Differences in Physician EHR Documentation Practices can affect Patient Care

23-November-2020 Rajeev Rajagopal EHR Transcription

EHR Documentation

The Electronic Health Record (EHR) stores patient health information in digital format and provides physicians and other authorized users with the medical and treatment history of the patient. EHR adoption rates in the US have been on the rise and up to 79.7% of office-based physicians have a certified EMR/EHR system, according to the Centers for Disease Control and Prevention (CDC). Physicians use the structured, point-and-click documentation templates within the EHR to capture patient data at the point of care and rely on medical transcription services to document narrative dictation. EHRs are designed to improve quality of care, improve patient safety, reduce risk of medical errors, and support effective communication between the physician and patient. However, recent studies found that variations in physicians’ EHR documentation practices could compromise patient care and safety.

EHRs provide the healthcare team with real time access to patients’ medical history, including diagnosis details, treatment plan and aftercare, allergies, lab test results, and more. They can improve workflow and streamline the healthcare process, but physicians find typing notes into the EHR a time-consuming task that takes attention away from patient care. This can also lead to errors in the health record due to the widespread use of auto-populated text.

One possible factor leading to EHR inefficiency is the variation in how physicians document patient data, according to a study published in the Journal of General Internal Medicine in 2019. The study used data from a national ambulatory EHR vendor to measure physician-to-physician variation for 15 categories of clinical documentation.

Commercial EHR systems offer several options to meet different preferences on how information is recorded for an identical patient in the EHR. For example, during a patient exam, a problem or diagnosis can be documented in the review of systems, the problem list, the assessment and diagnosis, or in all three categories, noted the authors.

The findings of the study are as follows:

Differences in the content, structure, or location of patient information in the EHR depends on factors such as user preferences, drive documentation decisions, and other penchants, rather than the differences in patients’ clinical status.
There was substantial variation in the completion of documentation for 5 clinical documentation categories.
There were different documentation styles across physicians in the same practice.
These variations led to extra effort by physicians to find important information in the chart and entering the same information multiple times.
Most respondents said that variation in EHR documentation was due to “idiosyncratic” physician choices, enabled by the multiple options available in the EHR to document each category of information.

The reasons for the variation documentation behaviors included lack of training, training on fast moving video (leaving little time for questions) instead of in person, and differences in how physicians viewed templates, with some providers preferring to use free-text fields instead of structured fields.

Documentation driven by individual preferences can create EHR inefficiencies and risk patient harm due to missed or misinterpreted information, said the study authors. “Our results revealed that such variation jeopardizes the efficient and possibly safe delivery of care,” they wrote.

Another study, also published in 2019, also looked into the veracity of physician documentation within EHR. Emergency department evaluation and management service standards comprise 7 elements, history, examination, medical decision-making, counseling, coordination of care, nature of presenting concern, and time. Of these, the first 3 are considered key factors, noted the study. When it comes to emergency physician documentation, elements such as the review of systems (ROS) and the physical examination (PE) were more likely to have errors due to the extensive use of auto-populated text.

The researchers found the EHR data did not always correctly reflect the level of care provided. The efficiency of EHRs depends greatly on the data elicited at the bedside and recorded in system by health care professionals. Therefore, it is critical that that clinicians document care provided correctly in the medical record.

The efficiency of EHRs depends on the quality of data they contain. Putting documentation responsibilities on physicians can lead to errors and inconsistencies in EHR data and cause problems for physicians, patients and the entire healthcare system. Outsourcing medical transcription are a practical option to ensure accurate, clean medical records so that patients receive the best possible care.

What Are the Different Types of Medical Transcription Reports?

19-November-2020 MTS TEAM Medical Transcription Company

Medical Transcription Reports

Medical transcription is a process that functions at the periphery of the healthcare industry. It is the process of converting dictations of the healthcare professionals into well-formatted text documents. It plays a vital role in creating the patient’s medical history which is used for reference by healthcare providers, medical practices, insurance companies, and lays a foundation for future patient visits. Choosing the right professional medical transcription service is important to ensure accurate and reliable transcription of your dictated notes.

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Understanding the Various Types of Medical Transcription Reports

There are different types of medical transcription reports that you can request.

History and Physical report: This report is usually dictated by physicians when a patient is admitted to the hospital. It starts with the main complaint, followed by history of the patient’s current illness, medical history, social history and family medical history. This is regarded as the complete physical examination of the patient and ends with an admission diagnosis and a plan of treatment.
Consultation report: This is dictated by the physician to whom the admitting physician has referred the patient. The consulting physician is usually a specialist in an area other than the admitting physician. It also includes a small description about the illness of the patient and a specific physical exam based on the type of consultation requested. It may also include x-ray or laboratory findings. This report concludes with the physician’s impression and treatment plan.
Operative report: This report is dictated by the operating physician, which includes a detailed description about operative procedure. Details include pre-operative and post-operative notes, the type of surgery, name of the surgeon, anesthesiologist, and a detailed description of the operative procedure itself. Based on the type of surgery, the count of instruments, blood loss etc are also mentioned. The report will end with disposition or where the patient was transferred when she left the operating room and the overall health condition of the patient.
Radiology report: This report is dictated by the radiologist once the diagnosis and radiology procedures are completed. It includes the radiologist’s findings and interpretations of x-rays, CT scans, MRI scans, and nuclear medicine procedures and so on.
Pathology report: This report is dictated by the pathologist and includes the microscopic findings of the sample.
Laboratory report: This report includes the findings of examinations of bodily fluids such as blood levels and urinalysis. This report is rarely dictated separately but often included in the H&P, consultation or discharge summary.
Hospital report: This will include all the reports that were dictated in the hospital – radiology reports, pathology reports and laboratory reports.
Discharge summary: This report is dictated by the physician at the end of the patient’s stay at the hospital. All crucial reports right from the admission of the patient until discharge will be included. The report ends with a detailed plan for the patient. If this report is transferred to another institution, then it changes from discharge summary to transfer summary. If the patient dies, then it will be called death summary.
Office reports: Reports that are created in a medical practitioner’s office not treated as hospital reports. Some of these are initial evaluations, letters to referring physicians, patient introduction letters to specialists, and chart notes for each visit.

Accurate medical transcripts contain important medical data of patients for future reference. Doctors go through these medical transcripts and charts to review patient evaluations and decide which treatment is best suitable. A minor error in the transcript or a misspelling of medicine or dosage can cause major health issues or even lead to death. Therefore, accurately transcribing doctors’ dictation into well-documented reports is essential to ensure patient safety and better healthcare service. Partnering with a reliable medical transcription company helps in transcribing audio files with utmost accuracy at affordable rates.

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Study: Peer Comparisons Can Improve Oncology EHR Documentation

16-November-2020 Julie Clements Oncology Transcription

Oncology

Proper and complete documentation of care for cancer patients is critical as their providers require a need a clear record to make informed treatment decisions and for information transfer with patients. Outsourcing medical transcription can ensure timely and accurate documentation of providers’ narrations of patient encounters in electronic health records (EHRs). However, studies have found that EHRs pose challenges when it comes to care coordination among providers and supporting communication with patients. According to a recent study in JAMA Network Open, the rate of cancer stage EHR documentation can be improved through peer comparisons (www.ehrintelligence.com).

Elements in medical documentation for cancer patients are details of radiation therapy including treatment modality/energy, dose per fraction and number of fractions, chemotherapy schedule, progress notes on response to weekly therapy, end of treatment note, side effects of treatment, medical management required during treatment, and details of any interruptions in therapy. Other essential elements in the documentation include the specific oncologic diagnosis and stage, care recommendations for side effects of therapy, documentation of drugs administered, dose adjustments or delays and reasons, tumor response to any anticancer treatments using the standard response assessment criteria and results of exams, images, or test used to assess response and adverse events.

Documenting the specific oncologic stage is the most important element in creating the cancer treatment plan as well as identifying patients for clinical trials or recognizing those who need further care. However, researchers from Harvard T.H. Chan School of Public Health reported that oncologists seldom document cancer stage in the EHR. Their findings were based on a study conducted at Massachusetts General Hospital Cancer Center from 2018 to 2019.

The researchers used an email intervention technique to improve oncology EHR documentation. The steps in the strategy were as follows:

The rates at which different oncologists documented cancer stage into the EHR were compared
The results were sent out in an email to the 56 participating oncologists
Up to three emails were sent to the oncologists over a period of 6 months
To make the comparison, the oncologists were shown the top EHR documenters
Similar peer comparisons were made among oncologists practicing in the same facility, treating similar types of patients while facing similar challenges

The study found that each peer comparison email was associated with continued increases in the documented staging rate. The results, as reported by EHR Intelligence were as follows:

A 9-percentage point probability increase of cancer stage EHR documentation
A relative increase of 69 percent within 28 days, compared to oncologists who did not receive comparison emails
The association increased with each subsequent email from 4 percentage points after the first email, to 11.2 percentage points
Peer comparisons could lead to better EHR documentation moving forward

The researchers also noted that oncologists were more likely to conduct cancer stage documentation with new patients than complete past documentation for established patients.

Within the medical oncology office, providers need a clear medical record, to make informed treatment decisions. Incomplete documentation can pose a significant problem for cancer patients who move or change physicians and for survivors. EHRs play a significant role in this complex health care process. However, keying patient information into the electronic health record (EHR) during and after the office visit is one of the most challenging tasks for physicians. However, complete EHR documentation is critical to improve physician-physician and patient-physician communication and coordination of care across health care settings.

The study authors noted that though EHR documentation can be a burdensome, nonclinical component of medical practice, it plays a fundamental role in modern health care delivery and quality improvement. “Our results suggest that peer comparison could be an effective tool to guide clinician behavior in domains beyond patient-directed care,” they wrote.

The email intervention technique was successful in improving documentation. However, as the highest documentation probability was 40 percent among new patients, further interventions are required to improve cancer stage documentation beyond this level, the study noted. Along with peer comparisons via email, the researchers recommend implementing reinforcing interventions and continued messaging at practice meetings to improve end-stage oncology documentation.

Medical transcription companies can play a key role in helping physicians manage EHR documentation-related workload. Partnering with an experienced service provider will allow oncologists to focus on their patients while ensuring accurate and timely oncology reports.

Patient Access to Medical Records Could Improve Medical Record Accuracy

09-November-2020 MTS TEAM Medical Transcription Company

Medical Records

The primary role of healthcare organizations is to provide quality patient care and any minor error can lead to severe patient injury or death of the patient. These errors could cause huge financial loss like penalty ranging from thousands to billions of dollars, along with psychological and emotional stress. So, to avoid medical errors, healthcare organizations should have proper rules and regulations and remain HIPAA-compliant to ensure that the medical records are accurate. To ensure accuracy in medical documentation EHR was introduced, however, it has led to other serious issues like typos, error with copy-paste functions, dropdown menu and auto complete feature, missing or incorrect entry etc along with physician burnout due to the excessive medical documentation process. Medical practices and hospitals are now hiring a medical transcription company to convert physicians’ dictation into accurate records and upload them into EHR using HL7 interface.

A Study Shows Common Types of Patient-reported Errors

A study “Frequency and Types of Patient-reported Errors in Electronic Health Record Ambulatory Care Notes” published by JAMA Network shows the patient-reported errors in their medical records. In the US, over 44 million can access their ambulatory visit notes online. Some studies have shown that patients have identified documentation errors in their medical notes and how these may inform patient engagement and patient safety. So, this study aims at assessing the frequency and types of errors identified by the patients who have read their ambulatory notes.

The study stated that errors in EHR are common and half of them are related to medication. Physician burnout from excessive medical documentation leads to inaccurate medication list, errors by copying and pasting from older records and errors in examination findings. EHR also lacks critical information because of limited interoperability among health care sites.

When patients can access their medical records, it enhances patient engagement and also improves patient safety and care quality. Patients say that they understand the notes very well and reading the notes helps them to remember the next step, enables timely follow-up, and provides information to family or friend care partners.

A total of 36,815 patients received survey invitations and 29,656 participants responded. 22,889 patients read one or more notes in the past 12 months. Out of 22,889, 73.4 percent reported reading notes for at least one year and 49.8 percent reported reading 4 or more notes. Among all patients that participated in the survey, 80.5 percent reported that they were confident in their ability to find mistakes whether or not they reported a mistake in their notes. In total, 4830 of 22,889 note readers (21.1%) perceived a mistake in their notes. Out of 4830 patients who found mistakes in notes, 2043 had serious mistakes and 480 cases were very serious.

Categories of Mistakes Described by Patients

Diagnosis-related mistakes (27.5 percent): Patients stated that diagnosis-related mistakes like perceived errors in specific medical diagnoses, including conditions that patients did not have, diagnosis that patients had and thought were relevant but were not recorded, problems or delays in the diagnostic process, or inaccuracy of existing diagnosis.
Medical history (23.9 percent): Some patients said that mistakes in their medical history like marking the wrong symptoms, mistakes in dates or types of operations, including documentation of operations they reported they never had. They have also had contradicting notes among practitioners.
Medications (14 percent): In this category, patients experienced mistakes such as prescriptions of medicines that the patient was no longer taking, missing new prescriptions for medicines that the patient was taking, wrong dosage and so on.
There were cases of medication allergies, and cases like omission of severe or anaphylactic allergic reactions.
Test Procedures and results (8.4 percent): Patients found that wrong test results were entered in the notes; some practitioners were unaware of more recent results that existed; mistakes in radiology test results or physician summaries of radiology reports, which make it highly challenging to determine whether the patient’s condition improved or worsened.
Other errors: Other errors, reported by 53 participants (14.9%), most commonly reflected errors stemming from copy and paste of prior electronic notes, and billing mistakes, like wrong codes implying conditions the patient reportedly did not have.

One solution to this problem is notifying the practitioner about the perceived error. Some patients commented that perceived errors led to emotional or psychological distress, delayed diagnosis or treatment, or lost days at work. Some other patients had to go through frustration, exhaustion etc trying to correct the error.

The study identified that giving patients access to their medical records would improve medical accuracy and patient engagement in patient diagnosis. This helps to ensure better patient care in the healthcare set up. The main aim of the healthcare industry is to provide quality and accurate medical records. So, investing in a reliable medical transcription service is important to increase the quality of patient care and to ensure error-free records.

Effective Tools to Reduce the EHR Documentation Burden: Scribes and Transcription Services

05-November-2020 Julie Clements EHR Transcription

EHR Documentation

It’s no secret that electronic health records (EHRs), despite their many benefits, can create an overload of documentation and clerical responsibilities for physicians. Medical transcription services and scribe support are popular solutions to increase clinicians’ documentation efficiency and improve quality of care. Both medical transcriptionists and medical scribes perform patient documentation and clerical tasks on behalf of a physician However, the costs associated with these services are often a cause for concern among practitioners. A recent study focused on assessing the productivity requirements of implementing a scribe program found that the cost of hiring these professionals can be offset within a year by increased profits due to a spike in patient visits (www.ehrintelligence.com).

According to the study conducted by the University of Chicago Medicine, hiring a medical scribe offers many benefits:

Frees up clinicians’ time
Allows them to treat more patients, add new patients, and schedule additional visits for returning patients
Reduces cognitive workload and physician burnout, which is closely linked to EHR documentation burden
Increases patient access and satisfaction

Importantly, medical scribe services will provide physicians with more time to fit in more appointments, which will increase revenue and profitability.

The study was led by Neda Laiteerapong MD, associate professor of Medicine at the University of Chicago Medicine and published in the Annals of Internal Medicine. The researchers performed an economic evaluation of 30 specialties as well as physician assistants and nurse practitioners. The outcome measures were the number of additional patient visits a physician must have to recover the costs of a scribe program at one year. The team reported that a provider would have a 90% chance of breaking even within one year after hiring a scribe with:

For new patients, an average of 1.3 new patients per day
For returning patients, an average of 2-3 returning patients per day

The addition of 2 new patient (or 3 returning) visits per day was profitable for all specialties, according to the study. The number of returning patients or new visits needed to break even would depend on the medical specialty. Regardless of this, the researchers wrote that hiring a medical scribe could increase the number of patients seen by a provider in two ways:

Decreased documentation time
Higher satisfaction levels for both clinician and patient

The researchers noted that most providers have a mix of Medicare, Medicaid, and privately insured patients, and assumed that Medicare would reimburse all beneficiaries. They observed that this would cut the amount of time needed to break-even.

“The idea that you have to see more patients can be really scary,” Laiteerapong said. “But the idea is that you’re actually spending that time more focused on the patient. A scribe allows doctors to focus on thinking and talking and listening, and not on the typing and clicking and ordering. I don’t know anyone who became a doctor to do those things.” (www.ehrintelligence.com).

The researchers referenced a 2018 University of Chicago study that examined the benefits of having a medical scribe in the examination room. However, they point out that the COVID-19 pandemic has changed things and it may not be possible to have additional staff in exam rooms. Laiteerapong suggests having the conversation in the room recorded and transmitted to the space where the scribe is working so that the final notes are 90% done when the consult ends.

Like scribes, medical transcription service is a reliable tool for reducing the EHR documentation burden. These services are a viable option for multiple settings such as physician practices, hospitals, emergency departments, long-term care facilities, long-term acute care hospitals, public health clinics, and ambulatory care centers.

Experienced medical transcription companies can deliver EHR-integrated documentation solutions in quick turnaround time to meet the requirements of all medical specialties. Their professional staff use advanced speech-to-text and voice recognition software to initially document their work, and put their work through stringent quality control processes, allowing for more editing before the dictating physician finalizes the transcript (HITEQ Decreasing EHR Documentation Burden). Experts can ensure a 99% accuracy rate.

Medical transcription services are also cost-effective. In addition to not having to free up more space for an in-house transcription team, the health center can save on training costs, as the vendor trains and houses specialized knowledge for transcription.

Physicians recognize that EHRs help legible, complete documentation and accurate, efficient coding and billing, and improve patient and provider communication. However, despite their many advantages, EHR data entry can place an increased demand on physicians’ time and compromise efficiency. Outsourcing medical transcription is a cost-effective solution to reduce the burden of EHR documentation.

Top 9 Reasons for Cardiologists to Rely on Medical Transcription Services [INFOGRAPHIC]

02-November-2020 Rajeev Rajagopal Infographics

For any medical specialty, including cardiology, it is crucial to maintain quality clinical records, as any error in these records could even lead to the death of the patient. Reliable medical transcription services help medical practices, hospitals, clinics and other healthcare entities to obtain accurate and affordable clinical documentation solutions.

Check out the infographic below

Medical Transcription Services

Is Telemedicine an Effective Option for Preventive Care?

29-October-2020 MTS TEAM Medical Transcription Outsourcing

Preventive Care

Preventive care improves health, increases life span, and eventually reduces the burden of chronic diseases on the healthcare system. With medical transcription services enabling physicians to maintain accurate patient records, interactive electronic health records (EHRs) have enhanced delivery of preventive care by involving patients in self-management of their health and disease.

Telehealth has been widely touted as an effective solution for preventive care. Telehealth makes it easier for people to access preventive health programs, especially those with financial or geographic restrictions to quality care. “Telehealth services are well suited to be used as tools that connect patients to their health care providers in order to prevent diseases from occurring or to help maintain health conditions in order to prevent existing conditions from worsening”, wrote supporters of telehealth in a 2018 National Law Review blog (www.mhealthintelligence.com).

Study: finds chronic, preventive care fell as telemedicine adoption rose

Since the outbreak of the COVID-19 pandemic and adoption of social distancing measures, the number of primary care visits have gone down and many patients have moved to telehealth appointments. According to a paper published by the American College of Cardiology, as of March 30, 2020, about 75% of all outpatient cardiology encounters moved to telehealth. Interruptions in care and increased morbidity and mortality due to direct exposure to COVID-19 are of particular concern for patients with cardiovascular diseases (CVD).

But how effective has telemedicine been for preventive care during the pandemic? Research published in JAMA Network Open found that, even as the use telemedicine soared during the COVID-19 pandemic, chronic, preventive care fell during the first half of 2020 compared to previous years. The key findings of the study as reported by MedScape are as follows:

In 2018 and 2019, most primary care visits were office-based, but in April-May 2020, as the COVID-19 pandemic spread across the country, the total number of primary care visits fell by 21.4%. Telemedicine visits increased from just 1.1% of total visits in Q2 of 2018 and 2019, to 4.1% of visits in the first quarter of 2020, and to 35.3% of visits in April-May 2020. Adults in the age group 19 to 55 years who had commercial medical insurance were more likely to use telemedicine visits than those younger or older.

Significantly, the study found a downward trend in preventive and chronic care in April-May 2020:

The number of visits in which blood pressure was assessed dropped by 50.1% and the number of visits with cholesterol level assessments fell by 36.9% during April-May 2020 compared to the same time in 2019.
Visits wherein new antihypertensive or cholesterol-lowering medications were prescribed and renewed dropped .
New treatments decreased significantly for patients with chronic conditions, including hypertension, diabetes, high cholesterol, asthma, depression, and insomnia.
The content of telemedicine vs in-person visits changed – proportion of blood pressure and cholesterol level assessments were lower in telemedicine encounters compared to office visit.s

According to the researchers, the decline in evaluations of cardiovascular risk factors such as blood pressure and cholesterol were due to “fewer total visits and less frequent assessments during telemedicine encounters.”

ACR: remote patient monitoring can improve telemedicine delivery

A paper published in July 2020 discussed the statement from the American Society for Preventive Cardiology on continuing preventive care during the pandemic. The American College of Cardiology recommends the use of remote patient monitoring (RPM) systems to improve the effectiveness of telemedicine. Such systems allow patients to track and record their own data and collect digital biomarkers such as vital signs, heart rhythm, glucose, or weight without having to go to a clinic or hospital. RPM systems with user-centered design could enhance patient engagement in their care, notes the report.

Social distancing could exacerbate mental illnesses such as anxiety and depression. Cardiovascular health also depends on addressing such psychological stressors. Telemedicine is a practical way to promote mental and physical health during the pandemic. The report observes that technology can be used for counseling patients on at-home exercises and healthy diet recommendations to improve their cardiovascular health.

As clinicians strive to make effective use of telemedicine to provide outpatient care and prevent serious lapses in care in these challenging times, outsourcing medical transcription can help them manage EHR documentation efficiently.

Improving Diagnostic Radiology Report Turnaround Times

26-October-2020 Julie Clements Radiology Transcription

Radiology Report

Radiologists play an important role in patient care by providing comprehensive radiology reports. Medical transcription companies focus on providing radiologists with accurate and timely radiology reports. The accurate interpretation of imaging studies and appropriate reporting of the imaging findings to attending physicians is vital for patient management and to improve workflow.

In addition to high quality images, radiology reports contain details about clinical presentation, diagnostic impression, examination procedure, and details about contrast administration. They also usually include recommendations on follow-up and other radiological or non-radiological investigations.

Report turnaround time (TAT) is a critical element in diagnostic radiology as delays in reporting affects all stakeholders – the radiologist, referring provider, patient, and administrator. Radiology departments track and seek to improve several types of report turnaround times, which differ for the various stakeholders. Radiologykey.com defines these TATs as follows:

Radiologist – from completion of examination to final report signature
Referring provider – from placement of order for examination to receipt of final report
Patient – from time of examination to communication of results
Administrator – from time of examination to submission of claim or bill

Turnaround times for reports also differ. While some tests such as chest X-rays for pneumonia or CT scans for brain bleeds require 15 minutes to interpret, and others take a longer time to read. TAT in radiology reporting is even more critical in the emergency department (ED). Expediting TAT to generate reports is crucial to increase throughput in the ED and provide better care, says Eric England, MD, assistant professor of radiology at the University of Cincinnati Health (www.diagnosticimaging.com).

With the transition to a value-based care model, improving TAT has become an important goal for radiology departments. Here are top strategies that experts recommend to improve radiology TAT:

Improve Practice Workflow and Activities: According to a diagnosticimaging.com article, improving radiology practice workflow in the following ways can improve TAT.

Carefully evaluate department workflow and activities and make changes that can contribute to lowering TAT. Data mining can help identify bottlenecks.
Ensure an efficient RIS/PACS system with well-integrated tools, such as speech, intelligent display protocols, 3D visualization, and other clinical applications
Identify, assess and fix paper-based processes that can cause delays
Develop a standard set of image viewing instructions for different reading situations
Leverage data to support potential investment in new hardware, software, or personnel
Train physicians to efficiently use systems for managing and sharing images, teaching files, and reference case information
Ensure that PAC systems can support increasing workloads
Check whether separating PACS administration from RIS administration can save time

Ensure Proper Study Prioritization

TAT times will fall if radiologists know which scans need to be read first. For this, referring physicians need to be educated on ranking ordered studies based on a patient’s condition or care. This is important to help radiologists generate reports in a timely manner.

Limit Distractions

Another strategy to improve radiology TAT is limiting the activities that don’t impact the report directly, such as phone calls or face-to-face reading room visits. Having dedicated staff to handle phone calls and other matters can prevent such interruptions from slowing down the radiologist.

Implement New Technology

Artificial intelligence (AI)-enabled solutions, structured reporting and voice Recognition are important advancements that can help eliminate time-consuming tasks in radiology. In structured reporting templates, certain portions are automatically completed, which saves time. Voice recognition avoids the need for typing and allows reports to be delivered immediately after the radiologist interprets the diagnostic exam.

However, despite the advantages of voice recognition technology for diagnostic radiology reporting, it comes with certain drawbacks. According to a Radiology Key article, there are many reasons why radiologists remain dissatisfied with speech recognition technology (SRT):

SRT has a negative impact on their productivity as the radiologist handles the editing which means that more time is spent on tasks other than image interpretation. The article notes that one study showed a 50% increase in report dictation time as well as an increase in costs by US$6.10 per case with SRT compared with conventional radiology transcription services.
SRT leads to a high rate of transcription errors in diagnostic radiology reports. One study which involved two radiologists dictating 100 magnetic resonance imaging (MRI) reports, 50 with VR and 50 with standard transcription, showed that while only 6% to 8% of transcription-generated reports had errors, 30% to 42% of the VR reports contained errors. Up to 22% of reported imaging studies had potentially confusing transcription errors with radiologists greatly underestimating the rate of errors in their reports. Such errors could even lead to misinterpretations of reports.

SRT can definitely improve TAT in radiology reporting. To ensure accuracy as well, imaging reports can be sent for proofreading and editing to a reliable medical transcription company that can expedite these time-sensitive items.

Patient Access to Medical Records – Benefits, Barriers and Solutions

22-October-2020 Rajeev Rajagopal Medical Transcription

Medical Records

Maintaining complete medical records is essential to coordinate patient care and most physicians rely on medical transcription services to ensure accurate and timely clinical reporting in electronic health records (EHRs). An accurate written record is also important because with digitization, physicians can share patient information with other health care providers involved in the patient’s care. Sharing patient data means two things: sharing this data across healthcare settings or EHR interoperability and giving patients access to their EHR. Federal law supports greater patient access to healthcare records and the sharing of such records across health networks. Communicating health care data can improve patient care but there are challenges to overcome. Importantly, physicians need to understand their obligations for patient record sharing.

The benefits of providing patients access to their own healthcare records are:

Improves patient engagement and involvement in their own care, which enhances the overall health care experience
Patients can use the patient portal to send and receive messages, get answers to questions, and fix appointments
They can check prescription information and request refills online
They can access their records from their devices any where and at any time
Patients can fill out pre-visit forms on the system, making the process smoother and hassle free
Being able to view their health summary before their visit will ensure that they are better prepared
Appointment scheduling and follow-up are easy to manage through the portal.

A recent Pew Research survey found that patients do want access to their healthcare data. The survey found that Americans are aware about the importance of getting access to their own health data and sharing it with their clinicians. Some key findings of the survey:

61% of adults said they would be comfortable with downloading their records to applications on mobile devices to help them manage their own health.
Up to 81% of adults said they would support allowing different health care providers to share their patients’ EHR data when they are providing care for the same patient.
A majority expressed concerns about privacy when informed that when downloaded to an app, their health care data would not be protected by federal laws such as HIPAA.

So, what are the barriers associated with patient EHR access? The problems range from high fees to outdated formats for information and state regulations.

High fees are a barrier to patients’ access to their medical records. While HIPAA laws require healthcare organizations to allow patients to access their own healthcare records in a timely, affordable way, a report released by the U.S. Government Accountability Office (GAO) in 2018 found that costs and state regulations surrounding access pose formidable challenges to this. The report, which was based on interviews with patient advocates and other stakeholders, noted the following concerns relating to costs of accessing medical records in different states:

Charges for per-page for records requests
Additional rates for X-ray and MRI image requests
Additional fees for third-party record requests, such as for a patient’s lawyer
High fees when records are requested in a healthcare emergency

Some patients cancelled their requests for access to their records when they were informed about the potential costs associated it.

Other problems, according to a recent Healthcare IT include: records not sent within the required 30-day period, records not shared in the requested digital format, refusal to send images, and not accepting requests by email or fax (as required by HIPAA).

Many healthcare organizations not aware about federal transparency law, according to a study by Accenture. The study revealed that more than half of technology executives in leading healthcare organizations in the US are only “somewhat familiar” with the federal law that requires providing greater patient access to healthcare records and the sharing of these records across health networks.

“Our survey findings are a wake-up call for health organizations and agencies that remain relatively uninformed about the regulations, or who are not actively preparing. Complying with the regulations will provide them with a major opportunity to enhance the services they provide and to fundamentally improve consumer engagement in their healthcare,” says Andy Truscott, managing director and technology consulting lead in Accenture’s Health practice and a member of U.S. federal government advisory groups on health IT and Health Level Seven (www.managedhealthcareexecutive.com).

The American Medical Association (AMA) recognizes that physician offices can find it difficult to navigate complex federal and state laws on allowing patients the right to access their medical records electronically. The AMA’s new Patient Records Electronic Access Playbook is focused on easing these concerns. A recent article published by the AMA provides 10 things that practices need to know about patients access to their records:

Patients have the authority to view/obtain a copy of their medical and billing information.
There are HIPAA fee limitations for patient records requests.
Patients can obtain copies of their medical information through means other than patient portals.
Patients have to fill out a request form for a copy of medical information.
A patient’s access cannot be denied on the grounds that the practice thinks it is not in their best interest.
Medical records can be sent to patients through unencrypted email if they are warned of the risk of unauthorized access in transit.
A HIPAA-compliant authorization form is required for a request comes from a third party and does not appear that it is at the patient’s direction. If the practice is unsure whether a third-party request is at the patient’s direction or not, the patient may be contacted to confirm the matter.
The patient has the right to request the practice to provide a copy of their medical record to a third party.
When patients request their record, the practice should try to inform them and their caregivers when the record request was received and, if possible, provide an estimated timeline for when they can expect to receive the records. The AMA also recommends allowing patients to flag emergency requests.
As patients who are sick may ask family/caregivers to help them access their records, practices should try to work with these caregivers to provide access in accordance with the patient’s wishes.

As health records are shared with patients and with their health care providers, US based medical transcription companies have a key role in ensuring that the records are completed accurately and in a timely manner.

Significance of Radiology Transcription for Neurologists and Researchers

19-October-2020 MTS TEAM Radiology Transcription

Radiology Transcription

To speed up medical documentation, many neurologists prefer dictating their notes and outsourcing medical transcription to a reliable vendor. Accuracy is an important element when it comes to transcribing neurology reports. A reliable service provider offers customized solutions to individual neurologists, physicians’ groups, hospitals, neurology clinics, acute care clinics and long-term care clinics. They provide radiology transcription for MRIs, CT scans, X rays etc.

Imaging technologies are used during surgery to guide the movement of surgical instruments. They are also used to deliver treatment to a specific body part without invasive surgery. Neurologists may use MRI scans and CT scans to get a better resolution of neural structures. It helps them to quickly diagnose brain injury, stroke, spinal cord tumours, and infections. Sometimes, imaging studies may be dictated as procedure notes or surgical reports if the study is performed in an operating room. So, it is important to ensure that radiology notes are accurately recorded and transcribed to help neurologists diagnose better and provide the most appropriate treatment as soon as possible.

Let us look at a research study where MRIs had a significant role to play.

Study Reveals Brain Regions that May Control Fatigue

Scientists at John Hopkins Medicine used MRI scans and computer modelling to find out parts of the human brain that can regulate efforts to control fatigue. The results of the study were published in Nature Communication.

For the study, the team developed a new way to quantify how people feel fatigued, which varies from people to people. 20 participants, with an average age of 24 (18 to 34), were asked to make a risk-based decision about exerting a certain amount of physical effort. Nine out of 20 participants were female.

The participants were asked to squeeze a sensor after training them to recognize a scale of effort. For example, zero was equal to no effort and 50 units of effort were equal to half the participant’s maximum force. The participants continued the grip exercise for 17 blocks for 10 trials until they were fatigued. After that they were offered one of two choices for making such an effort – a random choice based on a coin flip (which offered the chance to exert no effort) or a predetermined set effort level. This was with a view to understand how each participant valued their effort. It would also help understand how their brains and minds decided how much effort to exert.

The researchers used computerized programs to know how participants felt about the prospect of exerting particular amounts of effort while they were fatigued. The study found that most of the participants were risk averters. This means that when they were fatigued they were less willing to take the chance of having to exert too much.

Another group of 10 people were trained on gripping system but were not given fatigue trials. The participants’ brain activity was evaluated for the research with functional MRI scans, which track blood flow through the brain and show which neurons are firing most often. Just as in previous findings, it was found that when the participants chose between the two options, brain activity seemed to increase in all participants in the area of the brain known as the insula. MRI scans were also used to examine the motor cortex of the brain (which is responsible for exerting the effort itself) when the participants were fatigued. The research team found that the motor cortex was deactivated when the participants were making a choice. Participants whose motor cortex changed the least were the most risk averters. This shows that fatigue might arise from miscalibration between what an individual thinks they are able to achieve and the actual activity in the motor cortex.

Studies such as the above rely a great deal on MRI scans and such advanced imaging studies, which highlights the importance of such imaging procedures. The findings from similar research will help speed up the search for appropriate therapies that will enable healthy people as well as those with fatigue-associated conditions to improve performance.

How Radiology Transcription supports Neurologists and Researchers

Improving Clinical Decision-Making: By providing exact and in-depth radiological reports, transcription plays a critical role in assisting neurologists in correctly diagnosing and treating neurological diseases. By ensuring accurate MRI, CT scan, and other imaging investigation reports, radiology transcription guides neurologists’ treatment decisions and supports proper care delivery.
Supporting Neuroscience Projects: Radiology transcription is crucial to preserving the precision and dependability of imaging data in neurological research. Well-documented radiological reports are essential for the analysis of illness processes, treatment evaluations, and biomarker identification by researchers. High-quality transcripts ensure the consistency and reproducibility of research data, supporting neurological research projects.
Enhancing Interaction and Treatment with Patients: Precise transcriptions of radiology tests facilitate clear documentation of imaging findings, which improves communication between neurologists and patients. Patients gain a better understanding of their diagnosis and available treatments as a result. Furthermore, accurate transcriptions guarantee that all members of the medical team are on the same page, which facilitates coordinated and efficient care-especially when it comes to the management of long-term neurological disorders.
Encouraging Compliance with Laws and Ethics: Maintaining comprehensive medical records is necessary for both clinical practice and research, as well as for legal and ethical compliance. This is where transcription comes in. Precise documentation upholds the validity of the findings and protects medical professionals and investigators from legal disputes.

Radiology Transcription supports Neurologists and Researchers

Different Sections in a Transcribed Radiology Report

The particulars of the imaging study: Here the types of images taken, contrast material or medications used, and any relevant conditions related to the surgery (if the imaging is done in an operating room) are mentioned. For e.g.Procedure: MRI of the brain without contrast
In case the results need to be compared with those of an earlier study, the date and name of the comparison study will also be provided in this section or beneath a Comparison Heading.
Why the study was performed: This section could be titled History, Indication, or Clinical History. The information given here would include the reason for the study (for e.g. chronic headache), and clinical history (for instance, “the patient is a 50-year-old woman with chronic headaches”).
The technique employed: Here you will have a description of how the procedure was performed, and the kind of images obtained. For simple procedures, the description would be simple and for complex procedures a more detailed step-by-step description would be provided.
Results: This section would include all values, measurements, and observations recorded during the study. This section may also be titled as Findings or Interpretation. Here, any incidental findings that may be unrelated to the condition for which the study was performed, will also be recorded.
Impression: In this part of the report, the radiologist would provide his/her assessment of the significance of the findings. Specific diagnoses or suggestions of a probable diagnosis may be given.

Neurologists and other healthcare professionals can benefit by partnering with a HIPAA-compliant medical transcription company specialized in radiology transcription. Transcriptionists in such companies understand the specific terminology related to neurological diagnoses and procedures, ensuring the accuracy of transcripts for neurology and any related radiology reports.

Enhance your neurology practice and improve care with precise and reliable medical transcription services.