Points To Improve The Quality Of Open Notes And The Role Of Medical Transcription Services In It

02-December-2021 Rajeev Rajagopal Medical Transcription

Medical Transcription

Open notes enable patients to view their clinicians’ notes on patient portals. Sharing notes benefits both patients and clinicians. These shared visit notes were created almost a decade ago by OpenNotes with the aim to improve the patient experience by empowering patients and families, better informing patient caregivers, and improving the quality and safety of patient care. The movement expanded, allowing millions of patients across the country to view their clinical notes. The 21st Century Cures Act mandate that became effective April 5, 2021, requires open patient access to clinical notes as part of its information blocking prohibition. The mandate covers eight types of clinical notes that medical transcription companies help healthcare providers create:

1. Consultation
2. Discharge summary
3. Procedure notes
4. Progress notes
5. History and Physical
6. Imaging narratives
7. Laboratory report narratives
8. Pathology report narratives

According to the OpenNotes organization, more than 50 million patients could access their clinical notes by the end of 2020. Studies of open notes have found that the strategy is indeed beneficial for patient. A May 2021 Journal of General Internal Medicine study reported that 50 percent of clinicians who started offering open clinical notes found that their patients took better care of themselves when given access. About 75% of providers noted better patient empowerment.

In a March 2020 public statement announcing the final information blocking rule, then-HHS Secretary Alex M. Azar said, “These rules are the start of a new chapter in how patients experience American healthcare, opening up countless new opportunities for them to improve their own health, find the providers that meet their needs, and drive quality through greater coordination.”

However, with the Cures Act mandate, clinicians will need to balance clinical documentation with a good patient experience. This means they will need to make patient notes more “patient-friendly, more understandable and more appropriately or compassionately worded”, says Steven Lane, MD, MPH, FAAFP, FAMIA, a primary care physician and Sutter Health’s clinical informatics director for privacy, information security, and interoperability (www.fortherecordmag.com).

Writing Good Patient Notes – Key Considerations

Focusing on the following aspects is critical to write good patient notes:

Accuracy: Accuracy is vital. The physician should ensure documentation that is consistent, concise, and complete and captures the patient’s story correctly, so that both the patient and other healthcare providers can read and understand it. Patient care and safety would be compromised if treatment is based on inaccurate information in the chart. According to OpenNotes, when patients review their notes, accuracy improves as they become an extra set of eyes on the information and sometimes find issues that require correcting.

Patient-friendly: Physicians will have to work on making notes understandable for the patient. Also, as patients will be reading their clinical notes, providers should take care to avoid any verbiage or phrases that can seem offensive or judgemental to patients. According to a recent study on clinical notes published in the Journal of General Internal Medicine, words like “incorrect,” “obese,” “wrong,” “anxious,” “depressed,” “inaccurate,” or “elderly” came up quite often as unfavorable to patients (PatientEngagementHIT).

In its Steps Forward Module, the American Medical Association (AMA) notes that while providers don’t need to make any ‘dramatic changes’ in their style of writing notes, a recent OpenNotes follow-up survey reported that some said that they adjusted documentation to:
- Avoid language that might be perceived as critical of the patient.
- Remove terms such as “non-compliant,” “patient denies,” and “patient refuses.”
- Change how they document sensitive clinical, mental health, or social information.
When writing open notes, clinicians should focus on:
Being positive and supportive.

Including only things discussed with the patient during that visit.

Not including wording that could be interpreted by the patient as labeling or judgmental. For e.g., instead of “patient is obese,” say “Patient has BMI >30.” Don’t write “Patient refuses to take his medications,” instead note that the “Patient has been non-adherent to medications due to [provide a reason].”

Minimizing the use of medical jargon, acronyms, and abbreviations to avoid anything that may be perceived as offensive.

Capture pertinent information for coding and clinical documentation improvement (CDI): The medical record is the source document for coding and reporting diagnoses and procedures. The goal of CDI is to improve the clinical note, which contains information captured during the visit such as present illness, data measured and recorded, examination observations, an assessment, a definitive diagnosis, and a care management plan. Documented clinical notes should capture all the information required for coding and billing. Clinical documentation impacts the entire revenue cycle. Improper documentation of medical notes will lead to inaccurate coding, affecting billing and financial management, and care quality. While providing open notes that are useful to the patient, clinicians must ensure precise documentation that supports the service/supply billed. This will promote accurate coding and billing, which can lead to correct and timely reimbursements for the healthcare provider.

Consider practice-specific needs/concerns: The AMA says that when sharing patient notes, practices need to be ready to handle specific concerns such as:
- whether notes created prior to open notes implementation will be shared
- educating patients on registering in the patient portal and where to find their notes
- how to answer patients’ questions on notes and correct any errors they find
- how to handle sensitive topics like adolescent health, mental health, etc,
To successfully implement open notes, physicians should discuss the importance of transparency with their team and educate them on the benefits of open notes while addressing legal requirements. They should also prepare patients and their care partners using strategies like sending emails introducing the initiative, posting explanatory documents on their website, and promoting the adoption of open notes via social media channels.

Role of Medical Transcription Services

With the call for increased transparency in healthcare, open notes are here to stay. On its website, the Agency for Healthcare Research and Quality (AHRQ) notes that enabling patients to read and amend their chart enhanced opportunities to:

Identify serious inaccuracies and avoid medical errors

Share notes with other clinicians

Reinforce the clinician’s findings and recommendations discussed at a visit

Clarify something the clinician said or did at the visit

Improve patients’ insights into clinicians’ decision-making

Help patients gradually accept and adjust to some diagnoses

Motivate patients to comply with prescribed behavioral modifications

Help patients prepare for office visits

Dismiss unconfirmed worries about clinician findings or thoughts

Involve family and other caregivers in the patient’s care

Open notes would be able to successfully meet these objectives only if they are error-free.

Accuracy is paramount, says Association for Healthcare Documentation Integrity President-Elect Stacy Lehto, CHDS, AHDI-F (For the Record Magazine). Focusing on patient friendliness at the expense of accuracy and completeness could lead even the best provider or facility to lose all credibility, says Lehto.

Studies report that as much as 10% of patients find errors in their records, and they consider 25% of these mistakes as serious. Importantly, 25% of physicians who have been offering open notes for more than a year say that patients have found errors that the physicians themselves felt were serious.

A JAMA study published in 2020 that looked into the frequency and types of errors identified by patients who read open ambulatory visit notes found that a specific error in current or past diagnoses was most common (27.5%), followed by incorrect medical history (23.9%), medications or allergies (14.0%), and tests, procedures, or results (8.4%). Up to 6.5% notes were found to be written on the wrong patient.

Many errors occur when physicians are overburdened with documentation. According to the researchers, overburdened practitioners may import inaccurate medication lists, and transmit other flawed information electronically by copying and pasting older parts of the record, or enter incorrect examination findings. Among primary care physicians sharing notes with patients, 26% expected that patients would find nontrivial errors. As practitioners use EHR data for decision-making, such errors could lead to medication errors, wasteful duplication, redundant or incorrect treatment, and delayed diagnoses.

As clinicians focus on best practices for sharing clinical notes with patients, medical transcription outsourcing can play an important role making it work by ensuring accurate documentation. Family practice medical transcription service providers can ensure accurate documentation of consultation, procedure and progress notes, discharge summary, history and physical, and imaging report, laboratory report and pathology report narratives. They have experienced medical transcriptionists and quality assurance professionals on board who can ensure error-free documentation in the electronic health records (EHR), thereby reducing the likelihood of errors in open notes.

View our infographic on Key Tips To Write Open Clinical Notes [INFOGRAPHIC]

Global Electronic Medical Records Market To Witness Significant Growth Through 2021 – 2026

29-November-2021 MTS TEAM EHR Transcription

Electronic Medical Records

EMR or electronic medical record is the digitized version of paper records that stores all data related to a patient’s care under a particular doctor, such as demographics, progress notes, problems, medications and vital signs, past medical history, immunizations, laboratory data, and radiology reports. EHR-integrated medical transcription services can help physicians complete their day-to-day documentation tasks easily and thus improve overall clinical productivity. According to a report from Mordor Intelligence, the electronic medical records market is expected to register a CAGR of 7.5 % during the forecast period (2021-2026).The COVID pandemic is putting healthcare systems under strain worldwide and forcing hospitals and other medical facilities to scramble to make sure that data can be shared effectively.

Some of the key factors driving the market growth include

initiatives by the governments
technological advancements
low maintenance and wider accessibility
rising need for an integrated healthcare system
big data trends in the healthcare industry
technological advancements in the field of data storage

EMR systems are becoming increasingly popular, as the healthcare industry is moving toward digitization. A lot of government initiatives, such as encouraging physicians to adopt electronic health records, investing in training healthcare information technology workers, and establishing regional extension centers to provide technical and other advice, are triggering the market’s growth. The increasing volume of data and growing demand for cloud storage due to COVID-19 are also expected to augment the demand globally.

However, factors like data privacy concerns, high initial investment, shortage of properly trained staff and inter-operability issues are the primary restraints in the growth of the electronic medical records market.

Why Integrate Transcription into Your EMR System

What Are the Different Types of Electronic Healthcare Record Software?

Best Practices for Amending Electronic Health Record Documentation

The market is segmented on the basis of Component, End User, Application, Type, Mode of Delivery, and Geography.

By component, the market is divided into Hardware, Software, and Services. End users of this market are Hospital-based EMR and Physician-based EMR. On the basis of application, the market is segmented into Cardiology, Neurology, Radiology, Oncology, and Other Applications. Types of EMRs are – Traditional EMRs, Speech enabled EMRs, Interoperable EMRs, and Others.

Geographically, the market is divided into North America (United States, Canada, Mexico), Europe (Germany, United Kingdom, France, Italy, Spain, Rest of Europe), Asia-Pacific (China, Japan, India, Australia, South Korea, Rest of Asia-Pacific), Middle East and Africa (GCC, South Africa, Rest of Middle East and Africa), and South America (Brazil, Argentina, Rest of South America).

North America dominates the market and is expected to do the same in the forecast period. In the North America region, governments have advised hospitals and clinics to change conventional medical records into electronic format for better storage of patient data. Some of the factors driving market growth in the North America region during the forecast period are technological advancements, high investments in healthcare by the government and private sector, and the presence of key market players. Most hospitals and clinics in the U.S. region have widely implemented EHR solutions, due to stringent regulatory norms. Canada and the United States are the leading countries in this region that have implemented EHR systems. Asia Pacific is growing at the highest CAGR over 2021- 2026.

EMR delivery modes include Cloud Based and On-premise Model. Here, the cloud-based segment is expected to hold a major market share in the market. Unlike the client server-based systems, installation cost is lower for cloud-based systems. Key factors that are driving the cloud segment growth include rise in number of benefits, such as low licensing and start-up cost, low cost of maintenance and infrastructure requirements, and wider accessibility. This system also provides enhanced productivity and faster and smoother implementation. Cloud-based model makes the software extremely flexible, regarding scalability. It also simplifies and consolidates storage resources to reduce costs and enhance workflow. Cloud infrastructure also guarantees true disaster-recovery and business continuity solutions, to enhance the quality of patient care.

Major market players in the global electronic health records market are actively participating in the development of new platforms for patient records. Some of the market players are McKesson Corporation, Allscripts Healthcare Solutions, Inc., Cerner Corporation, NextGen Healthcare, Inc., Greenway Health, LLC and others.

With the increasing adoption of digitized patient records, accurate transcripts of physicians’ dictation are also important. Practices can take support from experienced medical transcription companies to get EHR-integrated and HIPAA adherent services.

Related Blogs:

How To Evaluate Medical Transcription Productivity

25-November-2021 Julie Clements Medical Transcription

Medical Transcription

Tracking time and productivity is important for any business. It helps managers gain insight on how everyone can improve their productivity levels, which in turn, will contribute to improved workflow throughout the organization. Productivity measurement is very important when it comes to evaluating medical transcription outsourcing services and in-house transcription.

Focus on quality: With the continued evolution of clinical documentation, technologies, and reasonable expectations of customers and service providers, measuring staff productivity and overall performance has become very important for medical transcription service providers. Various aspects such as quality assurance, timeliness of the information, and volume of the information need to be quantified and measured. Of these, measuring the text content of a transcribed document is the most widely discussed topic.

Previously, the standard unit of measure for medical record transcription was the 65-character AAMT line. The 65-character line described the text content of the medical report and was inclusive of letters, numbers, and symbols and other elements. However, there were many concerns about the use of the AAMT line. After evaluating the existing measurement standards — the ASCII line, the 65-character line, gross line, gross page, per minute pricing, and visible black character (VBC) measurement standards, the American Health Information Management Association (AHIMA) Joint Task Force on Standards Development identified VBC as the only counting method that could be “easily understood, verified, and replicated” by the vendor or the medical transcription company and the healthcare entity. The task force recommended that this all organizations producing medical transcription, including those using in-house staff to transcribe dictation should adopt this definition (perspectives.ahima.org).

According to an article in Radiology Today, measuring medical transcription productivity should be more than just about tracking numbers – it should be about quality. A reliable medical transcription service company would focus on improving document quality, decreasing turnaround time, and boosting physician satisfaction.

Measure transcriptionist productivity: Whether in-house or outsourced, monitoring transcriptionists’ performance is essential to meet productivity goals. This should include monitoring inactive time when transcriptionists are not actively working on a clinical document. According to the www.radiologytoday.net article, tracking excessive inactive time can help a manager understand the difference as to what the medical transcription is producing compared to what they could be deliver if they were fully productive. In specialty services like radiology transcription where editors are common, measuring proficiency can provide actionable information for training and mentoring to improve productivity and efficiency.

Evaluate accuracy and timeliness: Leading medical transcription companies strive to provide a 99% accuracy rate. Producing a clean, accurate transcript from the source document /dictation should be the top priority. In fact, transcript accuracy can make a major difference when it comes to delivering quality patient care. When it comes to clinical documentation, even simple typos can be catastrophic. Experienced transcriptionists are well versed in medical terminology and can also ensure proper grammar, punctuation, and spelling, which can be important in conveying the original message correctly.

Speed or turnaround time (TAT) is another factor to consider when measuring transcription productivity. Expert transcriptionists can type a minimum of 65 words per minute and complete reports within the specified deadline. But while speed is important, accuracy should be the top priority.

Assess workflow: Workflow plays an important role in overall productivity in both hospitals and medical transcription service organizations. Proper workflow is essential to improve customer satisfaction as well as productivity. For example, if a transcriptionist is learning a new skills like editing, it can reduce productivity. Time taken to complete a document can be greater when the transcripts have to go through several levels of quality assurance (QA), such as in medical transcription outsourcing companies. Productivity expectations are higher in this case. Likewise, in domestic workflows, managers need to count the time spent on QA per transcriptionist when measuring overall productivity.

Consider other factors: Many variables can impact a medical transcriptionist’s work and should be factoring in when measuring their productivity. These include:
- Whether transcription is done manually or automated (speech recognition technology)
- If the transcriptionist is dealing with difficult audio or handling the accounts of several physicians
- Whether the individual is handling both transcription and editing
- Experience and skill

In an established medical transcription service company, managers will clearly define and communicate productivity expectations and goals to the team. This is important to set realistic, reasonable tasks and deadlines to meet client goals.

View our infographic on Reliable Ways To Evaluate Medical Transcription Productivity [INFOGRAPHIC]

How To Use Telehealth To Improve Health Outcomes And Safety

22-November-2021 Rajeev Rajagopal Medical Transcription

Telehealth

The rapid expansion of telehealth during the pandemic allowed many patients to access healthcare safely, regardless of time or distance. In April 2020, use of telehealth for office visits and outpatient care was 78 times higher than in February 2020, according to McKinsey. Outsourcing medical transcription allows clinicians access to current, accurate information about telehealth encounters. Now that lockdowns have been lifted, patients are returning to in-office visits, but reports indicate that people will continue to use telehealth going forward. As virtual visits are here to stay, healthcare organizations need to consider how they can use telehealth to improve health outcomes and safety. Here are – effective ways to optimize telehealth:

Integrate EHR with telehealth platform: Patient information needs to pass easily from the telehealth platform to the EHR. This is important to avoid duplicate data entries and improve clinical workflows and care delivery. Notes taken during the telehealth visit should go into the patient’s health record. In addition to easing flow of information, integrating the EHR system with the telehealth platform reduces risks of error when updating a patient’s records, improves patient outcomes, and simplifies the billing process.

Optimize telehealth use: Telehealth has specific uses and benefits certain patient populations. According to a commentary on an AHRQ Evidence Report, experts support the use of telehealth for:
- Remote, home monitoring for patients with chronic conditions, such as chronic obstructive pulmonary disease and congestive heart failure
- Communicating with and counseling patients with chronic conditions
- Providing psychotherapy as part of behavioral health
Even before the COVID-19, telehealth was found to benefit specific patients, and can improve critical care, speed emergency care decisions, and replace many face-to-face care interactions. During the pandemic, this offered added benefits of reducing exposure to infection.
Address challenges associated with access to care: A Medusind survey found that the biggest challenge for physicians was getting patients to use telemedicine, resulting in a barrier to access to care (www.mhalthintelligence.com). The main problems were identified as getting older patients to use telehealth technology, patients’ challenges with technology, and patients’ technology issues. To address these problems, practices can assess which populations would benefit the most from virtual visits and are at ease when using the technology. To see more patients in a day, they can consider strategies such as:
- Providing a virtual follow-up to appointments for pre-qualified patients
- Providing an in-person follow-up for other patients
- Scheduling more virtual visits to make more time for in-patient visits
Using telehealth for post-op appointments allows patients to recover at home more comfortably.
Leverage team-based care: Today, medicine uses a physician-led team-based care approach. The American Medical Association (AMA) points out that the same team-based approach needs to be applied to telemedicine. The AMA’s toolkit lists 5 steps to optimize team-based care in telehealth:
- Identify and include the right people in the team: physicians, nurse practitioners, information technology (IT) partners, medical assistants and others.
- Choose a suitable approach – ‘synchronous’ or ‘asynchronous’. With synchronous support, clinical team member is present with the physician and patient during the entire visit (physically or virtually). In asynchronous support, the clinical team member helps with pre-visit planning and virtual rooming, but is not present during the visit. The AMA recommends allowing the patient to choose the visit type.
- Create detailed team-based care workflows adapted to telemedicine.
- Set a realistic timeline and have pilot teams implement workflows.
- Have regular team meetings to review work and make improvements.

One of the most important things when it comes to getting the most out of telehealth is to help patients gain familiarity with the technology and establish expectations. Technical support should be available real-time and there should be a ready backup plan to reach the patient in the event of technology failures. Practices implementing telehealth should also have measures in place to safeguard their patients and practice from liability and privacy concerns.

Integrating telehealth platforms with their existing systems like EHRs eases the clinician experience. Physicians, nurses and other healthcare providers should maintain proper documentation in their systems. Partnering with a US based medical transcription company can ensure comprehensive documentation that includes all information pertinent to the in-person consultation, such as initial and present complaints, review of systems, past history, relevant family and social history, allergies, medications, physical examination and test results, and assessment and plan.

What Are The Requirements For Storing Physical HIPAA Documents?

18-November-2021 MTS TEAM HIPAA Compliance

HIPAA Documents

While the healthcare industry has increasingly transitioned to electronic health records (EHRs) and digital systems, many healthcare organizations still maintain a combination of paper and electronic records. Most healthcare providers partner with a medical transcription company to ensure that dictated physician reports are converted into accurate text documents needed for patients’ medical charts, billing, insurance claims, and decision making. Regardless of format, medical records must be stored securely in compliance with the applicable law and the standards prescribed by HIPAA and the Joint Commission. While HIPAA compliance is often associated with electronic health records and digital data security, it is equally applicable to paper records containing PHI.

Elevate your medical transcription process with the assurance of HIPAA compliance.

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What is Protected Health Information under HIPAA?

HIPAA’s Privacy Rule and Security Rule are the primary regulations that address the protection of patient information. The Privacy Rule establishes standards for the use and disclosure of protected health information (PHI), while the Security Rule outlines requirements for safeguarding electronic PHI (ePHI).

Under HIPAA, protected health information (PHI) is defined as individually identifiable information relating to the past, present, or future health status of an individual that is created, collected, or transmitted, or maintained by a HIPAA-covered entity in relation to the provision of healthcare, payment for healthcare services, or use in healthcare operations
(PHI healthcare business uses). Information that is considered PHI includes, but is not limited to:

National identification numbers and demographic information such as name, birth dates, gender, ethnicity, and contact and emergency contact information
Health information such as diagnoses, treatment information, medical test results, and prescription information
Details about the type of care the patient received or how they paid for it

PHI is only considered PHI only when an individual can be identified from the information.

Paper Records and HIPAA Compliance

The medical record is confidential and should be protected from unauthorized disclosure by law. HIPAA was introduced before the widespread use of electronic health records (EHRs), and also applies to paper records containing protected health information (PHI). The Privacy Rule requires covered entities (such as healthcare providers, health plans, and healthcare clearinghouses) to implement reasonable safeguards to protect PHI, including information stored in paper form. Here are some key considerations for maintaining HIPAA compliance with paper records

Medical records and PHI must be stored and used so as to minimize incidental disclosure of PHI.HIPAA mandates that medical records must be appropriately secured against theft, fire and water damage, and erroneous destruction. Hard copy medical documents have similar standards for management as electronic records.

Here are 7 key considerations for maintaining HIPAA compliance with paper records:

Physical security: HIPAA mandates physical safeguards to secure PHI stored in paper records. Healthcare providers, covered entities, and business associates must implement measures to prevent unauthorized access, theft, loss, or damage of paper records containing PHI. This may involve locked file cabinets, surveillance systems, restricted access to storage areas, and controlled entry to facilities housing these records.
Administrative policies: Providers should develop and enforce policies and procedures related to the handling, storage, and disposal of paper records. This includes training staff on proper handling practices, establishing record retention periods, and implementing protocols for record destruction.
Access controls: Only authorized personnel with a need to know should have access to paper records containing PHI. Controls such as unique user identification, role-based access, and monitoring mechanisms to track access to PHI should be implemented. Staff members should be trained on the importance of maintaining the confidentiality of patient information and the procedures for accessing and handling paper records securely.
Data breach response: If there is a breach or unauthorized disclosure of PHI in paper records, HIPAA mandates that affected individuals, the U.S. Department of Health and Human Services (HHS), and, in some cases, the media, be notified. Healthcare entities should establish protocols for responding to and reporting data breaches involving paper records. Incident response plans are also required to address breaches promptly, mitigate harm, and comply with HIPAA’s breach notification requirements.
Business Associate Agreements: If a healthcare provider works with third-party vendors or business associates such as medical transcription outsourcing companies that handle paper records, they should have HIPAA-compliant contracts (business associate agreements) in place to ensure that the business associates also maintain the security and privacy of PHI.
Secure disposal of records: When paper records are no longer needed, they must be disposed of in a way that prevents unauthorized access. After they have been reviewed for a certain period of time, typically 30 to 60 days, and all the material has been properly scanned to obtain quality copies, those records can be destroyed, clarifies Raymond Rangel of Data Storage Centers (www.medicaleconomics.com). HIPAA regulations require proper disposal methods, such as shredding, to ensure that PHI remains confidential even after the records are no longer in use.
HIPAA requires avoiding incidental disclosure of PHI during disposal. Experts recommend professional shredding services, as this would ensure issue of a certificate of destruction.
Retention policies: Covered entities should have policies outlining how long paper records containing PHI should be retained and when they can be securely destroyed. These policies help prevent the unnecessary storage of records that are no longer needed. Each state has different requirements. Retention schedules also differ based on type of medical service or patient. For e.g., pediatric records have to be retained for a much longer period than typical adult healthcare records. For instance, though the period for which paper records have to be retained in Arizona is six years, pediatric records are required to be stored for a minimum of 10 years, and often, until the patient turns 18. Retention policies should be applied consistently so that records are not destroyed prematurely.

Additional safeguards for physical HIPAA documents:

Medical files, folders or records should be secured at all times. When moving or handling medical records and PHI in volume, medical records and PHI should be covered in a way that no personal identifiers are visible.
As it is privileged information, care must be taken not to discuss the medical record in an open setting.
Individual documents should not be separated from the medical record and PHI. If pages are removed to make copies, they should be arranged according to the specific record type. This important to know what that document is and how to acquire it or secure it.

Ultimately, achieving and maintaining HIPAA compliance with paper records requires a comprehensive approach that incorporates physical security, administrative policies, access controls, and secure disposal practices. Organizations should regularly assess their compliance efforts, conduct risk assessments, and stay informed about any updates or changes to HIPAA regulations to ensure ongoing adherence to the requirements.

Organizations that fail to comply with HIPAA requirements are subject to fines and, in serious cases, imprisonment. To cite a 2023 article in HIPAA Journal: “The penalties for non-compliance with HIPAA regulations include civil monetary penalties ranging from $100 to $50,000 per violation, depending on the level of culpability. Criminal penalties can also be imposed for intentional violations, leading to fines and potential imprisonment

Utilizing electronic medical records (EHRs) empowers physicians to oversee and enhance the quality of care provided within their practice or organization. With electronic records, organizations gain heightened security control, enabling precise management of patient information access and timing. Outsourcing transcription to a HIPAA-compliant medical transcription company guarantees utmost patient data privacy through robust encryption techniques and rigorous security protocols.

Secure your patient data with our HIPAA compliant medical transcription services!

Online Transcription Tools Market To Witness Strong Growth By 2026

15-November-2021 Julie Clements Medical Transcription

Online Transcription Tools Market

According to a report from Advance Market Analytics, the online transcription tools market is expected to witness strong growth by 2026. Transcripts of audio/video recordings are important to make text records of almost anything, improve the accessibility of online content, and to maximize SEO efforts. For reliable medical transcription services, most practices either outsource the task or rely on advanced transcription software to get transcripts. When using transcription tools, it is ideal for providers to get the transcripts proofread and edited by experienced transcriptionists. This will improve the accuracy rate. There are a number of real-time transcription apps that can be used easily on phone as well. These tools tend to work with any audio stream to text, and enables organizations and individuals to work faster and smarter.

Read

Top 5 Free Medical Transcription Software
6 Dictation Software Programs Physicians Can Use
Effective Tools to Reduce the EHR Documentation Burden: Scribes and Transcription Services

The report segments the market by Application, Enterprise Size, Platform, Pricing and Regions.

By application the market is divided into medical industry, education, legal and others. By enterprise size, the market serves small and medium enterprises and large enterprises. Here, small and medium enterprises are expected to boost the market. Based on platform, web-based and mobile application-based platforms are there, of which web-based platforms are predicted to boost the market. By pricing, the market includes annually and monthly pricing. By region, the market is divided into South America (Brazil, Argentina and Rest of South America), Asia Pacific (China, Japan, India, South Korea, Taiwan, Australia and Rest of Asia-Pacific), Europe (Germany, France, Italy, United Kingdom, Netherlands and Rest of Europe), MEA (Middle East and Africa) and North America (United States, Canada and Mexico).

Key factors that boost the market growth are –

Rising demand for the online transcription services for ease and efficiency of transcription
Elimination of manual work
Rising penetration of smart devices
Usage of digitized solutions for business procedures

However, restriction of online tools to text translation due to variation in regional accents is the major factor that restrains market growth.

Rise in educational institutes online and education modules requiring online transcription tools provide more opportunities for the market to grow. At the same time, integration of automation with the transcription tools and tracking of the scripting is one of the major influencing trends for these tools. Some of the challenges that these tool users face are – requirement of skilled personnel for supervision and efficiency, data breach and malware attacks.

Some of the key players profiled in the report are AT Transcript (United States), Gengo (Japan), GMR Transcription (United States), Google inc. (United States), Go Transcript (Scotland), Rev (United States), IScribed (United States), Scribie (United States), Temi (United States), TranscribeMe (United States) and Transcription Panda (United States). These players focus on employing artificial intelligence and different tools for analysis and decision making to survive the high competition. For instance, this year Microsoft has launched ‘Group Transcribe,’ a transcription and translation app for in-person meetings. This app makes meeting transcriptions a more collaborative process. It also offers real-time translation for languages spoken in more than 80 distinct locales.

Instead of manually transcribing audio or video files dictated by physicians, practices can use online tools to transcribe them and get them edited by editors at experienced medical transcription companies.

Read

How Digital Technology and Tools are Improving the Patient Experience
What Is The Best Dictation Workflow For Your Needs?

Management Of Medical Records – Key Considerations

11-November-2021 Rajeev Rajagopal Infographics

Proper medical record keeping is vital to ensure the care that patients need and medical transcription companies play a vital role in ensuring accurate and timely medical documentation. To maintain complete, accurate and concise medical records, it is important to document the patient encounter in real-time, or shortly afterward. Medical transcription outsourcing is an effective way to achieve this goal.

The services of a reliable medical transcription company can prove invaluable in this context. Professional service providers have a team of trained and experienced medical transcriptionists to ensure that patient charts, progress reports, doctors’ notes and other medical notes are accurately transcribed and delivered in quick turnaround time.

Check out the infographic below

Medical Records

How Can A Pain Management Practice Use EHR Correctly?

08-November-2021 MTS TEAM EHR Transcription

EHR

Millions of Americans are affected by chronic and acute pain which interferes with life and work activities. Electronic health records (EHRs) supported by pain management medical transcription services offer the opportunity to improve care for people suffering from pain by allowing for better documentation, information access, sharing and decision making by healthcare providers and patients.

pain management

Pain management EHRs are designed to help physicians work more efficiently and effectively, minimize risks, and improve decision making. The software also comes with features that help patients manage their check-in process and work with their physician to manage their care. Using the EHR correctly is a vital element in effectively running a pain management practice and keeping accurate health records to provide proper and timely care, especially for complex and costly patients. Here are 8 strategies to implement when using EHRs to improve the quality of care in pain management practices:

Use customized templates effectively: Pain management EHRs feature customized, flexible templates that allow physicians to modify their documentation process to suit their workflow or patient. Using templates effectively can reduce the time required to chart for patient visits, findings, referrals, etc. Importantly, physicians need to leverage the customized template to accurately chart and enter all details pertaining to the patients, which is critical for continuity of care.
Have a clear idea about patient’s visit history when using the scheduling tools: To schedule patient visits, physicians should have a proper understanding of a patient’s visit history (www.isalus.com). Quality pain management EHRs provide a clear picture of the patient’s visit history along with a user-friendly interface to generate pre-determined requirements. Patient scheduling tools in the pain management EHR will enable the physician to gain awareness about the patient before their visit and also provide the patient with access to important reminders.
Activate the patient portal: People experiencing pain find it difficult to fill out paper forms to get registered as a patient in the practice. Activating the EHR’s patient portal feature will allow them to get set up quickly. A secure quality patient portal will give patients 24-hour access to their personal health information (PHI) from anywhere. They can track their vitals and test results, and message their pain management physician. With a pain management EHR patient portal, patients can also schedule or cancel appointments, make payments, and more.
Utilize patient scheduling tools: Quality pain management software comes with a feature-rich user-friendly interface that offers the ability to create pre-determined requirements. Before scheduling a patient visit, the physician should review the patient’s information and history using the software patient scheduling tools. These features also provide the patient access to reminders that help participate in their treatment.
Leverage the software’s unique features: In addition to the standard features, top pain management EHR comes with unique features. Leveraging all these capabilities will allow pain management physicians improve productivity and efficiency. These features include:
- Dynamic reporting
- Extremities window
- Neurological section and assessment and treatment sections
- Referral letter, messages, and address book
- Find information, order, and view labs, analyze patient results, or graph patient vitals, and much more on a single screen
- Digital prescription – prescribe on-the-go while being able to monitor patient health information to support clinical decisions
- Reporting – use custom templates to develop customized reports quickly and act on them
- Electronic patient consent
- Automatic transcription
- Integrated digital imagery
Look at the patient: Precise and systematic pain assessment is essential for making correct diagnosis and deciding on the most effective treatment plan for patients presenting with pain. As both EHR use and communicating with the patient require focused attention, providers need to effectively balance the time given to the patient with computer use.

Physicians should also take care to enter data only after the patient has explained their concerns. Pain management specialists should take their patients’ needs into consideration when entering information into the EHR. They adjust their typing style and allow patients to express themselves and not interrupt them or turn away to look up information or write down something. Even if they need to enter data into the record at the encounter, they should continue communicating with the patient.

Providers of EHR-integrated medical transcription services can ease EHR data entry challenges. Outsourcing transcription is a viable strategy for pain management physicians as it will allow them to focus on managing their patients more effectively using the advanced features of their EHR. Even with automated transcription available in the EHR, having the documentation edited by professional medical transcriptionists is crucial for accuracy.

Guidelines To Complete A Transcript Quickly

01-November-2021 Julie Clements Medical Transcription

Transcript

Medical transcription is one of the most time-saving and essential processes that helps healthcare professionals generate and maintain accurate medical records. It helps in recording and dictating important notes, generating patient information and securely transforming the recordings into accurate text. A trained and skilled medical transcriptionist converts voice recordings made by physicians or healthcare providers into text format. Some people believe that medical transcriptionists require no particular skill or training. But the fact is that medical transcription requires good training and listening skills, and outsourcing medical transcription is one of the best ways to ensure utmost accuracy in transcripts.

The process of medical transcription is a three-level one that includes dictation, recording, and transcribing. Even though this may seem like a simple process, it requires exactness and detailed level of quality check. The accuracy level in the transcripts shows the quality of the transcription. The process of medical transcription begins with physicians or other healthcare professionals start dictation using a handheld digital recorder, or another digital recording device. It is important for healthcare professionals to use a good recording device so that the recording is clean, clear and easy to transcribe.

Here are some guidelines that one should know to perform medical transcription:

Set your tools and equipment before transcribing: Make sure that you have all the necessary tools and equipment.
- A good comfortable chair: The medical transcription process can take several hours and having a comfortable chair helps to support your lower back. It also helps to maintain a good posture and ensure proper blood circulation. This will also help you transcribe long hours of dictation without getting tired.
- Use good quality headphones: Noise cancelling headphones are a must to isolate distracting noise so that it is easier to transcribe.
- A foot pedal: This helps to control dictation playback with your toes. It allows you to easily play rewind and fast forward by tapping sections of the pedal with your foot.
- Online reference material: Keep dictionaries or Google ready to help in searching unfamiliar words.
Converting the files into text: In this step, the medical transcriptionist listens to the dictated files that have been uploaded to the secure server. The medical transcriptionist can type what they hear and save it. If there are any unclear or incomplete files, the medical professionals can be contacted to clarify the same.
Editing transcripts: Once the transcription is over, the transcripts are proofread and edited to remove errors or inconsistencies. Edit medical transcripts to ensure accuracy and also make the transcript shareable.
Sending the edited transcripts: The last step in the medical transcription process is sending the edited files to healthcare units using fax, email or the Internet.

There are transcription software options available today that let you transcribe easily. It helps you to automatically transcribe any recording in no time. All you have to do is upload your files, get them transcribed and then check and edit the transcripts. Many automated transcription software has dynamic range compressor that automatically increases the audio quality of your file for transcription. It reduces the volume of unnecessary loud sounds and amplifies sections that are difficult to hear. It also has a lot of built-in tools and features that will help you with transcription. But it is important to understand that automated transcription software does not ensure accuracy. Using such software to transcribe the physician’s dictation may lead to errors and inaccurate medical records that could compromise patient care.

Technology has changed the traditional method of medical transcription. Earlier, physician’s dictations were transcribed with the help of transcriptionist. But today with the EHR system, healthcare professionals can create accurate medical records using medical transcription services. Professional transcription services use HL7 interface which provides the framework for integrating, sharing and retrieval of EHR. It provides an encrypted and secure means of transferring files. Transcription services are available for all major medical specialities, whether cardiology transcription service, emergency room transcription service, neurology transcription service or any other.

What Is The Difference Between EMR And EHR

28-October-2021 Rajeev Rajagopal EHR Transcription

EMR And EHR

Well-designed EHRs and EMRs are the backbone of the healthcare system. Though both the terms are used interchangeably and have some common features, they are different concepts. Both are essential to meet the nation’s goals of improving patient safety, and the quality and efficiency of patient care, and to reduce healthcare delivery costs. While EHR is an appropriate choice to share important information with other healthcare stakeholders, EMR would be the best option for a specialty practice to provide personalized healthcare for each patient’s needs. Physicians can rely on a reliable medical transcription service to ensure accurate and timely documentation in these systems. Understanding the transition from EMR to EHR is important for healthcare providers to determine which application to choose and how it will affect their organization.

Electronic Medical Record (EMR)

The Office of the National Coordinator for Health Information Technology (ONC) defines EMRs as digital versions of the paper charts in clinician offices, clinics, and hospitals. An EMR comprises a patient’s medical history that is maintained by a single provider. The EMR system contains the following health information:

Demographic information
Medications
Allergies and immunizations
Lab results, radiology reports and visits

The EMR may also include billing information and insurance information.

As the EMR contains the patient’s medical and treatment history collected within a single healthcare organization, the system remains in that organization and is used by its clinicians. EMRs are not shared outside the organization. Providers use the EMR for diagnosis and treatment. A medical transcription company that provides EMR-integrated transcription services can ensure complete, accurate and timely documentation of a patient’s medical history, tests, diagnosis and treatment in the system, which is crucial for appropriate care throughout the healthcare organization.

EMRs improve the quality of care in a healthcare practice/organization by helping their physicians monitor care by:

Tracking data over time
Identifying patients for preventive visits and screenings
Monitoring patients for vaccinations and testing
Improving care quality by increasing accuracy, efficiency, and accountability

If a patient switches physicians or seeks care from an outside specialist, the information in the patient’s EMR may have to be printed out and sent to them by mail. Specialty EMRs feature customized templates. For instance, in a cardiology practice, specialized cardiology EMR software along with cardiology transcription services can improve healthcare delivery.

Electronic Health Record (EHR)

Similar to the EMR, the EHR also contains demographic information, medications, allergies, immunizations, lab results, radiology reports and visits, and often, billing information and insurance information. However, the EHR system has both a broader and deeper scope than the EMR system. The ONC explains: “Electronic health records (EHRs) are built to go beyond standard clinical data collected in a provider’s office and are inclusive of a broader view of a patient’s care. EHRs contain information from all the clinicians involved in a patient’s care and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient”.

What are the key features that distinguish EMR and EHR, including usability within a single provider versus data sharing across networks? While EHRs perform all the functions of EMRs, they are all-inclusive, much more complex, and reach out beyond the health organization that originally collects and compiles the information. The differences between EMR and EHR come down to accessibility and scope. EMRs are maintained by a single provider, while EHRs are maintained by multiple providers. EHR data can be created, managed, and accessed by authorized clinicians and staff across more than one healthcare organization as well as by patients themselves. As a result, EHRs contain more comprehensive information than EMRs. Providers primarily use EMRs for diagnosis and treatment purposes.

Furthermore, EHRs are designed to be interoperable, while EMRs are not. EMR and EHR interoperability refers to the ability of different systems to share and use data with each other. This is crucial because it enables providers to access a patient’s complete medical history, even if they see multiple providers. EHRs facilitate the transfer of a patient’s medical information to specialists, labs, imaging centers, emergency rooms, and pharmacies both locally and nationally.

EHRs:

Focuses on the overall health of the patient by going beyond standard clinical data collected in the provider’s office
Provides a broader view on a patient’s care
Allows the patient’s medical record to follow them to other healthcare providers, specialists, practices, hospitals, nursing homes, including across states
Allows clinicians access to a broader range of patient data than EMRs

A fully functional EHR can provide all members of the patient’s team with instant access to the latest information. The advantages of EHRs are:

They enable better coordination of patient-centered care.
In the event of a life-threatening condition, appropriate care can be provided even if the patient is unconscious.
Patients can access their own medical records and review their test results from the previous year. This can promote medication adherence and assist them in maintaining lifestyle changes.
Clinician notes from the patient’s hospitalization, discharge instructions, and guidance on follow-up care enable a seamless transition from one care setting to another.
A fully integrated EHR system encompasses practice management, medical billing, and interfaces with pharmacies, laboratories, radiology departments, and other healthcare facilities.

EMR vs EHR is a discussion that also touches on practical outcomes: EHRs reduce time spent searching for records, cut redundant testing, and enable smarter care decisions. In contrast, EMRs enhance care within a single network, making them more useful in small or specialty practices. An expert medical transcription business offers affordable documentation solutions that are integrated with electronic health records.

EMRs enhance the quality of care that patients receive, especially when a patient visits different providers within the same network of clinics, by enabling providers to keep track of a patient’s medical history in one place. This is also beneficial for small practices with fewer patients.

To sum up, EHRs go a lot further than EMRs.

emr ehr difference

EHR and EMR – Many Benefits

Though they are different concepts, both EMRs and WHRs are essential to meet the nation’s goals of improving patient safety, and the quality and efficiency of patient care, and to reduce healthcare delivery costs, according to Dave Garets and Mike Davis, the authors of a 2006 HIMSS Analytics white paper (www.ehrintelligence.com).

EMR and EHR

They noted that EMR is the foundation on which EHR interoperability is built. “The EMR is the legal record created in hospitals and ambulatory environments that is the source of data for the EHR,” they wrote. “The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual. Stakeholders are composed of patients/consumers, healthcare providers, employers, and/or payers/insurers, including the government.”

Well-designed EHRs and EMRs are the backbone of the healthcare system. In a general practice, where providers need to share information with other healthcare stakeholders, an EHR would be the appropriate choice. On the other hand, an EMR would be the best option for a specialty practice to provide personalized healthcare for each patient’s needs. Partnering with a professional medical transcription service organization in the USA can ensure error-free documentation in EHR and EMR systems.

Partner with a professional medical transcription services provider to streamline your EHR and EMR documentation.