I've heard and read the horror stories: the physician who dictates from her child's swim practice, the doc who treats MTs to his hacking cough, the PA who insists on scarfing a Big Mac while telling MTs about a patient.

I recently finished an article on dictation practices for our May 19 issue, and let me tell you--it's certainly an issue MTs are passionate about. The article focused more on the ways that MTs, MTSOs and HIM managers can quell bad dictation practices, so I didn't get to really go into all of the nasty things that MTs are privy to when they sit down to listen to dictations. I know there are some awful stories out there, so what's yours?

All the sources I spoke to had a particularly nasty story about dictation. One recalled physician who dictated from the bath. She also related a story about a report with 25 blanks. After the MT got two more people involved with the difficult report, they finally got it down to eight blanks--but it took 2 hours to finish--and the report was only 110 lines total. Another source talked about reports where the MT had to listen to 20 minutes of dead air for reports that ended up being less than a page long--where the MT must be a captive audience to the silence because they can't hang up, and they have to listen because the dictator may start speaking again.  

All the sources concluded one thing--better dictation practices will mean better reports and better patient care. Gone are the days of the private dictation booths in hospitals. Dictators now find themselves crowded into the nurses' station, huddled and interrupted in a busy environment, at best. Hence, the horror stories.

Can you top the stories above? Not only will venting your dictation horror stories possibly prove to be a bit cathartic, it might also open up some eyes to what MTs really hear when they listen to a patient's story--from chewing to splashes to who knows what else.

Turns out, missing or disputed medical records are the most common source of complaints on their Web site, so they've done an expose on two situations in California where patients didn't get the medical records they requested. Be sure to check it out, and the interesting comments too. Then come back here and tell us what you think. It's always interesting to get the HIM professionals' perspective on things like this.

The saga actually began last spring, when a tabloid ran an exclusive story about Farrah Fawcett's cancer returning. Shortly after UCLA doctors told Fawcett that her cancer had returned-and before she could even tell her son and closest friends-the National Enquirer posted the news on its Web site. Lawyers for the star claim that the information was leaked or sold to tabloids. After UCLA launched a thorough investigation, the medical center discovered "multiple reviews" of Fawcett's records by a worker who was not involved in her treatment.

Flash forward a few months and UCLA is back in the news as it takes steps to fire at least 13 employees and suspend at least six others for snooping in the confidential medical records of pop star Britney Spears during her hospitalization in its psychiatric unit.

State regulators entered the picture, and the California Department of Public Health reported that several investigations were under way.

Flash forward again about 3 weeks and UCLA is front and center in the headlines. On April 6, hospital officials reported that an employee improperly viewed the EHRs of 33 celebrities, politicians and other high-profile patients, including California first lady Maria Shriver. Overall, the medical records of 61 patients were accessed improperly.

OK, so that's the basic gist of the story. You can find all the sordid details by doing a Google search. Hundreds of headlines will no doubt pop up.

For its side of the story, UCLA Health System issued a statement on its Web site:

"...After news stories first appeared in May 2007 about an unauthorized release of patient information, we conducted a full investigation and determined that a single worker, who is no longer employed, was responsible for that incident, as well as the unauthorized viewings of multiple patient records. Consistent with state law and based on the findings of our investigation, we did not notify the Department of Public Health or the affected patients at that time.

"Like other medical institutions in California and across the country, UCLA Health System is engaged in a continuing effort to strengthen its information technology infrastructure to protect against the potential of patient information breaches. We continue to take steps to improve security systems designed to preclude access by unauthorized individuals, while also ensuring that properly assigned medical personnel can quickly retrieve the information required for emergency or other treatment decisions to best meet the needs of its patients.

"Importantly, UCLA Health System has stringent policies familiar to all employees to protect patient confidentiality. All staff and faculty members, contractors, volunteers and other workers are required to sign confidentiality agreements as a condition of their employment and they complete extensive training on federal HIPAA-related privacy and security issues. ..."

So, what do you think? As HIM professionals, the stewards of patient privacy, is this just unfathomable to you? Is UCLA Medical Center under added pressures because they treat more celebrity patients than the average hospital? Is HIPAA training and signed confidentiality agreements enough to guarantee a patient's right to privacy? Is HIPAA even working?

I'd love to hear your thoughts on this topic.

I took all this in while munching on a baked potato and chicken strips. I suppose you could say I have a strong stomach.

This story today somewhat turned that strong stomach. The tummy churning really has little to do with the fact that it's an abortion clinic, in all honesty. Any medical waste just laying out (investigators apparently found it "on the pavement across a five-lane street," as well as in Dumpsters) grosses me out, not to mention the fact that one woman actually picked the waste up and carted it back to her home. I was also shocked by the clinic operator's initial explanation of "They had a new employee on Saturday," which is in this article here, and serves as his explanation as to why medical waste and patient information was tossed in a Dumpster at one of the clinics.

But getting beyond all of the delicate topics involved and the queasiness factor, an important HIM-related issue also exists in this situation. While the pro-life activist that found the patient information turned what she found over to police, she "made copies of ‘representative samples of what was found in the trash,'" and according to the FOX article, she said she found 200-300 patient records. Dr. Abraham Alberto Hodari, who operates the WomanCare chain of clinics, said in the Detroit Free Press, however, that the protestors found patient sign-in sheets, rather than actual full medical records. The Detroit News article says that the patient information found was in "300 medical documents that included insurance, pathology and abortion schedules. Most were dated in 2008 and some included patients' names, phone numbers, pregnancy stage and abortion date." A police officer involved in the preliminary investigation said last week "that up to 50 patients could be identified in medical records, which were mostly created in February and included personal information and the types of procedures performed."

Scary stuff, no matter what exactly was found in the way of patient information. Already, according to FOX News, "at least one document has been posted on the Web site of an anti-abortion activist." Also, on a bit of a lighter note (and this story is just begging for a lighter note, is it not?) for you HIM professionals, the FOX article also gently informs readers that "throwing unshredded medical documents into a Dumpster is not considered a reasonable safeguard" to ensure that protected health information is not misused or wrongfully disclosed under federal patient privacy rules. Just so you know. The article also offered another caution to readers: "Officials advised against individuals digging through medical waste." Again, thanks.

Dr. Hodari invited a reporter from the Free Press in to see his spanking new biomedical waste bags, trash cans and paper shredders. He may face a misdemeanor charge for improper disposal of patient records and also may face sanctions for improperly disposing medical waste, a charge that would include a fine of up to $2,500 per violation and an additional $1,000 for each day the violation continues.

Looking at it only from an HIM standpoint and not at the medical waste/abortion rights aspect, how does something like this happen in the age of HIPAA and state laws? If I knew my medical record was one of the ones that might've ended up in the Dumpster, and then landed in the hands of protestors angry about what was in that record, I'd be terrified. In my opinion, cases like this are the reasons that privacy laws exist: information could end up in the wrong hands.

Yesterday, Google announced a pilot program with the Cleveland Clinic to give patients and doctors better access to a central records system that stores their health information. The pilot, an invitation-only opportunity offered to a group of Cleveland Clinic personal health record (PHR) users, plans to enroll between 1,500 and 10,000 patients. It will test secure exchange of patient medical record data such as prescriptions, conditions and allergies between their Cleveland Clinic PHR to a secure Google profile in a live clinical delivery setting.

According to C. Martin Harris, MD, chief information officer, Cleveland Clinic, "this collaboration is intended to help Google test features and services that will ultimately allow all Americans (as patients) to direct the exchange of their medical information between their various providers without compromising their privacy."

The pilot will eventually extend Cleveland Clinic's online patient services to a broader audience while enabling the portability of patient data so patients can take their data with them wherever they go-even outside the Cleveland Clinic Health System.

So, is this how the development of a national PHR, and eventually EHRs, is going to go-big business will run it? Is that any better than a national system created and run by the government? And how is Microsoft or Google making any money off of their PHR systems? Will we see pop-up ads dashing across the screen when we're trying to manage our personal information?

There are many reasons to pre-test (you can read them all here), but in short it saves everyone time: employers know exactly who they're getting and the candidate knows exactly what they're getting into. It's better to know going in than to find out after 3 months of trial, error and frustration that you didn't have enough experience, right?

Then I got a phone call from a woman named Carol. She said shame on employers who pre-test. Pre-testing shuts out talented candidates who may not have been given the time or chance to build experience yet. Coding is a skill--more like a trade--that needs to be taught and mentored. It is your responsibility as professionals to help the next generation learn these skills. Employers are lazy, she said, and it's no wonder recent graduates can't get a job.

Well, I hadn't thought of that.

What is your opinion on pre-testing? Do you use it?

And also-- is it better to hire for skill alone (and risk getting someone who is burnt out or has little work ethic) or hire someone for personality, passion and potential and then teach skill? I'd be interested to know your thoughts.

The physicians have never seen anything like it, according to the Los Angeles Times. A letter crossed the desks of California doctors that's led to outrage among the state's health care providers.

Help us out, asks the letter (warning: PDF) from Blue Cross of California. Tell us which of your patients hasn't told the whole story about their medical conditions, BlueCross asks. You're on the frontlines, and we're just trying to clean up a few discrepancies, the letter implores. "Within the first 2 years of membership, Blue Cross has the right to cancel the member's policy back to its effective date for failure to disclose material medical history," the letter says.

The discrepancies can be cleared up, according to Blue Cross, if physicians just pass along some information about pre-existing conditions. That health history form that patients fill out in the waiting room? Send that. Oh, and be sure to let us know about "pre-existing pregnancies." The list goes on, and includes seven pieces of information that Blue Cross says should be passed along from physicians to the insurance giant.

California doctors are less than thrilled with the letter, according to the Times. "We're outraged that they are asking doctors to violate the sacred trust of patients to rat them out for medical information that patients would expect their doctors to handle with the utmost secrecy and confidentiality," said the president of the California Medical Association., Dr. Richard Frankenstein.

Frankenstein went on to express worries that patients would stop telling doctors pertinent information for fear of being dropped or denied by insurance companies.

WellPoint Inc., which operates Blue Cross of California, pointed to the letters as a way to hold down costs. If applicants' "true condition[s]" aren't known, utilization insurance services will be increased, and all members of that insurance company will suffer. "Blue Cross feels it is our responsibility to assure all records are accurate and up to date for HMO providers," said a spokeswoman for WellPoint. "We send these letters to identify members early on in the process who may not have been honest in their application."

The spokeswoman said that doctors don't have to provide the information to Blue Cross, but they can volunteer the information to the insurance company. Insurers, including Blue Cross, recently came under scrutiny for hastily issuing policies and then canceling coverage after individuals incur major medical costs, according to an AP article. Insurers say that cancellations are important for fraud prevention and keeping costs down, and the insurers insist that cancellations aren't frequently used.

WellPoint also said that the practice of asking doctors for the scoop on patients has been around for "several years." Don Crane, executive director of the California Association of Physician Groups, said he never heard of such a thing. The California Medical Association shot off a letter to state regulators asking that they order Blue Cross to stop asking doctors to volunteer patient information, according to the Times, and the association said the request is "deeply disturbing, unlawful and interferes with the physician-patient relationship."

Is this genuinely an innocent attempt to keep costs down? Do you think the letter is clear that the information doesn't have to be disclosed, but that it can be given on a volunteer basis? Would you be less likely to share details with your doctor because of something like this? Does a request like this violate doctor-patient confidentiality?

Personally, this letter doesn't surprise me. I do wonder how many doctors volunteer the information, and I wonder how much my own insurance company knows about me and my health (I don't live in California, but I would be surprised if something similar was going on in my state, especially since this has been going on for years, according to the woman from WellPoint).

What are your thoughts? Does this letter go too far? What can be done to ensure doctor-patient confidentiality?

UPDATE: At around 6 p.m. last night (Feb. 12), Blue Cross of California announced that it would stop the practice of asking physicians to tell the insurance company certain information. Dr. Frankenstein praised the move, but expressed concern. "This letter was part of Blue Cross' pattern of unfairly canceling policies when people need coverage most," he said, according to the Times. "We're relieved that Blue Cross is ending this particular tactic but continue to have serious concerns about this company's practices looking forward."

In this week's Hands-on Help column titled "Automating the Coding Process," authors Leslie A Fox, MA, RHIA, FAHIMA, and Patty Thierry Sheridan, MBA, RHIA, discuss the role of computer assisted coding (CAC) and its impact on the coding function and the coding professional.

The article provides details on the different types of CAC and how the new technology creates new roles for skilled coding professionals.

"New coding professionals will be learning a completely different set of competencies than today's coders," explained Kathy Johnson, RHIA, director of coding services at CARE Communications. "Coders will be in positions that require interacting with providers, understanding documentation and reimbursement requirements, and knowledge of quality measures and reporting."

In the article, Johnson goes on to say, "The coding professionals will play a significant role in educating providers and working with them on the use of documentation terminologies and tools. It's critically important for coders to have a role in the EHR implementation right now. They can help providers define documentation requirements including where to record documentation in an EHR and the structure of that documentation. This involvement will make a difference in reflecting accurately the codes that translate the services and complexity of care provided. Expert coding editors will also be in positions to mine and analyze data."

With coders learning new skills and job responsibilities changing, Fox stated, "I am wondering if at one point you would envision the title coder changing to something else. Although throughout this discussion we have been using coding editor, I don't think the title really captures the expertise needed to assure accurately coded clinical data. Editing traditionally refers to changing or preparing text for publication. Clinical coding is so much more than that. I like data quality experts, which denotes mastery of a body of knowledge related to clinical data input and output accuracy."

So, what do you think? Fox, Sheridan and Johnson are asking for your thoughts on a new job title for coders. What should future coders, working with CAC, be called? We'll take your suggestions and create a reader opinion poll. Please enter your suggestions below in the comments section.

Today, I read an essay in the New York Times by Andrew Vickers, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York, that is saying basically the same thing. Vickers writes, "I'm sometimes told that sharing data would violate patient privacy-though changing names to codes is easy enough. Other requests are killed by red tape."

It's time to let researchers do their jobs. If we only shared all the information there is about the different cancers and treatments, don't you think we could start finding cures?

Vickers writes, "Given the enormous physical, emotional and financial toll of cancer, one might expect researchers to promote the free and open exchange of information. The patients who volunteer for cancer trials often suffer through painful procedures and harsh experimental treatments in the hope of hastening a cure. The data they provide ought to belong to all of us. Yet cancer researchers typically treat it as their personal property."

 An article in the November-December 2007 Journal of AHIMA urges HIM professionals to address the inconsistency and misinformation around HIPAA. You are on the front lines of protecting patient privacy, but it is also your responsibility to educate those employees in your facility who may be erroneously blocking access to medical records when informed consents and HIPAA authorizations are properly executed. You can also be a resource to researchers when they run into barriers.

Step up and help contribute to finding a cure for cancer.

Medical coding training programs that advertise and promise industry standard courses to aspiring HIM professionals but don't deliver are a hot topic in the forums and blogs on this site. Johnna Grzywacz, CPC, researched why such the disparity exists between what programs offer and what potential employers expect from job candidates to land a coding position. When numerous complaints were broomed by her states' licensing and approval agencies she turned to three state representatives in New Hampshire who, on her and the public's behalf, sponsored two house bills, one addressing curriculum standards in post-secondary career education for all industries, including HIM of which medical coding is one segment.

The first bill requires the NH post-secondary education commission to review the curriculum of their licensed career schools and to make sure that the education and training received by students would indeed prepare them for employment. The bill would also have the commission submit unbiased statistics pertaining to employment status of graduates in the field of which they trained.

According to Nancy Elliot, state representative, one of the sponsors, "The purpose of the bill is to ensure adequate training that will meet industry standards and lead to employability for graduates of these programs. It is an important accountability issue."

The second bill deals with prohibition of sexual harassment in all private post-secondary career schools.

The New Hampshire Department of Education will hear testimony on the house bills, Jan. 22. According to Grzywacz, feedback regarding these bills is important. "[It] would be great especially for others in the country to comment on this action who are indeed experiencing (medical) coding scam programs in their area," Grzywacz said. "Perhaps it will motivate other state representatives to listen and take action as ours are doing."

Grzywacz also wanted to give credit to the three state representatives who sponsored these House Bills.

What do you think of Grzywacz's efforts? Would something like this be possible in your state? How do you think legislation like this will affect the so-called scam programs already in operation?

I hate to be a downer during all of the holiday cheer, but this story struck me. Nataline Sarkisyan, 17, of Glendale, CA, died Dec. 20 amid a flurry of protest about Cigna's decision not to cover a liver transplant that may have prolonged or saved Sarkisyan's life.

"Protestors are here, the war is here," Hilda Sarkisyan, the teen's mother, told the group hours before her daughter's death. "We have a war here."

The Sarkisyan family claims that Cigna first agreed to the liver transplant surgery and had secured a match weeks ago. After the teen, who was battling leukemia, received a bone marrow transplant from her brother, however, she suffered a lung infection, and the insurer backed away from what it felt had become too risky a procedure.

"They're the ones who caused this. They're the one that told us to go there, and they would pay for the transplant," Hilda Sarkisyan said.

Sarkisyan's death brings many questions and much finger pointing. Many who commented on the article side with the girl's family and put the blame squarely on the shoulders of the insurer, Cigna. Cigna did, hours before the girl's death, change its decision to fund the transplant procedure, and, according to statement, "decided to make an exception in this rare and unusual case and we will provide coverage should she proceed with the requested liver transplant."

Sarkisyan's condition, however, may have rendered the procedure too risky, some said, because the girl was already in a vegetative state, according to an AP article, and had complications from a recent bone marrow transplant used to treat her leukemia. According to the article, the medical staff at UCLA Medical Center "felt comfortable performing the medical procedure."

Others lay the blame on the hospital for not just going ahead with the procedure despite potential non-payment. One commenter proclaimed (in typical Internet forum atrocious grammar and spelling), "WHAT CIGNA did was their job, review a claim for medical approval. what the DOCTORS/UCLA did was incomprehensible. if they felt the surgery was needed they SHOULD HAVE DONE IT. wait is it possible UCLA put money in front of this poor girls need?????"

Some even looked to the family-did the family sell everything they owned to ensure they could pay for the procedure that would potentially help Sarkisyan? Why didn't the family do everything they could financially to ensure that the procedure was completed, or did they already do everything they could?

And lastly, others debated whether or not the government was at fault for a broken health care system, with calls for government-run health care abounding. If the government ran the health care system and power was taken away from the insurance companies, some said, this never would have occurred.

Out of tragedy springs the blame game. It's easy to blame the big, bad insurance company, but could others have been at fault here, too? And who's to say that the transplant would've been a silver bullet, prompting a miraculous recovery from a girl who was obviously very sick?

In the end, the girl's death, beyond bringing up political and moral discussions, may just be further pulling back the curtain on the gaping holes in the current health care system in America. Or it may just become another tale to be told in a future Michael Moore film. Either way, questions need to be answered.

I attended a session at the American Health Information Management Association (AHIMA) Conference on CAC and the technology surprised me. It seems like the fears that used to exist surrounding technology in HIM have defused a bit. MTs understand that speech recognition probably won't rob them of their jobs, especially when they're seeing speech recognition that produces such gems as "We will prescribe see Alice for his erectile dysfunction." Hence, MTs are definitely still needed, but some have morphed into editors who ensure that speech recognition is correct.

CAC was feared as something that would take coders' jobs away. Codes would be generated using technology, and coders would no longer be needed. That, of course, hasn't really come to pass. Like MTs, some coders are making a transition, only the coders using CAC are becoming validators instead of editors.

So speech recognition will probably not be replacing MTs anytime soon, and CAC won't be taking the place of coders in the near future either. But one thing surprised me at the AHIMA session and as I researched for this article-did MTs ever think that CAC could take their jobs?

The article I'm working on is on the difference between natural language processing (NLP) CAC technology and structured input (SI) technology. In structured input coding, the physician enters all of the data about the visit or procedure using a series of drop-down menus. The vendor that presented at AHIMA, ProVation, demonstrated its technology, showing the drop-down menus and how the physicians couldn't just cash out in the middle-they had to enter everything in detail and were prompted repeatedly until the information was deemed complete.

Using the information entered by the physician, the SI system generates codes based on the terms entered. A coder/validator then checks the codes to make sure the codes are correct. SI CAC eliminates transcription, as the physician enters all the relevant information about the procedure or visit.

How widespread is this going to be, and will it work? Will physicians belly up to the keyboard and mouse if it means saving some money on transcription costs? The ProVation site shows that the technology is installed currently in more than 300 sites nationwide, with hospitals and ambulatory surgery centers as clients.

MTs-is this just like speech recognition, which Nick van Terheyden, chief medical officer of Philips Speech Recognition Systems, referred to as "2 years away for the last 10 years"? If you're an MT, have you heard of SI CAC technology, or have you heard of anyone losing transcription accounts because of this technology? What are some of the hurdles you predict for this technology, and is this something you expected would come about?

Reported by Yahoo news, the Senate Finance Committee is expected to weigh in later this week on how to pay for offsetting the cut, which some estimates put at $8 billion for a 1-year fix. Congress has stepped in and headed off similar cuts in previous years.

But according to Health and Human Services (HHS) Secretary Mike Leavitt, the onus is now on doctors.

"The benefits of utilizing health information technology for keeping electronic health records and other purposes are clear. This technology will produce a higher quality of care, while reducing medical costs and errors, which kill more Americans each year than highway accidents, breast cancer or AIDS. Congressional leaders are working on legislation to address Medicare's physician payment system, staving off a reduction in reimbursement rates that is set to take effect in January and is required by law," Leavitt said. "In my view, any new bill should require physicians to implement health information technology that meets department standards in order to be eligible for higher payments from Medicare. Such a requirement would accelerate adoption of this technology considerably, and help to drive improvements in health care quality as well as reductions in medical costs and errors."

So what do you think? Is the only way to get EHRs implemented across the country through the doctors' wallets?

In a nutshell, there was some discussion on a doctor's only Web forum about errors in medical records. The patients, however, were the doctors, who were finding errors and sloppy handwriting in their own medical records.

How is the physician documentation at your facility?

I'm working on an article for our ADVANCE Student Center on resources that will help students in their studies and in their future careers. Think back to when you were a student. Was there one book or (for you youngsters) one Web site that really helped you find your way in HIM? What references did you use when you began your first job, whether it be in coding, management or transcription? What resources have you found since you began your career that you wish you had when you were in school?

Comment away below, and I'll take those suggestions and add them to the article I'm working on for the Student Center.