transcription framework - | health · web viewtranscription services are primarily provided to...

Transcription FrameworkVersion 1.1

April 2018

CHHS18/205

Introduction 3

Background 3

Definition 3

Scope 3

When is Transcription Required 4

Winscribe 4

Access to Winscribe 5

Central Transcription Service 6

Access to Transcription Services 6

Decentralised Typists 6

Outsourced typing 6

Quality of Dictation 7

Dictation Devices 8

Quality of Transcription 8

Templates 8

Referrals 10

Approval 10

Distribution 10

Timelines 11

Document Storage 11

Additional Transcription Services 12

System Support 12

User Group 12

Debriefing Typists 12

Attachment 1: Winscribe Text within CHHS 13

Attachment 2: User group 14

Attachment 3: Request for Change Form 15

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Doc Number Version Issued Review Date Area Responsible PageCHHS18/205 1.0 20/07/2018 01/07/2022 CACHS 2 of 17

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/205

IntroductionTranscription is the translation of voice files into documents. Medical transcription has traditionally involved the typing of dictated letters as part of the communication between referrer and specialist as part of outpatient services.

Communication between the acute specialist, the referrer and primary health provider (when different to the referrer) is integral in the ongoing quality care provided to patients. It is critical in the facilitation of transfer of care from the tertiary setting back to the primary health care setting, and in some cases the primary carer, as is the case in paediatrics. This communication provides the opportunity for the specialist to provide an opinion on diagnosis, prognosis, complications and ongoing management.

BackgroundTo date medical transcription within ACT Health has been loosely governed, uncoordinated and costly. There have been no organisational policies and work under the Clinical Handover National Standard has not addressed or focussed on the issue of handover from the outpatient setting to primary health care. It should also be noted that a review of national resources on clinical handover, likewise found no focus or resources specifically addressing this handover path1.

As outpatient services have grown in CHHS, so has the demand for transcription services. Often it is the last issue to be considered, if at all, in the establishment, expansion and resourcing of services.

Exponential demand for medical typing services has seen an ad hoc approach to the provision of services. A rudimentary transcription platform ‘Winscribe Dictate’, has been in use for almost a decade in CHHS. Centralisation of some medical transcription services occurred in 2006. In addition some services employ dedicated typists or incorporate medical typing into other roles such as Personal Assistants. In an attempt to address escalating delays some services also use direct outsourcing for their typing requirements.

DefinitionClinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.

Transcription is the process of converting spoken word into digital or printed text.

ScopeThe Framework provides consistent, organisation wide, endorsed guidance for the use of transcription services in the ambulatory setting.

1 Patient Safety – handover of care between primary and acute care. Policy review and analysis. Dr Lesley Russell, Ms Jennifer Doggett, Dr Paresh Dawda, Mr Robert Wells March 2013

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This Framework applies to all transcription services for ambulatory services provided across CHHS, regardless of which system is used or who is providing the typing.

Transcription Services are primarily provided to facilitate expert communication between specialist service, referrer and primary health care provider as part of ambulatory services. In light of the expansion of outpatient services to include specialist services provided by non-medical staff and the increase of services being provided in the community this Transcription Framework will use transcription in its broadest sense and not be limited to services provided solely by medical staff. This will potentially lead to a significant increase in the use of transcription services to those groups previously excluded including nursing and allied health. This will need to be resourced – see section on user pays. In recognition of the broader scope, what was previously known as the Medical Transcription Unit will be known as the Central Transcription Service (CTS).

Transcription Services are not used where there are alternative, more appropriate options such as discharge summaries, ACTPAS letters or event summaries. It is not a replacement for contemporaneous clinical notes.

Transcription is not routinely used to generate clinical notes, reports, routine information or documents of an administrative nature.

When is Transcription RequiredTranscription services can assist with provision of information to the referrer and primary health provider at clinical milestones, for example:

• After the initial appointment• When there is change in care or treatment• Following a review appointment• At transfer of care or discharge to the primary health provider.

Post-inpatient reviews do not routinely require letters, only if there is a change to treatment, or a plan of care implemented, which needs to be communicated to the GP/referrer which was not communicated to the GP in the discharge summary.

Use of dictation and transcription services outside the scope of this Framework may result in the Operations Manager Transcription discussing a clinicians dictation practices with them to seek an agreed outcome. This may mean work considered to be additional to this Framework will be charged on a fee for service basis to the requesting service.

WinscribeCHHS has been using Winscribe Dictate since 2007. In 2016 CHHS went to the market to procure a more contemporary system to assist with current transcription requirements, particularly around the need for electronic distribution of letters, voice to text capability (both for front and back end users) and a workflow and reporting capability. Winscribe was the successful vendor and implementation of Winscribe Text will occurred in late 2017 / early 2018. This system will drive

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significant enhancements in efficiency, reducing the turnaround for typing and improving overall quality of letter production and distribution. Reference to Winscribe for the remainder of this document will be referring to the new platform, Winscribe Text.

The broad schematic of the new solution is shown in Attachment 1.

All services across CHHS will have access to Winscribe. Some services, because they do not schedule in ACTPAS and/or have a dedicated clinical record systems, will have different approaches to the workflows for transcription. These services include:

Radiation Oncology –letter development will occur in ARIA® – distribution will be via CTS until integration in ARIA for distribution is achieved

Renal – further integration between Clinicalvision V (CV5) and Winscribe will be undertaken as Phase 2, until then current processes will apply

Pathology – discrete anatomical pathology typists will explore the use of Winscribe in collaboration with current systems.

Medical Oncology / Haematology / Adult immunology– will require separate editing to verify appointment details. Winscribe will send to a Q Drive file for Oncology staff to upload to CHARM™. Distribution to CRIS and recipients will be automatic.

Access to WinscribeAbility to dictate in Winscribe requires a user based license. There is a fee for each license and an ongoing maintenance and support fee, therefore licenses/user access will only be issued to those authors who require access. Access will be controlled through the Identity and Access Management System (IAM), with overall control by the Operations Manager Central Transcription Services (CTS). Users will need to ensure their profile is updated to reflect their current clinical responsibilities/rotations as this will impact on template availability, signature blocks and distribution flows. License management will allow for registrars to have more than one profile during the transition period of rotations to ensure letters have been approved from the prior rotation. Authors should request access through IAM and to Digital Support for deployment of Winscribe to any specific desk top.

Access to these additional licenses will remain under the control of transcription services and will be charged back to the Service.

Services that have their own typists will be able to use the functionality of Winscribe without the need to use the transcription typists. The same access to licenses will apply and they will need to be set up as a discrete typing group within Winscribe and this will be managed by CTS.

Authors will be able to access the Winscribe App through any iOS device once they have a Winscribe log on. The actual app can be downloaded from the App store. Access to the app will only be available through mobile phones who have deployed Mobile Iron (as per current mobile device policy).

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In 2018 access to the Winscribe Web Portal will be available on CHHS desktops and on other devices through a Remote Citrix log on.

Additional functionality such as voice to text is available in Winscribe Text however these require additional licenses which will be issued on an at cost basis and will be tested and deployed in mid 2018.

Central Transcription ServiceThe Central Transcription Service (CTS) is part of Ambulatory Care Support, Division of Cancer, Ambulatory and Community Health Support and is managed by the Operations Manager, Outpatients and Transcription.

Transcriptionists within the CTS are highly experienced typists with formal medical terminology qualifications. CTS type documents based on the workflow tool in Winscribe. Where demand cannot be met within agreed timeline, an outsource provider will be contracted to type any backlog. Allocation of work to the outsource provider will occur direct through the CTS. This will ensure all transcription demand for CHHS is managed through the one platform and will ensure we can access the best value for money from the outsourced provider.

Access to Transcription ServicesThe Operations Manager CTS will negotiate agreements for provision of workflow management and typing services with each Division and their services.

Transcription Services will transition existing services to the new service agreements in late 2017. Additional services wishing to utilise Transcription Services will be negotiated with each Division.

CTS will honour volumes with each Division as of the end of the 15/16 financial year. Increases in volume and any additional services wishing to utilise Transcription Services will be required to pay on a fee for service basis. In line with industry standards this will be charged on a benchmarked per line basis.

Decentralised TypistsWhere it makes sense to do so, decentralised typists will be transitioned into the centralised team over 2017/18 to optimise:

• Workload sharing• Skill development• Backfill• Quality control.

In consultation with the Divisions resources may be transferred from services to support the move of decentralised typing into the central pool. Transition to this arrangement will occur in collaboration with the Operations Managers and Executive Directors of the relevant divisions.

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Winscribe will be the central platform for use by all typists within CHHS where their quality, output and workflow can be monitored, managed and reported.

Exceptions will be where systems incorporate a reporting/transcription function for example ARIA, Provation.

Outsourced typingCurrently some services have individual agreements with outsource typing companies. These are ad hoc agreements which were never formally procured and do not provide best value for CHHS. An approach to market has occurred and the successful tenderer is expected to commence in the beginning of 2018.

Workflow to the outsourced provider will be managed by the Operations Manager CTS through the Winscribe Text platform at which time services will stop using their current outsourced provider and will dictate into Winscribe Text.

Overflow and peak demand will be allocated to external typists to ensure KPI’s are met across all specialties.

This will represent a significant change for some services but will bring all transcription onto the one platform. This will allow the ability to monitor activity, timelines, quality and cost of all transcription.

Editing/quality assurance checks of externally typed letters will occur by the CTS to ensure accuracy of demographics, appointment details etc.

Quality of DictationQuality of dictation is critical in ensuring an efficient and effective transcription service.

Based on services currently using CTS the quality of dictation is highly variable. There is currently no formal training for authors. Nor is there any feedback provided on a formal or regular basis to alert the author to any issues.

The use of the new platform will allow reporting at an individual author level.

The quality of audio recording is the single biggest variable impacting on typing efficiency. In order to assist, authors are requested to ensure that all voice recordings:

• Use approved devices• Has minimal background noise• Speak directly into the recorder• Are succinct and clear with spaces, pauses and umms/ahhs limited• Include the patient’s URN and preferably the appointment date.

Improved use of standardised templates and block text will also significantly enhance the quality and efficiency of dictation.

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CTS will provide training on dictation to clinicians as requested, including the use of ‘snippets’ – insertion of common blocks of text.

CTS will work with specialties to implement standard text blocks for each specialty based on their requirements, where relevant.

CTS will provide feedback on the quality of dictation directly to authors. Any dictation not able to be deciphered or deemed to be of significantly poor quality will be rejected and returned to the author.

CTS will provide benchmarked reports to Operation Managers on variables such as recording time, lines per letter and other quality issues. Reports will be available at the author and specialty level. There is no right or wrong length of a letter, however benchmarking within services with similar cohorts of patients and consultations will allow authors to consider their own practice against the performance of their peers.

Dictation DevicesWinscribe allows dictation through a number of mechanisms: direct dial, mobile phone app and USB microphones. Dictaphones are not supported, CHHS will be phasing them out as they pose significant risk through document loss, timeliness and efficiency.

The USB Microphones provide high quality dictation for use at a desktop. To access a USB Microphone contact Digital Support. These will be charged to the requesting service.

Quality of TranscriptionCTS benchmarks their performance to ensure high levels of quality, accuracy and timeliness.

CTS will work with services to standardise templates and processes, which will further allow improvements in transcription quality.

CTS will provide reports to Operation Managers on both CTS and decentralised typists performance regarding:

• Accuracy• Throughput• Typing timeframes• Approval timeframes.

Strict quality controls have been factored into the contract for the new outsourced typing provider and this will be managed by the Operations Manager.

TemplatesA standardised template will be used for all specialist letters which will be:

Consistent with CHHS branding A consistent look for end users

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Structured to optimise page space Compliant with requirements for electronic messaging, postage and storage Not contain marketing or extraneous information.

Templates will ‘lock down’ fields which are integral to the electronic distribution and will not be able to be changed by authors or transcriptionists.

Arial size 11 font will be the default. The footer will include “Produced in Winscribe” which will allow identification of the source document post distribution for any audit purposes.

Signature blocks will be standardised and auto populated. Post nominals can be included, however these need to be manually entered into the Winscribe Platform. Please contact Digital Support (6207 9000) to have your post-nominals included. Note there is a limit of 100 characters per line and a maximum of three lines per signature block and these will be auto populated according the authors profile.

Lists of other team members in the unit and academic affiliations will not be included.

The Department Name is drawn from ACTPAS and will not reflect specific clinic names. These will need to be included in the dictation if required to appear in the letter.

A sample letter template is shown below.

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ReferralsMany authors currently include referrals to other services in the body of their letters. There have been some serious cases where these referrals have been missed, as the letter has been sent by hard copy mail and sat in pigeon holes, or filed as a specialist letter with no further action.

Within the new platform a separate Referral Template for referrals will be used. Authors can instruct the transcriptionist using the ‘generate a referral to …’ command, which will prompt the transcriptionist to complete the letter (or duplicate the letter if it the referral is contained within the

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body of the specialist letter) on the referral template. Referrals will then be automatically distributed to the Intake Service for actioning and filed in CRIS as a referral, not as a letter.

ApprovalAll letters will be approved electronically. Letters will automatically move to the ‘for approval’ stage in the Winscribe platform once the typist has completed their quality assurance. Winscribe will provide notifications to authors weekly to alert them if they have letters ready for approval. Approval is achieved electronically through either the Winscribe App or Winscribe Portal.

Where changes or additional instructions are made at the approval stage these letters will be redirected back to the transcription team for action prior to distribution.

Winscribe will allow for a hierarchy of approvers. This will be particularly useful where a junior doctor has authored the letter but which needs to be ultimately approved by the consultant. The junior doctor will have the ability to de-select the consultant to counter sign the letter if it is appropriate that the letter be signed by the Registrar alone.

If letters are not approved within the agreed key performance indicator (KPI) they will be escalated to the nominated person for that author.

There is also an option for consultants to ‘sign on behalf of’ where the author is unavailable to sign within the appropriate time frame.

DistributionDistribution will be automated and electronic where possible. This functionality will provide the single biggest improvement in efficiency over the previous system.

Authors via their secure log in, will approve final documents for distribution at which point the system will automatically send a copy to CRIS, nominated clinical record, and the nominated recipients / addressees. Winscribe will distribute letters according to the following workflow:

where a secure messaging ID exists, send via HealthLink, if not where a fax number exists, send via RightFax, if not it will be manually printed and posted.

As letters will be available in either Winscribe or CRIS authors are requested not to routinely request cc’s to internal members of the treating team. This just creates additional administrative work and usually results in multiple copies being scanned into CRIS.

TimelinesThe following graphs show the ideal timeline for the production of letters and the routine timelines for 85% of letters. Target timelines will be met for the various stages across the transcription lifecycle in 85% of letters.

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Authors using Dictaphones need to ensure their Dictaphones are docked and voice files are transferred on the day of dictation, in order for the above timeframes to apply.

Delays in any one component of the transcription lifecycle can lead to unacceptable delays in total time taken from appointment to letter reaching the recipients. The Winscribe workflow management tool will be configured according to these timelines and will alert the appropriate user when they have letters which are outside the agreed timeframe for the relevant stage. CTS will monitor this and escalate as required.

Document StorageOn approval, all letters will be distributed to the ACT Health electronic clinical record system. This will be the official storage of the approved document. Copies will also be stored in service’s nominated clinical record.

Letters will be stored in the Winscribe platform for a period of 2 years to enable access to old letters to facilitate documentation of current letters.

Under no circumstances are letters to be stored on network drives as these do not comply with the legislative requirements for the storage of health records.

No letters are currently stored in Winscribe and there will be no data migration from Q Drives. Therefore no historic letters will be available within Winscribe Text at the commencement of the new platform.

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Additional Transcription ServicesServices wishing to use transcription for non-clinical handover related documents such as reports, conference reports and clinical notes may do so in negotiation with the CTS. The production of these documents will be charged to the service on a fee for line basis. Where the central team is unable to meet requests the Manager will outsource to ensure reasonable timeframes are met.

System SupportGeneral help desk and access support will be provided by Digital Solutions Support. Digital Solutions Support will provide log in, access and basic user support. Secondary and tertiary level support will be accessed via the Winscribe Support Agreement but will be vetted by Digital Support/CTS in the first instance.

Training for use of dictation devices and Winscribe will be incorporated into the role based training being developed by Digital Solutions Support. Advanced training on dictation, use of Winscribe workflow and other functionality will be provided by CTS.

An e-Learning package for both authors and typists is available on Capabiliti.

Staff information “cheat sheets” are available on Digital Support under the Winscribe link.

User GroupA User Group will be established to undertake changes and issues management for the system. Draft terms of reference and forms for this group are at Attachment 2. This group will oversee all requests made to either the Systems Administrator or Manager Central Transcription which will affect the system or business processes for other users. A request for change form is provided at Attachment 3.

Debriefing TypistsDuring the course of their work, typists can be exposed to information that they may find confronting. CTS will ensure typists have access to debriefing and the Employee Assistance Program (EAP ) as required. Managers of decentralised typists will need to do the same for their staff.

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Attachment 1: Winscribe Text within CHHS

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Attachment 2: User groupTERMS OF REFERENCE

Winscribe User Group

Role Change and issue management for Winscribe system governance

Reporting mechanism

The User Group will report to the TBA Committee.

Functions Consider and coordinate change request impact on stakeholders, including:

o Workflow changeso System changeso Policy changeso Data quality and reportingo Vendor enhancementso Shared Services ICT changes

Assess success of changes through realised benefits against initial aim Discuss end user training requirements Assists and monitors change implementation and resource utilisation to

ensure timely and successful completion Provides guidance and support in mitigating and managing risks and

issues. Considers relevant standards. Consider alignment with relevant data security and privacy

requirements. Represents and informs stakeholders

Membership Chairperson: Manager Central Transcription Services

Members: System Administrator, CTS Team Leader, SSICT rep, Author Rep,

Remote Typist Rep.The Committee may invite other attendees at the Chair’s discretion.

Quorum 4 members must be present to represent a Quorum

Secretariat PA to the Director Ambulatory CareAgenda requests The secretariat is to receive requests for agenda items one week before

the meeting. Papers to be circulated with the agenda must be submitted three

working days before the meetingMeeting Frequency /Duration

Meetings will occur monthly Duration is 1 hour Out of session approvals will be granted as required

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Attachment 3: Request for Change Form

Winscribe Request for Change formTo be completed by the change requestor and submitted to the Winscribe User Group for review. Name of Requestor:Date completed:Change Title A brief description of the changeChange Category: Standard/Normal/EmergencyPriority: Consequence + Likelihood (see matrixsecond page)Details: What do you want to occur? Date of Implementation: When will the change occur?Reason for Change/Justification:

Why is this change required?

Business Impact: What is the impact of making the change? What is the impact of not making the change?

Affected User Groups: Who is affected by this change?

Risk: What are the risks to the Department? TCH?ACT Health?

Urgency: How quickly is this needed?

Change Plan How will the change be implemented?

Rollback Plan: What happens if there is an issue in implementation?

Testing Plan: What has been tested? What will be tested?

Readiness ChecklistStatus Comment:

User Acceptance TestingTrainingChange DocumentationImplementation PlanCommunication to StakeholdersKnown Errors Documented

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended Section Amended Divisional Approval Final Approval

This document supersedes the following:

Document Number Document Name

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