The Whole Point
Carol in Alaska left
a great comment last week that reminded me of concepts in MT I thought were gospel, but seem to be falling by the wayside:
"The whole point of the medical record is to give accurate, readable information about the patient. There are many shortcuts one could take to save time and space, but that would defeat the purpose. I try to keep this little scenario in my mind: What if this record I am typing were read out loud in a court of law. How would it sound? Would the attorney or the jury (or the judge, for that matter) understand the language? I've had numerous calls from court reporters wondering what on earth my doc said as an expert medical witness. It might have been simple and clear to me but to her it might as well have been in Swahili."
As MTs, we're always told that the transcribed medical record is mainly to provide lofty-sounding things like continuity of care and ensuring patient safety but as we all know, we live in a litigious society and the biggest reason of all is more likely to provide that oh-so-important way for a doctor to cover his hiney in the event of a medical catastrophe, should some suit-happy patient drag him into a court of law to explain himself. If this wasn't the case, why don't hospitals in every country employ transcriptionists? The fact is that no one does to the extent we do, and there are a goodly number of countries (we're not talking Third World nations, mind you!) who still find handwritten notes suffice. This is America, the country that's perfected the art of CYA, right? We've got dorky warning labels on everything to ensure corporate America is not held financially responsible for every half-wit who takes their blow dryer into the shower or folds their child up in a travel crib, fer cryin' out loud.
So how the heck do things like speech recognition and those awful point-and-click EMRs actually replace a proper, transcribed record in a legal scenario? SR is designed by software designers, not transcriptionists or even language specialists. I see over and over that MTs forced into new roles as editors of SR output are up in arms because the quality is so poor, they're having to practically re-transcribe them in full because it's less work than fixing the gibberish (at half the pay, mind you), and for too many dictators, SR just plain is never going to be able to learn well enough to churn out a usable document. . . and it surely isn't going to help a jury look favorably on the defendant when tallying up the damages. How are you going to counter a tearful family with vivid memories of what transpired if you can only counter with a computer-generated list, some lab values, maybe an x-ray, and vague recall of a patient treated months or years ago? Face it, if it boils down to "he said, she said," a jury's going to relate to the patient.
Likewise, I've had personal experience with an EMR when taking my mom to the ER with an allergic reaction. Never mind that her face was rapidly swelling, she was asked to answer the same medical history questions at the registration desk, the triage desk, and the exam room. . . pages and pages of questions, the clerk, nurse, and doctor--and I'm talking about people in the same 20 feet of hallway, mind you--all fumbling to navigate through the screens (often starting over at the beginning) before they could even treat her. In the end, what did they have? Basic insurance and billing info, and a little checklist of symptoms she came in with. Even armed with a copy of the printout on subsequent visits, we were obliged to go through the same process from scratch because it was apparently incapable of generating a followup visit with the information already provided. If the poor woman had suffocated in the end, what would their defense be? Proof that these people had ticked a few boxes, but a checklist falls far short of capturing the nuances of patient interaction or the doctor's rationale for how she's treated. In our case, it surely failed to provide timely treatment because it took almost two hours before she even saw a doctor--and when she did, the poor guy was alternately struggling with the touch screen or hitting his head on it because it was suspended from the ceiling like the overhead exam lamp in already-cramped quarters. Our third visit proved to be no quicker, and after sitting for four hours in the waiting room with everyone else suffering the same fate, she finally decided she wasn't going to die and we opted to go find some over-the-counter Benadryl without benefit of a medical degree. Pffft. Even if I wasn't an MT, it wouldn't have left a good impression.
I can recall feeling outrage that someone in bad enough shape to even go to the ER would be forced to sit with a clipboard and fill out an info sheet before being seen. Well, forget that--they've found a way to waste many more precious hours. Maybe the real goal is to clear the freeloaders out of the overcrowded waiting rooms. Anyone incapable of walking away in disgust is obviously sick enough to merit treatment.
Though MTs love to commiserate on the silly or horrendous dictation errors we encounter, the truth is that many dictators are actually pretty adept communicators. My favorite account of all time treated me to a huge number of Brit-educated dictators, whose reports were often downright poetic. When a doctor's narrative includes niceties and chit chat about personal interests, their admiration for a patient's supportive family, or a kindly reprimand to get out of the house, find some romance or hobby, and start enjoying life, you get the feeling they really care about their patients. All that is lost with checklists and canned transcription.
Forget the MTs displaced in this rush to embrace the latest technology for technology's sake. As a patient, I have to say that I deserve my physician's full attention, not the top of her head as she hunts and pecks on her laptop or Blackberry. (Is it really cheaper to have a physician transcribing her own reports, anyway?) I've had doctors make mistakes, occasionally with tragic results. If we've connected as human beings, I also found it very easy to shrug it off as their best effort in the circumstances. I suspect if the same kind of thing happened today, though, and I found my records dehumanized and distilled to a soulless checklist, I'd be feeling much less forgiving.
Obviously, the die is cast and all this is probably moot, but It'll be interesting to see how this plays out. Now they've all been sold the bill of goods on "cheap" technology, I don't foresee clients suddenly willing to pay more again for real transcription. I do think they're in for a rude awakening once the real costs reveal themselves, and in my admittedly humble opinion, I think the CYA department is going to turn out to be one of the biggest whoopsies. One thing's for sure, though--whether as a patient or as an MT, I'm not at all happy with what Big Business is doing to the quality of my healthcare.