The World of Medical Transcription - A Broad Perspective from a Team Approach.pdf

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Medical Transcription / Medical Word Editing College http://www.profitmt.com

The World of Medical Transcription From a Medical Language Specialist Point of View

As a certified medical transcriptionist who has become rather exophytic to the classic definition of such, I have been asked to write a column on what medical transcription is today, what it has meant to me, and what medical transcriptionists need. To me, the question is, “What do we need to not only survive the day, but embrace the day?” Of course, a medical transcriptionist (MT) in the purest form of the definition takes verbal dictation (sometimes supplemented with written notes) and by magic with one million variables, turns voice into a magnificent printed patient chart note, accurate and clear, encompassing the highest standards of accuracy in medicine, English, grammar and syntax.

In this discussion I will point out that the pursuit of excellence and embracing change are the two most-needed characteristics for medical transcriptionists today. We must evolve (and are evolving) into medical language specialists, medical word editors, team players, technologists, and diction experts for English-as-a-second-language authors. I’ll try to give you some ideas from a multifaceted approach, and perhaps enclose a little humor, as well, because I believe that taking a lighthearted but sure approach and keeping perspective is good for the soul.

AAMT and MTIA and other organizations are wonderful resources for industry ideas relating specifically to medical transcription. For example, the Journal for the American Association for Medical Transcription (JAAMT) has hundreds of wonderful articles on what exactly transcription is, where it is headed, the impact of overseas transcription on the United States, newest technologies, and other deliberations. I encourage you to join these organizations. I won’t belabor those ideas here, but rather let’s briefly discuss some broad-based health industry ideas and show how those relate to a medical word editor/transcriptionist as part of a team. As medical language specialists, we can elect to operate in more than one area of the modern-day healthcare team using our medical language skills. These topics are my favorites.

At the end, I will leave you with my 15 top tips as a medical transcription educator. A Beginning I had a humble inception to the medical world. I became the radiology department receptionist for our community hospital at the tender age of 21 years of age. A lot of harried physicians looking for that last-minute x-ray disrupted my ataraxy. One day, I glanced back at the radiology transcriptionist partially hidden from view behind a cornucopia of x-ray files. At that moment, I had missing plain films for a patient on a table in the OR, a doctor needing a courier to bring an x-ray across the street for a patient in treatment, and a resident physician asking for a chest x-ray for an acutely ill patient in ICU. But, there she was in the back, “ears in,” small turned up edges on her lips, (I know I saw the blithe smile!), transcribing away, oblivious to chaos. Or at least pretending to be oblivious to chaos. Given that her pay scale was higher than mine, as well, I made a pledge to myself that I would learn all about that “peaceful” job in the back corner. Medical Transcription. And I did. Every break and lunch hour for four (my goodness, should that be the numeral

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4!) months I would sit in the honored seat and practice those radiology reports. She would proofread what I did upon her return and gave great feedback. (A formula for success: transcription, receiving feedback, accepting feedback, and trying again.) Then one day, the skilled transcriptionist called in sick; I was asked to transcribe, and I said “yes”…ah, the beginning. I realized education and knowledge are the keys to this interesting world of words and grammar. The hospital gave me keyboarding, medical terminology, and anatomy and physiology at the community college. Galvanic words packed my life, a profusion of them (now, that’s not “perfusion”). I earned my associate’s degree and began working on a bachelor’s. My quest for intoxicating new words and knowledge soon found me transcribing ultrasound and radiation therapy reports downstairs at the end of my shift. An exciting new venture! What IS that word? A humorous side note: A medical society’s contribution I once read best describes that myelination process in my brain’s grey matter at that time; there were words everywhere! A chrysalis process developed with seemingly innocuous words: “The obituary gland seems a sad place to start? Moving down the ophagus tube, past the broccoli, a fundoapplication may help. You may recognize the psychiatric nerve, but what about the haricot veins? The introverted uterus is a little shy, but the crucial ligaments are obviously important. Platinums and playtex are everywhere. (Pituitary gland, esophagus, bronchi, fundoplication, sciatic nerve, varicose veins, retroverted uterus, cruciate ligaments, platelets.) Having sorted out the anatomy, the various ailments were next. There are many inflations in the vocabulary. Does the human Pavarotti virus affect the vocal chords? What organs are involved with a hippopotamus or a helicopter, and what causes the sinkable episode? (Inflammations, human papillomavirus, hypothalamus, Helicobacter, syncopal) For the surgeons, I need help with the biblical hernias and erupted spleen. It may be a little more difficult to decide which specialist to refer a fractured zygote, a utopic pregnancy, bunyips, painful anodes and the occasional Arnold Curarie. (Umbilical hernias, ruptured spleen, fractured zygoma, ectopic pregnancy, bunions, nodes, Arnold Chiari malformation.) We could probably send the pigsty, cellutosis, cradle crop, scarytosis, and ectopic eczema to the dermatologists (if they are not at a conference in Barcelona or Melanesia), but who treats those septic ulcers? (Stye, cellulitis, cradle cap, solar keratosis, atopic eczema, basal cell carcinoma, melanoma, peptic ulcers.) The respiratory physicians, with their stereophone moved from sleep apathy to bronchial ecstasy, but should postnatal drips and reproductive coughs go to them or the obstetricians? Even more confusing are Alka Seltzer's disease, tetanus and tendonitis, which are not what they seem. The physicians could investigate grout,

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osteoferocious and facetious anaemia and handle a myocardial infraction. And for the lawyers — is needless dysplastic syndrome considered as incompetence or a minuscule tear? (Stethoscope, sleep apnea, bronchiectasis, postnasal drip, productive cough, Alzheimer's disease, tinnitus, gout, osteoporosis, pernicious anemia, myocardial infarction, dysplastic nevus, incontinence, meniscal tear.) Then there are the things that doctors do to patients which make one wonder about transcribing informed consent. If you seduced the patient into a colossal story what would you expect? A tubal litigation may follow, or perhaps swifter justice with a lumbar punch. Monograms and egg, lettuce and fried tomatoes are common investigations, but who wants the Geiger counter or MI5? If the patient asked for the locum, or, worse still, for the results of their own autopsy, how would you respond? They may be better going to the physioterrorist, or just to the choir practice. (Induced, colostomy, tubal ligation, lumbar puncture, mammogram, E/LFT's, glucometer, MRI, local anaesthetic, biopsy, physiotherapist, chiropractor.) But the best mispronunciations of all are the muddled medications. The metropolis tablets are real blocker beaters, and others prefer the condominium lifestyle, but on a bad day it may be necessary to retreat to Nimbin for a bit of peace and quiet. We could go there in the Valiant, filling up with Caltex on the way, but hopefully avoiding an argument when the map reading leads us astray. (Metoprolol, beta blockers, Coumadin, Nemdyn ointment, Valium, Caltrate, Augmentin.) The medical profession has all sorts of alternative remedies, for Anzacs and aristocrats and perhaps even the odd pessowary. These include marzipan, genetic tablets and those well-known urinal tablets, and Laminex, but there is less demand for the repulsive tablets. (Zantac, Aristocort, pessary, temazepam, generic, Ural, Lasix, Propulsid.) On that note, now that you are completely confused by trying to be bilingual, get out the Kleenex, sit back and hope it all goes into remittance. (Nitrolingual, Keflex, remission.)” Working from a Home Office I began to ask physicians’ receptionists calling in to radiology if they needed any help with transcription. I soon landed two private practice physicians to transcribe in my spare time in the evenings at home. From there, I had my second child and garnered other accounts, starting my own transcription service from home, building a home office, and loaning myself out per diem to the hospitals. I began to be less “passive” in my transcription and more pro-active, less “verbatim” and more into risk management for documented patient information. Clients appreciated the attention to detail, mg and mEq dosing flags, and a left out plan or assessment item. American Association of Medical Transcription (AAMT) This wonderful organization came into view, and I joined the local chapter. In an inordinately short period of time I became president (I’m sure by default -- I think I was set up, honestly.) However, it was here that I was introduced to a Certified Medical Transcriptionist (CMT) who had a quest and a love for words. “The walking encyclopedia”

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was her unofficial title (if you are reading this article, Gail, you know who you are!) Wow, a mentor! One day, I transcribed overflow for her office and found my well-perused and labored-over documents returned punctuated (that’s not punctated!) in red marks. Ah, seems I knew the words, but not the syntax, language structure, and grammar rules to provide the polish. I tucked my head down and poured over a new book, the American Association of Medical Transcription Book of Style. I took the new rules, which I was cognizant were clearly in place for reasons I could not have had the opportunity to figure out for myself, the Style garnered from errors made in patient records that I was not privy to; and I realized it was a gold mine of professionalism. You see, a medical transcriptionist is part of large team. We do a lot more than drop words verbatim onto paper. Physicians, nurses, and even medical coders rely on our accuracy and knowledge of these rules. With skill, the transcriptionist reduces errors in healthcare and participates in risk management. I took the AAMT exam and became a Certified Medical Transcriptionist. Someone once said (now, I don’t CLAIM its true but it FEELS like it)… that it takes the head knowledge of a resident physician to pass the CMT exam. It is no easy task. Let’s discuss a couple health industry ideas that really impressed me reading industry-wide journals and taking college courses in principles of management. Then, we’ll discuss more of these later. The Onion Model and the Swiss Cheese Model You see, the Onion Model illustrates variables that affect the multiple levels of a tiered system in which a task is performed and errors can occur -- like layers being peeled from an onion. In transcription, the system is patient healthcare and we help provide the documentation layer. A fellow named James Reason also developed the "Swiss Cheese Model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to an actual negative event. In his model, each slice of cheese represents a safety barrier or precaution relevant to a particular hazard. For example, if the hazard were wrong-site surgery, slices of the cheese might include conventions for identifying sidedness on radiology tests, a protocol for signing the correct site when the surgeon and patient first meet, and a second protocol for reviewing the medical record patient notes and checking the previously marked site in the operating room. Many more layers exist, including the medical transcription layer, I might add, where lefts and rights are always verified during transcription. The point is that no single barrier is foolproof. They each have "holes"; hence, the Swiss Cheese Model or “layers” as in the Onion Model. For some serious events (e.g., operating on the wrong site or wrong person), even though those holes will align infrequently, even rare cases of harm (errors making it "through the cheese") will be unacceptable. The transcriptionist is part of the team providing accurate and as perfect healthcare as possible. We’ll discuss more about some of these industry ideas later. Educating Others Friends began to approach me to help them become transcriptionists. I worked with them and employed the most promising to help with my accounts. My transcription service grew as I watched the leading edge of technology. We originally started on IBM Selectrics in

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radiology (ha ha) and moved to “memory typewriters” and on to personal PCs. Then, I had the opportunity to set up and administrate a VDI voice system for a new family practice residency. It was there I was approached about teaching “dictation 101” to the resident physicians, which I did. Now that was fulfilling, catching those authors before they began a lifetime of iniquitous dictation. A Derailing Accident I personally was literally derailed at this point by an Amtrak wreck, which caused punctate hemorrhage in my brain, affecting word-retrieval abilities and partial complex seizures. Word retrieval returned relatively quickly, but subseizure activity in the brain kept me on medication that affected my “edge” and ability to both care for family and job, as well. I had to leave the profession. Slowly, most all resolved and I was able to pick up where I left off, starting carefully with a couple of small physical therapy accounts, which I felt were easier and not too demanding. My lesson learned: Hang in there! Educating Some More As a “people person,” I continued to find education and contact with others the most fulfilling. I began to teach medical terminology for a local personnel and training company a couple of years later. I began to realize, as many transcriptionists do, that there are opportunities out there that employ medical language specialists; “hitting the keyboard” all day is not for all. For some, straight transcription is all that is needed and wanted; for others, it is not. Soon the terminology students clamored for a medical transcription class, and so it began. Electronic Medical Records Soon after that, I answered an ad on the AAMT board for a “small part-time position for a medical transcriptionist to train physicians on the use of an electronic medical record.” Ha, that little part-time job soon took over my life. I connected remotely computer-to-computer to physicians all over the United States and trained them how to use their new electronic medical record (EMR). I learned more about connections and firewalls than about EMRs! My job as an MT was to help providers build their medical knowledge databases that could be dropped in to patient notes to supplement their transcription. Soon I was going on site to these offices all over the United States, and my dream was fulfilled to be able to use medical language and transcription skills and still be in an environs of people. For seven years I worked with this electronic medical record, using a knowledge of words and medicine to take what physicians gave me and constructing it into their personal medical knowledge databases. I attended many trade shows and studied other applications. Through these contacts and networking, I connected with persons developing web applications and helped write medical technical manuals for new medical software and web applications on occasion. QA and Training Supervisor Recently, I took a position as QA and training supervisor for a large multihospital heath system. This proved to be a difficult adjustment because for the first time I could see clearly what impacted quality, production, and morale, but had little say in what happened

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in this, and limited ability to introduce the successful ways from private practice client-centered business into a large corporate world. The point is, if the glove doesn’t fit, find your glove! Don’t be afraid to try that position that challenges you, teaches you, and moves you to your highest level of competency (my best advice). With that, if you find you don’t thrive, it will help you understand where you do thrive. As I took you through this glimpse into one transcriptionist’s incursion into the world of grammar, syntax, words, and yes people -- I hope that you feel you can broaden your own horizon. Every person is not going to have the same vision…but we all need the same vision of striving for excellence. As technology aids us in our quest for more and better communication in patient information, our positions will change. We all need to not only “ride the wave of technology” but embrace the technology and the pursuit of superlatives in our profession. Today’s medical transcriptionist needs to be a medical word editor, an English-as-a-second language specialist, a technology advocate, and a pursuer of latest terminology and ideas, all within the context of a team. Discussing Health Industry Ideas

AAMT and MTIA are wonderful resources for industry ideas relating specifically to transcription, as stated above. Wonderful articles are written, and I encourage you to read some of those. Here, let’s briefly discuss some broad-based health industry ideas that become specific to medical language specialists.

Health literacy is an individual’s ability to find, process, and comprehend the basic health information necessary to act on medical instructions and make decisions about their health. In classes, students and I discussed that medical terminology and an understanding of disease processes enhances your life. This knowledge helps you make more informed choices about your healthcare and the healthcare of ones you love. (Its not just about medical transcription or medical word editing.)

I took my own mother through Virginia Mason Clinic in Seattle as she died of metastatic lung cancer, and was able to help her make informed choices -- health literacy. If you have children, you’ll be more knowledgeable in your children’s healthcare. You see, it spills over into “life.” Which came first, the chicken or the egg? The love of knowledge and medical words, or did exposure to medical words teach us to love the knowledge? Patient Safety Networks – Healthcare Research and Quality Today, medical language specialists and medical word editors think in terms of risk management. We are part of a whole team providing care to patients. I am reminded of a verse in the New Testament, if I may: “For in fact the body is not one member but many. If the foot should say, "Because I am not a hand, I am not of the body," is it therefore not of the body? And if the ear should say, "Because I am not an eye, I am not of the body," is it therefore not of the body? If the whole body were an eye, where would be the hearing? If the whole were hearing, where would be the smelling?... But now indeed there are many members, yet one body.” Borrowing this biblical principle to medical language specialists, we are an important member of the body, the team, and we need to see ourselves as such. When we manage ourselves in a way that promotes excellence, including becoming certified medical

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transcriptionists, constantly increasing our knowledge, we promote professionalism for our field. (Why shouldn’t two separate numbers be transcribed as numerals together?) We take advantage of knowledge and professionalism that would have never come into our own limited view by borrowing from professional organizations such as the American Association for Medical Transcription and the American Medical Association. We participate in risk management by way of using the latest materials and resources available.

Crew resource management (CRM), also called crisis resource management in some contexts (eg, anesthesia), encompasses a range of approaches to training groups to function as teams, rather than as collections of individuals. Originally developed in aviation, CRM emphasizes the role of "human factors"-the effects of fatigue, expected or predictable perceptual errors (such as misreading monitors or mishearing dictation), as well as the impact of different management styles and organizational cultures in high-stress, high-risk environments. A culture of safety, in which individuals feel at ease drawing attention to potential hazards or actual failures without fear of censure from management.

In risk management, we discuss "active" and "latent" as applied to errors. Active errors occur at the point of contact between a human and some aspect of a larger system (for example, a human-machine interface). The results are usually felt immediately. Latent errors can be made by any part of the team, and are often removed from the operator’s control. Transcriptionists can contribute to latent errors by the healthcare team. We also discuss adverse drug events (ADE); transcriptionists are part of the lineup that actively has a part in avoiding adverse events involving medication use. We avoid latent errors as editors by checking and double checking what is dictated, not guessing, and being a detective on medications. A knowledgeable transcriptionist might know the top 200 medications and common dosages for each. He/she will double check that what sounds like a “teen” is not a “twenty.” I can’t tell you how many “cheat sheets” and word lists I’ve made for myself over the years, which I now use in my education site. I sometimes develop systems, which I teach my students, to remind myself of a reminder! (An example of this would be an autocorrect or autotext in Word that says, whether I type dysphagia or dysphasia, “check this – is it speech or swallowing?” I had one student who always had the following drop onto a page “affect is the verb usually and effect is the noun usually.” By seeing the printed rule drop over and over on the page, it provides a double check, as well as a way to memorize the rule.) We also discuss the “authority gradient” which refers to the balance of decision-making power or the steepness of command hierarchy in a given healthcare situation. If there is a dictatorial team leader, we experience a steep authority gradient. Expressing concerns, questioning, or even simply clarifying instructions requires considerable determination on the part of team members who might perceive their input as devalued or frankly unwelcome. As a transcriptionist, be cognizant of the authority gradient! We must persevere to be the best medical transcriptionists we can be, speaking out and drawing attention where it needs to be drawn. Suggest changes which cause confusion in reading of the patient record, and document it from three sources! Be discreet (that’s not discrete!) and be professional. If you are a team leader, effective team leaders consciously establish a command hierarchy appropriate to the training and experience of team members, and have an open, non-condemning ear. A person who needs to “vent” is a person who will contribute.

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MTs are part of the safety culture, also called culture of safety, referring to a commitment to safety that permeates all levels of an organization, from frontline personnel, technologists, medical records personnel, and even to executive management. More specifically, "safety culture" calls up a number of features identified in studies of high reliability organizations, organizations outside of health care with exemplary performance with respect to safety. These features include: acknowledgment of the high-risk, error-prone nature of our work, a blame-free environment where individuals are able to report errors without fear of reprimand or punishment; an expectation of collaboration across ranks to seek solutions to vulnerabilities; a willingness on the part of the organization to direct resources for addressing safety concerns. You are part of that team.

Decision Support – Refers to any system for advising or providing guidance about a particular clinical decision at the point of care. Transcriptionists are deeply imbedded in the point of care. Accurate transcription is a big part of the equation in reliable patient encounters by healthcare professionals. As MTs or medical language specialists, what we do directly impacts the point of care and the moment of decision making for that possibly fatigued physician who may or may not double check the transcription across other records in the chart. Alternatively, perhaps not check what we may have coded into a template or an EMR. We possibly can become part of an “error chain” – a series of events that may lead to a disastrous outcome. For instance, ordering an aminoglycoside for a patient with creatinine above a certain value might trigger a message suggesting a dose adjustment based on the patient's decreased renal function. Did the transcriptionist transcribe that creatinine value correctly?

We speak of errors and omissions - An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome. This idea was impressed upon me in my electronic medical record work. Sometimes the chain metaphor carries the added sense of inexorability, as many of the causes are tightly coupled, such that one problem begets the next.

And then, there is the Health Insurance Portability and Accountability Act (HIPAA) – new federal regulations intended to increase privacy and security of patient information during electronic transmission or communication of "protected health information" (PHI) among providers or between providers and payors or other entities. HIPAA also requires providers to offer patients certain rights with respect to their information, including the right to access and copy their records and the right to request amendments to the information contained in their records. The modern-day transcriptionist needs to have continuing education on PHI and be part of the team and staff training regarding that protection of patient information.

The acquisition of any new skill is associated with a lower initial success rate – the learning curve. Learning curves are inevitable; my best advice is “don’t be afraid of the culture.” MTs should constantly seek to improve their skills and be “on the learning curve” – not above being taught new ideas and admitting there is a “better way to transcribe that.” This is not unique to our field, the less-then-humble persons (Ok, let’s call them know-it-alls and be done with it!) Yes, they exist in all professions. Let the MTs never be counted among the persons who feel they cannot learn something new and already know the “best way.”

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Let us always be humble, open, receptive to metacognition (thinking about thinking) and education. Let us understand whether our transcription biases or cognitive short cuts may have a detrimental effect on the patient note! Let the medical language specialist employ the same care and metacognition, safety culture, and sensemaking that is applied by the rest of the patient healthcare team. Sensemaking is a term from organizational theory that refers to the processes by which an organization takes in information to make sense of its environment, to generate knowledge, and to make decisions. It is the organizational equivalent of what individuals do when they process information, interpret events in their environments, and make decisions based on these activities.

Structure-Process-Outcome Triad – Quality has been defined as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” This definition, like most others, emphasizes favorable patient outcomes as the gold standard for assessing quality. In transcription, of course, one would like to detect quality problems without waiting for poor outcomes or a misread note to cause a deviation from the best patient care. Thus is born quality assurance (QA).

The summary is…the lingo we hear on the Army commercial (drum roll!): Be the best you can be! (OK a little canned, but it’s true…) Get the best education; don’t be afraid of technology and change; don’t be overly sensitive to errors, but exploit sensemaking and learning skills; and be a part of your professional organization (AAMT). Be a technologist (root word being “knowledge”) in your chosen field. Moreover, don’t be afraid to choose a position outside of straight transcription; your skills are needed many places in today’s world. If you want to supplement your education, feel free to look us up at www.profitmt.com. Ask us questions, we’ll help you. I leave you with my 15 rules for the medical transcriptionist. They are based on being persnickety, persistent, professional, and taking pride in your work on the team.

RULE #1 (my favorite) NEVER GUESS

Look it up…know what it means….look it up….. know what it means…look it up….

RULE #2

BE PERSNICKETY Particular and precise……fastidious…..fussy…..

Showing or requiring extremely careful treatment

RULE #3 BE PERSISTENT

Refuse to give up, especially when faced with opposition or difficulty…tenacity…stubborn and persevering for better knowledge….

Rule #4

BE PROFESSIONAL Engaged in or worthy of the high standards of your profession.

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Rule #5 PRIDE YOURSELF IN YOUR WORK

Don’t be “proud” but take pride in being a medical transcriptionist or medical word specialist.

RULE #6

WHEN GETTING FEEDBACK, WRITE IT DOWN. Don’t get caught in the trap of taking corrections personally.

RULE #7

BE A DETECTIVE! Be a word person; care about words. NEVER take a “whatever” attitude. Try to be the

best! It DOES matter.

RULE #8 BE FLEXIBLE AND INSTRUCTABLE

Be honest about what you do and don’t know. Flag what you don’t know or can’t hear. Learn, and learn some more; rules change. Listen to your authors and your clinics, be in

their court.

RULE #9 SAVE EARLY AND SAVE OFTEN

Use reliable backups

RULE #10 BE HIPAA-COMPLIANT

Care about the safety of protected patient information. Always be confidential; never discuss or reveal patient information.

Rule #11

TAKE A BREAK Be aware of the role of "human factors"-the effects of fatigue in perceptual and omissions

errors. Plan with care your time, breaks, and rest.

Rule #12 GET CONTINUING EDUCATION -GROW AS A LANGUAGE SPECIALIST

Take classes; make your goal that of being a Certified Medical Transcriptionist after training and 2 years of acute care. Find excellent education.

Rule #13

CONTRIBUTE TO OTHERS AND BE CONTRIBUTED TO. Try a new method; do some new research; share your learning with others.

Rule #14

KEEP YOUR PERSPECTIVE Have a sense of humor; go easy. Remember what is important, the whole team providing

healthcare.

Rule #15 BE A PART OF THE CULTURE OF SAFETY AND RISK MANAGEMENT

Participate in metacognition and sensemaking in dictation given to your care.

Documents

The World of Medical Transcription - A Broad Perspective from a Team Approach.pdf