One of the most important barriers to the implementation of Electronic Health Records (EHR) systems is related to difficulties that physicians face in capturing the patient narrative (especially because of the structured templates of EHRs). In addition to the difficulty of entering information, physicians consider the checkbox or template methods inadequate and inefficient to capture the patient narrative.
From a practical point of view, medical transcription remains a vital component of clinical documentation workflow. The solution to ensuring efficient clinical documentation and improved patient care, say experts, is a blended approach which combines transcription with EHR.
EHR without Medical Transcription Services
Typically, in a situation using EHR without outsourced transcription, workflow will begin with the providers utilizing the structured documentation capabilities of EHR or dictating through a top quality microphone system at a designated computer. The providers will dictate into EHR by utilizing a front-end speech platform and edit the document as they dictate. This procedure would seem to eliminate the need for transcription.
However, this procedure poses some limitations to the efficient use EHR technology
- Limitations of templates and checkboxes – The checkboxes or templates in the software are such that they cannot capture patient information in a comprehensive manner.
- No quality checks – Since the patient health record is a valid legal document, validation of the content is essential.
- Low physician productivity – Self-editing dictation and filling out templates would lower physician productivity and reduce the total number of patients seen in a day.
Outsourced Transcription and the EHR – A Combined Approach
The medical transcription workflow that blends an outsourced solution with the EHR system would involve the following steps
- Physician dictates via phone or other handheld device.
- The digital voice files are clearly captured, encrypted and delivered to servers.
- Trained medical transcriptions who are experts in clinical documentation listen to the dictation and create the files.
- The transcribed files are integrated into the EHR utilizing the latest technology.
- Integrated patient records are made available to the healthcare provider.
Benefits of the Combined Approach
One of the most compelling benefits of the combined approach is that the physicians will be able to capture comprehensive patient details such as previous medical history, current medications, allergies, present medical status, assessment and plan and family history. Also, this method provides physicians with a report of their health records which helps them to interact better with their patients. This also helps them to make correct diagnoses and suggest the best treatment options based on specific patient needs. In short, capturing patient details in its entirety is the key to delivering quality care, and ensuring proper documentation and regulatory compliance.
Some of the other important benefits of this combined approach are
- Minimal change to clinician work flow – With the combined approach, the physicians can maintain their present workflow with minimum change. Physicians can continue to dictate into the automated system, which directly captures the voice and the medical transcription company can do the rest of the job.
- Clinician satisfaction and time efficiency – Choosing the services of experienced and qualified transcriptionists for medical record processing relieves the physician of the documentation burden. They can spend more time with their patients.
- Cost savings – Reliable transcription companies offer documentation solutions at affordable rates.
There is no doubt that blending the powerful capabilities of EHR with top quality medical transcription services can ensure the most efficient workflow in the current scenario.