There is no doubt that digitization of clinical documentation has greatly improved the efficiency of the healthcare system. It has minimized the risks posed by lost, illegible and inaccessible paper records. However, the next stage, namely EMR adoption has not gone down too well with health care providers. According to HIMSS EMR Adoption Model, only 7.3% of them have reached Stage 6 which includes physician documentation and structured templates. With all the issues related to using structured templates, it is obvious that professional medical transcription services are the better option when it comes to improving clinical documentation workflow.
What is the role of the medical transcriptionist in this fast-changing clinical scenario? The key lies in using the transcriptionist’s knowledge and skill to enhance the documentation process. Medical transcription outsourcing frees up physicians for their core tasks, improves physician-patient interaction, and captures information more comprehensively than structured templates.
In the present day scenario, the medical transcriptionist is helping the physician to get maximum return on investment in the latest technological innovations such as EHR and dictation software. Natural language processing (NLP) powered web-based platforms and technologies convert unstructured text into clinical documents, but a validation process is crucial to ensure accuracy. The role of the transcriptionist can be crucial here with services such as
- Checking that data capture by the NLP is accurate before it is uploaded to the EHR
- Checking and correctly tagging concepts such as allergies and medications
- Pre-coding validation of clinical concepts
All these validation measures help ensure accuracy in electronic clinical documentation systems.
Narrative documentation, as created by dictation and medical transcription, will continue to be relevant especially in the context of the creation of standards for the exchange and use of health information. In fact, all this tells us that the role of the medical transcriptionist is evolving and not being phased out. Medical transcription services can add value to the clinical documentation workflow.