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Plexus Sept Oct 2013
1. PLEXUS
Where Health Information Experts Come Together
SEPTEMBER/OCTOBER 2013 VOLUME 9, ISSUE 5
PLEXUS
clinical medicine page 28
Neurodegeneration
Does Risky
Behavior
Equal Risky
Business?
Risk
Management
Risk
Management
Does Risky
Behavior
Equal Risky
Business?
2. Take a Seat.
Get to Work.
This companion workbook is designed to work in tandem with The
Book of Style for Medical Transcription, 3rd edition. The Workbook
contains practical application exercises to assist students,
postgraduates, and working MTs with orientation to standards and
preparation for AHDI credentialing exams. Multiple-choice questions,
proofreading exercises, and transcription practice via interactive audio
CD included. Get your copy today!
Get your copy from the Online Store
at www.ahdionline.org!
Bookof StyleThe
THIRD EDITION
Published by the Association for Healthcare Documentation Integrity
(formerly AAMT)
Practical Application & Assessment
Lea M. Sims, CMT, AHDI-F
THEBOOKOFSTYLEWorkbook
.S.
3. A
pril 15, 2012, marked the
one-hundred-year anniversa-
ry of the Titanic sinking on
her maiden voyage. For 75 years the
Titanic was lost under the sea, even-
tually to be discovered off the coast
of Newfoundland in 1985. Decades
(and countless movies, documenta-
ries, and books) later, there is still a
strong fascination worldwide with
the story of the “practically unsink-
able” luxury liner that hit an iceberg
and sank to an ocean-floor grave two
miles below the surface.
According to History,1
a number
of theories have been speculated
upon as to the “fatal flaws” and
errors that led to the ship’s demise
along with the lives of over 1500
passengers. While the impact from
the iceberg, tearing a 300-foot gash
in the side of the ship, is suspected
to have been the primary cause
of the ship sinking, other poten-
tial causes or contributing factors
included a design flaw in the ship’s
watertight bulkheads, the ship’s steel
plates being too brittle for the freez-
ing waters, and an onboard coal fire.
As was dramatically demonstrated
in James Cameron’s 1997 film,
Titanic, it was most notably the far-
from-adequate number of lifeboats
and disorganized evacuation process
that added to the Titanic’s tragic
ending. Had the regulations for the
required number of lifeboats been
more stringent, had each lifeboat
been filled to the maximum capac-
ity of 65 occupants (instead of being
sent off with half that many or less),
and had the crew been given—and
followed—proper emergency
evacuation training and procedures,
the number of lives saved may have
been double or greater than the 705
who survived.
There is a lot to be learned from
epic tragedies such as the sinking of
the Titanic in 1912, the Challenger
space shuttle disaster in 1986, and
the bombing of the Twin Towers and
Pentagon and hijacking of United
Flight 93 in 2001—as well as from
everyday experiences like texting
and driving or unsafe food handling,
both of which could have disastrous
results for the “doer” as well as
those around him or her if laws are
not followed and common sense is
not embraced and exercised. It’s a
trickle-down effect of action and
reaction, of cause and effect.
An evaluation of policies and
procedures needs to be done. Chang-
es need to be made and documented.
Employee/contractor training needs
to take place. Agreements need to
be discussed and signed. Regular
followup, continuing education, and
reinforcement of the rules need to
happen. And an understanding of the
reasons why all of these things are
important is critical.
Ask yourself: Are you willing
to risk damages—and potential
lives—of “titanic” proportions?
Being healthcare documentation
specialists isn’t just about how well
you can document patients’ medi-
cal data. Knowing how to minimize
risk, complying with privacy and
security safeguards, and implement-
ing best practices are all ways to
help mitigate risk to the patients
whose records you transcribe and
edit as well as to yourself and/or the
company for which you work. Be
diligent and proactive in learning
about or coming up with prevention
tactics and solutions, because even
unintended consequences can result
from complacency, carelessness, and
blatant disregard of rules and regula-
tions. There is no excuse.
In this issue, you’ll read about The
Juno Case—an important “wake-up
call” for the transcription sector, as
well as quality in health information
documentation. As well, you’ll learn
the latest in neurodegeneration in
multiple sclerosis from Jane Warren.
Enjoy! P
EDITOR’S MESSAGE
Risk Mitigation—Enhancing Opportunities
While Reducing Threats
1Volume 8 • Issue 6 NoVember 2012
“Before, all I wanted was to fit in. But I
learned that we’re all searching to fit in
and we... we all feel like outsiders and
we all do things and feel things that are
bizarre and unconventional and dorky.
We’re all dorks! My name is Sydney
White, my dad’s a plumber, I collect
comic books, and I’m secretly terrified
of balloon animals. I’m a dork!”
– Sydney White [2008 movie starring
Amanda Bynes]
Technology is wonderful! Isn’t it?
I suppose the feeling behind that
statement could vary depending
on whether or not the particular
technology you are using is working
properly and efficiently. It’s inevitable
that your computer gets a virus, your
programs or Internet connection
runs slow, the screen freezes up, or
some other wacky technology glitch
ruins your day. But overall, I think
technology is amazing and fun and
just plain cool! It’s odd to think how
different the world would be today
had computers never been invented.
So what does an “app-savvy” user
look like? It used to be that people
who were really into technology
were considered “geeks” or “dorks.”
Over the years, computers, tablets,
smart phones, and other devices
have become more prominent and
accessible, and society has shifted
its stereotype of geeks and dorks.
Now the first adopters and efficient
users of technology are the cool kids.
If that’s the case, then pretty much
everyone I know is very cool!
Here is a brief recap of some of
the helpful, useful, or just plain cool
tech programs and apps I’ve used
this past year for work: Moodle,
Webassessor, Dropbox, SendSpace,
QuizFaber, nearly all the Microsoft
suite, Personify, SysAid, Adobe,
SpeedType, FileZilla, Windows Live
Messenger. On a personal note, I’ve
been using a slew of apps on my
iPad: iTunes, Pinterest, OneNote,
RecipeBook, iBooks, Maps, Flipboard,
games, and others. I even have apps
to check for movies at Fandango or
Redbox, or to do online banking and
pay bills. Many apps are available via
multiple devices—and synchroniz-
able across those devices—which
makes taking care of work or per-
sonal business quick and convenient.
I would be remiss if I didn’t
mention some of the great member
resources you may have forgotten
about: Matrix and Plexus article
archives; online CECs; component
resources; position statements and
best practices and standards guide-
lines; AHDI help desk; member, com-
pany, and credentialed professionals
directories; special interest alliances,
AHDI Lounge blog, and other net-
working avenues; and many others—
all available at www.ahdionline.org.
In this issue you will read about a
number of other great websites, tech-
nologies, and resources. Have a great
resource you want to tell us about?
Email me at kwall@ahdionline.org. P
Kristin M. Wall, CMT, AHDI-F
Editor-in-Chief, Senior Programs
Coordinator, AHDI
EDITOR’S MESSAGE
The App Savvy User
Kristin M. Wall, CMT, AHDI-F
Editor-in-Chief,
Senior Programs Coordinator, AHDI
VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 1
Reference: History. A&E Television
Networks, LLC. <http://www.his-
tory.com/topics/titanic>
4. FEATURES
CONTENTS
SEPTEMBER/OCTOBER 2013
Vol. 9, Issue 5
1 Editor’s Message
Kristin M. Wall, CMT, AHDI-F
4 President’s Message
Jill Devrick
6 Tech Talk
Curt Hupe
8 Newly Credentialed
9 Connections
22 In the Limelight
24 Life Unsedentary
Rachel Quatkemeyer, CMT
27 Exercise Your Brain
35 Professional Practice Desk
36 News and Who’s Who
39 Around the Country
40 Funny Bone
Richard Lederer, PhD
28 Neurodegeneration in
Multiple Sclerosis
Jane Warren, ELS
31 Let’s Talk Terms
Beverly Sofko, CMT
33 CMT Challenge Quiz
Brett McCutcheon, CMT, AHDI-F
Clinical Medicine
Columns & departments
10THE JUNO CASE:
A SENTINEL EVENT FOR THE TRANSCRIPTION SECTOR
Lea M. Sims, CMT, AHDI-F
14IT REALLY DOES MATTER
Debra Jones
18HEALTH INFORMATION DOCUMENTATION:
WHO OWNS THE QUALITY OF THE INFORMATION?
Karen L. Fox-Acosta, CMT, AHDI-F
TECHNOLOGY AND THE WORKPLACE
Clinical MEDICINE
Clinical MEDICINE
Clinical MEDICINE
2 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
Medicolegal
Medicolegal
6. 4 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
PRESIDENT’S MESSAGE
Jill Devrick
H
ave you ever had one of
those moments when you
stop and look around won-
dering, “How in the world did I get
here?” It reminds me of a quote
from the classic ‘80s movie
Ferris Bueller’s Day Off: “Life
moves pretty fast. If you don’t stop
and look around once in a while, you
could miss it.” I don’t know about
you, but for me, the “it” I might miss
is the “why” behind what I do. The
many obligations of my life keep me
constantly in motion. But every once
in a while, I need to take inventory
of my roles and responsibilities and
ask myself not just how I got here,
but “What’s the point?”
This is a question I’m sure many
healthcare documentation special-
ists frequently ask themselves. With
all of the changes due to regulations
and technology in the healthcare
industry, our workforce has endured
several years of instability and
uncertainty. AHDI has been weather-
ing the storm, too, and feeling the
effects. I bring this up because I
think that many of us feel like we
struggle along in our own little life-
boats, paddling upstream or around
in circles, just trying to stay afloat,
but not making any real progress.
However, one of the most valuable
aspects of being part of an associa-
tion like AHDI is that we are all in
the same boat and can not
only stay afloat, but also
set a course for a destina-
tion where our skills and
expertise will protect patient safety
and support organizational integ-
rity through high quality healthcare
documentation.
Over the next year, I will work
with the AHDI National Leadership
Board, as well as with regional and
local chapters, to navigate the chal-
lenges we face towards a destination
where our versatility, vitality, and
voice demonstrate our true value to
the healthcare industry. The evolu-
tion of the medical transcriptionist to
healthcare documentation specialist
reminds me of the evolution of the
telephone to the smart phone. The
essence and purpose of the telephone
is the same today as it was when it
was invented, but the packaging,
features, and benefits have been
enhanced over time.
I believe that MTs have always
been like smart phones that add
value to the healthcare documenta-
tion workflow far beyond converting
the dictation to text. The arrival of
meaningful use, EHR technology,
speech recognition, and the transi-
tion to ICD-10 has created many
opportunities to share our expertise
and fulfill our mission to protect the
integrity of patients’ health informa-
tion. We want to be known as the
champions of documentation excel-
lence in the healthcare industry, but
we can’t wait around
to be asked. We have
to make our move
yesterday, and if not
yesterday, right now.
If you are reading this and think-
ing, “Good, I’m glad someone is
getting out there and doing some-
thing,” then I’m sorry to inform you
that you are not off the hook. Every
AHDI member can—must—con-
tribute to our success. Being part of
an association is about sharing the
responsibility, as well as sharing the
benefits. Here are some ideas for
how you can contribute to our
mission and vision.
Workforce Development:
Cultivating our Versatility
• Promote continuing education,
even for the uncredentialed and
those looking elsewhere. Invite a
colleague to attend a webinar, read
a blog, or attend a training event.
• Look for opportunities in your
organization to ask questions,
learn, and be challenged. Find
out what you can do to assist with
ICD-10 or EHR preparations,
patient advocacy, etc.
• If you have a problem, suggest a
solution. Your perspective may
shed light where other ideas have
come up short.
• Inform AHDI about what we
can do to bolster your professional
development. We want to provide
relevant educational opportunities
Meaningful Momentum
7. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 5
that will help you grow.
• If you are a pioneer in a new role,
share your experience with others.
The lessons you learn in EHR
support roles, patient advocacy,
clinical documentation improve-
ment, and so on can help others try
new paths, too.
Credentialing:
Demonstrating our Value
• Obtain or maintain your certifi-
cation. Nothing demonstrates your
value as a healthcare knowledge
worker better than proving and
maintaining your mastery of our
body of knowledge.
• Transition to the CHDS or RHDS.
The bridge course is affordable and
provides 10 CEUs. Go for it!
• Promote the value of credentialing
and the body of knowledge you
mastered with employers,
physicians, uncredentialed HDSs,
and others.
• Encourage using the CHDS or
RHDS as a requirement for new
hires, promotions, or transitions to
emerging documentation roles.
Advocacy and Alliance Building:
Asserting our Voice
• Gather data and demonstrate the
positive return on investment
(ROI) that you provide as an HDS,
and if you are a manager, build a
strong ROI case for your depart-
ment or company. Toot your own
horn.
• Communicate real-life examples
of how you and your profession
make a difference in person and
on social media. How many
critical errors have you corrected
or flagged? What have you done to
improve productivity for yourself
or the physicians you support?
• Partner with physicians and other
HIM professionals to develop
practical solutions. Many
organizations need our assistance,
but don’t realize we are the ones to
ask for help. Share the success of
these partnerships.
• Promote the “Your Record
Speaks” campaign and how HDSs
contribute to patient safety.
• Create “elevator speeches” for
HDSs and AHDI. Be ready to
evangelize about the importance
of documentation integrity
whenever the opportunity presents
itself.
Community:
Strengthening our Vitality
• Encourage the downtrodden not
to stay stuck. Many of our col-
leagues need our support to find
the right path and move forward.
Build some mentoring relation-
ships and nurture them.
• Promote the value of AHDI
membership. Many in our work-
force don’t understand how an
association works and why it is so
important to our industry. Our
membership is what gives us
strength and vitality.
• Advise AHDI about the specific
tools, training, and events that you
want and offer your detailed ideas.
Better yet, volunteer to take action
– all hands on deck!
• Join an alliance, study group, local
chapter, etc. You will benefit from
the collaboration, and the group
will benefit from your contribu-
tions, even if you are a newbie.
• Speak out as a positive voice
on social media. Shed light in the
comments section and link to
blogs, articles, organizations, and
events that demonstrate forward
motion in addressing our
challenges.
My list may seem like a lot to ask,
but the verbs we use on our journey
will determine how happy we are
with the destination. Don’t be con-
tent to let others who don’t under-
stand our role define it – or elimi-
nate it – without understanding the
versatility, value, voice, and vitality
that our workforce brings to the
healthcare documentation process. I
look forward to hearing your stories
and celebrating our victories – both
big and small – over the next year. P
Jill Devrick is a proud 3M telecom-
muting software geek who has
worked with hundreds of healthcare
documentation organizations since
1995. She earned her BA and MPA
degrees from West Virginia
University. Jill is President of
AHDI’s National Leadership Board
and serves on the executive commit-
tee of the Health Story Project.
“Isn’t it funny how day by day nothing changes but
when you look back everything is different…” – C. S. Lewis
8. 6 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
Tech talk
I
n IT, “cloud” is one of the most
overused buzzwords in the
industry. There are companies
everywhere trying to sell cloud
applications, cloud storage, cloud
services, cloud monitoring, cloud
everything! But what exactly is this
cloud? You probably think you have
a good idea, but it’s likely not the
same idea as your neighbor has—
even though you both probably have
a good deal of data stored there.
Wikipedia even states that cloud
computing is a jargon term without a
commonly accepted non-ambiguous
scientific or technical definition.
In the simplest terms, the cloud
is a group of computer servers,
sometimes several thousand servers,
located at one or many datacenters,
which offer remote users (like you)
space to store their digital stuff.
Some of the most recognized cloud
products are email, websites, and
social media. If you can access any
of your information from a computer
other than your desktop or laptop,
that can be considered utilizing the
cloud. Facebook, anybody?
A cloud service that has taken
off in recent years is cloud storage.
Many of you have probably heard of
this or even use cloud storage. Cloud
storage provides users a way of ac-
cessing personal files from just about
any device that has an
Internet connection. For example, if
you saved your vacation pictures in
the cloud you could view them while
at a friend’s house; just log into your
cloud account and look at your pic-
tures. Working on a report for your
boss, and forgot the latest
revisions on your home computer?
That wouldn’t be a problem if you
saved the files in the cloud. Most
cloud providers even have a mobile
app to provide interoperability on
cell phones and tablets. No more
worrying about copying important
files to a USB drive to haul around
with you.
Some popular consumer cloud
storage applications are Dropbox,
Google Drive, and SkyDrive. These
specific providers all provide
solutions for Windows, Android and
iOS devices. They are also argu-
ably the three most popular names
in cloud storage, though, to be sure,
there are hundreds of other services
as well. So with all these choices,
how do you choose a provider?
Should you even be using cloud
storage? What about security?
Consumer cloud storage applica-
tions typically work by installing the
application on a PC. This application
creates a special folder on that com-
puter. Anything saved in that folder
is automatically copied to the cloud.
Then, any PC which also has that
application installed under the same
account will synchronize the folder
across all PCs the user designated
as belonging to that network. Files
Clearing up the Cloud
Curt Hupe
TECHNOLOGY AND
THE WORKPLACE
1 CEC
3 QUIZ
9. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 7
saved in this folder are also acces-
sible from tablets, phones, or the
provider’s website.
First, I’ll state that I think every-
one should use cloud storage for
their personal files. Especially since
all of the providers mentioned in
this article provide some amount of
free storage. It’s free; why not take
advantage of it?
Note that I mentioned “personal”
files. If you’re considering cloud
storage for business reasons, which
might involve storing protected
health information (PHI), special
care should be taken. Of course,
PHI always needs to be secure, even
if storing that information on your
local PC. When using the cloud, the
provider must be HIPAA compliant
or certified. If you’re not already us-
ing cloud storage I’ll provide some
brief insight into these most popular
services.
Dropbox has been around since
2007 and, according to their website,
has over 175 million users. Dropbox
has a user interface easy for even
novice users to learn. You can share
files with other users by just sending
them a link. Dropbox even integrates
with Facebook. Although Drop-
box offers the least amount of free
storage, starting at 2GB, you can
potentially earn up to 18GB extra
by referring new users. Dropbox
does not currently hold any HIPAA
certifications, so using Dropbox for
storing PHI of any kind could cause
a HIPAA violation.
Google Drive takes cloud storage
one step further by integrating with
its popular Google Docs, a suite
of office applications that include
simultaneous editing of documents
and spreadsheets. Google Drive
offers free storage of up to 15GB in
the cloud, though that can be
misleading because this total stor-
age is spread across Google Drive,
Gmail, and Google+ Photos. Google
drive also does not hold any HIPAA
certifications.
Microsoft’s SkyDrive integrates
well with the Microsoft Office Suite,
Windows 8, and Facebook. Similar
to Google Drive, users can edit
office documents saved on SkyDrive
within the web browser using Office
Web Apps. SkyDrive offers 7GB
of free storage. Microsoft states
that data stored on their systems are
HIPAA compliant; however,
remember it’s not just how the data
is stored. Users must be careful
when using any cloud storage, as the
point of the service is to make it easy
to share information, and you don’t
want to share PHI. It’s never a good
idea to store PHI on your local com-
puter unless absolutely necessary.
Although HIPAA requires the use of
passwords, it doesn’t specifically re-
quire them to be “strong” passwords.
The same holds true for encryption;
although it’s not required for stored
data, it’s certainly a good idea. If
you do store PHI locally, a combina-
tion of strong passwords, encryption
tools, and physical security will miti-
gate any potential HIPAA violation.
The best features of using these
services is that you can easily
share documents with others, and
it provides some peace of mind
that files are safe in the event of a
computer crash. Apart from sharing
and backup, cloud storage systems
also provide a great way to collabo-
rate with coworkers on communal
projects.
Each of these companies has their
own nuances that make them unique,
and different users certainly will
have their favorites. If you’re look-
ing for the most space, Google Drive
is your best bet. Although Dropbox
has the least free storage available,
its large user base and easy-to-use
software and mobile apps make it a
popular choice. P
Curt Hupe is director of operations
for ChartNet Technologies. Curt has
over 15 years in the IT industry and
5 years in the medical transcription
IT field. He welcomes your feedback
at Curt@ChartNetTech.com.
Freestoragecomparisonchart
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10. NEWLY CREDENTIALED
Stella Ebinger, RMT
Young Harris, GA
Amanda Parks, RMT
Greenville, MS
Laurie Patenaude, RMT
Fort Mill, SC
Rita Scanlan, RMT
New Castle, IN
Jerri Shook, RMT
Orland, CA
Ready to Practice!
Diana Boyd, CMT
Corning, CA
Annette Hager, CMT
New Market, MD
Jeannette Pemberton, CMT
St. Louis, MO
Jayaraj F V, CMT
Bangalore, Karnataka
Ajay Patil, CMT
Jaysingpur, Maharashtra
S D Sudhirrram, CMT
Tamil Nadu, Chennai
AHDI congratulates and welcomes the following healthcare
documentation specialists who achieved RMT status
between 7/1/13 and 8/31/13. Registered Medical
Transcriptionists have proven their ability to reach for
excellence by successfully completing rigorous testing
of all level-1 knowledge domains represented on the
RMT Exam Blue Print.
AHDI congratulates and welcomes the following
healthcare documentation specialists who achieved CMT
status between 7/1/13 and 8/31/13. Certified Medical
Transcriptionists have proven their level-2 transcription
knowledge, skills, and applied interpretive judgment in all
domains represented on the CMT Exam Blue Print through
AHDI’s rigorous credentialing exam.
8 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
Certified!
866-GO-EMDAT | WWW.EMDAT.COM
Technological
AdvantageBoost productivity quality
Customize workflow functions
Sophisticated management tools
Rapid implementation
No maintenance or support fees
More than 250 MTSOs use Emdat to provide quality
service and robust product functionality. Emdat
enhances a medical facility’s workflow by streamlining
output, optimizing workloads and complementing
EHR documentation through mobile apps and
seamless interfacing that supports meaningful use.
Demonstrate Professional
Pride
Visit the AHDI Marketplace at
www.cafepress.com/ahdimarketplace.
The AHDI Marketplace offers
something for every occasion. Visit
the AHDI Marketplace to browse the
merchandise created just for you,
including designs for: healthcare
documentation professionals, RMTs
and CMTs, ACE attendees, and
advocacy campaigns. Come back
frequently to find out what’s new! Wear
it, drink it, live it—Professional Pride!
11. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 9
Tanya Guenther, CMT, AHDI-F
H
ow is it that a student and
advocacy can go together?
Easily when you are a
healthcare documentation specialist
(HDS) student! Merriam-Webster’s
Collegiate Dictionary, 11th Edition,
gives the following definition of
advocate: One that pleads the cause
of another, one that defends or main-
tains a cause or proposal, one that
supports or promotes the interests
of another. Well, we can support and
promote the interests of our
profession for sure!
As HDS students and new gradu-
ates, we are all advocates for our
profession. We are educating our
friends and family about healthcare
documentation and its importance.
As we know, there are many people
who think of transcription in terms
of the process of “typing” a
document. By further explaining
healthcare documentation to our
family and friends, we are able to
increase public knowledge about the
important role we play in the health-
care system. This is advocacy! You
are probably already an advocate for
our profession without realizing it!
What are some of the other ways
you, a student or postgraduate, can
be an advocate for our profession?
Get involved with your local or
state/regional component of AHDI.
This is a great place to network with
other professionals and work collec-
tively as a group toward increasing
awareness of our profession.
Student and postgrad members
are also eligible to serve as officers
in a local component. As a student
or postgraduate, you can also work
to form a new chapter in your area!
Students and postgraduates can also
serve on local, state/regional, and
national committees—these are all
great ways you can get involved.
As advocates for our profes-
sion, we are also advocates for the
healthcare system. Many people are
completely unaware of the job we do
and how it may impact the quality of
their health care. We have the ability
to inform the public of what we do
and why it is important, not only to
us but to them as well. We can work
together to promote and advance our
profession, to increase awareness of
the important role we play, and to
educate the public about obtaining
and reviewing their healthcare rec-
ords (www.yourrecordspeaks.com).
As students and postgrads, we
need to jump in and learn everything
we can about our profession. By do-
ing so we are gaining the knowledge
and confidence to be advocates for
our profession. So go out there, get
involved, and advocate! P
This article has been modified from
the original article published in
Plexus, May 2007, Vol. 3, Issue 3.
Tanya Guenther resides in the Cariboo
region of British Coumbia, Canada,
and has been working in the HDS in-
dustry since 2005. She has served on a
number of committees through AHDI
in the past and currently is a member
of the AHDI Approval Committee for
Certificate Programs (ACCP).
Connections
Advocacy: You Don’t Have to Wait for Graduation
12. 10 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
The Juno Case:
A Sentinel Event for the
Transcription Sector
O
n December 13, 2012, a jury returned the largest
civil wrongful death judgment ever recorded in
Baldwin County, Alabama. The case involved
the death of Sharon Juno, who was administered a lethal
dose of Levemir insulin, an outcome that originated with
a transcription error. The jury awarded a stunning $140
million to the patient’s family, a verdict that was vacated
by the court shortly thereafter.
Thomas Hospital of Fairhope, Alabama, along with
its transcription outsource partner Precyse Solutions and
India-based Medusind Solutions and Sam Tech, Inc.,
entered into confidential settlements with the victim’s
family just prior to the reading of the verdict.
Regardless of the vacated verdict, the message from
the jury was clear. A documentation error, perpetuated
by questionable hospital policies and a series of even
more questionable clinical decisions, resulted in the
inarguable death of a patient. The fact that a transcrip-
tion company was even named in a wrongful death suit
should make the industry sit up and pay attention. The
issue of “liability” is now resoundingly on the table, and
everyone connected to the health information manage-
ment process would do well to consider the implications.
Who is ultimately responsible for the accuracy of
clinical information? This verdict challenges the long-
held assumption that the physician is the legally
responsible authority for the information in a patient’s
record. In this case, neither the patient’s physician nor
the nurse who administered the Levemir dosage
(ten times what the patient should have received) was
Lea M. Sims, CMT, AHDI-F
MEDICOLEGAL
1 CEC
3 QUIZ
13. held accountable for this outcome.
In addition to the question of liability, the healthcare
documentation industry needs to be mindful of the
critical role that quality assurance played in this case.
The plaintiff’s attorney was successful in convincing this
jury that poor quality measures and negligent quality
assurance practices contributed to the error in this
patient’s record and that if Thomas Hospital had
entrusted its documentation to a more qualified,
certified healthcare documentation team, this error likely
would not have occurred and this patient would not have
died as a result of it. In reality, the plaintiff’s argument
was fraught with misinterpretation and assumption,
both around the quality practices and “standards” of the
industry as well as what was reasonably within the scope
of control of either the hospital or its transcription
partners. Layered upon that rather dense landscape was
also the issue of offshore outsourcing, and the presump-
tion that “cheap” services offshore had compromised the
quality of this patient’s documentation clearly had an
impact on this verdict.
How did something that started out with a speech
recognition error end in the wrong clinical decision and
the death of a patient? AHDI has long warned the HIM
sector that such an outcome was not only a possibility
but a probability. Our “worst case scenario” involved an
error made either by an SRT engine or an MT/editor
(or both) that somehow went uncorrected through the
quality assurance process, unnoticed and uncorrected
by the physician, and unquestioned by a subsequent
healthcare provider at the point of additional care.
The case of Sharon Juno was the case we’ve been
holding our breath for.
The Case Timeline
Sharon Juno was treated in the spring of 2008 at
Thomas Hospital in Fairhope, Alabama. Despite the
recommendation from her physician (Dr. A) that she go
to a step-down rehabilitation facility, the patient opted
at the end of her stay to be discharged to her home. The
patient was sent home with discharge instructions and
a copy of her hand-written medication administration
record (MAR). The original MAR was then bundled
with her admission and treatment records to be scanned
into the EMR in the HIM department. Dr. A dictated Ms.
Juno’s discharge summary, and the audio was deliv-
ered to Precyse Solutions. Thomas Hospital contracted
Precyse Solutions for documentation services and opted
to participate in the Precyse offshore transcription pro-
gram. This meant that the audio dictated by Dr. A was
transmitted to the offshore partners where it was first put
through a speech recognition system and then delivered,
along with the SRT draft, to a series of MT editors and
QA personnel who were responsible for editing the draft
and finalizing it for delivery back to Thomas Hospital.
In the case of Sharon Juno, the SRT engine captured the
first draft, erroneously capturing “80 units” rather than
“8 units” for the Levemir dosage. Four additional sets of
ears, including both the QA1 and QA2 editors, saw the
reference to “80 units” in the draft and heard the dosage
as it was suggested by the SRT engine. None of them
heard it differently or had any reason to question what
they heard. The discharge summary was finalized and
transmitted to Thomas Hospital, where it was pending
signature by Dr. A at the time of this incident.
In the meantime, Sharon Juno spent her first night
after discharge at home alone and sustained a fall in
the middle of the night. Though she was uninjured, the
incident forced her to reconsider spending time in the
VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 11
14. 12 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
rehabilitation facility. She called her son the morning
after her first night home and told him she wanted to go
to Mercy Medical for rehabilitation. Her son transported
her to Mercy Medical but neglected to bring any of her
discharge paperwork or her medications. Upon admis-
sion, Mercy Medical contacted Thomas Hospital
seeking a copy of Ms. Juno’s MAR. Because it was
hospital policy that once bundled, a patient’s records
could not be unbundled for any reason until they had
been scanned into the EMR, the personnel at Thomas
Hospital contacted Dr. A, who told them to refer to the
patient’s discharge summary where her discharge
medications should also be listed, per his dictation.
The nurse transferred the medications by hand from the
discharge summary (which had not been read, reviewed,
or signed by Dr. A) to a new MAR and sent it to
Mercy Medical.
Sadly, the lack of critical thinking in the chain of
custody for this patient’s health information did not end
there. The treating nurse at Mercy Medical administered
80 units of Levemir to this frail, chronically ill patient
without questioning the dosage. The patient lapsed into a
coma, never regained consciousness, and died eight
days later.
The Arguments
The victim’s family filed suit against all parties
involved in the outcome – i.e., both hospitals, all three
transcription companies, the patient’s physician, and the
nurse who administered the medication to the patient. All
parties, the Complaint asserted, were guilty of clinical
negligence and of violating the standards of care that
should have prevented this patient’s death. Per the Com-
plaint, the nurse was negligent in applying the standard
of care for administration of this patient’s medications.
Dr. A should have requested a review of the discharge
summary before ever suggesting it be used in lieu of the
MAR. The hospital should not have permitted an un-
signed, unverified report to serve as an active physician
order. The hospital should not have restricted unbundling
of the MAR. And the hospital should not have tried to
save money by allowing its records to be transcribed by
allegedly “unskilled” offshore labor, especially without
strict oversight and monitoring of quality. Again per
the Complaint, Precyse should have engaged in more
rigorous monitoring and oversight of its offshore partner,
should have been using certified transcriptionist/editors,
and should have been following AHDI’s Quality
Assurance “standards.”
The Defense attorneys had their work cut out for them.
Clearly a patient had died due to clinical negligence.
The “series of unfortunate events” that resulted in this
outcome were contributed to by every named party in
the Complaint. Each defendant brought unique legal
representation and a bevy of subject matter experts,
and each one claimed no fault in the patient’s death.
The nurse claimed she was only following the doctor’s
orders. The doctor claimed he could not be responsible
for an error in a discharge summary he had not seen or
signed and that the hospital had behaved unethically
when it refused to unbundle the original MAR and created
an unverified secondary MAR. The transcription
companies claimed they had no legal liability for patient
care outcomes and that the Joint Commission holds the
physician responsible for authenticating a document
before it is used for clinical decision-making. And the
hospital pointed to every other named party in the Com-
plaint, blaming the nurse for administration, the doctor
for negligence over his record, and the transcription
companies for negligence in ensuring quality and accura-
cy. The buck was passed…and passed…and passed again.
The Implications
The jury returned with an inarguably biased verdict,
holding only the hospital and the transcription compa-
15. nies responsible for this outcome. In re-
ality, all parties were partially to blame,
but the two people most historically ac-
countable for care outcomes (the physi-
cian and the nurse) went largely unscru-
tinized by the plaintiff and unmentioned
in the verdict. How is that possible? The
scapegoat of an offshore transcription
program undoubtedly clouded the facts
of the case, making it easy for a jury to
ignore the responsibilities of the clinical
team and cast blame on a foreign source of error.
But the most compelling question for this industry is
this: Should the medical transcription companies have
even been named in the case? Should a documentation
service be held liable for medical malpractice? The jury
certainly believed that the error originated in documenta-
tion, and thus, a significant portion of the blame rested
there. A great deal of time was spent in deposition and
in the courtroom examining AHDI’s quality guidelines
to determine whether the transcription companies were
engaging in rigorous quality assurance practices. AHDI’s
reference to a “critical error” as one that can impact
patient safety reinforced the plaintiff’s argument that
transcriptionists should not be making documentation
errors that have the potential to “kill” the patient. Neither
the plaintiff’s attorney nor the jury were interested in en-
tertaining the argument that no matter how rigorous your
QA practices are, error in the record is not only likely but
inevitable. And for that reason, the transcription industry
could not possibly shoulder the burden of care decisions
made on the basis of an unsigned record.
What should the response of AHDI and the clinical
documentation industry be to this case? How does this
outcome impact HIM departments and outsourcing deci-
sions? The downstream impact of this case is unclear,
though certainly there is now a precedent in place for
more malpractice and wrongful death cases of this na-
ture. AHDI and the industry should consider the follow-
ing suggestions for leveraging this case on behalf of the
industry:
1. Issue a public response. The case provides AHDI with
a golden opportunity to issue a public statement/
release in response to the case around liability and the
importance of quality standards and credentialing.
2. Advance the argument for credentialing. Given the
reality that the hospital HIM department bore the
brunt of this vacated verdict (and presumably the
brunt of the settlement), the case affords AHDI with
an unprecedented opportunity to advance the
argument for transcription credentials with AHIMA.
3. Clearly define liability. The industry needs a clear
statement and supportive documentation that define
liability for the HIM documentation space. AHDI
should work with AHIMA to shape a position
statement and guidelines for defining legal liability.
4. Engage the Joint Commission. Where acute care
facilities are concerned, the Joint Commission is the
governing authority on policy and practice. AHDI and
AHIMA should work closely to engage the Joint
Commission around the facts and outcome of this case
so that the JC can reinforce its position on physician
authentication to its accredited hospital base.
5. Review and amend QA Best Practices language.
AHDI should revisit its current QA guidelines to
strengthen liability language around physician
authentication and better clarify the role of
retrospective review and scoring as a training
measure. The association should likewise consider
clarifying its explanation of critical errors in a way
that cannot be used to assign liability to transcription
in a court of law.
At the end of the day, this was a tragedy of decision-
making, but it can serve as a touchstone for this industry
moving forward to right-size and strengthen our
positions and practices. P
Lea Sims is the former Director of Professional
Practices for AHDI, author of The Book of Style for
Medical Transcription 3rd edition, and current Chair of
the AHDI’s Credentialing Commission for Healthcare
Documentation (CCHD). Sims was a key witness for the
Defense in the Sharon Juno case, testifying on the stand
in Baldwin County around transcription standards, best
practices, and prevailing policies.
VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 13
16. Debra Jones
I
’ve been a medical transcriptionist/editor/medical
language specialist since 1994. Anyone who has been
around in this business through these tremendous
changes has probably done the same thing—add one
title after another to the job description. When I started, I
worked in-house at a small rural Oregon hospital. I knew
the physicians because we’d greet each other passing in
the hall. Sometimes we’d sit at the same table for lunch
in the cafeteria. Every report was transcribed, although
we did use normals for the physicians already back then.
I started out with ER reports and discharge summaries,
and my supervisor worked closely with me as I pro-
gressed to consultations and operative reports.
I have been an at-home healthcare documentation
specialist since 1997. The hospitals I transcribe for are
rarely in my state. I have never met any of the physicians
whose voices I hear on digital recordings. I have never
even personally met my supervisor. Editing makes up
90% of my work volume.
Do I understand the need for greater efficiencies in
today’s healthcare delivery system? Of course. Anyone
not living under a rock these days knows that there are
more people on our planet who need medical care and
that governments and businesses alike do not have
unlimited funds with which to finance this care.
I have belonged to AHDI for a number of years. I
first joined when it was still AAMT. I have read all the
articles about how what we do is so important, now
more than ever. I have read how important it is for us to
know what is in our personal medical record. I have read
these articles and others and warned family members
for years not to go to the ER alone, and to try to have a
family member with them when they are really sick in
the hospital.
14 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
It Really
Does Matter
17. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 15
With all that experience, I still felt that my job
wasn’t very important. Line rates are less than they were
18 years ago when I started. I have no personal relation-
ship with the physicians whose voices I hear on digital
recordings. I have to correct ridiculous errors generated
by speech engines. I lost the “spark” that motivated me
when I first entered the field.
I have always had what my family dubs a
“sensitive” stomach. Neither my mother nor I can
remember the times she took me to see our family doctor
as a kid. Sometimes symptoms would become quiescent;
other times, they were quite bothersome.
Two and a half years ago, my nurse practitioner and
I agreed it was time to have someone take a “look-see”
to find out what was going on in my gastrointestinal
system, and I underwent both an EGD and a colonoscopy.
The colonoscopy was unremarkable. The pathologist
reported that random biopsies demonstrated increased
duodenal intraepithelial lymphocytes in the absence of
villous atrophy that could be suggestive of early celiac
disease. The EGD showed a small hiatal hernia. Noth-
ing spectacular on either study. I was referred back to my
nurse practitioner with the advice to take an H2 blocker
and, if that was ineffective, to try a proton pump inhibitor.
I talked with my nurse practitioner. I took ranitidine
daily and tried to watch my diet. That seemed to work
for about a year and a half. About a year ago, I began
having what I came to call “attacks.” I had increased
abdominal pain and bouts of vomiting that could last
for hours. I stayed in contact with my nurse practitioner,
and we discussed possible diagnoses. The next step was
diagnostic imaging. My NP was ready to proceed, but
tried to hold off due to costs and my busy life.
During a couple of these attacks we tried to get some
lab work done while it was happening to point us in a
direction. Unfortunately, I live in a rural area, 50 min-
utes away from her office. She either had a full day of
patients scheduled or I would convince myself that it
was because of too much stress, not exercising enough,
or some other justification. Perhaps having been an
MT all these years and transcribing reports for patients
diagnosed with “functional abdominal complaints” after
spending thousands of dollars on tests unconsciously
influenced me as well.
One Saturday night in May, I had the worst “attack”
I had ever experienced. I laid on the floor, as I could find
no position of comfort in bed. It was severe enough to
scare me. The next morning, I got up and went to the
ER.
My husband wanted to come along that morning.
I persuaded him it wasn’t necessary. Waits in the ER can
be long. I worked in a healthcare-related field. Certainly
I could speak for myself and express myself clearly.
Unfortunately, the hospital did not have an ultrasound
tech available that Sunday morning, one of the main
reasons I finally decided to go to the ER while symp-
toms were acute. The diagnoses were gastritis and acute
pancreatitis. I was discharged home with Zofran,
Protonix, and hydrocodone.
Even though I asked for copies of my labs several
times, I was told that my NP would need to request
them. I was in her office two days later, at 8:30 a.m.
Incredibly, my lipase had been 7100, amylase 1649,
AST 621, and ALT 447. That was shocking enough, but
reading the report the ER physician had written of my
ER visit topped that by a mile.
I told him I had not had more than 1-2 drinks in the
past 3 weeks, but that was reported as, “recently she tells
me that she stopped drinking alcohol.” I had
attempted to say I was not a regular, heavy user of
alcohol. I thought I said, several years ago I drank 1-2
drinks a night, 4-5 nights a week. That turned into,
“she said she drinks one to two alcoholic drinks per
night at least seven days a week and sometimes four to
five alcoholic drinks per night.”
While I innocently sat in the ER, calls were made to
other area ERs to check on my record of visits there.
Even though I had not been to another area ER in years
(I have had a total of three ER visits my entire life), my
record reflects that “they have somebody with the same
name but slightly different birth date and different PO
box number. The patient did present to [that hospital] in
March for a similar episode.” Indeed, I had not. Maybe
the tip-off should have been the slightly different birth
date and different PO box number.
All I can say is, thank God for my NP who has known
18. 16 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
me for 20 years and knew the record was not accu-
rate. After my visit with her that day, I went home and
contacted the hospital to start the process of “Request to
Amend Protected Health Information.” In all, I delin-
eated four errors in the physician’s History of Present
Illness, one error in my Past Medical History, one error
in my Physical Examination, and two errors in the Emer-
gency Department Course.
The ER physician did not even get the description and
location of my abdominal pain right. Throughout all of
this, I had never had pain in my right upper quadrant that
would be typical for a gallbladder. My NP documented
that I was clearly jaundiced with scleral icterus when
I went to see her. The ER physician noted twice that
my sclerae and pupils were anicteric. It is clear he used
templates for my physical examination which did not
correlate with the true findings.
Lab results two
days after my ER
visit returned show-
ing an AST of 82,
ALT of 236, amylase
of 97, and lipase of
67. Hepatitis panel
was normal. By the
time I returned again
to my NP for follow-
up, all values had
returned to normal.
AST was 18, ALT
27, amylase 50, and
lipase 49. Not bad
for someone accused
of being a chronic
habitual alcoholic.
Next stop for me
was imaging. Right
upper quadrant
ultrasound showed
“numerous shad-
owing gallstones
largely filling the gallbladder but noted to be mobile with
changes in position. There is some associated sludge.”
CT scan report stated, “The gallbladder contains layer-
ing dependent material consistent with a combination
of gallstones and sludge.” Liver was unremarkable, i.e.,
no evidence of fatty liver as can sometimes be seen with
alcoholic cirrhosis or liver disease.
Throughout this process, I continued to share results
of my follow-up examinations, lab results, and imaging
with the hospital where I had been seen in the ER. Con-
fident that I confirmed everything I had indicated as an
error in the ER report through subsequent reports from
my nurse practitioner and diagnostic studies, I felt sure
the ER physician would agree that errors had been made
in my report—errors potentially damaging to me should
I ever have to change insurance carriers.
I ultimately underwent a laparoscopic cholecystec-
19. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 17
tomy at a different hospital two weeks after being seen
in the ER. The surgeon was clear in his report that I had
“developed acute pancreatitis with appropriate elevation
of enzymes and liver function studies that seemed to be
related to the passage of common duct stones.”
In the operation, a “myriad of adhesions were taken
down, and the duodenum was stuck to the undersurface
of the gallbladder. There was some bleeding, and there
was a lot of bared parenchyma of the liver.” I ended up
with a J-P drain in my stomach and a three-day stay in
the hospital because of continued nausea, vomiting, and
slow return of bowel function. The drain was removed
on the fourth day. The actual postoperative diagnosis
was “acute and chronic cholecystitis with cholelithiasis,
probably passed choledocholithiasis, and pancreatitis by
enzymes.”
The pathology report confirmed “chronic active calcu-
lous cholecystitis, cholesterolosis, and adenomyomatous
hyperplasia.” It also states that “several of the small
stones are found blocking the cystic duct.”
At this point, I shared the operative report with the ER
physician, and I felt certain that the requested changes
would be made to my ER report, deleting the errone-
ous reference to excessive alcohol use on my part. The
source of my elevated amylase, lipase, and liver function
tests was clear.
Funny thing about physicians in this day and age of
medicine malpractice—they do not like to come close to
admitting anything that sounds like a mistake.
In the amendment, regarding the issue of alcohol use,
he stated, “I feel that this is the one area where, perhaps,
she does have a point. I did not mean to imply that she
was an alcoholic, but I did feel that this may be exacer-
bating her, either gastritis or pancreatitis.” I don’t know
what else stating that I drank 7 nights a week or 4-5
drinks a night would imply. He stated again, “I did not
mean to imply that she was an alcoholic, but I do recall
that she told me she had been drinking more alcohol than
usual, sometimes 4-5 alcoholic drinks per night, was, I
think, in reference to a distant past, and a reference to the
most she has ever drank in her life.” (Verbatim.)
I have spoken to an attorney regarding this matter.
It means that much to me that my medical history is
recorded correctly. Lawsuits, of course, are founded on a
claim being made for financial damages. I can prove no
financial damage at this point unless or until some day
when I am denied medical coverage or put into a high-
cost, high-risk insurance pool because of being cast as a
chronic alcoholic.
To summarize, here is what I hope you get out of this:
1. What we do as MTs matters. It is vitally important
that patients everywhere have an accurate, concise
history of their medical care. That is probably the
biggest gift I have received from this whole
experience. The “spark” has come back. I am again
proud to say I am a medical transcriptionist. I have
learned firsthand the havoc that can be caused in
patients’ lives when incorrect information is put in
their record.
2. As I have been telling family members for years, if
you can help it, don’t go to the emergency room
alone. If you are admitted and are quite sick or have
undergone surgery, arrange to have family or a friend
sit with you.
3. Make sure you keep a personal folder—whether that
be paper or electronic—of your medical history. I am
lucky in that I have been seeing the same nurse
practitioner for almost 20 years. She knows and trusts
me, and I have ready access to 20 years of my
medical history through her files, which is unusual in
this day and age. People move, physicians retire,
medical offices close, and it becomes difficult if not
impossible to track down old records. If something
ever does come of this ER report, I will have a
20-year track record of seeing the same healthcare
provider with no indication of exams or lab results to
indicate I was an alcoholic or heavy alcohol user.
4. Make sure the physician hears what you say. If you
have any doubt, ask them to reiterate. Repeat what
you said. It’s important that they get it right. Getting
it wrong can have bad consequences for you—
financially and emotionally. P
Deb Jones has been a healthcare documentation special-
ist for almost 20 years, witnessing lots of changes in the
field over that time, with more yet to come. Whatever hat
you wear wherever you work, she hopes that sharing her
personal experience will remind you that what we do is
important and something we can take pride in doing.
20. 18 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
A
s healthcare documentation
specialists (HDSs), we
envision ourselves as team
players, working in
concert with patients,
clinicians, and health
information management (HIM)
and health information technology (HIT)
professionals as partners; sometimes
referred to as the silent partners in
health care, often thought of as patient
advocates.
Some would argue our core transcription
responsibility in its purest form means
“only” to make a full written or typewritten
copy of dictated material, never to deviate from
the author’s word, edit, place blanks or flag, and
always to give the clinician the final say. Others
might emphasize our true skills lie in production,
grammar, punctuation, style, and looking up
referring doctor names and addresses. Then there is
the debate over verbatim transcription versus
appropriate editing. Traditional dictation/transcription
practice and editing comes with an inherent amount
of subjectivity; hence AHDI’s emphasis on
credentialing, life-long learning, approved education
programs, standards and best practices in education,
editing, auditing, researching, and ensuring quality
content and patient health records with integrity.
Did the HDS hear that right? Even if the documenta-
tion professional heard it correctly, is that really what
the clinician/author meant to say? That phrase “meant to
say” is extremely potent. It wields the power of how our
skills reflect much more than purely replicators of
dictated words. The phrase also implies a world
where dictation/transcription is the sole
source of patient care encounter
data capture, a
world we know no
longer holds true.
Documentation of the patient
experience by a clinician has taken
on myriad forms. We have dictation to
speech recognition, sometimes with
clinician editing or not, sometimes with
back-end speech editing by an HDS
professional, and oftentimes without
any further quality assurance or clinical
documentation improvement review. We have
the electronic health record in its variety of
presentations, vast or inadequate drop downs,
options to copy/paste, insert normal templates
and macros, auto sign and auto populate, often
lacking any form of quality control. The future of
speech recognition projects the promise of speech
intelligence—an auto-fill option where a clinician’s
typical phrases could be placed within the record at
the touch of a button with a computer algorithm sug-
gesting what the author meant to say.
I believe there is overwhelming evidence that the
responsibilities reflected in our knowledge, skills,
jobs responsibilities, and career paths are so much
more than purely transcribing exactly what clinicians
say, particularly because we now have so many forms
of documentation capture; hence the name change of the
association, the professional title change to healthcare
documentation specialist (HDS), and the evolution of
our credentials to Registered Healthcare Documentation
Health Information Documentation:
Who Owns the Quality
of the Information?
Karen L. Fox-Acosta, CMT, AHDI-F
MEDICOLEGAL
1 CEC
3 QUIZ
21. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 19
Specialist (RHDS) and Certified Healthcare Documentation
Specialist (CHDS). What remains to be seen is the rel-
evance of that evolution in today’s healthcare marketplace
and competitive business models. Can we really be seen as
more than just typists or medical secretaries, and are we, as
individuals and as a collective industry, ready to step up and
bear the weight of a title that reflects so much more than
being the messenger but instead an inspiring member of the
patient safety and risk management team focused on elimi-
nating sentinel events in patients’lives that could occur due
to medical record errors or health information that lacks the
nuances and uniqueness of that individual patient’s story?
Patients, clinicians/authors, healthcare documentation
specialists/medical transcription service organizations
(MTSOs), clinician authentication, and healthcare enterpris-
es/facilities/medical offices hold the qualitative responsibil-
ity to create, document, and provide a patient care record
with integrity; one that withstands the test of being useful
for real-time clinical decision-making, one that provides
safety for patients and mitigates risks, as well as rendering
a record that is supportive of reimbursement requirements.
These areas lend themselves to further scrutiny as we look
further into who owns the integrity of patients’health
information.
The patient owns quality and integrity of information
during the patient encounter as information passes from
patient to clinician/author.
Patient Care Encounter—The Patient
POTENTIAL RISKS
• Mistakes due to inadequate, erroneous, incomplete or
copious patient-generated information
• Omission of critical information due to length and/or
complexity of care encounter
• Propagation of researched symptoms or patient self-diagnosis
• Errors and omissions due to compromised clinician attention
(divided between patient and EMR/EHR)
AHDI ADVOCACY EFFORTS, PRODUCTS,
SERVICES, MEMBERSHIP BENEFITS
• Public education on the value of a well-constructed personal
health record (PHR Your Record Speaks website and
public awareness campaign)
• Promotion of the dictation/transcription process as the
fastest, most economical means of building a robust record
and preserving physician attention on frontline care
Responsibility for information integrity then shifts
to the clinician/author who compiles relevant data to
generate the care record.
Clinician Capture—The Author
POTENTIAL RISKS
• Errors and omissions due to poor clinician retention of care
encounter details
• Mistakes in data entry (EMR/EHR)
• Inaccuracies in dictation (wrong words or values,
transposed terms, nonpertinent info, etc.)
• Errors resulting from poor dictation quality (speed, clarity,
background noise, disorganized speech, challenges of
English as a second language, etc.)
• Technology-enabled errors (self-created terms, copy/
paste from past reports, erroneous templates, haste in using
pick lists, wrong selection by accident or intentional by ease
of access, coding expectations and, MU2 and MU3,
ACO-reporting requirements)
AHDI ADVOCACY EFFORTS, PRODUCTS, SERVICES,
MEMBERSHIP BENEFITS
• Promotion of standards of practice via AHDI’s Dictation Best
Practices tool kit to connect quality clinician input to quality
documentation output
• Promotion of HDS as qualified peer to support quality-
focused migration to the EMR/EHR and provide risk
management and quality assurance analysis of
EHR-captured clinical data
In traditional dictation/transcription, speech editing,
EHRs with partial narrative option, and quality assur-
ance review, the weight then transfers to healthcare
documentation specialists and healthcare documenta-
tion business owners who partner with the clinician/
author to ensure accurate data capture. In other forms
of data capture (clinician front-end speech, point-click
EHRs, once-and-done documentation, EHR scribes), the
burden of accuracy and completeness typically bypasses
a quality/integrity review touch-point in the workflow
process and moves directly to authentication.
Healthcare Documentation Specialists
and Business Owners
POTENTIAL RISKS
• Mistakes in documentation due to inadequate transcription/
editing skills
• Errors in speech recognition due to absence of, poor, or
inadequate back-end speech editing
• Errors and omissions perpetuated in the record due to
failure to flag for review
• Pressures of turnaround time that force production over quality
22. • Variance in standards and business best practices
• Inaccuracies due to unfamiliar dictation/authors, first-in/
first-out pressures; multiple accounts, specialties or work
types; multiple and conflicting client profiles
• Errors perpetuated via inadequate training, lack resources,
or access to tools like author samples
• Failure of proper knowledge or use of research tools and
techniques
AHDI ADVOCACY EFFORTS, PRODUCTS, SERVICES,
MEMBERSHIP BENEFITS
• Promotion of a defined scope of practice and professional
standards using The Book of Style for Medical Transcription
• Establishment of credentialing as standard of practice to
ensure appropriate skillset for access to clinical records
• Compliance with privacy security standards like BOS,
HIPAA education, Compliance Best Practices Manual
• Cultivation of standards and best practices for clinical
documentation training programs—ACCP Education
Approval Program
• Open access to verbatim transcription position paper
• Promotion of standards of practice in quality assurance
through use of Healthcare Documentation Quality
Assessment and Management Best Practices
• Recognition of relevant value of HDS through circulation
of equitable compensation position paper
• Advancement of standards of practice through widespread
use of BenchMark KB
• Establishment of best practices through utilization of
Turnaround Time (TAT) Guidelines
The ultimate accountability then passes back to the
clinician/author for the review and authentication
process. Healthcare enterprises via coding, HIM, HIT
and other entities in the work flow continuum have
touch-points that shoulder some of the burden of health
information with integrity through policy creation and
implementation of procedures that focus on the quality,
accuracy, and completeness of health information that is
unique to each patient prior to authentication; however,
most often, healthcare facilities assume once “signed by
the clinician” everything is as it should be.
Clinician Authentication—
The Healthcare Enterprise/Facility
POTENTIAL RISKS
• Errors in final documentation due to inadequate clinician
review
• Errors perpetuated due to lack of clinician review (flagged
items left blank or uncorrected, auto-signature, “Dictated
but not read” indicators, etc.)
• Insufficient policies/procedures or enforcement of PPs
by healthcare enterprises regarding authentication, author
review, and/or automated signature best practices
• Insufficient PPs, standards, or compliance with quality
assurance best practices
• Inadequate error data collection propagating lack of
knowledge of scope of problem
• Inadequate protocols to verify accurate and complete
patient health information
• Errors exponentially replicated in the interoperable EHR
and health information exchanges
• Emphasis of health information capture primarily for
revenue generation or cost savings versus clinical decision
making and building content-rich patient health stories to
provide better patient care
• Pervasive culture in healthcare delivery that keeps patients
in the dark about their own health records
• Inadequate knowledge and oversight by regulatory bodies
to ensure accuracy, completeness, and health information
that is unique to each patient
AHDI ADVOCACY EFFORTS, PRODUCTS, SERVICES,
MEMBERSHIP BENEFITS
• Public education around the importance of an accurate
health record and consumer engagement in health record
review—Your Record Speaks and Walking PSA - A Medical
Record Can Mean Life or Death
• Advocacy and alliance building with the Joint Commission,
Health and Human Services (HHS), Office of National
Coordinator (ONC), American Health Information
Management Association (AHIMA), Health Information and
Management Systems Society (HIMSS), American Medical
Association (AMA) to address error rates in the health
20 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
23. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 21
record and quality pre-documentation and post-
documentation review
• Improving the Accuracy of Narrative Patient Notes -
2009 Error Abstract
• Four-pillar strategic plan to include goal to collect data
of medical/health record errors regardless of capture method
• Creation and access to AHDI’s EHR Toolkit
Each of the complex core pillars explored have their
own attendant risks. AHDI has worked diligently to ad-
dress the potential risks and deliver solutions to the in-
dustry, workforce, AHDI members, healthcare providers
and consumers through advocacy tools or standards of
practice to diminish patient safety concerns and provide
effective risk management.
Ultimately, we all bear a collective accountability
to the question of who preserves the quality of patient
health information. Our industry and HDS profession-
als play a significant role in obtaining the best possible
outcome along the work flow path, yet the clinician car-
ries the definitive liability as the author of patient health
records, and it is patients who could pay the ultimate
price for records that are incomplete, inaccurate, or
contain misinformation. We aim to see a resurgence of
our relationship with clinicians/authors as critical team
members of the workflow process, and also recognition
within the entire healthcare system, as we demonstrate
how our skills protect the integrity of patient records,
culminating in the primary goal of improving popula-
tion health and lowering risks. P
This article was written by Karen L Fox-Acosta,
CMT, AHDI-F, based on a patient safety project devel-
oped in conjunction with Lea Sims, CMT, AHDI-F.
Karen L. Fox-Acosta is AHDI Immediate Past President
2013-2014, and has been a member of AHDI for over
10 years. She works as a quality assurance manager for
Shumaker Transcription Services and has been in the
healthcare documentation industry for 16 years.
This widely acclaimed industry standards manual has long been the trusted resource
for data capture and documentation standards in healthcare. The 3rd edition
delivers a streamlined and strategically reorganized flow of critical
data, enhanced explanation of standards and practical application,
robust examples taken from clinical medicine settings, trend
notes that identify the impact of technology on the state
of the industry, and new chapters on security/privacy,
standardized templates and nomenclatures, the
electronic health record, and speech recognition
editing.
The BOS 3rd edition is
available for purchase
online at www.ahdionline.org.
3rd edition price:
$50 members, $70 nonmembers.
The Book You
Reach for Most
The Book of Style
for Medical Transcription,
3rd edition.
Chapter 1: Types, Formats, and TATs
For coated:
Blue:534
Green:382
For uncoated:
Blue:547
Green:380
24. 22 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
My Career Path–From MT to Ninja.
Wait, What?
Sheryl Williams, CMT, AHDI-F
This column is dedicated to providing
examples of healthcare documentation
specialists who are actively seeking and
embracing new and/or expanding roles.
IN THE LIMELIGHT
K
at King’s career path start-
ed in medical records in
“pre-electronic” 1974 and
subsequently included many years
as a medical transcriptionist and a
business owner. She acquired and
utilized various skill sets along the
way, including a comprehensive
knowledge of medical terminology,
pharmacology, labs tests, procedures
and critical thinking skills. She has
an interest in technological advanc-
es, the ability to “play well with oth-
ers,” and access to a vast amount of
information and experiences through
being an engaged member of AHDI.
Little did she know that these skills
and experiences would eventually
serve her well in her new role as an
“electronic medical record Ninja.”
Circumstances presented them-
selves a few years ago necessitat-
ing a detour in Kat’s career course.
Having been intrigued by electronic
medical records and realizing the
inevitability of universal adoption
of these systems, Kat decided to
embark on an educational and
occupational journey to, as she puts
it, “embrace the Dark Side.”
As Kat had no prior college
credits, she needed to start from
scratch from an educational
standpoint. Following three
years of juggling school
and work, she attained
associate degrees in
general studies and
healthcare informatics from
Rogue Community College near
her home in southern Oregon. She
is now pursuing a bachelor’s degree
from the Oregon Technology (OIT).
Meanwhile, Dr. Kathleen Myers,
an emergency physician, recognized
the need for medical scribes and
founded Scribes STAT, based in
Portland, Oregon. The business later
expanded into offering support for
EMR implementations. A new
position, called EMR Tutor,
was created. Scribes STAT
began working with local
colleges to recruit employees for
these new and expanding roles.
EMR tutors are contracted to work
on-site at facilities during the first
several weeks of an EMR imple-
mentation. Kat was hired by Scribes
STAT to help provide “at the elbow”
support for providers, nurses, and
support staff learning to navigate a
new EMR. The tutors work directly
with facility staff, called “Super
Users,” certified platform trainers, as
well as IT analysts from both Epic
and Paragon/McKesson. The tutors
provide feedback with regard to po-
tential privacy concerns, especially
the usage of workstations on wheels
(WOW) units in public areas. They
25. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 23
help to identify and trouble-shoot
implementation glitches, and offer
optimization of physician order sets,
macros and templates.
Since being employed by the com-
pany, Kat has had many memorable
experiences. The term “Ninja” has
been applied as a term of endear-
ment referring to the fact these EMR
tutors, who wear black scrubs, seem-
ingly appear out of nowhere to help
solve whatever problem arises.
EMR tutors help determine whether
an issue relates to system design,
system implementation, or user
education. They are able to un-
derstand the “big picture” and the
significant down-stream impacts
of process changes. Following the
designed workflow within an EMR
is paramount to successful data cap-
ture, retrieval and continuity of care.
Scribes STAT provides EMR sup-
port at all levels of the healthcare
process; but the EMR should never
get in the way of providers and clini-
cal staff from providing care. One
example was when Kat and another
tutor were urgently paged to the op-
erating room because a patient being
prepped for surgery suddenly devel-
oped a catastrophic gastric bleed.
The anesthesiologist was not accus-
tomed to using the system to order
blood products, which is a complex
process. Before entering the OR,
they needed to follow strict scrub-in
protocols. It was quickly determined,
due to the emergent nature of the
situation, to temporarily bypass the
system and utilize a manual process.
All the necessary documentation
could be done once the patient
was stabilized.
Recently Kat was covering the
obstetrical/NICU floors, during
which time several sets of multiple
births occurred. Something as seem-
ingly simple as naming conventions
for newborn babies can create huge
system data problems if not followed
consistently.
Kat has been complimented on her
calming demeanor when approach-
ing problems. Through her efforts
she has been welcomed as a valued
member of the healthcare team. She
points out this role takes you out of
your comfort zone, behind a com-
puter screen, and into the real-time
“live action” of the hospital or
ambulatory setting.
Kat states medical transcription-
ists are perfectly positioned to enter
this new career field and are being
recognized as an untapped resource.
However, she cautioned that pursu-
ing additional education is critical.
The combination of an appropriate
degree, technological knowledge,
healthcare documentation expertise,
and soft skills will enable an MT to
successfully navigate this transition.
She added that many colleges and
online schools now offer excellent
programs in healthcare informatics.
The role of an EMR tutor is just the
tip of the iceberg of evolving and
expanding roles within the health-
care informatics arena, and could be
a viable option for many MTs.
Some of you may recall a late
1980s phenomenon known as the
“Teenage Mutant Ninja Turtles.”
These turtles remained isolated from
society except when their services
were required to battle crime, evil,
aliens, etc. Each of the four was
named for a Renaissance artist.
Somehow it seems especially fitting
that Kat King has come full circle
and has been reborn as an “electron-
ic medical record Ninja.” P
Sheryl Williams has been employed
in healthcare documentation since
the Reagan administration. She cur-
rently works for Command Health.
Sheryl is serving on the AHDI Na-
tional Leadership Board as District
3 Director. She lives on a small farm
near beautiful Red Wing, Minnesota.
Many healthcare documentation
specialists are speculating about
what the future holds for them;
others are taking steps to ensure
their place in the evolving workforce.
We would like to hear from you on
this topic! The focus of this column
will be to highlight healthcare
documentation specialists who are
utilizing and/or enhancing their skills
by performing in unique, nontradi-
tional, and expanding roles.
Please forward a brief summary of
the person or position you would like
us to know about, as well as your
contact information, to
Sheryl Williams CMT, AHDI-F,
at swilliamscmt@msn.com.
26. 24 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
A
s healthcare documentation
specialists, we are often on
the clinical side of medicine,
transcribing or editing the physician
point of view: the medical terms,
treatments, and recommendations.
Often, we don’t experience the
patient’s point of view. For this
article of Life UnSedentary, I did
just that. I interviewed three gracious
women who offered intimate details
on their personal battles with weight
loss and their experiences with
Roux-en-Y gastric bypass surgery as
a tool to help overcome obesity.
Roux-en-Y gastric bypass (RYGB)
is a type of weight loss surgery that
reduces the size of your stomach to
about the size of an egg by stapling
off a section of it, which reduces the
amount of food you can consume
at meals. The surgeon attaches this
pouch directly to the small intestine,
bypassing most of the rest of the
stomach and upper part of the small
intestine. The procedure reduces
the amount of calories and fat your
body absorbs from the foods you eat,
resulting in additional weight loss.
RYGB can be done laparoscopically
or as an open procedure.
Ava Marie George, MBA, CMT,
AHDI-F, who underwent RYGB
in early June 2010, was motivated
to gain control of her weight by
both her children and her health. “I
wanted to live to see my children
graduate from high school and
college, for them to marry and have
children. The potential for me to
not see any grandchildren was a
huge motivation. Secondary was my
health. I had uncontrolled high blood
pressure and adult-onset diabetes.”
Doctors generally recommend
surgery only if you are severely
obese—at least 100 pounds over-
weight for men and 80 pounds for
women. Karin Lucas, CMT,
underwent an open RYGB in
December 2002, and stated that
before surgery, “I could not get out
of bed without help...it was embar-
rassing to say the least.” Karin made
the decision to undergo surgery at
the age of 35. “I had type 2 diabetes,
sleep apnea, high blood pressure,
and I could not even walk around the
block to get exercise and enjoy my
two children.”
In addition, surgeons usually
don’t recommend RYGB unless you
haven’t been able to lose a large
amount of weight and keep it off
through diet, exercise, and changes
in lifestyle, as was the case for
patient Lori Follett, who underwent
the procedure in late December
The Patient’s POV:
An Intimate Look at Weight-Loss Surgery
Rachel Quatkemeyer, CMT
LIFE UNSEDENTARY
27. 2012. When asked what her deciding
factor for surgery was, Lori states,
“I have struggled with my weight
for as long as I can remember. Over
the years I just kept getting bigger
and bigger. I have tried every diet
you can possibly think of. I have
lost weight like a pro, but I always
gained it back and then some. I was
finally to a point where I didn’t want
to be involved in my life socially and
knew I needed to change because
I was missing too much. I wasn’t
successful on my own and needed
the tool that surgery would provide
for me.”
While recovery from RYGB is
about six weeks, Lori was “back
to my old self” within two weeks,
while Karin was bartending at her
parents’ bar within one week of
being released from the hospital.
Ava states, “I had three C-sections
before. This surgery was way easier
than those surgeries.” Precautions
were taken with Karin’s open RYGB
procedure. “I was in the hospital
for four days right after surgery,
and I had to remain in Spokane,
WA, where I’d had my surgery, for
a whole month before I could go to
my actual home 20 miles away, just
in case there were any issues.” With
a laparoscopic procedure, Lori was
in the hospital about 24 hours.
Ava, Karin, and Lori together have
lost enough weight to equal the size
of a 9-foot tall adult ostrich, a weight
loss of about 350 pounds collectively
(losing over 100 pounds
individually) through Roux-en-Y
gastric bypass surgery, and all of
them state they would absolutely do
it again, despite any complications
they suffered. While Ava experi-
enced no immediate postoperative
complications, she later had exten-
sive problems with malabsorption,
which caused uncontrolled tachy-
cardia, which in turn caused mini
strokes. “I am fully recovered and
on a strict regimen of vitamin and
mineral supplements as well as three
types of iron to keep my hemoglo-
bin and hematocrit up. I also avoid
greens to keep my potassium down.”
Ava states that despite her more
severe complications, the most
difficult part of her experience was
the diet. “I just could not eat. I could
not taste food at all. I ate just to be
sure that I did not lose weight too
fast. It took about two years for my
taste to come back. I was on 100%
liquids for about three months. I
gradually moved up to solids, but
it took about six months for me to
be comfortable with food.” In spite
of all that, Ava states, “I absolutely
would still go through it again.”
In the face of being fed through a
feeding tube for the first couple of
weeks after surgery and undergoing
four additional surgeries to release
recurrent abdominal adhesions,
Karin states she, too, would undergo
weight loss surgery again. Like all
RYGB patients, Karin underwent
major changes in diet post surgery.
For six weeks baby food was on her
menu. “You should have seen the
looks I received when I would bring
VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 25
28. my baby food to the bar to eat at
lunch when I worked...it was price-
less!” Karin also states the biggest
surprise was the amount of energy
she experienced right after surgery.
“It seemed like I could take on the
world and didn’t need to sleep to
rejuvenate at all. It was the most
amazing thing, especially after years
and years of being too large to even
think about exercising without practi-
cally giving myself a heart attack.”
All three women have had to
change their eating habits and adhere
to strict diets after surgery. Karin
warns, “Be committed to changing
your lifestyle for the rest of your
life; there’s no going back,” and
also states surgical candidates should be prepared to say
goodbye to carbonated beverages, alcohol, cigarettes,
and sugary foods. “To this day, I cannot have anything
carbonated, as it makes me bloat up, and sugar is a huge
no-no. I have to limit my sugars to 5 grams or less per
serving—so you can tell, it’s a little bland.” Lori also
limits her sugar intake and states that if she splurges on
sugary treats, she will get very sick for several hours
with nausea, vomiting, sweating, stomach cramping, and
dizziness. For comparison, most flavored yogurts have
around 20 grams of sugar per container, and these
ladies are consuming no more than 5 grams of sugar
per serving.
In addition to changing dietary habits, new habits have
to be formed with regard to regular exercise to keep
the weight off. Ava walks everywhere and is joining a
health club, having recently moved to the health-oriented
city of Loyola, IL. Lori works out at a gym four to five
times a week for one and a half to two hours, focusing
on cardio and strength training. In addition to changing
exercise habits, Lori states that candidates should be
prepared to dedicate themselves to a “massive amount
of vitamin supplementation for the rest of your life.”
As you can see, gastric bypass is a BIG commitment,
and Lori stresses that undergoing surgery is by no means
a “quick fix” or “magic cure” for weight loss. This is
not the easy way out. It involves possible complications
and major lifestyle changes. Ava, Karin, and Lori have
undergone tremendous life-changing transformations
through Roux-en-Y gastric bypass surgery, and they
encourage all surgical candidates considering the
procedure to thoroughly research their options before
making such a huge commitment. Health insurance may
cover the procedure, but specific requirements may need
to be met prior to coverage.
Thank you Ava, Karin, and Lori, for your contribu-
tions to this article. I wish you immense health and
happiness on your continued journeys!
As always, consult with your physician regarding
weight loss, or consult a surgeon in your area to decide if
surgery might be the right weight-loss tool for you. P
Rachel Quatkemeyer has been in the transcription
industry for 10 years. She lives with her husband and
two sons in Ravenna, Ohio. She can be contacted at
Rachel9580@aol.com.
26 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
LIFE UNSEDENTARY
29. EXERCISE YOUR BRAIN
Answers on page 37
Brand-Generic Equivalents Word Search Instructions:
Ten common brand name drugs are listed below. On the line provided, write the name of the generic drug for each
brand name drug listed, then find and circle all 20 drug names in the puzzle below.
1. Xanax = _______________ 6. Synthroid = _______________
2. Diflucan = _______________ 7. Zovirax = _______________
3. Prozac = _______________ 8. Flexeril = _______________
4. Prilosec = _______________ 9. Lopressor = _______________
5. Zocor = _______________ 10. Neurontin = _______________
VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 27
30. 28 SEPTEMBER/OCTOBER 2013 WWW.AHDIONLINE.ORG
CLINICALMEDICINE
Neurodegeneration
Jane Warren, ELS
I
n 1978, Louise, a petite 38-year-old receptionist, felt so
weak and hazy one day that she collapsed in her
bedroom. She couldn’t move her left side and was
unable to hold a conversation. She continued to have
occasional, unpredictable bouts of weakness, but she
never sought medical attention. Louise didn’t have
another one of these spells until 1998, three years after
she married her second husband, Sebastian, a profes-
sional ballroom instructor. It struck when she and her
husband were dropping a relative off at the airport.
Afterward, while in the car, she suddenly “felt funny”
and “out of it.” Since the feeling went away quickly,
she didn’t say anything to her husband.
They then stopped at a local restaurant. When Louise
got out on the passenger side of the car, her legs started
to give way, and the left side of her body felt as if it had
just shut down. She managed to make it into the
restaurant, but she collapsed once inside. She didn’t lose
consciousness but felt foggy. Louise was able to get
up with Sebastian’s help, and he drove her to the local
emergency room. The emergency room staff thought
she had a stroke because of the weakness on her left
side. She couldn’t even hold a pen to write, and to add
insult to injury, she was left-handed. In triage her blood
pressure was extremely high. She underwent a battery
of tests throughout the night, and her blood pressure was
monitored and stabilized. She also underwent magnetic
resonance imaging of the brain, which revealed multiple
sclerosis.
What is Multiple Sclerosis?
Multiple sclerosis (MS) is a chronic disease of the
central nervous system (CNS) in which myelin, the fatty,
protective substance that serves as an insulator for axons,
or nerve fibers, is attacked by our own body. The CNS
includes the brain, spinal cord, and optic nerves.1
Like a
teething puppy chewing on an electrical wire, MS eats
away at the myelin, resulting in demyelination of these
axons. Its onset is unpredictable because symptoms
can either be gradual or sudden. They can appear at an
instant but may not reappear until months, even years,
later. These symptoms include weakness in one or more
limbs, usually on one side of the body, visual problems
such as double vision or visual loss, lack of muscle
coordination, and an unsteady gait. In the later stages
of MS, most people experience bladder dysfunction,
extreme fatigue, and heat sensitivity. Symptoms occur
because myelinated tracts in the CNS are disrupted;
however, the peripheral nervous system is untouched.2
It has long been established that MS is primarily an
autoimmune disorder. However, in recent years, research
suggests that neurodegenerative mechanisms may also
be involved, especially in the early course of the
disease.3
How do these mechanisms strip the nerve fibers of
their protective myelin? Before we discuss this salient
point, let’s examine the four different courses of MS.4
Disease Courses
• Relapsing-remitting MS: This form of MS is the
most common. An estimated 85% of people start with
this disease course. The person may experience an
acute attack or flare-up and then recover completely
from the attack. Sometimes the recovery may be
prolonged, but function usually returns to near baseline
after the attack.
• Primary-progressive MS: In this stage, neurological
disability is more progressive, with almost no plateaus
CLINICAL
MEDICINE
1 CEC
3 QUIZ
Neurodegeneration
in Multiple Sclerosis
31. VOLUME 9 • ISSUE 5 SEPTEMBER/OCTOBER 2013 29
or remissions in between attacks. Neurological
function steadily worsens. Approximately 10% of
people experience this disease course. By the time a
diagnosis is made, the patient will have already
experienced neurological symptoms and much
disability.
• Secondary-progressive MS: This form occurs in
roughly 65% of individuals who start with relapsing-
remitting MS.5
People entering this phase have
neurological decline. Disability is progressive, even
between acute attacks, and patients have a harder time
recovering after an attack. They also have fewer
attacks. Time between onset of MS and transition from
relapsing-remitting to secondary-progressive MS is
approximately 19 years.
• Progressive-relapsing MS: This form is the least
common, occurring in 5% of the population. People
with this form have progressive disability from the
time of diagnosis but also experience clear acute
exacerbations.
Pathogenesis of MS
A well-established opinion of MS pathogenesis stems
from an animal model called the experimental autoim-
mune encephalomyelitis model. Experts believed that
T-lymphocytes in the immune system wreak havoc in the
CNS by targeting the myelin. According to Vyshkina and
Kalman, these T cells seep through the blood-brain
barrier, proliferate, and attack oligodendrocytes
(brain cells that support the axons) and myelin.6
However, in the 1990s, the scientific community
identified a neurodegenerative process in MS indepen-
dent of an adaptive immune response.7
This process
occurs after an inflammatory response and demyelin-
ation. T cells, B cells, plasma cells, and groups of cells
that actively defend the CNS against foreign invaders
partake in this inflammatory response. Thus, we now
believe that neurodegeneration in MS involves a com-
plex chain of events in which the myelin is no longer
protected; axonal loss ensues; metabolism is disrupted;
and, most importantly, mitochondrial function falters.6
These changes take place in different parts of the brain
and spinal cord, targeting both gray and white matter.
Lassmann and van Horssen 8
describe the neurodegen-
erative changes in MS according to disease stage:
• During the early stages of MS, when most patients
experience relapses and remissions, plaques or
lesions form in the white matter. These plaques stem
from inflammatory demyelination.
• In patients with primary or secondary progressive MS,
more degenerative changes are seen in the brain, such
as demyelination in the cerebral and cerebellar cortex
and degenerative changes in both white and gray
matter. Also, patients with severe disease demonstrate
atrophy in the brain and spinal cord, along with tissue
loss and dilatation of the ventricles (cavities in the
brain that contain cerebrospinal fluid).
• The severity of inflammation in the CNS declines with
patient age and duration of disease.
• In patients with secondary-progressive MS, dense
inflammatory cells are seen in the meninges, which
may promote active demyelination and damage the
cerebral cortex. This notion warrants additional studies.
• Ironically, inflammation in the CNS may decrease in
the very late stages of the disease in which the disease
process “burns out.” Axonal injury also decreases. Iron
accumulates in the brain during this burnt-out phase.
Possible Neuroprotection and Remyelination
Some experts agree that loss of axons, not the extent
of the demyelination, results in neurological disability
and maintain that neurodegeneration in MS still has yet
to be fully understood. However, looking at MS as a
neurodegenerative disease as well as an autoimmune
disease could yield more effective treatments in the
future. Such treatments could curb inflammation and
provide neuroprotection and repair of damaged nerves.
Current Treatment
After Louise was diagnosed in 1998, her doctor
wanted to start treatment right away, but she refused for
three years. During that time, she struggled with
constant weakness and had difficulty keeping up with her
beloved ballroom dancing. Finally, her doctor encour-
aged her to take interferon, a drug that jump-starts the
immune system and slows the progression of MS, which
