Importance of the “Human Touch” in Creating EHR Documentation

10-September-2020 Julie Clements EHR Transcription

EHR Documentation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Telemedicine in Top Five Medical Specialties [INFOGRAPHIC]

03-September-2020 MTS TEAM Infographics

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

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

Telemedicine

Best Practices for Amending Electronic Health Record Documentation

27-August-2020 Julie Clements EHR Transcription

Electronic Health Record

Electronic health records (EHRs) are designed to provide a legible, comprehensive, and lasting record of a patient’s medical history and treatment. Medical transcription companies play a key role in helping physicians maintain consistent, HIPAA compliant documentation. However, errors can creep into EHRs due to data entry mistakes caused by system design or user error, importing of inaccurate medication lists, confusing interfaces and complicated navigation, the copy-paste function, etc. Since physicians utilize EHR data to make decisions about the patient’s care, such mistakes could lead to medication errors, wasteful duplication, incorrect or unnecessary treatment, and delayed diagnosed, and result in malpractice litigation. The reality is that errors can occur when documenting medical records, but correcting the mistakes the right way and reporting them in a consistent and timely manner will make it easier to defend malpractice claims.

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Types of Corrections made in Medical Records

The principles for amending EHRs are the same as those for paper records, according to MedPro, and include:

not concealing the original documentation
making timely corrections, and
signing all entries

However, the EHR differs in terms of how it displays and records information and its ability to track user actions through metadata and audit trails.

Capstone Performance Systems lists four types of changes that can be made in medical records:

Addendum: This involves adding omitted information to an existing document without modifying the original document, along with the current date and reason for the additional information being added to the record. The added information should be connected to the original report and both should bear the signature of the same provider.
Amendment: After the original documentation has been completed by the provider, an amendment clarifies information presented in the original document without altering it. Amendments should bear the current date.
Correction: Corrections refer to changes in the information in the document to correct mistakes after the original document has been signed or completed.
Deletion: Incorrect information is removed or deleted from a closed/finalized document without replacing it with new information.

Best Practices and Tips for Amending Medical Documentation

The EHR is a healthcare organization’s most important business and legal record and physicians need to understand what they can and cannot do with regard to making changes in it. Following these best practices and tips can help organizations protect themselves when making changes to documentation:

Ensure that overall documentation policies and procedures include a clear process for amending patient records.
Follow state laws on amending medical records. Some states may have specific record amendment rules.
Verify if your EHR allows error correction and can track corrections or changes once the original entry has been entered or authenticated. Work with your EHR vendor on this.
Avoid deleting relevant information permanently. Line out and rewrite incorrect entries in the written medical record instead of obscuring them.
The altered EHR record should be flagged to indicate that a change has been made.
Make a narrative entry in the medical record statement indicating that an error has been made, and is being corrected.
Have a system in place to retain and easily access copies of the original data.
Clearly document both the original error and the correction for future reference.
Ensure that the record amendment policy specifies the precise information that should be included when a correction, addendum, or late entry is made (such as the date and time of revision, name of the person who made the change, what information is being changed, and the reason for the alteration).
The record amendment policy should state the appropriate timeframe for making corrections, addendums, and late entries.
Notify the original author of the content about the correction, addendum, or late entry so that they can verify that the amendment is necessary.
Educate providers and staff about documentation amendment procedures and the potential consequences of deliberate or inadvertent record falsification (www.medpro.com).
Conduct routine audits to ensure that providers and staff are complying with organizational documentation policies and procedures.

Physicians should focus on ensuring complete, accurate and concise medical records and the best way to do this is to document the patient encounter real-time, or shortly afterwards. Outsourcing medical transcription to an experienced transcription company can ensure that physician dictation is accurately transcribed in quick turnaround time.

For affordable and accurate medical transcription services in the US, call us today at 1-800 670 2809.

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Significance of Integrating EHR And Telehealth To Provide Better Patient Care

24-August-2020 Rajeev Rajagopal EHR Transcription

EHR

Electronic Health Records (EHR) completely changed the landscape of healthcare industry and the way how physicians treat patients. Today, around 95 percent of hospitals and medical practices use EHRs to ensure a uniform way of storing medical records and to provide quality care. The systems provide patient access to their medical records, which allows patients and their families to take charge of their own health. Companies offering medical transcription services can build HL7 integrations for any EMR system.

With the outbreak of COVID 19, the use of telehealth has surged. Telehealth helps physicians provide best care to remote patients and also maintain social distancing. It also makes it easier for more people to access medical care, especially patients who are unable to see their doctors as often as they need to, such as those with restricted mobility, the elderly, rural patients who don’t have a medical facility in their vicinity. In these difficult times, when the number of patients is increasing rapidly, hospitals are integrating EHR systems with teleheatlh platforms to provide quality patient care.

Before COVID-19 struck, not many patients were using telehealth. One EHR network experienced a 3400 percent increase in daily telehealth visits during mid Febuary and late April, when patient volume started rising rapidly due to the pandemic. Dr Dillon Miller, medical director of Blue Ridge Medical Group, and his team decided immediately that telehealth would be a major component during the outbreak and for a certain amount of time, it was the primary source of interacting with patients.

The telehealth experience is very similar to the virtual patient visit. Dr. Miller was conducting consultations with tools like Skype or Facetime. But he wanted a technology that had EHR embedded with it. Later, they stated using Athenahealth’s telehealth solutions, which allowed the front office to get the patient checked in easily and was simple for the nurse to manage. Miller found this technology to be a useful option that could be used lifelong.

EHR and Telemedicine

While there are many benefits to telemedicine, having the right EHR software in place is essential for maximizing those benefits. An EHR system allows medical staff to stay organized and keep patient data secure.

When a physicians consults a patient during via telehealth, they have to access to the patient’s health records to properly diagnose and assess the patient’s symptoms and provide efficient care. Integrating telehealth technology within the practice’s EHR system helps physicians to access the patient’s health records. Using audio or video consultations directly from existing EHR systems creates a seamless, simplified virtual care workflow, just like the face-to-face patient doctor encounter.This system helps patients understand their diagnoses and they can also see a summary of their visit along with the rest of their medical history, helping to provide context for any new information once the patient is finished with their telehealth visit.

A combined approach of both EHR and telehealth helps healthcare providers as well as medical facilities to provide seamless patient care. It also eases the flow of information, reduces the chances of error when updating a patient’s records, improves patient outcomes, and simplifies the billing process. Providers looking to implement a telehealth system should look for a platform that integrates with their current EHR system.

Providing the right care at the right time is very important and with EHR integrated telehealth, healthcare providers can provide quality patient care, especially during COVID-19 crisis. Today, many healthcare organizations opt for medical transcription services that can interface with their EHR system.

Documentation Lapses a Root Cause of Diagnosis-Related Malpractice Claims

20-August-2020 MTS TEAM Medical Transcription Outsourcing

Malpractice Claims

As a medical transcription company with years of experience in the field, we are focused on delivering timely, error-free medical reports. Error-free transcription is crucial to prevent misdiagnosis and misinterpretation that can have a disastrous effect on patient safety and lead to legal consequences for the physician. In 2019, Claims Journal reported on two research studies which found that diagnostic errors and lapses in documentation are a leading cause of medical malpractice claims. Reliable medical transcription service providers are well aware of the importance of accuracy in documentation to prevent misdiagnosis, ensure proper patient care, and avoid malpractice lawsuits.

Diagnostic Errors a Key Factor in Medical Malpractice Claims

Diagnostic errors include wrong diagnoses, delayed diagnoses, and missed diagnoses. A study led by David Newman-Toker, a neurology professor at Johns Hopkins University, reviewed 55,377 closed medical malpractice claims filed from 2006 to 2015 and found 11,592 that alleged diagnostic errors. The research found that:

34% of medical malpractice claims where the patient died or was seriously disabled, cited inaccurate or delayed diagnoses as the cause
In 65% of these claims, the diagnosis error led to death or permanent disability
Claims caused by diagnosis errors made up 28% of all payouts
Up to 74.1% of these diagnosis-related claims were attributable to three types of conditions: cancer, vascular events such as strokes or heart attacks, and infections
Cancer was the most frequently missed diagnosis in outpatient clinics
Vascular problems were the most common condition cited in malpractice claims in EDs and in hospital inpatient settings

The study was published in Diagnosis in July 2019 and according to the lead researcher, confirms the findings of earlier studies.

“Although diagnostic errors happen everywhere, across all of medicine, in every discipline with every disease, we might be able to take a big chunk out of this problem and save a lot of lives and prevent a lot of disability if we focused some energy on tackling these problems,” Newman-Toker said (www.claimsjournal.com).

Another report published in 2019 by medical malpractice insurer Coverys related to malpractice claims at hospital EDs. The findings of this study are as follows:

Diagnosis-related claims comprised 47% of malpractice claim payouts by EDs and 33% of the total of claims number filed
The diagnosis was the most common source of ED claims
More than 50% of inpatient hospital admissions begin in the ED (due to diagnostic errors)

According to the report, communications tend to drop easily in high-pressure, fast-paced environments like emergency room settings.

Documentation Lapses that cause Diagnostic Errors

Closed claims data from the MedPro Group’s show that documentation issues occurred in almost 1 in 5 diagnosis-related claims during the period from 2007 to 2016. These issues fall in three categories: insufficient/lack of documentation, content, and mechanics. Healthcare professionals must ensure accurate and timely documentation of clinical care to reduce risk of allegations and defend malpractice suits. To do so, they need to understand the types of documentation lapses that contribute to diagnostic errors. The clinical documentation mistakes to watch out for are:

Insufficient/lack of documentation: MedPro Group found that insufficient documentation dominated in diagnosis-related claims. Documentation deficits include:
- Not documenting attempts to follow up with a patient about care or test results.
- The clinician fails to document that he/she has been involved in a patient’s care.
- Missing documentation in the patient’s record (such as patient problem list, test results, consultations, referrals, signatures indicating review, or medication lists).
- Not providing sufficient details about the patient encounter, which may be a major problem due to the form fields and check boxes in EHRs.
Content-related mistakes: Altering content in documentation might suggest an attempt to conceal mistakes. Other content related errors include: opinions stated as medical facts, inappropriate comments or speculation, proliferation of errors due to wrongful use of copy/paste function in EHRs, or general documentation inconsistencies in patient records.
Mechanics: The mechanics category includes errors in transcribing or writing orders, illegibility, delays in documenting, and not using the proper method for correcting documentation errors and making amendments.

Each year, errors in medical documentation cost the US economy billions of dollars. Best practices to reduce risks of documentation errors include:

Ensure comprehensive documentation. Include details regarding the history and exam. Coverys recommends that to prevent errors, EDs should specifically focus on the patient history and physical examination, which was an issue in 33% of claims in their study. Using a template as a checklist can help. Physicians should also document patient compliance with physicians’ instructions, changes in the treatment plan, consultations and referrals, and patient education, including how they have understood instructions.
Pay attention to the communication hand-off. The “communication hand-off” is a key concern in the ED. Solveig Dittmann, a senior risk specialist for Coverys recommends that ED physicians should adhere to a process referred to as SPAR: situation, problem, action, report – to brief the incoming caregiver about a patient.
Fix a time-frame for completing documentation. All patient encounters should be documented within a specific time-frame.
Ensure that documentation supports clinical judgement, diagnosis and decision-making.
Establish policies for use of copy/paste, form fields, check boxes, etc.
Train staff on documentation best practices and the appropriate method to correct errors in records.

Outsourcing medical transcription is a practical solution to promote complete and accurate EHR documentation. Professional service providers have teams of expert medical transcriptionists that can ensure that patient charts, progress reports, doctors’ notes and more are accurately transcribed and delivered in quick turnaround time. This can help prevent documentation missteps that cause diagnostic errors, promote patient safety, and prove invaluable to the physician’s defense in the event of malpractice litigation.

Electronic Communication with Patients – Major Ethical Considerations

17-August-2020 Julie Clements EHR Transcription

Electronic Communication

Today, the widespread adoption of telemedicine is improving the delivery of medical care and patients’ health and well-being. Medical transcription companies help providers document virtual encounters, including information about the visit, the history, review of systems, physician notes or any information used in medical decision making. Other forms of electronic communication that physicians and patients use include email, patient portals, texting, and messaging applications. The American College of Physicians (ACP) recently published a position paper which states that while e-communication offers many benefits, it must be used “thoughtfully and effectively to ensure standards of ethics and professionalism are met and trust in physicians is maintained”.

The ACP’s recommendations for e-communication to maintain strong and trusted patient-physician relationships and expectations focuses on email, patient portals, texting and messaging applications. The position paper “American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations,” was published in the Journal of General Internal Medicine. The guidance in the paper includes the following:

Electronic communication can supplement in-person interactions between patient and physician but should not take the place of in-person communications.
Electronic communication should only take place after discussion with the patient about expectations and appropriate uses, and with the patient’s consent.
Electronic communication with patients should occur through a method that is patient-centered and secure such as patient-portals.
All electronic communications should be documented in the medical record.
Electronic communication between patients and their physicians, if done with attention to ethical and other concerns, may help improve patient care, patient satisfaction, and clinical outcomes.
Physicians and institutions should use electronic communication to promote health equity and proactively address the socioeconomic and demographic factors that may lead to disparities in uptake and utilization.
Physicians, institutions and patients should recognize and address increased workload associated with management of electronic communication and implications for physician well-being.

The guidance does not look into telemedicine, telephone, video, or other applications; or communication between clinicians, but notes that “with changing technologies some recommendations may need to be revisited”.

With the COVID-19 pandemic, the spotlight is on telemedicine and it’s important to look at physicians’ ethical obligations to patients as they use advanced communication technology. Telemedicine is transforming patient-centered care in the current situation where physical distancing is advised and the patient is unable to attend a healthcare facility in person. Telemedicine offers a wide range options with services for primary care consultations, prescribing, mental health treatment, speech and physical therapy, and even some emergency services. By facilitating communications between members of the care team, telemedicine platforms also improve coordination of care. However, it’s crucial for providers to remember their ethical responsibilities towards their patients. Physicians should maintain the same standards of professionalism that are expected with in-person consultations and also keep the following ethical considerations in mind:

Patient privacy: The confidentiality, privacy, security and integrity of the clinical information collected and transmitted during a telemedicine consultation should be protected in accordance with HIPAA. Other entities, such as medical transcription service providers and other related business associates must also be HIPAA compliant. With asynchronous communication, patients may be apprehensive about who exactly will be responding and sharing their personal medical information. Physicians must ensure that the telemedicine platform used for consultations is designed to prevent unauthorized access and to secure and protect data security. Practices need to have robust privacy and security protocols in place for their telemedicine program and patients should be informed about this.

Informed consent: Patients should be notified about the benefits, risks and inherent limitations of e-communication and be given the opportunity to accept or decline the use of the technology before privileged information is transmitted. Patients should be educated about the features of telemedicine technologies, how they will be used in their care and what will be expected of them when using these technologies.

Technical competencies and communication skills: Telehealth communication competencies are essential for the success of remote consultations. Health care professionals need to ensure that they have the competency to use telemedicine platforms effectively. Studies have identified the following aspects as important for establishing a therapeutic relationship or ‘telepresence, according to www.ausmed.com:

Pre-interactional preparation
Verbal communication and telemedicine etiquette
Non-verbal communication
Environmental considerations, and
Operational training.

When they cannot personally conduct a physical examination, clinicians must ensure that they have the information they need to make well-informed clinical recommendations using telemedicine (www.aao.org).

Additionally, the Code of Medical Ethics Opinion 1.2,12 states that all physicians who participate in telehealth/telemedicine have an ethical responsibility to uphold fundamental fiduciary obligations by disclosing any financial or other interests the physician has in the telehealth/telemedicine application or service and taking steps to manage or eliminate conflicts of interests.

Providers also have the obligation to ensure continuity of care and advise the patient on next steps after the consult ends. To ensure continuity of care and facilitate referral to other providers, clinicians should record and preserve all clinical data obtained during the remote consultation. Outsourcing medical transcription to an experienced service provider can ensure error-free documentation of telemedicine consultations.

Understand the Common Causes of Medical Errors in Healthcare

13-August-2020 Rajeev Rajagopal Medical Transcription Company

Medical Errors

The accuracy of medical records reflects the efficiency of physicians and the quality of patient care offered in the hospital or other healthcare facilities. Keeping a record of all relevant patient data is vital for physicians to monitor the treatment given to the patient and reduce the chances of risk. So, to ensure accuracy of medical records, healthcare organizations hire medical transcription services that help physicians with accurate EHR documentation.

Accuracy of medical records is essential in a healthcare setup to not just ensure quality patient care but to meet ethical and legal obligations. Error-free medical records not only ensure good patient care, they also promote effective communication between physicians, nurses, administrators and patients, assist with audits and Medicare payments, and improve day-to-day operations of hospitals.

Errors in the medical report can be dangerous in a healthcare setup. It could be harmful for the health of the patient or even be fatal in some cases. Apart from documentation errors, some of the common medical errors that occur are:

Medication errors
Errors with anesthesia
Missed or delayed diagnosis
Unnecessary delay in treatment
Failure to act on test or proper precautions
Inadequate follow-up treatment

According to the Agency for Healthcare Research and Quality, there are six common causes for medical errors:

Miscommunication: Poor communication is one of the main reasons for medical errors in the healthcare setting. This issue usually arises between physicians, nurses, patients or anyone who is a part of the healthcare system and is caused mainly due to lack of clarity in the information exchange or communication between these parties.
Improper flow of information: Proper flow of information is important in a healthcare setting. But inadequate information flow occurs when the information does not follow the patients when they are transferred to another facility or are discharged from one component or organization to another. Improper information flow can cause issues like lack of crucial information when needed to influence prescribing decisions, inappropriate communication of test results, no or lack of efficient coordination of medical orders and patient care.
Human error: Human error in documentation of medical records and labelling of specimens is a common problem in healthcare settings. This could be due to lack of knowledge in medical field or due to carelessness.
Insufficient training: Insufficient training or inadequate education for those providing care leads to inaccurate medical records. Transfer of knowledge is critical in most areas, specifically where new employees or temporary help is used. So, providing training to medical staff is essential.
Poor staffing pattern: Poor staffing or insufficient staffing is another reason for medical errors. If staffs are not rightly placed and sufficient, then healthcare workers are more likely to make mistakes.
Technical error: Technical failures with medical devices, implants, equipment like computers, recording devices etc result in wrong medical documentation.

Some Case Studies

In the year 2012 in Michigan, an 81-year-old woman died 2 months after undergoing an unnecessary brain surgery. The patient went to a hospital in Oakwood, MI, for jaw surgery due to temporomandibular joint (TMJ) disorder. But the hospital staff incorrectly mentioned her name on another patient’s medical scan records. The patient was then taken to an operating room where surgeons drilled five holes into her brain and removed the right side of her skull before the medical staff caught the error. Due to the incorrect procedure, the woman was on life support, and died shortly thereafter. The hospital did not disclose the mistake to the family or to the state of Michigan, only admitting to the error 2 years later during the lawsuit proceedings.

In another case in Minnesota, a surgical-site error occurred where a surgical team removed the wrong kidney from a patient who had kidney cancer in 2008 at Methodist Hospital in St. Louis Park, MN. This incident happened weeks before surgery when the wrong kidney was diagnosed as cancerous on the patient’s medical chart, according to hospital officials. The hospital publicly accepted the mistake and apologized to the patient and family, and took corrective action. The patient’s health has not been disclosed, but state reports indicate that another surgery was attempted to remove the tumor and save the kidney.

A medical record can be documented accurately with the help of medical transcription providers. It is a highly skilled task and requires keen attention, patience and focus to every detail. A transcriptionist has good knowledge about medical terminology, anatomy, physiology and good typing and listening skills. A reliable medical transcription company offers transcription services with utmost accuracy at reasonable pricing.

Top Technology Trends Shaping the Future in Healthcare

10-August-2020 MTS TEAM Healthcare News

Technology Trends

Patient record digitization and EHR-integrated medical transcription services have paved the way for quicker and smarter clinical documentation. Today, social distancing mandates and personal choices to stay out of public places are increasingly shifting the focus to the online world. This is fuelling the implementation of eHealth, defined by the World Health Organization (WHO) as the use of information and communication technologies (ICT) for health. In fact, telemedicine proved to be a game changer for many practices during the lockdown. Let’s take a look at the top healthcare technology trends to watch in 2020 and beyond.

Telemedicine: With reimbursement improving and restrictions being lifted for telemedicine across states, virtual consults scaled new heights since the pandemic started. From an outlier, telemedicine has become the de facto healthcare access option for low-acuity patients, those with routine care needs, and people 65 and older who face greater risks if they become infected by the coronavirus. Telemedicine is also allowing patients to see specialists, which is improving diagnosis and treatment. Access to medical experts is a significant advantage for patients in rural areas. The Commonwealth Fund reported that telemedicine made up nearly 30% of outpatient visits in April, while the number of clinic visits dropped almost 60% in mid-March and has stayed low (www.cidrap.umn.edu/). Healthcare IT News reported that a recent survey by the Association of Community Health Plans found that nearly 90% of consumers who used telehealth for accessing care expressed satisfaction with their experience.
mHealth: Over the past 20 years, mHealth has emerged as a viable option to improve patient care. The use of smartphones, mobile devices, implantable technology, cyber networks and interconnectivity for promoting health has become widespread. Cellular infrastructure and internet access and focus on leveraging innovations and connectivity are supporting the fast growth of mHealth. Mobile apps help patients to get actively manage their own health. Physicians can access mHealth tools at any time and access patient records, take notes or send e-prescriptions. Mobile devices and apps are allowing patients to take advantage of telemedicine to consult, connect and communicate with physicians remotely and on-the-go. According to a recent mHealth Intelligence article, for senior living facilities looking to implement telehealth, an mHealth messaging platform may be the best place to start.
Internet of Medical Things (IoMT): The growth of computing and wireless technologies is allowing healthcare organizations to harness the power of the internet. IoMT is the blend of medical devices, software applications, and health systems and services. According to a Deloitte report, IoMT is driven by “an increase in the number of connected medical devices that are able to generate, collect, analyze or transmit health data or images and connect to healthcare provider networks, transmitting data to either a cloud repository or internal servers” (www.healthtechmagazine.com). These widely used devices and mobile apps are now integrated with telemedicine and telehealth via the IoMT, and are playing a key role in tracking and preventing chronic illnesses. With benefits like accurate diagnoses, fewer mistakes and lower costs of care, IoMT is set to evolve in the future of care.
Cloud computing: Cloud computing allows storage of large files and record sharing, making it an ideal option for healthcare. Cloud computing does not require or use a local server and significantly reduces infrastructural expenses and cuts the overall cost. Medical data can be stored in the cloud in seconds and accessed just as quickly. This process eliminates the need for paper records unless specifically requested by the patient. According to a recent report, the healthcare cloud computing market is expected to grow to more than $55 billion by 2025.
Tech to enable “contactless” experiences: Another trend that is expected to gain ground, apart from telemedicine, is “contactless” experiences, according to Healthcare IT News. The report says that, with people wary of touching surfaces due to the virus, experts are visualizing airport check-in type healthcare appointments, both for in-person and virtual visits. Patients can now complete their pre-visit registration formalities online. The contactless patient experience may also involve the use of facial recognition software in hospital registration kiosks.
Predictive analytics: Predictive analytics in healthcare uses past data to predict the future. Predictive analytics can help achieve better care coordination through informed decision making, and improve healthcare delivery and patient care outcomes. Predictive insights can prove very valuable in intensive care, where a patient’s life can be saved by timely intervention when their condition is about to deteriorate. Predictive analytics can also help detect at-risk patients in their homes and prevent hospital readmissions. Beyond saving lives, it can reduce operating costs. Health Tech reported that Vanderbilt University Medical Center used analytics to predict the number and timing of expected surgeries, so that they could reduce staffers during slow periods. This improved staff scheduling and allowed the center to recover costs amounting to the salaries of 2.8 anesthesiologists.

The face of medical transcription is also witnessing technological advances that are altering the way patient records are produced. Innovative technologies like machine learning and natural language processing have emerged as viable solutions to tedious EHR data entry by physicians. However, even with advancements in speech recognition and transcription technology, the services of medical transcription companies continue to be relevant as the transcribed text still need to be checked by humans to ensure that healthcare providers get accurate and proofread notes.

Study Analyzes CBT Transcripts using AI to Identify Benefits of Psychotherapy

03-August-2020 Rajeev Rajagopal Psychiatry Transcription

CBT Session Transcripts

Providing access to mental health treatment in a timely manner is critical to improving patient well-being. Digital psychological interventions or telehealth are transforming the way mental health care is delivered, benefiting patients who might otherwise have difficulty accessing these services. Psychiatrists and psychologists who use telehealth can see patients in their own homes via digital platforms and high-speed Internet service. Medicare and Medicaid are now reimbursing different types of mental health services. Medical transcription service providers ensure error-free documentation of telehealth encounters in the electronic health record (EHR). According to a recent study, analyzing cognitive behavioral therapy (CBT) transcripts can help build new digital treatments.

According to Mental Health America, millions of Americans are going without access to care. The National Alliance on Mental Illness (NAMI) estimates that one-in-four individuals experiences a mental illness each year, but that significant patient access barriers prevent them from accessing a mental healthcare setting. An article published by www.patientengagementhit.com listed the various reasons for this. One reason is that there is a shortage of mental healthcare providers. A 2018 survey from the National Council on Behavioral Health (NCBH) survey revealed that 31 percent of patients had to wait longer than a week for a mental health appointment, which can have serious impact on a patient who is in crisis. Even if they do find a clinician, limited health insurance access or in-network care poses a challenge for many patients. Societal stigma too stands in the way of getting in the way of adequate care access. Patients may also have to travel long distances to visit a mental health clinician.

However, the recent pandemic-driven expansion of teletherapy has made a big difference. Psychiatric evaluations, therapy (individual therapy, group therapy, family therapy), patient education and medication management have all gone virtual, allowing providers to meet more people in their own time and deliver convenient, affordable and readily-accessible mental health care. Now that digital interventions are in the forefront, the challenge is how to improve these interventions and deliver the best possible care.

There are a wide range of technology-driven digital healthcare apps and services that are designed to support wellness. Clinical trials are also conducted to improve digital interventions. However, an article published in TechTalks points out the limitations of healthcare apps and clinical trials in building new digital treatments:

Most apps focus on the areas of wellness, diet and exercise, and act only as an aid to professional treatment, helping patients self-manage and monitor their symptoms like anxiety or stress better. The article notes that digital healthcare apps “don’t always treat the patient’s needs as effectively as a human or medicinal intervention and are by no means a standalone treatment”.
Though clinical trials establish the safety and value of digital treatments, they are conducted in a tightly controlled environment and may not be representative of real life.

A new study by UK-based online therapy provider Ieso Digital Health leveraged deep learning artificial intelligence to understand which aspects of psychotherapy are the most effective. This information can be used to improve to existing interventions and build new digital treatments and improve access to them, according to experts (thenextweb.com).

The study, published in JAMA Psychiatry, involved analyzing over 90,000 hours of internet-enabled CBT transcripts pertaining to over 14,000 patients aged 18 to 94. The impact of the therapists’ language during the psychotherapy sessions were quantified and correlated with patients’ clinical outcomes.

Using a deep learning AI, the researchers identified the content of language used by therapists during CBT sessions. Twenty-four therapy feature categories, such as greetings, mood checking and setting goals, were identified. The average number of words for each feature, averaged across all sessions, was calculated for each case. A real-time text-based system was used to capture the physician-patient CBT interactions as transcripts. The study of the transcripts showed that:

Patients had a reliable overall improvement rate of 63.4% and an engagement rate of 87.3%
Patients were more likely to show an improvement in their symptoms and engagement with the therapy when therapists focused on CBT behaviour change methods.

The study demonstrated the advantages of using a deep learning model to extract valuable real-world evidence and improve mental healthcare interventions.

With rising demand, shortfall of therapists and limited investment and resources, effective digital treatments have become paramount to deliver high-quality mental healthcare. Ieso’s deep learning model is an important step in this direction. Ieso Digital Health senior scientist Michael Ewbank said: “What is exciting about this study is that it demonstrates the potential of Ieso’s data set, where we can understand more about what the active ingredients of therapy are, what works for whom, and develop new and more effective treatments for mental health disorders. Our work represents a first step towards a practicable approach for quality-controlled behavioural health care with the goal of improving the efficacy of psychotherapy” (www.medicaldevice-network.com).

Digital interventions are an ideal option for monitoring chronic conditions, patient communication, counseling, and psychotherapy. Psychiatry medical transcription services are available to help clinicians ensure accurate documentation of these virtual visits.

Medical Transcription Services Embrace Innovative Approaches for Betterment

30-July-2020 MTS TEAM Medical Transcription

Medical Transcription Services

Over the years, technology has evolved considerably and just as various other sectors, it has changed how medical transcription is done. Today, it is more computer-based and uses advanced communication methodologies for faster transfer of medical data. The latest technological addition to the healthcare industry, EHR, has transformed medical documentation and made it more efficient and easily accessible. However, the implementation of EHR has also led to physician burnout as now providers have to spend more hours on computers to document patient details. However, with medical transcription services physicians can continue to dictate their notes, and the dictations can be transcribed and then uploaded to their EHR using HL7 interface. This shows that the medical transcription still plays a significant role and to survive in this competitive digital world, these transcription services have to adopt the latest innovative approaches.

Five New Techniques in Medical Transcription Process

Use of specialized industry software: Medical transcriptionists need to be familiar with medical terminology and the names of various medical procedures that doctors may mention in their dictation. Specific software may have to be used to verify spellings and medical terms. Therefore, medical transcription vendors should ensure that they use the latest and specialized software to provide seamless service.
Speech recognition technology: Speech recognition technology is an important development, with many vendors providing speech recognition software that can be integrated with the physician’s EHR. However, only if a physician can record the patient data efficiently, transcribing can be done effortlessly. Today there are several recording options like smartphones, toll-free number, voice recorder etc that enable you to record the voice clearly. Another advantage of multiple recordings is that if any one of these devices goes wrong, the transcription can be done with other recording options. When speech recognition software prepares the transcripts, the professional transcriptionist plays the role of a proof-reader/editor, correcting mistakes if any and adding any missing information.
Collaborating with third party: Transcription services can collaborate with cloud storage facility that allows data to be stored on cloud system; and it can be shared and accessed from anywhere at any time. Collaborating with these facilities is an innovative approach that allows transcription services to secure patient’s medical records and also share it with medical professionals if required.
Assure security: It is vital for all healthcare organizations and other related entities to be HIPAA-compliant. It ensures security while transmitting medical data between the clinicians as well as the transcription services. Professional transcription services use the latest and innovative security systems to ensure that no medical records are compromised.
Minimal turnaround time: Less turnaround time is one of the most important advantages of transcription services. Payments by insurance companies are done based on the submission of the bills and medical history. So, if the transcription companies deliver the records early, it helps clinicians in early reporting of the payments for reimbursement from the insurance companies.

Many advancements and innovative approaches in medical transcription services is important to provide accurate medical reports. These accurate reports allow physicians to offer better patient care, adopt effective treatment measures, and provide quality services. In order to obtain error-free medical records, a blended approach of both medical transcription and EHR system is the ideal option. Physicians can easily dictate using their preferred recording device; the data is encrypted and sent to a medical transcriptionist who transcribes the recordings into accurate transcripts, which are later integrated into the physician’s EHR. Reliable medical transcription companies use HL-7 interface to provide EHR- integrated medical transcription to healthcare providers.