From emergency rooms to specialty departments, hospitals rely heavily on accurate clinical records to ensure patient safety and streamline workflows. At such critical times, having access to accurate medical records is essential to quicken the process of treatment. Medical transcription for hospitals ensures error-free records of patient history, medications, allergies, past lab reports, and more, all of which help physicians make the right treatment decisions for patients. During such complex situation like the, it is important for hospitals to partner with an experienced medical transcription service provider to manage their medical documentation tasks efficiently.
Optimize EHR with Medical Transcription
For the treatment of cancer, the American Medical Association and other standards-developing organizations like the World Health Organization (WHO) and the American Joint Committee have emphasized the advantages of maintaining relevant medical documentation standards with regard to units of measure, pharmaceutical regimens, cancer protocols, laboratory studies, genetics, disease classifications, and the use of abbreviations and medical slang.
According to Laura Bryan, Chair of the Book of Style for Medical Transcription’s 4th Edition Working Group and the Association for Healthcare Documentation Integrity, there is a lack of awareness about the existence of standards of medical documentation. Using the standards of style for EHR templates like the drop-down text and data dictionaries minimizes the need for data correction or normalization. This improves results from Natural Language Processing and emerging technologies like AI. It allows primary users to be more consistent, prevents ambiguity in the communication of technical and laboratory information, and promotes clinical documentation improvement and patient safety.
Amazon’s Medical Transcription Service
In December 2019, Amazon introduced Transcribe Medical, a service to support hospital transcription services and good clinical documentation. Cerner Corp., which partnered with Amazon for cloud collaboration, stated that a few customers had already signed on. Cerner uses Transcribe Medical to develop a digital voice scribe that “listens” in the background during a patient’s visit and transcribes physician-patient conversations into text. The goal was to create a tool that can transcribe documents into EHR automatically while ensuring medical report accuracy.
Several healthcare technology vendors are also working on virtual assistance to help doctors with EHR documentation. Amazon’s service is designed to transcribe spoken medical dictation for primary care into text, including protected health information (PHI) covered by HIPAA. However, while these tools support using transcription to streamline hospital documentation workflow, they have some limitations.
AI Transcription: The Need for Human Oversight
AI-powered tools such as speech recognition engines and digital scribes have revolutionized how medical notes are created. They reduce manual effort and expedite EHR data entry. These innovations are particularly helpful during patient surges, such as those experienced during the COVID-19 pandemic.
However, while AI can recognize spoken words, it often struggles with context, accents, medical abbreviations, and multiple speakers. This can lead to misinterpretation and documentation errors, a serious concern in healthcare. That’s why improving compliance with accurate medical transcription still demands human oversight.
Medical transcriptionists ensure that the final documentation is precise, formatted according to regulatory guidelines, and contextually correct. They review AI-generated notes, clarify ambiguous terms, and make sure all critical patient data is captured clearly. The collaboration between AI and transcription professionals offers the best of both worlds, speed and accuracy.
Providing quality patient care and ensuring proper documentation is critical during the COVID-19 pandemic and beyond. Medical records must be easy to understand and contain all necessary information to provide efficient care. However, as they focus on patient care, updating medical records can be a tedious and time-consuming task for physicians and other healthcare professionals.
It is the responsibility of hospital administrators and clinicians to maintain a well-structured medical record that clearly shows the patient’s assessment and treatment, both for effective care and reimbursement. Leveraging EHR-integrated medical transcription services is a practical option to achieve these goals. Choosing a HIPAA-compliant medical transcription service ensures that patient data is handled securely, maintaining confidentiality and meeting regulatory standards
