Best Practices to Avoid Medical Transcription Errors

19-April-2021 MTS TEAM Medical Transcription

Medical Transcription Errors

Accurate, complete and timely medical record documentation is critical for patient safety and care. Today, most healthcare organizations rely on medical transcription services to ensure well-documented electronic health records (EHRs). In fact, it is critical that an expert handles the task of transcribing the oral dictation of physician interactions with patients or editing of reports generated by speech recognition software. Mistakes in EHR transcriptions can put patients at risk and lead to expensive medical malpractice suits.
So how do errors in medical transcription occur and how can they be prevented?

Reasons for Medical Transcription Mistakes

Factors that can Cause Medical Transcription Mistakes Include:

The person doing the documentation is not familiar or up-to-date with medical terminologies and other jargon that physicians use.
The audio quality is poor because the recording was not done in a professional manner.
The dictation is not clear or the physician dictates too fast, making it difficult to understand what is being said. This can lead to lab/dosage errors.
Homophones or words that sound alike but have different meanings, for e.g., hypertension and hypotension.
Misspelling of names of equipment and medications.
The dictated reports are not properly formatted, and information is missing.
The transcripts are proofread or put through the necessary quality assurance process before they are finalized and delivered.

Besides having experienced medical transcriptionists on board, reliable medical transcription companies carry out stringent quality checks to ensure that transcripts meet the highest quality standards and are delivered in quick turnaround time.

How to Avoid Medical Transcription Errors

The risks of medical transcription errors can be minimized by following these best practices:

Use Quality Transcription Equipment: Having the right hardware and software is necessary to produce error-free medical documentation. Essentials include a high-quality computer, PC or Mac, a good headset USB headset with noise-canceling capabilities, transcribing software, a foot pedal to make transcribing easier, a text expander program and a medical dictionary.
Listen Carefully to the Voice-Recorded File: Physicians send their dictation to the medical transcription company using different methods. This includes dictation via toll-free number to the company’s database, where the transcriptionist accesses the recording and converts it into a text document. Another method is to record the dictation using an audio recorder and then upload the files to the company’s secure FTP server for the transcriptionist to download and transcribe. The physician may also send in documents generated by voice recognition software for editing. Regardless of the method used, the medical transcriptionist has to listen carefully to the audio to produce accurate medical documentation. In fact, excellent listening comprehension is a key skill for a medical transcriptionist.
Follow Professional Transcription Guidelines: This includes:
- Listen to the whole audio first
- Transcribe one sentence at a time
- Use punctuation, hyphens, and capitalization properly
- Pay attention to spelling and use U.S. English
- Do not paraphrase or add additional information
- Don’t leave blanks – clarify any words or phrases you have not understood
- Ensure a verbatim transcript by removing utterance such as ums, ahs, stuttering, false starts, etc.
Stay Up-to-Date with Medical Terminology: Transcribing physician dictation requires extensive knowledge of medical terminology, including terminology relating to various specialties and pharmaceutical terminology. With the amount of research being published in medical journals and presented at meetings, new information, terminology and usages.
Cross-Check and Proofread Meticulously: Lab values are expressed as obscure abbreviations and standards of measurements that are hard to remember. The software may also misinterpret dosage amounts. This increases the likelihood of errors while entering values. Paying close attention to dictation, transcribing numeric values carefully, and cross-checking the information is crucial to avoid lab and pharmacy errors. If you’re unsure about something, search online or refer to your medical dictionary.
Prioritize Accuracy Over Speed: When it comes to medical documentation, remember that accuracy is more important than speed. Watch out for typos that can compromise the integrity of the transcripts. Nevertheless, typing speed is important and a skilled transcriptionist will focus on ensuring both accurate and timely documentation.

HIPAA compliant medical transcription companies with years of experience in the field follow these best practices to provide accurate, timely and secure EHR transcription solutions. Certified and experienced transcriptionists document physician dictation and the files go through stringent quality checks by proof-readers and editors before they are integrated into electronic patient records. By partnering with a reliable medical transcription service provider, healthcare providers can avoid the costs involved in inhouse transcription and get quality transcripts in short turnaround time. Importantly, outsourcing transcription will allow physicians to provide personalized care rather than be distracted by EHR data entry during the patient encounter.

Get Older Patients Vaccinated to Boost Their Immunity against COVID-19

15-April-2021 Julie Clements Medical Transcription

COVID-19

Elderly patients make frequent visits to the emergency department. This is because as an individual grows older, the immune system becomes slower to respond, which increases the risk of getting sick. Medical documentation of elderly patients needs to be maintained properly so that appropriate care can be provided at the right time. This is most significant in the current pandemic scenario. Physicians treating elderly patients can effectively utilize medical transcription services to streamline documentation.

Older people are vulnerable to many diseases and it is no different in the case of COVID 19 virus. The risk of getting infected with COVID-19 increases with age. According to the Centers for Disease Control and Prevention (CDC), older adults are at the highest risk. However, older adults are now getting vaccinated to prevent them from getting infected. However, another issue that older patients face is that they are likely to get COVID re-infection.

A study by Steen Ethelberg, PhD, of Statens Serum Institut in Copenhagen, and colleagues found that adults ages 65 and older had 47.1% observed protection against reinfection. The weekly medical journal The Lancet stated that overall observed protection against reinfection in the general population was 80.5% compared to PCR test results from the first and second surge. SARS CoV-2 reinfections are rare and only very few cases have been reported globally; the immunity following the infections lasts for 5 to 6 months.

Why Older People Should Get Vaccinated

Older people are at higher risk because they lose immunity as they get older and have more immune dysfunction. Data collected over the last year in Utah shows that 70 percent of deaths from COVID-19 have been in people 65 years old and older with over 1,500 deaths total. Age is a high risk factor in bad outcomes in COVID-19. So, it is extremely important for older adults to get the vaccine as soon as possible. People in this age group who have multiple chronic conditions, who may be frail, or living in a nursing home are in urgent need of the vaccine.

In the US, the vaccines authorized for used are Pfizer/BioNTech and Moderna; studies have shown that these vaccines are approximately 94% to 95% effective in preventing COVID-19 infection in all patients. The common side effects of this vaccination are fever, fatigue, headache, and muscle aches. This reaction is your body’s immune system mounting to the virus and building to your immunity.

The second dose provides 95% of protection against the virus. The antibody levels that are achieved with that 95% effectiveness will take place within 7-10 days after the second dose. The vaccine is only 50 to 55 percent effective after the first dose. The role of the second dose is boosting a patient’s immunity to the virus and it takes 10 to 14 days for the second dose to be 95 percent effective. While getting the vaccine into as many older adults as possible is important, it is equally important for older people to take necessary precautions even after being vaccinated. Even though the patient will be protected after taking the vaccine, it’s still not known whether they can spread COVID-19 to those people who are not vaccinated.

For elderly people who live alone, visiting a hospital can be overwhelming. They have to deal with many procedures and go through various questions before getting any treatment. So, older people should be educated about any underlying conditions they have and the precautions to take when they visit a hospital to avoid exposure to the virus. With accurate medical records older people can get the right treatment at the right time; and hospitals can maintain up-to-date documentation with the help of medical transcription services.

Maintaining Accurate Electronic Dental Record (EDRs) – Critical Considerations

12-April-2021 Rajeev Rajagopal Medical Transcription Company

Electronic Dental Record

The electronic dental record (EDR) also known as the electronic oral health record is an electronic health record (EHR). The American Dental Association (ADA) defines the EDR as “a combination of processes and data structures, used by dentists, for purposes of documenting or conveying clinical facts, diagnoses, treatment plans, and services provided”. Dental professionals need to maintain and produce accurate dental records to support good quality patient care and follow-up as well as for legal reasons. Many dental offices rely on medical transcription companies to document of the history of the illness, physical examination, diagnosis, treatment, and management of a patient in the EDR system. Such support enables efficient dental record keeping, which has become increasingly important due to the following reasons:

The prevalence of severe periodontal diseases in about 25% of people age 65-74 years old
Increased awareness about the importance of oral health, especially among the older population

Benefits of EDRs

Drives practice efficiency
Digital images can be easily stored and accessed
Provides instant access to a patient’s dental history and any pre-existing medical conditions, facilitating thorough and timely assessments
Can improve collaboration between medical and dental care practitioners and improve overall patient care
Offers various documentation options
Provides ease of storage and access to digital imaging
Can be integrated with other digital technologies and support for administrative tasks
Makes clinical data available for research purposes
can provide clinical support such as risk assessment tools and support decision-making.

Challenges of Maintaining EDRs

Large Amount of Information: The patient record typically comprises different elements, such as dentists’ notes, study models, radiographs, results of special investigations, referral letters, consultants’ reports, clinical photographs drug prescriptions, laboratory prescriptions, patient identification information, and a comprehensive medical history. All of this important information has to be entered accurately.
Records need to be Contemporaneous: In the context of dental records, the word ‘contemporaneous’ implies existing at or occurring in the same period of time, explains an article in Nature. In the dental office setting, this might mean, at the time the patient is present or immediately after, and before the next ‘period of time’ or appointment commences. Entering information in the record contemporaneously is crucial in dentistry to ensure that all important details of the treatment rendered are recorded. Time delays may result in incomplete and/or inaccurate entries as the clinician may not remember the details.
Copy-and-Paste Entries: The frequent and injudicious use of copy-and-paste functions, macros, templates and other tools by dentists is reported to be a major concern. While copy-and-paste and using standardized text are useful for certain aspects, a cloned entry from a previous record can pose significant dento-legal risks.
Knowledge about New Terms: Dentists and their staff use many terms in the course of providing patient care, maintaining dental records and preparing insurance claims. However, over time, new terms are introduced and old ones are revised. The ADA points out that while new dental professionals may be familiar with common terms, they may not be knowledgeable about new terms. Knowing these clinical terms is crucial for choosing the correct CDT Code for patient record-keeping and claim preparation. It is also important for medical transcription service providers to be aware about these terms. In fact, experienced medical transcriptionists who provide dentistry transcription services stay up to date on the glossary of dental and administrative terms available on the ADA’s website.

With its many benefits, EDR adoption and integration into the dental office is rising. Efficient electronic dental record systems capture patient data in a discrete or structured format system and come with advanced features such as treatment planning, specific protocols, electronic prescribing, clinical workflow, clinical alerts, and other integrated features. EDR integration with medical records allows healthcare professionals to provide comprehensive care. Outsourcing transcription to a company that specializes in dentistry transcription services can resolve many of the challenges associated with maintaining EDRs.

Key Tips to Document Operative Notes in a Practice [INFOGRAPHIC]

08-April-2021 MTS TEAM Infographics

Operative note is an important part of the medical chart that refers to a surgeon’s report and includes all necessary documentation regarding all the procedures ranging from what operation a patient had, what was found during surgery, and the post-operative instructions from the surgeon. Operative note includes the patient’s name, date of the operation, pre- and post-operative diagnosis, surgeon’s name along with other co-surgeon’s name, procedure, indication for surgery, findings of surgery and other details. These reports are increasingly accessible in electronic format with widespread electronic health record (EHR) system adoption. Physicians can ensure accurate EHR documentation and management with reliable medical transcription services.

Check out the infographic below

Operative Notes

Top Strategies to Address EHR Usability Challenges

05-April-2021 Julie Clements EHR Transcription

EHR

Electronic health record (EHR) adoption in the United States has reached a new high at 89%, according to a recent SelectHub report. However, even as EHR systems are constantly evolving, usability issues still persist. Surveys have found that lack of user-friendliness and documentation issues are major concerns for physicians. While medical transcription outsourcing helps physicians streamline EHR documentation, recent reports indicate that EHR usability issues are common during EHR implementation and optimization.

Key EHR Usability Problems

EHR usability problems are the main cause of patient harm, according to an article published in JAMA in 2020 (EHR Intelligence). Researchers from the Center for Clinical Informatics and Improvement at the University of California, San Francisco reported that about 40 percent of EHRs had an issue that could potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting.

Another study by researchers at The Ohio State University College of Medicine identified inappropriate EHR alerts, cognitive support matters, and objective encounters as key EHR usability concerns.

Problems attributed to poor system design, development and implementation included the following:

Drug Dosing Errors – when a dose was entered, the EHR system removed the decimal point from the entry, which could lead to overdosing
Extremely Cluttered Interface – a cluttered interface or a complex medication list could lead the physician to choose a wrong medication
Lack of Consistency in Data Entry – a complex interface can result in added clicks and scrolls. Heavy interaction with the EHR can lead to click fatigue which increases the risks of errors and cause clinician frustration and burnout.
Variation in EHR Usability Logic from User to User or Heterogeneity – Do EHRs present supporting the diagnostic reasoning process and the logical work flow that a specific user would want to undertake?
Alert Fatigue – EHR alerts have been identified as one of the most common usability interferences. Too many or random alerts can affect both the physician’s and pharmacist’s workflow.

Expert Recommendations to Mitigate EHR Usability Issues

EHR Reporting Program: The study recommends an EHR reporting program to promote EHR usability improvements. According to the researchers, a central reporting program can help clinicians and patients report potential safety issues when they are noticed. This will allow the issues to be analyzed and reported to the healthcare community. It was noted that any clauses that prevent clinicians from sharing screenshots and other information must the removed for this strategy to succeed.
Proper Certification Testing: Another strategy to improve EHR usability issued is to ensure that certification testing is done properly. It must be ensured that rigorous testing is during the certification process to ensure optimal product design and development. Further, the EHR product that is being tested and certified should be the same as the one that is being implemented and used by frontline clinicians. Some very basic accreditation standards should be introduced to encourage hospitals to do some very basic safety testing, researchers noted.
Improve Alert Systems: Experts recommend defining and improving the number of EHR alerts. It is necessary to remove alerts that do not make clinical sense and improve the ones that are not appropriate. Chief medical information officer at BayCare Health System, Florida, Alan Weiss, MD, and his team analyzed the signals, added more intelligence to alerts, and made them active (EHR Intelligence). He says that it is important to take steps to see that alerts do not trouble users. Alerts need to help users take action to improve quality, safety, and responsiveness to patients.
Quality EHR Training: EHR usability problems are associated with EHR optimization and the evolution of technology. An effective EHR training program is essential for users, especially for providers who are new to the technology. Proper EHR training can improve EHR usability and reduce chances of clinician burden and increase satisfaction. Experts recommend including EHR informatics in a training program so that users can understand EHR design and technology.

Over the past decade, EHRs have evolved into a critical element in the healthcare delivery system and will continue to progress in the coming years to improve the medical decision-making process and ease the tech burden on healthcare providers. With telemedicine rising in importance during the pandemic, providers and patients can initiate virtual visits via the EHR. Major improvements that EHR companies are planning in 2021 and beyond (www.beckershospitalreview.com) include: incorporation of natural language processing and voice assistants; fully connected, mobile EHR; enhancing the ability to access and exchange data regardless of its origin; inclusion of apps and technologies; cloud-based initiatives, and advanced artificial intelligence.

The quality of patient records is a critical focus for patient safety and improved patient outcomes. Partnering with an experienced medical transcription company is an ideal option to ensure accurate and timely documentation of patients’ conditions.

Solving the Problems Associated with Problem Lists in the EHR

01-April-2021 Rajeev Rajagopal EHR Transcription

EHR

The patient problem list, a key component of the electronic health record (EHR), is a list of the important illnesses, injuries, and other factors impacting a patient’s health. American Health Information Management Association (AHIMA) defines the problem list as “a compilation of clinically relevant physical and diagnostic concerns, procedures, and psychosocial and cultural issues that may affect the health status and care of patients”. The list usually states the time that the illness or injury occurred as well as when it was identified and addressed. Medical transcription companies help healthcare providers maintain dynamic problem lists that include all of a patient’s past as well as present medical problems.

A well-maintained problem list would provide the physician with a clear idea of a patient’s health problems that require medical attention or intervention. However, according to AHIMA, many organizations face challenges when it comes to defining what should and should not be included, responsibilities, and accountability for maintaining an accurate, updated problem list.

Uses of Problem Lists

The concept of the problems list was put forward by Lawrence Weed in the 1960s as part of a problem-oriented medical record (POMR). Today, problem lists are used for problem-oriented charting purposes, to meet accreditation standards and for EHR incentive payment requirements. The problem list:

helps physicians provide customized care based on the most important health factors for each patient
can be used to recognize disease-specific populations by identifying all patients with a common illness through ICD-10 codes in the EHR
is useful for quality improvement programs – helps health centers identify disease-specific patient populations, provide follow-up care, and ensure best practices in patient-centered care
serves as the basis for determining standard measures for practitioners and healthcare institutions.
can be used to identify patients for potential research studies

Problems with Problem Lists

Natural Human Errors: Problem lists often fail when it comes to complete accuracy because of natural human errors such as: forgeting to include a diagnosis or condition, describing a condition using incorrect terms or adding a condition that never occurred on the patient’s problem list.
Confusion about the Content to include the Problem List: Another major point of debate is regarding what diagnosed illnesses should be included in the problem list. Practitioners generally have their own opinions about what diagnosed illnesses should be included in the problem list. For instance, one study noted that practitioners may have differing opinions about listing a family history of breast cancer directly on the problem list. While one provider may consider this important to promote frequent testing, another may argue that this can clutter the problem list by repeating the family history section. (www.bmcmedinformdecismak.biomedcentral.com). As many organizations leave this decision to their practitioners, a shared EHR system may have differing problem lists.
Comprehensibility: While all of a patient’s health concerns could be included in the problem list, clarity can become a problem if the patient gets sicker. The problem list of a relatively healthy patient may include only less than five nontransitive illnesses, but that of a sicker patient may be a long document with a lot of text, making it difficult to obtain a clear picture of the patient’s health.
Challenges Posed by EHR Design: Utilization of free text, drop-down menus, data entry, and abbreviations in EHRs is another challenge. If the physician documents a condition or diagnosis and the EHR design does not offer the option to add this to the problem list, it will be difficult to maintain an updated list. EHR design issues that can cause information overload include the challenges of adding or deleting a problem and absence of a ‘recurring’ status option for a listed condition in addition to the existing ‘active’ and ‘resolved’ options.
Inclusion of Sensitive Information: A key debate is about how much behavioral health information can be shared across the organization. In some cases, access to psychiatry notes is restricted to the psychiatry department. state and federal patient privacy requirements should be considered for clarity on what problems should or should not be included on a problem list.

One serious issue, according to a For the Record article is that some EHRs are designed to automatically send the codes associated with the list of conditions in the problem list to the claim. If the provider does not maintain an accurate problem list that clearly represents the active conditions for which the patient is being treated, the claim will be an inaccurate representation of conditions associated with the services provided by the physician. Fraudulent medical billing attracts stiff penalties and expensive fines.

Creating Problem-Free Problem Lists

A trouble-free problem list is one that will provide the physician with a clear picture of the patient’s problems at a glance. Here are some solutions to maintain accurate problem lists:

AHIMA recommends that, to ensure integrity and reliability, organizations should establish clear policies and guidance about the structure and use of problem lists.
Having qualified medical coders review physician documentation can provide clarity about the conditions that are being assessed and treated. Coders can query the physician about any condition that cannot be ascertained.
Conducting annual reviews
Involving patients by encouraging them to review their problem list on a patient portal and report any errors they notice.

Outsourcing medical transcription can take care of EHR data entry tasks and allow physicians to focus on their primary goal of patient care.

Telehealth a Viable Tool to Combat the Obesity Epidemic

29-March-2021 MTS TEAM Medical Transcription

Telehealth

The electronic medical record (EMR) contains a ton of information – the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, results of lab tests, and radiology images. Outsourcing medical transcription helps providers ensure up-to-date information in the EMR. Today, integration of the EMR with a practice’s telehealth platform enables complete and effective care delivery, while also streamlining provider workflows. Telehealth is a useful tool to treat various medical conditions – from flu and hypertension to heart disease, skin disorders, mental health issues, and so on. Telehealth is now proving a viable tool to combat the obesity epidemic in the U.S., especially in the context of COVID-19.

Obesity is one of the most serious health concerns in the United States. The Centers for Disease Control and Prevention estimates that about 42.4% of the adult population was obese in 2017~2018, and that the prevalence of the prevalence of severe obesity increased from 4.7% to 9.2% during that period. A result of lack of exercise and an unhealthy diet, obesity is often responsible for serious health conditions such as diabetes, heart disease, hypertension, and certain types of cancer. Billions of dollars are spent every year treating obesity and obesity-related conditions.

Telemedicine an effective option for obesity treatment, say studies

A study published in the Journal of Telemedicine and Telecare in 2018 reported that combining video coaching and self-monitoring through mHealth devices led to “significant” reductions in weight and body mass.

In the study conducted by researchers at California State University at Long Beach, the University of Saint Mary, UCLA’s David Geffen School of Medicine and InHealth Medical Services, participants were enrolled in a 12-week program that made use of various apps and wireless devices. A registered dietitian conducted weekly health coaching sessions on a one-on-one basis and education materials sent to the participant every week. The study found that, over a 12-week period, the group with access to telehealth coaching sessions lost an average of 16 pounds, while the control group lost only an average of 3 pounds.

The researchers concluded that weekly video conferencing with a health coach and educational modules are an effective way to treat obesity by reducing body weight and increasing physical activity.

Telehealth platforms are also ideal to manage diabetes. According to the recent mHealth Intelligence report, providers and payers are integrating telehealth into diabetes prevention programs to help patients manage their weight and cut risk of developing diabetes.

The report also references Louis Aronne, MD, medical director of the Comprehensive Weight Control Center at Weill Cornell Studies who notes that studies have shown that one-third of people in telehealth-led obesity treatment programs have lost at least 5 percent of their body weight. Over time, this can improve health and also lead to significant reduction in healthcare costs.

How Telehealth helps in Obesity Management

Facilitates Expert Intervention: Fitness apps, exercise regimens and diet plans are available, but in many cases, these fail to work without expert intervention. With a telehealth platform, people have real-time access to an expert health coach. The expert can review real-time data from the patient’s mHealth devices and provide information, guidance and encouragement
Holistic Solution: platform offers an ideal opportunity to blend behavioral and clinical care, two critical elements of obesity treatment. Online coaching and wireless devices coupled with motivational strategies can be used to provide medication adjustments, exercise and counseling services and help patients lose weight and improve clinical outcomes.
Convenient Way to Connect: Both patient and provider have the opportunity to connect conveniently on the telehealth platform. Patients can connect with their provider on a daily or weekly basis, and discuss both motivations and care management.
Access to Different Types of Specialists: Use of video and telephone-based technologies provides patients with real-time access to a team of health experts such as physicians, nutritionists, fitness coaches, psychologists, and others. Telehealth builds an ongoing relationship between experts and the patient.
Allows for Effective Patient Management: Providers can monitor and assess progress, provide accurate feedback, and tailor programs based on the data that is transmitted via the telehealth platform and connected devices such as fitness trackers and BP cuffs.
Makes it Easier for Patients to Discuss a Sensitive Topic: People are sensitive about their weight issue and hesitant to discuss it or being advised to lose weight. Telehealth makes it easy for providers and patients to have discreet, personal conversations about this sensitive topic.
Personalized Solutions: Combining telehealth and mHealth apps can improve care management and allow for more personalized interventions. These tools allow providers to provide coaching and guidance on diet, exercise, and behavioral health and tailor a program to meet a patient’s specific needs.
Ensures Regular Follow-up: One of the excuses people make for not enrolling in weight management programs is lack of time for regular follow-ups. Telehealth provides the solution. Follow-up through video-based meetings between experts and patients make sessions convenient and comfortable for both parties, eliminating problems posed by time and distance.

Telehealth has soared during the pandemic. Telehealth is an extremely effective option when in-person care is not a necessity, such as in weight management, saves time, and reduces risk of exposure to infection for patients and providers alike. Medical transcription services play a key role in helping providers ensure quality documentation of virtual visits in the EHR. In January 2021, the Obesity Medicine Association (OMA) updated its OMA Obesity Algorithm to include practice guidelines for using telehealth.

Impact of COVID-19 Pandemic on Demand for Radiology Services

25-March-2021 Julie Clements Radiology Transcription

Radiology Services

The demand for imaging services has increased in the U.S. in recent years. Radiologists interpret images, manage urgent cases, and consult with referring physicians. Medical transcription companies have always and will continue to support them with timely and accurate transcripts of imaging reports.

Many reports have highlighted the critical role that radiology departments play in implementing processes to manage the pandemic, specifically for planning diagnostic screening, triage, and management of patients. According to a recent report in the Times, the demand for radiology services has surged significantly with the outbreak of the COVID-19 pandemic. Medical imaging plays a key role in supporting clinical decision making in the diagnosis, management and treatment of Covid-19 patients. Here are considerations that support this:

Fluid build-up in the chest is a complication of COVID-19 and ultrasound, CT, or x-ray equipment is generally used to guide thoracentesis or pleural taps.
Though imaging for COVID-19 screening is not done routinely, imaging is done in patients testing positive for or suspected of having COVID-19 to exclude other diagnoses that can be treated, including pulmonary embolism. CT and chest radiography in patients suspected of having or positive for COVID-19 depends on whether imaging will impact patient management.
Emergency imaging may be required for evaluation of many urgent conditions, including stroke, trauma, infection, and other disease conditions.
Medical imaging could be valid to distinguish between Covid-19 and other viral respiratory illnesses with similar symptoms.
Medical imaging modalities that are relevant for COVID-19 diagnosis and management include chest radiographs, chest CT, lung ultrasound, as well as MRI, according to a paper published in Radiography:
- Chest radiographs play a key role in the initial radiological assessment of patients presenting with respiratory distress and possible Covid-19. They are the most widely used imaging modality for suspected and confirmed Covid-19 cases.
- Chest Computed Tomography (chest CT) plays a limited but significant role in clinical management of Covid-19 patients. Experts recommend that CT should be reserved for seriously ill patients, with emerging awareness of high prevalence of pulmonary thrombosis. It can also help when chest radiographs are inconclusive. low-dose chest CT could be used for follow-up imaging where CT is required for clinical decision making.
- Point-of-care lung ultrasound can help in evaluation of COVID-19 patients in an intensive care setting.
- Though not directly relevant for assessing lung disease, Magnetic Resonance Imaging (MRI) can support diagnosis in patients with neurological manifestations, such as acute stroke, skeletal muscle injuries, and consciousness impairment.

In addition to the COVID-19 led surge for radiology services, several factors are driving the overall demand for diagnostic imaging studies:

Aging Baby Boomers: Between 2020 and 2030 alone, the number of people over 65 is expected to comprise 21% of the U.S. population, up from 15% in 2014, according to the U.S. Census Bureau. As people get older, they need medical services more frequently, including imaging.
Accessibility to Advanced CT and MRI Procedures: Hospital and freestanding emergency departments offer advanced CT and MRI procedures. Use of diagnostic imaging studies is increasing with rising ED volumes.
Teleradiology: Increase use of remote care services have increased the demand for teleradiology services. Partnering with teleradiology firms is helping many organizations to better manage imaging workflow while cutting costs.

Radiology workflows, volumes, and access must be optimized to prepare for expected surges in the number of patients with COVID-19, noted a paper published in Radiology last year. Radiographers should be aware of the main challenges related to imaging patients with Covid-19. This will promote patient care and safety, optimize image and support more accurate diagnosis. They should also be aware of how to keep themselves and their workspaces safe by using the right safety measures and precautions. Regardless of the challenges they face during the pandemic, radiologists need to prepare accurate and timely radiology reports. Outsourcing radiology transcription to an experienced medical transcription company could be the best solution.

How Clinical Decision Support Tools improve Clinician Efficiency and Patient Outcomes

22-March-2021 Rajeev Rajagopal Medical Transcription Outsourcing

Clinical Decision

The electronic health record (EHR) is designed to reduce risk of errors and help physicians make better decisions about patient care. When it comes to EHR documentation, medical transcription service providers deliver the necessary support to ensure that patient records have all the relevant information for physicians to render safe, appropriate, timely care. Clinical decision support (CDS) includes a wide variety of tools that are built into the EHR to help providers find the right information to make clinical decisions and provide the best possible patient care.

The amount of digital patient health data is increasing exponentially, leading to significant data management challenges for healthcare entities. Researchers estimate that healthcare data will grow at a CAGR of 36 percent through 2025 which this is much faster in manufacturing, financial services, or media, according to a Healthcare Analytics report. CDC tools are designed to sift through this data and provide clinicians with the information needed to make effective and reliable decisions to deliver value-based care.

Clinical decision support tools provide physicians, nurses, support staff, patients, and other caregivers with information relevant to a specific person or situation. These tools are meant to:

Improve the quality of care
Prevent errors/adverse events, and
Improve the efficiency of the care team

HealthIT.gov states: “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools”.

How CDS Tools Work

Computerized Alerts and Reminders: EHR alerts such as admission, discharge, and transfer (ADT) notifications or screening reminders quickly provide clinicians with critical patient information through the EHR interface to streamline clinical efficiency and care coordination. Here are three ways EHR alerts can improve care quality:
- Admission, discharge, and transfer (ADT) notifications help to keep care teams updated during these times to improve care coordination and reduce hospital readmissions.
- EHR alerts can also help providers monitor the patient’s health status which can help improve chronic care management.
- Alerts can also help providers reduce redundant testing and minimize patient safety risks. Medication errors can be prevented when an alert pop-up appears when submitting a prescription.
Clinical Guidelines: Computerized guidelines as decision support systems (DSS) in the EHR are documents that facilitate and regulate diagnosis, management, and treatment in specific areas. EHR can display standardized clinical guidelines based on diagnosis entry. EHR decision support tools can also alert clinicians about treatment plans and orders that are not in accordance with the latest clinical guidelines.
Condition-Specific Order Sets: EHR order sets allow providers to enter and send medication, laboratory, and radiology orders and other treatment instructions. Order sets or templates are tailored for specific diseases. By ensuring providers produce standardized, legible, and complete order, this CDS tool can improve patient safety. Computerized orders also save time and improve efficiency. Computerized order sets flag orders that require pre-approval from payers, and help reduce claim denials.
Focused Patient Data Reports and Summaries: Focused patient reports and summaries that medical transcription companies help physicians create are an important clinical tool that benefit both providers and patients. Providers can easily access these summaries of data reports for reference and review. Patients can access these individualized reports in the comfort and privacy of their home and get a clear understanding of their own medical condition.
Documentation Templates: EHR documentation templates are designed to facilitate the collection, presentation, and organization of clinical data elements. These templates come with prompts that alert the provider to specify required or missing documentation. Well-designed templates capture specific information needed for patient care and accurate reporting of the patient encounter, thereby promoting delivery of quality care and the completeness of documentation.
Diagnostic Support: EHR clinical decision support tools can also help physicians provide a proper diagnosis faster. By retrieving the medical history through the EHR, physicians can get a comprehensive picture of the patient. EHR clinical decision support tools can analyze patient data, suggest additional diagnoses, and recognize diagnostic errors, helping physicians make more accurate decisions.
Relevant Reference Information: Links to reference information for both clinicians and patients are another important CDS tool built into the EHR system. Examples of this intervention provided by digital.ahrq.gov include: Direct links to specific, pertinent reference information for clinicians, link from medication order screen to display of side effects and/or dosing for that medication, link from problem-list entry to latest evidence-based treatment overviews for that problem, link from immunization flowsheet to table of standard immunization intervals, and link within patient-messaging application to relevant patient drug information leaflets.

Medical Transcription Support for Documentation Accuracy

According to CMS, with efficient CDS tools, pertinent information would be delivered to the entire care team and patient through the right channels (EHR, mobile device, patient portal) in the appropriate intervention formats for decision making or action. Outsourcing medical transcription can ensure the documentation accuracy required to support clinical protocols.

Top EHR Trends for 2021 and Beyond

18-March-2021 MTS TEAM Medical Transcription

EHR

Electronic health records (EHRs) have come a long way since they were introduced and are continuing to evolve with flexible functionalities that improve the clinical decision-making process. Medical transcription services allow healthcare providers to manage the record keeping process and save time to focus on patient care. According to recent reports, with significant enhancements in health information technology, EHRs are poised play an even more influential role in healthcare. Here are seven major EHR trends to watch out for in 2021 and beyond.

Voice Recognition and Natural Language Processing: Voice recognition tools are mainly used to dictate reports and clinical notes into the EHR, making clinician interactions with the system less stressful. Voice assistants make it easier for clinicians to connect with patients, search a patient’s medical history and place orders using the EHR. Speech-to-text applications depend on natural language processing (NLP) to turn sound into text. Leading EHR manufacturer Epic says that, in future, their EHR voice assistant will also be able to write the clinician’s note and close the visit (www.beckershospitalreview.com).
Focus on Reducing Errors: In their 2020 report, the ECRI Institute identified several EHR related errors. One was the high number of alarms, alerts, and notifications that can overwhelm clinicians. This creates the potential for significant events to go unnoticed and unaddressed. Medication timing errors are another issue. Configuration and usability issues within the EHR can lead to mismatch between the order generated by the software and the prescribed medication administration time, the report noted. It’s obvious that providers will be looking to address such technology concerns to reduce errors and ensure patients safety.
Advanced Data Analytics: Each patient’s digital record includes demographics, medical history, allergies, laboratory test results, etc. EHR data analytics provide managers with timely information needed to generate customized reports. With technology advancing at a rapid rate, the possibilities of how healthcare analytics can be used is expanding. The future of healthcare analytics depends on using technologies such as artificial intelligence, machine learning and natural language processing for greater impact.
Increasing Patient Engagement: Patient engagement has always been a concern and the pandemic highlighted its importance like never before. According to a recent beckershospitalreview.com report, one of the several patents Allscripts has secured is for an app connecting EHRs to other wellness apps and supporting patient engagement through goal tracking. EHRs are being used to send text message appointment reminders to patients, which lowers cancellation rates quite significantly.
Cloud-Based Initiatives: Leading EHR companies are working with big tech to promote cloud-based initiatives. For instance, Medtech teamed up with Google Cloud in December 2020 to deploy a new cloud-based, subscription model EHR platform. An extension of Medtech’s cloud-based Expanse EHR, the new Cloud Platform comes with many new capabilities including a virtual care feature that provides new and existing patients with access to urgent virtual care through the provider’s website.
Blockchain: EHRs contain critical and highly sensitive private information for diagnosis and treatment in healthcare. Benefits of EHRs range from supporting medical prescriptions, improving disease management, and reducing severe medication errors. The sharing of healthcare data is essential for improving the quality of healthcare services. However, EHRs have interoperability issues. A recent study published in the Health Informatics Journal reported that blockchain could transform the way patient’s electronic health records are shared and stored by securing it over a decentralized peer-to-peer network. It has the potential to provide a new model for health information exchange (HIE) by making EHRs more efficient and secure.
Readying for 5G: Healthcare organizations and systems are increasingly implementing telehealth and IoT devices. The healthcare industry must embrace 5G to take advantage of the next generation of internet speed and the value it offers for telehealth and other wireless clinical applications that are transforming healthcare delivery. Next generation connectivity will provide efficacy and efficiency for several healthcare applications such as improving data management, better handling of large imaging files, remote patient monitoring and virtual care, and more.

Even as technology-driven initiatives like natural language processing (NLP) and speech recognition (SR) are incorporated into EHR systems, medical transcription outsourcing will continue to be relevant to ensure accurate documentation. While these new technologies can save time spent on EHR data entry tasks and reduce physician stress, research shows that medical transcriptionist review of SR-generated documents improves the quality of medical records, reduces errors and improves patient safety.