Expert Recommendations for Documenting an Older Patient’s Medical History

24-June-2021 Rajeev Rajagopal Medical Transcription

Medical History

The medical record is a medical and legal document that contains information about a patient’s health and medical history. The History and Physical (H&P) is fundamental part of a medical transcription service provider’s work and the first report added to the patient’s medical record when physicians see the patient for the first time. The H&P is crux of the medical treatment plan and the most important tool in the exam of the patient in the emergency department. When it comes to an older patient, a proper medical history and physical exam is critical for correct diagnosis and appropriate treatment.

The components of the H&P are: chief comp, present illness, past history, review of systems, physical exam, problem list and differential diagnosis. For older adults, physiology of aging and pathologic conditions related to aging can make diagnosis difficult. The National Institute of Aging (NIA) recommends that in addition to medical and family history details, the history for geriatric patients should include information about their social circumstances and lifestyle.

General Recommendations

According to the NIA and other valid sources, there are several factors that physicians should take into account when documenting older patients’ medical history:

It may take more time (even several sessions) as the patient may take more time to explain things or because of sensory impairment and cognitive decline.
It would be a good idea to obtain preliminary information before the consultation using printed (use large font) forms sent by email.
Choose the question format – open-ended or simple yes-no questions – based on the patient’s ability to respond.
Before evaluating the current illness, get the medical history immediately after the chief complaint. This will make it easier to understand the patient condition.
Though information is best obtained first-hand from the patient, caregivers or other sources should be contacted to if doubts arise.
The provider should refer to the mental health status report if the patient’s responses are clearly inadequate or inappropriate.
Make sure that patients only have to tell their story once. Also, find out if anything has changed since their last visit – whether living arrangements have changed or they have experienced any personal loss.
The physician should sit facing the patient at eye level and speak slowly and clearly, with good lip movement. Questions should be presented in print if the patient has hearing issues.
Pay attention when patients express their concerns – this in itself can be therapeutic and build trust.

Areas Needing Special Attention

Current Issues: Older patients may have multiple health issues. The focus should be on what’s currently troubling them the most. Certain medical conditions can increase risk for severe illness. Older adults diagnosed with COVID-19 are at greater risk of severe illness and hospitalization or death.
Functional Assessment: Functional impairments and cognitive and affective problems are common among older patients. The physician should ask questions to identify impairments in Basic Activities of Daily Living and Instrumental Activities of Daily Living. Recognizing these impairments would enable appropriate management or referral.
Medications: Polypharmacy and misuse of medications can lead to many health complications in older adults. It’s important to ask patients about all their prescription and over-the-counter medications and dosages as well as any alternative treatments and dietary supplements they may be using. A widely recommended strategy is to ask patients to bring along their medications in a paper bag.
Family History: The NIA notes that getting information about family history is important not only to understand the patient’s genetic risks but also to get information about the health of family members or relatives taking care of the patient and the kind of support that they can provide, if needed.
Social and Nutritional History: Assessment of social history will help reveal issues related to lifestyle, affect, cognition, function, values, health beliefs, cultural factors and caregiver support. Getting information about the patient’s home can provide an understanding their illness and might improve adherence to treatment. Nutritional assessment can identify risk of malnutrition and whether referral for dietetic consultation is necessary

All members of the patient’s care team refer to the H&P right from the point of its creation. The H&P remains a central element in the patient record even as additional reports are added on in repeat visits to document progress, interventions, surgery and so on. While the H&P for a patient with not-so-serious concerns may be brief, the reports for older patients with multiple chronic conditions are likely to be detailed and lengthy. Accurate and timely medical chart documentation by an experienced medical transcription company can go a long way in helping physicians focus on the consultation and interviewing older patients to elicit all the information relevant to their care.

Importance of Proofreading and Reviewing SR-Generated EHR Clinical Documents

17-June-2021 Julie Clements EHR Transcription

EHR

Speech recognition technology (SRT) converts the spoken word to text and helps physicians to improve productivity and turnaround time. SRT is widely used in Electronic Health Record (EHR) systems of healthcare organizations and medical practices. As it eliminates the need to use the keyboard, SRT simplifies and speeds up tasks like searches, queries, and even form-filling. Medical transcription services have evolved to include SRT editing which involves identifying errors in physicians’ SRT-draft documents.

In Front End SRT, the physician dictates directly into the machine and the words are automatically transcribed and displayed on the screen in real-time. Errors can be corrected and the document can be finalized and signed immediately by the physician. The main drawback of this method is that takes up a lot of the physician’s time. In Back End SRT, the speech-to- text conversion takes place after the dictation is complete. The software converts the digital voice files into a text document and this is sent to a medical transcription company for proofreading and editing. The transcriptionist has to listen to the voice file to identify errors in the draft document. With Back End SRT, the physician is freed of this task.

The goal of speech recognition software is to enable accurate, faster and more cost- effective healthcare delivery and documentation than handwritten notes or medical transcriptionists. However, in reality, speech recognition technology has fallen short of its potential, according to an article published in the Journal of AHIMA in 2020. The article cites a 2017 study published in Jama Network Open which found that SRT-generated documents did not provide the promised accuracy. The researchers found that editing, and review by healthcare documentation specialists and healthcare providers was crucial for SR generated clinical notes.

The study was based on 217 randomly selected medical reports of different types that had been dictated by 144 physicians from two different healthcare facilities using SRT. The error rate in the documents was:

7.4% in in SRT generated reports
0.4% after reports were reviewed by medical transcriptionist, and
0.3% in the final version signed by the dictating physicians

SRT made errors in the prescribed doses of medicine, medication names, numbers, and even medical conditions. There were also word deletions, omissions and misinterpretations.

The researchers pointed out that though the error rate is a little lower after clinician review, requiring clinicians to review notes rather than allowing medical transcriptionists to assist with review may further increase administrative burden.

“Clinicians face pressure to decrease documentation time and often only superficially review their notes before signing them,” wrote researchers. “Fully shifting the editing responsibility from transcriptionists to clinicians may lead to increased documentation errors if clinicians are unable to adequately review their notes,” they explained.

Other common SRT transcription errors include spelling, grammar, word substitution, homophones, incorrect tense, punctuation mistakes, incomplete phrases, and age/gender mismatching. Oftentimes, SRT cannot recognize heavy accents and multiple speakers.

Completed and signed medical reports are regarded as legal documents. Therefore, before signing, the document should be carefully proofread by an experienced medical transcription service provider or healthcare documentation specialist, and finally reviewed by the physician. Not having documentation quality assurance practices in place can lead to malpractice suits and heavy penalties. Experts also highlight the importance of investigating clinicians’ satisfaction with SR technology, its ability to fit in with clinicians’ workflows, and its impact on documentation quality and efficiency compared with other documentation methods (beckershospitalreview.com).

Organizations that utilize SRT should implement proper policies and procedures to ensure that SRT-generated clinical documents are proofread and reviewed. An ideal option would be to have a reliable medical transcription company check the accuracy, completeness and format of EHR documents transcribed by the software before they are reviewed and signed by the clinician.

Patients Access to Radiology Reports – Perspectives and Recent Developments

14-June-2021 Rajeev Rajagopal Radiology Transcription

Radiology Reports

Timely and accurate imaging reports are critical to help physicians determine the optimal course of care. Radiology transcription services play a key role in help radiologists prepare their reports. Today, hospitals offer patients access to radiology reports through secure online portals. Under a new information-blocking provision included in the 21st Century Cures Act, radiology practices are required to ensure a more timely release of imaging reports to patients.

Benefits of Reporting to Patients

Conventionally, radiologists reported results to the referring physician, and it was the referring physician who informed patients about their radiology results. With the recognition of individuals’ right to their medical information, there has been a shift in this practice and patients can now access their electronic health record, including radiology reports. Experience shows that allowing patients direct access to their radiology reports has a positive impact:

Reinforces patient-clinician communication
Enables radiologists to becomes more involved in their patients’ treatment decisions
Improves health literacy and helps patients use information and services to take informed health-related decisions and actions for themselves and others
Gives patients the opportunity to understand their reports before they see their doctor
Encourages patients to become more involved in their care and self-management of their disease
Clear and full radiology reports can be shared by patients with other specialists to obtain further explanations, second opinion, or continuous treatments
Boosts teamwork and care coordination

The components of radiology reports transcribed by medical transcription companies include the type of exam, clinical history, comparison with previous exam, technique, findings, and impression, which is the radiologist’s summary of the findings. Much of the early opposition to giving patients access to their imaging reports was due to the concern that patients wouldn’t be able to understand the content of the reports and could easily misinterpret the results for the worst (www.radiologytoday.net).

New Law Mandates more Timely Release of Imaging Reports to Patients

The information-blocking provision of the Cures Act is aimed at promoting data interoperability and allow immediate access and portability of personal health information by patients, providers and payers. The law requires that electronic reports – including radiology reports – be released to patients immediately after finalization.

Prior to the Information Blocking Rule, most radiology departments had followed time-delayed releases (embargo) of radiology reports to patients. One reason for the delayed approach was technologic feasibility barriers. A more typical reason was to give the treating physician who ordered the test to first receive, review and discuss the radiology report with their patient. One study found that embargo periods varied among the surveyed institutions from 1-3 days (34.4%) to 7-14 days (9.4%) and indefinite (20.3%) (www.auntminnie.com). With the new rule, researchers are expecting a major change in practice with regards to patients’ early access to radiology report. Radiology departments are preparing to eliminate the embargos and provide patients with prompt access to their radiology reports.

Need to make Radiology Reports more Patient Friendly

It’s not enough to give patients quick access to their imaging reports – radiologists need to make the reports more patient friendly. In fact, a new study published in Insights into Imaging found that patients were not satisfied with current radiology reports because the reported results were not easy to understand. The study which was based on an online discussion forum analysis found that:

There is a big gap between patients’ understanding and current radiology reports
Online question and answer platforms are an important option to understand about patient needs
Patients’ need to understand their reports should always be taken into consideration
Providing appropriate reports that patients understand should be a priority

The researchers concluded that radiologists should focus on designing a consumer-friendly radiology report that focuses on major patient concerns.

As radiologists prepare to provide speedy patient access to their imaging reports, a team from Massachusetts General Hospital radiology department offered several recommendations to streamline the process and improve patient understanding of their imaging reports (www.diagnosticimaging.com):

Providing a short summary at the end of reports in lay language to help patients better understand their results.
Including a message for the patient about whether findings are normal or abnormal
Add any recommended next steps to help ease patient worries
Change workflow and operations to shorten the interval between imaging and appointments to about 48 hours.
Include the radiologist’s phone number on the imaging report. Conversations with the radiologist can improve a patient’s understanding of imaging results.
Provide patients with simple definitions of complex terms as well as pictures or links to information sources

Radiology transcription services play an important role in ensuring accurate, complete, and timely radiology reports to enhance the quality of patient care. As the nation moves towards a more transparent health records, an experienced medical transcription company can help organizations improve data interoperability and facilitate easy patient access to medical records, including radiology reports.

Importance of Interface between Practice EMR and Pathology LIS

07-June-2021 Julie Clements Pathology Transcription

EMR and Pathology LIS

Every day, pathologists and other laboratory professionals work with primary care physicians as well as specialists and utilize laboratory testing to find or rule out diseases and conditions. These laboratory experts help physicians make critical decisions about treatment for cancer, management of diabetes, heart disease, and other chronic conditions. Advanced, high-quality lab medicine is crucial for patients to receive the right diagnosis and appropriate treatment for the identified disease. Timely and accurate pathology transcriptions ensure that interpretations of biopsy results, Pap tests, and other biological samples are documented.

Pathology tests include blood tests, and tests on urine, stools and bodily tissues. Specimen processing relies on turnaround time and efficiencies, making it one of the most critical elements of lab workflow. Fast processing of laboratory test results is essential to quickly and accurately diagnose and treat patients. Over the last decade, labs have steadily moved on from manual to implementing automated testing. Lab tests support overall health improvement and better disease management throughout a person’s lifespan.

The volume of laboratory tests being performed has been increasing at a rate of 6-8% per year, according to a study published in the American Journal of Biomedical Science & Research in 2019. Since the COVID-19 outbreak, clinical laboratories have been in the forefront to provide quality and accurate test results, even as they faced unprecedented challenges and uncertainties. The digital care environment has made things even more complex. Experts say that establishing an interface between practice electronic medical record (EMR) systems and pathology laboratories can improve workflow and efficiency in both settings. This implies the efficient deployment of laboratory Information System-Electronic Medical Record (LIS-EMR) electronic interfaces.

A laboratory information system (LIS) is a software program that receives and stores requests for tests, and results entered by laboratory technicians or directly from laboratory instruments. LIS capabilities include handing patient check-in, order entry, results entry, patient demographics, specimen processing, and routing test results. The electronic medical record (EMR) is a computerized medical record that holds the health records of a hospital, clinic, physician’s office or any organization that delivers care. Modern LIS systems are designed to interface with EMRs of health care organizations. Such interfacing offers many benefits:

Precise and Prompt Communication between Medical Practice and Pathology Lab: With the clinician and patient waiting for test results, labs aim to get final reports out as soon as we can. With LIS-EMR interface, practices have the capability to order lab tests and receive the results directly within their system. Timely and accurate communication of test results is central to ensuring the provision of appropriate care.
Smooth Workflow without Additional Staff Involvement: Interfacing LIS with the practice EMR allows important information to be shared instantly. Practices can receive lab results into the EMR will allow clinicians to automatically review, search, track and sort results without involving additional support staff.
Reduces Risk of Data Errors: By sending requisitions digitally, practices can reduce the probability of errors by avoiding the need for the lab to re-enter the data in the LIS. Data delivered directly into the LIS helps in avoiding errors such as absent or incorrect patient demographic data, technical errors, lack of medical necessity, lack of pre-authorization, erroneous patient demographic information, incorrect provider data, and more, according to www.mlo-online.com.
Saves Time and Helps Clean Claim Submission: Interfacing the laboratory ordering system with the practice management or EMR system ensures that labs receive clean up-to-date patient demographic and insurance information directly from the EHR. Demographic data is pulled into the lab requisition at the time of the order, saving the time and effort needed to retype patient data. Clean orders information in the LIS through EHR connectivity will improve the quality of care and also helps labs reduce operational costs, submit clean claims and improve their bottom lines.
Improves Patient Satisfaction: Patients are anxious about their results, which is why reliable and timely delivery of lab results is critical. EMR interfaces and optimal laboratory processes can reduce the turnaround time from when a sample is taken to when a result is received, promoting better quality care and patient satisfaction. As LIS-EMR interface improve data integrity, it also contributes to patient safety.

Producing accurate pathology reports depends on having the pathologist’s reports documented by an efficient medical transcription company. Trained and experienced transcriptionists would be familiar with medical terminology and can ensure complete, accurate and interpretable pathology transcriptions. Partnering with a reliable company can help pathologists focus on their core tasks – delivering timely and accurate test results in real-time through LIS-EMR interface to support the physician decision-making process and drive positive patient outcomes.

What Are the Different Types of Electronic Healthcare Record Software?

03-June-2021 Rajeev Rajagopal EHR Transcription

Electronic Healthcare Record Software

Medical documentation is an important aspect in the healthcare industry, and over the years it has undergone several changes. Earlier, the medical record was a simple handwritten document which has now transformed into digital format. Today, healthcare units and hospitals have adopted EHR systems for efficient management of medical documents. It improves speed and access to the medical data physicians need to make the right healthcare decision for their patients. EHR is an electronic record of an individual’s medical history and this standardized system ensures secure exchange of health information. EHRs are designed to improve healthcare quality, ensure patient safety, and reduce health costs. With the EHR, patient health data can be shared among all the authorized parties involved in the patient’s care: clinicians, labs, pharmacies, emergency facilities, nursing homes, state registries, and patients themselves. However, EHR documentation burden often leads to physician burnout. The conventional dictation- transcription process can be utilized even in this EHR age, wherein professional transcriptionists help in creating structured narrative medical reports of patients. Reliable EHR-integrated medical transcription services ensure quality and accuracy of the medical records. This system helps physicians focus more on providing patient care rather than wasting time in documentation.

EHRs play a crucial role in the healthcare industry. The information included in the EHR include the patient’s medical history along with the diagnoses, treatments, immunization dates, allergies, tests and laboratory reports that allow physicians to decide on the best treatment plan for the patient. There are four types of EHRs.

Software: This is a traditional model of EMR, where the healthcare organization has to physically install software on to a computer or a server at the practice location. This is usually used to get the infrastructure started and running and when the infrastructure needs updating, new installations are upgraded. It can accumulate data within the silos of the healthcare practice and are visible to them but cannot provide any insights into the program.
Software as a Service (SaaS): With the SaaS model, the practice does not have to exert any technical effort or perform any maintenance; all work is done by the provider and stored in the cloud. The software can be updated on a single network and supports a nationwide provider database for healthcare needs such as orders, referrals, and globally deployed vocabularies and templates. It also serves as a single communications connection to payers, clearing houses, hospitals and pharmacies. The drawback of this model is that it provides only management and maintenance of the software and no services are provided.
Cloud-Based Service: In this type of service, the location and hardware are owned by a third party that offers its services by providing software and storage space for your EHR system. Here, the onus of maintenance of the hardware and regular backups is on the vendor. The main advantage of implementing this kind of EHRs is that there is no need for an upfront investment for the hardware requirements and the services can be used on lease with only a monthly fee. However, the disadvantage with these is that they are dependent on internet connectivity.
Application Service Provider: With an ASP, the software is installed on the vendor’s system and not on the practice’s own servers. As compared to conventional EHR software technology, this model is more advanced, as it can reduce a practice’s initial expenditures. However, on the other side, the operating costs of this model can rise. The demand for ASPs increased to respond to small- or medium-sized businesses that have tight budgets and cannot afford expensive up-front costs for software. ASPs deliver lower start-up costs for smaller medical practices, but they lack the value of a shared data network or any visibility into a practice’s performance, pertinent benchmarks and growth opportunities. The type of cloud system used in ASP is a closed or private cloud one which allows easy web-based access, but it does not offer open sharing.

EHR is essential in the healthcare setup for ongoing clinical decision making, providing quality patient care, quick reimbursement and risk management. But to ensure accuracy, it also requires the intervention of medical transcription services that can contribute to quick and error-free EHR documentation. Once the dictation is run through the speech recognition software, it has to be edited either by a medical transcriptionist or by the physician for better workflow of the medical practice. After the physician signs the transcript, it can be uploaded into an EHR using HL7 interface for the exchange of health information, medical coding and reimbursement, medical decision support system etc. Accurate medical data helps physicians and healthcare providers to provide better patient care.

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.

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.

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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.

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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.