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.

6 Dictation Software Programs Physicians Can Use

06-June-2019 Julie Clements Medical Transcription

Medical documentation is very important when it comes to patient care because it includes all healthcare details of the patient such as patient history, test results, diagnoses, procedures, providers and so on. It provides a complete picture of all outcomes and conclusions. Dictation is an easier option for physicians compared to entering all the required details in the electronic health record system. Today, EHR-integrated medical transcription is provided by medical transcription companies that allow physicians to continue with their practice of dictation. Professional transcriptionists will listen to the dictated medical data and enter all the required details into the EHR. Another option for physicians is to use reliable dictation software. Medical document production can be made more efficient and quick with speech recognition software and by outsourcing medical transcription.

6 Dictation Software Programs Physicians Can Use

Manually typing up data into a system amounts to wasting a good amount of time on something that could be automated. Nowadays automated speech recognition (ASR) software platforms are widely used by healthcare entities. The speech recognition software converts spoken words into text format. Automated speech recognition relies on deep learning models including deep neural networks and many of their variants.

This is not only convenient but also speeds up the rate at which text is entered into the system. There are also dictation apps that allow you to speak into your mobile device or computer.

Here are some reliable dictation software physicians can use to dictate their notes:

Dragon Medical One from Nuance: This software is designed for speed, accuracy, and flexibility. It offers personalized vocabularies and templates that can be accessed and shared across a number of devices. A secure, cloud-based speech platform for medical professionals, it allows secure documentation of complete patient care in the EHR. This dictation software is highly versatile and allows the user to set up custom commands. It is also highly, almost 99%, accurate. Moreover, it learns better, the more you talk to it. By identifying your voice to a specific user profile, Dragon analyzes what you say and how you correct it to make it more accurate.
Apple Dictation: By default, Apple Dictation requires the internet to work and for doing an enhanced dictation, you need OS X v10.9 or later for a speech of more than 30 seconds duration. It is a good choice if you own a Mac or iOS device. It is free and easy to use. Apple Dictation is also highly accurate. Disadvantages are that it is only available on Mac and iOS devices; and you cannot use it to dictate into Google Docs.
Gboard: Available for both Android and iOS, it requires an internet connection to function. It has an accuracy of 90.1%. It is powered by Google and allows users to use their voice to enter text as well as search Google for any information you may need. Gboard transcribes everything you dictate in real time, without any time limit. It is the fastest dictation app with a low accuracy, and supports 185+ languages.
Google Docs: Google Docs contains a built-in tool for dictation called Voice Typing, which is available when running Google chrome. Voice Typing offers many voice commands for formatting, editing, and navigating the page as you write. If you work primarily in Google Docs and are looking for a free dictation software, it’s a good option. It supports 119 languages and has an accuracy rate of 94.4%.
ListNote: It is an app that can be used in Android devices. It works on the basis of classic notepad functionality with voice dictation. It offers password protection as well as backup and encryption options. It supports all languages offered in Google’s dictation services.
Express Dictate: Express dictate performs digital audio recording with superb signal processing quality. The software works like a Dictaphone with its Voice Activated Recording feature, which avoids long silences in a recording. It lets you use your PC or Mac to send dictation to your typist by email, Internet or over the computer network.

The most important aspect in selecting a dictation software program is finding the one which suits your language and the purpose of using it. Dictation along with speech recognition ensures that your dictation files are processed into text files automatically. In this setup, transcriptionists provided by medical transcription services can work as editors, proofreading and editing the transcripts prepared by the software and ruling out any error. Another option is outsourcing medical transcription. You can send audio files safely and securely to a medical transcription company and get them transcribed within your required turnaround time. This is a much preferred option because it is much more cost-effective in the long term than in-house transcription. It also frees up the time of your in-house staff for other administrative tasks. Providers can also consider outsourcing transcription in peak times for a short term and thereby reduce backlogs and speed up patient care.

Resurgence of House Calls Bridging Care for Vulnerable Adults

03-June-2019 MTS TEAM Medical Transcription

According to recent reports, home-based primary care is making a comeback. The revolutionary Primary Cares Initiative recently announced by the Centers for Medicare and Medicaid (CMS) aims to bring comprehensive care to the patients who are homebound. This is a welcome development for vulnerable older adults with chronic conditions who are unable to visit a physician’s office. Home-based primary care teams comprise specialists from internal medicine, family practice, geriatrics, and more, as well as nurse practitioners, physician assistants, social workers, and practice managers. Medical transcription outsourcing companies in the US are well-equipped to meet the anticipated increase in demand for primary care documentation.

Resurgence of House Calls Bridging Care for Vulnerable Adults

House calls were common half a century ago. The numbers of physicians seeing patients in their homes dwindled over the years, but these interactions are increasing, say recent reports. However, there is immense potential for expanding home-based primary care.

According to a 2015 article in JAMA Internal Medicine, up to 2 million Medicare patients age 65 or older were completely or mostly homebound in 2011. An additional 2 million people have severe chronic conditions and functional problems, which makes it difficult for them to access care outside the home.

The study found that only about 12% of homebound patients receive primary care in their homes. The lead author Katherine Ornstein, PhD, MPH, noted that the number of homebound patients is larger than the nation’s nursing home population (www.news.aamc.org).

Since many of these patients have multiple comorbidities, they often rely on the emergency room when they do not have access to primary care. Emergency department (ED) visits tend turn into lengthy hospital admissions. CDC statistics show that in 2016, up to 12.6 million ED visits resulted in hospital admission.

With the shift to the value-based healthcare system, home-based primary care offers the optimal solution to bring care to the growing population of older adults and those living with chronic diseases. House calls are an excellent way to optimize care for needy patients while significantly reducing treatment costs. The key benefits of hone-based primary care are:

Viable option for homebound and functionally limited patients with complex care needs
Allows providers to teach patients how to manage chronic conditions like diabetes
Supports interdisciplinary care
Patients treated at home recover well, on par with patients admitted to the hospital
Improves patient compliance and satisfaction
Decreases hospitalization rates and saves costs
Integrates behavioral care and social supports into primary care
Promotes rapid response to urgent and acute care needs
Offers palliative care
Supports family members and caregivers

Home-based primary care offers the benefits of personalized care as well as modern technology. Providers who make house calls use cutting-edge technology, including lab tests, EKGs, X-rays, ultrasounds, IVs, and more, to diagnose and treat patients. Consistent comprehensive care can help prevent medical complications, avoid hospitalization, and allow patients to age in place (www.todaysgeriatricmedicine.com).

A recent Pacific Standard report describes how Mount Sinai hospital was among the first to start a house call delivery program in New York City. The program involves community agencies, such as visiting nursing associations as well as a network of nurses, social workers, and others, to predominantly treat persons with functional disabilities and multiple health conditions. It currently covers 1,800 homebound patients in Manhattan over the age of 18 who have difficulty accessing care outside the home. The Mount Sinai Visiting Doctors program is widely acclaimed as an effective option to treat the sickest patients.

In 2012, CMS launched the Independence at Home demonstration project to test the efficacy of house calls. The participating house-call programs saved about $3,070 per patient, and reduced Medicare costs by 30 percent, by cutting unnecessary hospitalizations. House calls also improved care quality and patient satisfaction. Participants in Independence at Home (IAH) included the MedStar House Call Program Boston Medical Center, Christiana Care Health Services, University of Pennsylvania Health System, and Virginia Commonwealth University.

The success of house call medicine depends on many factors. According to Dr. Linda DeCherrie, clinical director of Mount Sinai at Home, identifying the patient’s goals for care is crucial (www.psmag.com). Patients with chronic illness would benefit from a combination of primary care and palliative care. Meeting these goals is important.

Another factor is having good medical staff perform the home visit. Providers need to be educated to deliver home-based primary careas the experience of seeing patients at home is significantly different than in a clinical setting.

Providers of home-based primary care also need to be paid for their services. The success of house call medicine will also depend on attracting a larger workforce and providing the necessary training (www.news.aamc.org). According to a 2016 Health Affairs study, rural regions had only limited accessto home based primary care due to a shortage of trained providers.

The new CMS Primary Cares initiative is expected to open up new opportunities expanding home-based primary care. In a press release dated May 9, 2019, Dr. Thomas Cornwell, a practicing home-based primary care physician and Founder and CEO of the Home Centered Care Institute (HCCI), noted that the CMS Primary Cares initiative offers “a real chance of attracting more providers to the field – creating universal access to best practice house call programs, making home-based primary care the national standard for treating medically complex patients who are better cared for in the home.”

As the Primary Cares Initiative increases patient access to advanced primary care services, physicians’ documentation tasks will also increase. Medical transcription outsourcing is a practical option to meet these requirements.

Best Practices When Doing a Dictation in the EMR Setting

30-May-2019 Rajeev Rajagopal Medical Transcription

Emerging trends in the healthcare facilities are Internet of Things, data analytics, artificial intelligence and machine learning.The growth will continue to increase,as the latest technology is vital for advancement. Now, many healthcare organizations are leveraging Software as a Service (SaaS) for key applications. The digital or analog record, detailing a medical treatment or clinical test is the physician’s clinical documentation. Recording patient details in the form of medical reports for future referral has now become a part of the technological advancement. Medical transcription companies can provide documented medical reports for physicians.

Best Practices When Doing a Dictation in the EMR Setting

Benefits of the Electronic Medical Record

EMRs provide easier access to accurate clinical data and up-to-date information about patients for more coordinated and efficient care. It has the ability to establish and maintain effective clinical workflows. There will be fewer medical errors, improved patient safety, and stronger support for clinical decision-making.The ability to quickly transfer patient data from one department to another will be easier. Operational costs in transcription services will be low. Also, you are ensured an uncompromised legal document.

Types of Medical Transcription Dictation

Physicians can dictate a medical report in three different ways. This includes telephone dictation, PC-based dictation, and mobile dictation.

When using a telephone to dictate, the telephone’s keypad is used to control the recorder. This is an old technique used by them to dictate medical reports.
In PC-based dictation, physicians dictate clinical data to any standard computer, which provides special dictation microphone and installed software. By integrating this computer to clinical EMR systems, you can save time and maintain accuracy.
Dictation on-the-go is a necessity for many healthcare providers. Physicians then started dictating patient reports through digital portable recording devices and smartphones, which support quality voice recording.

Guide to Physicians When Doing a Dictation

Documentation is the essential ingredient of good medical care. Install good dictation software and use a quality recorder for clear communication. Gather all patient information and organize data before dictating. When dictating in an EMR setting, physicians should follow certain guidelines for quality dictation. Provide patient demographics with more than one patient identifier to get the best service done,e.g. birth date, MRN, or account number. It is mandatory to dictate the date of service for every report. Physically pause the recorder when yawning or coughing while doing a dictation; also avoid eating or chewing gum. When engaging in other conversations, pause the recording when in the middle of a dictation. Avoid extraneous background noise areas while recording. Also avoid crowded places for better voice quality. Clarify words and numbers that may sound the same when dictated. Clarify uncommon abbreviations, use facility approved list. Avoid the risk caused by dangerous abbreviations that can mislead or have more than one definition by expanding them. Include units of measure when necessary and appropriate. When dictating lab tests and vital signs, the numbers should not ambiguously stand alone. Provide feedback and direction to medical transcription outsourcing division or transcription staff to improve data capture and to avoid repeated errors.

In order to maintain efficient workflow status, physicians should quickly complete consults by dictating directly into the EMR or letter templates and by minimizing transcription turnaround time.The main problems that can lower the dictation quality are rapid speech, poor articulation, insufficient volume, background noise, incorrect or insufficient patient information, and erroneous demographics. A high-quality documentation outcome starts with high-quality dictation.

Do Electronic Health Records Pose Risk of Wrong Patient Orders?

27-May-2019 Julie Clements EHR Transcription

Transcribing patient orders is one of the many documentation tasks that medical transcription companies help physicians with. Today, computerized physician order entry (CPOE) allows providers to transmit orders quickly via the electronic health record (EHR). While EHRs are designed to optimize work flow and communications and offer a way to document patient care accurately, wrong-patient orders continue to be a problem. According to a recent report published by Columbia University Irving Medical Center, there are about 600,000 wrong-patient orders every year. A wrong-patient order is when an order meant for one patient is issued for another patient. These “wrong-site, wrong-procedure, wrong-patient errors” (WSPEs) can cause serious harm and even prove fatal. The question is whether EHRs pose a high risk of wrong patient orders.
Do Electronic Health Records Pose Risk of Wrong Patient Orders?
CPOE systems come with several high-end features (searchhealthit.techtarget.com):

Ordering: Clinicians can enter physician orders into a workstation, laptop or secure mobile device instead of completing a paper chart.
Patient-centered decision support: Integratingclinical decision support systems and EHRs will ensure up-to-date patient information and complete medical history, enabling better care decisions.
Patient safety: CPOE allows healthcare providers to perform real-time patient identification, review medication dosage recommendations and screen for potentially adverse drug interaction as well as for patient allergies and treatment conflicts.
Intuitive user interface: The order entry workflow can be easily managed by new or infrequent users.
Regulatory compliance and security: CPOE systems ensure safety of access and information in compliance with state and federal guidelines.
Portability: The software accepts and manages orders from all departments at the point of care through various devices.
Management: Reports generated can be analyzed and evaluated, which helps improvements to be made if needed.
Billing: Documentation and billing is improved.

CPOE can lead to Wrong Patient Orders

Several studies have found that wrong patient orders occur quite often with CPOE. The reason for this, according to an article in The Hospitalist is that “physicians toggle back and forth between screens in the system interface”, making data entry errors and placing wrong-patient orders. This leads CPOE systems to unintentionally cause errors.

According to arecent JAMA study by researchers at Columbia University Vagelos College of Physicians and Surgeons, the risk of wrong-patient orders was similar whether providers were allowed to have just one patient record open or multiple patient records open at the same time. The study covered 3,356 health care providers treating patients in the emergency department, hospital, or outpatient setting. Fifty percent of the participants were allowed to open up to four patient records at a time, while the rest could open only one record at a time.

On tracking the number of wrong-patient order sessions, the researchers found that the error rates of both groups were similar. However, providers in the hospital and emergency department used multiple records and made more errors than clinicians in outpatient settings who usually opened one record at a time. The team concluded that the environment played a role in causing errors. In a busy healthcare environment, clinicians tend to open multiple records as they care for multiple patients simultaneously, which could cause more errors.

Another study identified 644 probable wrong patient orders in a pediatric hospital (www.chpso.org). In most cases, the wrong order was quickly cancelled and replaced with the correct order for the correct patient. The researchers identified the risk factors for wrong patient orders as follows:

Age: infants and newborns were much more likely (2.9 and 3.6 times, respectively) to have wrong-patient orders
Last name: two-letter overlap 4.4 times more likely
Location: patients in nearby rooms 2.8 times more likely
Day of week: Friday 2 times more likely than Monday
Hour of day: midnight to 6 am 1.7 times more likely than 6 pm to midnight
More physicians ordering for the patient: 1.4 times more likely

Mitigation Strategies

Appropriate interventions can help lower the odds of wrong-patient errors.

Automated verification systems (such as bar-coding technology) may help to reduce the chances of misidentifications for patients with similar names. A particular team member must be given the responsibility of matching the bar code on the patient’s identity bracelet to the bar code on the medication or surgery schedule.
Implementing a patient verification alert can decrease the number of order retractions and re-orders due to wrong patient order entry in the emergency department setting.
Using two patient identifiers when entering orders into EHRS, in compliance with the recommendations of the Joint Commission’s national patient safety goal (chpso.org).
Patient ID verification alerts and patient photographs in EHRs
Proper communication among physicians, nurses and others in the care team as well as communicating with patients.
Provider training
Limiting, when feasible, the list of available patient records for each provider

Outsourced medical transcription services can ensure accurate, well-formatted feeds in EHRS. Well-versed in drug names, medical conditions, and transcribing different accents and dialects, experienced medical transcriptionists can correctly document physicians’ verbal orders. It is up to healthcare providers to follow best practices when maintaining orders to promote patient safety.

Tips for Medical Transcriptionists to Improve Their Skills

23-May-2019 MTS TEAM Medical Transcription

Even though technological advances and EHR have changed the way medical transcription is done today, it is critical for medical transcriptionists to work on improving their skills to provide accurate transcripts. Medical transcription companies are often required to deliver accurate transcriptions, often within short time frames. To meet the target requirements, the transcriptionists serving the company should be skilled enough and be capable of generating accurate transcripts. Remember that even minor errors in medical reports can lead to inaccurate diagnoses and possibly serious complications for the patient.

Here are some tips you can consider to provide error-free transcripts.

Choose a calm work environment

Choose a quiet environment to work, so that you can focus on the audio files without any distractions. Try to leave your phone and TV far from you or you will be distracted by the messages you get or by any interesting programs on television. While working from home, choose a pleasant and tidy place.

Master medical specialty terminology

Get familiar with frequently occurring medical terms, as this will also help to differentiate between the abbreviations. Clear knowledge of medical terms will help avoid transcribing the wrong information. Also, you need to be very careful while typing in medication and dosage details.

Improve editing skills

Editing is now the most crucial task for medical transcription. With the introduction of Electronic Health Records (EHRs) and speech recognition technology, in many professional companies, transcriptionists do not have to manually transcribe the recorded notes. Instead they have to edit the transcripts the system provides to ensure accuracy and completeness. Improving your editing skills helps to identify spelling, syntactic, or grammatical mistakes as well as other errors in the transcribed file.

Use quality headset and advanced software

As a medical transcriptionist, you should use the right tools to get the job done. Quality of the equipment and software you use will also impact your work’s accuracy. A good headset will help you better understand the dictations with clearer sound, by blocking out noises in your environment. Install advanced transcription software in your computer that comes with rewind and forward functionalities.

Improve typing speed

To avoid typing errors, practice using the correct fingers for the different keys and type without looking at the keyboard. Know your keyboard well and try to improve your speed, as long as you are sure that it will not compromise your accuracy in the process. Diverse online programs are now available to help you increase your typing speed. Good knowledge of keyboard shortcuts can also help enhance your typing skills.

Listen before transcribing

Even if you are working on a tight schedule, take some time to listen to the file before you start working, as this can improve accuracy. Note down any key points you listen to, which helps to create a brief summary. If any area needs clarification, contact the doctor before you start typing. Having a clear picture of what you have to transcribe helps speed up the process.

Medical specialties rely on medical transcription outsourcing solutions to save precious time for their core activities. Before transcribing, check whether the physician requires verbatim or non-verbatim transcripts. While verbatim transcription will take longer to transcribe, intelligent verbatim transcription cuts out unnecessary words, repeats, pauses, ‘ums’ and the ‘ers’. This will save transcription time.

2019 National Medical Transcriptionist Week, May 19-25

20-May-2019 Rajeev Rajagopal Healthcare News

This is an update to the blog, “National Medical Transcriptionist Week, May 17-23”

Each year, the Association for Healthcare Documentation Integrity (AHDI) observes a week in May as National Medical Transcriptionist Week. This year, May 19-25 will be observed as Medical Transcriptionist Week. This week following National Hospital Week from May 12-18, celebrates the role of medical transcriptionists in managing key medical records. Medical transcriptionists or healthcare documentation specialists (HDS) play a key role in supporting clinicians with precise documentation, which helps them provide quality care for patients. Professional medical transcription outsourcing companies also take part in this event to highlight their skilled resources’ important role in assisting doctors in all medical specialties receive accurate patient records. With the introduction of Electronic Health Records (EHRs), though transcriptionists do not have to manually transcribe the recorded notes, they have to edit the documents produced for medical accuracy. They audit and correct medical records to ensure accuracy and completeness.
2019 National Medical Transcriptionist Week, May 19-25
This year’s theme for the week is “Success is a Journey.” This week-long event helps to recognize the contributions made by these healthcare documentation specialists in ensuring complete and error-free patient health records. To promote this campaign in 2019, AHDI recommends organizations / businesses to

Get credentialed, become a mentor and help someone get credentialed
Invest in membership and invite healthcare colleagues to join AHDI
Take advantage of member benefits, continuing education, and networking opportunities
Invite a friend or colleague to their Healthcare Documentation Integrity Virtual Conference (HDIVC) this August
Share their message with healthcare colleagues far and wide

AHDI has announced that this celebration will be newly titled as Healthcare Documentation Integrity Week beginning in 2020.

Healthcare Documentation Specialists – They Are the Unsung Heroes

Medical documentation specialists such as medical transcriptionists, editors, QA specialists and auditors of clinician-created documentation are valuable resources and assets to clinicians as they protect healthcare documents, focusing mainly on patient safety and risk management. Knowledge in healthcare privacy and data security, they follow best documentation practices. A professional medical transcriptionist will also possess certain key skills such as – good knowledge of medical terminology related to the specialty they are trained in, ability to use correct grammar with correct punctuation, better typing and analytical skills, capable of following written instructions, sound listening skills and more.

There is no doubt that a human interface is needed to make new technologies work optimally. Healthcare documentation specialists can ensure quality patient care documentation, by clearly understanding the requirements of HIPAA and HITECH. As editors, they now scrutinize each patient record, monitoring documents for wrong patient/wrong content (demographic mismatches), wrong provider name, wrong dates of service, incorrect work types, medication dosage errors, right/left, male/female inconsistencies, medical contradictions as well as other missing elements and speech recognition errors. Reliable medical transcription services help health systems document a wide range of reports including medical histories, discharge summaries, physical examination reports, operating room reports, diagnostic imaging studies, consultation reports, autopsy reports, referral letters and other documents.

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2019 National Medical Transcriptionist Week, May 19-25

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