Are you for real

Are you for real? [2008-04-08]
Yes!!!! This is a profession. Any key our fingers touch, push, punch, or click should be counted, and we should be paid accordingly. By the way, I feel we should be paid more too. How do you like them apples?? Don't like it? India is always an option.

Study on outsourcing -- For Real! [2008-04-08]
Put this under your hats, but there has been a study performed in Ohio regarding the cost effectiveness of outsourcing transcription versus bringing American MTs onboard to handle all of it. Oh, happy day!! The concensus is ..... sit up and read this twice ...... it is more lucrative to hire more people who are skilled and pay them a nice hourly rate with benefits than tooutsource some or all of the work.Hang in there. What goes around, comes around. It's about timethat the true cost effectiveness of inferior work be scrutinized. There are managers and QA's and editors and customer service people up the ying-yang who may have to worry a bit because I truly feelthat doctors across the county (many of whom have invested in outsourcing medical transcription)are beginning to realize that it definitely is a skill/profession that needs to stay here in The States. Woooohooo!

Real nice to know [2006-03-29]
that the doctor has so much more respect for a machine than he does the human ears that have to make a living listening and typing the reports day after day! This is what the doctor said... “Try a few charts each day, and sit down where it’s quiet, where you can relax and concentrate on your speaking habits. Tech support is great; they’ll help you, and be sure to read the help file “How to Speak to a Computer”—and the manual. Especially for often repeated phrases, the voice-actuated “macros” are great, a real time-saver. It’s well-worth the time you invest in learning how to use this tool.” What are the pitfalls? “Mumbling,” says Dr. Block, “that’s the main problem. Doctors are used to dictating in a low, monotone mumble, as fast as they can. A person might be able to handle it by going back and listening to the recording again and again. But for voice recognition, doctors need to speak in a normal, conversational tone of voice, just like we are doing right now. Speak normally, and Dragon has no problem, it works very well. It’s really quite simple.”

you get what you pay for - [2008-06-20]
I attended M-TEC, graduated in 2001, and have been working at home doing acute care ever since. I cannot say enough good things about their program or about Kathy and Susan (who were reallythe only instructors back then, not sure about now). I had recruiters banging down my cyber door to test when they learned where I had gone to school. I tested with a few of them and had job offers within a few days of graduation. Many, many companies will waive the 2-year experience requirement if you graduate from M-TEC. I hear Andrews is also very good. You cannot go wrong with either of them. Remember, cheap, quick, and easy will not sustain you in the long run because you will be ill equipped for work in the real world. Best of luck.

i so don't agree w/this post...I made more doing [2007-02-18]
so I continue to say to the newbies to the field, be careful what you read on these types of bulletin boards and/or forums - everyone's experience is different and please do not book your $$ on people whose experiences have not been as good as others..... I'm telling you, I'm in this biz close to 30 years and 10 years on my own and this year I made a fewgrandmore in $$ working for a nat'l than last year.......... If you plug it out, stick to a schedule,it still can be done, and I'm doing editingtoo (love it, easier on hands) and am twice as fast as I am on regular typing reports so.......again, some are just AGAINST editing, whereas I LOVE editing (did it 30+ yrs ago for a newspaper)..... Best of luck - remember to try to be optimistic (glass half full) versus choosing to be pessimistic (glass half empty) - THAT, TOO, WORKS REAL WELL.........

CBaySystems Introduces CBayFlo VoiceDirect [2006-07-07]
ANNAPOLIS, Md., July 6 /PRNewswire/ -- CBaySystems Services, Inc., one of the industry's fastest-growing providers of medical transcription solutions, today announced the general availability of CBayFlo VoiceDirect -- its own automated digital dictation and voice capture system. Using CBayFlo VoiceDirect, everyone involved in the medical transcription process -- physicians, HIMs, and transcriptionists -- is able to take advantage of greater speed, quality and security, from capture, to review, to transcription, to approval, to records management and archiving. At its core, CBayFlo VoiceDirect enables physicians to dictate into any digital recording device -- a PDA, tablet PC, desktop or phone -- and have it securely captured for transcription. Highly accurate, and featuring natural language processing, it eliminates the time and cost of manually transcribing recorded dictation. With the introduction of CBayFlo VoiceDirect, hospitals who are dependent on expensive, proprietary dictation systems from Dictaphone, DVI, and Lanier can enjoy new freedom and flexibility. CBayFlo VoiceDirect incorporates the same features and quality at a significantly lower price. At the same time, it is built on an open technology platform that allows it to interface with legacy Dictaphone, DVI, Lanier and home-grown systems. This allows a smooth migration path (with zero training) as well as easy integration with other HIM systems. By developing our own technology, we're able to seamlessly integrate the power of voice into every component of our CBayFlo platform, said Christopher Foley, President of CBaySystems Services. Our commitment to RD means we're no longer reliant on a third party system, and can deliver more of the benefits from this powerful technology -- and significant savings -- directly to our customers. Some of the specific benefits of CBayFlo VoiceDirect include: * High security and voice quality -- resulting in better quality records, and easier workflow * Compliance with the latest HIPAA regulations and technologies * Customized/advanced reporting capabilities, through a secure web portal: making it easy for HIMs to review and manage the entire workflow process Part of a Comprehensive CBayFlo Technology Suite CBayFlo VoiceDirect is just one of the components of the CBayFlo System -- a fully-integrated technology platform that manages medical transcription records at every stage of their lifecycle, from dictation and scheduling, through transcription, editing, web-based management, and long-term archiving. Unlike other systems that force hospitals into a fixed process, CBayFlo is flexible and customizable to work the way you want to work. All processes and workflows can be configured to your exact business and information/reporting requirements. Specific components of this powerful technology platform include: * CBayFlo DocView: advanced document viewing/editing/reporting * CBayFlo VoiceRecord: software for PDAs and digital recorders that allows voice to be uploaded to the web, and offloaded to a dictation server for transcription * CBayFlo eDemographics: an HL7 interface engine to exchange data with other HIM and patient records * CBayFlo Enterprise Document Manager: hospitals can manage and track the transcription process through a web-based portal -- CBayFlo DocuTrack: real-time updates of the status of each record and file -- CBayFlo DocView: document view/edit -- CBayFlo E-signature: document e-sign -- CBayFlo DocXchange: an HL7 compatible interface engine As an ASP application (no additional hardware or software is required for the hospital to purchase), CBayFlo is extremely secure and reliable, with multiple levels of redundancy incorporated into its standard architecture. The CBayFlo platform represents an important component of the WorldClass Advantage we deliver to our customers every day, noted Foley. By providing advanced technology, hospitals and physician practices can significantly reduce costs and save time -- allowing them to devote more resources to improving patient care.

Real nice to know [2006-03-29]
that the doctor has so much more respect for a machine than he does the human ears that have to make a living listening and typing the reports day after day! This is what the doctor said... “Try a few charts each day, and sit down where it’s quiet, where you can relax and concentrate on your speaking habits. Tech support is great; they’ll help you, and be sure to read the help file “How to Speak to a Computer”—and the manual. Especially for often repeated phrases, the voice-actuated “macros” are great, a real time-saver. It’s well-worth the time you invest in learning how to use this tool.” What are the pitfalls? “Mumbling,” says Dr. Block, “that’s the main problem. Doctors are used to dictating in a low, monotone mumble, as fast as they can. A person might be able to handle it by going back and listening to the recording again and again. But for voice recognition, doctors need to speak in a normal, conversational tone of voice, just like we are doing right now. Speak normally, and Dragon has no problem, it works very well. It’s really quite simple.”

Medical Transcription Recognized as an Apprenticeable Occupation [2006-03-14]
CHICAGO--(BUSINESS WIRE)--March 10, 2006--Graduates of selected medical transcription training programs will now have access to registered apprenticeship programs, as the U.S. Department of Labor (DOL) has now declared medical transcription to be an apprenticeable profession - the first step in establishing a national apprenticeship program. The Office of Apprenticeship Training, Employer and Labor Services approved the application for apprenticeability determination submitted by the Medical Transcription Industry Association (MTIA) along with the American Association for Medical Transcription (AAMT). Having a recognized apprenticeable occupation will provide a pipeline of medical transcription professionals entering into a workforce facing a serious labor and skills shortage. stated Keith Flannery, Vice President, MTIA. Workforce development under the standards established by this apprenticeship program will aid in facilitating the transition between student and an employable, productive, and qualified medical transcriptionist. Given the challenge the industry faces in recruiting qualified candidates to meet the ever-increasing demand for real-time, quality healthcare data, a registered apprenticeship program couldn't be developed and launched at a more critical time, stated Peter Preziosi, PhD, CAE, AAMT Executive Director. Workforce development is essential to ensuring that documentation experts are in place to assist the industry in transitioning to an electronic health record and to preserving the quality and integrity of the health record in that future. The Registered Apprenticeship Program, sponsored by the Medical Transcription Industry Association (MTIA), will offer structured on-the-job learning and related technical instruction for qualified medical transcriptionists entering the profession. The two associations, along with the Office of Apprenticeship Training, Employer and Labor Services, are finalizing program details. Medical Transcription is a crucial process in the provision of quality healthcare in our country. This is a hallmark program for the industry, said Sean Carroll, President, MTIA.

Experience & proficiency requirements [2006-03-01]
What are the experience and proficiency industry requirements for U.S. MTs? Per this article (http://www.fortherecordmag.com/archives/ftr_071805p26.shtml), Competition from overseas sources is also emerging in large part due to the lack of minimum wage laws in those countries. Low entry-level wages and lack of adequate compensation for skilled, experienced MTs have discouraged many individuals from selecting medical transcription as a viable career option at a time when the MT workforce is aging. Compounding the problem is the fact that many new MT graduates are not able to find employment because they are unable to meet experience and productivity requirements for U.S. MTs as mandated by the industry. A real eye-opener to say the least. Wholesale giveaway of good quality American workers.

Neurologist saves $12,000 per year on medical transcription [2006-02-22]
Recognition vs. Transcription W. Palm Beach, FL neurologist saves $12,000 per year on medical transcription using state-of-the-art voice recognition software [ClickPress, Tue Feb 21 2006] Dr. H. Steven Block, M.D. uses Dragon NaturallySpeaking Medical Edition, voice recognition software for medical professionals, to eliminate a very real business problem--medical transcription costs-- which six years ago, began topping the $1,000-a-month mark. Today, a doctor can easily spend three times that amount. Very open about his high regard for the Dragon Medical VR product, Dr. Block had much to say about its place in his solo practice: “I purchased Dragon Medical from Eric Fishman’s company, Nuance, which is actually located in the same building as my practice, on the floor above me. Neurology is all about ‘nuance’, no pun intended. But ‘nuance’ is really the best word to describe the health effects of a neurological problem. It has been a major focus of my practice.” “Very subtle neurological changes can have devastating health consequences. You have to be able to communicate those subtleties in order for a medical record to have any meaning.” “I see some really sick patients. Using an on-the-spot note generation product like Dragon, instead of a transcription service, let’s me get back to the referring physician with a fast note, usually within 10 minutes of seeing the patient. That kind of speed in delivering a medical exam note with ‘nuance’ can mean a great deal to everyone involved. You see, I can’t type. I never learned how to type. My kids who grew up instant-messaging can type faster than I can speak. They don’t need Dragon. But for me, Dragon is a wonderful tool.” Dr. Block, 49, is no stranger to high technology tools: “There are only so many hours in the day,” he laughed, driving down the road, talking via wireless cell phone headset, “and I’m very detail-oriented. I couldn’t be without Dragon, quite frankly.” One word I did not hear from Dr. Block is the word “downtime”. It doesn’t seem to exist in his vocabulary. Having traveled the long and winding upgrade path for both Dragon and laptop hardware, Dr. Block has watched and participated in the evolution of the product for six years. “Like a surfer looking for the perfect wave,” he joked. The improvement he’s seen in the most recent version of Dragon Medical—combined with a high-RAM laptop with at least 512MB—has boosted performance to an almost unbelievable 99.5% real time voice recognition accuracy level, according to his observations. His advice to new users: “If you haven’t tried Dragon Medical in the last four years,” he said, “try it again, the way it is now, with the new speech engine. It uses mathematical models to analyze word groups. There is a learning curve, but the training is not that bad, consisting of you reading a 15 minute script into a microphone, then a little touch-up here and there.” “Try a few charts each day, and sit down where it’s quiet, where you can relax and concentrate on your speaking habits. Tech support is great; they’ll help you, and be sure to read the help file “How to Speak to a Computer”—and the manual. Especially for often repeated phrases, the voice-actuated “macros” are great, a real time-saver. It’s well-worth the time you invest in learning how to use this tool.” What are the pitfalls? “Mumbling,” says Dr. Block, “that’s the main problem. Doctors are used to dictating in a low, monotone mumble, as fast as they can. A person might be able to handle it by going back and listening to the recording again and again. But for voice recognition, doctors need to speak in a normal, conversational tone of voice, just like we are doing right now. Speak normally, and Dragon has no problem, it works very well. It’s really quite simple.” He stated that using a handheld Sony digital voice recorder with removable memory stick allows him to dictate anywhere, anytime, then later, “feed” the sound file to Dragon, achieving about 98% voice recognition accuracy. (Please note: If you are considering making a recording for later voice recognition by Dragon, be sure and use 16-bit resolution .avi format, or Dragon won’t even try to “digest” it. It won’t bother with a recording of poor quality, because the end result would be useless.) Although he is considering it, Dr. Block has not yet adopted a commercial EMR(Electronic Medical Records) software system for his medical records, mainly because of concerns about interoperability standards. (Coming soon to an EMR near you.) However, by using Dragon Medical as his “front-end” for the creation of detailed paper medical records, email reports, and digital-FAX messages, Dr. Block not only uses computers, but has also created a highly personal and expressive way to “chart” a patient, unmatched in detail, depth, and the “human touch” by out-of-the-box EMR software. Would EMR software developers do well to discuss with this doctor any design plans for a voice-controlled, voice-recognition-based EMR program? I think so. Will a “hands-free” EMR workstation which responds to voice commands--as does the entire Dragon program--ever be used to help maintain a “sterile field” in the medical environment of the future? It certainly worked well on the Starship Enterprise, didn’t it?

HL7 Launches eHealth Effort for Katrina Relief [2005-09-30]
The Health Level Seven, Inc. (HL7) community is supporting the development of portable, interoperable electronic health records for the hundreds of thousands of people whose lives have been disrupted by Katrina. Many HL7 members are already involved, improving access to vital healthcare information and HL7 has formed a task force to support and guide further efforts. Last week, HL7 issued a call to members to participate and is forging relationships with other industry groups to solve the immediate and long-term problems of disaster relief and preparedness. The HL7 community represents the most concentrated group of interoperability expertise anywhere. We are rising to the challenge of rebuilding the medical records of the displaced population and doing so in a way that can become a model for the future of the country, says Mark Shafarman, HL7 Chair. We stand ready to work with anyone and everyone implementing standards-based applications. Our Reference Information Model for healthcare, our community of experts and our standards and specifications for interoperability can guide this process. The Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record Vendors' Association (EHRVA) is already working with the Office of the National Coordinator for Health Information Technology (ONCHIT) towards constructing and integrating an electronic health record (EHR) infrastructure within the areas of the gulf coast affected by Hurricane Katrina. HL7 Standards Making a Difference HL7 standards are already making an impact on the ground in the wake of Katrina providing access to records of childhood immunization records. The American Immunization Registry Association (AIRA) (www.immregistries.org) -- an HL7 member organization -- reports that nine registries are now using HL7 messages to query the Louisiana Immunization Network for Kids Statewide (LINKS), resulting in retrieval of 4,250 records as of Tuesday, September 27. Immunization registries querying LINKS are: Arizona, Houston, Idaho, Indiana, Maryland, Ohio, Washington, West Virginia, and Wyoming. The importance of HL7 standards was never more evident than during Katrina, said Julie A. Boom, M.D., Medical Director, Houston-Harris County Immunization Registry and Director of the Immunization Project at Texas Children's Hospital, and AIRA member. Literally overnight, the Houston-Harris County Immunization Registry was able to be connected to the 'LINKS' Louisiana statewide immunization registry with the assistance of Scientific Technology Corporation. Because each registry was fully HL7 compliant, this link was able to be made quickly and easily. Retrieving these records from LINKS has saved the public health community thousands of dollars for the cost of re- immunizing these children and it saves the children of Louisiana from the discomfort of additional immunizations. This experience truly highlights the importance of following national standards and should encourage other immunization registries to fully support HL7 standards as soon as possible. More solutions are in the works: * Oracle Corporation, an HL7 benefactor, had been working in close cooperation with the Louisiana Department of Health and Hospital to create a regional solution for health information sharing before the hurricane struck and is now accelerating those efforts. * HL7 member organization OZ Systems, which provides information technology for the State of Texas' Early Hearing Detection and Intervention Program (TEHDI), is exploring ways to use HL7 messaging standards to transfer hearing screening results data for Louisiana newborn evacuees who had to have their screenings done in Texas. This data needs to be sent back to respective birthing facilities in Louisiana or the Louisiana Department of Health as needed for CDC reports, or to assure that an infant receives care if necessary. * Intel Corporation is coordinating the donation of 1,500 laptop personal computers to the American Red Cross for distribution to shelters in support of Katrina disaster relief efforts. In addition, Intel will donate 150 wireless Internet access points. * Additional support for the Gulf region has been pledged by HL7 members including the Los Angeles County Department of Health Services, Information Systems Branch; Medquist Corporation; Microsoft Corporation and TeleVital. HL7 and its more than 2,220 individual and corporate U.S. members have information technology expertise in all segments of the healthcare industry, and real-world experience in developing an infrastructure that is standards based and allows interoperable records to be distributed over multiple sites using multiple local applications. In addition, HL7's more than 500 corporate members include not only EHR vendors, but infrastructure and integration vendors together with suppliers of standards-compliant dictation and transcription. HL7 Response and Recovery Taskforce The HL7 Response and Recovery Taskforce has been meeting daily, speaking with government officials, technologists and planners. The Task Force will coordinate education and outreach to the HL7 community including vendors and providers, HL7 International Affiliates as well as other standards development organizations, and U.S. national bodies such as the Office of the National Coordinator for Health Information Technology (ONCHIT), the Department of Defense (DoD), the Veterans Health Administration (VHA), and the Centers for Disease Control and Prevention (CDC). The Taskforce will design, coordinate and organize implementation projects focusing on the creation of a healthcare information infrastructure to help address the personal and public health information crisis created by Katrina. HL7 members wishing to be involved in this effort should respond via katrina@HL7.org and sign onto the Katrina support listserv available on the HL7 web site (www.HL7.org). Participation by EHRVA In the aftermath of Katrina, the EHRVA has been actively engaged with the Office of the National Coordinator for Health Information Technology (ONCHIT) and other healthcare stakeholders to support the potentially nomadic evacuee population in the goal of making medical record information available wherever they receive care. * The EHRVA is on task of suggesting immediate means to meet emergency patient information needs and laying the groundwork for rebuilding a patient information management infrastructure. During this process, the EHRVA is dedicating workgroup and executive committee time to plan a practical framework. * EHRVA contribution to Katrina Relief leverages the organization's partnership with IHE and an ongoing commitment to devise viable interoperability models. * EHRVA is in dialogue with ONCHIT and channeling updates and requests to members to support roll-out of response plans now and in the near future. EHRVA has joined with HL7 in this call to members to participate and pool resources for interoperable electronic health records. The two organizations are ideal partners in this effort, since two of their core goals are based on making progress in the areas of standards and interoperability. EHRVA is comprised of 35 member companies that serve the vast majority of healthcare providers in the nation with Healthcare Information Technology (HIT) solutions, which complements and overlaps with HL7's membership. Since Hurricane Katrina we've been humbled by the dedication of our clients in hospitals and physician practices as they have brought EHR technology into the heart of the crisis. We are taking our cues from providers who are working from the conviction that a stronger HIT foundation will better prepare us for any eventuality such as these recent storms, said Charlene Underwood, EHRVA chairperson and Director, Government and Industry Relations for Siemens Medical Solutions. Collaborative Efforts toward a Regional Recovery The HL7 community has the largest single pool of expertise on healthcare information systems and how to connect them for effective collection and delivery of healthcare information. Its members are active in efforts with state and local and national agencies, including the Department of Health and Human Services and the Centers for Disease Control and Prevention. In addition to EHRVA, HL7 is offering to collaborate with all organizations providing solutions for the affected area. About EHRVA HIMSS EHRVA (http://www.himssehrva.org) is a trade association of Electronic Health Record (EHR) vendors who have joined together to lead the HIT industry in the accelerated adoption of electronic health records in hospital and ambulatory care settings in the US. The association provides a forum for the EHR vendor community to speak with a unified voice relative to standards development, the EHR certification process, interoperability, performance and quality measures, and other EHR issues as they become subject to increasing government, insurance and provider driven initiatives and requests. Membership is open to HIMSS corporate members with legally formed companies designing, developing and marketing their own commercially available EHRs with installations in the USA. The association, comprised of 35 member companies, is a partner of the Healthcare Information and Management Systems Society (HIMSS) and operates as an organizational unit within HIMSS. About HL7 Founded in 1987, Health Level Seven, Inc. (http://www.HL7.org/) is a not- for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services. HL7's more than 2,000 members represent approximately 500 corporate members, including 90 percent of the largest information systems vendors serving healthcare. HL7's endeavors are sponsored, in part, by the support of its benefactors: Accenture; Centers for Disease Control and Prevention (CDC); Duke Clinical Research Institute (DCRI); Eclipsys Corporation; Eli Lilly Company; the Food and Drug Administration; GE Healthcare Information Technologies; Guidant Corporation; IBM; IDX Systems Corporation; Intel Corporation, Digital Health; InterSystems Corporation; Kaiser Permanente; McKesson Provider Technologies; Microsoft Corporation; Misys Healthcare Systems; NHS Connecting for Health; NICTIZ National ICT Institute for Healthcare in The Netherlands; Oracle Corporation; Partners HealthCare System, Inc.; Pfizer, Inc.; Philips Medical Systems; Quest Diagnostics Inc.; Science Applications International Corporation; Siemens Medical Solutions Health Services; Solucient, LLC; the U.S. Department of Defense; Military Health System; the U.S. Department of Veterans Affairs; and Wyeth Pharmaceuticals.

Philips, Citrix Co-Operation Enables [2005-09-21]
Philips, Citrix Co-Operation Enables Speech Recognition and Digital Dictation for 50 Million Professional Users World-Wide VIENNA, Austria--(BUSINESS WIRE)--Sept. 20, 2005--Royal Philips Electronics (NYSE:PHG)(AEX:PHI) announced today the release of an enhancement to the professional document creation platform SpeechMagic(TM) enabling for the first time adequate speech recognition in Citrix(R) environments. With SpeechMagic supporting 23 recognition languages and providing a portfolio of more than 150 recognition vocabularies for the medical, legal, governmental and financial sectors, potentially more than 50 million Citrix users worldwide can now benefit from increased documentation efficiency and reduced operating costs. The deployment of speech recognition and digital dictation applications from Citrix servers will be a key factor in more efficient documentation workflow. It will also enable the centralization of IT administration, and bring critical speech recognition features such as automatic learning and acoustic adaptation - significantly reducing the strain on financial and human resources. By centralizing applications and the delivery of data, Citrix and SpeechMagic are able to provide an extremely high level of security (no files are stored locally), dramatically improving the protection of personal data. By adding bi-directional audio capabilities, Citrix enabled the digital recordings to be uploaded and Philips developed a real-time speech recognition channel. This channel improves the usability of dictation hardware, such as the industry-leading Philips SpeechMike and allows for the deployment of the full range of speech recognition features within a Citrix environment. Numerous authors can now dictate simultaneously anywhere within the Citrix network and either delegate the dictation to a secretary/ Transcriptionist or correct it themselves. Citrix infrastructure is popular with large institutions in the healthcare, legal and finance industries. With SpeechMagic being geared towards industrial-grade document creation, our award-winning platform has been optimized for these industries, says Marcel Wassink, Managing Director Philips Speech Recognition Systems. This co-operation with Citrix opens the door to a vast new market for Philips and its partners. As a worldwide leader in Speech Technologies, we're delighted to be working closely with Philips. SpeechMagic brings tremendous value to our customers in significantly increasing their documentation efficiency and hence improving the return on their investment in Citrix Access Infrastructure, said David Jones, corporate vice president, business development, for Citrix. SpeechMagic for Citrix will be presented live at the Citrix(R) iForum(TM) Global conference in Las Vegas, Nev., on October 9 - 12, 2005. The new component to the SpeechMagic platform will be released to the Philips global network of more than 200 integration partners on September 20, 2005.

Losing medical integrity [2005-08-05]
Losing medical integrity By Pius KamauDenver Post Columnist Not too long ago, all my local transcriptionist had to do was call me when she couldn't understand something in my medical dictation. Now, I no longer know who transcribes reports of my surgical procedures and physical exams or where they are. I only know that most hospital transcriptions have been outsourced. At times, the resulting inaccuracies are incredible or enormously amusing. Transcription is only one of many medical fields facing outsourcing, which is rapidly making inroads into American health care. The stability of medicine is being chipped away to satisfy America's Wal-Mart belief that cheaper is better. While the public prefers not to know how fundamental changes in health-care delivery may be adversely affecting it, real harm to patients has resulted from outsourcing. Recently a lab that processed specimens from across the nation was found to have misinterpreted Pap smear results. In some cases, a pathologist hadn't actually read some slides. Such labs aren't chosen because they do a better job than local pathologists. Simply put, they're cheaper. Cost-cutting is the new mantra, and shoring up profits the prevailing credo in a world where the quick fix trumps the long-term, universal good. The net result has been to throw many competent lab techs out of work. Valuable, highly qualified people have forever been lost to the medical world. My former medical transcriptionists were used to my accent, and offered occasional advice on how Americans pronounce certain words. They were replaced by others who find American speech heavily accented and sometimes indecipherable. Hospitals are not factories; they don't manufacture screwdrivers or light bulbs. Hospitals are small communities, where sundry departments and personnel form a mosaic that fulfills the essential function of the institution: to heal the sick. It's a cohesion that has slowly been dismantled to squeeze out more profits for investors and HMO moguls. The practice of medicine is unique in that each person in the system plays a vital role. Frequently, we discuss puzzling radiologic images, weird pathological presentations, and brainstorm difficult surgical cases in corridors and lunchrooms. Unfortunately, there's now a move to outsource imaging technology as well as other forms of testing and therapeutic modalities. Without casting aspersions, I believe many of us wouldn't like to discover that our scans are read in Beijing, Bombay or Manila. Hospital staff collegiality has suffered irrevocable damage. X-ray, lab technicians and other medical colleagues have been let go or moved away because their expertise was deemed useless. Change is inevitable. But it should always be geared toward making patient care better and safer, not jeopardized by profit- taking. It's conceivable that future insurance policies will offer several options: Pay more if you want care in local facilities or pay nothing if your treatment is provided in Mexico, South America or Africa. If you could save a few dollars, would you do the latter? Looking at this as well as other aspects of our failing system, it's easy to see that the businessmen we have entrusted our health care to will do anything they can to shortchange the public, as long as we let them. The question is: What will it take before we all say enough? I want my transcriptionist down in my medical records office. I don't want to talk to a radiologist in Bombay or Nairobi about a patient in Denver. I want a pathologist I can interact with on a regular basis. Surely you don't want your surgeon to be located in Guadalajara? Pius Kamau of Aurora is a thoracic and general surgeon. He was born and raised in Kenya and immigrated to the U.S. in 1971. His column appears on alternate Wednesdays.

Electronic Health Records: Just around the Corner? Or over the Cliff? [2005-08-02]
We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment. Policymakers and physician leaders are counting on electronic health records to improve quality of health care and revitalize practice , and a recent report forecasts that widespread use of electronic health records will save the health care system $77.8 billion annually—5% of total health care expenditures in the United States. It is difficult to get an accurate figure for use of electronic health records by primary care physicians, but estimates range from 5% to 13%. Seventy-eight percent of physicians in the United States practice in groups of 8 or fewer; therefore, understanding and overcoming the obstacles faced by small practices will be essential to successful use of electronic health records. Although the experience of small physician practices that implemented electronic health records has been usefully described, more work is needed. Our independent, community-based, 4-internist primary care medical practice went live with an electronic health record system on 14 July 2004. We report on our experience. Our medical practice, Greenhouse Internists, has operated in Philadelphia since 1989. We serve an economically and ethnically diverse urban and suburban population. We derive approximately 60% of our revenue from capitated managed care and participate in Medicaid (through 2 Medicaid health maintenance organizations) and Medicare (fee-for-service and capitated managed care). We handle more than 16 000 patients encounters yearly, and our focus is comprehensive ambulatory care. We have 1 registered nurse who handles clinical and administrative contact with insurers, forms, telephone triage, and routine prescription refills; a front desk staff that handles reception, referrals, and telephone calls; and medical assistants who handle chief symptoms, vital signs, phlebotomy, and electrocardiography. We have no mid-level practitioners. Before we instituted electronic health records, we used computers for scheduling and billing only. When our malpractice carrier stopped offering occurrence coverage and we had to accept claims made coverage, we used the 2-year savings window to invest in an electronic health records system. Our motivation was complex: We hoped it would automate frustrating repetitive processes (such as prescription refills) and minimize some of the ways in which we routinely failed to meet patient expectations (such as one of us not knowing what another had said the previous day to a patient on the telephone). We hoped that the system might pay for itself, but we were not at all confident that it would. We made a leap of faith that pay for performance was coming and that this investment would eventually position us for greater success. Like many of our colleagues, we believed that we would have to implement an electronic health record system sooner or later, and the one-time cash surplus made it possible for us to do so sooner. One of us had experience in managed care and population health and was hoping to use those insights at the practice level. We chose our system on the basis of recommendations of colleagues and because it was offered by a large national company. We hoped that the latter attribute would make it more likely that we could count on long-term support. We did not interview multiple vendors because we believed that all full-featured products would have unanticipated advantages and disadvantages. To support our electronic health records system, we needed to change the practice management system that was in place for scheduling and billing. To minimize the impact on physician–patient interaction, we opted for an encrypted wireless network with Tablet personal computers (Hewlett Packard, Palo Alto, California), which we purchased from a different vendor. None of the physicians was especially computer-literate. The total quoted cost of our system, including hardware, software, training, and 1 year of support, was approximately $140 000, which is within the range that other investigators have reported on a cost-per-physician basis. Staff and Physician Training Training meant different things to different team members. None of the physicians had previously used a Tablet PC with a Windows XP operating system (Microsoft Corp., Redmond, Washington), and we needed training on the device as well as on the new system. Some staff members had never used a mouse (our previous practice management system was not Windows-based). The medical assistants, who had previously made notes by hand, were now asked to use wireless-equipped laptops with mouse pads or track-ball pointers. For the system itself, 2 types of training were given. Super users were taught how to set up and administer the record (and therefore were enabled to make some structural changes to the system). Regular users were trained in basic system operation but were not given administrative training and privileges to make changes to the system. Super users were charged with customizing the system for our particular practice environment and developing work flows, which were clearly defined and documented steps to guide everyone on how to use the new system to accomplish the work of the office. After 2 rounds of planning meetings and 2 days of on-site training, we went live, meaning that we committed to using our electronic health record to document clinical care from that time forward. Training requires organizational redundancy or reserve; in a busy physician practice, neither is present. Our business manager incurred an injury that kept her out of work for 1 month before we went live; during that month, much of our focus became covering her core functions (payroll, billing, scheduling, and staff management) rather than training. For the first 3 days of live operation, we reduced our appointment schedule by 50%; thereafter, we attempted to maintain our schedule at two thirds for 2 weeks, but ongoing demand for appointments made this impossible. Hardware and Performance We had put in place a complex computer network that none of us knew how to support, maintain, or operate. Shortly after we implemented the practice management system, we experienced a virus attack that crashed our system. After the virus was removed, we experienced several lengthy losses of both telephone and data service. Identifying the cause of each of these system failures was a diagnostic problem well beyond our skills, with several possible corporate culprits. Before we went live, we had had a limited, inexpensive relationship with a small local computer support company; because we were paying annual support fees to both hardware and software vendors, we thought we would not need these local services after implementation. We were wrong. In fact, our relationship with the local company expanded rapidly in time, importance, and cost after implementation. Because we now rely on our system for core clinical functions (prescriptions, telephone calls, and accessing records), small technical malfunctions create major operational problems. Our expanded relationship with the local computer company now costs an unbudgeted $2000 per month, and the response time of our technical support is often inadequate. Redesign of Office Work Flow A well-run primary care office is a complex interdependent operation with well-defined work flows. General principles that guide the design of work flows in our office include simplicity and accessibility for patients, safety, comprehensive documentation, and delegation. We operate under the assumption that the physician is the most skilled, and most expensive, person in the office and should only do what no one other than a physician could do. Our entire office meets monthly for 1 hour, and weekly meetings of staff teams are held to adjust work flows as conditions or demands change. Responding to a request for a prescription refill, for example, requires 3 or 4 people performing interrelated but distinct tasks to deliver it safely, reliably, and promptly; we average 30 to 40 such requests daily. The collective integrated operation of our office thus represents 15 years of weekly and monthly staff meetings that constructed our functional systems piece by piece over time. On 14 July 2004, we had to redesign every office system we had in place. Our commitment that going live would mean that documentation of clinical care on or after that date would be created and found in the electronic health record seemed simple, but clinical care included not only office visits but telephone calls, prescription refills, handling of laboratory results, and other functions. Each of these tasks had a work flow, and all work flows had to be redesigned more or less simultaneously. A clear go-live date was desirable because, as a matter of patient safety, we needed to know where to look for information, and the longer we ran parallel paper and electronic systems, the harder that would be. The process of radically redesigning 15 years of accumulated work flow in a short interval was extremely stressful. The system we chose is designed for flexible application in a variety of settings, ranging from large integrated delivery systems to smaller practices. Although the vendor urged us to think through and document the new work flows in advance, we found ourselves making innumerable decisions about how we would use the system before we really understood how it worked, and our vendor did not know enough about how our office worked to help us. We were forced rapidly to adjust our work flows during implementation, which seemed akin to redesigning an airplane in flight. Decreased Competence and Increased Effort Going live rendered everyone in the office incompetent to do their core jobs. The front desk had to use new on-screen forms to record telephone messages; pairing electronic messages with paper charts required the file clerks to follow a new work flow; physicians had to find telephone messages on their computer desktop rather than neatly piled in a physical telephone message bin. The medical assistants had to record vital signs and chief symptoms in the computer and had to learn how to record results of a tuberculosis skin test, visual acuity test, or urinalysis. Everyone in the office simultaneously experienced pervasive anxiety and unhappiness. Waiting time for patients dramatically increased. In short, people were miserable at work. We began to have weekly full staff meetings and weekly physician meetings, all of which were more acrimonious than they had ever been. Variations in clinical style and work flow among the physicians—which had seemed acceptable if unnoticed before—now became a subject of group scrutiny. What did we have to change, and what could we hang on to? What did the physicians have to do the same way, and where could we tolerate difference? All these issues had to be renegotiated at a time of enormous stress on the practice. We observed that a culture of blame set in: Things were not going well, and it had to be someone's fault. Several staff members complained that the work environment was less collegial, and they often felt criticized, as one put it, by everyone. They did not associate these feelings with the electronic health record and, at least initially, neither did we. Coincident with our shared frustration came a dramatic increase in workload, especially for the physicians. Even when we had reached the point where we could competently use the new system, every patient represented a new patient to the electronic health record, and the old paper chart had to be abstracted and data moved into the electronic chart. Some aspects of chart abstraction could perhaps have been delegated (for example, entering medication lists or immunization histories), but we worried that our staff—who have only limited clinical training—might make mistakes, and decisions about what data to abstract require the clinical judgment of a physician. At first, the system shut down daily at midnight for backup and maintenance; backup was later moved to 2:00 a.m. to accommodate 2 of the doctors who were trying to work from home in the evening. The stress level in our office remained high for about 3 months, by which time we had seen most of our complex patients and entered their long medication and problem lists into the system. We had now begun to realize some of the benefits of computerization, including computer-generated prescriptions, faster access to specialist correspondence, real-time access to charts anywhere in the office, the ability to message or route information and tasks electronically in the office, and the ability for the same chart to appear on multiple desktops. Within 4 to 6 months, waiting time had improved and staff were more excited and confident. Patient Acceptance Patients have been impressed and pleased to see their prescriptions appearing on wireless-enabled printers sitting unconnected to our Tablets. They have also enthusiastically benefited from occasional use of the Internet or such tools as the National Cholesterol Education Program Risk Calculator during their visit. Some patients, however, found the increased waiting time during the early phase of implementation unacceptable, and many left our practice because of it. At a time when everyone in the office was stressed, our customer service skills were not at their best. Several patients have asked a version of a question posed by a supportive, long-established patient: Doctor, do you find you are spending more time interacting with the computer than with your patients? For a while, the answer was clearly yes. Financial Impact Our total annual budget for technology support before implementation was approximately $10 000, which comprised maintenance and support of our previous practice management system and limited network. Our postimplementation annual budget will be $40 000, which includes annual support payments to hardware and software vendors and our local computer support vendor. We will have $24 000 in annual carrying costs for the financing of our system purchase over the next 5 years. The clearest savings we have seen was from the elimination of $45 000 in annual transcription costs. Although the file clerks no longer do filing, they now scan and name correspondence (see the following description), and we have been able to eliminate only 1 staff position for an additional annual savings of $20 000. We expect savings on chart supplies to be offset by increased costs of toner and printer maintenance, technical support, and replacement of equipment. At best, we see the expense side as a wash. On the revenue side, we accrue no additional revenue from any current payer for having an electronic health record. We had already maxed out on most quality incentives for which we were eligible when we were using well-organized paper charts and office systems. The electronic health record may enable us to see more patients in the same time or offload physician work more reliably and safely because the system provides clear, timely, legible documentation to support expanded clinical team activities, but this reallocation will require substantial staff retraining. Within 1 year of implementation, we expect to free up our current file room space and perhaps make it clinically productive and revenue-generating. As an offset to these potential gains, it is possible (although unlikely) that physicians will be less productive because the electronic health record generates more work for them. For example, whereas the physicians used to dictate notes, they must now type them. Physicians must also participate more in filing. Our electronic system offers us 24 document types (for example, consultation or laboratory report), and each document must be assigned a type and given a name. Because accurate labeling and data entry are essential both to take advantage of the information retrieval capability of the system and to find anything once it is filed, the physicians must oversee and modify the categorization and manual input of key data elements. As a result, we often feel like data input drones. No wonder one of us described the new work flow as a physician speed-up. Computerization in a world without established standards that link medical data systems is inefficient. When we have a working interface, as we do with our main outside clinical laboratory (which handles about 80% of our laboratory testing volume), the reports come named, and the individual laboratory results automatically populate flow sheets and letters to patients. Results can be efficiently retrieved and graphed, and trends can be analyzed. Unfortunately, most of the information we receive (such as radiology reports, consultations, and procedure reports) does not come to us in a format that the system can recognize electronically. Our colleagues in integrated delivery systems and the Veterans Administration do not face this problem because most of their clinical data are generated within their system and the interfaces already exist. National standards on the interoperability of medical data systems would be a big step forward for small practices. For now, we may switch referral patterns to hospitals and specialists who will give us information in a form that flows most easily into our system. Lessons Learned It is naive to assume that small practices will move to electronic health records without a variety of supports, one of which is certainly financing. None of the many beneficiaries of our investment—patients, insurance companies, our specialist colleagues, health plans, our liability carrier—have directly shared in the cost of implementing an electronic health record system. Enhanced reimbursement models will be needed for wider adoption. This could be achieved through performance incentives tied to implementation of such systems in capitated contracts or through a common procedural terminology code for data transfer to reflect the one-time increased effort and cost of moving data from paper to electronic format. A recent report estimates incentives of $12 000 to $24 000 per full-time physician per year would be needed to make the business case for immediate adoption of electronic health records, with those incentives transferring to performance-based incentives over time. Any of these incentive models would work for us and make adoption easier in other small practices. Although some predict that vendors will shift their focus to the small practice market, it is difficult to see how vendors will support implementation of an electronic health record in the small practice setting while keeping prices affordable. Small practices need much more training and support from vendors than do large groups. The support provided by our large national vendor presupposed the existence of dedicated information technology staff and an administrative layer that could plan work flow and train staff. Neither of these infrastructures are present in a small office, and both are critical to success. In addition, small practices need structured assistance to develop their capacity to manage organizational change. Models of shared local training and support must be developed if small offices are to be successful in implementation. Perhaps the most important asset we could have used to ease the pain of implementation was more clinical capacity. A decline in productivity after implementation of an electronic health record seems inevitable, and if a practice is already straining to meet patient demand, an absence of reserve magnifies the stress of implementation. For us, the financial stress of acquiring the electronic health record precluded simultaneous addition of a new mid-level practitioner or physician, which argues even more strongly for the need for financial support. Patients want and expect their physician, especially their primary care physician, to have a comprehensive grasp of what is going on with them medically and to be able to respond to such questions as, How much weight have I lost? or What was my cholesterol level last time? Clearly, aggregating comprehensive clinical information at the point of care is a basic function of excellent primary care. Why is it that every academic health center and hospital acquires state-of-the-art cardiac imaging tools promptly, but primary care offices and residency training programs are still using paper records? Given their experience with other customer service operations, such as retail, banking, or travel, patients assume a level of information technology infrastructure that most of us in health care simply do not have. Unsupported by technologies now taken for granted almost everywhere else, we in health care regularly fail to meet basic patient expectations. A major factor that prompted us to adopt an electronic health record was the hope, now at least partially fulfilled, that it would improve our ability to meet patient expectations and improve our job satisfaction. Despite the difficulties and expense of implementing the electronic health record, none of us would go back to paper. We find ourselves able to be better physicians: We communicate more quickly and clearly with patients on the telephone and by letter, transmit important clinical information (albeit on paper produced automatically by our system) more efficiently to specialists, and spend less time paging through charts to find out what the previous cholesterol values (for example) had been. Practicing with a computer in hand allows us to access current health information for ourselves and our patients without having to leave the room or interrupt the flow of a patient encounter. We have already caught a glimpse of population health possibilities when, on the same day as the withdrawal of valdecoxib from the market, we were able to identify and send letters about the withdrawal to the 16 patients in our practice who were taking the drug. We expect soon to produce a list of patients with diabetes so that we can audit their care and see how well we meet our care standards. We also plan to use our electronic health record to provide each of these patients with an individualized report on services for which they appear to be overdue. If the United States is to realize the benefits of information technology in health care, substantial investments will be needed to shepherd small offices through what is an arduous process. We believe that many practices will examine the current environment and defer a decision to adopt an electronic health record, and given our experience, it would be hard to disagree with them. All the hoped-for benefits to the overall delivery system and to patients will only accrue if small offices, which are the access points to health care for most patients in the United States, successfully adopt information technology. We believe that new models are urgently needed to deliver both financial and administrative support to those who would accept the challenge. Author and Article Information From Greenhouse Internists, P.C., Philadelphia, Pennsylvania. Acknowledgments: The authors thank their office staff for their courage, flexibility, and support throughout this project. Without their willingness to try something new, implementation of the electronic health record would not have been successful. They also thank business manager Debbie Preite for her leadership and willingness to learn more about computers than she ever thought she could, or wanted. Finally, they thank Cheryl Norvell for manuscript assistance and Steve Downs, Holly Humphrey, and David Reuben for their encouragement and review of an earlier draft of the manuscript. Potential Financial Conflicts of Interest: None disclosed. Requests for Single Reprints: Richard J. Baron, MD, Greenhouse Internists, P.C., 345 East Mt. Airy Avenue, Philadelphia, PA 19119; e-mail, rbaron@greenhouseinternists.com .