Tuesday, March 06, 2007
Embrace technology - prudently
Can you imagine medicine today without technology? We're committed to computers, dedicated to databases, bonded to billing systems. Without the time-saving, labor-reducing benefits of technology, we'd nearly be at a loss as to how to care for patients and keep track of their visits.
But how much of a good thing is too much? Are we letting electronic bells and whistles overwhelm our organizations so that we actually sacrifice efficiency to mechanization? Take a moment to consider technology's place in your practice. Are you running it - or is it running you?
More technology not necessarily better
How many disparate systems does your organization currently support? Electronic medical records (EMR)? Billing? Accounting? Scheduling? Credentialing? Transcription? Do they integrate with one another or function as islands that require many staff to operate them? Could they integrate with one another and share data? If not, perhaps your practice would be better off with a new suite of office management products that work together. Many unrelated systems may hamper the efficiency of your practice operations, rather than streamline them.
Something else to consider: How many manual processes did technology replace? Or did it actually add labor because a product was not really a good fit for your particular organization, causing you to work around it? If your scheduling software doesn't communicate with your EMR, your employees may need to check patient records against patient requests for appointments to prevent duplication of services. If your billing data aren't available for use with your accounting software, you're creating extra work.
Possibilities and pitfalls of outsourcing
Outsourcing has become a $4 trillion-a-year business, according to Dun and Bradstreet. Outsourcing potentially enables businesses to reduce costs and concentrate on core competencies while transferring noncore business processes, thereby providing more effective goods and services elsewhere. But is it a boon or a boondoggle?
Many healthcare organizations are finding that diverse functions can be outsourced without affecting the core competency of health care. Although outsourcing was once primarily used to provide noncore services such as dietary, housekeeping, and security, it has extended to top executive jobs, clinical areas (e.g., nurse and physician staffing), and a growing number of business functions, including coding and billing. Functional outsourcing involves a single function that solves one problem in a facility, such as outsourcing transcription or coding. Departmental outsourcing is much broader in scope and may include reengineering of a department, such as the health information management department or the payroll department. Strategic outsourcing involves more than one department, such as the human resources division (including payroll, benefits, hiring, and firing) or the business office (including chargemaster, insurance, admissions, and collections). There is no general consensus on the optimal mix of in-house and outsourced functions. Each organization should assess its own needs and determine for which functions benefits outweigh the concerns discussed below.
Outsourcing offers many potential benefits to healthcare organizations. One major benefit is providing enough staff to operate the facility. Altoona Hospital in Altoona, Pa., for example, successfully outsourced some of its radiology readings to India. Outsourcing routine X-rays and scans helped to stabilize the heavy workload for the hospital's in-house physicians. The number of nighttime radiology calls was swamping the seven on-call radiologists at the hospital. In addition, transferring routine paperwork off-site allowed in-house staff to concentrate on core competencies, such as improved patient care, and to spend more time practicing medicine.
Another major benefit is the cost savings resulting from reducing the in-house full-time and/or temporary staff and the training associated with that staff. In addition, healthcare organizations can invest capital in new medical equipment and supplies rather than in staff and/or technology to complete core business processes such as billing and coding. For example, an Evanston Northeastern Healthcare executive in Highland Park, III., estimates that the organization's outsourcing contract will save it about $400,000 annually. By outsourcing coding, Hennepin County Medical Center in Minneapolis reduced its discharged not final billed due to uncoded records from $13 million to $4 million. Its outpatient unbilled encounters also improved from more than $2 million to less than $800,000.
Concerns Regarding Outsourcing
Outsourcing does carry risks. Several hospitals have been stripped of their tax-exempt status due to the extensive use of outsourcing, that is, having for-profit entities operating inside a tax-exempt facility. Provena Covenant Medical Center in Urbana, Ill., received a $1.1 million property tax bill after its status changed. Another concern is potential declining employee morale and the loss of community support due to layoffs associated with outsourcing, especially when unemployment is high in the United States.
A healthcare organization considering outsourcing must be assured that the vendor can provide credentialed, knowledgeable, properly trained staff. Liability must also be addressed. No one knows if liability is going to fall on the healthcare organization that is doing the outsourcing, the referred physician, or the third-party provider. Other factors at issue include cultural barriers, differing management styles, potential political instability, time zone differences, and labor pool quality that may add real costs through resulting management inefficiencies.
A key ethical consideration is whether a healthcare organization should inform its patients that their information is being outsourced. Most healthcare organizations do not tell their patients that some services are outsourced. Other professions have dealt with this issue by requiring such notification. In late 2004, the American Institute of Certified Public Accountants issued several ethics rulings, one of which requires its members to inform clients, preferably in writing, of the transfer of personal information to a third-party supplier before the transfer takes place (see www.aicpa.org/download/ethics/ 2004_1028_outsourcing.pdf). However, the rule does not require a member to inform a client when he or she uses a third-party service provider to provide administrative support services, such as record storage or software application hosting services, to the member.
Speaking of Efficiency - Technology Information
Next generation of voice recognition products comes with gentle learning curves and integration to clinical workflow.
Discard any preconceived notions or past experience with voice recognition (VR) and what it can do for your practice. Once a "not ready for prime time" oddity, voice recognition technology has become a productive citizen.
Early VR products in healthcare had several shortcomings. First and foremost, they were not integrated into the clinical workflow. Medical documentation generally follows a predictable flow from front office sign-in to chart review, patient encounter and documentation. Early VR systems simply sat on a stand-alone computer where a physician had to walk over and dictate, apart from workflow. There was no interface to existing systems, which created inefficiencies and slowed physicians down.
Voice recognition software works by hearing the spoken word and converting it to text by making an "educated guess" at what the user is saying based on an individual voice model and associated vocabulary. Earlier voice engines (and many still today) used a medium such as Microsoft Word or WordPerfect to display and store the text. The second problem arose with these forms and the inability to organize them in a database format. Dictated and completed notes were stored in Windows Explorer and provided no organized access, useful search ability, means for electronic distribution such as faxing or e-mail, or anything more than transcriptionists normally supplied.
Third was the problem of editing limitations. Voice recognition requires an edit process to improve. As dictated text is edited for accuracy, any changes update and improve the user's voice model. Most VR products digitally record and save the user's voice and synchronize it with the created text as they dictate. This is done to create an audible reference. If the user said "the lumbar spine" and the system interpreted it as "the lumber is pine," there would be a recording associated to the incorrect text that would allow the user to understand what was actually said and make the correction.
In earlier products, editing for recognition accuracy had to be completed immediately after dictation; otherwise this recorded audio file was lost. In addition, dictated text and audio files could not be moved across a network so the physician had to complete the editing tasks himself, instead of delegating it to a staff member.
Finally, the learning curve was unbearable. Early models required two or three hours to "enroll" or create a voice model and there was virtually no training available. Many were discrete speech, which meant a user could not dictate at normal conversational speeds, but had to pause between each word. Training consisted of a user's guide or a video, and users had to self-train and self-implement.
Early products were designed for the masses and generally sold off-the-shelf; they were not designed for the specialized healthcare utilization. Even those designed for healthcare only offered a preloaded medical vocabulary of terms.
Today's Difference
Today some VR systems can interface and share data with legacy billing and electronic medical records (EMR) systems. This is significant for several reasons. First, when starting any note, the physician typically identifies the patient or chart number, visit date and type, and maybe a carbon copy reference. Some systems today can import this information from the billing system and shorten dictation time by eliminating dictation of redundant data.
Second, some current systems can export dictated or captured information such as charge codes back to the billing system and can export completed dictation into an existing EMR system. When interfaced with the electronic patient scheduler, they can also manage the outstanding dictation queue, thereby eliminating the possibility of missed dictation.
Import of demographic data elements, including referring physician information, can be downloaded from the practice management system. Dictations can then be automatically faxed or e-mailed to a referring physician or colleague after dictation is complete.
Some systems today can provide useful and timesaving dictation templates. These forms or note templates should be in some database format to maximize their benefit. The application also should be able to provide voice macros whereby the user can give a short verbal command and have repetitive statements or preformatted text inserted into the note automatically. Macros can also contain information that has been downloaded from the billing system.
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