Medical errors can be prevented with the help of precise, prompt, and well-structured medical record documentation. Medical transcriptionists (MTs) have always contributed to the production of quality medical records, though with the advent of electronic health records (EHRs), their work is being increasingly supported or replaced by artificial intelligence (AI) and speech recognition technology (SRT). However, front-end SRT comes with accuracy concerns. When dictation is used, medical transcription outsourcing is the best way to create accurate and complete medical records. In fact, today, medical transcriptionists play a vital role in the creation of accurate and complete medical records, which are essential for patient care, clinical decision-making, and legal documentation.
It is important to note that while SR and artificial intelligence (AI) have reduced the prominence of the transcription industry, the medical transcription services market is still a billion-dollar industry. Vantage Market Research estimated that the global medical transcription market, which was valued at USD 1.50 billion in 2021, is projected to reach a value of USD 5.11 billion by 2028 at a CAGR of 17.1% during the forecast period 2022-2028. The report attributes the growth of the market to factors such as the increasing demand for EHRs, the rise in healthcare spending, and the need for accurate and timely documentation.
A Health Informatics Journal article points out that there is a general perception among clinicians that MTs ‘just type’ what doctors dictate and that SRT can produce a verbatim transcript of this dictation. However, the authors note that this perspective that verbatim transcription will result in an accurate medical record ignores the wide range of skills and knowledge MTs apply to the work of producing medical records.
Here are some ways in which medical transcriptionists add value to the creation of medical records:
- Accurate documentation: MTs listen carefully to the audio recordings of healthcare providers’ dictations and convert them into written medical reports, ensuring accurate and complete documentation of patient encounters. They can ensure error-free documentation of patient history, physical examination findings, diagnoses, treatment plans, and other relevant information. Accurate documentation preserves the integrity of the medical record, facilitates communication among healthcare providers, and supports patient care.
Far from being a mechanical process of typing the words the physician has dictated, medical transcription requires specific skills, a strong memory, and attention to detail. The Association for Healthcare Documentation Integrity (AHDI) opposes the mandate for MTs to perform verbatim medical transcription, arguing that this requirement neglects the valuable role that MTs are trained and prepared to play in risk management.
Trained and experienced MTs:
- Have extensive knowledge of medical terminology, anatomy, physiology, procedures, diagnosis, and treatment
- Have good comprehension of spoken language, healthcare documentation processes, and relevant technologies
- Ensure that the grammatical structure of the transcribed content is correct and use appropriate synonyms when needed
- Deduce the meaning of unclear or conflicting dictated patient demographic information
- Apply their medical knowledge to ensure that the textual report accurately describes what the physician conveyed verbally
They can also verify the spelling of medical terms, detect critical medical errors made by dictating physicians, interpret voice inflections for punctuation, filter out background noise and distractions in the voice file, and cross-check specific elements in the dictation against the larger context of the record. The authors of the study in Health Informatics Journal found that even as MTs follow the work rules, they use their understanding of the report and their knowledge of medical terms and procedures to place punctuation ‘correctly’ – so that the doctor’s meaning is preserved.
- Compliance with medical standards: Professional MTs strictly adhere to established medical standards, guidelines, and templates when transcribing medical reports. They will follow industry best practices to ensure consistent medical record documentation that is compliant with regulatory requirements. Compliance with medical standards helps ensures that the information is readily accessible and understandable by physicians and other healthcare professionals.
- Proofreading and editing: After they convert physician dictation into medical reports, medical transcription service providers carefully review and edit the transcribed reports for grammar, punctuation, and other errors to ensure error-free medical records. They also verify the accuracy and consistency of medical terminology, drug names, and other technical jargon. By helping to reduce errors and inaccuracies in the medical record, MTs improve the overall quality and reliability of the documentation.
- Time-saving for healthcare providers: Partnering with a medical transcription service organization saves valuable time for healthcare providers, allowing them to focus on patient care rather than spending time on documentation. MTs can quickly and accurately convert physician dictation into written reports and make the information available for future reference, enabling healthcare providers to communicate their findings and treatment plans efficiently.
- Interdisciplinary collaboration and communication: By transcribing and disseminating medical reports, MTs facilitate communication and coordination among health care providers involved in primary care, nursing care, and specialty care, therapists and administrative staff. When relevant information is accurately documented and shared in the medical record, it promotes interdisciplinary collaboration and continuity of care.
- Medical record integrity and confidentiality: HIPAA compliant medical transcription companies have strict protocols in place to ensure that patient information is protected and kept confidential at all times. This includes using secure systems for transcription, and maintaining strict data privacy practices. By ensuring patient confidentiality and data security, MTs contribute to the integrity and trustworthiness of medical records.
Physicians use front-end SRT to complete EHR data entry, but find this a challenge due to lack of training in EHR use, the time-consuming nature of data entry, difficulty in finding relevant information, increased administrative burden, and concerns regarding patient-physician interaction. Moreover, speech recognition technology also comes with several constraints when used for medical documentation. These include challenges in accurately recognizing intricate medical terminology, the possibility of errors arising from diverse accents and speech patterns, and the need for extensive training to enhance precision. In addition, background noise and disruptions during dictation can further impact the quality of the transcribed text.
Outsourced medical transcription services significantly ease these concerns. With their editing and proofreading skills, MTs check SRT-generated EHR records for accuracy.
To conclude, the role of the medical transcriptionist is vital in upholding the reliability and integrity of medical records, a key aspect in delivering high-quality patient care.