Benefits of Harnessing Telehealth for Chronic Disease Management

30-November-2020 MTS TEAM Medical Transcription Company

Telehealth

Chronic disease, which affects about half of all Americans at some point in their lives, poses a major problem and costs the United States an estimated $3.7 trillion annually, according to the American Action Forum. Chronic diseases such as heart disease, stroke, cancer, diabetes, pulmonary disease, and arthritis are common, costly, and preventable health problems. Reports suggest that patients with chronic diseases account for 81% of all hospital admissions. People with chronic conditions need continuous monitoring and ongoing care. Telehealth, supported by EHR-integrated medical transcription services, offers many benefits for chronic disease management. Telehealth expansion proved critical to care delivery with the onset of the novel coronavirus pandemic.

There are many benefits to using telehealth for managing chronic conditions:

Patients get ready access to providers and specialized care: With telemedicine, patients with chronic conditions can get appropriate care at the appropriate time and place. People in rural areas often lack easy access to sufficient medical care and may need to travel long distances to see a specialist. One-fifth of Americans live in areas that experience physician and healthcare specialist shortages (www.healthaffairs.org). Patients with mobility issues may find this even more challenging. Telehealth provides them with the care they need in the comfort of their homes, saving time and reducing the costs of transportation.
Remote patient triage and regular follow-up: By facilitating greater access to healthcare, telemedicine supports remote patient triage. If a new symptom develops, patients with chronic conditions can consult with their healthcare provider in real-time. This will allow the physician to modify treatment accordingly or instruct the patient to visit the nearest emergency room if the condition is serious. By facilitating timely treatment, telemedicine prevents chronic conditions from getting worse.

Live video and audio, mobile devices and other smart digital tools are used to manage patients’ conditions with regular follow-up. For instance, a patient’s ECG can be actively monitored in real-time using a remote cardiac device. The device constantly collects and compiles patient data and uploads to the cloud. With a summary report of the patient’s data, physicians can make an accurate diagnosis and prescribe an effective treatment plan.
Reductions in hospital admissions/re-admissions, length of hospital stay, and emergency department (ED) visits: Telehealth can reduce hospital readmission rates by improving the patient’s ability for self-care. It allows patients to communicate with their physician frequently after being discharged and discuss their symptoms and medications. Providers can share educational content with patients every day on the telehealth platform. Mobile devices and live video and audio can be used to remind patients to take their medication, maintain a healthy diet, exercise, and make other lifestyle changes which can improve the patient’s condition. Remote interventions help chronically ill patients care for themselves better. Frequent communication helps with proper treatment and reduces the rate of readmissions, duration of hospital stays, and ED visits.
Lowers costs: Telemedicine is a cost-effective way to deliver care for chronic conditions for both providers and patients. By triaging cases that can be addressed through a remote visit or until a regular office consultation, telemedicine reduces costs for patients. telehealth technology involves lower overhead costs than physical facility costs, which includes rent, salaries, and utilities. By allowing remote monitoring of chronic conditions, telemedicine lowers costs, improves efficiency, and increases revenue.

Experts believe that, even after the pandemic abates, telemedicine visits will continue to remain a part of the healthcare system in the future. In a recent survey from the COVID-19 Healthcare Coalition, up to 75% of healthcare providers said they would like to continue using telehealth for chronic disease management.

“Remote visits will become a permanent part of healthcare in the future because of both their efficiency and their convenience to patients,” Stafford wrote. “For patients with chronic diseases that benefit from regular follow-up, video visits provide a useful tool for maintaining high quality care. This is especially true for older patients with mobility problems or those patients who live far from their primary care physician,” noted Randall Stafford, lead author of a Stanford Medicine study published on Oct. 2 in “JAMA Network Open” (www.stanforddaily.com).

With a severe provider shortage and a growing gap in access to care for rural communities and most vulnerable populations across the nation, telemedicine can provide a cost-effective option to provide care to patients with chronic conditions. As the use of telemedicine expands, US based medical transcription companies will continue ensure quality EHR-integrated documentation solutions for remote patient consultations.

What are the Key Components Included in a Hospital Discharge Summary?

26-November-2020 Julie Clements Medical Transcription

Hospital Discharge Summary

A hospital discharge summary refers to a clinical report prepared by health professionals that outlines the details of the hospitalization of a patient. Lack of discharge details, diagnosis information or patient’s health status in discharge summaries can lead to poor treatment plans. A discharge summary is an important document to have when discharging patients from a hospital. In addition to the essential medical information, the discharge summary may also include some other components such as a nursing discharge note, and hospital discharge paperwork. Physicians can rely on medical transcription companies to get accurate transcripts of discharge summaries and any other medical records.

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Research published by BMC Health Services Research in July 2024 recommends making the discharge summary a patient-centered tool that enhances communication and understanding between healthcare professionals, patients and relatives. The researchers noted that several issues have been identified related to the medical discharge summaries such as delayed transmission of the DS to the subsequently treating physician and others, low quality or lack of information, lack of consistent formats, lack of patient understanding, and insufficient training for medical students in writing these summaries. They highlight the importance of transferring all relevant information in a discharge summary to ensure a safe patient discharge from hospital. The study states that it’s essential that the patients understand the discharge summary and recommend simple measures to improve content readability for patients as well as healthcare providers.

A structured and accurate discharge summary is crucial –

For transferring information between the hospital care team and aftercare providers
To help physicians quickly identify how to respond to the patient’s hospitalization
To promote patient safety
For legal purposes to show evidence of patient care, if errors are made

The discharge report must give a summary of everything the patient went through during the hospital admission period – physical findings, laboratory results, radiographic studies and so on.

Significance of Discharge Summary

There are various reasons why discharge summaries are essential.

Clinical Accuracy: By providing a thorough description of the hospital stay, they reduce the possibility of clinical errors during care transfers.
Continuity of Care: For specialists and outpatient providers, they give guidelines for continued care, which is essential.
Communication Improvement: They make it easier for different healthcare organizations that provide patient care to exchange reliable information.

Effective documentation of discharge summaries improves health outcomes while streamlining patient management.

Main Components of a Discharge Summary

Here’s a look at the essential components of a well-structured medical discharge summary, each crafted to capture vital aspects of the patient’s care journey. These components ensure that healthcare providers have a complete, clear record of the patient’s condition, treatments, and necessary follow-up care, providing a seamless bridge between hospital and post-discharge settings.

Reason for Hospitalization: Understanding the cause of hospitalization helps comprehend the entire treatment plan for the patient. It enables medical professionals to decide on the patient’s treatment strategy. It serves as a foundation for foreseeing any issues and putting preventative measures in place both before and after the hospital stay.
Diagnosis: The basis for the entire treatment approach is a proper diagnosis. It assists in choosing the right treatments and drugs. A proper diagnosis can also help in predicting the disease’s probable course, directing follow-up care and observation. It also helps the patient and his/her family create reasonable expectations about the prognosis and potential results.
Findings: Together with imaging and lab results, these findings provide insight into the patient’s health and response to therapy. Significant findings may also draw attention to any unforeseen side effects or disorders that could affect the course of treatment. They offer crucial information for assessing the effectiveness of current treatments and figuring out what has to be changed for the best possible patient results.
Understanding Test Findings: Test findings can help determine whether the treatment strategy is sufficient or needs to be modified. Furthermore, routine evaluation of these data enables proactive interventions and improved patient care by assisting medical professionals in anticipating possible dangers or consequences.
Procedures and Treatments given: These can include anything from physical therapy and surgery to the use of medical gadgets or drugs. A better understanding of these treatments and measures can help the patient and their caregivers recognize the value of follow-up care and better follow post-discharge recommendations. A thorough list of all the drugs the patient has been given, together with dosages and frequency of administration, is also included. Since it enables the primary care physician or the next healthcare provider to continue or adjust the medication regimen as needed, this information is essential for guaranteeing continuity of treatment. Additionally, it also makes it easier for the patient and their caregivers to comprehend and follow the prescription regimen, which promotes the best possible health results.
Condition of the Patient at Discharge: A summary of the patient’s health at discharge is provided by the discharge condition. The state of the patient upon discharge can reveal information about their immediate medical needs after release as well as the efficacy of the treatment they received. During the follow-up care time span, it also acts as a baseline for tracking any changes in health condition.
Post-discharge Treatment: These guidelines address food, exercise, medicine administration, and warning indicators. Depending on the patient’s condition, the dietary recommendations may include certain diets or limitations. Guidelines for physical activity strike a balance between the need for rest and recuperation and preserving general health, and warning indicators assist patients and caregivers in spotting possible problems or relapses early.
Physician’s Signature: The accuracy and completeness of the facts in the discharge summary are verified by the doctor’s signature. The credibility of the information provided is ensured by this signature, which attests to the doctor’s evaluation of all the details. Also, it encourages a greater degree of effort and completeness in recording patient treatment by holding the doctor accountable for the patient’s care plan.

Failure to report any patient discharge condition details may affect patient safety. It’s important for a discharge summary to include key components such as nursing discharge note and hospital discharge paperwork. Reliable medical transcription services can efficiently meet physicians’ patient record documentation needs to a great extent.

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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

02-November-2020 Rajeev Rajagopal Medical Transcription Company

Medical Transcription Services for Cardiologists

Accurate documentation plays a critical role in cardiology. Heart-related conditions require careful monitoring, detailed patient histories, and precise treatment records. Even small documentation errors can affect diagnosis, treatment decisions, or follow-up care. Medical transcription services for cardiologists ensure that clinical documentation remains accurate, organized, and easy to access.

Medical documentation, however, can take up a significant amount of time during a busy clinical schedule. This is why many healthcare providers rely on medical transcription services to convert voice dictations into structured and accurate medical reports. Medical transcription for cardiology practices helps maintain clear patient records while reducing the documentation burden on physicians.

Why Medical Transcription Services for Cardiologists is Vital

Here are 9 reasons why cardiologists rely on professional medical transcription solutions.

Access to Advanced Technology
Cardiology is a specialized field that requires precise documentation of patient conditions, procedures, and treatment plans. Professional cardiology documentation services use advanced software and updated technology to process medical dictations and create structured reports.

These systems help ensure accuracy, consistency, and proper formatting of patient records. By using modern transcription platforms, cardiologists can maintain high-quality documentation that supports clinical decision-making and patient care.

Easy Access to Patient Records
Cardiac emergencies can occur without warning, and quick access to patient information is necessary for immediate treatment. Medical transcription services help convert dictations into digital records that are stored securely in databases.

These records can be accessed anytime and from different locations when required. Easy access to patient charts allows cardiologists to review medical history, previous diagnoses, and treatment notes quickly, which supports timely medical decisions during emergencies.

Faster Medical Report Charting
Professional transcription services simplify the process of creating medical reports. Cardiologists can record their observations and treatment notes using tools such as:
- Toll-free phone dictation
- Digital voice recorders
- Mobile or smartphone applications
Once the dictation is completed, it is sent to trained transcriptionists who convert the audio into written reports. These documents then go through multiple quality checks before being finalized. The completed reports can be integrated into Electronic Health Record (EHR) systems using interfaces such as HL7.

This streamlined workflow enables cardiologists to complete documentation faster and spend more time focusing on patient care.

Improved Accuracy in Medical Documentation
Clinical documentation for cardiologists must be done accurately, incorporating complex terminology, medication names, diagnostic test results, and treatment recommendations. Professional transcriptionists are trained in medical terminology and documentation standards.

Their expertise helps ensure that the reports are clear, accurate, and free from spelling or formatting errors. High-quality transcription reduces the chances of misinterpretation and supports reliable medical records that physicians can confidently use for treatment planning.

Expertise in Medical Terminology
Transcription professionals working with healthcare providers are familiar with clinical language, cardiology procedures, and diagnostic terminology. Their knowledge allows them to correctly interpret physician dictations and produce accurate transcripts.
This expertise is particularly important in cardiology, where documentation often includes complex terms related to heart diseases, imaging reports, diagnostic tests, and treatment procedures.

Faster Insurance Claim Processing
Accurate documentation is essential for medical coding, billing, and insurance claims. Properly transcribed medical records provide clear documentation of diagnoses, treatments, and procedures performed during patient visits.

When medical reports are complete and well-organized, insurance providers can review claims more efficiently. This helps speed up claims processing and reduces delays in reimbursements for cardiology practices.

Better Security for Patient Records
Protecting patient health information is a priority in healthcare. Professional transcription providers follow strict security standards when handling medical data. Many organizations rely on HIPAA-compliant medical transcription for cardiologists to ensure that sensitive patient information is handled according to healthcare privacy regulations. Secure communication channels and advanced data protection measures are used when sharing and storing patient records.

These safeguards help prevent unauthorized access and ensure that confidential medical information remains protected throughout the documentation process.

Reduced Administrative Burden for Cardiologists
Medical documentation can take a considerable amount of time, especially when physicians must enter detailed information into EHR systems. The administrative workload associated with documentation has also been linked to physician burnout.

Medical transcription solutions help reduce this burden by handling the documentation process. When cardiologists dictate their notes instead of typing them manually, they can focus more on patient consultations, diagnosis, and treatment planning.

Cost Savings for Healthcare Practices
Maintaining an in-house transcription team involves several operational costs, including:
- Staff salaries
- Training expenses
- Employee benefits and insurance
- Office infrastructure and equipment
Outsourcing transcription helps healthcare organizations avoid these overhead costs. Medical transcription solutions for cardiology clinics help to manage documentation efficiently without maintaining a full in-house transcription department. Professional transcription vendors provide scalable solutions that help practices control operational expenses.

The Role of Accurate Documentation in Cardiology Practices

Accurate documentation supports every aspect of a cardiology practice. Well-maintained medical records provide clear information about patient history, diagnostic findings, treatment plans, and follow-up care. These records also support medical coding, billing, and auditing processes.

Medical transcription helps cardiologists maintain detailed and organized records of a patient’s heart condition and treatment progress. When dictations are converted into structured reports, the information can be easily stored, retrieved, and integrated into EHR systems.

By using professional medical transcription services, cardiologists can streamline documentation, reduce administrative workload, and maintain precise patient records. Reliable transcription support enables healthcare providers to focus more on patient care while ensuring that clinical documentation remains accurate, organized, and accessible.

Focus on patient care while experts handle your cardiology documentation.

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.