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Transcription for the Future

Editing for Quality and Efficiency

All information methods and concepts contained in or disclosed by this document is confidential and proprietary to Multimodal Technologies Inc. By accepting this material

the recipient agrees that this material as well as the information and concepts contained therein will be held in confidence and will not be reproduced in whole or in part without express written permission from Multimodal Technologies, Inc. Client use of M*Modal

tools or information (excluding any services or tools provided to the Client that are covered under a separate written agreement) is subject to the terms of a legal

agreement between the Client and M*Modal.

Agenda

� What is transcription and why is it still relevant?

� Editing for quality and efficiency

� The Career-Minded MT

� Managing for efficiency

Company Confidential

� Managing for efficiency

� Transcription Innovation in the World of Meaningful Use

2

What is Transcription?

3

Electronic Health Record Universe

� Two opposing needs

� Enterprise need for structured and coded information capture

� Physician’s practical

Company Confidential4

� Physician’s practical need for a fast and easy method for creating clinical notes.

The Current Situation

Direct Data Entry: Dictation:


� Tedious, manual

� Time-consuming

� Documentation lacks expressiveness of natural language

� Transcription can be expensive

� Longer turn-around times

� Clinical data lost, documents neither structured nor encoded.

Direct Data Entry: Structured and encoded information.

Lack of interoperability – within and across organizations

Dictation: Fast and easy, expressive.

Reality

Medical Transcription is competing with –

• Front-end speech recognition

• EHR – Direct entry

• Front-end speech rec

• Templating


• Templating

• Direct data entry

Hospitals are looking for the most cost-effective solution…

6

Changing Face of Documentation

� Back-end speech recognition

� Front-end speech recognition

� Dictation and speech recognition

� Direct into EMR

� Eliminates transcription costs


� Eliminates transcription costs

� Direct data entry

� Physician data entry into fields of EMR

7 M*Modal Proprietary and Confidential

The Competition

“Front-end” speech recognition

• Physician self-edit

• “Once and done”

• Physician behavior modification


• Physician behavior modification

• What do I need to say?

• How do I need to say it?

• For the fewest edits

8

Value of Narrative Dictation

Doesn’t interfere with the doctor’s day

• Where and when he wants to do it

• Lots of information in a little bit of time

• Comprehensive information

• Documents intuition and inclination


• Documents intuition and inclination

• Physician behavior modification -

None!

9

The “Chart Reader”

� “…when Dragon Medical was integrated with the organization’s EHR, emergency department (ED) transcription costs went from $1.4 million per year to zero.2


from $1.4 million per year to zero.

2 - Shepherd (July 22nd, 2009) Vive La Voice. For the Record. Vol. 21 No. 14 P. 24

10

The “Scribe” Strategy: Could You Use a Scribe?

Are your patient encounters hampered by incessant charting and documenting? Perhaps a medical

scribe can help.

By Shirley Grace


By Shirley Grace

http://www.physicianspractice.com/display/article/1462168/1590060

11

The “Scribe”� “Rather, they allow the physician with whom they work

to shift his focus off of his tablet PC or paper chart to his patient. Specifically, a scribe is responsible for:”

� Patient histories

� Transcribing exams and orders

� Documenting procedures


� Follow – labs and x-rays

� Recording discharge information

12

The CDI Specialist

� Evolving role…

� “More important than coding”

“…pharmacology; knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to


the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and analyze clinical documentation program performance.”

13


CMS reduction in hospital base rates

� Clinical Documentation Improvement

� MS-DRG for coding - reimbursement

� Specificity requires documentation

� ICD-10


� ICD-10

� POA indicators

� RAC review

14

Transcription and Editing

Backend speech recognition plus MT editing

• Efficiencies and cost savings

• Cost avoidance

• Comprehensive and complete documentation

• High adoption by physicians



15

At the end of the day….

� $$ Talks….

� Can human talent combined with technology solve the problem?


Where does that leave us?

Is backend speech recognition plus MT editing the answer?

• Efficiencies and cost savings

• Cost avoidance





• Pricing opportunities

Yes!

17

What is “Speech Rec” all about?

18

The “Chart Reader”

� “…when Dragon Medical was integrated with the organization’s EHR, emergency department (ED) transcription costs went from $1.4 million per year to zero.2


from $1.4 million per year to zero.

2 - Shepherd (July 22nd, 2009) Vive La Voice. For the Record. Vol. 21 No. 14 P. 24

19


CMS reduction in hospital base rates

� Clinical Documentation Improvement

� MS-DRG for coding - reimbursement

� Specificity requires documentation

� ICD-10


� ICD-10

� POA indicators

� RAC review

20

MT Responsibilities

Produce a Quality Document

� Always comes first

Accept that you will make edits

� Speech recognition is not perfect

Edit efficiently


Edit efficiently

� Learn to make edits quickly

21

A New Mindset

Editing is more than learning keyboard shortcuts…

An MTE must:

� Overcome “the power of suggestion”efficiency


� Overcome “the power of suggestion”

� Attend to a bi-directional flow of information

22

efficiency

Exercise 1

How many F's does the following passage contain?

Finished files are the result

of years of scientific study



combined with the experience of years.

23

Exercise 1

How many F’s did you count?

Did you get 3? If so, you missed a few.

There are actually six F’s in the passage…


There are actually six F’s in the passage… don’t forget to count the of’s.

Finished files are the result


combined with the experience of years.

24

Exercise 1

Read the following sign. Are you sure you read what you thought?

ILOVE


LOVEPARIS IN THE

THE SPRINGTIME

Exercise 1

Read the following sign. Are you sure you read what you thought?

A


ABIRD

IN THETHE HAND

Human vs Machine “thinking”

“The patient’s mother brings him in today after referral from hispediatrician.”

“She says he has had several ear


“She says he has had several ear infections in the last year and he thinks he might need to have tubes placed.”

27

Human vs Machine “thinking”

“May I see your pen”


“May I see your pen”

28

Expectations

1. There WILL be edits!!

2. Quality will improve, but only to a certain extent

3. Variables to quality

1. Use of incorrect IDs


1. Use of incorrect IDs

2. Audio or voice quality

3. Doctor's dictation habits

4. Disorganized dictation

5. Background noise

6. Highly customized account instructions

29

“Draft” text as a tool

� Consider the “pre-edit”

� Use the context

� Use previously dictated terms to fill in blanks

� Use the draft to research unfamiliar terms


� Use the draft to research unfamiliar terms

When in doubt – look it up!

…..Never assume the draft is correct!

30

Proficiency tools

What is a Keyboard Shortcut?

� Navigational – move from here to there

� Editing – Make changes and corrections

� Rearrange and replace

� Move and manipulate


� Move and manipulate

� Application – Command and control

31

Skill Impact


The Basics

� Home

� End

� UP/DOWN Arrow

� Right/Left Arrow


The “Helper” Keys

CONTROL

� Makes the action BIGGER

� One word instead of one character

� One paragraph instead of one line

� End/Beginning of document instead of


� End/Beginning of document instead of End/Beginning of line

SHIFT

� Selects or “highlights” the text

� Prepares you to take action

� Delete or type-over

� Move or Copy 34

More Shortcut Basics

Application Shortcuts –

� Switching from one application to the next

� Saving your work

� Opening a new window


Shortcuts –

� Alt+Tab

� CTRL+N

� CTRL+S

35

The OOPS Keys!

� CTRL+Z: Un-do (woohoo!)

� CTRL+Y: Re-do

� F7: Spellcheck


Editing Practice


How would you –• Delete the red words?• Replace the purple phrases?• Change letters in the green words?

Participate!

Volunteer –

• Meetings

• Discussions

• Voluntary training


Listen

Ask questions

Learn from those with positive messages

Speak up

38

Practice

Take every opportunity

• Sharpen editing skills –

• Attention to detail

• Practice shortcuts


Patience!

Give yourself a break!


Persevere!

Remember the lesson of your first difficult dictator…


Positive!

• Avoid the nay-sayers

• Surround yourself with those determined to succeed

• You CAN do this!


The Career Minded MT

43

The Career-Minded MT

� Professionalism

� Remote workers

� Scheduling

� Productivity based pay

� The Independent Contractor


� The Independent Contractor

� The “hobby MT”

� I’m not budging

� Compensation

� Training and education

� Credentialing

44

Measuring Success

� Increased % gain is only one metric to be monitored!� Increased OUTPUT = organizational efficiencies!


FACT!!MTE 2 with a 50% gain will produce 450,000 more lines over the course ofa year than MTE 1 with a 125% gain!!!

Output versus “% Gained”


Managing for Efficiency

47

Balancing Efficiency and Requirements

Dictation Practices

No change for doctors

Pro

duct

ivity

Pro

cess

Level


Pro

duct

ivity

Pro

cess

Level

Productivity Analysis

�Optimal Account Implementation

�Strong Performance Management

Strong Workforce Management

�Physician and HIM best practices

�Standard requirements

�Tiered Pay Structure

80%

>100%

>90%

Verbatim Editing


�Basic SR Implementation

�Technical implementation

�Minimal training

�Account conversion

�3 - 6 months experience (FT – PT)

�Basic Performance management

�Basic workforce management

�Strong Workforce Management

25%

50%

How Do You Measure Productivity?


Workforce Management

Output –not “% Gain”

Editing –Typing

distribution

Headcount Impact

� Output – not “% Gain”

� Editing – Typing distribution� 75% rule

� Use productive typists


Workforce

Management

n

FTE/PTE work

assignment

Gap Analysis

� FTE/PTE work assignment

� Total efficiency –� Headcount impact� Gap analysis � Assign editing to high producers

Performance Management

Effective

Training

Weekly

Mentoring

Final Document

Quality

• Monitor final quality

• Effective training

• Ongoing Mentoring


Performance

Managemen

t

Mentoring

Most-Common

Edits

KeyboardShortcuts

Quality

• Basic editing skills

• Can your MTEs quickly –• Create sections/subsections• Create numbered lists• Replace incorrect text• Insert text

Back to Basics

� Valuable Implementation

� Meaningful Documentation

� Useful Documentation

� Partnership

� Be the expert


� Be the expert

53

Physician Adoption

We can’t rely on lack of adoption to save us for long…

� Power shift - Physician to CFO

� Physicians will eventually be forced

� Alternative methods -


� Alternative methods -

54

Document Elements


Meaningful Documentation

Old Ways

• Sacrifice content for productivity

• “You get what you say”

Or

New Way

� Standards based on usefulness

� Expert service provider

Focus on content


• Customization

• Invisible service provider

• Focus on print format

• Reactive to complaints

� Focus on content

� Proactive to needs

56

Standard Content

What content is required in each document type for –

• Patient care

• Coding and billing and revenue cycle tasks

• Compliance


• Compliance

• CMS

• Pay for performance

• Quality improvement – PQRI

57

Service Level Options

� Lowest Cost Line

� Optimal Cost Reduction

� Meaningful Clinical Document

� Useful clinical documentation

� EMR readiness


� EMR readiness

� Useful documentation

� Premium Service

� Retention of demanding difficult customer

� Customization

� Keeping speech invisible


Lowest Cost Line

� Attract the low-cost seeking customer

� Retain the high-priced existing customer

� Financial incentives to hospital

� Driven by draft quality

� Hospital requirements changed to


� Hospital requirements changed to accommodate

� Transcription “as dictated”

� Most accurate drafts

� Highest productivity

� Involved at typing stage if possible


Meaningful Clinical Document� Standards based on useful content

� Highest quality for patient care

� Compliance� CMS

� JCAHO

� Ease of use for healthcare providers


� Ease of use for healthcare providers� Physicians

� HIM

� Risk management

� EMR readiness� The Health Story

� Content requirements

� CDA4CDT

� HL7 CDA

M*Modal Proprietary and Confidential

Premium Service Offering

� Keep the demanding customer

� Speech invisible to hospital

� Customized requirements

� Expectations for productivity adjusted

� Optimal account implementation including


� Optimal account implementation including

� DMs to the work type and physician level

� Rendering automation

� Requires highest level of MTE skill

� Appropriate MT compensation

� Appropriate hospital billing


Premium Service Offering

Cost Impact

� High-cost implementation

� Customization =

� Lower productivity

� Higher transcription production costs


� Higher implementation cost

� Lowest productivity benefit

� High-range line rates for MT

� Value proposition

� Invisible to healthcare provider

� Satisfy demanding physicians62

Speech Technology and Pricing

Warning!

� Beware of demands for customization at the price of a low-cost line

� Don’t provide a Cadillac for the price of a bicycle


bicycle

� Educate customers about what they are paying for

� Would they rather pay for –

� Physician specific preference

� Meaningful Clinical Documents

63

Transcription and the HIM

Re-connect with your HIM roots!

� What are the documents used for?

� Are they used for coding?

� If not, why?

� What works?


� What works?

� What’s missing?

� “What can I do to make this document more useful?”

64

Coding – ICD-9-M

Wanted – more documentation!

� 3 – 5 digit codes

� Additional digits add specificity

� “unspecified” is bad

� Severity indicators - resource consumption


� Severity indicators - resource consumption

� CC – Complications and Co-morbidity

� MCC – Major CC

� MS-DRG

65

Coding – ICD-10

And even more documentation!

� ~ 5x the number of codes

� Lots more specificity required


The CDI Specialist

The value of complete, comprehensive information…

How can transcription help?

� “ICD-9-CM Coding Essentials: What every CDI Specialist needs to know”


CDI Specialist needs to know”

� CCDS credential

� Focus on documentation affecting the DRG (diagnosis Related Group) and payment

67

More information

� Always Understanding – MT Editing

http://mmodal.wordpress.com

� Management for the Modern MTSO


� Management for the Modern MTSO

http://mmodal2.wordpress.com

68

Step Away from the Mouse….

….And let’s get started!


Questions?

70