How to Stay HIPAA Compliant when Using Telemedicine

12-October-2020 Rajeev Rajagopal HIPAA Compliance

HIPAA Compliant

Telehealth got a major boost when the U.S. Department of Health and Human Services (HHS) expanded the number and types of interventions that can be provided remotely during the COVID-19 public health emergency. According to a HIT consultant report, many health systems report that more than 50% of primary care visits are now being performed via telemedicine. US based medical transcription companies have stepped up their efforts to meet providers’ EHR documentation requirements. However, as the access to telemedicine services was broadened, it has triggered security concerns. Remote electronic communication must not compromise the safety of protected health information (PHI). Though the Office for Civil Rights (OCR) has lifted penalties for breaches that result from the good faith provision of telehealth services during the COVID-19 crisis, staying HIPAA compliant is critical to ward off cybersecurity attacks.

Partnering with a HIPAA compliant medical transcription company is necessary when it comes to documenting telehealth consultations, as PHI includes transcribed documents. Additionally, experts recommend the following strategies to remain HIPAA compliant while providing telemedicine services:

Utilize enterprise virtual private network (VPN): Successful implementation of telemedicine depends on ensuring the secure transit of virtual consultations and related communications. The channel of communication that is used for communicating ePHI is critical. Experts consider enterprise VPNs a must-have for telemedicine. A Health IT Security article notes: “Enterprise VPNs are the mainstay for protected communications for about 95 percent of organizations, including those in the healthcare sector, as a best practice for remote access security and compliance”. VPNs ensure that data is encrypted and sent to the right person. However, it’s important for providers to ascertain that the VPN software is up to date and current to rule out potential VPN vulnerabilities, Pulse Secure’s CMO Scott Gordon told HealthITSecurity.com.
Desktop-as-a-service: (DaaS) to reduce surface attack risks: DaaS is a desktop virtualization solution that securely delivers virtual apps and desktops from the cloud to any device or location. It is an ideal option for accessing PHI via the cloud without revealing connections or records. A DaaS is generally deployed using secure encryption keys and as all user data is stored on the cloud, the risk surface area attacks are reduced (www.hitconsultant.net).
Use automation in remediation: “Automate everything that can be automated”, says Gerry Miller, Founder & CEO at Cloudticity (www.hitconsultant.com). Remediating potential compliance problems manually can consume a lot of time and resources. By integrating AI and operational intelligence, cloud-based services can recommend the best approach in a given situation.
Continuous identity authentication: Experts recommend multi-factor authentication (MFA) to prevent automated cyberattacks. The National Institute of Standards and Technology (NIST) considers MFA the preferable authentications method for strong authentication. MFA remembers a device. Continuous identity authentication should aim to verify usernames and passwords with a security question as well as another factor, such as using a key code for verification after the initial login request (www.healthitsecurity.com).
Continuous endpoint authentication and compliance: Endpoint posture checking will ensure that remote users have access to minimum resources for as little time as needed so as to minimize risk and maximize security. Users privileges can be marked. Experts recommend continuous endpoint posture checking using cloud applications to quickly organize telemedicine support and engaging with patients both virtually and on premises. Applications should be accessible to healthcare providers regardless of their location and allow running of antivirus software, a personal firewall, and anti-phishing software.
Encryption of data storage: When PHI and other critical information are encrypted, hackers will not be able to access them. Best practice is to ensure that all web and application servers running on cloud are encrypted using a custom master key from a key management service.
Secure operating systems: Microsoft Windows and Linux are popular operating systems (OS) for telemedicine, but they have many vulnerabilities. The HIT Consultant report explains that criminal access to OS can be prevented by using hardened images of Windows Server and Linux virtual machines (VMs) with default configurations recommended by the Center for Internet Security (CIS).

Also Read: Best 10 HIPAA-Compliant Telemedicine Platforms

HIPAA compliant medical transcription is essential to ensure the security and confidentiality of PHI created when providing telemedicine services. US based medical transcription service providers have all the necessary measures in place to ensure the protection of the data they handle, including provisions for regular auditing for HIPAA compliance.

Best Practices to Preserve EHR Documentation Integrity

08-October-2020 MTS TEAM EHR Transcription

EHR Documentation

Electronic health records (EHRs) offer many benefits such as improved patient care, better care coordination, improved diagnostic ability and better patient care, increased patient participation, improved practice efficiencies and cost savings. Medical transcription companies help physicians document a wide variety of reports, save time, overcome stress, and focus on care. EHR documentation integrity is essential to realize the benefits of EHRs. The three “Rs” of well-kept, accurate and complete medical records are:

The right information
At the right time
For the right patient

Loss of documentation integrity can undermine patient care, affect compliance, and lead to legal issues.

What are the factors that compromise EHR documentation integrity? Experience shows that integrity issues are directly related to EHR automated functions and short-cuts.

“Copy and paste” or cloning: Copying and pasting allows users to copy text verbatim from any note and paste it into any another location. Common copy-paste errors include not updating the information, mistakes in the time element of a visit, contradictory information in a note, lack of clarity on authorship, and omitting relevant data when cutting and pasting (www.eyecareleaders.com). It can also lead to bloated notes that make it hard to find relevant new information.
Automatic fill-ins: While auto-fills can facilitate documentation and save time, invalid auto-population of data fields can lead to major errors. Verifying auto-populated entries is necessary to identify real from incorrect data.
Drop down menus: Data can be automatically entered in drop down menus for diagnoses if the provider holds the mouse over them too long.
Carry or pull forward entries: This refers to carrying forward the same notes from past entries and the same plan of care. The copy forward command allows bringing forward parts of or the whole previous note into a new progress note. It is useful to update structured information such as blood pressure, labs and medications. But errors occur when the physician does not verify if the information carried forward is pertinent to the current encounter. One study of a medical intensive care found that 74% of attending physicians’ EHR notes and 82% of residents’ notes had at least 20% of the information copied from previous notes (ACP Hospitalist). This can create a lot of confusion as to what was done and when it was done.
Auto prompts: While auto‐prompts can support and improve provider documentation, they can also be misused. Prompt fatigue, a result of inability to control prompt occurrence, can lead to the physician not using it or even misusing it when entering information.

Good document keeping is an essential element in healthcare. The concerns about the accuracy and quality of EHR documentation started right from the time EHRs were introduced and continue to exist even today. In an update published in 2017, the American Health Information Management Association (AHIMA) stressed the importance of having processes in place” to ensure the documentation for the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely”.

Following these best practices can help physicians preserve EHR documentation integrity:

Document the health services provided to each patient separately from all others.
Avoid copying forward a previous finding or section of an exam that is not pertinent to the current visit or progress note. If a prior finding is copied forward, it should be edited as appropriate. At each encounter, the physician must ensure that what is documented is appropriate and correct.
Check dictated information for errors. Before sending dictated files to a medical transcription service provider, physicians need to review, edit and validate dictated information. The AHIMA report notes that organizations using a speech recognition tool (SRT) without checks in place experience significant data quality problems and documentation errors.
Set up a patient identity integrity program to ensure that information is recorded on the correct medical record. Organizations should ensure that key demographic data are correct. Errors in patient identification can have a ripple effect across the healthcare network and compromise patient safety.
All information created within the EHR should be linked to its author. This is important as multiple providers contribute to an EHR note. The signatures of all authors or contributors should be preserved so that each individual’s entry can be clearly identified.
Rules on amending EHR documentation should be diligently followed. Every healthcare organization needs to have policies and procedures in place regarding when changes need to be made, the type of changes that can be made, who can amend the documentation, and how the changes will be tracked and supervised, notes the AHIMA report.
Conduct audits. Providers should perform EHR data audits to review templates. By identifying and pointing out instances of poor documentation, audits can help organizations educate providers on improving templates.
Educate providers. EHR users must be trained about EHR documentation requirements, security requirements, and compliance and legal risks, including their own responsibility in preventing problems.

Medical records can support clinical decision-making only if they contain reliable information. Information that is inaccurate, contradictory or hard to find can compromise care and patient safety. Outsourcing medical transcription is a viable option to ensure accurate and timely documentation and preserve the integrity of patient medical records.

Benefits of Cloud-based EHR systems for Medical Practices

05-October-2020 Julie Clements EHR Transcription

Cloud-based EHR systems

Electronic health record (EHR) systems have made it easier for medical practices to store and manage patient information. Outsourcing medical transcription allows physicians and their staff to focus on patient care rather than managing burdensome EHR documentation tasks. There are two types of EHR systems: on-premise and cloud-based. On-premise or server-based EHR systems store patient data within the practice’s personal server. In a cloud-based EHR system, data is stored on off-site servers and accessed through the web. 2018 Black Book survey found that 30% of practices with more than 11 clinicians are looking to replace their EHR system by 2021, and 93% are focusing on cloud-based mobile solutions. Amidst the pandemic, efficient transition to cloud computing could protect patient data, say IT experts (www.hitconsultant.net). Let’s look at the key advantages of implementing cloud-based EHR systems in medical practices.

Seamless integration and data sharing: Cloud-based interoperability allows seamless integration and data sharing which streamlines the healthcare process, improves care coordination, and optimizes health outcomes, notes a recent Physicians Practice report. Physicians need to share clinical data with labs, referring physicians, and payers and doing this manually can difficult and time-consuming. Cloud-based interoperability allows all parties to connect and share healthcare information efficiently and securely to improve the patient experience. A 2019 PointClickCare reported that 49 percent of acute care providers and 31 percent of post-acute care providers had limited patient data sharing access. Cloud-based EHRs could address this challenge (www.ehrintelligence.com).
Promotes data security: Patient data security is a critical element in EHR adoption. As patient health information (PHI) is shared between applications, providers and patients, it must be easily accessible and shareable, and also safe. Experts point out that cloud-based EHRs are more secure than in-house EHRs which are inherently vulnerable to data breaches. Poor security can be the result of the software itself or due to the lack of good practices by users. UChicago Voices reported 2,181 healthcare data breaches involving more than 500 records during 2009-2017. Experts say cloud-based EHRs are more secure than in-house EHRs. In a 2017 guide on cloud computing in healthcare, Cloud Standards Customer Council (CSCC) authors explained that cloud services are maintained by expert professional staff and come with sophisticated security controls, including data encryption and fine-grained access controls and access logging (www.ehrintelligence.com).
Saves money and boosts revenue: Experts say that a cloud-based EHR system can also improve a practice’s bottom line. First, it comes with significant up-front savings as implementation is far less expensive than client-server systems. As the EHR system is maintained by a Service (SAAS) provider, the practice does not have to spend time or money on server installation, maintenance or updates. Next, as Physicians Practice notes, adopting cloud-based interoperability allows practices to offer patients various payment options and methods, which speeds up collections and boosts patient satisfaction. Adopting interoperability and accompanying standards will help physicians connect with multiple payers more efficiently, and improve claims payment and revenue.
Greater flexibility: A cloud-based EHR system is scalable, allowing growing practices to easily add on physicians, users, and locations. As a HIT Consultant report points out, cloud-based solutions can generate more power as necessary to handle additional traffic, and cut it during downtimes so that providers do not have to pay for unused capacity.
Benefits public health: Relying on outdated communication technology like fax machines is a major barrier to communication and collaboration in healthcare. The COVID-19 pandemic highlighted the significance of cloud-based EHR interoperability for physicians to identify a lab and order lab tests in a timely manner, according to Physicians Practice. By enabling a nation wide lab network, cloud-based interoperability improves the coordination of testing and provides physicians with improved ways to find a lab, order a test, get the results, and provide care for patients who test positive.

Adopting a cloud-based EHR can create more patient-centered healthcare system and safeguard data. With accurate and timely medical transcription services and a cloud-based EHR, physicians can share medical records easily, and improve communication and compliance. Interoperability also supports telehealth, which has gained immense significance during the COVID-19 healthcare crisis.

What Today’s Patients Expect from Medical Practices [INFOGRAPHIC]

01-October-2020 Rajeev Rajagopal Infographics

All physicians are focused on providing the best care and ensuring that each patient experience is a positive one. Relying on medical transcription outsourcing companies helps physicians maintain complete and accurate patient records which is crucial for patient safety and delivery of quality care. However, physicians need to know what today’s patients expect from a medical practice, in addition to quality care. By meeting these expectations, medical practices can improve the patient experience, attract new patients and increase patient retention.

Check out the infographic below

Medical Practices

Evaluating the Pros and Cons of Telehealth Adoption

28-September-2020 MTS TEAM Medical Transcription

Evaluating the Pros and Cons of Telehealth Adoption

Healthcare providers across the country were quick to adopt telehealth services when the COVID-19 pandemic hit. With lockdown and social distancing, telehealth provided access to care remotely. State and federal governments took emergency measures to reduce barriers and improve coverage for telehealth. Medical transcription companies ensured accurate and timely documentation of telehealth encounters in electronic health records (EHRs). While telehealth has proved a game changer during the ongoing crisis, healthcare organizations are now reviewing their experience in the virtual realm and evaluating the pros and cons of telehealth adoption.

Pros of Telehealth Services

According to a report from the U.S. Department of Health and Human Services (HSS), in February before the public health emergency, less than one percent (0.1%) of Medicare primary care visits were conducted through telehealth, but this proportion rose to 43.5% in April 2019. This clearly shows that Medicare providers and beneficiaries have rapidly embraced the new opportunities for telehealth provision. Many providers believe that people will want to use telehealth more often in the future. For instance, Mei Kwong, executive director for the Center for Connected Health Policy says, “Telehealth has been the missing element to how we deliver healthcare. But now people are familiar with it. They now have the experience and will want to see it used more often.” (www.mhealthintelligence.com).

The pros of telehealth services are:

Expands access to essential health: Various categories of patients, such as self- or home-isolated patients, those with mild cases, patients needing follow-ups after discharge, can get the essential care they need, including for chronic health conditions and medication management, using telehealth platforms. Telehealth provides access to primary care physicians and specialists, including mental and behavioral health professionals. One way the pandemic has changed telemedicine services is that physicians can provide services not only for established patients but also for new patients.
Telemedicine triage: Reports predict a sustained interest in telemedicine triage even after the pandemic. Teletriage allows care teams to screen patients, assess their risk and urgent care needs, answer their questions, and decide on a course of action before they see them in person. This capability greatly reduces the demands on in-person primary care, urgent care, etc. It also benefits patients as they can get expert guidance quickly using tele-triage. Many patients will continue to see telehealth as their first point of contact for urgent care, notes Ethan Booker, MD, medical director of Maryland-based MedStar Health’s Telehealth Innovation Center and the MedStar eVisit platform (mhealthintelligence.com).
Reduces healthcare providers’ risk of exposure to the virus (sick persons): The adoption of telehealth technology helps reduce staff exposure to infected and potentially contagious patients, preserves personal protective equipment (PPE), and minimizes the impact of overcrowding in facilities.
Offers flexibility and saves costs: Patients and providers can connect and participate in video/audioconferencing sessions and exchange information using any device, from computers to smartphones. Patients do not have to leave their homes to meet with their physician, avoiding the costs and challenges of travel/transport. Visits can be scheduled at a time convenient to both the patient and provider. Physicians are now allowed to waive/reduce cost-sharing for telehealth visits.
Streamlines workflow: Telehealth services include real-time telephone or live audio-video interaction, asynchronous wherein patient information is collected at one point of time and responded to later, and remote monitoring of vital parameters like blood pressure, blood glucose, other remote assessments. With a well-integrated, telehealth portal, providers can log in, see patient requests, and set up a video conference with the patient. They can also view patients in the virtual waiting room and obtain patient medical records from the EHR. Physicians can enter notes directly into the system at the encounter, and automatically generated transcripts can be later reviewed and edited by their medical transcription service provider.
Reduces non-shows and cancelations: When patients can see their physicians from home, the possibility of no shows and cancellations are reduced. Talking about her experience providing virtual therapy services during the present crisis, Pam Shepard, LCSW, Supervisor of Clinical Services, Holt-Sunny Ridge says, “Because clients did not have their usual schedules and extracurricular activities, they typically looked forward to our sessions!” (www.holtinternational.org).

Cons of Telehealth Services

Telemedicine is not without its drawbacks, with the main criticism revolving around its potential impact on quality of care. The key limitations of remote care are as follows:

Patient data confidentiality: Concerns have been expressed about patient privacy policies. According to a HIT Consultant article, while healthcare organizations have stringent measures in place to comply with HIPAA regulations, the HITECH Act, etc., telehealth raises concerns about patient privacy. The article lists various emerging telehealth-related security threats: Unauthorized access to patient data by employees, snooping on patient data, compromised records (unusual access patterns across locations), failed logins and download spikes, gaining access via terminated or dormant user accounts, and accessing discharged patient records or deceased patient records.
Image quality: The effectiveness of telemedicine in certain fields depends on image quality. When external signs and symptoms are important to identify the problem, such as in dermatology, telemedicine can be useful. However, image quality can be a challenge when using telemedicine. Medical image compression for image sharing in telemedicine applications can affect picture quality – the lower the resolution, the lower the end quality. There is also the question as to whether images taken using smartphones are reliable for accurate clinical diagnoses (www.swymed.com).
Cannot always replace actual face-to-face visit: There are many situations wherehands-on care would be necessary, such as for providing chemotherapy to a cancer patient or fixing a fracture. In his article on www.hbr.org, Dr. David Blumenthal, who is president of the Commonwealth Fund, asks, “Could a Zoom visit detect a lymph node too firm, a spleen or liver too large, or an unexpected prostate nodule (with a normal PSA)?”
Patients’ lack of technology and knowledge to use it: In a recent Kaiser Family Foundation survey only 7 in 10 adults age 65 and older (68%) reported having a computer, smartphone, or tablet with internet access, compared to all younger adults. Many older patients did not know how to use digital tools for health, and were also concerned about their privacy and preferred face-to-face consults. For telemedicine to succeed, it should be user-friendly and assistance should be made available online for patients who lack technological abilities.

Despite these barriers and challenges, telemedicine has proved its value during the COVID-19 pandemic by speeding and expanding access to care. Though telehealth visits have reduced since healthcare facilities opened up, they offer many benefits and there is an increasing demand to make them more available in the future.

Proper documentation of medical consultations is crucial. Medical transcription services are available for documenting remote consultations as well as in-person care.

Top 6 Reasons for Medical Errors in Healthcare

24-September-2020 Julie Clements Medical Transcription

Medical Errors in Healthcare

Medical practices have to maintain a record of all relevant patient data to monitor the treatment given and thus reduce the chances of risk and adverse medical events. Accurate medical records are important in a healthcare setting to not just ensure quality patient care but also to meet ethical and legal obligations. Medical transcription services can provide healthcare firms and physicians with accurate EHR documentation.

Most common medical errors are:

Medication/ anesthesia errors
Late diagnosis
Delay in treatment
Failure to act on test or proper precautions
Inadequate follow-up treatment

Medical Errors in Healthcare

Healthcare facilities must therefore take adequate precautions and have proper measures in place to prevent costly medical errors. Patient records can be documented accurately with the support of experienced medical transcription providers.

Automated Communication Improves Patient Engagement while Social Distancing, say Studies

17-September-2020 MTS TEAM Medical Transcription Outsourcing

Patient Engagement

Meaningful patient engagement means building relationships with patients and families to improve care, processes, and outcomes. Healthcare providers employ many strategies to connect with patients and improve care. For instance, hiring medical transcription services provides physicians with more time to focus on patient care, especially during the office visit. However, with social distancing due to the coronavirus pandemic, healthcare providers’ communication with patients has dipped, affecting the patient experience and satisfaction. According to recent reports, automated communication options could be the answer to improving patient engagement and outreach in these challenging times.

Surge in Use of Automated Communication Tools by Patients

Studies conducted since the pandemic outbreak revealed that patients are comfortable with telehealth visits and other digital communication tools, and want to continue using them in future.

A study commissioned by SR Health by Solutionreach revealed a drop in patient satisfaction with regards to provider communication after the COVID-19 outbreak (www.patientengagementhit.com). The researchers conducted two surveys, one before the pandemic and another after its outbreak. The study found that patients did not report provider communication skills as improving patient satisfaction during the pandemic as they did before it occurred.

Before COVID-19:

10 percent of patients said timely provider messages improved satisfaction.
9 percent of patients reported they felt that their providers had heard them, which improved patient satisfaction.

During the pandemic

Only 2 percent of patients said provider communication improved satisfaction.
None of the patients could say that they had been heard by their providers.

Automating patient communication could prevent lapses in care, say experts.

Patient Engagement HIT recently reported on another survey conducted by Accenture that covered 2,700 patients in the US and other developed nations. Four in ten of the respondents started using a digital tool to communicate with their healthcare providers when the pandemic started. Tools used included video conference calls, online chat, and mHealth apps. The survey revealed that patients liked digital health technology because it offered both convenience and personalized, timelier care. The key findings are as follows:

70 percent of the patients were new to video chats and telehealth care access
Up to 63 percent of the respondents who used a video visit said they experienced good or excellent quality virtual care
90 percent of those who began using a digital health tool during the pandemic rated a good experience
80 percent of those who had previous experience using patient engagement technology also rated their experience as good
40 percent of the respondents reported digital health tools as being more convenient than conventional physical office visits
41 percent said their providers responded faster via telehealth
47 percent reported that digital tools offered more personalized communication experience with their provider
60 percent of patients reported they had increased trust in their providers, while 50 percent said their trust in urgent care clinics and public health had increased

Why Patients Prefer Digital Communication

The SR Health study also found that there are many reasons why patients currently prefer digital communication such as text messages, automated messaging, and telehealth over phone:

Text messages are more convenient as they are easy to check and can be accessed anywhere, at any time
It is easy to respond to and get replies via text messages
Digital tools can easy fit in with patients’ daily lives, and are usually prompt

One of the areas where automated communication was especially relevant was appointment scheduling. Up to 73 and 83 percent of patients in the SR Health survey found email outreach for appointment scheduling useful before and during the pandemic, respectively.

A high no-show rate can prove costly for a health system, in addition to leading to affecting patient care. In January, Patient Engagement HIT reported on how NYC Health + Hospitals resolved their appointment no-show rates by implementing a patient outreach campaign based on text messaging. Short text messages are sent to patients asking them whether or not they can keep their appointment. The messaging platform was integrated to the hospital’s call center system so that canceled appointments could be viewed and new appointments could be scheduled in their place.

The bottom line: there are many reasons why it may be practical for healthcare organizations to consider automated communication options. To ensure that these tools meet their goals and yield patient satisfaction, physicians must ensure that patients know how to use them effectively.

As healthcare providers explore various ways to touch base with patients and improve care amidst and beyond the COVID-19 pandemic, outsourcing medical transcription would be the best way to ensure accurate and timely medical documentation.

What Are the Most Common Factors That Lead to Physician Burnout?

14-September-2020 Julie Clements Medical Transcription

Physician Burnout

Rising levels of burnout among physicians is a critical challenge affecting health systems across the country. In a recent athenahealth survey conducted by Harris Poll, an overwhelming 93% of the physicians surveyed said they feel regularly burned out. A recent Fierce Healthcare article refers to physician burnout as “a challenge that’s reaching a crisis point”. While electronic health record (EHR) systems contribute to physician burnout, outsourced medical transcription services including AI-powered solutions, play a key role in ensuring accurate and timely EHR documentation.

Discover how our medical transcription services can ease your EHR documentation challenges.

Call (800) 670-2809 today!

Physicians recognize the value of the EHR for patient care but using the system during the office visit negatively impacts patient interactions and work-life integration. In addition to the EHR data entry challenge, there are several external factors that are responsible for physician burnout. Recent studies have expressed concerns on how this can affect access to care, patient safety, and care quality.

Main Causes of Physician Burnout

Time and work pressures: According to the Minimizing Error, Maximizing Outcome (MEMO) project funded by the Agency for Healthcare Research and Quality (AHRQ), over 50% of primary care physicians report feeling stressed due to time pressures and work conditions. Researchers found that more than 50% experienced time constraints during exams, and nearly a third felt they needed twice as much time. Additionally, nearly a quarter said they needed 50% more time for follow-ups. Factors like chaotic environments, low work control, and unfavorable culture contributed to physician dissatisfaction, burnout, and intent to leave.
Laws, regulations and standards: Healthcare providers need to comply with various health care laws and regulations. This growing burden of administrative requirements can affect patient care and negatively impact physician morale.
Healthcare reform and payer policies: Physicians face challenges navigating the evolving landscape of payment systems, which often come with complex rules and processes. Private insurers are increasingly utilizing risk-sharing contracts, which adds significant administrative burden for healthcare providers.
Medical record documentation and coding requirements: Patient records are vital for assessing a patient’s health condition, planning and evaluating the patient’s treatment and to ensure the best care possible, However, EHRs have specific documentation requirements and on physicians and complying with them can be challenging.
Quality reporting: Quality measures in medical reporting are vital to ensure accountability, transparency and to deliver increased value in health care. However, there are various performance measures that need to be filled and this adds to physician burnout.
Prior authorization: Physicians may need to obtain preapproval from payers before prescribing medications, other forms of treatment, diagnostic procedures and referrals. This can make things difficult for providers and patients. Submitting and obtaining prior auth is a complex process, with rules varying among payers.
Drug monitoring: Physicians use authorized prescription drug monitoring programs to make prescribing decisions, reduce polypharmacy, and avoid supplying opioids to patients that have drug-seeking behavior. However, access to the database differs from state to state, making matters difficult for physicians.
Professional liability: Obtaining medical licensure requires meeting certain criteria, Despite recent efforts to simplify and standardize the licensing process, physicians are still required to provide detailed information about their physical and mental health as part of their application. This includes answering questions about their health status and any past or current conditions that might affect their ability to practice medicine. The process of disclosing this information can create a barrier to seeking the necessary treatment.
Patient-physician relationship: The conventional societal value “doctors know best” has changed to a “patient centric model” where physicians and patients build a rapport to create a better medical experience. Although this system is useful for patients, it could lead to deterioration of trust with physicians and the healthcare system.

EHR-related Physician Stress

EHRs (Electronic Health Records) have many advantages for physicians’ offices and hospitals. However, they have also transferred several administrative tasks to physicians, including billing, coding, and electronically prescribing medications. Reports also point out that the focus of EHR systems on documentation for billing purposes can be contrary to effective and efficient documentation of clinical care. This means that EHRs can, in fact, contribute to increased stress and burnout among healthcare providers.

A study titled “Association of Electronic Health Record Design and Use Factors with Clinician Stress and Burnout” found a link between key aspects of EHR design and physician well-being. An article from the American Medical Association (AMA) lists these factors as:

Information overload.
Slow system response times.
Excessive data entry.
Inability to navigate the system quickly.
Note bloat.
Fear of missing something.
Notes geared toward billing, not patient care.

The lead author of the study, which was published before the pandemic, stated that physicians experience burnout because they are spending so much time on the computer and don’t feel they get enough time to take care of their patients.

So what is the solution? Here are some strategies recommended by industry experts.

Strategies to Combat Physician Burnout

Physician Burnout

Streamline administrative tasks: Implement efficient systems and solutions like medical transcription services to reduce the burden of paperwork and administrative duties.
Implement flexible scheduling: Explore options for flexible work schedules or part-time opportunities to help physicians manage their workload more effectively.
Promote work-life balance: Encourage physicians to take regular breaks, use vacation time, and establish boundaries between work and personal life.
Provide mental health support: Offer access to mental health resources, counseling, and support groups to help physicians manage stress and emotional challenges.
Create a supportive work environment: Create a collaborative and supportive work culture where team members can share responsibilities and provide mutual support.
Improve work conditions: Implement solutions to improve the efficiency and comfort of the work environment like ergonomic workstations and updated electronic health records systems.
Offer professional development: Provide opportunities for continuing education and career growth to keep physicians engaged and motivated.
Peer support: Develop mentorship programs and peer support networks to help physicians share experiences and advice.
Recognitions: Recognize and reward physicians for their hard work and contributions to the practice.

Today, hospitals and health systems are investing in AI medical scribes and generative AI tools to tackle the burden of administrative tasks that take up so much of clinicians’ time, according to the Fierce Healthcare report. Even so, the support of a medical transcription company remains relevant. Human medical transcriptionists can interpret complex medical terminology and jargon with a level of precision that current AI tools might struggle with, particularly in cases where context or specialized knowledge is crucial.

Learn more about our transcription solutions and reduce the stress in your practice.

Importance of the “Human Touch” in Creating EHR Documentation

10-September-2020 Julie Clements EHR Transcription

EHR Documentation

Speech recognition technology (SRT) has been widely adopted in healthcare institutions across the country. It saves time in completing EHR documentation, a task that is shown to cause physician stress and burnout. However, medical transcription services or the “human touch” continue to be relevant to ensure the accuracy of medical documentation created by SRT technology. Unedited speech recognition-generated documents were found to have clinically significant errors by a study published in JAMA Network Open in 2018.

The journal article notes that SRT supports the clinical documentation process in two ways:

In back-end SR, the physician’s dictations are recorded and converted to text by SR software. The SR-generated text is then sent to a professional medical transcription service for editing, following which it is returned to the physician for review.
In front-end SR, the physician dictates directly into EHR free-text fields, edits the transcribed document and saves it.

The study found a higher error rate in notes created with SR. According to the researchers, while back-end SR systems are widely used in medical settings in the U.S., the quality and accuracy of clinical documents generated through back-end SR has not been properly investigated.

Looking into physicians’ dictation errors, a 2014 Berkeley University study highlighted the importance of quality assurance processes for medical records (www.fortherecordmagazine.com). The researchers examined errors in physician dictation of medical records created using only SRT and found an average of 315,000 mistakes in every 1 million dictations. This is a much higher rate than those made by experienced medical transcriptionists (MTs).

The study was conducted in collaboration with medical transcription service organizations and professional organizations. The key findings were as follows:

When working with speech editing/recognition, physicians’ dictation errors resulted in 153 critical errors and 403 major errors in inpatient records, while errors with transcription were just 20 and 82 respectively.
Incorrect patient and drug names, and wrong dosages were the most common critical errors in dictation.
The most common major errors in dictation were made-up words or acronyms, and gender and age mismatches.

The study noted that errors in physician dictation led to inaccurate medical records which may or may not affect care, but could certainly impact coding and billing.

The researchers concluded that disregarding the quality assurance role of medical transcriptionists and clinical documentation specialists can have important repercussions on documentation quality. QA checks by qualified medical transcriptionists are critical to prevent errors in medical records caused by physician dictation and SRT.

“The human review of these reports provides a vital quality assurance function, and when that human is a health care documentation specialist, especially one who is certified, organizations know that deep medical and language knowledge is being used to review and edit the records to accurately reflect the clinician’s intention.,” said Susan Dooley, MHA, CMT, AHDI-F, then president of the Association for Healthcare Documentation Integrity (AHDI) National Leadership Board (fortherecordmagazine.com).

The evidence in support of the human touch continues to mount. A recent article published in www.business2community.com cited a study which compared accuracy levels of human transcriptionists with ASR software and found that human transcriptionists had an error rate of about 4% versus 12% for ASR transcription software. The article lists several reasons why human transcriptionists are still relevant in this age of artificial intelligence (AI):

Professional transcriptionists can understand accents and dialects, while machines are usually unable to capture these things.
Professional transcriptionists have an in-depth knowledge of industry-specific jargon which is critical for creating accurate documentation. On the other hand, automated transcription software may not be able to comprehend technical terms, complex medical jargon, or homophones.
Verbatim or word-for-word transcription created by SRT can be confusing. Human transcriptionists can provide intelligent, edited transcripts with correct punctuation.
If the audio or video recording lacks clarity, experienced transcriptionists will check for facts to produce reliable documentation. Automatic transcription software cannot perform such checks.

SRT does offer advantages for physicians. First, it is easy to implement. Next, as the American Medical Association explains, it helps tell patient stories. Today’s systems come with technological capabilities to collect and organize data elements out of free text, allowing physicians to effectively create records for complex patients without having to type out everything. With SRT, physicians can also document all their thought processes by thinking out loud. It also improves the patient experience as the patient hears every word that the physician says at the encounter when documenting the history and assessment.

However, as the AMA and other industry experts point out, SRT generated medical documentation needs to be checked for errors. Clinical documentation errors can have a ripple effect and spread quickly, making them difficult to correct. This is where QA processes by medical transcription companies play a critical role. By blending speech recognition technology with quality assurance processes by human transcriptionists, clinicians can enjoy the best of both worlds.

Telemedicine in Top Five Medical Specialties [INFOGRAPHIC]

03-September-2020 MTS TEAM Infographics

With social distancing becoming an increasing priority due to the pandemic, telemedicine has become a valuable tool for physicians to care for patients and protect themselves and their staff. The federal government’s policy changes have provided virtual care the boost it needed. Medical transcription companies expect that the wave of telemedicine will continue even after the outbreak ends.

Check out the infographic below to learn which medical specialties benefit from telemedicine:

Telemedicine

How to Stay HIPAA Compliant when Using Telemedicine

Best Practices to Preserve EHR Documentation Integrity

Benefits of Cloud-based EHR systems for Medical Practices

What Today’s Patients Expect from Medical Practices [INFOGRAPHIC]

Evaluating the Pros and Cons of Telehealth Adoption

Top 6 Reasons for Medical Errors in Healthcare

Automated Communication Improves Patient Engagement while Social Distancing, say Studies

What Are the Most Common Factors That Lead to Physician Burnout?

Main Causes of Physician Burnout

EHR-related Physician Stress

Strategies to Combat Physician Burnout

Importance of the “Human Touch” in Creating EHR Documentation

Telemedicine in Top Five Medical Specialties [INFOGRAPHIC]

KEY FEATURES

RECENT BLOGS

Categories

Quick Contact