Six Key Tips for a Successful Doctor Appointment

18-July-2019 Julie Clements Medical Transcription

This is a continuation to the blog “Is There a Right Time to Visit Your Doctor?”

So, you have chosen a doctor and made an appointment. May be you have waited weeks or months for this appointment and so it’s crucial to make the most of this consultation time. Often, patients will get only a modest amount of time with the doctor. Medical transcription services that are EHR-integrated are of great assistance for busy doctors to save their time for quality patient care. Whether you are starting with a new doctor or even continuing with the doctor you’ve been seeing for years, prepare a basic plan to make the most of your appointment. The following tips will make it easier for you and your doctor to cover everything you need to talk about.
Six Key Tips for a Successful Doctor Appointment

Consider these tips for a more successful and stress-free doctor visit.

Prioritize your concerns and make a list
You may not remember everything you have to ask. So try to make a list of all your concerns. Preparing and prioritizing key questions that you should ask can help you feel more confident when talking with your doctor. Also, you will get the answers and info for all your concerns.You can even hand the notes to your nurse or doctor, providing them time to prepare the answers. A recent WebMDarticle discussed studies that proved that patients who filled out a detailed checklist before an office visit asked more questions during their doctor visit and got more satisfaction from the visit.

Record instructions or note them if you can’t remember
If you think you can’t remember everything that a doctor says during consultation, record them via smartphone with the doctor’s permission. This audio can be replayed for better understanding of the instructions and information provided. If recording is not allowed, take notes of the key points the doctor says during the visit.

Get all your medications and records
If you are a new patient, share your medical history and discuss your illnesses, operations, and medical conditions. Make a list of all the medications you take, as it will be difficult to remember the exact names and dosages of your medications when your doctor asks. Along with prescribed medications, make sure to include all supplements you take such as over-the-counter sleep aids, and other pain medications. Remember to bring results of medical tests – blood tests, X-rays or scans recommended by the doctor.

Note your symptoms
While meeting your regular doctor, if there’s a new symptom that you need to bring to your doctor’s attention, make sure to take a symptom diary with you which should include all the details like – what does the symptom feel like, when does it occur, how long does it last and more. Such a symptom journal can help you and your doctor to spot patterns and identify triggers for your symptoms, leading to more effective medical treatment.

Provide time for doctor’s EHR documentation
While large practices rely on medical transcription outsourcing companies to get their documentation tasks done, in small practices doctors have to feed the consultation details into the electronic medical records themselves. So provide time for doctors to complete their documentation as well.

Bring a family member or close friend with you
It is best to let your family member or friend accompany you to the doctor. Make sure they know the purpose of the visit so that they can remind you what you planned to discuss with the doctor, in case you forget any key points. They may also help take notes for you and can later remind you of what the doctor said. They can also help you make important decisions.

Check your insurance coverage also before you meet the doctor. Make sure to double check your insurance coverage. Also, confirm that your doctor accepts your health insurance before your appointment. Doctors can also add value to their time with patients by following certain tips such as using better verbal communication techniques than non-verbal and using open-ended questions.

Is There a Right Time to Visit Your Doctor?

15-July-2019 MTS TEAM Medical Transcription

Yes, there is. Workload is more for healthcare providers, mainly in primary care. These primary care doctors often spend 11 to 18 hours a day providing preventive and chronic care. AMA Insurance has reported that most physicians work between 40 and 60 hours per week and nearly one-quarter of physicians work between 61 and 80 hours per week. For every hour physicians spend with patients, they have to spend one to two hours updating the electronic health record. EHR documentation is another time-consuming task that physicians should focus on along with providing quality patient care. Outsourcing medical transcription can reduce the documentation workload to a great extent for physicians. A large proportion of medical errors are caused by physicians’ excessive workloads.

Is There a Right Time to Visit Your Doctor?

Physicians Suffer Decision fatigue, Finds JAMA Study

One important consequence of excessive workload is decision fatigue, which refers to the decline in decision quality due to an increased number of patients and treatment decisions. With excessive workloads, physicians will be forced to make more medical decisions.

According to a recent JAMA study, doctors ordered fewer breast and colon cancer screenings for patients later in the day, compared to first thing in the morning. This study was approved by the University of Pennsylvania researchers. It has been highlighted that

patients seen earlier in the day were more likely to have their doctors order cancer screening tests
ordering rates were highest for patients with appointments around 8 a.m.
but, by the end of the afternoon, the rates were 10 percent to 15 percent lower

Clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Decision fatigue is reported to be the key reason for this decreased rate of ordering tests. The researchers also acknowledged that the decline could also stem from doctors running behind on their appointments. As each shift progresses, clinicians may fall behind schedule, leading to shorter interactions with the patient at the end of the morning and afternoon shifts.

The first of its kind, this study also demonstrates that primary care clinic appointment time is associated with both ordering and completion of screening for breast and colorectal cancer.

The University of Pennsylvania researchers in their study has discussed an example that if at 8 a.m., 64% of women eligible for breast cancer screening left their appointments with an order for a mammogram, this declined to 48% by 5 p.m. A 2014 report highlights that as the day moves on doctors are increasingly more likely to prescribe antibiotics even when they are not indicated. The number of prescriptions also increased with time.

Physicians devote more time on EHR tasks

Several reports highlight the fact that electronic health records (EHRs) is a leading driver of physician burnout as doctors spend more than half of their workdays on the keyboard. A 2016 report published in Annals of Internal Medicine provides details about how physician time is allocated in ambulatory care. This study based on observation of 57 U.S. physicians in family medicine, internal medicine, cardiology and orthopedics for 430 hours points out that during the office day physicians spent

0% of their total time on direct clinical face time with patients
2% of their time on EHR and desk work

While in the examination room with patients, physicians spent

9% of the time on direct clinical face time and
0% on EHR and desk work

The study concluded that for every hour physicians provide direct clinical face time to patients, nearly 2 additional hours are spent on EHR and desk work in the office. Even outside office hours, they spend another 1 to 2 hours of personal time doing additional computer and other clerical work.

It is critical for physicians to find some innovative ways to stop spending too much time on EHR. Consider choosing a professional medical transcription services company that can provide EHR-integrated services.

In our next blog, we’ll discuss useful tips for a successful doctor appointment.

Common Emergency Room Errors and Ways to Avoid Them

08-July-2019 Julie Clements Emergency Room Transcription

Each day, thousands of patients seek care in emergency departments (EDs) across the country. Many hospitals outsource medical transcription to ensure accurate, fast and reliable documentation so that ER physicians can focus on care. Law requires hospitals to guarantee a certain level of care for patients who come to the Emergency Room. Physicians can be held liable for any harm that comes to a patient if the ER treatment that was provided fell short of the appropriate standards of care. In a malpractice lawsuit, physicians need to prove that proper care was provided. Also, with the rise in consumerism in healthcare and payers now linking reimbursement to quality, hospitals need to provide a first-rate experience to maximize revenue. In addition to recognizing patient rights, Emergency Rooms need to assess their capabilities to follow standards of care and avoid common mistakes.

Common Emergency Room Errors and Ways to Avoid Them

Emergency Room Errors – Types and Causes

A study by the physician-owned medical malpractice insurer Doctors Company that covered 332 Emergency Room visit related claims between 2007 and 2013 revealed that the four most common errors as:

Failure to diagnose – 57 percent of cases
Failure to properly manage a patient’s care – 13 percent
Failure to properly execute a patient’s care – 5 percent
Failure to order medication for a patient

The researchers identified the reasons for these errors as:

Not conducting a thorough review of the patient’s medical chart, leading to failing to order a test to diagnose a patient or discharging the patient prematurely
Communication problems among physicians and also between physician and patient
Poor documentation
Inadequate staffing

More recent studies have also pointed to human error as the cause of ER mistakes. A study published in BMC Emergency Medicine in 2017 also found that most emergency department mistakes that compromised patient safety result from human error. According to a study published in De Gruyter’s Journal Diagnosis in 2018, about 45 percent of medical errors in the emergency room are due to problems with information processing. The researchers noted that it is a cognitive limitation and not related to technology.

Measures to Avoid Preventable ED Errors

Between 210,000 and over 400,000 premature deaths per year (575-1,095 deaths per day) are associated with harm that is preventable in hospitals, according to a study published in Journal of Patient Safety in 2013.

Avoid cognitive biases: There are five significant cognitive biases that can cause preventable errors: availability bias, anchoring bias, framing bias, confirmation bias, and premature closure. Emergency Room physicians can avoid these errors by:

Not basing a diagnosis on previous patient experiences with similar symptoms
Avoid making decisions based on the first piece of information received
Avoid accepting someone else’s diagnostic or personal biases
Check past medical history and risk factors for serious disease or poor outcome
Check vital signs and nurses’ emergency notes
Avoid premature closure if the diagnosis is not certain – keep the patient informed about the uncertainty, arrange for appropriate follow-up, and provide specific written precautions

Recognize patient rights: Physicians need to adhere to the Emergency Medical Treatment and Labor Act (EMTALA) by guaranteeing the stipulated level of care for Emergency Room patients. According to WebMD, this includes:

Offering patients a timely and appropriate medical screening exam
Stabilizing patients with emergency medical conditions
Maintaining proper and centralized records on ER patients and their care
Having a list of on-call physicians who provide emergency treatment
Accepting patients from other hospitals if the receiving ED has the facilities to provide the care they need
Reporting improperly transferred patients within 72 hours

Ensure emergency preparedness: Timing is crucial in a medical emergency. A survey by health site HealthGrove found that in many states, patients face a painfully long wait before they are seen by a physician or properly diagnosed (www. com). Long emergency wait times can exacerbate the problem. ERs and their physicians need to be prepared to handle themselves in a crisis, from man made calamities to natural disasters. They should:

Have the staff and resources necessary to assess all patients presenting to the ED. They should do a monthly stock check to make sure all drugs and supplies are available and up to date.
Have a emergency preparedness plan, clearly indicate who is responsible for implementing it, and ensure the staff is educated about the policies
Conduct mock drills and make sure that each staff member is flexible enough to step into a different role
Have proper communication strategies in place to contact staff as well as local, state, and federal emergency response personnel
Keep patients informed about their emergency care options

Improve the discharge process: Hasty or poor ED discharge can have significant clinical implications for patients, including unfinished treatments and progression of illness. EDs need to follow rules and ensure that meet patients discharge criteria when they are allowed to return home. According to the Agency for Healthcare Research and Quality (AHRQ), the characteristics of a high-quality discharge are:

Informs and educates patients on their diagnosis, prognosis, treatment plan, and expected course of illness, including treatments, tests, procedures
Supports patients in getting post-ED discharge care, including medications, home care of injuries, use of medical devices/equipment, and further diagnostic testing and health care evaluation
Coordinates ED care within the context of other health care providers, social services, etc.

Outsource Medical Transcription for High-quality Medical Record Keeping

Maintaining high quality patient medical records in the ED can promote improved patient care, according to the American College of Emergency Physicians (ACEP). An experienced medical transcription services company can help ER physicians maintain proper and legible documentation of the relevant aspects of the patient encounter including laboratory, radiologic, and other testing results. Good documentation can

Help prevent medical errors
Improve efficiency in the patient encounter
Enhance communication with other providers
Support coordination of follow-up care
Ensure identification of who entered data into the record
Assist with discharge instruction communication

Reliable outsourcing companies can provide HIPAA compliant medical transcription to ensure that ED medical records comply with applicable state and federal patient safety and confidentiality regulations.

Avoid Errors and Delays in Dictating Operative Reports

04-July-2019 MTS TEAM Medical Transcription

An operative report is dictated by the surgeon immediately after the procedure, detailing who did what to whom using what materials and methods. Operation reports also include dictations that surgeons or their assistants complete after operative procedures. Typically there is a brief written operative note and a more detailed operative report that is dictated by the attending surgeon in the chart. Medical transcription service providers can convert these dictated records into accurate transcripts.
Avoid Errors and Delays in Dictating Operative Reports
The dictated operative note is an integral component of patients’ medical records. Good surgical practice emphasizes the need for clear operative notes for every operative procedure done. Any error in dictation made by the surgeon can lead to errors in transcripts and thus in EHRs. Hospital payments are also facilitated by accurate coding that is ascertained from patient notes including the operation note.

A clear dictation should describe the operative indications and findings and detail the steps of the procedure performed. Though dictating operative notes seems to be straightforward, it may happen that surgeons fail to include certain crucial information.

What Do Operative Reports Include?

Immediately after surgery, a record of the operation should be made including the following details.

The names of the operating surgeon(s), assistant and theater anesthetist, the name of the consultant responsible
The diagnosis made and the procedure performed
Description of the findings
Details of tissue removed, altered or added
Details of serial numbers of prosthetics used
Details of sutures used
An accurate description of any difficulties or complications encountered and how these were overcome
Immediate post-operative instructions
The surgeon’s signature

The record should also contain information relating to anesthesia. Follow-up notes should be sufficiently detailed, which allows other doctors to assess the care of the patient at any time.

Surgeons Cannot Delay Operative Notes Dictation

If an operation is conducted, then the surgeon is responsible for dictating the operative report of the patient, describing in brief the details of the surgery. This report should be entered in the medical report immediately after the procedure.

If there is any delay in entering the reports, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. Surgeons should make sure that such an operative progress note contains at least minimum comparable operative report information such as the name of the primary surgeon and assistants, procedures performed, estimated blood loss, specimens removed, and post operative diagnosis.

In case the assistant surgeon is dictating the op note to bill for the surgery as primary surgeon, he/she must at least sign the operative report, attesting that the information in the report is accurate. Without this confirmation, things may lead to potential malpractice if something goes wrong.

Also, if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be dictated in that unit or area of care.

Within the operating room, surgical reporting best practices are key to reducing post-operative complications and preventing operative report errors. Most general surgery residents (92%) report that they use at least one method to improve their dictations. Surgeons can improve their dictating skills by considering these tips –

Dictate soon after the procedure, as the information will be fresh in your mind
Speak at a reasonable speed. Volume issues usually involve a dictator who whispers, possibly because of confidentiality concerns.
Choose a silent, quiet area. Always state your name and the name of the patient you are documenting care for.
Organize reports before dictating. With unorganized reports, you are likely to leave something out, especially if they are interrupted.

A poorly dictated report requires greater attention and more time from transcriptionists, which increases the turnaround time as well. Consider outsourcing medical transcription tasks to an experienced company to avoid any documentation quality issues.

An Ambient Listening System in the Exam Room – New Tech to Support EHR Documentation

01-July-2019 Rajeev Rajagopal Medical Transcription Outsourcing

One of the most challenging tasks for physicians is typing patient information into the electronic health record (EHR) during and after the office visit. US based medical transcription services ensure dedicated EHR-integrated clinical documentation, including editing of speech recognition-generated documents. At the same time, companies are in the race to develop innovative voice-enabled products and services to make EHRs easier to use and minimize the documentation burden for clinicians. The latest advancement in the field is an ambient listening system in the exam room.

An Ambient Listening System in the Exam Room - New Tech to Support EHR Documentation

Instantaneous EMR-integrated Transcripts of Physician-Patient Dialogue

Developed by speech recognition software maker Nuance, the Ambient Clinical Intelligence (ACI) solution is a tailor-made device that can be wired into the walls of the exam room. It combines ambient detection tools with Nuance’s Dragon Medical virtual assistant to transcribe the physician-patient conversation and upload key portions of it into the EMR.

This artificially intelligent software product is a rectangular box equipped with 16 microphones and a motion-detection camera. Mounted on the wall of an exam room, the system comes with the following capabilities:

Can record patient encounters and automatically load key data into matching fields within the EMR
Can capture and distinguish speech from up to eight persons in the room
Comes with as a computer vision sensor that can track speakers as they move and attribute speech to the right person
Convert layperson terms into their clinical language, promoting natural patient-physician conversation, while capturing details to support coding and clinical history
Allow for real-time documentation of patient visits, without the computer encroaching on the physician-patient relationship

The goal of the new technology, which is also HIPAA-compliant, is to address physician burnout and create meaningful, personalized patient experiences. Performing EHR data entry during the office visit leaves physicians frustrated as they are not able to focus on their patients. In a 2018 Stanford Medicine poll, physicians consistently ranked electronic health record as the top reason for the breakdown of the physician-patient relationship.

Similar to medical transcription services, ambient technology allows providers to avoid burdensome EHR data entry. The system is still in validation process, and if successful, would be a significant advancement in voice technology in healthcare.

Speech Recognition Technology in Medical Record-keeping – Key Challenges

Stat News points out that one key concern about ambient technology is whether patients will be at ease having a third-party company with camera and microphone present during their conversation with their physician.

Another major challenge is accuracy in documentation. Speech recognition (SR) helps with clinical documentation process in two ways: back-end and front-end. In back-end documentation, physician dictations are captured and converted to text by voice technology. This text is then edited by a medical transcription service provider and returned to the physician for review. The second type is front-end speech recognition where the clinicians dictate directly into free-text fields of the EHR and review and edit the transcription themselves. Front-end systems tend to increase the physician’s administrative burden instead of reducing it.

A recent study revealed that in clinical documentation created using speech recognition technology seven in every 100 words contained errors. Moreover, 1 in 250 words contained clinically significant errors. One error that the researchers discovered was a reference to a patient having a “grown mass” instead of a “groin mass”.

“Although adoption of SR technology is intended to ease some of the burden of documentation, that even readily apparent pieces of information at times remain uncorrected raises concerns about whether physicians have sufficient time and resources to review their dictated notes, even to a superficial degree,” wrote researchers (www. ehrintelligence.com).

Documentation errors that affect clinically relevant information put patient safety at risk. Though nearly all the errors were identified by follow-up review and editing, the researchers stressed the need for careful supervision to prevent errors in the final version of physician notes.

Speech recognition technologies are being increasingly recognized for their ability to help physicians manage the care of their complex patients. Patients with complicated conditions would have a complicated story to tell and physicians would find it difficult to type out quickly, according to a report from the American Medical Association.

All these challenges indicate that, even as technology advances, medical transcription outsourcing companies continue to have an important role in helping physicians maintain accurate, timely and clear medical records.

Electronic Consultations Expedite Care in Allergy and Immunology, finds Study

27-June-2019 Julie Clements Medical Transcription Company

The effective use of electronic health records (EHRs) can improve the quality of health care and patient safety. Supported by medical transcription companies, providers leverage EHRs to maintain better documentation and file organization. EHRs also help patients with adherence to medication regimens and scheduled appointments while assisting physicians in tracking their treatment protocols (IOM, 2010). Digitizing patient records has also facilitated electronic consultations or “e-consults”-asynchronous, electronic clinician-to-clinician consultations based on data in the EHR. A recent study by researchers at Massachusetts General Hospital (MGH) found that e-consults can streamline and expedite care in allergy and immunology by significantly reducing wait times and need for specialist visits. The study was published online in the Journal of Allergy and Clinical Immunology: In Practice.

Electronic Consultations Expedite Care in Allergy and Immunology, finds Study

According to statistics from the American Academy of Allergy, Asthma & Immunology and the National Institute of Allergy and Infectious Disease, allergic problems in the United States are the sixth-leading common cause of chronic disease. Allergies and autoimmune disorders are complex conditions. They include allergic rhinitis, angioedema, asthma, atopic dermatitis (eczema), autoimmune (e.g., lupus, multiple sclerosis and rheumatoid arthritis), bronchitis, celiac disease, contact dermatitis, chronic cough, food allergy and sensitivity, hives, and immunodeficiency diseases. When diagnosing and treating these conditions, the allergy and immunology team often has to work with other experts to ensure that patients benefit from specialist care.

The researchers looked at data regarding allergy/immunology e-consults provided under the MGH program from August 2016 through July 2018, as well as in-person consults beginning in August 2014. As of January 2019, the MGH e-consult program involves 47 specialty areas, and almost 10,000 e-consults were provided during 2018. Approximately 300 e-consults completed during the study period. Two-thirds of e-consults related to patients with histories of potentially allergic reactions to drugs like penicillin, many in conjunction with a program to evaluate pregnant patients with a history of penicillin allergy. Immunology e-consults could result from patient or provider concerns about frequent infections or abnormal antibody levels.

The study found that e-consults in allergy and immunology can simplify the process of providing proper care, often reducing the need for in-person specialist visits and the time needed to access specialist guidance. The findings are as follows:

About 60 percent of the 300 e-consults led to recommendations for in-person specialty visits, while 27 percent provided only advice and education to the referring practitioner.
When the e-consult led to a recommendation for an in-person specialty visit, information from the e-consult improved the productivity of visits by allowing the allergist to be better prepared.
The educational information that e-consults provided benefited both referring physicians and the patients, often providing reassurance on the appropriateness of a treatment plan.
Before setting up the e-consult program, the average wait time for an in-person allergist visit was 22.5 days. After the program began, the wait time reduced to 21.0 days.
Allergists completed e-consults in an average of 11 minutes, and the average turnaround time for the referring provider to receive allergy specialist guidance was less than 24 hours.

For many patients, e-consults avert the need for an in-person visit entirely; and even when an in-person consult is required, the initial e-consult provides valuable information – including additional patient history, previous diagnostic testing and treatment trials – that can make the in-person consult more productive and valuable for the allergist, the referring provider, and the patient.

Earlier studies have also reported that e-consults offer a potential solution to the challenge of enhancing access to specialty care. They offer the primary care physician (PCP) and the specialist a “rapid, direct, and documented communication pathway for consultation”, according to a study published in the Journal of Telemedicine and Telecare in 2015.

These studies show that e-consults are:

Offer flexibility and are a practical option in a variety of settings
Are very useful to PCPs by allowing them quickly to determine the best course of action with the guidance of a specialist
Improve timeliness of specialty consults
May help avoid the need for a face-to-face visit between the specialist and the patient
Frees up specialists’ office time to prioritize patients who need more complex care
Promote cost-effective and convenient care for patients
Enhance access to and coordination of specialty care across the healthcare system

Medical transcription services have improved the integrity of electronic medical records (EMRs), including record retrieval and management, and other processes. EMRs come with condition- and specialty-specific templates that prompt PCPs to document their expectations for care and determine the next course of action. Specialists who have opted to be in an e-consult program can write an effective e-consult response. This would ensure that the PCP has a record of specific instructions from a specialist (www.news.aamc.org).

However, a key limitation to more widespread use of e-consults is the reliance on EMR systems that may not be shared between specialists and referring physicians, according to Neelam Phadke, the first author of the MGH study.

Recognizing and Responding to Changes in Vital Signs – Key Concerns

24-June-2019 MTS TEAM Medical Transcription

Physiological abnormalities in vital signs such as body temperature, blood pressure, pulse, respirations, and oxygen saturation are common before preventable adverse events. Changes in vital signs that occur before cardiac arrest, unexpected admissions to intensive care, and unanticipated death need to be properly documented and effectively communicated between clinicians and across multidisciplinary teams during transitions of care. This can help prevent further deterioration in the patient’s condition. Medical transcription outsourcing can ensure clear, current, relevant, accurate, and complete documentation of this information. However, the problem is that medical staffs often miss these health status changes. In fact, the Emergency Care Research Institute (ECRI) listed detecting changes in a patient’s condition as a major challenge in its 2019 Top 10 Patient Safety Concerns report (www.medscape.com).

Recognizing and Responding to Changes in Vital Signs - Key Concerns

Types of Adverse Events

The Agency for Healthcare Research and Quality (AHRQ) categorizes adverse events as follows:

Preventable adverse events: These result from an error or a failure to apply an accepted strategy for prevention.
Ameliorable adverse events: These are not preventable, but could have been less harmful if proper care was provided.
Adverse events due to negligence: These occur when care falls below the expected industry standards

In addition, there are safety concerns such as near misses and errors that do cause harm but expose patients to a potentially hazardous situation. Measuring recording or acting on changes in a patient’s vital signs is vital to determine the level of care needed, provide the necessary treatment and prevent deterioration from an otherwise preventable cause.

Understanding patients’ risks will help providers prioritize care and anticipate potential problems. There are many reasons why patients deteriorate. Exacerbation of the patient’s acute condition is the most common reason. For example, a patient’s respiratory distress or sepsis may be the result of pneumonia. Another reason could be medication – a patient’s condition may get worse due to certain medicines or drug interactions. Other reasons why patients may get worse include comorbidities or past medical history. For instance, a patient admitted with kidney disease may also have a history of hypertension, heart disease, and diabetes. The patient’s age, mobility, nutritional status, and frailty put additional stress on the body and increase risks of deterioration.

Reasons for Not Recognizing Changes in Vital Signs

The factors that cause ward staff to miss changes in patients’ health status are complex and often interrelated. They include:

Failure to monitor vital signs consistently or detect changes in health status
Inability to recognize signs and symptoms that warn of deterioration
Lack of knowledge about responding to alarms
Doubts about calling for assistance
Delays in informing medical staff about changes in vital signs
Delayed response to these physiological abnormalities
Lack of knowledge and skills about acting upon changes in vital signs
Not communicating with other staff about concerns, including during patient transfer
Failure of monitoring equipment

Improving Capture and Interpretation of Vital Signs

Vital signs have become a subject of active research, and play an important role in emergency departments and on the wards. One study found that more than half of patients who had a serious adverse event could have been identified as high-risk up to 24 hours previously (www.nursingtimes.net). All significant changes in patient vital signs must be captured, monitored, interpreted, reported and documented. Here are four strategies to improve vital sign monitoring:

Nursing staff should measure vital signs at least once every 12 hours unless instructed otherwise. They should be recorded on admission and clearly documented. Vital signs should be considered part of an overall assessment and made part of an early-warning scoring system.
Staff members should review triggers, warning scores, and areas of concerns during their shift. This will promote discussion on how to deal with these issues, allowing for a review of the trend of patients’ progress and support for acting upon any deterioration in vital signs.
Patient safety should be the core concern during handovers and care should be taken to hand over early warning scores.
Handover documentation must be clear, accurate and complete. All escalation must be properly documented and staff caring for the patients should be knowledgeable about the next steps.
Improved communication can prevent adverse events. Settings where fast and effective communication and management is critical include the perioperative period, the intensive care unit (ICU) and the emergency department.

Importance of Good Documentation

There is evidence that poor documentation at transitions of care can increase readmission rates to hospitals and increased presentations to the emergency department. Outsourced medical transcription services are a feasible strategy to ensure effective communication among clinicians. An experienced service provider will ensure that all necessary information about the patient, including vital signs, is fully and accurately documented, facilitating early response to the patient’s condition and patient safety improvement across all settings.

Disclaimer – The content in this blog that is provided by Managed Outsource Solutions (MOS) is only for informational purposes and should not be seen as professional medical advice. MOS is only passing on information that is already published and does not accept any responsibility for any loss which may occur due to reliance on information contained in this blog.

Patient Consultations in Radiology can Improve Overall Care

20-June-2019 Rajeev Rajagopal Radiology Transcription

Radiology information systems (RIS) in conjunction with hospital information systems (HIS), picture archiving and communication systems (PACS), and radiology transcription service providers help radiology practices maintain accurate records and manage image archives. The RIS improves workflow and efficiency, resulting in fewer medical errors and promotes accuracy in diagnosis and transcription.

Patient Consultations in Radiology can Improve Overall Care

Heavy utilization of imaging technology is a major factor driving overall healthcare expenditure in the U.S., according to a new study published in the Journal of the American Medical Association (JAMA). Researchers found that the U.S. had the second highest number of imaging exams, and the second highest MRI and CT technology utilization rate, following Japan. Given the expanding role of the imaging, radiologists can play a larger role in patient management. M Health lab reported on a U-M survey which found that:

84 percent of patients were interested in meeting with a radiologist
Patient comfort level was three times higher with the prospect of a radiologist interpreting an image versus a non radiologist physician

In fact, there is evidence that patient consultations in radiology can improve care and enhance the patient experience:

Many patients want to know more about their medical tests, diseases and treatment. A radiology consultation clinic provides patients the opportunity to meet directly with radiologists and get a better understanding of the meaning and implications of their imaging findings.
Radiologists can clarify details and answer any questions after delivering test results directly to patients, reducing anxiety for some patients.
Reviewing the images with the radiologist is very meaningful because radiologists are trained to look at imaging from many angles, where other physicians look at it only from the point of view of their specialty.
In addition to improving patients’ understanding of radiology reports, radiologists can also educate them about the practice of radiology and the risks and implications of radiation.

Radiologists can also benefit from communicating directly with patients:

By going through imaging findings with patients, answering questions, and explaining ambiguous statements or clarifying misconceptions, radiologists can better understand patient perspectives. They can use the information to improve their practice.
Interacting with patients on a regular basis can help radiologists produce better radiology reports.
Educating patients on the importance of appropriate imaging follow-up can improve patient adherence. While this is typically the responsibility of the primary care physician, it could be beneficial for the patient to hear it from actual radiologist.
Interaction with patients improves patient perceptions of radiologists and demonstrates the value of their services.
Consultations improve relationships with referring physicians and enhance the role of radiologists.

The radiology department at Massachusetts General Hospital is an example of an organization that has successfully implemented consultation services (www.diagnosticimaging.com). The department offers complimentary consulting service for select patients. Residents contact the primary care physician (PCP) about patients with upcoming appointments and chronic issues as revealed in recent past imaging that can be impacted by lifestyle changes or medication. When the patient checks into the office, they are offered a 15-30 minute radiology consultation along with their PCP visit. According to the chief resident in radiology at Massachusetts General Hospital, Harvard Medical School who set up the program in early 2014, “The PCPs said it really impacted their patients, and completely changed their perspective of their health”. Radiologists also received e-mails from patients thanking them for their time and lauding the value of the interaction.

However, implementing radiology consultation clinics can be challenging, according to a new analysis published in the Journal of the American College of Radiology (www.radiologybusiness.com).

One barrier is location. Teleradiology provides a way for diagnostic radiologists to interpret images off-site. This means they don’t come into contact with patients.

Another hurdle, according to the study, is lack of time. Radiology operations are complex with many variables and challenges. Inefficiency in workflow impacts emergency departments, operating rooms, inpatients, and other healthcare providers. It can lead to longer turnaround times and slow delivery of results. Such challenges leave radiologists with little time for patient consultations.

Further, though radiologists may want to communicate directly with patients, this can affect the time available for image interpretation, a revenue generating activity. Most payers don’t reimburse radiology consultations. The authors suggest that this concern could be addressed by viewing direct consultations with patients as “value-adding activities that deserve proper compensation.” Another strategy would be to have a separate billing process for patient consultation.

The authors concluded that though additional work is needed before radiology-patient consultation become a reality, direct patient communication would benefit not only radiology and radiologists but also allow patients to participate actively in their care.

Patient consultations in radiology need to be properly documented. Transcription of the video recordings of consultations can be outsourced to a medical transcription service organization specialized in radiology transcription.

Electronic Medical Records Assisting U.S. Doctors to Fight Measles Outbreak

17-June-2019 Julie Clements Infectious Diseases Transcription, Medical Transcription

A highly contagious viral disease, measles can cause blindness, deafness, brain damage or even death. Though this virus was declared eliminated in the U.S. by 2000, its outbreaks have reappeared. According to the reports from CDC – from January 1 to May 3, 2019, at least 764 individual cases of measles have been confirmed in 23 states. The major reason behind this outbreak is avoiding vaccination. It is crucial for those concerned with potential outbreaks to get their vaccination status verified by a healthcare provider and assess their possibility of measles based on the clinical assessment. Infectious disease specialists busy treating measles can streamline their healthcare documentation with quality U.S. based medical transcription services.

Electronic Medical Records Assisting U.S. Doctors to Fight Measles Outbreak

Doctors Using Electronic Medical Records to Check Vaccination Rates

Most U.S. doctors are now making use of electronic medical records (EMR) to spot patients who are unvaccinated and potentially infected individuals to resist the worst U.S. measles outbreak in 25 years. Hospitals are also building alerts into its EMR system to notify doctors and nurses about the patient’s location, based on their Zip code.

Reuters recently discussed the case of New York City-based NYU Langone Health that has installed measles alerts within its Epic EHR system (using software from Madison) to identify patients who are unvaccinated and those who have been infected.

A good EHR system can help physicians to –

identify incoming patients who may have been exposed to measles and need to be assessed
be alert and raise awareness for doctors and nurses to be on the lookout not just for their own patients, but anybody who comes into the building
find all those patients missing the MMR vaccine and send out a message to patients or providers

Alerts in a patient’s medical record also help providers to talk to and counsel other visitors who may also have been exposed to the virus. Physicians will enquire about their health, prior exposure to measles, and vaccination history.

In the case of patients with fever or symptoms like a rash, doctors will ask questions to check whether they have been exposed to anybody with measles. If ‘yes’, this patient will be called to schedule an appointment so that the staff can take precautions to protect themselves and other patients.

Lower Vaccination Rates – A Concern

A lower rate of vaccination is the key reason for this measles outbreak and it creates increased risk when the virus is brought in from other countries. Communities with lower vaccination rates are vulnerable, as this viral infection spreads quickly through coughing and sneezing. According to reports, more than 70% percent of individuals who’ve contracted measles were unvaccinated, while another 18% had an unknown vaccination. At the same time, only 11% were vaccinated.

Parents refusing to vaccinate their children put those children at risk and it also affects those who have got vaccinated. Washington’s state Senate has passed a bill to eliminate personal and philosophical exemptions for the measles-mumps-rubella vaccine. CDC recommends two doses of the MMR vaccine, to protect against measles – starting with the first dose at 12 to 15 months of age and the second dose at 4 to 6 years of age. This viral infection is most problematic in babies and pregnant women, according to health care professionals.

Many hospitals also introduced screening questionnaire about potential measles risk for every patient who tries to book their appointment online. Based on such surveys, two hospitals in Illinois have sent hundreds of letters to parents urging them to ensure their kids get their measles shots. CDC opines that it is the misinformation about vaccines that has triggered the recent outbreaks. Ensuring that everyone who can be vaccinated is vaccinated is the best way to keep the virus from gaining traction in the US again.

While physicians are busy spreading awareness about the importance of measles vaccine, professional infectious disease transcription services can help your practice to ensure that your document workflow is stable, with accurate transcripts.

Documenting Patient Allergies in the Electronic Health Record

13-June-2019 MTS TEAM Allergy & Sleep Medicine Transcription

Allergies affect more than 50 million Americans each year and are the sixth-leading cause of chronic illness in the United States. While year-round allergies are usually a reaction to food, medications, dust mites, pet dander, or mold, seasonal allergies affect people only during certain times of the year. Experts point out that allergies are getting worse year after year due to climate change. Recent reports of the “pollen-ocalypse have raised concerns among allergy specialists. Regardless of the cause, patient allergies need to be documented properly in their electronic health record (EHR) so that they can be shared among all the health care professionals involved in their care. With the start of the allergy season, allergy and sleep medicine transcription services are a practical option for physicians to manage challenging documentation tasks.

Documenting Patient Allergies in the Electronic Health Record

Common Allergy Triggers

Allergies are the result of the reaction of the body’s immune system to a foreign substance or allergen, even though it is not harmful. Allergies can affect the skin, sinuses, airways or digestive system. Allergens responsible for allergic reactions include:

Pollen
Dust
Food
Insect stings
Animal dander
Mold
Medications/Drugs
Latex

Seasonal allergies or hay fever, which occur between spring and autumn, are typically caused by pollen produced by plants such as grass, trees, and weeds. Hay fever symptoms include sneezing, itching of the nose, eyes or roof of the mouth, runny or stuffy nose, and watery, red or swollen eyes.

The allergic reaction to insect stings include swelling in the area of the sting, itching or hives all over the body, cough, chest tightness, wheezing or shortness of breath, and anaphylaxis, which is a life threatening reaction.

Penicillin is the most common trigger of drug allergies. A drug allergy causes reactions similar to an insect sting as well as facial swelling. According to the Asthma and Allergy Foundation of America, drug reactions affect 10 percent of the world’s population.

Documentation of Patient Allergies in the EHR

Drug allergies are usually overdiagnosed, misdiagnosed, and self-diagnosed, according to a commentary published by the Agency for Healthcare Research and Quality (AHRQ). Patient allergies need to be documented correctly and promptly in the EHR. Up to 18% of serious, preventable adverse drug events (ADEs) occur as a result of practitioners having insufficient information about the patient before prescribing, dispensing, and administering medications (www.magmutual.com). However, a study published in Ann Allergy Asthma Immunol reported that the EHR allergy section is often handled by providers with limited drug allergy training and knowledge, resulting in missing reaction details and discrepancies with patient interview.

MagMutual cites a Pennsylvania Patient Safety Advisory report which found more than 3,800 reports of cases in which patients received medications to which they had documented allergies. The failures in communication of allergy information include:

Entry of patients’ allergies on paper but not in the organization’s computerized order-entry systems
Allergy information not consistently documented in expected locations
Organizations’ attempts to include all drug allergens on the wristband
Allergies occurring during treatment but not entered in the medical record or communicated to appropriate staff.

Incomplete and inaccurate EHR allergy entries affect future prescribing and lead to patient harm.

Best Practices for Documenting Allergies in the EHR

Healthcare practitioners should have access to current and accurate medication information about patients when prescribing, dispensing, and administering medications. The Pennsylvania Patient Safety Advisory recommends these best practices for documenting allergy information:

Standardizing the current location(s) where allergy information (including patient reactions) is documented and retrieved by practitioners and staff
Having a process in place to ensure that the information is update if the patient’s allergies change. Providers and staff should be educated on this.
Including clearly visible and prominently placed allergy prompts in consistent locations on the top of every page of all prescriber order forms
Developing processes to check and update allergy information upon each patient encounter.
Making the allergy reaction selection a mandatory entry in the organization’s order-entry systems for prescribers and pharmacists.
Asking for patient’s allergies and reactions when communicating medication orders verbally or by telephone. The receiver of the order should always present this information to the authorized prescriber.
Documenting “No Known Allergies” and the date recorded if the patient reports having “no known allergies”.

The National Institute for Health and Care Excellence (NICE) states that the following information should be documented when a patient presents with a suspected drug allergy:

Generic and proprietary name of the drug or drugs suspected to have caused the reaction, including the strength and formulation.
Description of the reaction.
Indication for the drug being taken; the illness should be described if there is no clinical diagnosis.
Date and time of the reaction, number of doses taken, or number of days on the drug before onset of the reaction, and route of administration.
Which drugs or drug classes to avoid in the future.
Wherever possible, recording drug allergies separately from adverse drug reactions

The guideline also suggests taking a drug allergy history and updating this at all patient encounters and whenever a drug is prescribed, dispensed, or administered.Above all, prescribers, nurses and pharmacists should be educated about medication allergies, focusing on screening patients, recognition of an allergic reaction, and the treatment of serious allergic reactions.

The allergy season is in full swing. US based medical transcription companies specializing in sleep and allergy medicine transcription are ready to help healthcare providers ensure that allergy status is properly recorded and updated in the EHR. Partnering with a reliable service provider will allow physicians to focus on the complex task of diagnosing and treating allergies.

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