Seven Key Reasons Why Cardiologists Should Consider Medical Transcription Services

23-July-2020 Rajeev Rajagopal Medical Transcription

Medical Transcription Services

Accurate and error-free cardiology transcription is essential to ensure appropriate ongoing treatment and care for heart patients. Maintaining quality cardiology clinical records takes skills and discipline. There is no room for error and mistakes could even lead to the death of the patient. The best way to obtain accurate patient records is with the help medical transcription services, an innovative, accurate and affordable clinical documentation and technology solution for hospitals, clinics and medical practices. Here are seven important reasons why cardiologists could consider professional medical transcription.

Access to advanced technology: Cardiology is a major medical specialty and accurate medical records are vital to provide optimal care. Cardiology transcription service providers utilize advanced technology and the latest software to ensure accurate patient records. This enables cardiologists to provide timely and appropriate patient care.
Easy accessibility to patient records: There is always a possibility of emergency in cardiology and it is important to act fast and give the right instruction to provide value-based healthcare delivery. Transcribing the medical records and storing them in a secured database allows access to a patient’s chart from anywhere at any time and cardiologists can provide optimal care in case of an emergency.
Quick medical report charting: Toll-free phone dictation, digital recorders and smartphones made available by the transcription company make it easier for cardiologists to record their dictation. Once the dictation is done, it is then sent to professional transcriptionists who transcribe the recording. The dictation then goes through several quality checks to ensure accuracy. This accurate medical data is then uploaded into the EHR using HL7 interface. This facility allows cardiologists to focus on their patients instead of wasting time on medical documentation.
Ensures accuracy: The transcription services have experts who are skilled and also are well aware of medical terminology that is vital for medical documentation. They also make sure that there are no typos or misspelt words.
Easy medical claim processing: Using medical transcription helps with easy insurance claim settlement. It provides proper documentation of all medical reports and this will accelerate insurance claims processing.
Privacy of patient records: Ensuring safety of patients’ health records is important and the transcription services use secure lines to share medical records. They also prevent any unauthorized disclosure or access by implementing state-of-the-art security measures that prevent network-based and physical intrusions.
Saves time, costs and effort: The implementation of EHR has led to physician burnout; however, with transcription services, physicians can save time as well as spend quality time with their patients. Similarly, outsourcing to a transcription vendor is a much better option than having an in-house team as it prevents unnecessary expenses like salaries, insurance, payroll and providing various facilities to your in-house team. Outsourcing would bring you considerable cost savings.

Proper documentation of cardiology diagnosis and treatment is important for the successful management of a cardiology practice or department. It ensures easy and convenient medical coding and billing, gives facts, finding and observation of patient visits and also becomes useful at the time of auditing. Accurate medical transcription allows cardiologists to maintain accurate medical reports of a patient’s heart condition. A dedicated medical transcription service helps cardiologists obtain accurate transcripts of their audio recordings; it ensures that the treatments offered to the patient are appropriate and also helps to prevent any kind of mishap. After your dictations are converted into timely and complete pieces of documentation, the data is entered into your EHR through an interface. When your documentation needs are handled professionally, it helps to improve the quality of care, facilitating enhanced focus on patient interactions instead of being burdened with heavy medical documentation.

Why Dentists Should Choose Medical Transcription Over Speech Recognition

20-July-2020 MTS TEAM Medical Transcription

Medical Transcription

Keeping accurate and clean patient records and managing them efficiently is important for dentists to provide optimal care to their patients. With EHR system, healthcare practitioners are struggling to draft patient records and the same applies to dentists too. They are forced to spend too much time documenting patient data and this negatively affects their productivity as well as the patient satisfaction. An effective solution to simplify documentation is hiring a medical transcription company that can transcribe the dentist’s dictations into accurate transcripts or records.

Good record keeping is fundamental for good clinical practice and is an essential skill for dental practitioners. A dental consultation involves several concerns and treatment options like oral examination, checking for any risks of tooth decay, cavity, gum diseases and then recommending oral hygiene and preventive measures like tooth filing, dental implants, dentures etc. All of these procedures require accurate patient data to provide optimal care. Keeping all the patient records safe can also serve as defense in case of a malpractice lawsuit.

Digital Dictation and Speech Recognition for Dentists

Digital dictation and speech recognition are two technologies in the healthcare industry that are useful for medical doctors. However, dentists too may be able to improve productivity and efficiency with the technology. Just like general physicians, dentists also face the problem of mounting paperwork. So to make the process of medical documentation easier, like general physicians, dentists use speech recognition and digital dictation to reduce report turnaround time and improve patient care. Dentists can use digital voice recorders and transcription solutions to record a patient’s visit and other related data in the electronic record and with speech recognition, they can quickly and easily add notes to a patient’s history or complete other every day reporting processes.

Although speech recognition is useful for real-time medical documentation, it is important to understand that it comes with some disadvantage that can compromise the quality of the medical records.

One of the main disadvantages of speech recognition is poor accuracy. This is because the software cannot understand the complexities of jargon or phrasing, and it can lead to misinterpretation. It fails to understand the context of particular references and is incapable of choosing the correct meaning.
Another disadvantage of speech recognition is that it may not be able to transcribe the words of those who speak quickly or have a different or thick accent. It requires physicians to speak consistently and clearly at a slow pace to minimize errors, which is not possible during busy hours.
It is believed that automating a process can speed it up but speech recognition may not be like that. It requires more time to review and edit the medical records for any spelling mistakes, punctuation error etc. and this can affect your workflow and productivity.
To get the best results from speech recognition software, it is important to choose a quiet environment. It does not provide accurate results if the recording is made in a noisy background. This is because the software cannot differentiate between the dentist’s speech and other voices. And it is not possible for dentists to wear microphones and noise-cancelling headsets while treating the patients.

Considering all the above points, it shows that medical transcription is more reliable than automated transcription. Therefore, to obtain error-free, higher quality medical documentation, dentists could outsource their transcription requirements to a dedicated provider of dentistry transcription services. They offer transcription services for various medical reports including history and physical examination reports, operative reports, medical evaluations and other important records.

How Technologies Can Improve Medication Adherence

13-July-2020 Julie Clements Medical Transcription

Medication Adherence

Clear and transparent documentation of medications in patient records is crucial to care, and physicians can rely on EHR-integrated medical transcription services to manage this. The value of the medication process depends on patients taking prescribed medications correctly or medication adherence. However, medication noncompliance is a major concern for clinicians. Not adhering to prescribed medication schedules can have disastrous effect on patients’ health, especially in these challenging times of social distancing and stay-at-home orders. Patients with chronic illnesses, such as cardiovascular disease, diabetes, HIV, and depression are at higher risk of negative outcomes due to medication non-adherence. The good news is that the use of digital technologies can go a long way in improving medication adherence.

Factors that influence medication adherence include getting prescription filled, remembering to take medications at the right time, and understanding instructions. According to a new Physician’s Practice article, up to 25% of new prescriptions are never filled, and even when they are, about 50% of patients with chronic conditions don’t take their medications as instructed. Common reasons for medication nonadherence, according to the FDA, include:

Not being able to afford medications
Lack of symptoms and not understanding the necessity of treatment
Challenges of managing multiple medications and complicated dosing regimens
Confusion about the right way to take the medications and when to take them

The effective use of technology can address these challenges.

Automated reminders: A smartphone medication automated reminder can boost medication adherence. Patients can be sent an SMS
- when their prescription is ready
- is sent the pharmacy
- is ready for pick-up
- when it is time for a refill

Timely text reminders increase the likelihood of medications being picked up and taken on time.

Digital pill boxes: There are various medication compliance devices that can ensure that the right medications are taken at the right times. An electronic pill box features a storage device with in-built reminder alarms. The alarms can be set to multiple times during the day to remind the patient when it is time to take their medication. The best medication reminders and compliance devices available on the market include Reminder Rosie, Hero Health, MedCenter pill organizer and reminder system, the MediSafe app, Dispill, and the MedQ Smart Medication Reminder. The MedQ Smart Medication Reminder features flashing LED lights to indicate the correct medication to take. The device also comes with special features such as oversized and easy-to-open compartments, an anti-skid bottom, and a low battery indicator to help caregivers keep the unit in good working order. All of these simple, easy to use systems are designed to inform patients when to take which medications and their correct doses.
Wearable devices: Various studies have found a strong association between the use of wearable devices and medication adherence. A study by digital health tracking company Evidation Health found that people who engage in activity tracking using wearable devices such as activity trackers like Fitbit, Garmin, Jawbone and Apple products have significantly higher medication adherence than those who do not track their activities. The researchers also reported that medication management improved as these individuals tracked their activity more frequently (www.mhealthintelligence.com).
Electronic Medication Event Monitoring Systems: The Medication Event Monitoring System (MEMS) is an advanced indirect method of measuring patient adherence. MEMS medication bottles contain a microelectronic chip that registers the date and time of every bottle opening (www.who.int/bulletin). It is assumed that the bottle openings represent medication intake. Collecting data about adherence electronically provides a detailed profile about the complexities of patient adherence that may not be possible to obtain through other methods.
Telehealth: A recent Forbes article referred to telehealth as ‘the silver lining’ to the coronavirus outbreak as it could improve patient adherence and persistence. Today, providers are communicating with patients in their homes using telehealth platforms and these services are being reimbursed both government and private payers. Integrated with EHRs, digital platforms provide physicians with real-time updates on patients’ adherence to prescription schedules. Even telephone consults – the most basic form of telemedicine can support patients who are at high risk of non-adherence. Telemedicine interventions are especially useful to improve medication adherence among patients with severe mental disorders such as schizophrenia and bipolar disorder.

While medication adherence is crucial to patient well-being, incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse event. Healthcare providers can rely on medical transcription companies to ensure accurate documentation of medication administration.

AI-assisted Transcription Helps Physicians with EHR Documentation

09-July-2020 Rajeev Rajagopal EHR Transcription

EHR Documentation

Today, technology plays a significant role in the healthcare industry. The rising pressure to generate accurate and timely medical reports to provide optimal care to patients has led to the adoption of AI or artificial intelligence in medical transcription. Now, professional medical transcription services utilize AI-based medical transcription software to provide seamless transcription to hospitals and other healthcare systems.

Almost all hospitals in the US use EHR for documenting patient data and we already know that implementation of EHR has led to large-scale physician burnout. According to a survey by The Harris Poll on behalf of Stanford Medicine, 71 percent of the respondents said EHRs result in physician burnout and 69 percent respondents stated that EHR affected the productivity of physicians as they were forced to spend considerable time on the computer drafting patient records. Low physician productivity and burnout result in poor patient satisfaction.

Is EHR Actually Effective?

The first federal system to support widespread implementation of EHRs across the healthcare industry was The Health Information Technology for Economic and Clinical Health (HITECH) Act, a component under the American Recovery and Reinvestment Act of 2009. Since then, laboratory managers and physicians have seen their parent healthcare organizations struggling to implement EHR documentation systems and comply with the new regulations.

A large number of healthcare practitioners and physicians believe that EHRs help them to be compliant with all the regulations. The EHR plays a crucial role in shaping the patient-physician relationship which impacts the quality of patient care. EHR systems are expected to bring about better patient outcomes. But in reality, despite spending huge dollar amounts, nothing much has changed and EHRs lacks interoperability. Healthcare networks are forced to integrate a mix of mismatched and disparate EHRs to survive in the current healthcare scenario. There is no doubt that clinical documentation processes need to be improved to facilitate collaboration, communication, and trust between patients and providers.

Use of AI in Medical Transcription

The answer could lie in innovative technology. AI (artificial intelligence)-based medical transcription can ensure accurate and speedy medical transcripts and medical documentation. Advanced technologies like speech recognition and natural language processing (NLP) help in the creation of medical transcripts by processing patient-physician conversations on a real-time basis and collating, sorting and assembling clinical information from multiple disparate sources in a matter of seconds. Advanced AI-based medical transcription that is embedded with speech recognition software application allows providers to use their preferred devices to record their dictations. Cloud-based medical transcription devices like DVR or dictation microphones can be used for recording physician’s dictation. For example, Mid Carolina Cardiology, a part of Novant health uses intelligent voice-based document management system that helps healthcare organization to document clinical records easily.

To provide quality care to the patients, medical practitioners need not be technology literate. Having a cutting-edge transcription platform with speech recognition tools and other patient-centric tools helps physicians to deliver care to the patients.

Technology has also changed the traditional method of medical transcription. While artificial intelligence helps to do the major task in transcription work, human transcriptionists still have an important role to play in ensuring the accuracy of transcriptions. This is especially so, when it comes to transcribing audio recordings that contain overlapping voices, or wherein speakers use different dialects or languages, or wherein people speak too quickly. Professional transcription services use HL7 interface which provides the framework for integrating, sharing and retrieval of EHR. It provides an encrypted and secure means of transferring files. Outsourcing to a reliable medical transcription service will help you document medical records accurately and precisely.

Medical Errors That Lead to Unreliable Healthcare Documentation [INFOGRAPHIC]

06-July-2020 MTS TEAM Infographics

Every year, errors in medical documentation cost billions of dollars to the U.S healthcare industry. Medical records are a combination of self-reported patient information and physicians’ notes on the diagnosis, care and treatment given to the patient. It is important to have complete and accurate medical records for smooth and efficient communication between healthcare providers, patients and payers about patient health status, treatment planning, delivery of care and preventive health services. Even the smallest error in the medical record can have serious consequences for the patient. Accuracy of medical documentation can be ensured with the support of dedicated medical transcription companies.

Check out the infographic to learn about the common medical errors that result in unreliable healthcare documentation.

EHR Systems linked to Physician Burnout but Prove an Asset to Care during the Pandemic

02-July-2020 Julie Clements EHR Transcription

EHR Systems

Electronic health record systems or EHRs are designed to provide easy access to patient information such as medical histories, prescriptions, lab reports and physician notes. Medical transcription companies focus on helping physicians ensure accurate EHR documentation, and importantly, help reduce the EHR-related data entry burden. Recently published research linked physician stress directly to the EHR documentation task. However, reports indicate that electronic patient charts are proving an asset during the coronavirus pandemic.

Clinician EHR Use – What Studies Found

While the goal of EHRs is to make paperwork easier, a study by researchers from the University of New Mexico (UNM) that covered 282 clinicians reported that EHRs contribute to approximately 40 percent of clinician stress (www.hscnews.unm.edu). Previous research had linked 13 percent of physician self-reported levels of stress and burnout to EHRs.

The survey helped the researchers correlate what EHR design and use features were most highly associated with respondents with high measured stress and burnout. The clinicians were asked to evaluate how their work day was affected by excessive data entry, inability to navigate the system quickly, and challenges to integrating notes into external systems. The survey findings, which were published in September 2019, showed that:

The time that clinicians spend on medical record-keeping has doubled and extended into their home life.
Clinicians need a 60-hour week just to keep up with documentation.
Physicians now spend two minutes at the computer for every one minute spent with patients.
Electronic notes affect focus on patient care – “face-to-face time with the patient has turned into face-to-screen time”

While the respondents appreciated the ability to access and update patient medical records at their convenience, they disliked how it led to after-hours EHR time.

A Yale-led study published in Mayo Clinic Proceeding journal in 2019 linked frustration with EHRs to high rates of physician burnout as well as medical errors. (www.courant.com). Concerns reported include:

EHRs have massive structured data entry requirements, but the information doesn’t do much to improve care.
It is very difficult to find communication from another doctor or a specific test result in a patient’s chart.
EHRs pose significant user challenges for dermatologists, orthopedic surgeons, general surgeons and older physicians.

In May 2020, Medical Economics published the results of its 2019 EHR Scorecard conducted in October, which asked physicians the following question: “In your opinion, what is the biggest problem with EHRs across the marketplace?” The criticisms are grouped into six categories:

Interferes with doctor patient relationship – far too much time on the computer, need to capture bullet points to bill different levels of care.
EHR systems not designed for patient care – More useful for billing and tracking
Lack user-friendliness – system is too cumbersome, too many clicks to search the chart, not organized physicians have been trained to organize charts, not designed with user in mind.
Exchanging information with other EHR systems – inability to share information, for example, between physician’s office and hospital, lack of proper interfaces for export and import of data
Impact on productivity – documentation mainly to meet insurance requirements and takes too long
Expense – costly to upgrade and maintain, need to hire additional staff

HSS Takes Action to Reduce Physicians’ EHR Burden

In February 2021, the Department of Health and Human Services (HHS) came out with a comprehensive strategy to reduce the regulatory and administrative burden related to the use of health IT, including EHR (www.healthit.gov/buzz-blog). These recommendations and policy shifts are meant to provide clinicians with more time to focus on what matters most – caring for their patients. The report outlined three goals designed to reduce clinician burden:

Reduce the effort and time to record health information in EHRs for clinicians;
Reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and healthcare organizations; and
Improve the functionality and ease of use of EHRs.

Responding to clinician feedback and input, CMS has made changes to E/M documentation and coding framework that clinicians use to bill Medicare for common office visits. These changes will allow clinicians to make better use of their time and strengthen the physician-patient relationship by spending less time on documenting visits and more time on treating their patients.

COVID-19 – EHR Systems Prove an Asset to Patient Care

Experts point out that EHR systems have been more of an asset, than a burden, during the coronavirus outbreak (www.ehrintelligence.com). With their telehealth functionalities, EHR systems are helping clinicians test and manage COVID-19 patients, and reduce the spread of the virus, according to Tom Still, president of the Wisconsin Technology Council. The benefits of EHRs during the pandemic are:

EHR systems were able to quickly respond to telehealth implementation and the need for virtual care.
Telehealth and EHR technology have enhanced the “human aspect” in care by allowing physicians to see patients and their families remotely in their homes.
Telehealth services have eased the overcrowding in hospitals and practices.

There are still issues to be sorted out such as lack of interoperability, not having patient data accessible in one place, and limits on who can access virtual care. However, according to the Wisconsin Technology Council president, “For many people, however, electronic health tools may be a way to fight back against COVID-19.”

As EHR-embedded telehealth grows, using medical transcription services can help busy physicians save time and labor and ensure accurate and timely records of patient interaction and care.

Key Considerations for Expanding Telehealth beyond the Pandemic

29-June-2020 Rajeev Rajagopal Medical Transcription Company

Telehealth

While telehealth has been around for a long time, its rapid adoption across the country was catapulted by the pandemic. Federal and state laws and regulations were relaxed to enhance the ability of physicians to provide, and patients to receive, telehealth services. Now, industry experts are saying that telehealth will continue to grow after the COVID-19 pandemic, and our medical transcription company agrees these views.

Telehealth technologies connect patients and healthcare providers from a distant location, allowing patients to access healthcare services conveniently using computers or mobile devices. Telehealth adoption has grown over the years. A survey by American Well (now Armwell) found that physician use of telemedicine rose from 5% to 22% of doctors between 2015 and 2018, an increase of 340%. When the novel coronavirus struck and social distancing was recommended to mitigate its impact, it sparked off a telehealth boom. Several legislative and policy measures were enacted to facilitate the widespread adoption of telemedicine. As the pandemic evolved, both providers and patients appreciated the convenience and speed of virtual care. Lawmakers are now under pressure to make some of these emergency permission permanent.

Digital tools have enormous potential to enhance access to healthcare, but the success of telehealth after the pandemic depends on various factors:

Removal of state licensure barriers: State licensure laws have been one of the greatest hinderances to interstate telehealth expansion, Nadia de la Houssaye, a partner with the Jones Walker law firm (www.mhealthintelligence.com). The licensure process is costly, time-consuming and difficult, and state policies and regulations also vary. Interstate telehealth expansion cannot take place unless state licensure barriers are evaluated and addressed.
Cost and reimbursement policies: Before the pandemic, Medicare fee-for-service coverage of telehealth services was extremely restrained. There were multiple coverage limitations for rural locations, originating sites, eligible practitioners and services, and qualifying technology. The broad waivers of the CARES Act allowed CMS to temporarily remove these requirements. A statutory change will be needed to give CMS flexibility to act so that telehealth continues to be an option for all Medicare beneficiaries after the pandemic. State and federal action is also needed to incentivize providers to continue telehealth usage post-pandemic. Currently, state guidelines for private payer coverage vary widely.
Data to prove potential cost-savings realized through telehealth expansion: Advocates of telehealth are well aware about the need for evidence to prove that telehealth utilization improves health outcomes and reduces costs. The proven benefits of telehealth include improved health outcomes, patient satisfaction, and cost reduction from chronic disease management through telehealth. However, additional data on telehealth outcomes, accurate cost estimates on the use of telehealth in the Medicare program, and favorable scoring are needed before legislation to support expansion of Medicare telehealth coverage can be achieved.
Gaps in broadband: Lack of access to high-speed broadband internet is a major barrier to adoption of telehealth in rural areas. To take advantage of telehealth’s potential and support its expansion, there must be proper connectivity to support the live-video connections between patients and providers. Dropped calls and delays in video feeds can pose a hinderance to care delivery and result in patient dissatisfaction with telehealth. Measures are already underway to address this infrastructure barrier through initiatives such as the COVID-19 Telehealth Program and the three-year Connected Care Pilot program.
HIPAA compliance: The OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. Covered health care providers can conduct video chat on applications such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype, to provide telehealth. For telehealth to succeed, it is important that patient privacy gets the due protection and HIPAA and data security measures are restored to post-pandemic standards. New technology platforms need to comply with established HIPAA regulations and standards.

In a recent COVID-19 update, the American Medical Association discussed a very valid consideration for the success of telehealth: how physicians can maintain the human touch when using telehealth platforms. One of the participants, Jen Horonjeff, PhD, founder and CEO, Savvy Cooperative, says that they are focusing on understanding the needs of different patients and communities they are trying to serve. They are getting patient insights all along the entire development process of their telehealth platform so that it is capable of meeting their needs, and fits seamlessly into their lives. Telehealth solutions also need to be available and accessible for different communication methods, including for the deaf community. It’s also critical to provide outreach to patients with limited technology and connectivity and offer flexibility when possible, for consultations via video consultation platforms or non-video options.

Telehealth is here to stay. As CMS Administrator Seema Verma stated in a live virtual event with STAT on June 9, “I can’t imagine going back.” As physicians focus on delivering remote care, medical transcription service providers are ready to help them meet their EHR charting needs.

Medical Transcription Market Growth Forecast 2020-2027

25-June-2020 MTS TEAM Medical Transcription

Medical Transcription

Accurate patient’s medical records are critical for proper patient care. The smooth functioning of healthcare organizations depends on the accuracy of structured narrative reports and the speed with which they are fed into their electronic health record (EHR) system. But the introduction of EHRs has adversely affected the physician-patient relationship as physicians spend a lot of time in documenting onscreen during the encounter. However, most healthcare organizations have implemented a combined approach of EHRs and medical transcription services. This integrated solution removes the burden on the physician, ensures accurate clinical documentation and enables focused interaction with the patients. This improves quality of patient care as well as job satisfaction among physicians.

Global Medical Transcription Market 2020

The medical transcription market is expected to grow during the period 2020 to 2027, according to a Data Bridge Market Research report. The study suggests that the market growing at a CAGR of 6.0% during the forecast period 2020-2027

The rising incidence of health conditions such as melanoma, cardiovascular, and, diabetes disorder has vastly increased the volume of medical documentation produced by healthcare facilities. EHRs play a critical role in helping providers store and manage this burgeoning increase in the volume of healthcare data. Today, healthcare organizations are using advanced technologies such as instant report formatting, audio identification, and ADT normalization that convert voice-based documents into text-based automated data. These advanced superior encryption technologies will advance the opportunities for market growth.

Medical transcription companies have skilled medical transcriptionists who are experts in handling EHR-integrated documentation. They transcribe dictation with great focus and attention to details. Medical transcriptionists are well-versed in medical terminology and have critical thinking skills to ensure accurate medical documentation, which is critical to patient care and safety. The advantages of medical transcription include:

Better accuracy: Medical transcriptionists help physicians maintain accurate records of the treatments given to the patient in the past, their current health status, and recommended treatment.
Helps provide instructions for support staff: Transcription provides error free patient records that help the support staff like nurse and other healthcare related workers to collaborate and provide quality care.
Promotes HIPAA compliance: HIPAA compliance is a vital requisite in the modern healthcare industry and medical record-keeping and standardization of written medical communications is very important. These records assure proper care and attention towards the patient and it also forms the basis for legal arguments, in case of any lawsuit is filed against the medical provider.
Minimizes dependency on software tools: Medical transcription plays a crucial role in helping clinicians ER documentation and reduces their EHR-related tedious data entry tasks.

Tools like front-end speech recognition may speed the documentation process, but having a medical transcription service proofread the files is necessary for error-free health records.

Medical Records Retention – Challenges and Solutions

22-June-2020 Julie Clements Medical Transcription

Medical Records Retention

Electronic health record (EHR) systems are designed to improve the quality of care and patient safety, improve physician efficiency, and cut costs. EHRs have also reduced paperwork and eased patient record storage, accessibility, retrieval and retention. Integrating medical transcription services with electronic medical record (EMR) software ensures accurate and timely patient charting.

While EHRs ease storage and access, one concern is about how long a medical practice should retain patient records. Physicians keep medical charts for various reasons:

To providing good care and sharing information with other physicians
To meet patient requests for their records
A patient’s medical history may prove useful to diagnose a condition that a family member develops at some time in the future
An accurate, properly documented medical record is the best defense in the event of a malpractice suit

HIPAA does not have any specific rules about medical record retention and it is State law that mandates how long records should be kept. CMS states, “While the HIPAA Privacy Rule does not include medical record retention requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal” (www.cms.gov).

However, while state laws on record retention exist, there are many challenges associated with developing a records retention policy:

One main problem is that record retention laws vary from state to state. Some states require medical records to be retained for a longer period of time than other states do, varying from 5 to 10 years.
Additionally, state and federal laws on mandatory record retention requirements for hospitals are different from those for physician practices.
The retention period for a pediatric patient’s record also varies. Minors’ records would have to be kept until they reach the age of majority in that state, or longer.

The minimum medical retention period for state and practice type are available on the Office of the National Coordinator for Health Information’s website.

The American Academy of Pediatrics (AAP) notes that to determine how long medical records must be maintained in every case, a practice would need to “piece together a patchwork of statutes, regulations, case law, and State Medical Board position statements”. The AAP recommends that every practice should develop a record retention policy based mainly on medical considerations and continuity of care.

Developing a records retention policy is important for many reasons. Practice transitions such as a change in ownership or EHR vendor can create record-related problems. If a partnership practice had a common EHR system, the records maintained by both physicians would likely be comingled as they would have treated each other’s patients. If the partnership is dissolved, each physician would have access to the other’s EHR system. This may lead to conflicts.

Practices can take the following steps to store and retain medical records:

Practices should make decisions about record segregation when forming a practice agreement or dissolving a practice (www.physicianspractice.com).
In the event of closure of a practice, providers can consider various options for record storage: paid storage in a neighboring medical office, transfer to a secure document storage facility or in the practice of a colleague.
Patients should be informed about practice closure so that they can take a decision about their records and designate a physician or another provider who can receive a copy of the records.
If patients don’t designate another physician, the practice can designate a physician to act as the custodian of the records.
If two practices are merging, it should be decided upfront about how records are going to be handled.
If a physician chooses to destroy clinical records after the required period of time, confidentiality must not be compromised, says the AAP. The task can be assigned to record destruction services that guarantee records are properly destroyed without compromising any information.

Medical record safety and retention concerns also arise if practices decide to switch EHR vendors. In this case, too, the language in the contract should ensure that the transition a smooth one (www.medicaleconomics.com). One way to safeguard records would be to get a weekly or monthly backup of the data from the EHR vendor.

Medical transcription outsourcing makes patient data available in the EHR systems of hospitals, physician practices and other health care entities. Healthcare providers need to work with other stakeholders to make informed business decisions about retaining medical records in order to provide patients with access to their information when they want it, to protect their own interests if a legal claim is made, and to comply with federal and state regulations.

How Healthcare Organizations can Better Manage EHR Data Growth

18-June-2020 Rajeev Rajagopal EHR Transcription

EHR

Electronic heath records (EHRs) are a treasure trove of patient information. EHRs enable healthcare providers to record and store patient information electronically, simplifying the process of creating medical records. This system allows organizations to consolidate, centralize, and securely access patient medical data. Medical transcription companies play a key role in ensuring that data is entered accurately in these electronic filing cabinets. EHRs are aimed at improving care, efficiency and interoperability, but just having more EHR data will not provide better results. A proper data management strategy is essential for EHRs to serve their purpose. Healthcare data management is defined as “the process of storing, protecting, and analyzing data pulled from diverse sources. Managing the wealth of available healthcare data allows health systems to create holistic views of patients, personalize treatments, improve communication, and enhance health outcomes (www.evariant.com).

If managed efficiently, EHR data can provide meaningful insights and help physicians make informed decisions to streamline operations, enhance patient care, and attain better outcomes. A Becker’s Hospital Review article recommended the following four strategies to better manage EHR data growth:

Creating a data governance strategy
Collecting quality information
Moving data to a centralized repository, and
Investing in healthcare CRM

Creating a data governance strategy: Health data comprises patients’ personal and health information as well as financial data. A proper data governance strategy is essential to help manage and interpret EHR data and get value from it. AHIMA defines data governance in healthcare as “an organization-wide framework for managing health information throughout its lifecycle-from the moment a patient’s information is first entered in the system until well after they are discharged”. The lifecycle covers aspects like treatment, payment, research, outcomes improvement, and disease reporting and tracking by government agencies such as the CDC. To develop a good data governance strategy, healthcare providers must determine the what kind of data they need and how to access it, what problems the data can be used to address, and the outcomes that the data can provide.
Collecting quality information: Physicians deal with an avalanche of EHR data on a daily basis, but this information would be useful only if is accurate. Ensuring accuracy during medical record documentation is crucial for patient safety, provision of appropriate care, and care planning. However, physicians are not cut out for EHR data entry tasks, especially in the office setting, where their main focus is the patient. Even a minor data entry error can lead to a wrong decision and compromise care. To avoid this, healthcare facilities can train their staff in EHR data entry. A more cost-effective option would be to outsource the documentation task to a US based medical transcription service organization. The Becker’s Hospital Review report also recommends applying algorithms to verify data for accuracy and eliminate mistakes such as duplicate information or discrepancies in procedural and billing codes.
Moving data to a centralized repository: Data fragmentation is the primary problem that needs to be addressed in healthcare organizations. Data available in EHRs include patient identifiers, demographics, diagnoses, medications, procedures, laboratory results, vital signs, and utilization events as well as financial records, and pay or information. Bringing all this data together, converting it to a usable format and putting it a centralized location is critical to improving EHR data management. Investing in health IT can make fragmented electronic data usable and quickly retrievable.
Investing in healthcare CRM (customer relationship management): Healthcare CRMs integrate data from various sources (such as consumer and patient demographics, psychographics, social, behavioral, clinical, financial, website, call center, provider credentialing, etc.) to provide a comprehensive view of patient habits and activities. While most EHRs are designed to consolidate, centralize, and provide secure access to patient data, investing in technology solutions can help interpret and report on EHR data from various sources including social media and mHealth. This can help healthcare providers extract valuable insights from the date to improve patient care and communications.

These tips can help overcome the challenges of managing growing EHR data, but implementing a data management plan requires having a skilled team of HIM professionals and EHR optimization experts on board. Partnering with a reliable medical transcription company can ensure accurate, consistent and relevant data in the EHR.