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Standards in Healthcare Documentation: A Work in Progress
Brenda J. Hurley, CMT, FAAMT
Chair of ASTM E31.22

Within the medical transcription industry and in healthcare documentation, the lack of standardization of our systems and our processes, challenges us all--the users, practitioners, vendors, healthcare providers, and patients.  Standardization is important in our professional and personal lives.  When we make purchasing decisions for standardized items, we can do so with confidence that they will fit and work for our needs.  Imagine how complicated it would be if faxes could only be sent and received specific to the same manufacturer, or email could only be sent and received specific to the same internet provider service.  Standards allow for systems, regardless of the manufacturer, to work together.  In order to provide procedural consistency and proficiency in performance, processes can also be standardized. This saves time and aggravation, rather than repeatedly taking resources to re-invent the wheel.

ASTM, which prefers the acronym and not the extended form, was founded in 1898, recently changed its name to ASTM International.  There are 30,000 members from 100 nations in this not-for-profit organization.  Over 130 committees from various industries have published more than 11,000 standards in materials, products, systems, and services.  Through the ASTM standards development process, consensus through balloting is reached by voting within the subcommittee (i.e., E31.22) and the main committee (E31).  All negative votes must have an accompanying comment (the reason for the negative vote).  These must be resolved either through adoption of changes within the document or a committee vote claiming the negative comment was non-persuasive, therefore not adopting that change within the document.  Affirmative votes can also have comments and are also considered when finalizing the document.  The final document is often improved from comments submitted through this balloting process.   Also, a minimum of 60% of ballots must be returned to validate the balloting process. 

The ASTM subcommittee E31.22 Health Information Transcription and Documentation was formed in 1995, with the scope to develop standards for the systems, processes, and management of medical transcription and its integration with other modalities of report generation.  Since its inception, this subcommittee has created important standards that are useful and significant to the medical transcription industry and in healthcare documentation.

The first standard from E31.22, successfully balloted in 1997, was E1902: Standard Guide for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Record.  This standard was updated in 2002 with language and processes consistent with HIPAA (Health Insurance Portability and Accountability Act of 1996).  Within this revision, the document was upgraded from a standard guide to a standard specification.  According to ASTM definitions, a guide is a compendium of information or series of options that does not recommend a specific course of action; however, a specification is defined as an explicit set of requirements to be satisfied by a material, product, system, or service.  Here are some of the important items included within this document:

• Updated language to be consistent with HIPAA. 
•  Identifies transcription processes to enhance security.
•  Addresses system maintenance procedures.
•  Provides off-site medical transcription policies.
•  The only standard from any organization that addresses security issues related to dictation.

The next approved standard from E31.22 was E1959: Standard Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions.  This document takes the mystery out of requesting or submitting a bid for medical transcription services.  It also provides a large terminology list, establishing a common definition of terms for all parties involved in the RFP (request for proposal) process. This standard is now undergoing a review within the E31.22 subcommittee to update it to current industry trends and language consistent with HIPAA.   Although it is five years old, there are some still important benefits of this standard, as it:

• Provides a foundation for reasonable expectations for each party involved.
•  Outlines items to include in the RFP with clear explanations for each.
•  Defines terminology used within the document and the RFP process.
•  Establishes the responsibilities of each party involved.

The next approved standard from E31.22 was E2117: Standard Guide for Identification and Establishment of a Quality Assurance Program for Medical Transcription.  This standard is significant as it provides a common understanding of related terminology, and a consistent foundation for the development of a QA (quality assurance) program.  It is applicable to all work environments and scalable to any size medical transcription service or department.   It can also serve as an excellent tool for establishing internal workflow within the medical transcription environment. Here are some of the important benefits from this standard:

• Provides essential components for the QA process.
•  Offers guidance in establishing a QA program.
•  Clarifies the purpose and value of a QA program.
•  Delineates the responsibilities and processes.
•  Defines terminology related to the QA process.

The last standard approved from E31.22 was E2185: Standard Specification for Transferring Digital Voice Data Between Independent Digital Dictation Systems and Workstations. This is a highly technical document that has taken a considerable amount of time to finalize.  This standard provides a mechanism to enable the interoperability of digital voice files and their identifying data elements between disparate systems, regardless of the manufacturer.  The lack of compatibility of digital dictation systems has long been a problem, so a method for obtaining the vital "header" information (i.e., original job number, original dictation date, etc.) with its accompanying digital voice file is applauded by many within the medical transcription industry.  Important benefits from this standard include:

• Defines a mechanism for transferring digital voice files with its accompanying data elements.
•  Provides a glossary of terms with definitions specific to this technology.
•  Describes the format and content of digitally recorded voice and data files.
•  Identifies common acronyms involved with this technology and their extended forms.

Another important standard related to healthcare documentation, E2184: Standard Specification for Healthcare Document Formats, came from the subcommittee on Data Capture and Report Generation (E31.27).  Required headings, arrangement, and appearance of the sections and subsections within healthcare documents are provided in this document.  Benefits of this new standard include:

• Information presented will be easily identified, as it will be consistently arranged within healthcare documents.
•  Retrieval of critical health information can be enhanced through standardized titles for sections and subsections, potentially improving patient safety.
•  Promotes greater efficiency in transcription and other forms of data capture.

Of note, the subcommittee E31.27 merged last year with two others to form E31.28 Electronic Health Records. 

Currently the E31.28 subcommittee is working on a Standard Specification for Continuity of Care Record (CCR), and this standard is expected to be finalized in April 2004.  This project is a joint effort by this subcommittee, the Massachusetts Medical Society, the Health Information Management and Systems Society, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Association, and the Patient Safety Institute. The CCR is intended to improve the continuity of patient care when a patient is referred, transferred, or goes to another provider setting.  The CCR will provide a basic set of patient information consisting of the most relevant facts about a patient's condition.  These would include diagnoses, recent procedures, allergies, medications, recent care provided, recommendations, and the reason for the referral or transfer. The CCR would be created by a healthcare provider at the end of an encounter, or at the end of care, such as a hospital or rehabilitation stay, and would be a vehicle to exchange information when a patient goes on to another provider.  Benefits of the CCR include:

• A mechanism for the exchange of information when a patient is transferred, referred, or goes to another provider.
•  A national standardized form that can be used by healthcare providers in order to support the safety, quality and continuity of patient care.
•  Provides the patient and other healthcare providers with a brief summary of recent care.

The E31.22 subcommittee has two standards currently in the ballot process.  The Standard Guide to Speech Recognition Products in Health Care has just completed the final ballot process and comments will be addressed at its next meeting.  Once the comments have been resolved, this document will be submitted for formal ASTM approval, which is E31 committee ballot.  The scope of this standard is to identify types of speech recognition systems, and describe features and benefits of those systems used to create medical documentation.  This will assist users in making informed decisions related to the design and purchase of these systems.  This will certainly be a timely and useful tool for those interested in evaluating speech recognition systems.  Some of the benefits of this document will include:

• Defines the types of and use of speech recognition systems with definitions.
•  Provides scenarios where speech recognition systems are used in healthcare environments.
•  Addresses benefits and common misconceptions.
•  Identified features that would be important to include in speech recognition systems.

The Standard Guide for Data Capture through the Dictation Process, which is commonly referred to as dictation guidelines, is a newly approved ASTM standard E2344 and will be available for purchase soon.

As a background we began this activity involving the guidelines for the dictation process following the report from the Institute of Medicine on medical errors and the recommendation to eliminate handwritten clinical data.  As handwriting is currently the most used form of data capture in healthcare documentation, many healthcare providers will need to transition to other forms of data capture, and for some their choice will likely be dictation.  It is important to recognize and understand that quality documentation begins with quality dictation.  Many times the quality of the final transcribed document is hindered from poor dictation habits, distractions to the dictator, or the environment where the dictation is performed.  As problematic dictation often results in blanks within reports and/or additional reviews by multiple medical transcriptionists and editors, there can be a delay in report completion.  This delay may also compromise the quality of the patient care or potentially negatively impact patient safety.  Some of the benefits of this new standard will include:

• Provides helpful hints for dictators.
•  Reduces turnaround time for report completion.
•  Potentially may enhance patient safety with completed quality documentation available in a timely manner.
•  Defines appropriate dictation environments for security of content and recording optimization.
•  Outlines equipment training for dictators.
•  Facilitates transition to new speech technologies.

A new activity for E31.22 was started last year, the development of a standard guide for the MT Workstation.  This standard guide would include appropriate tools, references, equipment, and environmental issues such as ergonomics and security.  This document would be a valuable resource for remote medical transcriptionists, medical transcription service owners, medical transcription departments transitioning to remote employees, medical transcription instructors, medical transcription students, and vendors. Our work on this standard guide continues.

You can purchase any of the ASTM standards referenced in this article through ASTM (www.astm.org) or AAMT (www.aamt.org).  If you are interested in participating in any of the E31.22 activities, or would like to stay informed regarding our meetings or progress, email me at Bhurley@medware-inc.com.  The next meeting for the E31.22 subcommittee is scheduled for Tuesday, May 18, in Ft. Lauderdale, Florida. The following meeting has also been scheduled and will be on Friday, August 27, at Atlanta Marriott Marquis. 

I encourage your active participation in ASTM, as a diversity of volunteers is truly needed to create useful and relevant standards.  Varying ranges of experience, expertise, and ideas help to assure our success, as we gain from the perspective shared by all who become involved. 

As you can see, the work done within ASTM is making a difference and is helping to solve today's problems and shape the future within the medical transcription industry and in healthcare documentation!




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