Most providers are transitioning to EHR technology owing to the EHR incentive program, and they must be sure of their clinical documentation integrity. A 2014 survey by the Healthcare Information and Management Systems Society (HIMSS) found severe deficiencies with EHR technology that disrupt physician workflow, increase the difficulty of clinical decision making and delay the accomplishment of vital clinical tasks. These challenges make one think about the need of human intervention – medical transcriptionists in a new role – as healthcare documentation specialists or HDS.
The survey identified plenty of vulnerabilities in multiple categories. Some of them are:
- Clinical Data Review – There were too many clicks with confusing data placement and organization. Hidden information, lack of customization and difficulty in seeing trends were other deficiencies.
- Physician Documentation – Too many clicks required while templates impair data quality. Structured documents conflict with the thought process, context and reasoning hard to communicate.
- Medication Reconciliation and Prescribing – Inability to e-prescribe controlled substances, inaccurate prescription data and difficulty in entering or reconciling combination medications.
- Provider to Patient Communication – Diverting attention from the patient interferes with face to face care, loss of nonverbal cues as well as emotional connection with the patient, increased work and regulatory burden owing to required secure electronic communication.
How an HDS (Healthcare Documentation Specialist) Can Be of Assistance
The umbrella term "healthcare documentation specialist" includes medical transcriptionists, speech recognition editors, QA reviewers etc. Working as a human interface, this specialist maximizes the quality of data and narrative necessary for optimal performance of EHR technology. HDS also support physician choice of document creation methodology according to the workflow and environmental needs.
Healthcare documentation specialists provide front-line document risk management and monitor documents for:
- Wrong patient/demographic mismatches
- Wrong provider name
- Incorrect dates of service
- Incorrect work types
- Errors in medication dosage
- Right/left, male/female inconsistencies
- Medical contradictions
- Other missing elements and speech recognition errors
In this way, they will ensure documentation integrity and save a significant amount of time for physicians so that they can focus more on patient care. This will also improve the ability to prescribe medications. With discrete reportable transcription (DRT) technology, physicians can avoid the problem with templates and too many clicks. Once the HDS edits your documents, they can be populated into relevant EHR fields through this technology.
Overall, HDS facilitate successful transition to EHR and the speech recognition technology. Reliable transcription companies offer the service of medical transcriptionists along with three-level quality assurance ensured by editors and proofreaders. With such a service, you can effectively address EHR vulnerabilities without compromising the data quality.