribing those difficult dictations,” Vogt says.
Joyce Smith, manager of transcription services at Spectrum Health System says health care organizations are unlikely to accept such contract language, but concedes there is some validity to an MTSO’s argument that poor dictation penalizes them unfairly. “We often have something in our contracts that says if [the MTSO] doesn’t meet turnaround, we get a credit on the document,” she explains.
But instead of inserting a clause that addresses poor dictation, Smith would probably prefer that the MTSO contact her directly if a problem arises, particularly if it’s a physician with a track record of dictation issues. “We might consider taking that provider out of the turnaround calculations, so they don’t have to pay a credit on that one person,” she says.
— Julie Knudson is a freelance business writer based in Seattle.