Replacing transcriptionists with physicians is a fool’s bargain

Replacing transcriptionists with physicians is a fools bargain

My general internal medicine practice is equidistant from the three academic institutions and a Veterans Administration facility, and thus I have patients who receive primary, secondary and tertiary care at each of these institutions.

The notes I receive back from one of these organizations are hands down the best of the four institutions. These notes are personal, concise, precise and clear. If the patient had a complicated outpatient work-up the communicating physician will send a problem-oriented summary of the patient’s symptoms, the work-up, the conclusion and the recommended next steps. There is a clinical narrative with clear communication of the patient’s unique story and the medical decision-making. Furthermore if the patient saw more than one physician, the note I receive integrates the impressions of all of the physicians.

For my patients hospitalized at this institution I especially value the discharge medication list, which is broken down into fields for continued medications, modified medications, new medications and discontinued medications. In most circumstances the patient has also received a copy of the inpatient and outpatient notes and the medication list.

From the other organizations the communication is rather more like a “ransom note,” a multi-font collection of structured text entries, pieced together with imported labs and x-ray results into a hard-to-read document, typically 6 pages of structured text, with an emphasis on billing justification and compliance language. Scanning through these lengthy documents for the “meat” of the note I struggle to find a coherent story (but I readily see what type of learner the patient is, and what part of the visit the attending was present for and other billing and compliance information.) Three different EHRs are represented. Here is a typical emergency room note:

The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: near syncope

Transcriptionists are being replaced by physicians for cost reduction, a calculus that doesn’t consider reductions in patient safety and quality, or lost physician productivity and well-being.

This “savings” in transcription costs also comes at a cost to the clinicians who subsequently read through multiple pages of low value text to find the kernel of useful information. And because the person documenting the care spent considerable time processing through the drop down boxes, less effort has been applied to the assessment and plan, often leaving the receiving physician in the dark when trying to pick up the thread of care.

I have always appreciated the care my patients receive at the first institution, not just for the care itself, but for the systematic, reliable communication I receive back about my patients. I recognize that having one physician summarize complicated care across many specialties, and having dictated notes is an expense, but it is an expense that makes a difference in the care of patients. Replacing transcriptionists with physicians is a fool’s bargain.

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations

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  • LeoHolmMD

    “Ransom note” nails it at so many levels.

  • buzzkillerjsmith

    A fool’s bargain? Perhaps you’re just not seeing the big picture here.

    A fool’s bargain only if you care about medical care. If you care about profit, it is a genius’s bargain since it makes doctors do work for free. So what if it’s an important job done poorly? CorpMed won’t look a gift doc in the mouth.

    • James O’Brien, M.D.

      For it to be a fool’s bargain, the fools (us) would have had to participate in the bargain. I would call it a pawn’s destiny.

  • guest

    If it doesn’t show up on a patient satisfaction survey, or a joint commission inspection, the hospital could care less.

  • LeoHolmMD

    Instead of ejecting transcriptionists, they should have been brought to the next level as documentation and coding experts combined. So many things could be solved with a “super scribe”.

  • Karen Ronk

    Excellent article. I would only add that along with the lack of quality of the notes (I have read mine from a doctor who does their own), there is also the lack of attention during the visit as the doctor is typing away and not even looking at the patient.

  • PrimaryCareDoc

    I don’t think this has anything to do with saving money on transcription. It’s all about “meaningful use” of the EMR. Check all the boxes, collect your prize at the end!

    I agree with you about the uselessness of the notes. I might not be able to figure out what treatment the patient got for his new onset a-fib, but at least I know that safe sex was discussed!

    My personal favorite EMR boilerplate that I got from a local ER was this “The patient presents with an animal bite. The animal was a tick. The bite was unprovoked.”

    Well, thank god for that useful bit of info. We all know that there are hoards of roving packs of ticks who will bite at the slightest provocation.

  • SteveCaley

    “Big Data” is pumped up into the Emperor’s New Fashion Line, and bloats into a bigger bag filled with more useless jargon. Making bigger sausages by adding sawdust makes a bigger sausage, that’s right. Grandmother’s birth-weight, uncle’s hat size. That is data, too. A datastream is not communication.

  • SteveCaley

    Hallelujah, friend! I have been in the peculiar situation of arguing with people who have Seen the Vision of Big Data – and arguing that I didn’t need all that rubbish to diagnose a patient properly. “Yes you do, that’s just your opinion,” say the Lotus-Eaters. “You are just unenlightened.”
    I favor Joseph Weizenbaum’s take on the perils of data. I suppose I am just a primitive.

  • Christine Sinsky

    It is true that much will be different in healthcare in 30 years. That realization, though, shouldn’t distract us from dealing with the present.

    Technology promises many wonderful things, but the current reality is that its application to healthcare has been both a blessing and a burden.

    When administrators and regulators make decisions (i.e. to eliminate dictation) and impose regulations (i.e. Meaningful Use requirements for who can type in the doctor’s orders) for the present based on the hope for future functionalities, the patient, and the health care professionals working closest to the patient, can lose out.

    A medical education is a terrible thing to waste. Physicians are spending the majority of their days on mostly clerical tasks and some clinical tasks that other members of the healthcare team, including transcriptionists, “super-scribes” and a well-trained nurse could do.

    • Nahum Kovalski

      Thank you very much for your comments. I still feel that a focus on the present case for physicians will likely not bear any fruit. The only way, in my opinion, for physicians to improve the situation is to become members of the development teams that design medical software. EPIC will not be re-written. But a startup, with doctors on board, could build a new “skin” for EPIC that allows doctors to interact purely with a clinical interface. If doctors focus their energies not as much on bemoaning the present situation, but rather on creating their own new environment, then a great deal of positive change can happen in less than 10 years. And I still feel very strongly that doctors need to embrace this new kind of future medical practice now, because the doctors starting first year medical school today will face a brave new world early on in their careers. And I believe that medical schools should already be preparing students for this new reality.

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