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.
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.
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.
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.
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.
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.
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.
The adoption of electronic health records in behavioral health care has transformed how patient information is documented, stored, and shared across medical settings. While general healthcare providers were rapidly embracing digital systems, many behavioral health and substance use disorder (SUD) treatment programs were slower to transition from paper-based documentation to electronic platforms. This created a gap in adoption of EHR in behavioral health care. Mental health records are often more detailed and nuanced, containing medical prescriptions, therapy session start and stop times, frequency of treatment, clinical assessments, diagnostic summaries, reported symptoms, and prognosis updates. This, along with privacy concerns and workflow disruptions, contribute to lower mental health EHR adoption compared to other specialties.
At the same time, accurate and compliant documentation remains critical in behavioral health settings. Mental health transcription services play an essential role in ensuring precise recording of patients’ mental health history and current status, reducing administrative burden while maintaining confidentiality. Use of transcription services helps in bridging the gap between traditional recordkeeping methods and fully integrated digital systems in behavioral health care.
Key Challenges that Contributed to Slow Adoption of Electronic Health Records in Behavioral Health Care
Lack of Incentives:
Unlike hospitals and primary care providers, behavioral health clinicians were largely ineligible for federal incentive payments under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. This limited financial support slowed investments in infrastructure and delayed the implementation of specialized behavioral health EHR systems.
Privacy and Confidentiality Concerns:
Behavioral health records include highly sensitive information related to psychiatric evaluations, therapy notes, and substance use treatment plans. Federal rules, such as those governing SUD records, impose stricter confidentiality protections on behavioral health records compared to standard medical records—making many providers wary of digitizing data that could be subject to broader access.
Complex Documentation Needs:
Unlike structured data in other health specialties, behavioral health documentation relies on narrative or free-text notes to capture nuanced clinical details. Traditional EHR systems were not always designed to accommodate this unstructured content easily, leading to inefficiencies and frustrations among clinicians.
Interoperability Challenges:
Early behavioral health EHR systems often operated as isolated or standalone platforms. This prevented smooth data exchange with broader healthcare systems, limiting care coordination and contributing to fragmented patient records.
These hurdles made EHR adoption slower than in other sectors, and they also hindered the full potential of technology to improve care quality, safety, and coordination.
Catch-up Phase of EHR in Behavioral Health Care
According to NovaOneAdvisor, the U.S. behavioral health EHR market was valued at USD 316.5 million in 2024 and is expected to reach approximately USD 849.73 million by 2034, expanding at a CAGR of 10.38% between 2025 and 2034. Web- and cloud-based solutions dominated the market in 2024, accounting for more than 84% of total revenue. By end user, private providers led in revenue share during 2024 and are projected to register the fastest growth over the forecast period.
Overall, the U.S. Behavioral Health Electronic Health Records (EHR) market is emerging as a dynamic and fast-growing segment within health IT. The market’s growth signals more than technology adoption; it reflects a broader digital transformation in behavioral healthcare. Growth is being driven by increased national attention to mental health and substance use care, along with the push toward integrated, value-based service delivery. These specialized EHR systems are designed specifically for mental health professionals, enabling streamlined documentation, coordinated care, regulatory compliance, and efficient billing within a complex healthcare framework.
Improving EHR adoption among Behavioral Health Providers
Over the past several years, there has been a marked shift. Behavioral healthcare providers are increasingly recognizing the value of digital records for enhancing patient care and practice efficiency. Advancements in EHR design, interoperability standards, and targeted training are helping to break down many of the historical barriers. Moreover:
More affordable, cloud-based EHR solutions are now available, making implementation feasible for smaller clinics and solo practitioners.
Improved interoperability frameworks and APIs are enabling behavioral health systems to share data more securely and reliably with other healthcare platforms.
Greater emphasis on care coordination and integrated behavioral-physical health models have created new incentives for providers to adopt comprehensive digital records.
Today’s EHR technologies also address the narrative nature of behavioral documentation, allowing clinicians to capture free-text notes, structured data, and standardized assessments seamlessly within the same system.
Role of Medical Transcription Services in Behavioral Health EHR Documentation
As the use of EHRs in Behavioral Health Care continues to rise, one of the most effective enablers of smooth adoption is AI-integrated medical transcription services. Behavioral health documentation is narrative-heavy, clinically detailed, and often emotionally nuanced. Therapy notes, psychiatric evaluations, medication updates, risk assessments, and treatment plans require precision and contextual understanding, making documentation both time-intensive and critical.
AI-powered transcription solutions, combined with skilled medical transcriptionists, help bridge the gap between detailed clinical narratives and structured EHR documentation.
Here are the key reasons why medical transcription services matter in behavioral health.
Preserves Meaningful Patient Interaction
Behavioral health sessions depend on active listening and emotional presence. Instead of typing into EHR templates during appointments, clinicians can dictate their notes naturally. This allows them to maintain eye contact, build rapport, and focus entirely on patient care.
Supports Accurate and Structured EHR Documentation
AI-driven transcription software converts voice dictation into text in real time. It organizes notes into appropriate sections within the EHR system, making documentation structured, searchable, and compliant with clinical standards.
Ensures Human Review and Error Correction
While AI transcription software improves speed and efficiency, skilled medical transcriptionists carefully review the transcribed medical documentation. They correct minor errors, clarify ambiguous phrasing, verify clinical terminology, and ensure contextual accuracy. This human oversight is essential in behavioral health, where subtle wording can significantly impact interpretation.
Enhances Compliance and Confidentiality
Behavioral health records are subject to strict privacy regulations. Professional transcription services understand HIPAA requirements and other confidentiality standards, ensuring that documentation aligns with regulatory expectations while protecting sensitive patient information.
Reduces Administrative Burden and Clinician Burnout
Documentation demands often extend beyond clinic hours, contributing to provider fatigue. Outsourcing EHR documentation through AI-integrated transcription services minimizes after-hours charting, allowing clinicians to focus more on patient care and less on data entry.
Improves Workflow Efficiency and EHR Adoption
One of the historical barriers to EHR adoption in behavioral health was workflow disruption. By integrating transcription software directly with EHR platforms, documentation becomes faster and less intrusive. This makes EHR systems more practical and appealing to providers who previously resisted digital transitions.
The Hybrid Advantage: AI + Human Expertise
AI alone cannot fully capture the nuance of behavioral health documentation. However, when advanced transcription software works alongside experienced transcriptionists, the result is a powerful hybrid model. AI accelerates the transcription process, while human professionals ensure quality, context sensitivity, and compliance.
This combination transforms EHR documentation from a perceived burden into a streamlined process. As behavioral health providers continue embracing digital transformation, AI-integrated medical transcription services play a critical role in improving EHR adoption, enhancing documentation accuracy, and supporting better patient outcomes.
Make behavioral healthcare EHR workflow faster, smarter, and stress-free.
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.
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.
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.
Retained surgical items are a major concern for infection prevention and surgical services departments. In hospital settings, incidents of unintended retention of foreign objects occur in operating rooms, labor and delivery areas, ambulatory surgery centers, and other areas where invasive procedures are performed. Good evidence-based processes for preventing retained objects are as crucial as the quality operation notes that medical transcription companies provide.
Magnitude of the Problem
Retained surgical items were ranked eighth on the ECRI Institute’s 2016 Top 10 Patient Safety Concerns list. The Joint Commission received 772 voluntary reports of retained surgical items from 2005-12, while other research found that 4,500 to 6,000 surgical item cases occur annually in the U.S. (Becker’s Hospital Review). According to the Association of periOperative Registered Nurses (AORN), the most common inadvertently retained items are:
Soft goods, such as sponges and towels
Small miscellaneous items, including unretrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters, and pieces of drains
Needles and other sharp implements
Instruments, most commonly malleable retractors
Risks to the patient depend on what the item is, where it is in the patient and how long it has been there. Complications result when the retained item leads to infection or causes damage to surrounding tissue. Surgical cotton gauze sponges are the most harmful retained surgical item because additional surgery is usually required for removal (Becker’s Hospital Review).
In addition to posing a serious health threat for patients, unintentionally retained surgical items can cause financial and reputational damage for organizations. In February 2019, The Sacramento Bee reported that the California Department of Public Health announced that regulators were fining Redding’s Mercy Medical Center after a patient died due to chest inflammation caused by a medical sponge left behind during surgery.
Root Causes of Unintended Surgical Items
The main reasons for unintended surgical items are:
lack of policies and procedures
unreliable practices such as inconsistency when counting sponges
noncompliance with existing policies and procedures
failures in communication with surgeons
nurses not communicating relevant patient information
problems with hierarchy and intimidation
inadequate or incomplete education of staff
According to a 2017 study about 88 percent of retained surgical item cases happened during a procedure in which sponge and instrument counts were declared “correct,” which suggests human error.
Risks for unintended retained items include: patients with high body mass index, an emergency procedure, and unexpected intraoperative development. Other risk factors include more than one surgical procedure, multiple surgical teams, and multiple staff turnovers during the procedure.
Prevention Measures
Experts recommend several measures to prevent retained surgical items. The recommendations of the AORN Guideline for Prevention of Retained Surgical Items are as follows:
A consistent multidisciplinary approach that includes standardized, transparent, verifiable and reliable prevention measures
Accounting for instruments, surgical soft goods, sharps and other miscellaneous items opened onto the sterile field during all procedures in which these items are used
Taking measures to prevent device fragments
Taking standardized measures for reconciling count discrepancies during the closing count and before the end of surgery. If there is a discrepancy in a count, the surgical team should take actions to find the missing item
Evaluation of adjunct technologies for use as a supplement to manual counting procedures
Readily available documentation to reflect activities related to prevention of RSIs
Development of policies and procedures for the prevention of RSIs, with periodical review and revision as necessary
Participation of perioperative personnel in quality assurance and performance improvement activities
The Joint Commission recommends that a counting procedure should be performed audibly and visibly by two persons engaged in the process. The surgical team should verbally acknowledge verification of the count. The count should be performed before the procedure begins, in order to establish a baseline count; before the closure of a cavity within a cavity; before wound closure begins; at skin closure or end of procedure; and at the time of permanent relief of either the scrub person or the circulating registered nurse.
A July 2019 article in Outpatient Surgery (XX, No. 7) titled “Technology to Prevent Retained Items” provides several examples of sponge-detection technology that can protect against retained items. These include:
Matrix label or barcoding – using each sponge’s unique identifying number, this program tracks sponges counted in and out.
Radio frequency detection device – all the sponges for a case come with a small tag that can align with a radio frequency device. The detection wand can detect the tagged sponges if they are left in a patient or put in the trash.
Combined approach – In this system, each sponge features its own unique RFID transmitter that can be detected by a wand device and scanned into and out of a program on a touch-screen table. It can identify the exact location, type and number of sponges in the surgical site.
As counting is prone to error, standardized counting practices are obviously the best way to make certain that all surgical items are accounted for and recorded. New technology can go a long way in preventing counting errors and ensuring that nothing is left behind.
A crucial aspect of documentation for surgical procedures, quality operation notes are essential for patient safety, post-operative care, remuneration and defense in litigation. Partnering with an experienced medical transcription services company can help providers ensure proficient, legible operation notes.
Electronic health records have the potential to make health care more precise and preventive, and support retrieval of patient information to support clinical decision making. Medical transcription services ease the data entry burden on providers, allowing them to spend more time with their patients rather than in front of the computer. Such documentation support is especially useful for surgeons who need to take time to discuss treatment choices with patients, and after the decision is made, specifics of the procedure, as well as its risk, expected recovery, and care. Advance care planning (ACP) is an important communication topic between patients, their family, and their health care providers.
Advance care planning (ACP) helps patients prepare for current and future decisions about their medical treatment and place of care. The patient’s preferences about end-of-life care are expressed in an advance care directive – a legal document that comes into force if the patient is incapacitated or unable to speak for him/herself.
ACP involves making decisions about emergency treatments in the event of a life threatening illness, injury, or surgical complications. It is also recognized as a valuable tool for everyone, regardless of age or current health status. Decisions that come up during emergency treatment usually relate to cardiopulmonary resuscitation (CPR), ventilator use, dialysis, tube feeding, medically administered hydration, and comfort care.
However, even as ACP is widely accepted as a way to maintain patient self- determination, facilitate medical decision making, and promote better care at the end of life, a new study found that many patients do not have advance care directives in their medical records.
The study, published in the Journal of Internal Medicine, examined at EMRs of 400 patients who underwent preoperative evaluation. The researchers reported that about 71% of patients seen in preoperative testing clinics before surgery do not have an advance directive (AD) in place. In the event of surgical complications, this can result in patients’ families having to take difficult decisions about the kind of care their loved one receives. Importantly, ADs better align the care people receive in a crisis with their wishes and desires.
Healio summarized the findings of the researchers at the Regenstrief Institute, Indiana University Health and Indiana University School of Medicine as follows:
only 30% of patients in their study had some form of AD documentation that spelled out the kind of emergency medical care they wanted
only 16% had had ADs that were scanned into the EMR where a clinician could access it
Of those with AD scanned into the EMR, only 11.8% had a surrogate decision maker and 11.5% had a living will
People age 65 and older and patients with congestive heart failure were significantly more likely to have an AD scanned in their EMR
One of the researchers said that the study findings suggest that there is significant scope for improvement in advanced care planning in the clinical setting.
“When an AD is not available in cases of emergency, it creates a complex situation for the care providers and surrogate decision makers. Emotions are often high, and family members may have difficulty navigating those emotions to make the best decision for their loved ones,” she said.
The American Medical Association (AMA) recommends that physicians routinely engage their patients in ACP and provides the following directives on the matter:
Encourage all patients to consider their values and perspectives on quality of life and document their goals for care if they faced a life-threatening illness or injury, including preferences for specific medical interventions.
Patients need to identify a person who could make decisions on their behalf if their illness rendered them unable to do so, and make their views known to the designated person, and their family members and close friends.
Physicians should be prepared to answer patients’ questions about ACP and refer them to additional resources for reference, if required.
Patients should be educated about how ADs can help guide treatment decisions in collaboration with patients themselves when they have decision-making capacity, or with surrogates when they do not. The patient’s surrogate should be included in the discussion whenever possible.
Notes from ACP discussions, including the patient values and preferences for treatment in an emergency, should be incorporated into the EMR. The patient should be advised to give a copy of the advance directive document or written designation of proxy to the surrogate and others so that it will be available when needed.
As the patient’s goals, preferences, and choice of decision maker can change over time, physicians should periodically review these matters with the patient (and surrogate, whenever possible). The EMR should be updated with the changes.
Effective interactions between surgeons and patients require time. Medical transcription outsourcing can help providers focus on addressing patients’ concerns and expectations, clarify any misunderstandings they may have about specific medical conditions or interventions, and help them plan for care at the end of life.
