Administration and Leadership, Documentation & Patient Care Reporting, Training

Colorado Paramedics Save Time on PCRs Using Medical Transcriptionists

Issue 2 and Volume 40.

Medical director for South Metro Fire/Rescue in Centennial, Colo. John Riccio, MD, was confident his paramedics were giving good care. But, when he reviewed patient care reports (PCRs), it just didn’t look that way.

Treatments were entered out of order, some narratives offered only a brief paragraph, and assessments were so full of abbreviations that the reader needed a medical dictionary to understand them. Misspelled words and poor grammar made even smart paramedics look bad, but the problem wasn’t just mistakes by the crew. A lot of the difficulty came from the format of the reports; important information was often buried in long lists, but not included in the narratives where most healthcare professionals put them. Riccio wasn’t the only doctor struggling with PCRs.

“Several of the doctors said to me, ‘I tried to look at those things but I gave up. It took me 20 minutes to find the information I needed,'” Riccio said.

He emphasized that he was very proud of the work being done by the paramedics. “The old PCRs didn’t reflect the quality of care that was really being given.”

Not only were the reports falling short, they were taking up lots of paramedics’ time.

“I’m not a great typist and a 1:00 a.m. I’m even worse,” said Todd Parson, EMT-P, a South Metro paramedic who’s practiced for more than 30 years.

Riccio and the department’s EMS bureau discussed bad PCRs with paramedics in the bureau’s regular meetings and in continuing education classes, but the paramedics greeted the criticism of their reports with skepticism. Doctors, after all, are either followed around by an eager young scribe or simply call a dictation service.

Borrowing a Trick from Doctors

South Metro’s officers were concerned by the demands on paramedics’ time and asked Rick Lewis, the EMS bureau chief, to lighten the paramedic workload. During his research, Lewis learned that dictation had saved time for physicians. He decided to give his idea a try.

A small group of paramedics tested out a system in which they dictated, rather than hand typed, their reports. Lewis was so happy with the dictated reports that he soon decided that all paramedics would use the system.

“My goal, since I’ve started, has been to make paramedics’ lives easier,” Lewis said. “This takes something that can be difficult, especially if you’re not great on a keyboard, and turns it into a phone call. If it’s easy for them, they’ll provide more information.”

Most of the department’s paramedics prefer the dictation to the old typed methods.

“It’s added years to my career,” said Parson. “When I started using dictation it was like a weight was lifted off my shoulders. Dictation is a medic’s best friend.”

South Metro researched various dictation services and settled on Washington-based Versio, largely because the company uses U.S.-based transcriptionists.

Good, But Not Perfect

Although a majority of South Metro’s paramedics like dictation, it isn’t for everyone. Some paramedics would still prefer to type out their narratives, and others have found that creating custom templates in the department’s reporting software was the most efficient way to create a PCR.

Speaking a narrative aloud takes some getting used to. One veteran paramedic said he still writes his narratives by hand, then calls Versio to read them into the dictation system. Others use a printed template to guide them.

As with any form of technology, there are technical problems. Voice files have occasionally been lost. Though they’re usually found, the process can take hours. And as with any human process, there are human errors. Paramedics who are picky about grammar and syntax will often spend several minutes cleaning up punctuation or moving words around.

Just as often, the errors begin on the other end of the phone with the medic. The recordings are often filled with ums, uhs and awkward pauses, all of which take time for the transcriptionist to clean up. Other times background noise, like a diesel engine, makes it difficult for the transcriptionist to hear.

Despite these problems, the transcriptionists will always try to produce a narrative, according to Helen Shirts, a sales executive with Versio.

“What’s important to us is that we tell everybody’s story,” Shirts said. “These aren’t just patients, they’re people with a story. Our goal is to help the paramedic tell that story as clearly and accurately as possible.”

That includes telling the paramedic when a part of the recording is unclear. Transcriptionists will mark unclear words with a “sounds like,” and if the transcriptionist can’t even make a guess, they’ll leave a clearly marked blank space. They call the paramedic’s attention to the questionable area with a flashing red banner at the top of the transcription.

South Metro’s paramedics agree that dictation has improved the accuracy of PCRs, which could also be seen when Parson reviewed PCRs both before and after the dictation program.

“The dictated reports were easier to follow and understand,” he said. “There was a lot more subjective information, like whether an elderly patient’s home was well kept.”

How it Works

The dictation process is similar to that used by doctors in hospitals. South Metro’s paramedics dial a phone number and enter a personal code. A computer system records as the paramedic dictates his or her narrative. South Metro’s paramedics are limited to the use of the CHART (chief complaint, history, assessment, Rx/treatment, transport) and SOAP (subjective, objective, assessment, plan) formats—a decision made by the department.

The recording is automatically turned into a digital sound file that’s sent to a Versio transcriptionist. The transcriptionist transcribes the recording into a typed narrative. Sometimes an editor reviews the file, though not always. Writing a narrative has shifted from being a solitary process completed by the paramedic to a team process involving one or two additional sets of eyes.

The paramedic logs into the Versio website and copies and pastes the narrative into her PCR. If everything goes right, the process takes less than an hour from the start of the phone call to the finished narrative being sent to the paramedic. Medics who dictate their narrative while at the hospital sometimes find it waiting for them when they return to the station.

Paramedics can speak in plain English. There’s no need for time-saving abbreviations like “PERRL” because it doesn’t take much longer to say the actual words “pupils equal, round and reactive to light.” However, paramedics can still choose to speak in abbreviations and the transcriptionists will translate the abbreviations into full words; “HEENT” becomes “head, eyes, ears, nose and throat.” As long as the transcriptionist understands the paramedic, or can look up the meaning of an abbreviation, it will be translated.

“We assign a team to each group of providers, that way they get used to that provider’s style,” said Shirts. “So, there are only a few transcriptionists in our company that handle South Metro paramedics. They know how the medics work so the transcriptionists are more accurate and quicker. We also spot check their work for accuracy.”

Shirts is quick to point out that all of Versio’s transcriptionists are bound by U.S. patient privacy laws.

Busy Day Bailout

Most paramedics have had the experience of running several calls back-to-back. You return to the station late at night and begin to slog through the reports that have now piled up. There’s that frustrating feeling as you try to remember, “Did I start that IV on the left or right arm?” South Metro paramedics can now refer back to the “treatments” section of their transcribed narrative.

Dictation allows the paramedic to get the basic facts on the record before returning to service after a call. South Metro now automatically returns medic units to service seven minutes after they arrive at the hospital. While some paramedics dislike the “seven-minute ticker,” they now have the option of completing the narrative before returning to
service—something that was nearly impossible with typed narratives.

“In my 30 years of being a paramedic there have been a lot of changes, but only two really made my life better: Zofran and dictation,” joked Parson.

Better Billing

Neither South Metro nor Versio wished to disclose the details of their contract, but South Metro pays Versio by the line, which is an industry standard.

South Metro billing officials said that the cost of the transcription is very small when compared to an average medic bill, and added that the improvements in narratives have smoothed out the billing process. Insurance companies have fewer questions and South Metro’s EMS staff spends less time following up with paramedics.

More in the Future

South Metro is the first EMS agency Versio has served. They hope, however, more will follow South Metro’s lead. Other departments in the region are trying out dictation on a small scale.

Versio is also working to expand the service. Today, a paramedic must copy the narrative from the Versio website and paste it into his or her report, which requires flipping back and forth between two screens. Versio would like to be able to drop the finished narratives directly into the PCR so medics would no longer need to log into the Versio website or toggle between the screens. When the paramedic returned to the station and opened a report, the narrative would be waiting in the PCR to review.

South Metro is in the process of choosing a new PCR system. When that selection is done, South Metro and Versio plan to try out the streamlined system.

Versio’s vision goes even further, though. The company isn’t only a transcription company; it also works to integrate patient records from different doctors and hospitals.

If Versio gets its way, paramedics will be able to use a cellular connection to send vital signs, treatments and history to the hospital before they arrive. More importantly, paramedics might gain access to a patient’s history.

Trying to figure out if that elevation in V2 and V3 are new or are the result of an old myocardial infarction? Pull up the ECG from the patient’s last physical. But this sort of access is still years away, Shirts emphasized.

That sort of integration, Riccio said, is a big reason he wanted to see a better report.

“Cardiac alerts, sepsis alerts and stroke alerts are all examples of integrating prehospital care with what we do in the hospital,” Riccio said. “Making the reports clearer is really about improving this integration so that we can improve patient care.”

Real Professionals

Dictation is far from a cure-all, and South Metro continues to work through the same challenges as any EMS provider. The overall quality of PCRs, however, is no longer one of them. The observations of South Metro paramedics are also carrying more weight with physicians from the ED to the cath lab, according to Riccio.

“It’s really a pat on the back to [South Metro paramedics],” Riccio said. “It’s indicative of paramedics being real healthcare professionals. We want to know what you thought. We want to know what you observed. You’re our eyes and ears in the field and that’s really important for improving patient care.” jems