With the introduction of electronic health records (EHR), many believed that medical transcription will be wiped out from the healthcare field. But medical transcription still continues to exist and grow as many segments of the medical community are likely to continue using the dictation – transcription model. Physicians who have to communicate with an agency or professionals outside of their healthcare setting/practice may require medical transcription service. The conventional transcription model continues to be useful for providers called to provide a second opinion, and those who are performing examinations for workers’ compensation and disability claims, and insurance companies.
When EHR systems were implemented, EHR vendors projected traditional transcription as an outdated and costly method of transcription. They tried to convince physicians to use the new innovative system to generate error-free medical records. But now, with electronic medical record systems, the physicians have to spend more hours on their computers to document patient records themselves, and spend less time with their patients. Most doctors are frustrated with spending their valuable time entering data into the computer.
- The physician has to enter all the key strokes
- Switch between many screens to enter the patient data
- View multiple tabs within the screens
- If using a speech recognition system, they have to spend considerable time learning how to dictate correctly, do the dictation, and ensure that the dictation is clearly recognized by the system
- Handle excessive alert fatigue from the electronic medical record
- Focus on sections/subsections within each screen to make sure that all data has been captured correctly. This is important from the point of view of ensuring revenue integrity and accuracy in coding.
- Ensure that all QA criteria are addressed efficiently
The excess administrative burden imposed on doctors has also affected the quality of patient care, reducing the time for face-to-face consultation and leading to poor performance of the physicians. Some doctors have even employed new assistants called medical scribes to help them with EHR documentation. Other doctors have reverted to the old transcription method and have a medical transcriptionist either transcribe their dictated notes to be attached to the patient’s EHR, or enter the data directly into the EHR.
Voice recognition technology yet has shortcomings. It is an expensive setup and is prone to make errors when used in noisy places. It cannot recognize more than one voice and cannot determine disorganized dictation, poor grammar, or missing/over used punctuation. It requires human intervention to ensure accuracy of the medical records and therefore medical transcription continues to grow.
Consider the highly significant role played by clinical documentation in any patient’s care. In the present healthcare scenario, providing high quality care to a patient is often complex and may involve multiple providers across multiple care settings. Since this type of physician involvement is becoming increasingly important with the introduction of value-based payments and bundled payments, high quality clinical documentation is also imperative and should accurately capture all patient details. Surely, point and click data capture cannot ensure this because the narrative should include the physician’s critical judgment and insights. Other disadvantages of EHRs include:
- EHR-based clinical documentation mainly serves the purpose of capturing the necessary clinical terms needed to perform accurate coding and billing. It provides more or less incomplete patient details. This will lead to diminished quality of care.
- Studies show that EMRs persuade physicians to make defensive documentation or superfluous documentation. There is an excessive use of the copy and paste function that is risky, and also does not add any significant value to the medical document.
In order to attain error-free medical records and efficient medical documentation, a blended approach combining medical transcription and EHR system would be the ideal option. Physicians can continue to dictate their notes, and transcriptionists in the partnering medical transcription service company can access the physician/hospital EHR system, transcribe the notes and enter the details in the electronic health record. Reliable medical transcription outsourcing companies use HL-7 interface to provide EHR-integrated medical transcription to healthcare providers.