By Line, By Hour: Keeping the Transcription Machine Running

by Sally Beahan, RHIA

A well-run transcription department is the product of strategic planning and due diligence. In the second installment of the Journal of AHIMA’s series on transcription, learn how a major medical center manages its transcription with internal and external support.

It’s no small task to run a transcription department when there are a lack of qualified transcriptionists, economic downturns, and an emphasis on improved documentation. At the University of Washington Medical Center, a 450-bed facility in Seattle, we manage 120 hours of incoming dictation per day. With more than 350,000 clinic visits per year and 1,500 inpatient discharges per month, dictation volumes have steadily increased by an average of 15 percent each year since 1996. In this article, we’ll discuss our strategies for keeping quality high and costs under control.

From Many to One

To attract qualified medical transcriptionists (MTs), we offer an incentive program, allow employees to telecommute if they live within a 100-mile radius of the medical center, provide equipment, including a computer, chair, phone lines, and reference materials, and offer optional overtime. Despite these efforts, we still outsource 40 percent of our total dictation volume to meet turnaround time expectations. Currently, the medical center employs a total of 52 medical transcriptionist FTEs (full- time equivalents) including 46 telecommuters and 20 on-site staff.

We have tried working with multiple transcription outsourcing vendors but found the management too challenging. For example, it took nearly four FTEs to load reports manually into our electronic health record (EHR). Turnaround time often stretched seven to 14 days between dictation to availability to the providers.

Through an extensive request-for-proposal process, we chose a large national vendor to manage all our outsourcing. The vendor could handle our fluctuating volumes and provide nearly 30 MTs to work our account. We determined that an HL7 interface would be the most efficient way to move reports into our system from the outside. Since the implementation a year ago, the four FTEs needed to manually load reports have been reduced to 1.5 FTEs to manage the “fix file” (when documents are incomplete or fail the interface).

The next hurdle came when our aging dictation system not only lacked the storage capacity to keep up with the incoming volumes, but volume also exceeded available access ports for transcriptionists to call in on. We needed more help from the outside service but couldn’t provide them access to the dictation due to the access port shortage. Our only choice was to transfer dictation from eight of our 25 clinics directly to the outside service dictation system.

Although we were concerned about providers accepting an outside system for dictating their clinic notes when all other dictation came through our internal system, we tried to minimize confusion by making the change as transparent as possible. With the help of our teleservices department, we programmed more than 200 clinic phones with a “clinic note” button that led directly to the outside dictation system. The new system emulated our keypad entries so providers would not need to learn a different process. We also posted instruction cards near the phones in case a provider needed to review his or her dictated reports on the new system. Clinic managers helped educate the providers about the change, which decreased the volume coming into our own dictation system by 15 hours per day. Outside MTs continue to access our dictation system for the other clinics using the internal dictation system.

We recently upgraded our dictation system and gained 30 additional ports along with the ability to transfer voice files to the outside service. Our next step is to move all dictation back to our system and reduce access port usage by outside MTs through voice transfer to their internal system.

A Complex Relationship

The medical center’s relationship with our transcription vendor has not been without complications. Working in a complex and changing environment makes maintaining turnaround times, quality, and good communication essential. In the past, the contracted turnaround time had not been met consistently. For example, in July and August 2002, only 25 percent of the vendor’s work was completed within the turnaround time. As a result, we began tracking late transcription and deducting a percentage from our invoices. Coupled with frequent conference calls and close tracking of issues, this action has dramatically improved turnaround times. Additionally, we keep our own issues list along with a history log so we’re prepared to address repeat problems.

Without quality checks and frequent feedback, transcription quality can suffer. The medical center has taken several steps to ensure internal and external dictation meet our quality standards. First, we check internal and external quality quarterly through our peer review program. We expect 98 percent accuracy from both internal and outsource staff. Additionally, if a provider gives us feedback on errors, we pass it on to the vendor. To improve accuracy, we have assisted our vendor in producing training materials and sample reports for the MTs working on our account. Frequent and prompt feedback is given if problems arise. Also, if we find one MT making errors repeatedly, we’ll request that the MT be removed from our account. As a result of addressing issues on our log, we’ve implemented a daily tracking tool. Finally, we receive a daily report of the total number of reports waiting in our vendor quality assurance (QA) process, as well as the date of the oldest report. This allows us to monitor the frequency of the QA process and ensure reports aren’t held up in QA for long periods.

Paying the Right Price

In addition to a daily account of reports in the vendor QA process, we also receive daily notification from the vendor outlining the total jobs waiting for transcription on their own dictation system. This includes the date of the oldest report and the total number of minutes transcribed from the previous day. We keep track of the minutes transcribed by the vendor MTs on their own dictation system so it is easy to check the vendor’s invoices.

We have worked closely with the vendor to establish a reconciliation process for invoices. Per our contract, we are charged according to the American Association for Medical Transcription (AAMT) line definition (a common billing standard), but found it difficult to reconcile the invoices. The AAMT definition leaves room for vendors to add in hidden costs, such as macro text (instead of keystrokes) and hidden formatting not seen on the printed page. We learned a valuable lesson from this process: It is critical that contract language and definitions be clear to both parties prior to signing. It is not uncommon for vendor line count programs to be proprietary, which makes it difficult to understand exactly what is being charged.

After spending significant time hand-counting reports, we opted to be charged by the gross line rather than the AAMT line definition because it was easier to reconcile. We’re currently reconciling the number of reports we’re charged per month against the number of reports completed on both dictation systems. We know the average cost and length per report and are comfortable with this method of reconciliation. If the discrepancy between the number of jobs on the invoice and the actual number completed is too great, we notify the vendor and request an explanation. We have had to short pay invoices when the vendor could not explain the discrepancy. As a result of this effort, the vendor instituted a daily check system of jobs transcribed on both systems against jobs sent through the interface. This has greatly improved the accuracy of the invoices because the vendor charges are initiated when a report is sent. If duplicate reports are sent, the vendor does not bill twice.

Onward and Upward

We continue to look for ways to increase the transcription department’s efficiency. We are in the process of designing a new transcription platform that will be a part of a large integrated hospital-wide EHR product. Although the transition may be a bit tumultuous, we are hopeful that moving to a Windows environment from a DOS platform will increase efficiency.

Allowing providers to dictate into handheld devices is our next goal. Providers will dock their device into the network via a USB port and upload their voice files. The software on the handheld device interfaces with the scheduling system, which reduces the amount of information required by the dictator to be entered at the time of dictation. We plan to test 20 users in the next six months.

In the future, we plan to use a back-end speech recognition solution to increase productivity. With this, the MTs can edit documents that are fed through the speech recognition engine after dictation, making it transparent to the dictators.

Although we’ve been charged with decreasing the amount of incoming dictation, we do not anticipate transcription volumes to decrease any time soon. Our EHR project will allow us to increase the use of templates by offering structured documentation and giving providers the mechanism to enter their own reports. With these improvements, we are confident that we will continue to meet the needs of our providers.

Check the Fine Print

Acknowledgments

Michelle Dougherty, RHIA
Dayna Pierzchala, MBA, RHIA

Sally Beahan (sbeahan@u.washington.edu) is manager of reimbursement and physician support services at the University of Washington Medical Center in Seattle.