AMERICAN HEALTH INFORMATION
MANAGEMENT ASSOCIATION (AHIMA)
NATIONAL MEETING
MIAMI BEACH, FLORIDA
OCTOBER 17, 2001
PRESENTATION
TECHNICAL PAPER
WHAT’S IN?
TRANSCRIPTION
REVERSE RE-ENGINEERING
WHAT’S OUT?
TRANSCRIPTION
OUTSOURCING
Submitted By:
Octavia D. Kelly-Gaston,
RHIA
Director, Health Information
Management
Newark Beth Israel Medical
Center
Maria A. Muscarella, RHIA
Director, Health Information
Management
Saint Barnabas Medical
Center
Jamie Collins, BS, RHIT
Director, Consulting and
Re-Engineering
Diskriter Inc.
INTRODUCTION
Many healthcare organizations outsource most, or all, of their transcription, simply because they don’t want to deal with the “pain” of managing transcription operations. However, with the increasing costs of outsourcing, organizations are looking for ways to reduce costs and bring transcription back under their control without sacrificing turnaround time and quality. Newark Beth Israel Medical Center in Newark, New Jersey and Saint Barnabas Medical Center in Livingston, New Jersey, both affiliates of the Saint Barnabas Health Care System (the largest healthcare provider in the state of New Jersey), outsourced 100% of their transcription operations. A plan was put in place, with the assistance of the transcription re-engineering specialists at Diskriter Healthcare Documentation Solutions to bring transcription back under the control of each facility and to take advantage of “best practices” identified in recent comparative analyses of comparable organizations. The ultimate goals of both re-engineering initiatives were to improve quality, reduce turnaround time, and significantly reduce costs.
Because each facility outsourced 100% of their transcription operations, the project was labeled as a “reverse re-engineering” initiative, since transcription departments had to be shifted from total outsourcing and reintroduced, from scratch, to each facility. Diskriter appointed a project team of four transcription re-engineering specialists with their areas of expertise focusing in administration, human resources, technology, and transcription management. All team members used a detailed (600-700 action items) project plan as their working document during the planning, development and implementation phases. At each facility, the HIM director was identified as the “contact person”. However, one goal was to make the reverse re-engineering initiative as “painless” as possible, with minimal involvement by the HIM directors. A second goal was to make the transition as transparent as possible to the medical staff and other caregivers.
Basic Concept:
· Utilizing current “best practices” identified in multi-facility studies of departmental control and efficiency.
· Replacing the existing transcription outsourcing program with a hospital-controlled, home-based, incentive-based program.
· Hiring transcriptionists as employees of the health system.
· Renting dictation and transcription applications from an Application Services Provider (ASP) or on a National Time Sharing Network.
· Having the re-engineering company be totally responsible for the planning, development and implementation, as well as the on-going administration of the project and full management responsibilities of the medical center’s remote transcription employees.
· Making sure that all procedures and equipment considerations were compliant with HIPAA and all other regulations.
There were several cost considerations which included:
· The transcriptionists being employees of the health system.
· The one-time cost of the re-engineering engagement.
· The cost of equipment time-sharing (dictation and transcription applications).
· The home-based equipment, reference materials, maintenance and Help Desk.
· The remote management agreement.
· Interfaces.
· Dedicated voice and data lines (if desirable).
The equipment and capital investment considerations were:
· Implementation of a program with minimal or no capital investment.
· The renting of dictation and transcription applications from an Application Service Provider (ASP) or on a National Time Sharing Network (no capital investment, no expensive annual maintenance agreements, no obsolescence).
· The purchase, rental or lease of equipment for the home-based transcriptionists.
· The purchase, rental or lease of interfaces (ADT and/or repositories).
· The rental or lease of dedicated voice and data lines where necessary for interfaces.
· The equipment maintenance and Help Desk support (could be provided through the re-engineering company).
Equipment:
It was decided that the equipment (dictation and transcription applications) would be rented on a National Time Sharing Network (ASP model). This approach would provide state-of-the-art dictation and transcription systems with no capital investment by the hospitals. These systems can emulate all traditional manufacturers, thus allowing this approach to be transparent to the physicians and other caregivers. Other advantages were:
· Full compliance with proposed security requirements as stated in HIPAA legislation.
· 100% uptime of dictation network, guaranteed through contingency networks.
· 100% uptime of transcription network, guaranteed through backup off-line networks.
· No long distance charges (toll free 800 line dictation system access).
· No long distance charges for the home-based transcriptionists (the Internet used as a conduit for compressed, encrypted voice and data files that are compliant with privacy regulations).
· No obsolescence.
· No expensive annual maintenance contracts.
· 24/7 services and 24/7 Help Desk.
· Pay only for the time the system is utilized.
Recruiting:
It was determined, from the
annual workload information provided in the Benchmarking Study, that seven FTEs
would be needed to perform the workload at Newark Beth Israel Medical Center,
and ten FTEs would be needed to perform the workload at Saint Barnabas Medical
Center. The assumption for determining the required staffing was that each
medical transcriptionist would be transcribing an average of 150 (65-character)
lines per hour. The re-engineering company utilized its “Transcription
Placement Division” to attract and recruit qualified transcriptionists. The
interested applicants were given a battery of tests (including selective
re-recorded dictation from the facility to which they were applying). Their
levels of expertise in medical terminology, anatomy and physiology, Microsoft
Word and Windows, and the four basic work types (Discharge Summary, History and
Physical, Operative Note and Consultation) were measured, and only those
applicants found to be qualified were hired.
Scheduling:
To effectively manage staffing and scheduling, peak dictation times were analyzed at each facility to determine which days and hours staffing would be required. The remote transcription manager conducted this analysis and concluded that 24-hour staffing would be needed at both facilities. The transcriptionists were assigned four “core hours” each day which they were required to cover. Beyond those “core hours,” each MT could flex the remaining four hours during the day or evening shifts. By utilizing “flexible scheduling,” a transcriptionist is able to take longer breaks and is typically more productive than working a “straight shift.” In order for output (transcription) to match input (dictation), core hour assignments were made to sufficiently staff for the workload on each particular day and increment of time. However, each transcriptionist works a 40-hour schedule and overtime is strictly limited and must be authorized by the appropriate HIM director.
Orientation and Training:
Once the transcriptionists were hired, they underwent an intensive training program of 120 hours. During this training program, they became oriented with the software and hardware they would be using, as well as hospital policies and procedures. There was also a focus on productivity training in order to ensure there was maximum utilization of the productivity tools available within the software. Quality assurance and productivity expectations were discussed and a complete understanding of these expectations was verified with the transcriptionists. Productivity expectations were 150 (65-character) lines per hour, and quality expectations were 97% to 100%. Each MT was granted a 90-day orientation period (consistent with the new-hire orientation periods of each facility). During this time, the MT’s were expected to have become proficient with the equipment and software, to have mastered a complete understanding of the policies and procedures, and have reached the medical center’s productivity and quality expectations. New hires were paid a training hourly rate for their first three weeks (120 hours) of employment. For the remaining initial period of employment and thereafter, the employees’ compensation was strictly based on the amount of production.
Turnaround Time and Quality Assurance:
The remote transcription manager monitors turnaround time and quality assurance on a daily basis. Work was pooled according to turnaround time priority for that particular work type. For the initial 90-day period, all work performed by the newly-hired transcriptionists was reviewed for accuracy. If, after three months, the MT was meeting the quality expectation of 97% to 100%, his or her work was then reviewed quarterly.
Productivity:
The remote transcription manager monitors productivity on a daily basis. Guidelines for productivity were set at 150 lines/hr, 6,000 lines/week or 24,000 lines/month. These standards were based on an 8-hour day; if a part-time MT was hired, this standard was adjusted accordingly. In the event the defined standards were not met, and the transcriptionist had completed the 90-day introductory period, other sanctions or counseling methods were applied. Additionally, all transcriptionists who produced greater than 6,000 lines in a 40-hour workweek were paid an extra penny per line for those lines over 6,000.
Transition from Outsourcing to
Home-based, Incentive-based:
In order to ensure a smooth transition from total outsourcing to a fully operational hospital-controlled, home-based, incentive-based transcription program, a plan was put in place to gradually decrease the amount of work being outsourced. As the productivity of the home-based MT’s increased, they were able to gradually absorb additional work formerly being outsourced. Using this methodology, outsourcing was totally eliminated at both facilities in a short period of time.
Outsourcing
has proved to be one of the most costly methodologies for providing transcription
services. There are usually hidden costs involved which are not obvious to many
HIM managers. These hidden costs continue to impact skyrocketing budgets.
Obviously, the best way to control costs is to maintain control of the
resources. This was the goal at both Newark Beth Israel Medical Center and
Saint Barnabas Medical Center. By implementing a hospital-controlled,
home-based, incentive-based transcription program, each facility will recognize
at least a 30-40% cost savings. Factoring in the initial investment in a
hospital-controlled, home-based, incentive-based program against the long-term
cost savings makes the ROI (return on investment) most impressive. The only
additional responsibility the HIM manager will have at this point is the
enviable task of reporting transcription reverse re-engineering total cost
savings versus outsourcing to the Health System senior management team on a
monthly basis!
· Octavia D. Kelly-Gaston, RHIA, is Director of Health Information Management at Newark Beth Israel Medical Center in Newark, New Jersey. Newark Beth Israel Medical Center is a 669-bed acute care, teaching facility with over 31,500 discharges and 87,500 ancillary visits annually and is one of nine acute care facilities of the Saint Barnabas Health Care System. Octavia is responsible for the day-to-day operations of the HIM Department. She has worked at Newark Beth Israel Medical Center for the past 10 years, starting as Assistant Director in 1991 and becoming HIM Director in 1999.
Octavia has over 20 years experience in the Health Information Management field, having begun her career as a Tumor Registrar at Memorial Sloan Kettering and subsequently holding several managerial positions in the HIM profession.
After 10 years of involvement on various committees with the New Jersey Health Information Management Association (NJHIMA) and having served as Committee Chair on various committees, Octavia will serve as the NJHIMA President for the 2001 – 2002 term.
· Maria A. Muscarella, RHIA is the Director of Health
Information Management at Saint Barnabas Medical Center (SBMC), a 620-bed
teaching facility, located in Livingston, New Jersey. Saint Barnabas Medical Center is one of nine acute care
facilities of the Saint Barnabas Health Care System. In addition to overseeing the operations of the Health
Information Management Department and Medical Transcription, Maria is
Co-Chairperson of the SBMC HIPAA Steering Committee as well as a member of the
Saint Barnabas Health Care System HIPAA Steering Committee. Maria previously served as the JCAHO Survey
Coordinator for SBMC, resulting in accreditation with commendation.
A former educator and artist, coupled with her experience as a HIM Director, Maria’s varied background and managerial skills have enabled her to develop her own unique style and approach to the Health Information Management field. In this ever-changing healthcare environment, Maria’s management approach is one which ensures her staff are educated, motivated and empowered. She feels it is her responsibility to provide her staff with the tools to perform their tasks efficiently and optimally.
Due to this philosophy and her enjoyment of teaching, Maria has given several seminars on Organization and Motivation, as well as Confidentiality and Release of Information, and Effective JCAHO Preparation.
A former member of the Board of the New Jersey Health Information Management Association and adjunct professor at Kean University of New Jersey, Maria acknowledges the importance of mentoring future HIM professionals. In so doing, Maria enjoys guest lecturing HIM students and monitoring students on site during their management affiliations.
Jamie feels her full-time mission is working with clients
across the country to help health information managers save money, improve
productivity, reduce turnaround time, and still pay their transcriptionists
more.
Prior to joining Diskriter Healthcare Documentation
Solutions, Jamie was the Director of Medical Information Services at Phoebe
Putney Memorial Hospital in Albany, Georgia. While there, she implemented a
home-based, incentive-based transcription program which moved 13 medical
transcriptionists from working in the hospital environment to working at home,
resulting in a 30% increase in productivity.
Jamie has over 24 years experience in the health information management field, having begun her career as a medical transcriptionist and, subsequently, expanding her experience to include various managerial positions in hospitals and transcription services.
Jamie is also on the part-time faculty at Darton College in Albany, Georgia where she has taught courses in medical transcription, medical transcription supervision, as well as other information technology and allied health courses. She also serves on the Advisory Board of Darton College for the development of a medical transcription curriculum. She is still an active mentor to students in both the academic and home-study settings.
For more information: contact Will Hull via email
or via phone at (800) 876-4737 ext. 300