Passage : EHRs

Fan Mail From Some Flounder

Jeanne Johnston — Tue, 19 May 2009 12:31:00 GMT

I am beat. Spent the last week being thrown into the deep end of the pool without swimming lessons (well, I had them, but that was almost 10 months ago and I forgot most of it) and am just now feeling like I'm starting to learn how to float again. I used...(read more)

EMRs for Better or Worse?

Jeanne Johnston — Thu, 12 Feb 2009 13:39:00 GMT

As I watched this week's first official presidential press conference, the thing that stood out to me (well, after the outrage at all the political posturing and stonewalling that are getting the stimulus plan nowhere) was a comment that reminded me of Pres. Obama's gung ho stance on EMRs. Mainly, I guess my feeling about this subject has been tainted by my own experiences with the automation of medical transcription and the abysmal impact speech recognition has had, not only on the field of MT, but also in driving the quality of the medical record down to the lowest common denominator. How will the EMR fare any better?

As a patient (more accurately, the daughter and mother of patients), my own experiences with EMR are mixed, but leaning heavily toward the negative. When I had to take my mom to the ER with an allergic reaction (repeatedly), we spent hours repeating the same information to everyone we dealt with--the receptionist, the triage nurse, the nurse in the cubicle, the doctor (when he finally came). Oddly enough, entering the information in that form did not seem to mean it was there for the next person, merely that they had to enter it all again, too. Shiny new workstations took up precious space and in the exam room; that even meant that every person who came in to treat the patient was guaranteed of hitting their head on the monitor and/or running into the keyboard. Subsequent trips were similarly not simplified by the information monster, sadly enough. It wasn't enough to simply show her ID bracelet so they could key in the number and call up her very recent past medical history. . . We once again had to repeat everything to everyone. By the third visit and after sitting in the waiting room for three hours (apparently, it was prime heart attack time at the nursing homes), she finally allowed me to play doctor and we bailed to head to the nearest drug store for a box of Benadryl.

This was a very expensive private hospital (the only one in my little burg) and clearly, some software salesman had sold them a very expensive system with the promise of saving them transcription expense and streamlining their record keeping. I notice he wasn't around for the fallout when they put it into practice and had doctors and nurses doing my job for them. Is it a savings when you pay a nurse $30/hr to enter data versus a transcriptionist who's nowadays lucky to get hired for 6-7 cents per line? How about that doctor who has to spend 15 minutes fumbling through a wizard and then has no patience to deal with the face-to-face patient care because he's got to run off to the next one and do it again? (My mom's doctor looked up from the monitor, declared that she didn't look too bad and dashed off a prescription. We waited three hours for less than 60 seconds of actual care.)

When my son was recently hospitalized with an infection, we opted for a much bigger, better, and public hospital. Once again, they had that evil EMR, only this was a more manageable laptop on wheels. We answered questions once and though people occasionally asked again, it was usually to clarify details as they read from the screen. They were indeed able to call up prior admissions to help jog our memories of past history. The real advantage I saw here was that in everything they did, they were able to answer questions. My son (probably not the easiest of patients because he has to ask WHY and HOW about everything) would ask for specifics and his doctor or nurse could pull it to the bedside and say, "Let's look at your lab values and imaging studies," or "I bet I can find a good illustration online." They utilized this to make the patient a working part of the team and not merely a victim or child. At discharge, they were also able to generate instructions and followup.

Nothing with the finesse of a carefully crafted and conversational dictation, but clearly more along the lines of how an EMR is supposed to work. After the latter experience, I have to say my sadness at being put out of a job was not uppermost in my mind. The biggest danger I saw was that a keyboard itself has got to be a major player in the spread of pathogens. As most of the patients I transcribe end up suffering as much (or more) from opportunistic infections, maybe I'm just attuned to this negative, but clearly, there is no way to prevent the spread of germs when everyone's sharing a keyboard and that device is being wheeled from room to room. This hospital also has instituted a protocol that provides antibacterial foam dispensers to use as you enter and leave each room, but does nothing to sterilize computers, IV poles, and other equipment.

But I digress. In my world, speech recognition engines are poised to eliminate straight transcription. This isn't because the technology is good, but because there are software people selling the product as though it were. I have yet to hear from an MT who's been asked to help develop a platform that truly works and in the end, we're merely asked to correct the gibberish, essentially working twice as hard as we do now, but for half the money. All those great Shorthand macros we've created over the years for those dictators who always say the same thing every time? Forget that it's a time-saver, a wrist-saver, and just plain more accurate to have a whole paragraph pop up with a few keystrokes. Nope, can't use them because the SR engine won't learn unless we work with what's already given to us and make specific corrections. We are working crap wages to train computers to take our jobs, and are supposed to be grateful to have jobs at all. In the end, those long, rambling office notes will no longer contain information that conveys a patient's humanity, but only the facts necessary to fill those key boxes on a form. I suspect the only thing holding them back is the fact that there are too many old-school docs who refuse to dictate carefully enough for SR to understand them. The new kids are learning and the old ways will die off as their generation takes over.

So how will EMR be any better? Once again, we're talking software developers, salesmen, and little to no input from the people who actually have to work with these things. To complicate matters, how does the government mandate a nationwide compliance with EMRs when competing platforms can't even communicate with each other? I think the answer is simple, but I don't see the money guys being too happy about it: There are already FREE EMRs out there (Practice Fusion and Synapse are good examples and seem to get favorable reviews), many developed by doctors with a geek gene on the side. The new technology czar (yes, we're actually supposed to be getting a cabinet position along those lines) should study what's already available and pick the best one. Make it open source--i.e. free to use and to customize--so that everyone's on the same page, and so that no one stands to profit at the expense of our healthcare or livelihoods. This would be totally in keeping with the new agenda to make our government itself more transparent and accessible to citizens.

Of course, I still think the EMR's greatest potential for evil lies in the fact it will serve as a storehouse of private information that can be farmed to deny us care on the basis of preexisting conditions, to deny us employment based on facts no employer should have access to, or to target us for marketers and other unscrupulous people, but at least we could avoid the snafus that have plagued the transcription world. If this administration does manage to do this right, who knows--maybe they really will succeed in disabling Big Pharma and Big Insurance, too, and making health care for all a right, not a privilege.

MTs are clearly not the only ones in a bad place right now. Change is inevitable, but it will be interesting to see if greed continues to make policy or if common sense finally becomes a player.

Changing of the Guard!

Jeanne Johnston — Tue, 20 Jan 2009 17:57:00 GMT

It seems like an eon since the election, and like a little kid at Christmas, it hardly seems real that today is finally The Day. Regardless of how you feel about the transition, I think everyone agrees that we're on the cusp of some of the biggest changes in our lifetime. Certainly, not all of them will be good because we have to claw our way up from Ground Zero first, but one thing obstacles do is to unite people--and in a decidedly nonpartisan way because our problems aren't going to discriminate along party lines or other arbitrary criteria. We've already witnessed the biggest political awakening of our younger generation and political activism such as we haven't seen since the '60s. I think there are equal parts of trepidation and excitement. Did you volunteer for yesterday's Day of Service? Will you continue to do so? Do you know that you can actually have a voice, or at least vent your concerns to let this administration know what WE find important?

For those of us in health care specifically, it will be interesting to see how the new regime will affect us. I personally don't think EHRs (which are, unfortunately, supposed to be a priority) are going to be as great a boon as promised, unless you're the ones selling the software--which probably won't work so swiftly, if they operate anything like the crap MTs have to deal with already, especially speech recognition engines. More importantly, I'm anxious to see how the new agenda to keep jobs in this country will impact us, and whether we have new avenues to obtain education for those of us who've already been outsourced to extinction. What new jobs are likely under new regulations?

Yep, it's a new day dawning. After the pomp and circumstance, we all get down to business. We're sure to have a wild ride, but at least it feels like there's a steady hand at the helm. Out with the old and in with the new!

Say What What?

Jeanne Johnston — Fri, 25 Jul 2008 11:22:00 GMT

Everyone loves a boner. Reader’s Digest has practically made a career of them, as they comprise a good percentage of their various humor columns. I’ve always found their articles to lean toward the superficial and sappy, but hey--who isn’t agreeable to skimming through Laughter is the Best Medicine when sitting in the bathroom or whilst waiting for your tires to be rotated? MTs seem to especially love them--I suspect because so many of us are working from home and a good, “Can you believe the goofy thing this dictator said?” thread can quickly become a pile-up of hilarity and commiseration. It not only reassures you that you’re “superior” to someone out there who apparently doesn’t know that “chiefically” isn’t a word or doesn’t click that Mr. Smith shouldn’t have a hysterectomy in his past medical history, but it lets you know you’re not crazy, and there are other MTs out there who see this stuff, too. Doesn’t matter if you can top or just marvel at someone else’s bit, it’s all in good fun. We get our camaraderie where we can, to help stave off that feeling of isolation. Even Advance has taken advantage of this with the column, “Say what?” wherein MTs are invited to share their favorite gaffes. It was always one of the first things I read on the way back from the mailbox.

There’s been a disturbing trend in these submissions, though, thanks to the spectre of speech recognition. . . Many of the submissions are not spoonerisms dictated by some tired doctor or finger-tied transcriptionist who catches herself before sending a typo or Freudian slip. Nope, more and more, it’s the ridiculous gibberish churned out by SR that poor MTs-turned-editors are getting to correct (this month, I see gems like, “Wound will heal by secondary infection.”). Despite the wild claims of vendors and MTSOs who seem to think this technology is the greatest thing since electricity, most of us are seeing the ugly truth behind that. Much of it is so nonsensical that the only way to fix it is to scratch it and start over.

Of course, it’s been my contention for a long while that SR has been eyed to replace us. MTSOs who are implementing it assure us that MTs will never be replaced because there are so many dictators who will never cooperate and learn to dictate coherently. The Organization Formerly Known as AAMT assure us that we’re now “more” than MTs, we’re “medical language specialists” (gahh) and if we use our magic parachute, we will float effortlessly into our future roles as minimum wage editors.

But wait. . . according to an article this week, even AAMT bigwigs like Claudia Tessier (what acute care MT doesn’t consider her Surgical Word Book to be a requisite?) is sounding the death knell for MT (article here--you may need to register to read it):

“The movement is toward real-time documentation, which improves patient care and patient safety,” she said. “As this happens, it diminishes the need for medical transcription as we know it. It’s not going to happen overnight, but it’s a reality.”

***

The goal is for all MeritCare clinicians to fill out electronic patient records in other ways, such as by pointing and clicking and using voice-recognition software to add notes, she said.

At first, those notes will need to be edited and proofed by a transcriptionist, but eventually the health organization wants technology to allow physicians and nurses to self-edit, eliminating the need for those services, Hewitt said.

***

Completing patient records during an examination or visit is the goal of the industry, said Tessier, who spent 20 years as chief executive officer of an association for medical transcriptionists.

Technology can make that happen, but clinicians also need to be willing to use tools like handwriting recognition software and direct data entry, she said. Some adapt readily to the technology; others don’t.

The $28 billion a year industry won’t disappear immediately, but she expects it to diminish over the next decade.

Say what? Not exactly the AAMT party line of “MT isn’t going anywhere,” is it?

I have personally suffered at the hand of our local hospital's new point-and-click EMR, wherein the same information was laboriously reentered every time we were shuffled to the next room and spelling errors were shrugged off as unimportant. Sure, it's funny when we see that SR has declared that, "both breasts are equal and reactive to light and accommodation," but somehow, I get nervous thinking that my chart could be one of those travesties lost in translation. It sounds like it's every man for himself in this brave new world, and I think I'll take charge of my own health records and just come armed with my history already transcribed and in digital and hard copy formats.

Maybe it'll get so bad that MTs can start marketing themselves directly to consumers.

Channeling Walter Mossberg

Jeanne Johnston — Thu, 12 Jun 2008 16:32:00 GMT

Still struggling to find a way to make my coursework doable on my Mac with the least contortions possible, I’ve spent the last week indulging my inner geek and trying on different software for size, and I have to say I’m enjoying it immensely.

My Computers In Healthcare course has presented more than a few challenges, not the least of which is that the text is written around things like Word 2003--absolutely ancient, in software terms. Granted, they mention frequently that students are not required to own M$ products and we can do the exercises using open source apps like OpenOffice (or any of its permutations--available for every platform out there). Now, last week I had slogged through all the chapters from Word to Access to Excel to Powerpoint, using my favorite of these, NeoOffice. This is basically a clone of OOo, except that it runs as its own application (OOo actually utilizes X11 and runs through UNIX, which can get a little tricky if you get confused by seeing that command line business.) It looks like the M$ Office applications. . . but as I discovered, there are occasional bugs in that a crucial button or function is missing here and there (hello, no one at OOo thought we might like to delete a record from a database?) I got through the exercises okay, but I knew it had been harder than it should have been.

I’m not sure why it took me until afterward to hit upon the idea of using the Mac counterparts I already had and simply saving them as Office-friendly formats. Rummaged around my hard drive and tried out my old iWork applications--which are so completely wonderful in comparison, it isn’t funny. Keynote versus Powerpoint is like comparing satellite HDTV to that 13” B&W set with rabbit ears that barely got four channels. It’s slick, it’s easy, it packs so much stuff in there that my mother (who didn’t do Ziploc bags until they came out with the ones with a zipper) could grope around it and look like a professional in the end. Likewise, Pages is Word to the nth degree--not just a WP app, but complete enough to do desktop publishing. Except. . . dang--Numbers is simply a spreadsheet app and I needed to be able to work with a relational database. It compares to Excel, but there was no way I could substitute that for Access. . .

So I flitted around the internet a bit and found the solution is Bento (lovers of Japanese cuisine will appreciate how cute and clever that name is), which is not just a database app from the makers of the old fave Filemaker Pro, but may be The Ultimate Database app. It syncs everything you’ve got into one place so your calendar, address book, iTunes library, iPhone/iPod, projects, event planning, and anything else you want to throw at it is in one cool spot. No fumbling around with formulas, queries, and awkward menus like I just learned in Excel--this is gorgeous, effortless, and powerful. Of course, I’m only able to vouch for that because I have no life and spent a morning watching all the tutorials. . . As I never got around to upgrading my OS from Tiger, I can’t even run the trial version yet. I had to throw some money at Apple and am awaiting my new Leopard installer this week so I can try it, but I have no doubt I’ll be paying to keep Bento around, even if I never use it for work.

In the meantime, however, how do I deal with this coursework? Well, much as I am loathe to install anything M$ on my computer, I decided just to bite the bullet and get the trial of Office 2008 and see if that didn’t make me see my homework in a little different light. Harumf--what a difference 5 years makes! It’s still a fairly ugly bunch of applications, but it’s nowhere near as basic as 2003. You can call up windows for tools, rather than just the mishmash of icons on the toolbar at the top of your window. You still have to run queries as a separate function, rather than filtering within the spreadsheet as you can do in the Mac apps (where you simply hold down a cell to bring up a menu), but it seems a little less clunky than what I’ve been working with. The jury is still out until I have time to go back and re-do all my exercises for comparison. In the end, however, I don’t see this as worth the price tag of over $300 because they chose not to include the most important part of the suite: Access! What the heck? In the end, it’s going to be cheaper to stick with my Mac apps and cough up another $70 for Bento, which I’ll use for everything IRL anyway, or continue plugging away with OpenOffice (FREE). Office 2008 without the database application is insane. I'm just glad I didn't buy the suite outright and then find it isn't complete!

I don’t know who decided that business applications needed to be ugly, boring, and soulless because keeping things cutting edge certainly makes the job easier to focus on, easier to impress people, and just more fun. If you're going to go utilitarian, it does make sense to use open source applications; I've encountered some pretty slick ones currently in use as ER and other hospital platforms, like Synapse EMR, which I believe was originally written by a doctor. The beauty of open source apps is that no one profits from their sale, only from providing support (ask Linux!), which means actual users can have a hand at developing products to maximize their usefulness, rather than software vendors who simply throw things together and make a fortune by endlessly correcting their problems. As a former accounting major, I do have a strange joy at plunking numbers into neat little boxes, but in the end, I really thrive on a 3D, Technicolor world. I don’t think I’m unique in that. Of course, in the end I’m going to wind up in a job that most likely will use the ugly, utilitarian, 2-dimensional applications because that’s what they do. I really have had a blast geeking out this week and playing with all the possibilities, though.

In Which I Wonder How I Got Here

Jeanne Johnston — Wed, 30 Jan 2008 14:57:00 GMT

I don't think anyone who is not a medical transcriptionist has a real appreciation for what the job entails. How many of us have had someone marvel at the ability to work from home and ask for a quick tutorial in how to get started?

"Gee, I've got a computer and a toddler, and I'd love to avoid paying for day care. I could do this, too! You just type what you hear, right?"

Ummm. . . in a word, NO. Although the field has lent itself to outsourcing and telecommuting, that does not put it on a par with an Avon gig. You need to commit yourself to space, a schedule, and be every bit as reliable and professional as if you worked on site. Even doctors-and certainly, hospital administrators-often fail to realize that it's a very important part of patient care, risk management, and even reimbursement. I've heard it said that an acute care MT needs the equivalent fund of knowledge to a third-year medical student. Not only do we need to be self-motivated and self-disciplined, our English skills need to be impeccable, we need to know anatomy, pharmacology, surgical instruments, disease processes, fundamentals of Latin and Greek, computer, keyboarding, and research skills, and possess an ability to understand myriad foreign accents (or just inconceivably poor dictators). We don't even get to specialize. We have to know it all and be prepared to handle everything from trauma to morgue. Whilst transcription is often viewed as something a typing monkey (or now voice recognition) could do and thus, is one of the first things to take a hit in a budget crunch, those of us who do it know better.

I was thrilled to discover the field, which offered a way to utilize my love of language and medicine and seemed to be The Perfect Career to take me all the way to retirement and beyond. I thought I had researched thoroughly and had a good sense of job security, as well. From the beginning, I saw there were people predicting gloom and doom because of everything from the advent of the personal computer to offshoring, but I noted there were many grande dames of MT assuring us that the field wasn't going anywhere. People have been predicting an end to MT for decades and it's still here. Surely, there will always be a need for transcriptionists, right?

A lot has changed in the past five years, though, and I see many of those same people admitting that it may well be time to move on. To my vision, the issue of offshoring has not helped wages, but it's almost a nonissue now that the industry has been overrun with software developers, speech recognition, simplistic EMRs, and more and more clients being sold a bill of goods wherein they believe they are saving money by having a physician playing hunt and peck around a keyboard in the exam room instead of dictating and waiting for the MT to produce a much more useful record of patient care. Even the transcriptionists' supposed representative organization has abandoned the practitioner in favor of the "medical document." Yes, offshoring gave clients a sense that they could save huge quantities of money and that has become the driving factor. It's been said that transcription involves three client needs: Speed, cost, and quality. Of those, it's only possible to have two. Naturally, cost is the one clients seem to feel is most important. All this has conspired to drive down MT wages to a point where it's getting hard to make a living. Wages that seem generous in Bangalore translate to well below poverty level here. Editing speech recognition may sound easier than straight transcription, but in fact it often involves almost as much work-double the production quotas for half the pay or less. With downwardly spiraling wages, I don't see the field attracting qualified MTs as the veterans retire-not when you can make higher wages for so much less work at your nearest McDonald's. No, transcription is increasingly becoming viable only to people with limited options or as a second income, and even independent contractors are beginning to complain that clinic work is disappearing to computerized record-keeping.

In pondering all this, I have come to the sad conclusion that medical transcription as we know it is marching along toward its demise. It's no longer a matter of keeping up with the technological changes, but of turning into a whole 'nuther animal entirely. Transcriptionists are becoming SR editors. Those sometimes-eloquent physician narratives are giving way to point-and-click EMRs. The profession I'd been so thrilled to find and proud to be a part of is starting to feel like it's built on quicksand, and I finally reached the point where I knew I needed to prepare for Plan B.

So what do I do with this head full of medical lingo? I could become a nurse, but I don't exactly have youth on my side there. I'd probably enjoy being an OR technician, but again, am I physically up to long hours on my feet or heavy lifting? I seriously considered phlebotomy or x-ray technician, and ruled out coding because I have a strong feeling it's a bit too "left brain" and requires a mindset completely opposite transcription.

Amid all my mental floundering, I saw it: That fateful letter to Advance by a woman who gleefully related how she took her skills as an MT into a new career as a cancer registrar. I paid heed to that "aha" voice in my head and spent the next couple months using my MT research skills to figure out exactly what this involved, and came to realize my name might be all over this thing.