Study: Fitbit Data can Improve Influenza Surveillance and Estimation

23-January-2020 Rajeev Rajagopal Healthcare News

Fitbit Data can Improve Influenza Surveillance
The flu season in the US usually runs from October to May and peaks in February. As healthcare providers grapple with feverish patients and take extra precautions to prevent the spread of flu, medical transcription outsourcing helps them maintain complete and legible documentation on immunizations, relevant details of patient consultations, and care provided. Complete and consistent medical record documentation is an important for influenza tracking to understand the severity of the outbreak and plan public interventions. New research has found that data provided by Fitbit devices could help inform timely and accurate models of population-level influenza trends. The Scripps Research Translational Institute study was published online in The Lancet Digital Health earlier this month.

The current flu outbreak is on track to be one of the worst in years, according to the Director of the National Institute of Allergies and Infectious Diseases (www.cnn.com). According to the CDC, this year’s flu season has led to at least 5.9 million medical visits and 120,000 hospitalizations, with 39 pediatric deaths reported as of Jan. 11. The Influenza Division at CDC collects, compiles and analyzes information on influenza activity year-round through a surveillance network that includes doctors’ offices and clinics. The key flu indicators that the agency uses include the percentage of influenza-like illness (ILI) visits to outpatient clinics, the rates of influenza-associated hospitalizations, and the percentage of deaths resulting from pneumonia or flu. Timely and accurate estimates of population flu tracking are necessary to:

Understand the seasonality of influenza
Determine the extent of the illness
Identify and monitor groups at high risk of severe disease and mortality
Recognize circulating viruses
Indicate the start and end of the influenza season
Help plan public interventions

However, according to the Scripps Research team, the CDC’s influenza-like illness (ILI) data are typically reported one to three weeks late and reported statistics are often revised months later. They noted that though Google Flu Trends and social media tools have attempted to capture real-time flu surveillance data, they have not been always successful.

The new study suggests that heart rate and sleep data from Fitbits devices can predict and alert public health officials to real-time outbreaks of flu more accurately than current surveillance methods.

“The ability to harness wearable device data at a large scale might help to improve objective, real-time estimates of ILI rates at a more local level, giving public health responders the ability to act quickly and precisely on suspected outbreaks,” the researchers wrote.

One of the most well-known names in fitness trackers, Fitbit wearable devices allow users to keep track of their activity. Fitbit devices measure daily steps, calories burned and distance traveled as well as floors climbed, sleep duration and quality, and heart rate. Newer Fitbit devices feature special hardware that provides blood oxygen data to help track health issues like asthma, heart disease and sleep apnea.

Researchers tested if Fitbit data could be used to improve prediction of flu outbreaks at the state level. This was based on the hypothesis that when sick, people’s resting heart rate, sleep patterns and daily activities change, and fitness bands or smart watches could help identify such fluctuations.

They tracked more than 200,000 US Fitbit users who wore their device for at least 60 days during the period March 2016 to March 2018. The average age of the Fitbit users was 43 and 60% were women. To measure population-level changes, data was collected from the five states with the highest Fitbit use: California, Texas, New York, Illinois, and Pennsylvania.

The researchers concluded that using RHR (resting heart rate) and other metrics from wearables has the potential to improve realtime ILI surveillance. They noted that Fitbit data improved flu predictions by 6% to 33% over baseline models.

“New wearables that include continuous sensors for temperature, blood pressure, pulse oximetry, ECG, or even cough recognition, are likely to further improve our ability to identify population and even individual-level influenza activity. In the future, with access to real-time data from these devices, it might be possible to identify ILI rates on a daily, instead of weekly, basis, providing even more timely surveillance. As these devices become more ubiquitous, this sensor-based surveillance technique could even be applied at a more global level where surveillance sites and laboratories are not always available,” they wrote.

Real-time data from EHRs plays an important role in helping local public health authorities monitor and provide guidance for influenza and other outbreaks. In 2019, Healio reported on a study which found that real time data mining of EHRs can rapidly identify the transmission route or routes that are responsible for a hospital disease outbreak. Accurate and timely infectious disease transcription services can ensure comprehensive EHR data to help public authorities with infectious disease surveillance. Determining the influenza burden can help decision-makers prioritize resources and plan appropriate public health interventions.

Study: Fitbit Data can Improve Influenza Surveillance and Estimation

Rajeev Rajagopal Healthcare News

The flu season in the US usually runs from October to May and peaks in February. As healthcare providers grapple with feverish patients and take extra precautions to prevent the spread of flu, medical transcription outsourcing helps them maintain complete and legible documentation on immunizations, relevant details of patient consultations, and care provided. Complete and consistent medical record documentation is an important for influenza tracking to understand the severity of the outbreak and plan public interventions. New research has found that data provided by Fitbit devices could help inform timely and accurate models of population-level influenza trends. The Scripps Research Translational Institute study was published online in The Lancet Digital Health earlier this month.

Understand the seasonality of influenza
Determine the extent of the illness
Identify and monitor groups at high risk of severe disease and mortality
Recognize circulating viruses
Indicate the start and end of the influenza season
Help plan public interventions

New Study Highlights Need for Appropriate Documentation for Antibiotic Prescribing

20-January-2020 MTS TEAM Healthcare News

With the continual emergence of new disease-causing viruses, bacteria and other infections, infectious disease specialists face numerous challenges for patient diagnosis and treatment. Bacteria that are resistant to antibiotics have made illnesses that were once easily treatable with antibiotics untreatable, leading to dangerous infections. Medical transcription outsourcing is a practical option to maintain legible, timely, complete, precise, and accurate infectious disease electronic health records (EHRs). Importantly, proper documentation is crucial for appropriate antibiotic prescribing. However, a new study found that nearly half of all antibiotics are prescribed without a documented indication in the ambulatory care setting.

The Challenge of Antibiotic Resistance

While antibiotics aim to fight infections, overuse and misuse of antibiotics have led to the development of antibiotic-resistant pathogens. Antibiotic resistance is now an urgent global public health threat. The US Centers for Disease Control and Prevention (CDC) estimates that 2.8 million antibiotic resistant infections occur each year, leading to 35,000 deaths annually.

Overuse and misuse of antibiotics leads to the development of antibiotic-resistant bacteria. When exposed to antibiotics, bacteria change so that they become resistant to the action of the medication. Such antibiotic-resistant bacteria can multiply and even transfer their resistant properties to other bacteria. Many illnesses that were once easily treatable with antibiotics have become untreatable due to antibiotic resistant bacteria, leading to dangerous infections. Antibiotic-resistant bacteria are usually difficult to destroy and more expensive to treat.

Important examples of antibiotic resistant bacteria are:

Methicillin-resistant Staphylococcus aureus (MRSA)
Clostridioides difficile (CDI)
Candida auris
Vancomycin-resistant Enterococcus (VRE)
Multi-drug-resistant Mycobacterium tuberculosis (MDR-TB)
Carbapenem-resistant Enterobacteriaceae (CRE) gut bacteria
Neisseria gonorrhoeae

According to the CDC’s 2019 “biggest threats” report on antibiotic-resistant pathogens, Clostridioides difficile (CDI), carbapenem-resistant Enterobacteriaceae (CRE), and drug-resistant Neisseria gonorrhoeae continue to be “urgent threats” and they are joined by carbapenem-resistant Acinetobacter and Candida auris (www.contagionlive.com).

Importance of Documenting Indications of Antibiotic Prescriptions

Antibiotic prescriptions should be accompanied by appropriate documented indication and intended duration of antibiotic use in drug charts.

Documentation of indication and intended duration of antibiotic use in drug charts based on antibiotic guidelines is important for many reasons:

To estimate the actual scope of inappropriate antibiotic use
To support efforts at antimicrobial stewardship and reduce inappropriate antibiotic prescribing
To improve the quality of communication between healthcare providers and patients by keeping the team up to date of the plan for antibiotic use and of any intended reviews
To support continuity of care

Requiring clinicians to document the reason for prescribing an antibiotic could also get them to evaluate its appropriateness and curb overuse.

Study warns about Inappropriate Antibiotic Prescriptions

The results of a national study published last year indicated that compared to other health care settings, urgent cares have both the highest percentage of visits resulting in antibiotic prescriptions as well as the highest rate of inappropriate prescribing for respiratory tract infections.

Despite the importance of proper documentation for antibiotic prescribing, the study found that in 2015, about 24 million antibiotic prescriptions in the US lacked a documented indication and 32 million prescriptions were identified as inappropriate.

Researchers conducted a cross-sectional study based on data from the National Ambulatory Medical Care Survey to determine how frequently antibiotics are prescribed without a documented indication in the ambulatory care setting, and to identify characteristics of the patient, provider and visit associated with inappropriate antibiotic prescribing. According to the study published in the BMJ, patients visiting urgent-care centers were most likely to receive an antibiotic prescription, even if they had a respiratory illness for which the drugs are inappropriate (www.contagionlive.com). The researchers found that of the 990.9 million ambulatory care visits across the country in 2015, 130 million resulted in an antibiotic prescription. Of these visits:

57% were for appropriate indications
25% were inappropriately prescribed
18% had neither appropriate nor inappropriate documentation
43% of prescriptions may have been potentially inappropriate

Antibiotic prescription without an indication was more common among adult male patients and seeing a non primary care specialist. It was also associated with longer visits, which could indicate more complex patients, “coding fatigue,” or “insufficient consultation time.”

“Our study identified several independent risk factors for antibiotic prescribing without a documented indication; these may be useful in directing initiatives aimed at improving documentation. With 60% of antibiotic expenditure and up to 90% of antibiotic use originating in ambulatory care settings, more focus is needed to support well informed stewardship efforts beyond the hospital,” the study authors concluded.

Medical transcription companies providing infectious diseases transcription services can support providers in the efforts to improve antibiotic prescribing and patient care.

Online Reviews driving Older Adults’ Choice of Physicians, finds New Poll

16-January-2020 Julie Clements Healthcare News

People are increasingly researching online before buying a product or service, and healthcare is no exception, according to recent reports. Several factors influence a person’s choice of a healthcare provider. Many physicians rely on medical transcription outsourcing to maintain complete and accurate medical records and ensure that patients get the right care at the right time. This is important as patients using online reviews are basically looking for information about the quality of care a physician provides. In fact, more and more people are now using the internet to research and select their physicians. A recent national poll revealed that online reviews of physicians have a strong influence on Americans who use the most health care: people over age 50.

The National Poll on Healthy Aging administered online by the University of Michigan in May 2019 studied adults between the ages of 50-80 on their use and perceptions of online doctor ratings. The findings on the use of online reviews are as follows:

43% review physician ratings online
14% had reviewed ratings more than once in the past year
19% had done so once in the past year
10% had reviewed ratings more than one year ago

Among older adults who had reviewed physician ratings within the past year:

65% read reviews of a physician they were considering
34% read reviews to find a new physician
31% read reviews for a physician they had already seen

What factors influenced physician choice?

71% said that they would select a physician with many positive ratings, even if he/she had a few negative reviews
69% said that they would avoid selecting a provider with mostly negative ratings, even if he/she had a few very positive ratings
41% considered the total number of reviews as important for selecting a physician

However, 53 percent the respondents felt that some physicians may manipulate their ratings to make themselves look better. As a result, many older adults also rely on traditional ways to get information about providers. These methods include: time taken to schedule an appointment, the physician’s experience, recommendations from another physician, word of mouth from family and friends, and ability to communicate with their physician online for scheduling and refills.

What are the implications of the poll results?

“Online doctor ratings and reviews represent a potentially useful resource for older adults,” the researchers wrote. “While some may think that choosing a doctor using online ratings is something only younger people may do, this national poll shows that this practice is also common among older adults”.

According to the study, online physician ratings represent a potentially useful resource for older adults to overcome the challenges of finding a new doctor, and are likely to continue to increase in use over time. The results of this poll also show that a positive reputation is a great asset for a physician practice. While positive reviews can boost business, negative reviews can cost a practice. In this digital era, practices would benefit greatly by investing time and effort to build a beneficial image and get positive online reviews.

Don’t ignore negative reviews: To fuel positive patient reviews, practices need to make asking for and responding to feedback a top priority. Physicians should never dismiss or ignore negative reviews or complaints. While acknowledging positive feedback, they should work towards manage negative feedback by resolving pain points and providing a better patient experience.
Build rapport with patients: Good manners and proactive efforts to understand the patient’s feelings are the first steps to building good rapport with patients. Focusing on meeting patient expectations will promote a positive clinician-patient experience which can improve care and patient satisfaction.
Utilize social media: Patients are leveraging different social media platforms to express their healthcare experience. Physicians can leverage these digital platforms to understand how people perceive their practice and improve patient outreach. Social media can help drive health literacy for patients. Physicians can provide answers to their questions on symptoms, diseases, and conditions on these channels. However, they must be mindful about HIPAA regulations on patient privacy while social media.

In 2014, 14.5% (46.3 million) of the US population was aged 65 or older and is projected to reach 23.5% (98 million) by 2060 In 2014, the adult population age 65 years or older in the US was 46.2 million, and this number is projected to increase to 98 million by 2060 (www.healthypeople.gov). As older adults are major consumers of health care and turn to online reviews to make informed decisions, physicians need to focus on meeting their expectations and supporting them through health maintenance and health information management. Medical transcription services are available to help practices with their EHR-related documentation requirements.

Tips to Reduce Risks of Surgical Site Infections (SSIs)

13-January-2020 Rajeev Rajagopal Infographics

Infection control and prevention is a major safety issue in hospitals across the United States. It is important for surgical facilities to take measures to ensure patient safety and prevent surgical site infections (SSI). As strong clinical documentation improvement (CDI) is crucial, many surgical specialties outsource medical transcription to improve documentation in surgical operation notes.

Check out the infographic below.

Risks of Surgical Site Infections

Opioid Prescribing – Importance of Comprehensive EHR Documentation

09-January-2020 MTS TEAM Pain Management Transcription

Patients suffering from chronic pain rely on opioid therapy for pain management. However, opioid misuse, addiction, and overdoses are serious public health problems in the United States. Despite recent declines, medical use of opioids remains high and inconsistent across the U.S., according to the Centers for Disease Control and Management (CDC). While pain management medical transcription services can ensure timely and accurate medical records, not maintaining appropriate documentation can potentially expose clinicians to medico-legal scrutiny. When treating patients taking long-term opioids, providers need to ensure that prescriptions are medically justified and provide justification for continuing treatment with opioids.

A study published in Annals of Internal Medicine in 2018 reported that medical indication is not documented for many outpatient opioid prescriptions (www.healio.com). The researchers found that:

Opioids were prescribed for cancer-related pain in 5.1% of visits and non cancer pain in 66.4% of visits
Patients with no pain diagnosis were prescribed opioids in the remaining visits (28.5%)
Compared to new prescriptions, continued opioid prescriptions lacked a pain diagnosis (22.7% vs. 30.5%)

Documenting treatment of chronic pain patients with opioids

When prescribing opioids, the clinician needs to maintain comprehensive documentation for the initial visit as well as for follow-up visits. An article in Practical Pain Management Appropriate lists the current recommendations and requirements for documentation of visits with patients prescribed opioids and other controlled drugs for chronic pain as follows:

Initial visit: The following information should be documented in the patient’s chart:

Specific information about past treatments: In addition to the ongoing problem, the clinician should document the doses and duration of medications tried, and if a medication was stopped, the reason
The type and intensity of the pain
Results of previous diagnostic studies
Treatment plan and goals – goals should be as specific and measurable as possible. Documentation of the plan should include a list of all prescriptions given, including dose and quantity, as well as referrals for lab tests, imaging studies, and physical therapy or other specialists

The guidelines recommend requesting and reviewing the patient’s old records and obtaining a baseline urine drug screen (UDS) at the initial visit. The documentation should include the last dose of each medication taken including the date and time. The clinician should also check the patient’s history on the state’s Prescription Monitoring Program (PMP website and document this in the patient’s chart, including whether there are any results of concern.

Follow-up visits: How often the patient should be seen would be based on how stable the patient is, how often a physical exam is needed, and the clinician’s reckoning as to the patient’s ability to follow the recommended regimen.

The article recommends that documentation for the follow-up visit based on “5 A’s”:

Analgesia: The level of pain on a scale of 1 to 10
Activities of daily living: Specific information about what the patient actually does (e.g., “Walking the dog for 15 minutes, about half a mile.”)
Adverse effects
Aberrant drug-related behaviors
Affect-the patient’s mood

Appropriate documentation of evaluation and assessment in follow-up visits would include the following:

Review of previous office visit: At the start of the follow-up visit, the clinician should review the plans documented in the record for the preceding office visit with the patient and the outcomes of each plan. Things to evaluate include whether any lab tests and imaging studies were ordered, if the results are in the chart, if a UDS done, and if the results are “consistent” or good.
Assessment and plan: The clinician should summarize and document the patient’s current medical status, level of compliance, and also the clinician’s reasoning for continuing the same regimen, making changes in the patient’s medication management, making a new referral, altering the goals, and compliance concerns. If a prescription is renewed by phone, email, or fax between visits, this must be documented on the master medication list.
All electronic communication: All electronic communication with the patient, such as phone calls, faxes and emails, should be documented.

The article cautions clinicians about problems associated with utilizing the copy-and-paste function in EHRs when documenting treatment of chronic pain patients with opioids. Copying and pasting past entries into the current EHR can lead to serious errors, negatively impact care, and increase risks of malpractice.

Physicians can protect their practice with thorough documentation of opioid prescribing in the medical record and adhering to extra regulatory requirements. HIPAA compliant medical transcription can ensure safe and effective documentation of opioid management.

EHR Interoperability: Importance, Challenges and Solutions

06-January-2020 Julie Clements EHR Transcription

ehr interoperability and its major advantages

The digitization of health information and adoption of electronic health records (EHRs) have revolutionized patient data management. While medical transcription services are practical approach to guarantee precise and timely EHR documentation, achieving EHR interoperability – the capability to exchange EHR data among healthcare providers – is vital. EHR interoperability facilitates seamless sharing of information and improves health care delivery by making data available at the right time to the right people.

Struggling to maintain up-to-date and accurate patient records? Reach out to our medical transcription company.

Call (800) 670-2809 today!

Even as demand for enhanced patient care is increasing, the goal of seamless data exchange in healthcare remains challenging, according to a Forbes article titled “Healthcare Interoperability Considerations We Can’t Ignore In 2024”. The article, published in Jan this year, noted that Office of the National Coordinator for Health Information Technology (ONC) reported that though 88% of hospitals used electronic data exchange in 2021, almost half of the hospitals (48%) share patient data with other providers but don’t receive data from them.

Let’s explore the benefits for EHR interoperability, its challenges and the solutions.

Essential Components of EHR Interoperability

The Healthcare Information and Management Systems Society (HIMSS) defines interoperability as the extent to which systems and devices can exchange data, and interpret that shared data. One of the goals of the World Health Organization’s Global Strategy on Digital Health 2020-2025 is creating an interoperable digital health ecosystem.

According to WHO, “An interoperable digital health ecosystem should enable the seamless and secure exchange of health data by and between users, health care providers, health systems managers, and health data services.” WHO recognizes interoperability as one of the main principles of how digital health should work.

EHR interoperability requires healthcare organizations to adopt and adhere to technical standards, such as the Health Level Seven International (HL7) standard, which defines a common language for exchanging health information. They also need to develop policies that govern the collection, use, and sharing of health data to ensure patient privacy and security. The 21st Century Cures Act aims to promote health data interoperability by requiring healthcare organizations to allow patients to access and share their health data electronically.

Importance of EHR Interoperability

Seamless sharing of patient health information across providers, payers, patients, and locations is vital for improving care, reducing errors, and enhancing population health management. When health data is siloed, it leads to fragmented care and poor coordination, affecting patient outcomes. With an aging population and rising chronic conditions, interoperability and data sharing are crucial for effective healthcare. The AHRQ estimates that two-thirds of older Americans have multiple chronic conditions, driving up healthcare costs. Effective data interoperability is key to a more connected, patient-centered healthcare system.

EHR

The benefits of health data interoperability include:

Improved patient outcomes: When healthcare providers have access complete and up-to-date patient information it can drive informed treatment decisions, improved care coordination, and better care outcomes.
Increased efficiency: Interoperability enables more efficient care delivery and reduced administrative burden by reducing the time and resources required to share health data between different providers
Better patient engagement: When patients have access to their health data and can share it with different providers and healthcare organizations, it can improve patient engagement and support more personalized care.
Cost savings: By preventing medical errors, reducing unnecessary tests and procedures, and improving care coordination, interoperability can lead to cost savings for providers and patients.
Improved population health management: When healthcare organizations can aggregate and analyze health data across different systems, it can inform population health management strategies and support public health initiatives.
Supports research: By allowing for the use of large-scale, real-world data sets, interoperability helps the development of new treatments and technologies.

Challenges to EHR Interoperability and Solutions

Achieving healthcare interoperability is crucial for effective clinical decision-making. Here are some of the challenges to achieving this goal and the solutions:

Lack of standardization: Although standards like FHIR and HL7 and APIs are designed to enhance interoperability, many providers still use customized EHR systems that resist standardization. Developing APIs for secure, efficient data exchange can address this issue.
Patient privacy concerns: Balancing data accessibility with security is challenging due to increasing cybersecurity threats. Ensuring robust privacy measures and compliance with regulations is essential to prevent breaches and protect patient information.
Data management issues: Inconsistent data across large networks complicates data retrieval and management. Effective integration technologies and analytics solutions can streamline data handling and improve coordination.
Varied data formats and data quality issues: Although standards like FHIR and HL7 and APIs are designed to enhance interoperability, many providers still use customized EHR systems that resist standardization. The Office of the National Coordinator for Health Information Technology (ONC) states that establishing an interoperable health IT environment requires standardizing four key areas of EHR technology:

1. User interaction with applications (e.g., e-prescribing)
2. Communication between systems (e.g., messaging standards)
3. Information processing and management (e.g., health information exchange)
4. Integration of consumer devices with other systems and applications (e.g., tablet PCs)

Inaccuracies, irrelevant data, and other quality problems in text, digital, audio, and graphic formats also pose a major challenge.

Patient consent: Legal and ethical requirements for patient consent complicate data sharing. Clear guidelines and informed consent processes are necessary to navigate privacy concerns while facilitating information flow.
Financial constraints: Implementing and maintaining interoperable EHR systems is costly, involving software, hardware, training, and ongoing upgrades. Financial investment is needed to support data conversion and migration efforts.

The following measures can provide solutions to address these challenges:

Implementing common data exchange standards like HL7 and FHIR
Developing APIs for secure, efficient data exchange
Using machine learning to improve data quality and accessibility
Ensuring stringent measures to safeguard patient information.
Making health data accessible and understandable to patients for informed consent
Obtaining explicit patient consent for information sharing
Investing in integration technologies and analytics solutions

Achieving Interoperability: Importance of Collective Action

Achieving interoperability requires collective action by all stakeholders: healthcare providers, patients and technology developers. To facilitate seamless data exchange and enhanced patient care, practice managers should keep interoperability at the forefront of their requirements when selecting an EHR. Cloud-based EHRs enable easy integration and access to various data sources, including clinical, lab, and pharmacy systems, ensuring interoperability and improving the quality of care for patients. These EHRs also allow for storing of data on multiple servers across different geographical locations, enabling retrieval of data as needed. They also come with advanced security features to protect against cyberattacks and unauthorized access to sensitive patient data.

As patient data is shared across healthcare systems and organizations, ensuring accuracy and timeliness in the information is crucial. Healthcare providers can partner with a reliable medical transcription company to maintain up-to-date and accurate EHR data to support clinical decision-making and patient care.

Optimize your workflow and save money with our accurate and timely EHR documentation support!

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Impact of Medical Terminology on Patient Care

02-January-2020 Rajeev Rajagopal Medical Transcription

Medical terminology is the standardized language that allows healthcare providers, HIM professionals and medical transcription service companies to communicate on a patient’s condition and medical needs. This specific language is used to discuss everything from human anatomy and physiology, to clinical diagnoses, procedures and processes. With discoveries and advancements in medicine, healthcare professionals, medical transcriptionists, as well as patients need to continuously deal with new terminology, broadened medical language, and descriptions. Correct understanding and use of medical terms has a significant impact on patient care.

Proper physician-patient communication is an essential element of care. When patients interpret medical terms correctly, it can improve the physician-patient relationship and promote adherence to care instructions. However, studies show patients’ often don’t understand the diagnostic and treatment process as they are confused about medical terminology, which affects healthcare outcomes.

In articles published in 2015 and 2016, California-based not-for-profit public-benefit corporation Dignity Health listed the common medical terms that patients may not understand. The lists include the following:

Positive and negative: Understanding the terms ‘positive’ and ‘negative’ is essential to comprehend medical test results. In layperson’s language, positive means that whatever the test was looking for was found and negative means that whatever the test was looking for was not found. False-positive results mean a disease is detected even if it is not present, while false-negative results mean that the test failed to detect the disease or condition that the person has. According to Decision Health, many patients think that positive test results means they are free of the disease or condition being tested for.
Prescription instructions such as twice daily and every 12 hours: According to the Institute of Medicine, nearly half of US adults have some difficulty understanding their medication instructions. With billions of prescriptions dispensed in the United States each year, this challenge can affect a substantial number of patients. Misunderstanding prescription instructions such as twice daily or every 12 hours is more common among patients with low levels of literacy.
Diet and exercise: Diet refers to food you eat and exercise refers to physical activity. However, when their physician talks about diet and exercise, people with low levels of health literacy may misinterpret diet as meaning going on a diet and exercise as meaning going to the gym.
Chronic and acute: Chronic pain is pain is ongoing, long-term pain. Acute pain is short-term and occurs suddenly, and typically lasts less than 3 to 6 months. Many patients do not understand these distinctions.
Stable: In medical terms, stable means not deteriorating in health after an injury or operation (www.lexico.com). But as the word ‘stable’ has many meanings, it can confuse patients. Decision Health recommends that physicians should stick to using ‘the same’ or ‘unchanged’ to describe the patient’s condition.
Screening: Screening is another commonly used, but complicated word as far as patients are concerned. Many patients do not recognize and understand such terms as screening, mammogram, tumor, and growth, and how they relate to their specific condition.

In addition to these, patients are often confused by technical terms such as “myocardial infarction” (heart attack), “hyperlipidemia” (high cholesterol) and “febrile” (feverish). Other complex and commonly used words include:

Annually → Yearly or every year
Arthritis → Pain in joints
Cardiovascular → Having to do with the heart
Dermatologist → Skin doctor
Diabetes → Elevated sugar in the blood
Hypertension → High blood pressure
Sutures → Stitches
Abdomen → Belly

Studies have found an association between poor health literacy, especially among the elderly, the poor and recent immigrants, and higher rates of hospital readmission, expensive and unnecessary complications, and even death. A 2006 study by the U.S. Department of Education found that 36 percent of adults have only basic or below-basic skills for dealing with health material. However, according to a patient education manager, even highly educated patients are affected, particularly if they’re stressed or sick (Kaiser Health News).

Proper communication is essential in a time when patients are being asked to take more responsibility for their own care. Using complicated medical terminology during the consultation can leave patients poorly informed. This can lead to indifference and decreased of involvement of patients, which can affect patient outcomes. Physicians need to ensure that patients have a clear understanding of information during diagnostic and treatment process. One standard method is to ask patients to repeat what they understood, and then clarify any errors. If the patient doesn’t understand English, an interpreter should be used. Helping patients understand their treatment will improve the patient-physician relationship, help reduce morbidity and mortality, and prevent misuse of health care.

When it comes to the medical record, HIM professionals such as medical transcriptionists should have a thorough knowledge of medical terminology to ensure an accurate and complete working document. Continuous quality improvement is the hallmark of established medical transcription outsourcing companies where teams make extensive use of reference material to help providers ensure quality documentation in the electronic health record. Also, the support of a medical transcription company would be invaluable for time-strapped physicians striving to focus on patient care and their literacy concerns.

Integrated EHR will not support Interoperability, says HIT Consultant Report

30-December-2019 MTS TEAM Medical Transcription Company

More than 95 percent of hospitals and nearly 90% of office-based physicians have adopted an electronic health record (EHR) system, according to the Healthcare Information and Management Systems Society (HIMSS). EHRs are designed to provide access to complete and accurate information, allowing patients receive better medical care. Medical transcription outsourcing is a reliable strategy to improve the quality of EHR data.

Now that EHR adoption is widespread, physicians are looking to optimize EHR use at the point of care. EHR interoperability, which will allow seamless data exchange, is a key element in such optimization. Healthcare facilities often need to interact with each other in order to share patient information and EHR interoperability is necessary to make this possible. Interoperable EHRs enable allow patient information to be shared electronically between different EHR systems and healthcare providers, enabling physicians to ensure continuity of carepatients as patients move in and out of different care facilities.

So what are providers doing to address EHR interoperability challenges? When asked this question in the recent CCM survey, 60% of respondents who included informatics, business, and clinical staff, said that their organizations were moving to a single, integrated EHR. However, a recent report from HIT Consultant points out that interoperability challenges will continue to exist even if organizations implement a single EHR system.

The American Academy of Family Physicians (AAFP) defines an integrated EHR as one that is integrated with practice management software. The AAFP states that typical choices include purchasing a fully integrated product which performs all the functions of practice management software, or a stand-alone EHR which is compatible with an existing practice management system.

Interoperability involves aggregating the rich data generated through EHRs by health plans, health systems, vendors, and patients, analytic systems, and leveraging that data to improve patient diagnosis and treatment. However, even with widespread EHR adoption, interoperability continues to be a major challenge. A Health Affairs study reported that, as of 2014, only about one-fifth of U.S. hospitals were engaged in all four elements of interoperability – finding, sending, receiving, and integrating information (www.healthanalyst.com). According to new survey research from the Center for Connected Medicine (CCM), less than 40% of healthcare executives believe that their organizations successfully share clinical data with external health systems, payers, and other partners, notes the HIT Consultant report.

The HIT Consultant report identified several reasons whymoving to a single EHR will not address all the challenges of achieving true interoperability in healthcare:

Small practices may not be able to afford moving to a single EHR system: Interoperability will work only if all providers adopt a single EHR across a network of both employed and associated physicians. Implementing a single system may be possible and practical from an IT perspective within a hospital system. But the survey found that only 14. 40% of practices with 1-3 physicians use big systems like Epic or Cerner. Smaller practices typically use self-developed or small vendor EHR systems and will be unlikely to move to a single system due to financial constraints.The report says that adopting a single system across the entire network of providers is not practical or possible due to the expense and disruption it would involve.
The same EHR may have different codes for a particular condition: Even if health systems have implemented the same EHR, they may be using several codes to report a particular condition. The HIT Consultant report cites the example of a hospital system that had implemented a single EHR and has 18 different codes to document a mammogram.
Documentation methods by practice setting: Providers may use different clinical documentation approaches. While some may document diagnosis and treatment in detail and type a narrative into a note, others may rely perform data entry using the drop-down menu or structured fields in the EHR. If a field is unfilled, relevant history would be missing, and this can affect data integrity and care.
Semantic interoperability is a challenge even with a single EHR: The HIT Consultant report notes that several common documentation issues can limit interoperability. These include:
- use of local versus standard terminology libraries
- entering free text instead data capture via the structured fields
- using the wrong unit of measure such as a percentage instead of a count
Moving to one EHR won’t solve these issues that will affect downstream use by both software and human users. Proper interpretation by all users and the software system is crucial for interoperability to work.
Need for interoperability across the entire ecosystem: Implementing a single EHR will not help with interoperability across the vast ecosystem of systems and applications. Interoperability means supporting healthcare processes in the single-use case of care coordination as well ascollecting and communicating data from pharmacy systems and other parts of the supply chain captured at the point of care with disease registries, clinical trial systems and so on.

Research has shown that both providers and patients see EHR interoperability as crucial for high-quality care. As the industry strives to overcome the challenges to interoperability, EHR-integrated medical transcription services are a valuable tool for ensuring timely and accurate updating of health information. Experienced medical transcription companies are well-equipped to provide accurate and timely EHR feeds, which is critical to enhancing the quality of care.

2020 New Year Resolution Ideas for Healthcare Providers [Infographic]

26-December-2019 Julie Clements Infographics

As we enter 2020, physicians would do well to make resolutions to improve patient access to care, services provided, and overall practice efficiency. If they are looking to improve documentation, they can always rely on professional medical transcription companies.

Check out the infographic below

2020 New Year Resolution Ideas for Healthcare Providers

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2020 New Year Resolution Ideas for Healthcare Providers [Infographic]

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