Know More about NSAIDS, Precautions and Side Effects

14-October-2019 Julie Clements Medical Transcription Company

In any healthcare setting, patient diagnosis and treatment protocols have to be properly and accurately documented to ensure appropriate treatment and care. A clear understanding of various prescribed drugs, their interactions with each other, side effects, and precautions to take is necessary for healthcare providers. To ensure error-free and timely medical charts, many physicians and health systems utilize in-house or outsourced medical transcription service. NSAIDs (non-steroidal anti-inflammatory drugs) are often prescribed to treat pain and inflammation. Inflammation is the immune system’s response to infections or injury. The signs of inflammation are heat, redness, and swelling, and the body gets pain signals from nerve receptors when inflammation occurs. These signals are due to complex responses and interactions between cells and chemicals present in the body. Anti-inflammatory drugs reduce pain by reducing inflammation. These drugs are used to relieve symptoms of pain, stiffness, swelling and fever.

NSAIDs are often given for cramps, aches and pains, or for pains along with fever or swelling. Many of these drugs are available over the counter as they are safe and are used as per the label. Some of the OTC drugs are Ibuprofen, Aspirin, Naproxen Sodium; and prescription NSAIDs include Oxaprozin, Etodolac, Indomethacin, Naproxen, Nabumetone, Diclofenac and so on.

However, there are some risks in taking these drugs, if they are taken for a long period of time. So it is important to seek the advice of physicians when taking NSAIDs for long-term pain complaints.

Functions of NSAIDs

There are various drugs under the category of NSAIDs with different chemical structures. But they all have the same functions of

Reducing high temperature
Reducing inflammation
Reducing pain

NSAIDs work gradually with the formation of compounds known as prostaglandins. Prostaglandins play a significant role in the body’s inflammatory response. Minimizing the amount of prostaglandins produced by the tissue damage reduces inflammation. NSAIDs block an enzyme called cyclooxygenase, also known as COX. The COX enzyme helps the reactions that produce prostaglandins.

NSAIDs are used to ease pain in a number of conditions like arthritis, backache – particularly long-term pain in the lower back, cold or flu, headaches, period pains, joint or bone injuries, sprains, and strains, muscle or joint complaints, toothache and so on.

NSAIDs like aspirin are consumed by people to help prevent artery disease that can lead to heart attack or stroke. It may also be used to reduce the risk of some types of colorectal cancer. Similarly, for many years, NSAIDs were given to patients to treat symptoms of the common cold. But these drugs do not kill the virus or improve the course of illness. A systematic review of the best available evidence for treating a common cold with NSAIDs shows that they produce significant results with regard to headache, ear pain, and muscle and joint pain.

NSAIDs – Precautions and Side Effects

The body’s response to NSAIDs differs from person to person and there may be side effects. There is a high chance of experiencing side effects if patients take a high dose of NSAIDS for longer periods of time. So here are some precautions to keep in mind:

If the patient is taking any other medicine, then they should let their pharmacist know about it.
Taking excessive amounts of NSAIDs and drinking alcohol can irritate the gut and increase the risk of internal bleeding.
There can be adverse effects if the patient is taking more than one NSAID.
Patients should not take NSAIDs at the same time as anti-clotting drugs such as aspirin or Warfarin.
Patients must follow the label for the particular NSAID they are using because each drug in this category is different.
NSAIDs should not be given to children who are below 16 and people who are 65 and above.
People who are allergic to NSAIDs, pregnant women, people who have asthma and anyone with heart disease should avoid consuming NSAIDs or take them only with medical guidance.

The side effects of NSAIDs can be severe or mild and differs from one person to another. As mentioned earlier, people who consume high doses of NSAIDs are more likely to experience side effects. Mild side effects can be indigestion, headache, dizziness, and drowsiness. Severe side effects could be problems with the kidneys, liver, circulation, fluid retention and so on. NSAIDs can increase the blood pressure; they reduce the blood flow to the kidneys, and slow down the functioning of the kidneys.

Another adverse effect of NSAIDs is that, long-term consumption of NSAIDs can lead to ulcers in the gut known as peptic ulcers. NSAIDs reduce the actions of prostaglandins, which reduce inflammation; however, prostaglandins also protect the stomach lining by helping it to produce mucus. In this way, NSAIDs leave the stomach open to the effects of acid.

So, people who take NSAIDS for a long period of time should consult their physicians to avoid any severe side effects. Accurate medical notes prepared with the assistance of a medical transcription companies prove valuable for both physicians and patients. Only with such reliable medical documentation, can physicians decide on the right treatment plan and provide the right medical advice to their patients.

How to Maintain Electronic Health Records Effectively

10-October-2019 Rajeev Rajagopal Medical Transcription Company

Accurate record-keeping is an integral element in providing safe and effective patient care. Far more than a computerized version of a paper chart, an electronic health record (EHR) contains information such as administrative and billing data, patient demographics, progress notes, vital signs, medical histories, diagnoses, medications, immunization dates, allergies, radiology images, and lab and test results. Good clinical record keeping is essential to promote effective communication between different healthcare professionals involved in the patient’s care and enable continuity of care. Poor clinical record keeping can increase medico-legal risks and lead to serious incidents. Well aware of these facts, medical transcription companies help healthcare professionals maintain timely and accurate patient records.

Providers are expected to provide legible, factual, complete, clear, consistent, precise, and reliable documentation of a patient’s health history, present illness, and course of treatment. The documentation of the clinical encounter includes observations, evidence of medical decision making in arriving at a diagnosis, treatment plan, and outcomes of all tests, procedures, and treatments.

EHRs have not lessened the significance of narrative notes which provides the basis for the healthcare provider’s decision-making process. EHR-facilitated documentation with dropdown fields and multi-pick boxes are not a substitute for physicians’ narrative reports. All communication with the patient, family members or other caregivers should be scrupulously documented. Narrative notes are crucial for important clinical events such as events, consent discussions, transfer of care, and changes in patient condition.

For each entry and action, the EHR should capture each healthcare provider’s identification automatically. This applies for actions such as data entry, modification, and deletion. Well integrated and seamless documentation of progress notes of all healthcare providers is necessary to avoid communication problems.

In paper records, edited, corrected, or deleted notes may be easily visible. However, this is not so with the EHR. The system should be able to track who made the change, the date on which change was made, and the reason for the change. Audits are necessary to track modification of electronic health information. The original information should be visible and easily retrievable by healthcare providers and other users.

Much has been said about the EHR’s copy-paste function, which allows a user to copy information from a prior note and paste it into a new note. Using copy-paste indiscriminately comes with risks such as inaccurate information, repeated information and documentation bloat, reproduction of potential errors in the documentation. This practice can cause serious errors, negatively impact care, affect the credibility of the patient record and the healthcare provider, and increase risks of malpractice.

Finally, EHRs must be stored securely and should be retained following the state’s policy.

An article in Paediatr Child Health lists the following best practices for appropriate use of EHRs:

Separate routine data entry from the patient encounter: An article in Paediatr Child Health says that separating routine data entry from the patient encounter will improve patient satisfaction. Reviewing the list of concerns, problems and previous notes before entering the examination room will provide more time for physician-patient communication. The EHR can be accessed during transition times.
Listen to the patient’s concerns before entering data: Physicians should allow patients to communicate their concerns before they begin entering information in the EHR. Patients should not be interrupted from expressing themselves.
Involve the patient in building the chart: Allowing the patient to actively participate in chart building will improve the patient-physician relationship and also promote patient confidence in the care they receive. Patients can also be shown the trend of their results.
Improve computer and typing skills: Researchers recommend that physicians improve screen-scanning speed, browsing speed and accuracy, and learn to use the decision support effectively.

The key to good clinical documentation is to know exactly what is relevant to document, and being able to concisely summarize and report main concerns. Healthcare organizations should develop clear policy and procedures, education and training to support good documentation practices and proper EHR use. Providers can outsource medical transcription to ensure accurate documentation of physician notes for integration into the EHR.

October Is Observed as National Physical Therapy Month

07-October-2019 MTS TEAM Physical Therapy Transcription

Physical therapy is proven to be an effective treatment in improving your overall function, movement as well as general wellbeing. The American Physical Therapy Association (APTA) considers physical therapy as “the safer way to manage pain.” By observing October as National Physical Therapy Month (NPTM), this Association encourages everyone to raise awareness of physical therapy as a safe, effective alternative route to medication such as opioids for treatment of even chronic pain conditions. The goal of NPTM is to raise awareness about the importance of physical therapy in helping people find relief from pain, improve mobility, and live healthier lives. EHR-integrated medical transcription services in U.S. are of great support for busy physical therapists in maintaining accurate patient records and clear transcripts.

The treatment covers a range of different interventions, including manual therapy, ice/heat therapy, ultrasound and traction therapy. During this National Physical Therapy Month, physical therapists and PT clinics are encouraged to engage their communities in many activities to promote healthy lifestyles among patients and to raise awareness of the importance of this non-invasive treatment. To spread awareness, APTA recommends physical therapists to consider sharing resources from “ChoosePT.com” which includes conditions guides, health tips and podcasts; getting their ChoosePT shirts and accessing handouts or updating the Find a PT profile, which would make it easier for consumers and other health care providers to locate you for the purposes of seeking care.

Though it was started as Physical Therapy Week in June 1981, it became National Physical Therapy Month and was moved to October in 1992 so as not to conflict with the American Physical Therapy Association’s annual conference and exposition held each June. Practices can also take part in the Day of Service October 12, 2019 that brings together thousands of volunteers such as PTs, PTAs, students, and physical therapy staff from over 50 countries that gives back to the community.

Documentation is the most time-consuming task for such specialties. Physical therapy practices are now widely using EMR software to meet their documentation tasks, billing requirements and to improve clinical reporting capabilities. According to the Physical Therapy Board of California, patient records must be maintained for at least seven years following the discharge, except the records of unemancipated minors must be maintained for at least one year after the minor reaches the age of 18.

Medical records that a physical therapist handles also include films and tracings from diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound and more. Comprehensive physical therapy transcription services provided by reliable medical transcription companies help practices get accurate transcripts of diverse reports such as consultation notes, procedure notes, letters, and discharge summaries.

Mental Health Awareness Week: October 6 – 12, 2019

03-October-2019 Julie Clements Medical Transcription Company

Millions of Americans live with a mental health condition, but many don’t recognize the symptoms and don’t seek treatment in the early stages. Mental Health Awareness Week is from October 6 – 12, 2019. This year, Mental Health America (MHA) is hosting a #7days7ways campaign to share facts about mental health conditions and ways to fight the stigma.

Companies providing mental health transcription services help psychologists, therapists, psychiatrists, and other mental health professionals capture and chart patient encounters and ensure accurate EHR documentation. Such support is crucial as mental illness is complex, subjective, and difficult to treat. Mental healthcare often involves more time than a regular office visit allows. Members of mental health care teams collaborate with each other to diagnose and treat patients.

The U.S. Congress established Mental Illness Awareness Week in 1990 to recognize the efforts made by the National Alliance on Mental Illness (NAMI) to educate and increase awareness about mental illness. This observance takes place every year during the first full week of October.

The theme of Mental Health Awareness Week in 2019 is7 Days, 7 Ways. During this week, MHA will focus on sharing information about 7 major mental health conditions:

Anxiety
Bipolar Disorder
Psychosis
Eating Disorders
Depression (on October 10 to coincide with World Mental Health Day and National Depression Screening Day)
Post Traumatic Stress Disorder (PSTD)
Addiction/Substance Use Disorder

According to MHA:

1 in 5 American adults will have a diagnosable mental health condition in any given year.
46% of Americans will meet the criteria for a diagnosable mental health condition sometime in their life, and half of those people will develop conditions by the age of 14.

People need to learn to recognize the warning signs. However, it is not always easy to distinguish between what expected behaviors are and possible signs of a mental illness. The National Alliance on Mental Health (NAMI) lists the typical signs of mental illness in adults and adolescents as:

Excessive worrying or fear
Feeling excessively sad or low
Confused thinking or problems concentrating and learning
Extreme mood changes, including uncontrollable “highs”
Prolonged or strong feelings of irritability or anger
Avoiding friends and social activities
Difficulties understanding or relating to other people
Changes in sleeping habits or feeling tired and low energy
Increased hunger or lack of appetite
Changes in sex drive
Delusions or hallucinations
Inability to perceive changes in one’s own feelings, behavior or personality
Abuse of substances like alcohol or drugs
Multiple physical ailments such as headaches, stomach aches, etc., without obvious causes
Thinking about suicide
Inability to carry out daily activities or handle daily problems and stress
An intense fear of weight gain or concern with appearance

It is now recognized that improving overall health is impossible without addressing behavioral health. A Modern Healthcare article provided the following statistics about behavioral health’s effect on chronic conditions:

Between 15％ to 30％ of people with diabetes also have depression, leading to worse outcomes, such as higher body-mass index and increased risk of conditions like coronary artery disease, cerebrovascular disease, and microvascular complications
Up to 33％ of those who suffer a heart attack later experience depression
15% to 25% of people with cancer have comorbid depression

MHA recommends taking a mental health screening as one of the quickest and easiest ways to identify symptoms of a mental health condition. MHA provides tests to screen for various mental health conditions at mhascreening.org. A person who completes screening is also provided with information, resources and tools to discuss the results with healthcare professional.

Anyone can get involved in Mental Illness Awareness Week. MHA suggests various ways to do this: learning about different types of mental illnesses, taking a screening test and encouraging others to do so too, and using social media to create messages and provide tips on how people can get involved with mental health advocacy, awareness and education.

As mental health professionals focus on diagnosing and treating mental health disorders, medical transcription service companies can provide EHR-integrated documentation solutions to improve behavioral health workflows, reporting and analytics.

Using EHR Alerts to Improve Care and Practice Efficiency

01-October-2019 Rajeev Rajagopal EHR Transcription

Medical practices strive to use EHRs to improve workflow and deliver optimal patient care. US based medical transcription companies help physicians integrate free text, dictated reports, and results of lab and imaging tests into EHRs to improve the usability of patient records. EHRs come with various features to support physicians in providing better healthcare. EHR alerts are intended to provide physicians with reminders and updates regarding potential patient issues. Practices can integrate different types of EHR alerts into clinical workflows to communicate critical patient information and improve care coordination.

using ehr alerts to improve care and practice efficiency

These flags can alert a healthcare provider and even a patient about health-related issues through the EHR. Digital alerts can be set up for prescriptions filled from pharmacy to healthcare provider, blood pressure levels, heart rate changes, blood sugar levels, etc. Digital alerts for regular screening tests such as prostate, Pap smears, breast exams and dental check-ups could benefit patients and physicians.

Effective use of EHR alerts can promote patient safety and streamline practice efficiency. EHR Intelligence describes how admission, discharge, and transfer (ADT) notifications or screening reminders can improve the following operations in the following areas:

Transitions of care: ADT notifications and alerts can promote provider communication during transitions of care. This will ensure that care teams have the information required for proper decision making during patient admission, transfer or discharge to other facilities. Such coordination can improve patient safety and save money.
Chronic care management: EHR-integrated alerts can help providers better manage patients with chronic illnesses. By reminding clinicians to screen for different conditions, these prompts can help providers diagnose and treat chronic illnesses.
Patient safety: By reducing incidence of on unnecessary testing, alerts can help minimize potential instances of patient harm, save time, and also reduce hospital spending.

However, EHR notification overload has become a major concern for healthcare providers. Too many alerts or low value alerts compromise patient care instead of improving it and contribute to physician burnout. The Agency for Healthcare Research and Quality (AHRQ) discussed research on the problem of alert fatigue. In one case, researchers found that physiologic monitors in an academic hospital’s 66 adult intensive care unit beds to 187 warnings per patient per day. Another study reported that CPOE systems generate warnings for 3%-6% of all orders that are entered, so that a physician could easily receive dozens of pop-ups each day.

The multiplicity of computerized alerts has led to ‘alert fatigue’ – clinicians have become desensitized to safety alerts, and as a result ignore or fail to respond appropriately to such warnings. Too many alerts occur when alerts are not properly well tailored in context or perception or because alerts are turned on with little specificity. The result is that physicians are ignoring both the annoying, clinically meaningless alarms as well as the important alerts that warn of looming serious patient harm (AHRQ).

Alerts are added to increase the efficiency of EHRs in imparting quality patient care and need to be used with caution for lowering the incidence rates of medical errors, increasing patient safety, and enhancing operational efficiency. Here are the strategies that AHRQ and Medical Economics recommend for using alerts appropriately and efficiently:

Increase alert specificity by cutting or eliminating clinically insignificant alerts.
Filter the warnings based on importance and sensitivity.
Use customized reminder alerts that are color-coded based on severity, such as red for alarm, etc.
Customize alerts to patient characteristics, for e.g., integrating renal function test results into the alert system will ensure that notifications for nephrotoxic medications are triggered only for high risk patients.
Ensure that only severe alerts are interruptive.
Determine the type of alerts that each staff member in the practice sees based on their specific roles.

Recent reports indicate how hospitals are leveraging alerts improve care. Oakland, Calif. -based Kaiser Permanente added a notification to its EHR to alert physicians when a patient has an abnormal test result for chronic kidney disease. Loyola Medicine is using EHR alert capabilities to improve sepsis care, reports Becker’s Hospital Review. The EHR-integrated alert system used by the University of Utah Health has reduced its sepsis mortality rate by 20 per cent, saving 40 lives annually. EHR vendors are also now focused on creating smarter alerts that improve office workflow and patient care.

Providers can outsource medical transcription to ensure that all critical patient information is entered accurately in a structured form to minimize the risk of errors and maximize patient safety. As new features and functionalities are introduced in the EHR, physicians should be properly trained to use the system in a meaningful way.

Top Techniques to Record and Transcribe Physicians’ Dictation

26-September-2019 Julie Clements Infographics

In medical documentation, accuracy is critical to ensure patient safety and documentation integrity. In the case of transcription, the quality of physician dictation is one of the factors that could compromise the quality of transcribed patient records. Even a professional medical transcription service may find it difficult to convert the records, if the recording is vague.

Check out the infographic below

Record and Transcribe Physicians’ Dictation

How Mobile Medical Apps are Transforming Health Care

23-September-2019 MTS TEAM Medical Transcription

Patient engagement can result in improved experiences, better healthcare outcomes, and reduced costs. EHR-integrated medical transcription services allow physicians to quickly produce medical documentation that can be accessed by patients, which improves patient engagement and satisfaction. Today, patient engagement technologies and apps are allowing patients and providers to collaborate more effectively. These online tools can improve not just satisfaction, but also access to care, care quality, and a practice’s productivity and bottom line.

how mobile medical apps are transforming health care

Studies show that engaging patients in their care is more likely to result in better healthcare outcomes. Having access to the right tools and technology is essential for successful patient engagement. The electronic health record (EHR) system along with a patient portal allows patients access to their information anytime, anywhere. It also provides patients with comfortable and easy access to their physicians and staff. They can use the portal to view test results, discharge summaries and other personal health information, request prescription refills and referrals, schedule and cancel appointments, and access educational materials.

For online portals to work effectively, patients have to log on to the provider’s website. According to Pew Research Center, 81% of Americans owned some type of cellphone as of February 2019. With the explosive use of smartphones, mobile apps offer a simpler, personalized and more user-friendly way of communicating with patients. Mobile devices offer multiple means of communication, including: voice and video calling; text, e-mail, and multimedia messaging; and video conferencing. Properly implemented mobile apps facilitate ongoing collaboration between providers and patients and can perform the following functions:

Improve care coordination: Mobile applications are aimed at supporting patient engagement in their care coordination. The US Agency for Healthcare Research and Quality defines care coordination as “deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care”. Patient-centered care coordination puts the focus on patient preferences, needs and values as well as on increasing patient engagement and participation in their care coordination. Mobile apps allow providers to communicate outside formal health care consultations. Patients can be provided with information in a format that meets their needs. Apps allow better collaboration with patients about the diagnosis, medication and medication instructions, and the follow-up process. With an app, patients can track their medications and set up reminders so they don’t miss a dose. Such capabilities have the potential to decrease read missions and improve patient recovery.
Monitor and improve health: Apps allow patients to measure and record their weight, blood sugar level, heartbeat, blood pressure and cholesterol. If levels increase or decrease, patients can take immediate action. Fitbit Coach and Nudge are popular apps that aim to improve a person’s health.
Allow seamless and secure sharing of healthcare information: Smartphones and tablets help move information securely, faster and more efficiently. Such seamless sharing of data is important for providers as well as among patients and providers. For example, Practice Fusion is a cloud-based electronic health record management app that allows physicians to connect with their patients and their data all in one platform. With a telehealth component, patients can share symptoms and description of side effects via video calls, text chats and multimedia messaging. This allows them to receive timely care while avoiding the hassles of travel for an in-person consult. Physicians can use their phones to view patient reports and make quick and correct decisions in emergency cases.
Reduce wait times: Long wait times, especially in emergency departments (ED), are frustrating for patients and may make some leave without receiving treatment or even being seen. This can have an adverse impact on patient outcomes. Apps can provide the solution. According to medcitynews.com article, a health system-branded mobile app can have a tremendous impact on patient experience and satisfaction. The functions of such an app can include:
Providing ED wait times and a list of alternative providers
Providing a reputable symptom checker
Collecting patient feedback on care
Supplying resources for patients with chronic conditions

Apps can also be used to fill out pre-admission forms, reducing lengthy waiting times.

Provide appointment reminders: In addition to allowing patients to immediately connect with their clinicians, mobile apps allow patients to schedule appointments and get appointment reminders. DoctorConnect is a medical app that allows medical and dental practices to engage with their patients in a more controlled and streamlined way. Its features include appointment reminders, patient retention management, and waiting list management.
Improve access to healthcare in rural areas: According to Forbes, as of 2018,85.5 million people in rural areas lacked access to proper healthcare and 4,022 rural doctors were needed to close this gap. Many mobile health apps are designed to address this problem. Those who live in rural communities can use these apps to book appointments and buy medicines online without having to travel to a hospital. For instance, Practo is an app that enables users can find medical services and solutions online. They can schedule medical appointments, order medicines, schedule diagnostic tests or even have an online consultation.

By helping people exercise more control over their medical decisions, receive faster care and answers, and save costs, medical apps have a bright future. Medical transcription outsourcing companies help healthcare providers maintain up-to-date and accurate medical records. However, as medical apps are prone to potential hacking and personal privacy issues, manufacturers need to ensure that data is encrypted before it is sent out.

Gap in Adoption of Electronic Health Records in Behavioral Health Care

19-September-2019 Rajeev Rajagopal EHR Transcription

Mental health records contain medical prescriptions, session start and stop times, frequency of treatment, clinical tests, summaries of diagnosis, symptoms, prognosis, etc. HIPAA-compliant mental health transcription services ensure accurate records of patients’ mental health history and status.

Gap in EHR adoption in Behavioral Health Care

Recent reports indicate that while electronic health record (EHR) adoption is widespread among clinicians across all specialties, digitization of patient records is slow among providers in the behavioral health space. This prevents behavioral health providers from sharing patient information with other providers and results in less than optimal care.

Slow Adoption of EHRs in Mental Healthcare – Reasons and Implications

A 2012 survey conducted for an AHIMA study published in Perspectives in Health Information Management found that only 21 percent of behavioral health organizations used EHRs (www. healthitanalytics.com). On looking into the hurdles to EHR adoption in the behavioral health community, the researchers found a link between clinician age and perception of usefulness. Older clinicians were less likely to see EHRs as useful to their practice than younger clinicians, according to the study. Those who saw EHRs as useful had a positive attitude towards EHR adoption.

The study results indicate that to encourage EHR adoption in behavioral health, providers must view the EHR as a tool that will increase the efficiency and effectiveness of their practice.

In January 2019, FierceHealthcare reported on a new Bipartisan Policy Center study which found that most mental health care providers don’t use electronic health records (EHRs). According to researchers, there are two reasons for this:

The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 did not make incentive payments available for mental health and SUD providers, as it did to encourage EHR adoption among other healthcare providers and entities.
The Confidentiality of Alcohol and Drug Abuse Patient Records statute of the 1970s requires substance use disorder (SUD) records to be kept separate from other parts of the patient file. In other words, SUD providers are prohibited from sharing patient information, the rationale being that unauthorized disclosure of SUD treatment could have a negative impact on a patient’s career and personal life. Also, SUD patients’ confidentiality needs to be protected so they wouldn’t fear seeking treatment.

However, lack of EHR adoption among behavioral health clinicians could prevent care coordination. The main concerns that researchers highlight are as follows:

Not using EHR systems in mental health care can pose a barrier to developing improved behavioral health treatments, as EHRs offer a platform that can be used to assess the impact of interventions
Primary care physicians would not know about a patient’s SUD and associated treatment unless the patient reveals that information during a visit.
Not exchanging health information across medical practices will lead to incomplete patient data and fragmented or duplicated care delivery

Improving EHR Adoption among Behavioral Health Providers

The EHR is here to stay and therefore, the goal should be to find ways to increase adoption rates and clinicians’ attitudes towards the technology, say experts.

To improve EHR adoption among behavioral health clinicians, researchers recommend that organizations partner with other healthcare stakeholders to demonstrate the benefits of EHR use to clinicians. They should help clinicians better manage, track, and provide enhanced services to people dealing with significant behavioral, emotional, and mental health needs. This can change their attitudes toward EHR adoption.

The AHIMA study authors wrote, “Behavioral health organizations and professional associations should work collaboratively to mitigate concerns about workflow burden and effects on the physician-patient relationship and to demonstrate the value of EHRs to improve professional practice, efficiency, safety, effectiveness, and patient outcomes.”

Efforts must also be made to ease concerns that behavioral health clinicians have about safeguarding sensitive patient information while sharing it with other providers. The American Psychiatry Association reiterates that sharing patient information is necessary to generate a complete health picture of the patient that can be accessed and utilized in multiple care settings. Clinicians can make more informed care decisions and improve patient health outcomes when they have access to the whole health picture of their patients.

The American Psychiatry Association also points out that vendors of EHR systems can adapt their EHRs to the needs of individual practices. They can build data segmentation into the platform so that the patient and provider can control what information can be shared with other entities. This process, which is underway, can decrease the stigma that prevents people from seeking treatment for psychiatric conditions.

As behavioral health clinicians increasingly embrace digital solutions, HIPAA compliant medical transcription companies can provide accurate and timely psychiatry transcription services to meet their documentation needs.

EHR-related Malpractice Suits Growing, finds Study

16-September-2019 Julie Clements Medical Transcription Company

Electronic health records (EHRs) have fast become a staple in the healthcare sector and medical transcription companies play a key role in helping providers leverage EHR systems. However, EHRs have been found to contribute to malpractice suits. A new analysis by leading malpractice insurer The Doctors Company found that the number of malpractice claims in which EHRs have contributed to patient injuries has been rising during 2010-2018 (www.medscapecom). The trend is attributed to the increase in EHR adoption over these 8 years. As of 2017, nearly 9 in 10 (86%) of office-based physicians had adopted any EHR, and nearly 4 in 5 (80%) had adopted a certified EHR, according to the Health IT Dashboard.

ehr related malpractice suit growing finds study

In January 2018, we had reported on a Doctor’s Company study which found that the number of claims in which EHRs were a factor rose to 161 in July 2014 through December 2016 from just 2 (claims) during 2007-2010.

Key Findings

Researchers with The Doctors Company analyzed closed claims during 2010 to 2018 in their nationwide claims database. The report shows that:

A total of 216 EHR-related malpractice claims were closed during the 8-year period
The number of such claims rose from 7 in 2010 to an average of 22.5 in 2017 and 2018
In 2018, these claims formed just .39% of the claims universe – up from 1.02% in 2017 and 0.35% in 2010
Rather than being the primary cause of claims, EHRs are typically contributing factors
System technology and design problems and user-related issues were the causes of the EHR components of claims closed from 2010 to 2018.
Family physicians and internists face higher risk of malpractice suits than other specialists when EHRs a cause of patient injuries
Serious injuries cited in EHR-related malpractice claims include death (25%), adverse reaction to medication (23%), need for surgery (15%), emotional trauma (14%), undiagnosed malignancy (13%), and organ damage (11%).
31% of the EHR-related malpractice claims involved diagnosis-related allegations

EHR System Failure and User Issues Top Causes of Malpractice Suits

The researchers reported that system failure and user errors are the top reasons for malpractice claims. The technology-related factors identified include:

EHR failures (12%)
Lack of or failure of an EHR alert or alarm (7%)
A fragmented record (6%)
Failure or lack of electronic routing of data (5%)
Insufficient scope/area for documentation in the EHR (4%), and
Lack of integration/incompatible systems (2%)

The report identified the key user-related issues that led to malpractice claims as:

Entry of incorrect information (13%)
Prepopulating/copy and paste (13%)
Hybrid health records/EHR conversion issues (13%)
Other user errors (12%)
Insufficient training and/or education (7%)
Alert issues/fatigue (2%), and
Computer order entry workarounds (2%)

The study cited examples of how system failure and user issues led to malpractice suits. In one case, an elderly female patient was given the wrong medication – Flomax, a medication for enlarged prostates in men – instead of Flonase nasal spray which the physician meant to order. The EHR misinterpreted his abbreviation of “FLO” in the medication order screen as Flomax. However, according to an attorney, this is actually a case of human error which occurred because neither the doctor nor the pharmacist caught the mistake (www.medscape.com).

Another serious problem that the study identified is copy-and-paste. Looking into the death of a 38-year old obese patient from pulmonary embolism, experts found that the physician had not documented changes in his condition during visits. A previous note had been copied into the current one. The final visit progress note was the same as the earlier note made 3 months ago, including previous vital signs and spelling mistakes.

Clicking numerous drop-down menus during the course of a busy day can lead physicians to make some mistakes. When repeated across the organization’s system, pharmacies, and other providers’ EHRs, such errors can have grave consequences. Even if the physician corrects these errors, they many remain in other systems.

EHR-related Claim Risk Highest in Primary Care

The Doctors Company study found that family medicine and internal medicine had the highest percentage of EHR-related claims (8%), followed by: cardiology and radiology (6%); obstetrics, orthopedics, and nursing (5%); hospital medicine and gynecology (4%), and emergency medicine, anesthesiology, plastic surgery, urology surgery, and general surgery (3%).

The reason why risk of malpractice suits is higher for primary care physicians (PCPs) is because they tend to use the EHR more than other providers. PCPs see a comparatively larger number of patients and for a wider range of complaints. As a result, they are more likely to make errors related to cut-and-paste, drop-down lists, and prepopulation of EHR data.

Managing EHR-related Malpractice Risks

Electronic medical records are a desirable change, but come with many concerns, including professional risks. Patients complain about their physician focusing too much on the computer during the office visit instead of on them. While almost 90% of physicians are using these digital records, they complain about too much manual data entry, alert failure, and lack of standardization across systems.

Data that resides within the EHR can be used against the physician. As we have seen, ineffective EHR use and incomplete information can be used in a malpractice case to weaken the entire electronic patient record as well as the quality of patient care provided (www.medscape.com). Physicians should understand the system and be trained on how to use it. Medical transcription services from an experienced outsourcing company can ensure accurate and timely support for EHR documentation.

Stem Cell Medicine for Good Health and Better Treatment of Diseases

09-September-2019 MTS TEAM Medical Transcription Company

Medical research is indispensable when it comes to finding effective treatment for various health conditions. To study a patient and his/her medical condition, response to treatment and so on, accurate documentation is very important. Medical records created with the support of medical transcription companies provide a clear understanding of the patient’s health condition and care offered, and at the same time act as valuable research material for researchers working in the field.

Medicines are prescribed by doctors in the right proportion to patients to cure diseases. Advances in medical research and new medications and treatments have enabled doctors to cure many diseases and save lives. Medicines come from various sources like substances made from nature, extraction from plants etc. Some medicines are made in labs by mixing together a number of chemicals. Others, like penicillin, are byproducts of organisms such as fungus. All these are used to treat diseases. The latest development in this area is stem cell research.

Stem cells play a crucial role in treating disease because of their flexibility under the right conditions that enables them to be coaxed to develop into many other types of body cells. Researchers are learning new techniques to use stem cells’ natural potential to create any type of cell that is in demand. For instance, oligodendrocyte progenitor cells that could protect nerve cells that have been damaged by an injury to the spinal cord; or retinal pigment epithelium cells that could help restore vision to patients blinded by dry macular degeneration.

Deepak Srivastava, president of the Gladstone Institutes, a non-profit research center affiliated with UC San Francisco is a doctor who has first-hand experience with the potency of stem cells. This doctor has studied early heart development and how cells can be reprogrammed to repair damaged heart tissue.

Diseases could be considered as organs that have lost cells they need to function, and they have little to no capacity to regenerate themselves. Doctors usually find therapies and medicines to get around the disease’s effects. But with stem cells people no longer accept the idea that people have diseases from lost cells. The objective here is to regenerate cells, restore them and fix the crux of the problem.

The latimes.com spoke to Dr. Srivastava on the topic of stem cells. This doctor believes in the regenerative power of stem cells; in other words, stem cells can help regenerate damaged tissues in cells and cure the disease caused by cell degeneration.

Stem cell research is not just for regeneration and replacement, but also for discovering appropriate drugs for a host of diseases. When the stem cells are programmed into any cell type in the body, researchers have been doing that in two dimensions or a monolayer. But in reality, organs exist in three dimensions. They have their own architecture and to understand the disease, you will need to examine the entire structure and not just a cell. For the researchers, the breakthrough has been in their ability to involve multiple types of cells that have to work together to form an organ. They developed organoids that are not full organs but replicate a large part of the complexity of an organ. They try to make organoids that contain mutations that cause disease, and thereby get a better idea of how medicines will play a role. This has worked with brain tissue, eye tissue, kidney tissue and others.

Many clinical trials are under way right now – trials for spinal cord injuries, Parkinson’s disease, and even blindness and the researchers are looking at situations where the cells in those areas have died. So all a patient may need is a simple treatment that turns stem cells into the missing cells and transplant them back in.

The researchers and Dr. Deepak Srivastava are trying to bring focus on policy area, where the ISSCR (International Society for Stem Cell Research) can make a big difference. Their next agenda is to advocate for policies worldwide that would accelerate the safe and effective use of stem cell medicine.

Healthcare professionals, scientists and researchers are conducting various studies to ensure quality medical care and the latest advancements in medical technology to people. Transcription service providers also play a significant role, providing accurate and reliable medical transcription service.