By Rebecca A. McSwain, PhD, CMT, CPC-H-A
Experienced transcriptionists spot mistakes or inconsistencies in a medical report and check to correct the information. Their ability to understand and correctly transcribe patient assessments and treatments reduces the chance of patients receiving ineffective or even harmful treatments and ensures high-quality patient care. US Department of Labor, Bureau of Labor Statistics, www.bls.gov/oco/ocos271.htm
The above paragraph, at the US Department of Labor's Bureau of Labor Statistics Web site, mentions an aspect of our job that seems underappreciated: quality assurance. Patient by patient, report by report, for every one of the millions of files that pass through our hands every day, the MT is closely scrutinizing the medical record for accuracy, our own and others'. Currently, there is no one else, and no machine, doing this job. Health care providers, though ultimately responsible for the content of records they create, do not have the time or inclination to control quality at this level of detail in their documents. Health care institutions can (and do) conduct random assessments of medical record quality in various ways. But it is literally impossible for such programs to scrutinize every narrative record. Fortunately, medical transcriptionists are doing it. Unfortunately, various systems that eliminate or drastically reduce the role of the MT are also getting rid of this quality assurance (QA) function, thus throwing a pretty important baby out with the bathwater.
Anyone who honestly assesses documents currently created by voice recognition systems, and those created through self-entry by health care personnel, must acknowledge that these documents today pose a major quality risk. It's likely that in the future--and, by the way, after extensive feedback training provided to the machines by human MTs--VR systems will improve. But will it be enough?
As for self-entry: there may come a day when health care providers can evaluate, diagnose and treat patients while at the same time writing and keyboarding accurately and efficiently--with a mastery of spelling (even in areas outside their expertise) and grammar (even if English is their second language)--but I suspect that day is not now dawning. I think it may arrive about the same time that all health care providers are capable of doing their own coding accurately and efficiently.
And the medical transcriptionist brings something else to the creation of the medical narrative: a global understanding of language (medical and secular) and medical practice, combined with a comprehension of relevant community, provider, technology and individual patient circumstances for each of millions of encounters. This wide knowledge base, of course, grows bigger and better the longer an MT works in a particular context. But an experienced MT brings a store of information into any clinical situation, even an unfamiliar one. This specific kind of knowledge is not really held anywhere else in the health care system. Individual providers don't have it--they have pieces of it, but not the whole picture. Electronic data bases don't have it. I won't assert that computers will never be capable of this level of value, but they are far from it now. And this MT knowledge is a source of quality in the medical narrative for which there is currently no substitute.
If this QA function is, in fact, important, then HIM managers, administrators, planners, need to consider how to preserve it, whatever the mode of record-creation may be in the future. If not MTs, then who?
Rebecca A. McSwain is currently working as a production MT for a national service. She has worked as an MT supervisor, business owner, instructor and QA manager. She's a member of AHDI and the American Medical Writers Association. She has a PhD in anthropology and continues to work on anthro-related writing projects in her spare time. She can be reached at rmcswain_985@fuse.net.
Copyright ©2008 Merion Publications
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