Medical transcription is dead. Long live medical transcription!

Many in the EMR industry have long forecasted the demise of the medical transcription industry.  However medical transcription still continues to exist and this industry is starting to see an uptick in the dictation volumes in the past 18 months.  The EMR vendors have aggressively sold their software by convincing physicians that transcription was an old fashioned idea and that it only adds significant costs to their operations without giving any corresponding return. They also convinced them that EMR was the panacea that would cure all the ills of clinical document creation using traditional transcription services. Physicians reluctantly adopted this technology without fully realizing the consequences of what doing away with transcription service can do to their current work load. Once physicians started realizing the woes of generating the documentation themselves, they started to push back on this workflow process. The EMR industry came back with even more crisp PowerPoint presentations, colorful data sheets and cookie cutter templates which showed that incorporating speech recognition into the EMR workflow would make the clinical documentation task easier for the physician, and tried to convince them again that using a transcription service was a bad and an expensive idea.

Now the physician has to not only enter all the key strokes, spend hours learning how to correctly dictate, actually dictate and make sure that the dictated text is accurately recognized by the speech recognition program, deal with excessive alert fatigue from the EMR, switch between multiple screens to enter patient data, view multiple tabs within the screens, and within each screen focus on a sections and subsections to ensure that all data points are correctly captured to maintain revenue integrity and coding accuracy, make sure that all quality measures criteria are being addressed, all population health alerts are reviewed etc. And they have to do all these while the patient is sitting in front of them and when they should actually be focusing on the patient and listening to the patient’s story!

Physicians are increasingly getting frustrated with these tasks. No wonder that a recent article in The Wall Street Journal states that doctors are increasingly getting disillusioned with their profession. Too much work is being pushed on to the physicians and too much is being expected from them; and many of these additional tasks are less about patient care and more about coding, billing and compliance. Doctors are not trained to do this and the patients are suffering because of this. Under the pretext of reducing the cost of healthcare we cannot unfairly push the burden onto the physicians. A 2014 nationwide survey has actually shown the doctors who use EMRs spend more time on administrative work than those who use paper records. The authors who are lecturers at Harvard Medical School state “Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork,” they write, “we found the reverse is true.”

Physician appointments are generally slotted every 15 minutes and this includes the time a physician has to spend outside the exam room. A 2014 article from Kaiser News says the physicians are being asked to see a patient every 11 minutes! Physicians are under constant pressure to churn patients through the system. Research has shown that patients are allowed to speak for 12 seconds before they are interrupted and more than a quarter percent of the time physicians did not allow the patient to complete a sentence. The same research also points out that computer work interrupts the physician and patient interaction much more than all other interruptions like a knock on the door, etc.

Clinical documentation plays a very critical role in any patient’s care and the objective of creating a clinical document is for the physician to capture the patient’s story and then document each patient’s care episode in detail so that the same physician can go back and refer to the notes when the patient is back in his office again, or when the care is being shared by multiple physicians. These days providing high quality care to a patient is often complex and each episode of care involves multiple doctors across multiple care settings.  This type of involvement by multiple providers is becoming more and more important with the advent of bundled payments and value based payments. Therefore, it is going to become even more imperative that the clinical documentation be of high quality and that the document accurately captures the entire patient’s story. This cannot be achieved with point and click data capture alone. It requires physician’s narrative and documenting his or her critical insights and thinking.

Over the last few years, the role of clinical documentation has been reduced to a point where it mainly serves the purpose of capturing the required clinical terms that are needed for performing accurate coding and billing.  With this new emphasis on collecting and documenting structured data for coding and billing, the role of the narrative is highly diminished. When doctors are asked to work with such an incomplete picture of the patient story, quality of care is bound to suffer. The longitudinal care document is critical in improving the doctor – patient communication and trust.

Research has also shown that EMRs encourage defensive documentation by physicians. Defensive documentation is defined as ‘note bloat’ which means superfluous documentation that unnecessarily highlights negative findings and obscures positive results.  It also means that there are excessive brought forwards and use of copy and paste function from previous notes that oftentimes do not add any significant to value to the current document.

The pendulum has swung too far to one side in the last few years and now there is an urgent need to find an equilibrium. An equilibrium where the EMR and transcription can each play a complementary role so that the requisite information is available in a form and manner that enables the physician to improve patient care.