Study: Medical Transcriptionist Review improves accuracy of Speech Recognition Generated Clinical Documents

04-February-2021 Rajeev Rajagopal Medical Transcription Outsourcing

Medical Transcriptionist Review

Accurate and timely clinical documentation is paramount to quality care and patient safety. Even with the widespread adoption of electronic health records and speech recognition technology, medical transcription services continue to be relevant to create error-free patient records. Many US physicians use dictation services supported by SR technology and professional medical transcriptionists. Researchers found that errors in dictated clinical documents reduced following manual review by a professional medical transcriptionist.

EHR clinical documentation is a time-consuming task and is a key factor in physician stress and burnout. The introduction of speech recognition (SR), the automatic conversion of voice into text, in the 1980s has eased the task. There are two types of SR: back-end and front-end.

Back-end SR converts dictation into electronic text, which is then edited by a medical transcriptionist (MT) and then sent back to the clinician for review and a signature.
In front-end SR, the physician dictates directly into the EHR free-text fields. The audio is captured by the software and converted into text. The clinician self-edits and signs the notes, which immediately become part of the patient’s record.

A 2018 study that analyzed the quality of SR-assisted documentation found that seven in 100 words in SR-generated documents had errors. The study, published in JAMA Network Open, examined 217 documents dictated between January 1 and December 31, 2016 from hospitals at 2 health care organizations in the US.

Of the 217 notes collected, there were 83 office notes, 75 discharge summaries, and 59 operative notes dictated by 144 physicians using SR technology. The researchers noted the errors contained in the SR engine–generated document, the medical transcriptionist-edited document, and the physician’s signed note. The original audio recordings and medical record review were used to create a criterion standard and each document was compared with this criterion. The study found that:

The SR software generated document had an error rate of 7.4%
This error rate fell to 0.4% after review by a professional medical transcriptionist
The error rate was 0.3% in final version of the document signed by physician
Of the errors at each stage, 15.8%, 26.9%, and 25.9% involved clinical information and 5.7%, 8.9%, and 6.4% were clinically important, respectively
Surgeons’ SR notes had lower than average error rates (6.0%) than SR notes of other physicians (8.1%).

The study authors referenced a study in Australia that analyzed the type and prevalence of errors in documents created using a front-end SR system and those created using a keyboard and mouse. In this case too, the researchers found more errors in SR-generated notes.

The key takeaways of the study:

The error rate of more than 7% observed in SR-created clinical documents show the importance of manual editing and review by a medical transcription service provider.
As most errors are corrected before the physician signs the notes establish the importance of manual review, quality assurance, and auditing.
Though SR is rising in popularity, back-end SR systems continue to be used in many US health care institutions, and studies have demonstrated the significant productivity enhancements associated with these systems.

Many medical errors occur due to communication failures. Accurate, complete, legible, and readily accessible clinical documentation is critical to communicate the patient’s diagnosis and treatment and facilitate care coordination by the healthcare team. Documentation errors can put patients at significant risk of harm. Studies have found that EHR data entry mistakes or inputting incorrect information in the EHR is a major reason for medical malpractice. With the increasing adoption of SR technology for clinical documentation, hospitals need to better understand how it can be used safely and efficiently. While such technologies can save time and reduce physician stress, they eliminate the quality assurance that medical transcription outsourcing offers. SR technology can help generate clinical documentation but not replace the valuable manual work done by skilled medical transcriptionists.

What are the Five Cs for Quality Radiology Reporting? [INFOGRAPHIC]

01-February-2021 MTS TEAM Infographics

Radiology reports are one of the main ways of communication between the radiologist and the ordering physician. These reports are also accessed by specialists such as neurosurgeons, neurologists, and orthopedic surgeons – who require the imaging results of a patient or use them as a reference. With the introduction of EHR, patients also access their radiology reports, which is also an important medico legal document. For all these reasons and more, diagnostic imaging or radiology reports must be accurate, detailed, and written in a way that they clearly interpret and communicate the findings. Radiologists should also fully proofread the report, verify it and review the images being reported before sending it out for transcription. However, errors in documentation can be avoided by outsourcing radiology transcription to a reliable medical transcription service provider.

In this infographic, we discuss the six Cs for a good radiology report.

Check out the infographic below

Radiology Reporting

Telehealth Is Expected to Stay Even after COVID-19

28-January-2021 Julie Clements Medical Transcription

Telehealth

Telemedicine allows healthcare professionals to evaluate, diagnose and treat patients who are at a distance through telecommunication technology. Even though telemedicine was already there in the healthcare industry, it gained huge popularity with the outbreak of COVID-19. With telemedicine, patients are able to connect with the healthcare providers and discuss their health concerns virtually. Telemedicine is an effective solution for minimizing unnecessary and expensive emergency room visits and a useful practice in case of an emergency. With the help of a medical transcription service, all telemedicine consultations can be converted into accurate medical records and uploaded into the EHR conveniently.

Telemedicine is an advanced method of providing medical care via your smartphone, tablet or desktop along with other equipment to monitor your blood pressure, sugar, weight, etc. The medical information gathered is reported to the physician who then provides the appropriate recommendations.

According to an article by WebMD, the U.S. Department of Veterans Affairs saw a massive spike in the number of patients seeing doctors online. Between February and May, about 120,000 appointments a week were conducted via the VA’s Video Connect system. That compares to 10,000 a week during the same period in 2019. Statistics from the Centres for Medicare & Medicaid Services (CMS) show that telehealth visits during the pandemic surpassed 11 million through mid-September of this year.

Telemedicine allows patients in rural areas to access healthcare during outbreaks such as the current pandemic. It also allows seniors to communicate with their doctors without having to travel to a healthcare facility and thereby limit the risk of exposure and spread of this virus.

A Drastic Change in a Positive Way

Telehealth has huge coverage with its RPM technology and this improves the options for patients and healthcare providers to continue providing patient care. This will ensure that the patients have more options to access and receive patient care. Today, telehealth is a virtual version of the latest model of delivering patient care. But it can only marginally address the concerns of the healthcare providers. So to resolve these concerns, advanced technology can be implemented to transform the care delivery model into one that is more focused, efficient and proactive. For example, the cRPM solution (continuous remote patient monitoring) allows healthcare providers to efficiently target care resources as soon as it is needed. The ability to identify the patient in the early course of sickness helps healthcare providers to provide better care to the patient before the illness worsens. This applies mainly to 5 percent of those chronic healthcare conditions that drive 50 percent of the healthcare costs.

RPM and other related technology has been delayed by the lack of reimbursement -incentive alignment. But today, Medicare’s fee-for-service program is covering telehealth, and so its use along with complementary technology like cRPM will continue to grow. This trend is expected to grow as payers shift from traditional fee-for-service, volume-based care to value-based care that reimburse quickly depending on the medical care provided in the right place, at the right time and in the right amount. The shift has been under discussion for a long time, but today with the outbreak of the COVID-19 virus, healthcare providers are financially stressed and are considering other alternative payment models. Embracing this new model will be an important enabler in the shift to value-based reimbursement and the related care models that will improve health outcomes and the care experience, while also saving money through the efficient targeting of care resources.

Related blogs

A Change to Value-Based Future

Technological advancement is of great value in the healthcare industry, especially when it comes to providing quality care. By continuously monitoring the physiologic status of at-risk populations, cRPM solutions help healthcare providers to more efficiently focus healthcare resources to where and when they can be most effective in preventing or controlling illness. This helps to enhance the value and quality of patient care.

Telemedicine technology allows patients to avail quality consultation, and remote monitoring; it facilitates electronic house calls, and treatments in remote locations that lack medical services; connects patients, and ensures a reliable global healthcare system. It also saves costs and provides better care in locations where the quality of healthcare is not up to the mark. Telemedicine also requires proper and timely documentation, and here professional medical transcription services can prove to be a valuable support for physicians and healthcare systems overall.

Five Major Challenges facing Healthcare Organizations in 2021

25-January-2021 Rajeev Rajagopal Healthcare News

Healthcare Organizations

Words can hardly describe just how challenging the year 2020 was for the healthcare industry. The COVID-19 pandemic has had a significant effect on healthcare organizations including both large and small physician practices, and introduced a lot of uncertainty about the future. Our medical transcription company takes a look at the major challenges that industry experts say physicians will face in 2021 and strategies to address them.

EHR Documentation: In several survey and studies covering specialties, physicians reported filling out forms and other administrative tasks as the major problem, according to Medical Economics. Close to 90% of practices have implemented electronic health records (EHRs), but digitizing patient information has increased physicians’ data entry burden. Not cut out for such paperwork, physicians complain about too much time in front of the computer. This has resulted in high burnout rates, especially among primary care physicians (PCPs). EHR documentation tasks have also taken time away from patient care. A study in the Annals of Family Medicine found that PCPs spend nearly two hours on EHR tasks for every one hour of direct patient care. Rather than saving time, EHRs have led to physicians doing EHR-related tasks beyond normal office hours, resulting in an average of six hours per day spent on the EHR. As these challenges will persist in 2021, physicians can consider outsourcing medical transcription to ensure timely and accurate EHR documentation. A 2018 study in JAMA Internal Medicine noted that scribe support can reduce paperwork and other administrative burdens, and significantly reduce EHR documentation time and lead to “significant improvements in productivity and job satisfaction.”
Prior Authorizations: The paperwork involved in prior authorizations is another challenge that physicians continue to struggle with. The number of treatments and medications requiring prior authorizations from payers is on the rise, causing administrative headaches for practices and their staffs. Up to 86% of respondents in a 2020 American Medical Association survey reported the administrative burden of prior authorizations as being “high or extremely high.” Likewise, a Medical Economics Physician Report found that physicians and their staff spent an average of 16 hours per week of practice time on prior authorizations. In 2021, PWC’s Health Research Institute expects providers to invest in advanced strategies to deal with prior auth.
Streamlining Care Delivery: The pandemic drove an explosion telemedicine with physicians meeting patients where they were. A new annual report on PwC’s Health Research Institute survey noted that the deadly pandemic thrust patients, healthcare providers, and payers onto virtual platforms and other digital technologies that many had earlier approached with caution. In the public health emergency, some virtual care was provided on nontraditional mobile platforms, on personal phones, through texts and through messaging platforms used for personal interactions. The report noted that in 2021, “the industry will work to determine which virtual visits make the most sense, and where and how they should take place.” The experiences with virtual care have provided valuable insights and organizations can now find ways to balance virtual and in-person care delivery to optimize the patient experience, reimbursement and clinical research as well as to navigate vaccine delivery (www.healthcareitnews.com).
Cybersecurity: Cybersecurity has long been a concern for healthcare organizations. With the widespread adoption of digital technologies and virtual care during the pandemic, it has become an even more serious concern. There have been reports of several COVID-19 fraud schemes, phishing attacks, and related cyber threats designed to target natural vulnerabilities. the Department of Health and Human Services (HSS) saw a nearly 50% increase in the number of health care-related cybersecurity breaches in the first half of 2020, with 132 reported incidents compromising network servers, desktop and laptop computers, email and electronic medical record (EMR) systems. With the increased use of virtual care and online healthcare options in 2021, organizations will need to focus on safeguarding process and patient information from cyberattacks. In addition to increasing investment in modern IT infrastructure with effective patch management and malware protection, healthcare organizations should ensure that staff are educated about common cyberattack tactics. Staff will need to be also educated about the importance of using strong passwords, refraining from unknown emails and links, and enabling of firewall protection at work and home. Choosing a HIPAA compliant medical transcription company is another important step to keep patient records safe.
Hiring and Retaining Clinical Staff: The uncertainty and increased scrutiny created by the COVID-19 pandemic is expected to make hiring and retaining clinical staff more challenging, according to a Medical Economics survey. Up to 35% of PCPs said that hiring new staff is a major obstacle to their practice. To deal with this, practice leaders can implement attractive schemes such as rewarding hard work, boosting the total compensation package, bonuses for staff members who achieve productivity goals, growth opportunities through training, flexible hours, and more vacation time. Employing millennial physicians can also help as they tend to focus on fulfillment of purpose, developing meaningful relationships with patients and spending more time with them, and doing what it takes to improve health care outcomes (www.medicaleconomics.com).

As healthcare providers focus on improving practice management, dealing with administrative burdens and improving the patient experience in a more virtual world, they can rely on medical transcription services to ensure high quality EHR documentation that meets industry standards.

What are the Practices that make a Patient Feel better after an Operation?

21-January-2021 MTS TEAM Medical Transcription Outsourcing

Operation

Healthcare providers aim to provide high quality care and medical transcription services enable them to maintain accurate and timely documentation. When it comes to surgery, patient satisfaction depends a lot on improving pre- and post-operative care.

Today, patients do their research before they choose a facility and spend considerable time learning about the procedure they are going to have. “If you want to wow patients and ensure they post positive reviews when they leave your facility, pay close attention to their needs as soon as they schedule procedures,” says a recent article in outpatientsurgery.net (Vol XXI, No 10, Oct 2020).

So how can ambulatory surgical facilities improve patient satisfaction? Here are five practices that experts say will make a patient feel better after an operation:

Understand Instructions Clearly: Patients should make sure they understand the pre- and post-operative instructions that their surgeons provide. A smooth healing process depends on understanding these steps and following them. Generally, physicians take care not to use complex medical terminology when providing instructions and make sure that they can be understood by the layperson. If patients have any questions, such as, when they can resume routine exercise, what kind of diet they should follow, etc., they can find them in the list of dos and don’ts before and after surgery. Surgeons will discuss medications the patient is currently taking or will be prescribed, and provide instructions about when to discontinue medications or start taking them and whether to eat before and after surgery. One study showed that needs-based education reduced patient anxiety and increased patient satisfaction quite significantly, both immediately after the education and postop. Experts recommend using a patient navigator as the point of contact to handle patient concerns, which can improve satisfaction among people scheduled for surgery. For e.g., Boston Out-Patient Surgical Suites in Waltham, Mass., utilizes a patient navigator for all of its total joint cases (www.outpatientsurgery.net).
Technology to Improve Engagement: Patients should follow the pre- and post-operative care given to them before their procedure. Many facilities use communication apps to connect with patients and send them automated messages and reminders about their care steps before their surgery and instructions to follow pre-op directions. By engaging with their provider using these apps and following instructions, patients can improve the likelihood of successful outcomes. Facilities use a variety of apps that focus on wellness, nutrition, fitness, diabetes management and smoking cessation to engage patients and improve their health and well-being. NYU Langone Health’s Helen L. and Martin S. Kimmel Pavilion provide bedside tablets for patient use as well as a high-definition display medium that allows patients to order meals, read educational materials or review their care plans (www.healthtechmagazine.net).
Pre-op Mental Preparation: For smooth recovery, patients should keep in mind that preparing for surgery mentally is as important as physical preparation. Studies have shown that poor mental health can negatively impact pain perception, return to work and normal activities, and quality of life. Low preop mental health affects postop recovery including quality of sleep and general well-being. Physicians will assess and document the patient’s preoperative psychological status as part of the preop evaluation. Based on their mental health status, patients will be provided with formal counselling and support to psychologically prepare them for surgery.
Pain Management: Effective postop pain control is an essential element of surgical care. Physicians use pain management modalities to improve pain as the effects of anesthesia begin to diminish. Patient-controlled analgesia (PCA) involves the use of a computerized pump to dispense physician pre-set doses of pain medication intravenously at the push of a button. Local anesthesia can help control pain and enhance the post-surgical experience. In many facilities, the goal is to reduce high doses of opioids. Modalities used include transverse abdominis plane (TAP) blocks to help manage the post-op pain of abdominal surgery and regional blocks for shoulder surgery, osteotomies, and arthroplasties (www.outpatientsurgery.net). These modalities can reduce postoperative nausea and vomiting (PONV) and reduce the need for oral narcotics.
Patient-Centered Care: As patients expect a personalized experience, most surgical facilities take steps to provide this. They follow-up on patients within 24 hours to check if the patient is experiencing pain and answer any further questions the patient may have. Staff should be trained in communicating properly with patients and listening to them, understanding their concerns, and delivering patient-centered care. Patients should be informed of delays, if any. Down time should be made as comfortable as possible. Patients can be asked for feedback on their experience and this can be used to address their issues and improve systems and practices.

Focus and commitment on the part of medical staff, clinical teams and nonclinical workers can improve the patient experience. Such commitment can leave little time for electronic health record (EHR) documentation. Outsourcing medical transcription will ensure timely and accurate charting, and help physicians focus on providing their patients with personalized care, which will improve patient satisfaction and drive positive reviews.

Significance of EHR Training to Minimize Physician Burnout

18-January-2021 Julie Clements EHR Transcription

Burnout

Healthcare organizations still rely on medical transcription services to assist physicians in streamlining EHR documentation. Electronic Health Records are implemented in healthcare units to help physicians improve their practice and productivity. However, many physicians feel that they spend more time on medical documentation rather than with their patients. Pre-occupation with EHR documentation will also extend the patient’s visit time, reduce eye contact with the patients, cause distress in patients and physicians from processing the information, obstruct workflow and eventually lead to physician burnout.

Physician burnout, poor usability of EHR, and EHR-related financial problems are some of the issues that almost all healthcare organizations face and this leads to EHR failures that can put patient safety at risk. According to Fox Group, a health care consulting firm, 20% of EHR system installations could be considered a failure. Another study published by SceinceDirect shows that 50 percent of EHR systems either fail or are not properly utilized. Likewise, there are several studies available online that shows the EHR failure in healthcare organizations. This can be resolved with proper EHR training.

Proper EHR Training

Quality EHR Training is important in a healthcare setup and it can also minimize the chances of physician burnout and improve satisfaction. According to a survey by KLAS, a leading healthcare IT research firm, proper EHR training is essential to increase EHR user satisfaction. According to the researchers, if the healthcare organizations provide good educational opportunity for their healthcare providers, they will be able to master EHR functionality and thereby eliminate many EHR challenges. It is also important to implement some standards to ensure that the clinicians across health systems receive proper EHR training.

The researchers also added that healthcare organizations that provide less than four hours of training session seems to be creating frustration among physicians. These organizations have lower training satisfaction, lower self-reported proficiency and are less likely to report that their EHR helps them deliver quality patient care. So, organizations that invest in EHR training help physicians to easily navigate their EHR systems and also minimize the chances of physician burnout.

Beginning EHR Training at an Early Stage

Providing training to young health care clinicians is the best decision. According to Andrew Symons, MD, MS, vice chair for medical student education in the Department of Family Medicine at the Jacobs School, medical documentation is an important skill that student physician should learn. When students begin clinical rotations in the third year of medical school, they all need to utilize an EHR. This school utilizes Cerner’s EHR system. The students were already transcribing their clinicals in Microsoft Word, after this launch, the students will use Cerner’s EHR educational domain, just like a clinician. It is expected that by the time the students are into their third year, they will be quite familiar with the electronic medical record system.

Super Use EHR Training

Finding out and training the super users and clinical leaders will create a core of knowledgeable staff members who align with the organization’s goals and EHR system requirements. Some super users should have clinical experience and super users should be fully trained about EHR functions. Training a super user early is important to streamline the process of change throughout the organization, including both clinical and technical perspectives. These users help to have an in-depth analysis of the EHR workflow and the system configuration to successfully meet the organizational goals and its client base.

Remote Online EHR Training

With the outbreak of COVID-19, remote learning and remote working has become more popular than ever. This has also made hospitals and EHR vendors to be more creative in forming new ideas because of social distancing and stay-at-home restrictions. Due to travel restrictions and social distancing, healthcare providers conducting an EHR implementation during COVID-19 had to adjust to the lack of in-person training.

At Valley Children’s Healthcare in California, they transformed their on-site command center into a virtual helpline for its clinicians and replaced in-person consultants to provide aid during training sessions. Joel Brownell, MD, vice president and chief medical information officer at Valley Children’s Healthcare said that “One of the things that was critical for success was an easily implemented screen sharing technology. If we had used solely telephone support, rollout would have failed”. So, in short, EHR training can be a long process but it makes a huge positive impact on the healthcare organizations.

The state of quandary created in healthcare systems by EHR documentation-related challenges can be resolved by utilizing medical transcription solutions. It allows physicians to dictate the patient’s notes and the transcriptionist can transcribe the dictation, make necessary corrections and transform it into a well-written patient health record with accurate clinical facts and codes. Once this is done, the codes must be recorded in the EHR, and this should be reviewed by the physicians to ensure that the medical record is error-free. For efficient documentation of patient’s record the best option is to hire a medical transcriptionist service. They transcribe patient’s notes with top-notch quality and accuracy. This will help the physicians spend more time consulting patients and deliver quality care.

EHRs need to Adapt to Changing Clinician and Patient Needs

14-January-2021 Rajeev Rajagopal EHR Transcription

EHR

Regardless of the illness or healthcare setting, patient records that medical transcription companies help physicians document contain similar information such as the chief complaint or reason for the visit, history and physical or assessment and plan, progress notes, test results, and orders. Certain medical specialties and settings have requirements that are exclusive to their fields.

According to recent reports, the COVID-19 pandemic calls for a new kind of electronic health record (EHR) that can better meet patient needs. The main problems with EHRs that are confusing physicians include:

User interfaces and usability issues
Overloading of information
Quality of the data entered
Limited ability of the data to support discovery and interoperability among systems
Limitations in supporting complex clinical care
Do not support clinicians’ dynamic needs
Inability to exchange information

The large amounts of data EHRs contain can overpower clinicians and negatively impact efficiency as providers spend time searching through large quantities of clinical data to find the specific information they need. With information overload, clinicians have a tough time determining what data is important and what is the right treatment and prevention plan for each patient, notes Harvard Business Review (HBR). This has become especially challenging in the context of COVID-19. Modifying EHR design to reduce the amount of time providers spend searching through EHRs for specific data, and interacting with EHR systems can help to boost clinical efficiency and reduce provider dissatisfaction with EHR technology.

According to the American Medical Association, EHRs should be designed and configured to:

Improve physicians’ ability to provide high-quality patient care
Support team-based care
Promote care coordination
Offer product modularity and configurability
Minimize cognitive workload
Help data liquidity
Allow for digital and mobile patient engagement
Expedite user input into product design and post-implementation feedback

HBR is optimistic that the experiences of leading EHR vendors will pave the way for a new kind of EHR that can not only track what happened to the patient, but also help clinicians plan for the patient’s health and deliver information to the physician and patient. Such as plan-focused EHR would be better equipped to deal with outbreaks like Covid-19 by:

Ensuring that each patient’s care plan incorporates the latest evidence-based treatments based on their current status and underlying health conditions
Providing data of each patient’s response so that the plan for the next patient can be improved.

EHRs with these capabilities could dramatically improve outcomes and reduce fatalities.

HBR lists the features of a plan-centric EHR as follows:

A library of care plans for different situations: Plans would differ among patients depending on their individual circumstances, medical conditions and how well they are managed, and preferences.
Combination of appropriate algorithms to form a patient’s master plan. Patients may have more than one medical condition and a master plan should combine appropriate algorithms for treating these different conditions.
Support for the care team. The master plan can be viewed by the patient and all professionals involved in a patient’s care such as the primary care physician, specialists, nurse practitioners, pharmacists, and case managers. Each team member would have their own to-do list and would be able to assign tasks to one another.
Interoperability: The plan must travel seamlessly with the patient. It will be able to navigate care settings, geographical areas and different EHRs. With interoperable systems, providers can integrate a patient’s plan regardless of where it was created.
Decision support and workflow logic. The system would alert team members of upcoming and overdue activities, suggest changes in the plan based on the changing care needs of the patient, and informed the concerned team member about new test results or patient events.
Analytics for both individual patients and populations. The system must be able to evaluate the plan’s progress towards its goals, both for the individual patient and for the larger population under the provider’s care. The experiences of treating one patient can then be applied to other patients.

As EHR technology advances to better meet clinician and patient needs, medical transcription services will continue to be relevant to ensure accurate and timely documentation in the system.

Rising Use of Teleradiology During the Pandemic

11-January-2021 MTS TEAM Medical Transcription

Teleradiology

An increasing number of radiologists today rely on accurate transcription to ensure better diagnosis and patient care. Medical diagnosis begins with radiology, and radiology reports are extremely time-sensitive and require perfect accuracy. It helps to pinpoint a patient’s condition and provide treatment before a disease gets worse. With radiology transcription from a professional medical transcription service, high-quality and error-free transcripts can be obtained for better treatment. Some of the popular imaging technologies like MRI, CT Scan, X rays etc are used in radiology to generate images of different organs and parts of the body and diagnose it.

Teleradiology and Its Significance

With a focus to improve patient care, healthcare professionals now use teleradiology. It is a branch of telemedicine where a radiologist interprets medical images while not being physically present in the location where the images are generated. In other words, teleradiology is the transmission of radiological patient images like x-rays, CTs, and MRIs, from one location to another for the purposes of sharing studies with other radiologists and physicians.

Teleradiology is not a new concept but was used only during emergencies. However, with the outbreak of COVID 19, teleradiology has been very useful, because doctors cannot be always physically present where the patient is due to the lockdown. It allows people to avail of medical services irrespective of geographical challenges. Using such technology based on transmission of radiological patient images from one location to another allows radiologists to provide services without having to be in contact with patients, and is particularly important to minimize the spread of COVID-19.

Surge in Teleradiology During COVID 19

According to Jules Sumkin, DO, chairman of the Department of Radiology at UPMC, before the spread of the pandemic, remote teleradiology services at the University of Pittsburgh Medical Center (UPMC) was limited to a 24/7 teleradiology group in the medical center. The teleradiology service was designed to provide overnight subspecialty radiology service to emergency departments throughout the UPMC health system. The team includes nine body-trained radiologists and nine neuroradiologists.

When Dr Sumkin undertook the role of department chair in 2014, he offered radiologists a remote work option to increase flexibility and ideally enhance job satisfaction. This allowed almost all the faculty to have a home workstation at the time of COVID-19 pandemic. It was relatively easy for the faculty to switch to a remote reading model. This allowed radiologists to work with referring doctors, going through lists of cases and discussing which imaging exams can be safely postponed.

Private practices have also now embraced teleradiology. Texas Radiology Associates (TRA), that serves over 70 hospitals and health care centers across Texas, significantly expanded remote work for its staff of 140 radiologists. According to John Y. Kim, MD, chairman of the Department of Radiology, THR Presbyterian Hospital Plano, TX, and chief technology officer at TRA, TRA’s remote work had largely been limited to its Hawaii office, that provides the rest of the practice with substantial overnight coverage.

Overall, COVID-19 has served as a wake-up call about the need for telemedicine and teleradiology and its potential for the future. More and more healthcare providers are now used to telemedicine and teleradiology and it becomes more acceptable to hospitals, referring physicians and patients.

Accurate documentation of telemedicine and teleradiology reports is essential for making the correct clinical decision. It is also important to choose a reputable medical transcription company that provides error-free transcripts. It provides the following benefits also:

Improves productivity and efficiency of physicians with quick access to timely reports
Physicians can get customized transcripts in short turnaround time
Is a cost-effective option
Transcripts can be obtained in any desired file format
They ensure accuracy with stringent quality checks at various levels.

Guidelines to Ensure Quality Radiology Reporting

07-January-2021 Julie Clements Radiology Transcription

Radiology Reporting

Safe, high quality imaging is crucial for disease diagnosis and medical decision-making. Radiology transcription service providers ensure x-ray, scan and MRI reports in quick turnaround time, which is crucial for speedy diagnosis and proper care. Imaging studies are used to diagnose many diseases. A recent study found that chest x-rays could help in a rapid diagnosis of COVID-19, especially in locations where testing capacity is limited or test results are delayed.

The radiology report is the main means of communication between the radiologist and the ordering physician. Radiology reports are also accessed by specialists such as neurosurgeons, neurologists, or orthopedic surgeons, who require the imaging results of a patient or use them as a reference. With the advent of electronic health records, patients also access their radiology reports. The radiology report is also an important medicolegal document. For all these reasons and more, diagnostic imaging reports must be accurate, detailed, and written in a way that they clearly interpret and communicate the findings.

An article titled “Radiology reporting-from Hemingway to HAL” published in Insights into Imaging in 2018 cited a study that listed the qualities of a good radiology report that will allow for effective communication, as the six Cs:

1. Clear
2. Correct
3. Confidence level (which should be indicated)
4. Concise
5. Complete
6. Consistent

Clarity or clearness means that the radiologist should not use difficult or ambiguous terms. The person reading the report is not a radiologist. Even if the radiology report contains information that is critical to patient care, this information can be helpful only if the reader understands it well. For instance, referring providers will find words like “suggest” or “possible” ambiguous and confusing. Unless the interpretations and conclusions of the radiologist are conveyed clearly, concisely, and unambiguously, the care team cannot make efficient and quick decisions about the patient’s care. In short, the radiologist should convey the point quickly.

A radiology report can be termed correct or accurate only if it provides an error-free identification of relevant findings. Effective image interpretation depends on the skill, diagnostic ability, and knowledge of the interpreting radiologist, which in turn are influenced by the radiologist’s education, training, and experience, according to an article published by RadioGraphics. Even a minor mistake like omitting the word ‘no’ in the report can lead to misinterpretations and affect patient care.

Radiology reports should be concise and brief. Avoiding redundant words and phrases is important as busy clinicians have little time to read radiology reports that are complex and wordy. For example, “review of the scan at bone windows shows no evidence of metastatic disease” is too wordy. “No bone metastases are seen” conveys the same meaning concisely (Style Guidelines for Radiology Reporting: A Manner of Speaking in the American Journal of Roentgenology).

Complete radiology reports contain sufficient detail to allow the interpreter to envisage the critical findings. A complete report is one that accurately identifies the relevant findings, provides an intelligible interpretation of the likely cause of the disease and recommendations on further investigations, if appropriate. Structured radiology reports are found to be more complete than unstructured reports

Uniformity, organization and consistency are key qualities of good radiology reporting. In structured reporting, both basic and disease-specific templates improve consistency. However, one study notes that providing structured reports alone may not be sufficient since primary care physicians prefer “clear indications of the meaning of radiology terminology, likelihood of disease and clinical relevance of findings, including the normal sizes of anatomical structures”, notes the Insights Imaging article.

Finally, radiologists should always fully proofread the report, verify it and review the images being reported before sending it out for transcription. Errors in documentation can be avoided by outsourcing radiology transcription to a reliable medical transcription service provider.

Key Tips for a Successful and Stress-free Doctor Visit

04-January-2021 Rajeev Rajagopal Medical Transcription

Doctor Visit

For patients, it is important to make the most of the consultation time with doctors, as they will get only a modest amount of consultation time. So, it is ideal to prepare a basic plan to make the most of the appointment, whether it is with a new doctor or even with the doctor whom they’ve been seeing for years. As a provider of EHR-integrated medical transcription services, we know how precious time is for doctors and the more time they get to spend with the patient, the better would be the treatment outcome. There are a few useful tips physicians can recommend to their patients to ensure that their office visit is stress-free and effective.

doctor appointment

These tips will make it easier for patients as well as providers to cover everything they need to talk about. Before the appointment, the patient should also make sure whether his/her doctor accepts their health insurance. To add value to their time with patients, doctors can also follow certain tips such as using better verbal communication techniques.