Telemedicine and Emergency Care during the COVID-19 Pandemic

31-May-2021 MTS TEAM Medical Transcription

Telemedicine

Emergency departments (EDs) are at the frontline of care during the coronavirus pandemic and medical transcription companies are focused on meeting need for prompt and accurate electronic health record (EHR) documentation. One significant development since the pandemic began is the increased use of telemedicine in emergency care. This trend was supported by the easing of regulatory and administrative barriers in telemedicine. By limiting face-to-face interactions, tele-triage keeps both patients and clinicians safe, and prevents the spread of the virus.

Benefits of Telemedicine for Emergency Care during the Pandemic

With telemedicine services, healthcare providers and their patients can stay connected and communicating from anywhere. When the pandemic broke out, virtual platforms allowed emergency physicians to triage patients outside the four walls of the hospital. Telemedicine was used to help providers determine whether patients needed to visit the ED or if a virtual consultation would be sufficient. By directing patients to the appropriate setting, physicians could emergency department overcrowding at a time when resources had to be safeguarded for treatment of severely ill COVID-positive patients. Tele-triage also became an important method to identifying patients who were possibly infected with COVID-19, but who did not need emergency care and could remain under home isolation, reducing the risk of transmission to front-line health care workers and other ED patients.

A paper published on Wiley Online Library in May 2021, discusses studies that evaluated the pandemic‐related uses of telehealth in emergency care in five areas:

Pre‐ED/Prehospital: Telehealth has functioned as a screening tool for patients with emergency care needs and to support care coordination in the pre‐ED setting. By facilitating per-hospital evaluation, telehealth services weeded out non-emergency situations from those needing serious attention. Patients with COVID 2019 exposure but no serious safety concerns could be directed to alternative testing locations instead of the ED.
Within ED: EDs used telehealth as a tool to screen patients for acute care needs. This helped limit staff and patient exposure and conserved the use of personal protective equipment (PPE). Teleconsultations also allowed ED physicians to interact with specialist services and specialists to interact with patients. One study discussed how telehealth was used by an institution to coordinate transfers of emergency patients, enable remote ultrasound, and provide virtual consultations.
Post‐ED discharge: Emergency departments have utilized telehealth following patients’ discharge from ED to extend care, especially for follow‐up and remote monitoring. EDs and skilled nursing facilities were used to triage patients discharged patients appropriately.
Education: Telehealth platforms and digital tools have supported new educational initiatives and strategies, minimizing the need for in-person contact. Robust digital initiatives have made possible continued education for trainees, nurses, and physicians. Organizations are using iPads and telehealth to help with interhospital care coordination as well as telehealth to enable patients to self‐monitor vital signs.
Care and Resource Coordination: Telehealth helped EDs and hospital systems coordinate and conserve scarce medical resources during the pandemic.

Even before the pandemic, telehealth supported EDs in many ways. Virtual care is a solution for overcrowding in emergency departments and urgent care centers. It is a useful option for older adults with chronic conditions on a lot of medications, when transition of care becomes critically important. Video-based consultations have helped physicians assess fevers in children, rashes in adults, abdominal pain and facial swelling. Patients could transmit information about their health and readings with at-home monitoring tools, enabling physicians to identify new symptoms, worsening health, and potential emergencies. This helped patients get life-saving interventions without delay. Telehealth is also a great option for mental health emergencies, allowing people to connect with a therapist at any time.

Telehealth Visits – Optimizing Documentation

Optimizing EHR documentation is essential so that ER physicians can focus their time and attention on patient care. If clinicians record patient information as notes in the EHR in real-time during a patient encounter, patient data can be shared among health providers. However, this practice is the main cause of clinician burnout. Telehealth undoubtedly has immense value in emergency care. Integrating a telehealth platform into the EHR and patient portal supported by EHR-integrated medical transcription services can reduce clinician burden and ease documentation. Even if clinicians use voice recognition technology to save time with EHR documentation, outsourcing medical transcription will ensure that physician dictation is edited and proofread to produce quality medical records.

Four Common EHR Errors and How to Avoid Them

27-May-2021 Julie Clements EHR Transcription

EHR Errors and How to Avoid Them

The electronic health record (EHR) is designed to improve patient care and streamline physician workflow. With the widespread adoption of digitized patient records, medical transcription companies enter physician narrations directly into the EHR instead of into word processing systems. Medical transcription services ease physician burnout, improve document quality, and increase patient satisfaction. However, many studies suggest that EHR users are highly prone to making errors which can endanger the reliability of information, and thereby patient care, safety and the provider’s bottomline.

Medication Errors: More than 30 percent of all EHR-related malpractice claims are associated with medication errors, according to a study in the Journal of Patient Safety in 2019. On analyzing 248 malpractice claims involving EHR technology, the researchers found that 31 percent of these claims involved medication errors. Another study reported that two-thirds of prescription errors (65.7%) occurred during prescribing or transcribing (info.nhanow.com). Causes include: entering wrong information, entering information in the wrong place, and overlooking EHR flags/warnings for interactions or contraindications. Serious harmful results of a medication error may include death, life threatening events, hospitalization, disability, etc.
Training users on EHR processes can minimize prescription errors. Outsourcing medical transcription to an experienced service provider can prevent potentially harmful medication errors.

Patient Identification Errors: Patient ID errors are another common problems associated with EHRs. Correct patient identification is fundamental to safe care delivery. However, an ECRI Institute study found that the risk of wrong-patient errors is a chronic problem with the large numbers of patient encounters occurring daily in healthcare settings. According to the study, patient identification errors in the EHR were quite common, leading to injury, wrong treatment, and even death. A 2018 Pew Charitable Trusts report revealed that one out of every five patients may not be completely matched to their medical records. Charting to the wrong patient occur when the admission, discharge, transfer (ADT) system fails to put a patient in a bed in a timely manner, according to a Healthcare IT News article.
While EHRs are a major step towards going paperless, digitization of patient records has led to duplicate and disparate medical records. Patient information in EHRs is also inconsistent as systems have different ways of capturing patient demographic information. Leveraging an efficient enterprise master patient index (EMPI) industry best practice essential to prevent duplicates and inaccurate patient information, according to a Health IT Outcomes report.

Inaccurate Medical History: Patients who read their own records online often find mistakes in their medical history, some of which are serious. An January 2021 article in physiciansweekly.com references a study that found that of 22,889 surveyed patients who read their own records, 4830 (25%) found mistakes. While 10% were classified as very serious, 42.3% were reported as serious, and 32.4% as somewhat serious. When patients were asked to provide free text descriptions of mistakes, it was found that the most common type of error involved a current or previous diagnosis.
Simple miskeying could be the reason for such errors. On the other hand, miscommunication or wrong information from the patient could also lead to errors in medical history and bad data in the EHR (healthcareitnews.com). Allowing patients to review their notes routinely could improve EHR accuracy and also provide an opportunity for organizational learning. If patients find errors in their records, they should make sure they are corrected.

Flaws in EHR System Design: Apart from user-related problems, studies have reported that EHR system design flaws can lead to a glitch and cause inaccurate recording of patient information, such as allergies or medications. Software bugs, disorganized data, system interface problems, and missing/corrupted data can affect decision making, and lead to delays, errors, unnecessary testing, and system downtime. Fortunately, EHR companies are working to ease the tech burden on healthcare providers and improving system design to enhance the clinical decision making process.

With the increasing scope and complexity of tasks that clinicians can perform using EHRs, effective end-user training is critical for success. Benefits of effective training programs include greater accuracy in charting and coding, improved productivity and efficiency that benefits both providers and their patients. Outsourcing medical transcription can optimize the EHR documentation process to support delivery of superior quality care and enhanced ROI for healthcare organizations.

Study Calls for Creating Clear, Patient-friendly Radiology Reports

24-May-2021 MTS TEAM Radiology Transcription

Radiology Reports

Imaging reports present the findings of diagnostic radiological studies which are communicated between the radiologist and the referring physician. These reports are also read by other healthcare professionals with varying levels of knowledge. Outsourcing radiology transcription helps radiology clinics and departments get quality reports in quick turnaround time. Today, patients can view their reports via online portals. However, according to a new study, patients are finding it difficult to understand their radiology reports, especially MRI findings (www.healthimaging.com).

Giving patients access to their electronic radiology reports allows them to become more involved in their care. It helps them make informed decisions and share the reports with other physicians, which can improve care quality, safety, and efficiency.

While wording, length and clarity differ widely in radiology reports, diagnostic imaging reports should present an accurate and detailed explanation of the imaging findings. Any ambiguity can make them difficult to interpret by the referring clinician. Reports that lack clarity can make patients confused and anxious.

Patient Questions on Discussion Forums throw Light on Information Gaps

Researchers from the University of Wisconsin Milwaukee College of Health Sciences analyzed patient questions posted online to identify patient needs and understand information gaps in radiology reports.

The team collected 659 questions that patients posted on four online discussion forums – Yahoo Answers, Reddit.com, Quora, and Wiki Answers. Up to 35.5% of the questions posted on online discussion forums were about radiology reports. The questions were analyzed and the major themes and topics were identified. Procedures tracked included Magnetic Resonance Radiology (MRI), Nuclear Imaging, Ultrasound, X-Ray, Computer Tomography (CT), Fluoroscopy, and Angiography. As well as radiology services for specific indications like breast cancer or lymphoma. The collected questions were classified into eight major themes related to the following topics: radiology report, safety, price, preparation, procedure, meaning, medical staff, and patient portal.

The researchers noted that patients want to improve their understanding of the report by improving the following elements:

Image visualization – issues about images, resolution, contrast, and color.
Report representation – format of the radiology interpretations, such as font size, font color, unstructured information, information abundance, and confusion about what documents relate to what information.
Resources – links and brochures that provide additional information to patients.
Understanding – issues such as explanations unclear medical terms, and general confusion about results.
Preference – the way results can be provided.

The key findings of the study are as follows:

Questions regarding explanations, unclear terms, and general confusion accounted for 26.49% of the total, with image visualization and preference both accounting for 22.64%.
Another 19.65% of the questions related to report presentation comments such as format, structure, font size and other features.
20% of the questions highlighted the need to improve report representation by addressing issues such as unstructured nature of the report, information bloat, or font or color issues.
Compared to other imaging modalities, up to 32% of patients had problems understanding their MRI reports.

Recommendations to Create Patient-Friendly Radiology Reports

According to the researchers, their findings point to the need to create patient friendly radiology reports. They put forward five recommendations to this end:

Including blood tests and the patient’s genetic history in the report would be very useful for future decision making.
Rethinking report design to make it more organized and reviewing the level of language used to improve understanding.
Improving understanding by quantifying results such as dimensions, volumes, Hounsfield numbers, and ADC values.
Provide tips and instructions to improve patient satisfaction.
Automating quality control to create a more patient-friendly report

A commentary published in Academic Radiology offered other suggestions to improve the quality of radiology reports

As far as possible, avoid imaging related terminology and jargon which can confuse both referring physicians and patients
Create and include a summary specifically for patients, which is free of medical terminology that they would not understand
Avoid language that patients may consider hostile, such as ‘the patient refused’, etc

Researchers also recommend that radiologists proofread reports to ensure that they are free from spelling and voice recognition errors. Medical transcription service providers can handle this task. Outsourcing radiology transcription can help busy radiologists deliver patient-friendly reports in quick turnaround time.

How to Use the EHR Copy-Paste Function Safely

20-May-2021 Julie Clements EHR Transcription

EHR Copy-Paste

Documentation integrity refers to the accuracy of the complete health record. Clear, consistent, complete, precise, reliable, timely, and legible electronic health record (EHR) documentation is necessary to reflect the patient’s disease burden and the services provided. Outsourcing medical transcription goes a long way when it comes to maintaining error-free medical records. Dictation and transcription are used alongside structured templates. When physicians enter patient encounter data into EHRs, they tend to use the copy-paste function to overcome the clerical workload and save time. However, if not used judiciously, copy-paste can cause documentation errors and negatively impact patient care.

Get in touch to learn how our medical transcription outsourcing solutions can transform your documentation workflows!

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Uses and Risks of the EHR Copy-and-Paste Function

Physicians who use copy and paste experienced less burnout symptoms, according to a study published in the Journal of the American Medical Informatics Association. The EHR copy-paste function serves several important purposes:

Improves efficiency by allowing physicians to quickly and easily transfer relevant information from one part of a patient’s EHR to another, eliminating the need for manual typing.
Promotes consistency in the data and documentation across a patient’s record, maintaining accuracy and minimizing errors.
Supports complete documentation of a patient’s history, symptoms, treatment plan, and other key details, avoiding the need for rewriting the information.

However, copy-and-paste can easily introduce and propagate errors into the medical record. Indiscriminate copying and pasting can result in inaccurate, redundant, or outdated information becoming part of the permanent medical record, say experts. Potential risks associated with EHR copy-and-paste practices include:

Copying and pasting information that is inaccurate or outdated
Superfluous information in the EHR, which makes identifying current information a challenge
Not being able to identify the author or intent of the documentation
Inability to identify when the documentation was created
Propagation of incorrect information – errors may be repeated in the record for months and even years
Inconsistent progress notes
Note bloat or progress notes that are too lengthy, making it difficult for future members of the care team to analyze the details of a patient’s medical care

Despite these risks, the Medscape study notes that many physicians continue to overuse copy and paste. A 2022 JAMA study found that, on average, half the clinical note at one health system had been copied and pasted.

Physicians who misuse the EHR “copy-and-paste” feature can face lost hospital privileges, fines, and malpractice lawsuits. A recent Medscape article reported that locum tenens physician in California lost her hospital privileges after her repeated violation of the copy-and-paste policy impaired continuity of care. Another study reported that approximately 2.6% of documentation errors related to note templates, EHR-featured text auto-population, and copy-and-paste functions lead to serious medical issues for patients (Tech Innov Patient Support Radiat Oncol., 2024).

So, what’s the way out? Is it to disable the copy-paste function? No, say experts.

“There’s no question that copy-and-paste can be misused or overused, but it’s also a helpful function for reducing burden when it’s appropriately used, says Dr. Christopher Longhurst, chief information officer at UC San Diego Health. “There’s a place for it, and turning it off completely is not helpful.” (www.modernhealthcare.com).

Best Practices for Safe Use of Copy-and-Paste

Steps that physicians can take to promote safe use of copy-paste, including recommendations from the American Health Information Management Association:

Establishing policies on where copy-paste can be used and where it cannot to assure compliance with governmental, regulatory and industry standards.
Address copy-and-paste utilization in the organization’s information governance processes and monitor physician adherence to the policies.
Encouraging physicians to adequately edit the copy-pasted information to ensure it is still up-to-date and relevant for the patient’s current care.
Train and educate all EHR system users on proper use of copy-and-paste.
Establish corrective action as needed.

Monitoring of Copy-and-paste Use

Hospitals and health systems can periodically audit medical records for excessive copy-paste use, recommends the Medscape report. This includes penalizing physicians for overusing copy and paste. Many institutions have taken a proactive approach to managing the use of copy-and-paste functionality within their electronic health records (EHRs).

Banner Health in Arizona, Northwell Health in New York, and University of Toledo in Ohio have introduced formal policies with regards to how physician can copy and paste. Santa Rosa Memorial allows some copy-paste, but has a specific policy which bans using it for the chief complaint, the review of systems, the physical examination, and the assessment and plan in the medical record, except when the information can’t be obtained directly from the patient. Geisinger Health in Pennsylvania regularly monitors and tracks the frequency and patterns of copy-and-paste usage among its physicians, according to a 2022 presentation by a Geisinger official,

The bottom line: Organizations can direct physicians on the use of this EHR function and discipline them for copy-and-paste abuse. Leveraging medical transcription services can help with EHR documentation, allowing providers to focus on the patient during the office visit. With EHR voice-recognition software, physicians can directly dictate into the system and have an experienced medical transcription company review the automated notes for accuracy.

Let our skilled team handle your medical documentation needs as you focus on patient care!

HIPAA Privacy Rule – Proposed Changes and Updates in 2021

17-May-2021 Rajeev Rajagopal HIPAA Compliance

HIPAA

Digitalization of healthcare has improved the efficiency of healthcare delivery, benefiting patients and physicians. Electronic health records (EHRs) supported by medical transcription services provide accurate, up to date and complete information about patients at the point of care, improving quality of care and practice efficiency. Telemedicine, mobile health, wearable medical devices, and other digital health solutions are driving a revolution in healthcare.

However, increased adoption of IT systems in healthcare has increased cybersecurity risks. Cybersecurity breaches of 500 records or more rose from 371 in 2018 to 618 in 2020, according to a recent For the Record article. In 2020, the Office for Civil Rights (OCR) settled 20 cases with resolution agreements or corrective action plans, and reached settlements totaling more than $55 million over the last three years.

In addition to increasing existing security risks, the COVID-19 pandemic has given rise to new challenges. In April 2020, the World Health Organization announced that there was a fivefold increase in cyberattacks targeting healthcare. Compliance with Health Insurance Portability and Accountability (HIPAA) regulations has become more important than ever before for all Covered Entities, including Business Associates with access to Protected Health Information (PHI).

On January 21, 2021, the Department of Health and Human Services (HSS) proposed modifications to the HIPAA Privacy Rule. However, organizations are calling for a review of these proposals and alignment of HIPAA with other health data regulations.

HSS Proposes Changes to HIPAA Rule

The proposed changes or reforms as published on www.healthcareinfosecurity.com are as follows:

Strengthen individuals’ rights to access their own health information, including electronic information;
Improve information sharing for care coordination and case management;
Facilitate greater family and caregiver involvement in the care of individuals experiencing emergencies or health crises;
Enhance flexibilities for disclosures in emergency or threatening circumstances, such as the opioid and COVID-19 public health emergencies;
Reduce administrative burdens on HIPAA-covered healthcare providers and health plans while continuing to protect individuals’ health information privacy.

Concerns about Personal Health Applications and HIPAA Compliance

However, many organizations have expressed concern about the proposed changes and called for aligning any potential HIPAA Privacy Rule changes with other regulations that deal with privacy, patient access to records and secure exchange of electronic health information (www.govinfosecurity.com).

Tech savvy consumers are now using PHIs on their personal devices to access their electronic medical record, view lab results, schedule appointments, manage chronic conditions, track disease outbreak information and locate clinical trials. However, PHAs fall outside the scope of HIPAA.

The College of Healthcare Information Management Executives (CHIME) says that in proposed HIPAA changes, a “personal health application” is defined as a direct-to-consumer application used for the individual’s own purposes that would fall outside the scope of HIPAA’s protection. PHAs are not subject to HIPAA privacy and security obligations and, thus, can share patient protected health information.” CHIME draws attention to the fact that there are no business associate agreements in place for PHA vendors to help ensure the privacy and security of patient information.

The American Hospital Association (AHA) has also expressed similar concerns about PHAs. “Personal health applications should be limited to applications that do not permit third-party access to the information, include appropriate privacy protections and adequate security and are developed to correctly present health information that is received from electronic health records,” says the AHA.

HIMSS and other industry groups have urged HHS OCR to bring any potential HIPAA Privacy Rule changes in line with other regulations, including the provisions that recently went into effect and allows patients to access their health information via smartphones and application programming interfaces. HIMSS has called upon the agency to support the development of robust, up-to-date privacy and security frameworks and regulations to boost widespread adoption and build trust in new, innovative technologies that support the free flow of information between patients and providers.

HHS OCR will review all comments before deciding whether to go ahead with changes and issue a final rule or revised proposed rule.

HIPAA Compliance 2021

All organizations subject to the HIPAA Act (HIPAA) should periodically review their compliance to ensure that they meet HIPAA requirements for the privacy and security of PHI. Failure to do so would lead to severe penalties, including fines, fees, and audits imposed by the Office for Civil Rights (OCR), in addition to the costs of lost business, damaged reputation, and lawsuits.

For every covered entity, HIPAA compliance means implementing controls and protections for relevant PHI. This includes facilitating the secure transfer of healthcare records to provide continued health coverage, taking steps to prevent healthcare fraud, and ensuring standardized electronic billing and healthcare data. New technology that has not been properly vetted for security risks can pose security risks.

Here is a basic checklist to track your HIPAA compliance in 2021:

Make sure you have implement privacy policies and procedures to safeguard PHI.
Conduct a HIPAA compliance audit, assess results, and document gaps.
Document plans to correct deficiencies, take action and update strategies as necessary.
Have a designated HIPAA Compliance, Privacy and/or Security Officer implement HIPAA policies.
Train staff on HIPAA compliance and make sure everyone is aware of potential threats as well as HIPAA violation penalties.
Have systems and controls in place to prevent data breaches

It’s also important to ensure that third parties (business associates, partners, and subcontractors) also meet HIPAA regulations. Organizations outsourcing medical transcription, for instance, need to evaluate whether the company meets HIPAA requirements. HIPAA medical transcription service providers will have the necessary technical, physical and administrative safeguards in place to ensure that client data is handled with utmost confidentiality.

How Medical Transcriptionists Edit Physician Dictated Records

10-May-2021 MTS TEAM Medical Transcription

Medical Transcriptionists

Medical transcriptionists (MTs) basically convert the physician’s dictated report into text format and highlight any discrepancies. Though this may sound relatively simple and straightforward, there’s more to it. A reliable and skilled medical transcription service provider will ensure that the physician receives an accurate, timely, and secure record. With computerized audio-to-text conversion by a speech recognition software, medical transcriptionists have a crucial role in editing the results. They make the necessary corrections by reviewing the text while listening to the original audio file to ensure accurate capture and formatting of the content. Experts will provide flawless reports by editing them and correcting discrepancies in grammar, style, and even clinical information, saving the medical practice valuable time and resources that would go into making these corrections.

How MTs Preserve the Integrity of the Medical Record

What exactly is the MT’s role in editing patient medical records? The Association for Healthcare Documentation Integrity (AHDI) provides specific guidelines about this. The AHDI notes that MTs should proactively correct discrepancies in dictation that fall within the scope of their interpretive skill set and clinical knowledge. This is important even in a verbatim environment. MTs can preserve the integrity of the medical record by:

Providing an accurate account of the conversation between the provider and the patient during that encounter
Preserving the tone and scope of that encounter
Ensuring a clinically relevant long-term care record
Honoring the physician’s dictation style, recognizing error/inconsistency in the record, and correcting them
Avoiding correcting or changing anything that cannot be confirmed
Flagging errors that cannot be corrected and notifying the provider about them

What does Editing the Medical Record Involve?

Experienced MTs clearly know when to edit the medical record and the kind of corrections that can be made.

Grammar and Punctuation: Errors in grammar and punctuation need to be corrected, including the instructions that the clinician provides on paragraph breaks and punctuation. Common errors in dictation related to subject-verb agreement in sentences, transposition of personal pronouns and pluralization (Latin and Greek plurals, for e.g., the plural of axilla is axillae, and conjunctiva is conjunctivae.
Syntax: Word order in sentences have to be corrected, which is crucial to ensure clarity of communication. While the physician may use the correct vocabulary and concepts, the MT need to ensure appropriate word order and avoid misplaced modifiers. A modifier is a word, phrase, or clause that is improperly separated from the word it modifies/describes and sentences with misplaced modifiers can seem illogical. Take the following example provided by BioMedical editor: It is incorrect to say “the 49-year-old patient experienced severe pain in the left heel when walking for two months”. The sentence should be corrected as: “For two months, the 49-year-old patient experienced severe pain in the left heel when walking”.
Spelling: Electronic spell checkers are a very useful tool for medical transcriptionists as they can identify misspelled words in the record. However, experienced transcriptionists will additionally verify the clinician’s dictated spelling using reputable resources. If the spelling can be verified, transcriptionists will correct it. If the term cannot be verified, they will retain the spelling provided by the clinician and flag it for verification.
Slang, Jargon, and Abbreviations: Physician dictated notes often have clumsy use of language and frequent neologisms. Medical transcriptionists need to edit unsuitable slang words and phrases to avoid misinterpretation. Corrections are made by consulting a reputable industry reference book or resource to verify what abbreviations are acceptable and which terms need to be edited. Obscenities, derogatory or inflammatory remarks, and double entendres are left blank and flagged, unless the clinician has dictated them as part of a direct quote.
Back Formations: Coming to new words formed by altering an existing word or back formations, transcriptionists need to know which ones have become acceptable. Back formations that are widespread and acceptable include ‘diagnosis-to diagnose’ and ‘Bovie-bovied’ (AHDI). Care should be taken to avoid illogical back formations.
Incorrect Terms: Experienced medical transcriptionists are well versed in English and medical terms and will recognize and edit incorrectly dictated terms. Making such corrections also requires interpretive judgment and the ability to recognize ambiguity in dictated terms and phrases.
Contextual Discrepancies: Common sense and critical thinking can resolve certain inconsistencies in the physician’s statements. For instance, if a female patient is referred to as ‘he’ in the report, the transcriptionist can easily make the correction. However, other contextual discrepancies that cannot be resolved should be flagged for verification by the clinician. An example would be directional and positional terms (like left and right), which the transcriptionist should never try to guess.
Transposition of Terms and Values: This is one of the most common medical dictation mistakes. If the transcriptionist can easily identify flipped or transposed words or values, they can be edited appropriately. If there is any doubt, about the terms or the correlation of values, the report should be flagged.
Demographics: Accurate patient demographics is essential for managing health information. With dictation software, the demographics are automatically at the point of dictation and electronically linked with the transcribed record. The role of the transcriptionist is to ensure precise demographic mapping by checking the information captured against the physician’s dictation.

Even is this age of electronic health records and speech recognition systems, the human medical transcriptionist has a significant role to play in ensuring error-free transcription with proper formatting and grammar correction. Moreover, continuous speech recognition technology can malfunction, and the support of a backup medical transcription service can prove invaluable when it comes to maintaining accurate and timely medical records.

Traits of an Efficient Medical Transcription Company

06-May-2021 Julie Clements Medical Transcription Company

This is an update to the blog: “Key Features of a Good Medical Transcription Company”

Transcription

For any medical specialty, voice dictations or audio recordings created by physicians, nurse practitioners or other healthcare providers need to be converted into accurate transcripts. While physicians require medical transcripts for treatment purposes and future reference, insurers require them to review claims. Maintaining an in-house transcription team can be quite expensive for medical practices, in addition to having to manage staff’s time, HIPAA compliance, technology, administration, turnaround time, and more. This is why busy practices rely on medical transcription outsourcing. With a reliable medical transcription company, practices can get accurate transcripts in short turnaround time while they focus on delivering quality patient care.

Medical Transcription Services vs. Voice Recognition Software – Which Works Best

Many practices are now using voice recognition software that makes documentation much easier. Physicians speak into a recording device in the software which then converts the physician’s speech into written text. Even though speech recognition software offers many advantages over traditional documentation such as reduced turnaround time and less costs, it has certain disadvantages. Accuracy of the software cannot be predicted and often the dictating physician has to review and edit the transcribed text to get reliable documentation, which is quite time consuming. Outsourcing transcription is a practical way to overcome these challenges.

Professional medical transcription companies are technically advanced and provide EHR-integrated medical transcription services. They have efficient and skilled professionals and resources to provide superior quality medical transcription services for all specialties. Experienced medical transcriptionists edit and proofread the transcripts generated by speech recognition software and deliver error-free EHR-integrated medical documentation. By partnering with a medical transcription company, physicians can spend their valuable time focusing the patient, while getting their dictation transcribed accurately and promptly.

Marketprimes recently reported that the global medical transcription services market that was valued at 5759.7 Million USD in 2019 is expected to showcase a year over year growth rate of 5.3 % during 2019-2025, subsequently generating around 7071.5 Million USD by 2025.

Here’s what an experienced medical transcription company can offer:

Accuracy

Professional medical transcription companies are well aware of the fact that practices require error-free medical records to treat patients better, to get appropriate reimbursement from payers, and for legal purposes. Even a minor error in patient records can lead to wrong treatment decisions that could endanger patient’s lives. These records are also necessary to submit the claims to insurance companies and any mistakes can result in claim denials or delays or even denials. Medical records serve as crucial evidence in medical malpractice, personal injury, civil suits or criminal cases, and it is critical for the practices to maintain accurate patient records, which proves that the right treatment was provided to the patient.

Reliable medical transcription service providers have multi-level of quality assurance processes in place to ensure transcript accuracy. Before they are delivered to the physician, the transcripts are put through strict quality checks by experienced editors, proofreaders and subject matter experts.

Fast Turnaround Times

Experienced companies make sure they can meet even the most demanding deadlines – STAT or immediate requirements, practices can decide how quickly they want transcripts back. They deliver the transcripts in custom turnaround time (anywhere from 24 hours or less). Many firms also offer real-time transcription from voice to text that quickens the process of medical documentation and improves the efficiency of physicians and other medical staffs.

Expert Resources

Professional firms employ certified and trained medical transcriptionists. These experts are familiar with even difficult medical terminologies and conditions. They will be well trained in

understanding different accents
providing transcripts for a broad range of medical specialties and sub-specialties including family practice, physical therapy or others

HIPAA Compliant

Reliable medical transcription companies strictly comply with HIPAA guidelines and standards and ensure that patient health information they handle is safe and secure. To protect patient data, their servers and computers will be protected by 128 bit encryption and their staff will be provided training on HIPAA and PHI regulations. Files that are received from exterior sources and transferred will be encrypted.

Free Trial

Instead of just boasting about their service features, leading medical transcription companies offer a free trial, so that practice can be convinced of their excellent service, professionalism, quick turnaround times, and competitive rates.

Want proof of medical transcription quality? Get a no-obligation Free Trial from MOS Medical Transcription Services today!

Professional firms also offer flexible dictation options, EMR integration, electronic signatures, real-time transcription progress reports, secure file transmission options and more. By outsourcing medical transcription tasks to such companies, physicians can save time, maximize cash flow, improve overall efficiency, save costs in training and managing in-house staff, meet industry compliance standards, focus on providing quality patient care and improve report accuracy.

Related blogs:

How to Write SOAP Notes for Physical Therapists

03-May-2021 Rajeev Rajagopal Physical Therapy Transcription

Physical Therapists

Physical therapy notes are documents used by physical therapists in the form of soap notes which include Subjective, Objective, Assessment and Plan. These notes record information about the progress of the patient and a professional medical transcription company can deliver accurate transcripts for hospitals, outpatient clinics, group practices and individual physicians. Converting physical therapy dictations or notes into proper and accurate medical records is vital to ensure appropriate patient care, accurate medical claim submission, and efficient administration of hospitals. A good transcription service understands the working environment of the physical therapist and their need to maintain accurate medical records.

What Do You Mean by SOAP notes?

Physical therapy SOAP notes contain details about the condition of the patient, and the treatment to be provided. It should also include the frequency, duration and the equipment used for treatment. The progress of the patient and the response towards the treatment may also be mentioned in the physical therapy notes. With all this information, it provides an outline of the course of treatment provided that are later transcribed. Here are some tips to write SOAP notes for physical therapy.

SOAP refers to Subjective, Objective, Assessment and Plan. According to the American Physical Therapy Association the Physical Therapist SOAP notes should include:

Self-report of the patient
Information about the specific intervention provided
Equipment used
Changes in patient health
Any drastic reactions or changes
Progress
Communication with other physicians or other healthcare professionals

Let us consider the 4 Parts of SOAP notes

Subjective: This part includes every detail about what the patient has to say about his/her health condition. It provides insights about how the patient feels about his/her progress, whether they are able to function well and whether their quality of life has improved. It also includes the patient’s description of pain, dizziness or any other discomfort. Sometimes patients may not have any opinion about their treatment. So when required, it is useful to take subjective opinion from the family members too.
Objective: This includes all the pertinent measurements like vital signs, range of motion, muscle setting measurements and so on. The therapist should also include frequency, duration and the equipment used. Although this document does not have much legal value, all details should be accurate as it determines the treatment.
Assessment: It includes all the impressions from the physician regarding the patient’s health condition. In this document, the physicians must explain how they have decided about the treatment, and how they intend to work with the patient. This is the document where therapists record their professional take on each session, therefore it holds legal value.
Plan: This is the final step which mentions all the details about what treatment plan is set for the patient. It also has the development of the patient’s treatment plan.

Advantages of Writing SOAP Notes

Act as Proof: Accurate SOAP notes serve as proof of interaction between the doctor and the patient. It covers all basic details like date, time, and location that are relevant. It also includes different types of treatment. The physical therapist may use these SOAP notes if they work with patients who may need extra level of documentation for legal purposes.
Useful for Future Reference: SOAP is a detailed report of treatment that allows medical professionals to build their own mini-research library. SOAP notes help to collect data that can be used as reference throughout a patient’s journey.
Information can be Shared among Peers: SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers. SOAP notes play a huge role in ensuring clear communication regarding the patient across all healthcare team members.

A good transcription service provides accurate medical records for conditions associated with back pain, sports injury, cerebral palsy, frozen shoulder, osteoarthritis of the foot, strains and sprains. An experienced and reputable provider of medical transcription services can be of great support in preparing SOAP notes for physical therapists, ensuring confidentiality of patient data while also maintaining security policies.

Top 5 Free Medical Transcription Software

29-April-2021 MTS TEAM Medical Transcription

Medical Transcription Software

In order for medical practices to make informed treatment decisions and plan care, it is crucial to produce precise transcripts of patient stories and treatment notes that are recorded through voice dictation by healthcare providers such as physicians and nurses. Medical transcription outsourcing can ensure accurate transcripts in EHR systems in fast turnaround time. There are a variety of software and tools available that can streamline the medical record documentation process, enabling physicians to concentrate on patient care. The global medical transcription software market is expected to exceed USD 190.3 billion by 2032, with a projected CAGR of 9.60% between 2023 and 2032, according to Market.us. The report notes that market growth can be attributed to factors such as an increase in awareness for quality patient care, the rapid expansion of the e-health industry, and a surge in healthcare expenditure. Most dictation platforms also offer remote access, allowing healthcare providers to dictate from anywhere and at any time.

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5 Top Medical Transcription Software – Features and Benefits

Listed below is what we consider the 5 best free medical transcription software in the market:

Express Scribe

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Express Scribe is a professional dictation software tool that offers a fast and easy way to transcribe audio files. It can transcribe dictations, voice notes, hearings, interviews, and much more. Express Delegate enables users to scan and import dictations from various sources, such as FTP server, LAN, local computer folder, portable dictation recorder (dictaphone), and more. Noteworthy features of this software include variable speed playback, foot pedal control compatibility with professional controllers, hands-free playback, and automatic file management to facilitate dictation loading and transcription sending. Additionally, Express Scribe can be used in conjunction with other software, allowing users to type in their preferred word processor. For instance, the software integrates with speech recognition software, such as Dragon Naturally Speaking, to automatically convert speech to text. The free version of Express Scribe supports popular audio formats, including wav, mp3, wma, and dct, with more advanced features available in the paid version.

The FTW Transcriber

ftw transcriber

If you are an individual transcriptionist, or if you work in a hospital, clinic, or laboratory, the FTW Transcriber is a free transcription software option that may meet your needs. Available for both Windows and Android operating systems, this software offers a range of useful features that can save time, such as automatic timestamps and excellent sound quality. With timestamp formatting, you can add timestamps in the format that best suits your needs. Additionally, the software includes hotkeys for common phrases, such as “overtalking” and “unclear,” which can further streamline the transcription process.

The software can handle a wide range of file types, including 3gpp, aac, ac3, ape, asf, dat, dss, ds2, dts, flac, flv, hdmov, it, m2ts, mkv, mkv, mo3, mod, mov, mp3, mp4, mpeg, mpg, mtm, nuv, ogg, ogm, ps, s3m, ts, tta, umx, vi, vob, vorbis, wav, wma, wmv, wv, xm, and more.

INVOX Medical

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INVOX Medical speech recognition software is ideal for hospitals, clinics, diagnostic centers and laboratories. INVOX Medical works by allowing users to dictate notes, reports, and other medical documents using a range of input devices, including smartphones, landline phones, or digital recorders. The software then uses advanced speech recognition technology to transcribe the spoken words into text. It is compatible with any medical or EHR software and features specific dictionaries for more than 15 medical specialties, and allows for seamless transfer of transcribed documents into patient records.

INVOX Medical is very simple to use. This software leverages the power of AI/Machine Learning to provide highly accurate dictation transcription. Some of the features of INVOX Medical include customizable templates for different medical specialties, secure data encryption, automatic archiving and backup, timecoding, customizable macros, concatenated speech, transaction history, and real-time transcription editing.

SMARTMD

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SMARTMD is an excellent choice for a medical transcription service, according to techradar.com. It offers clinicians a variety of dictation options to fit their specific workflows. These options include a toll-free number, a digital recorder, or an iOS app that is compatible with both the iPhone and iPad. This tool incorporates cutting-edge technology to simplify the entire transcription process. Dictated notes are transcribed directly into the patient’s chart, saving time and maximizing the use of the EHR. The software also includes a secure cloud backup that ensures offsite backup of all patient records, enabling access anytime, anywhere. SMARTMD helps medical practices streamline operations, cut costs, comply with industry regulations, allowing physicians to dedicate more time to delivering quality care. There are no minimum or setup fees, and users can take advantage of live phone support.

KILI Technology

kili technology

KILI Technology is a software platform that provides automated medical transcription services. The software utilizes advanced artificial intelligence and machine learning algorithms to transcribe audio recordings into accurate and reliable text documents. Users can even classify audio to identify speakers or topics. The platform also includes a range of features to help streamline the transcription process, including automatic timestamping, natural language processing, and the ability to easily edit and format transcribed documents. File types supported are mp3, mp4 and flac. It also features built-in labeled data quality control, consensus analysis, honeypot, review, and last but not least, instructions for speech to text tasks. KILI Technology is designed to help healthcare providers save time and reduce costs associated with manual transcription, while also improving the accuracy and quality of patient records.

Several organizations that utilize transcription software also rely on medical transcription service providers to ensure that machine-generated medical dictation transcripts are thoroughly edited and proofread by expert medical transcriptionists. This practice significantly enhances the accuracy of the transcripts. Medical transcription outsourcing companies offer their services to a range of healthcare providers, including primary care and specialties such as cardiology, neurology, gynecology, radiology, pediatrics, urology, among others.

With years of experience and a proven track record of excellence, we can meet all your medical transcription needs.

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Accurate Physical Therapy Records Vital for Better Profitability

26-April-2021 Julie Clements Physical Therapy Transcription

Physical Therapy

Medical records are a combination of both self-reported patient information and physicians’ notes on the diagnosis, care and treatment given to the patient. When a patient visits a physician, he or she diagnoses the patient and dictates the patient’s medical condition via a digital recording machine. Medical transcription services transcribe these recordings into accurate medical records and via HL7 interface the transcription vendors can access the physician’s EHR and upload the information. Medical records should be documented in a timely and error-free manner.

The need for accuracy in medical transcription is rising rapidly. This is due to increased demand for medical documents to ensure quick and efficient patient care. It helps the healthcare providers to come up with the most appropriate treatment plan and correctly follow it. Accurate medical records not only improve the quality of care, but also help increase revenue.

What is the Reason for Poor Documentation?

According to an article by Promptemr, $10.7 billion worth software problem in physical therapy was caused by bad software, leading to indefensible documentation and bad billing processes. This not only affects the health of the patients but also results in loss of revenue for the medical organization. Another blog published in www.rightpatient.com stated that patient identification errors have been a long-term issue in the US healthcare system.

Significance of Patient Identification

It is estimated that every year, around 195,000 deaths occur because of medical errors. Patient identification errors are a major concern in this regard. Identity theft also leads to financial loss for patients. For instance, a person who did not undergo a particular treatment could receive a bill stating that they did. Patient identity may sometimes get mixed up due to common names, age, DOB etc. This can cause a ripple effect and damage the reputation and credibility of the healthcare organization. The right solution to this issue is to improve the accuracy of medical records by hiring a reliable transcription vendor.

Documentation Tips for Accurate Medical Records and Better Revenue

Accurate medical documentation is important to protect the patient’s health. It promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. With duplicate or inaccurate medical records, larger hospitals can have more than a million records stored in their EHR systems that are of no use. It leads to mistreatment, wrong medical decisions, and wrong medications, based on inaccurate or incomplete medical history arising from duplicate records or overlays. If the patients are identified before any service, the right patient will receive the right treatment. This will help the healthcare organization to save millions of dollars.

Set Achievable and Measurable Goals: The most common cause for denial of the claim in physical therapy is poorly documented treatment goals. So, the goal must be measurable and impact the patient’s daily life to be defensible and justify continued skilled treatment. Examples:
- Inaccurate: Improve Right Shoulder Range of Motion – 6 Weeks
- Accurate: Improve Right Shoulder Flexion Range of Motion by 20% to allow patient to reach into kitchen cabinets – 6 Weeks
Consider Objective Measurements more Frequently: Documenting objective measurements every time a patient visits may be of no use, as the patient’s measurements may be identical. Increasing the frequency of your objective measurements will however, allow you to prove your value to your patient and get them to continue going to therapy.
Track and Show Progress on Flowsheet: Illegible flowsheets impact the ability to treat your patients, and it can also lead to claim denial. Another issue it that it is not possible to use flowsheet to show a patient how much they progressed. An electronic flowsheet which is easy to use is a useful tool that help you get paid and also help you retain patients longer.
Document on the Same Day: Make sure to complete the documentation while you treat the patient. The ideal practice is to have the patient fill in his/her chief complaint, primary concern, and pain levels for the day. This practice helps to create defensible documentation that is accurate and saves you from getting behind on your notes.

Accurate medical documentation is an essential element for any hospital, clinic or healthcare unit, and a professional medical transcription company can help ensure this. It consists of all important information from the admission of the patient till his or her discharge. These records become useful for the patients as well as the healthcare providers for future visits.