Studies reveal Patient Acceptance of Telehealth Services

16-May-2019 MTS TEAM Healthcare News

In many organizations, telemedicine is providing significant benefits for both patients and providers. Recent studies indicate that convenience and care quality are the main factors driving patient approval for virtual care. Telehealth service documentation requirements are similar to that of face-to-face encounters, and it is expected that the demand for telemedicine transcription services will increase with the growing popularity of virtual care.
Studies reveal Patient Acceptance of Telehealth Services
Patent Perspectives on Virtual Care

According to a recent Massachusetts General Hospital (MGH) survey, accessibility and care quality are the key drivers of patient satisfaction with telehealth. The study revealed that 68% of patients rated telehealth visits a nine or ten on a ten-point patient satisfaction scale (www.patientengagementhit.com).

The researchers noted that telemedicine was convenient for pediatric patients and their families as well as older patients for whom traveling was difficult. In other words, virtual care overcomes hurdles to care access. Parents can get their children medical help at a convenient time such as after school or work. Up to 79% of the respondents said that scheduling a telehealth follow-up at a convenient time was easier than for an office visit.

The study also found that patients were impressed with the quality of virtual care.  Up to 62% of patients said that telehealth offered the same quality of care as in-person visits. Twenty-one percent reported that the quality of telehealth visits or communication was the same as or superior to traditional office visits.

Patients also reported meaningful connections with their providers even when using video visits. Sixty-six percent of patients said they had strong personal connections with their providers using telehealth.

Telehealth also saves time. In a telehealth visit, up to 95% of the patient’s time is spent face-to-face with the physician. On the other hand, an office visit involves traveling, waiting, and limited patient-provider communication time.

A 2017 survey by American Well also found that patients are satisfied with video visits. When asked whether video, telephone and email could lead to the most accurate diagnosis by a physician, 69% of the respondents chose video. Additionally, patients said that telehealth services resolved their health concerns 85% of the time, compared with 64% of the time in a brick and mortar setting (www.americanwell.com).

Other findings of the American Well telehealth patient satisfaction survey:

  • Patients prefer telehealth for minor concerns like prescription refills as well as for complex ones involving chronic disease management
  • Two thirds of consumers are willing to see a doctor over video
  • Access and time saved are the two factors driving patients’ readiness to see a doctor over video.

According to a 2018 report from the Deloitte Center for Health Solutions, millennials, generation Xers, baby boomers and seniors are embracing virtual care, but vary in how they’re using it. Virtual care was most popular among millennials with 50% using it to fill a prescription, 61% to measure fitness and health improvement goals, 36 percent to monitor health issues, 37 percent to receive medication alerts or reminders, and 34 percent to measure, record or send data about medication.

 What Providers Think

The MGH study reported that 70% of clinicians agreed that telehealth facilitated timely follow-up care visits and 50 percent found telehealth an efficient option. However, about 46 percent said that in-office visits promoted “deeper patient-provider connections” than telehealth visits, while one-third noted that traditional office visits led to higher care quality than telehealth.

Healthcare professionals must pay attention to patient needs when using telehealth. In fact, physicians stress that telehealth is not a suitable option for all patients and some need in-person care.

Many innovative organizations are using telemedicine technology to improve the patient and provider experience. A Health Tech article explains how Cleveland Clinic’s telemedicine initiatives are keeping patients out of hospital. Patients who undergo bone marrow transplants usually have to return to the hospital every day for temperature and blood pressure readings. However, this puts them at a high risk of infection. In Cleveland Clinic’s telemedicine program, these patients are provided with a blood pressure cuff, thermometer and activity tracker through which their progress can be tracked even after they return home. Nurses can reach out to those who are not making progress.

 The Bottomline Line – Telemedicine is the Future of Healthcare

 Both patients and providers can benefit immensely from the comprehensive integration of telehealth into healthcare system. Benefits of telehealth include reduced healthcare costs, fewer hospital readmissions, improved care, and enhanced doctor-patient relationships, especially in remote areas.

As telemedicine services are provided, organizations can find it challenging to capture the documentation accurately and in a timely manner. Medical transcription outsourcing is a practical option to ensure proper documentation of the telehealth visit, patient history, consultative notes, etc.

How to Ensure Better Dictation Quality for Your Medical Reports

13-May-2019 MTS TEAM Medical Transcription

In this era of digitalization and automation, conversion of audio recordings into data files is common in various transcription fields like medical, general, business, legal, academic, insurance, media, etc. Among all these, the demand for medical transcription services has expanded considerably worldwide because of the ever increasing work requirement. Physicians have been dictating their patient data for years, but transcriptionists often find it difficult to understand the dictated material entirely. This is because the quality of dictation is poor with many factors contributing to the sub-standard dictation quality.
How to Ensure Better Dictation Quality for Your Medical Reports

  • The first thing transcriptionists struggle with is the poor audio quality. This may be due to low volume or other disturbances that occurred while recording the audio. The audio quality may vary on some recording devices while traveling, eating, or dictating in public places.
  • Poor dictation is not always about accents, background noise, speech patterns or faulty devices. Various habits contribute to poor dictation, such as mumbling or gurgling sounds, which can severely affect quality of the audio.
  • When more physicians are involved in the care of a patient, dictation quality may become poor especially when all of them speak together.
  • .Some physicians may not even provide patient demographic information and are very inconsistent regarding the format they use. Such reports could be very confusing for the transcriptionist.
  • The tendency to multitask also can detract from dictation quality.
  • Fast dictation and poor articulation are considered the most frequent causes of transcription errors, as an AHDI (Association for Healthcare Documentation Integrity) study points out.
  • Physicians may also misuse medical terms.

The quality of patient care and safety are the primary concerns that arise from poor dictation. Incorrect dosages could be disastrous because treatment decisions are based on information mentioned in the chart. When it comes to difficult dictators, the medical report will be on hold within the transcription team to complete the report. That obviously holds up the patient care and timely physician reimbursement. Medical transcription companies are paid on production basis. If they have to struggle through reports of difficult dictators, it will slow down their overall productivity and thus negatively impact their income potential.

How to Ensure Better Quality Dictation

Physicians need to be trained or given certain instructions before dictating a medical record. They should collect their thoughts before they start dictation or learn how to use the pause feature available in the devices instead of saying ‘Um’, ‘Let me think’, etc. Transcriptionists also need clear voice quality for digits that are easily confused (e.g. 15 and 50). Here are some other best dictation practices to follow:

  • Physicians must familiarize themselves with the recording equipment they plan to use and do some practice sessions.
  • Ensure that the background is quiet so that they are not distracted or disturbed during the dictation.
  • Before starting to dictate, make sure that all papers and reports are at hand.
  • Speak clearly and at an even pace. It is important that doctors do not eat or chew gum when dictating.
  • The physician should identify himself/herself at the beginning of their dictation. Also mention the type of report and the date to be mentioned in the report.
  • Spell out full details such as addresses, full name, file numbers, reference numbers, subject matter and patient record number.
  • When dictating, ensure that words spoken do not get cut off.
  • Spell unusual diseases, drugs with complex names, and procedures not normally performed in the physician’s daily work or specialty.
  • Mention all punctuation clearly.
  • Ensure that the dictation equipment is serviced regularly.

Doctors need to be held accountable for the quality of the dictation they provide, just as they are for all other facets of the patient’s care. Medical transcriptionists are not expecting physicians to speak in slow motion, spell every word, or exaggerate enunciations. However,because of patient safety concerns, they wish the dictation should be in a clear and concise manner. Depending on the organization, incentives and penalties may also be tools to improve dictation practices.

National Nurses Week 2019 Observed from May 6 – 12

09-May-2019 Julie Clements Medical Transcription

“Constant attention by a good nurse may be just as important as a major operation by a surgeon.”
Dag Hammarskjold, a Swedish Economist and Diplomat

National Nurses Week is celebrated annually from May 6 through May 12, the birthday of Florence Nightingale, the founder of modern nursing. Nurses play a key role in healthcare.According to the American Nursing Association, there are more than 4 million registered nurses in the U.S. Their responsibilities range from assessing patients’ needs and diagnosing illnesses to engaging in health promotion strategies to maximize optimal health outcomes.Physicians refer to nursing reports to effectively monitor and treat patients’ conditions. Accuracy in these reports is ensured with the support of professional medical transcription services.
National Nurses Week 2019 Observed from May 6 - 12
It was in 1993 that the American Nursing Association permanently designed such a national week to honor the nursing profession. While May 8 is considered as National Student Nurses Day and National School Nurse Day, May 12th is observed as International Nurses Day each year. Hospitals can use this opportunity to extend a special thanks to nurses, for their dedication and the quality care they provide patients. The theme for National Nurses Week in 2019 is “4 Million Reasons to Celebrate“. This theme reflects the number of nurses nationally. This week long celebration aims at raising awareness about the value of nursing as well as educating the public about the role nursing plays in meeting their healthcare needs.

A 2018 survey conducted by Gallup found that 84% of those surveyed rated the honesty and ethical standards of nurses as “very high” or “high” – above that of doctors, pharmacists and teachers.

Hospitals can applaud their team of nurses, nursing assistants, CNAs, and new nursing grads, by

  • Presenting them gifts including tech items, apparel, lapel pins, lunch bags, and more
  • Conducting contests and letting them win great prizes
  • Offering special treats

The American Nurses Association (ANA) also supplies free toolkits to celebrate National Nurses Week in hospitals, practices, and other organizations, which includes large banners for display purposes, thank you card templates, recognition certificates, online digital ads, letterheads and more.

Nurses have to make sure that the reports they submit are accurate. HIPAA-compliant nursing transcription services are available to transcribe all types of nursing reports, including history and physical reports, clinic notes, office notes, and operative reports among others.

Significance of Virtual Care Doctors in Better Health Care [infographic]

06-May-2019 Rajeev Rajagopal Infographics

Many doctors are now providing their valuable services virtually online to a broader audience and patients, who can access their doctor through emails, video conferencing or even telephonic conversation. When it comes to documentation, recordings of such care provided can be transcribed into accurate patient records with the help of quality medical transcription services.

Read the infographic below
Significance of Virtual Care Doctors in Better Health Care

Infectious Disease Specialist Shortage: a Looming Crisis

02-May-2019 MTS TEAM Medical Transcription

We must hurry. Superbugs are coming for us. We need experts who know how to treat them – Matt McCarthy, MD, in an open-ed for the New York Times.

Experienced medical transcription companies know just how important it is to ensure accurate and timely narratives of physician dictation that feed into electronic health records (EHRs). Error-free provider information and clinical records promote continuity of care. However, some medical specialties face more specific challenges. A recent New York Times report highlights the urgent need to tackle the shortage of infectious disease specialists in the US. According to the author, Matt McCarthy, an infectious-disease physician at Weill Cornell, with the rise in drug-resistant infections, the growing shortage of infectious disease specialists “could not be happening at a worse time”.

Infectious Disease Specialist Shortage: a Looming Crisis

Infectious diseases are a major global health threat. In the US, endemic diseases such as chronic hepatitis, HIV, and other sexually transmitted infections affect millions of people. Foodborne infections pose an additional threat. According to the US Centers for Disease Control and Prevention (CDC) two million Americans develop antibiotic resistance infections each year, which cause up to 23,000 deaths. Although there has been considerable progress in the reduction of vaccine-preventable diseases, drug-resistant superbugs are spreading. The CDC lists C. difficile or C. diff, Carbapenem-resistant Enterobacteriaceae (CRE) and N. gonorrhoeae as three “urgent” antimicrobial resistant threats. The CDC recently reported that Candida auris, an emerging fungus infection, is on the rise worldwide, and that the number of confirmed cases and in the U.S is 587. The shortage of infectious disease specialists makes these threats even more frightening.

Dr. McCarthy points out that, like nephrology, infectious diseases too do not fill all of its training spots every year in the National Resident Matching Program. The number of programs filling all of their adult-infectious-disease training positions fell by more than 40 percent between 2009 and 2017.

Why is there a deficit of infectious disease doctors? According to Dr. McCarthy, the reason is lack of proper compensation. While infectious disease specialists handle some of the most complex patient cases in healthcare, they are among the lowest paid due to Medicare’s reimbursement process. Medicare and Medicaid use relative value units (RVUs) as the basis for reimbursement to physicians. Many private health insurance carriers also use RVUs as their reimbursement basis. Each RVU is assigned based on the complexity of the services as by a defined CPT code, and each has 3 components:

  • Physician work RVUs are related to the time spent in providing a service or performing a procedure, the overall difficulty involved, and the cognitive and technical skills needed
  • Practice expense RVUs represent non-physician clinical staff time, medical supplies, and equipment used to maintain and operate the medical facility where the patient encounter occurs
  • Professional liability RVUs account for the cost of malpractice insurance

Of the three RVU components, physician work RVUs have proved to be the most contentious and difficult to accurately quantify. While the RVU formula prioritizes invasive procedures over intellectual expertise, the problem is that infectious-disease specialists provide expert consultation rather than procedures, and they don’t get reimbursed much for that, says Dr. McCarthy.

He explains how diagnosing a case of fungal pneumonia took hours with reviews of X-rays and imaging studies, discussions with the radiologist and primary care physician, and microbiological study. Most of this work was unpaid. Today, new threats require sophisticated diagnostic techniques that need a lot of expertise. While the Food and Drug Administration has approved new powerful antibiotics to confront the rising threat of superbugs, infectious-disease specialists are often the only health care providers who know how to use them, says Dr. McCarthy. Unless the insurance system has a better way to measure the value of diagnoses and treatments, physicians in cognitive specialties will not get the compensation they deserve.

A recent article in Contagion Live highlighted the problem of burnout among infectious disease specialists. According to the report, the causes of burnout among infectious disease physicians include focus on documentation, billing, RUVs, administrative tasks, and lack of support staff, concerns which also affect other physicians in other fields. However, infectious disease specialists face many unique challenges, according to Kwan Kew Lai, MD, DMD (www.contagionlive.com).

“Infectious disease is also the only field where illnesses are emerging [that] did not exist before, such as extensively drug-resistant organisms or new influenza viruses due to genetic re-assortment. Infectious diseases are also re-emerging due to political factors, civil wars, lack of access to vaccines, anti-vax movements, climate change, globalization, etc.”, she noted.

Dr. Lai also says that new treatments for various diseases may affect patients’ immune system, predisposing them to various infectious diseases. Further, as life span increases thanks to bone marrow or solid organ transplants, infectious disease specialists need to work to prevent and treat patients’ infectious complications.

Outsourcing medical transcription is a viable strategy to overcome the challenges associated with EHR documentation. The industry needs to work towards addressing the other concerns faced by infectious disease specialists so that the nation has experts who can treat deadly superbug infections.

Strategies to Retain Nurses in the Workplace

29-April-2019 Julie Clements Healthcare News

Nurses make up the largest proportion of healthcare workers in the US.  Nurses are involved in almost all aspects of care, including monitoring and assessing patients, bedside and medication management, assistance with surgeries, data collection/reporting, etc. In fact, a large proportion of the recordings that medical transcription companies transcribe consist of nurse dictation.

Strategies to Retain Nurses in the Workplace

However, recent reports indicate that the nation is projected to experience a shortage of Registered Nurses (RNs) due to factors such as the aging Baby Boomer generation and the growing need for health care services (www.aacnnursing.org).According to US Bureau of Labor Statistics (2018) projections, 1.1 million additional nurses are needed to avoid a further shortage.

The RN Work Project, a 10-year national longitudinal study of new nurses started in 2006, found that more than 18% of new nurses quit their first job within a year and more than 26% leave it within two years. Healthcare organizations need to take measures to retain their nurses. The first step in this direction is to look into the reasons why nurses decide to stay or decide to leave their job. Here are the findings of the 2018 Press Ganey Nursing Special Report on this matter:

  • Nurses across all age groups and experience levels cited dissatisfaction with the work environment as the key factor driving them to quit.
  • For nurses who had been practicing less than two years, praise, recognition, nurse manager support, certification, and joy in work were the key predictors of intent to stay.
  • For RNs practicing for more than 20 years, intent to stay was driven by leadership, influence over their schedule, and quality of care.
  • Nurses in adult step down and med/surgical units with sick patients and less staffing than a critical care unit, were more likely to say they were going to leave within one to three years.

As one expert notes, to prevent nurse attrition, organizations need to understand the varying motivators of job satisfaction across the nursing life cycle (www.healthleadersmedia.com). The following strategies can help organizations retain nurses in the workplace:

  • Improve the work environment: It’s hardly surprising that organizations with a negative reputation see an outflow of nursing staff. According to the Health Leaders Media report, one hospital struggled with nurse recruitment and retention due to its punitive environment leading to a lack of respect toward nurses by physicians and administrators, and from nurse to nurse. The hospital also acquired a negative reputation because of its poor quality outcomes and a restrictive policy of recruiting only experienced nurses. The situation improved significantly when the hospital took steps to improve the work environment.
  • Overhaul the recruitment process: The healthleadersmedia.com report describes how the hospital reversed its policy of hiring only experienced nurses and focused simply on recruiting graduates. The CNO met each candidate personally and spoke about the hospital’s vision for the future.
  • Flexible scheduling:  Flexible work options can serve as organizational recruitment/retention strategies. While needing significant work, nurses want to balance their many work-life responsibilities. With flexible work schedules for nurses, hospitals can manage their round-the-clock patient care needs. Flexible work options are a win-win situation for health care organizations and nurses.
  • Efficient role assignment: Hospitals will benefit if they deploy older nurses as mentors for new nurses. Experienced nurses can guide younger nurses and help them discharge their duties efficiently. The organization will benefit as the protégé’s confidence grows and the mentor contributes to the retention of a new nurse.
  • Fostering career development and recognition: Implementing measures to promote both career development and recognition are important to keep both experienced and fresh RNs. Nurses need professional support to stay abreast of technological advancements and innovations and get to the top of the game. Career ladders rooted in accomplishment vs. tenure can help organizations retain RNs.
  • Promoting a healthy work environment: Creating a healthy work environment allows nurses to provide high standard, compassionate patient care while promoting professional fulfillment and self-care to prevent burnout. Measures to improve working conditions and ease workload include adding more elevators and ceiling lifts, and investing in quality medical transcription services.

Organizations should also offer compensation and benefit packages to retain seasoned nursing staff. Older nurses should be adequately compensated for their role and experience. Additional incentives for retention include rewarding high performers, offering paid training opportunities, and providing more opportunities for internal advancement.

Unscheduled Return Visits after Emergency Department Discharge

25-April-2019 Rajeev Rajagopal Emergency Room Transcription

Emergency physicians provide quick diagnosis and treatment for acute illnesses. Emergency departments (EDs) function as a focal point for care and care transitions, and emergency room transcription services help ensure flawless medical records. According to the Centers for Disease Control and Prevention (CDC), ED visits in the US reached a record high of 145.6 million patients in 2016. One matter of concern is the frequency of patients returning to the ED within a short period of ED discharge.
Unscheduled Return Visits after Emergency Department Discharge
The CDC found that the most common medical factors driving ED visits were stomach pain (8.6%) and chest pain (5.2%). Injuries due to falls and motor vehicle crashes were the main types of injuries leading to ED visits. But while emergency physicians are focused on providing quality care that patients cannot get anywhere else, a 2018 article published by the American College of Emergency Physicians (ACEP) notes that, for over 20 years, “emergency physicians have been faced with hospital programs that report ED return visits, usually in a 72-hour window.”

Why do patients return to the ED? Studies have identified various reasons for this.

  • Concerns that their first visit did not adequately tackle their complaint.
  • Fear that their condition was getting worse and they did not understand their symptoms.Patients need assurance from their physician that their clinical symptoms do not signify a serious health concern.
  • Their needs were not adequately met and feel they need more tests.
  • Apparent inability to get timely follow-up care, to address ongoing concerns, and get answers to questions.
  • Patients’ preference for hospital-based care because of increased convenience and timely results.
  • Unscheduled return visits after ED discharge may also be an indication of poor discharge practices.
  • The ED is the most convenient place to get speedy care

Patients may return to the same ED or to another ED. Reasons for return visits to the same ED include a revisit for wound check, the deterioration of the original medical problem, treatment-related complications, repeat diagnostics or treatment, or the need for reassurance.On the other hand, a patient visit to another emergency department may be indicative of a transition to a higher level of care or of an inadequate initial patient encounter, where a concern was not addressed or resulted in a complication.

The ACEP report provides the latest (2014) data from the Centers for Disease Control and Prevention National Hospital Ambulatory Medical Care Survey on unscheduled return visits to the ED:

  • About 5.7% of ED visits were made by patients who had been seen in the same ED in the preceding 72 hours
  • About 4.8% of ED visits were for “follow-up.”
  • For around 3% of ED visits resulting in hospital admission, the patient had been seen in the same ED within the previous 72 hours.

Unscheduled return visits are often seen as an important indicator of treatment quality.  Return visits to the ED consume medical resources for more examinations, tests or observations, increasing expenses as well as ED overcrowding. A 2014 Agency for Healthcare Research and Quality report stated that hospital read missions in the United States cost $41 billion as of 2011. Medicare’s share was $26 billion annually, with $17 billion accounting for avoidable re-hospitalizations.

An ACP Hospitalist article identified several steps to prevent potentially unavoidable read missions. First, ER physicians need to know what patients expect from their hospital admission, and what they hope will improve. They should ask patients if they have any questions or if they are worried about something that has not been discussed. Patients should be also made to understand that the purpose of admission to the ED is to diagnose, assess, and triage. Most patients tend to think that the ED is a therapeutic place. Finally, as follow-up is critical in post-ED, ER physicians should work with primary care physicians (PCPs) to ensure that they prioritize discharge patients.

The ACEP article highlights recent studies which found that return visits resulting in hospital admission are not a sign of poor care. According to researchers, patients receive high-quality care in the ED, where they undergo appropriate testing and treatment, and are discharged because they do not meet admission criteria. They point out that encouraging return ED visits may in fact be a practical strategy as it will ensure that EDs are available for patients, especially for return visits.

 Medical transcription outsourcing can ensure high-quality ED medical records for improved patient care. With a reliable service provider, physicians are ensured of ED medical records that accurately reflect the evaluation, management, medical decision making, and disposition process.

Dictation Tips for Healthcare Practices – Get Great Transcripts

22-April-2019 MTS TEAM Medical Transcription

Accurate clinical documentation is critical to health care quality and safety. The quality and accuracy of medical transcripts are also crucial, because treatment decisions are based on the information in the chart.Error-free transcripts can be achieved only with clear medical dictation. With poor dictation and recording, even a professional medical transcription company will find it difficult to transcribe the records and thus fail to meet the turnaround time. Documentation errors that have an effect on clinically relevant data may pose risks to patient safety.
Dictation Tips for Healthcare Practices
Poor dictation habits can severely affect

  • the quality of patient care
  • timely reimbursement
  • medical transcription provider’s turnaround time

Often physicians may not pay due attention regarding the format they use, patient information, accents, background noise, and speech patterns. Such a poorly dictated report requires more attention and time from transcribers as well as multiple levels of review.

Best dictation practices to follow

While recording an audio file that needs to be transcribed, you must keep in mind these best practices.

Choose a calm and quiet environment

Doctors are often interrupted in their consultation room and background noise can be overwhelming.For transcriptionists, it may be challenging to deliver error-free transcripts especially when the dictation contains incomprehensible accents, mumbling, rapid speech and disturbing noises, which prevent them from meeting the expected accuracy level.You can even consider dictating in an outdoor location, while avoiding noisy areas such as that with traffic noises or windy areas which can compromise the audio quality. Hospitals should understand that high-quality dictation is for their own good too. Recording in incorrect formats can also impact the timely return of reports.
You should avoid speaking with your team members during the recording and also avoid other noises such as the ringing of mobile phones. In case of any distraction, make sure to pause the recording on your device.

Watch the dictation speed and volume

Often, physicians may be busy with their schedules and rush through the dictation process, resulting in reduced clarity.Dictating at an even pace helps the transcriptionist hear every tone of a vowel or consonant in a word.Volume issues are also a concern. If the volume of the recorded file is low or if the physician whispers, transcriptionists will be stuck. They can’t get what they can’t hear.Dictators have to speak loudly and clearly.
If you are new to the recording equipment, try test dictations and send the final copy. Send only encrypted audio files for transmission to your transcription provider.

Data organization matters

Another factor that leads to poor dictation is the lack of organization. If a medical case is reported unorganized and if they are interrupted, there are chances for doctors to leave out key points.For instance, if the dictator is explaining a surgical procedure and failed to mention closing the incision, transcribers too will not report this, leading to further consequences. Physicians should organize the data before dictating, by identifying details of referring physician information – address and/or fax number, the patient’s demographic details as well as how to send the report (mail or fax) and to whom. Start each dictation with your name.

Provide clear details

Make sure to include the patient’s full name, proper mailing address; file numbers; reference numbers; patient record number; and subject matter. Also, give clear instructions such as a starting a new paragraph as well as indicating punctuations, open or closed quotes and parenthesis.
Use abbreviations, only if their expanded form is reported at least once in the recording. Never abbreviate names of medications. Dosage instructions should also be dictated consistently to avoid any errors in transcript.

Plan a clear dictation process

With a clear dictation system and best practices prepared, doctors joining the facility can just go through and follow them to ensure quality dictations.The hospital’s transcription department or the medical transcription company the hospital has partnered with needs to maintain a log that records documentation problems, which would enable them to track any physician issues.Transcription providers can also rank their physicians in terms of correction effort, which provides another level of measuring their success as dictators.Physicians can ask for feedback on their dictations from the transcriptionist, which would help them improve.

Hire skilled transcriptionists

While poor dictation makes quality healthcare documentation a difficult job, practices must make sure that their transcriptionists have sound knowledge of basic to advanced medical terminology related to diverse areas including anatomy and physiology, disease process, and laboratory values and procedures.While dictating too hard medical terminologies, it is better for physicians to just spell out the word.It is recommended to consider medical transcription services provided by an experienced company, as an established firm will meet better accuracy level.
Many practices are now relying on speech recognition tools to transcribe their recordings, which help to improve EHR clinical documentation accuracy and boost patient safety. Even if such software can convert your words into text, quality checks need to be done to ensure accuracy. A study published in JAMA Network Open that analyzed how accurate dictated clinical documents created by speech recognition software are, has observed an error rate of more than 7% in speech recognition – generated clinical documents, which demonstrates the importance of manual editing and review.

Key Causes of Medical Diagnostic Errors

18-April-2019 Julie Clements Medical Transcription

key-causes-of-diagnostic -errors

Diagnostic errors have emerged as a pressing public health problem. Studies report that thousands of patients die or are permanently disabled every year due to diagnostic errors. While outsourcing medical transcription helps physicians focus better on their patients during appointments, errors in diagnosis can occur due to various reasons. According to a new analysis of national data from John Hopkins Medicine, diagnostic errors result in nearly 800,000 Americans dying or facing permanent disability annually across all clinical settings, including hospitals and clinics.

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Diagnostic errors often arise from a mix of clinician biases and systemic issues in healthcare, according to the Agency for Healthcare Research and Quality (AHRQ). Missed or delayed diagnoses, especially for conditions like cancer, are a major reason for malpractice claims. Research into these errors is frequently based on closed malpractice cases in primary care, pediatrics, emergency medicine, and surgery. Poor teamwork and communication among clinicians are common factors for diagnostic mistakes in emergency and surgical settings. Lack of reliable systems for managing outpatient care-like handling urgent patient calls or ensuring test result follow-ups—further raise the risk of diagnostic errors.

Let’s take a look at the common causes of diagnostic errors and effective strategies for prevention.

Why Diagnostic Errors Occur

There are different types of diagnostic errors that can occur due to various reasons. Different types of diagnostic errors include:

  • Misdiagnosis or incorrect diagnosis
  • Missed diagnosis – completely failing to identify a present condition
  • Delayed diagnosis – diagnosing a condition too late)
  • Failure to recognize a related condition
  • Missed complications – failing to recognize complications arising from a diagnosed condition
  • Communication errors – poor communication between healthcare providers or between the provider and patient

Many factors can cause diagnostic errors:

  • Flaws in clinical reasoning: Diagnostic biases or inaccurate beliefs affect decision-making. Physicians often rely on heuristics (“rules of thumb”) to reach a provisional diagnosis, especially when the patient has common symptoms. Cognitive biases include:
    • Availability heuristic – Diagnosis of current patient biased by experience with past cases or referring to what comes to mind most easily
    • Anchoring heuristic – Sticking with a diagnosis. For instance, when a patient does not respond to treatment, this type of bias would lead the physician to order a stronger dose or a different formulation of a previously prescribed medication instead of considering another diagnosis
    • Framing – Assembling elements that support a diagnosis
    • Blind obedience – Relying on another physician’s opinions, where an agreement is reached based on an authoritative source (such as laboratory and imaging test results) without adequate examination.
    • Omission bias – Placing excessive emphasis on avoiding the adverse effects of a therapy, which leads to under-utilization of a beneficial treatment.
  • Communication problems: Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication can result in diagnostic errors.
  • Errors related to testing: Diagnostic errors in the testing process can be classified as preanalytic, analytic, and postanalytic. Preanalytic errors refer to problems with test selection, ordering, and specimen collection. Analytic errors refer to problems performing a clinical laboratory test. Postanalytic errors include problems with interpreting tests, reporting. and use of test results to make a diagnosis.
  • Lack of reliable systems for common outpatient clinical situations: The AHRQ points out that lack of proper mechanisms for triaging acutely ill patients by telephone and following up on test results, also increases the chances of diagnostic error. Errors leading to misdiagnosis included inadequate documentation, faulty triage, and lack of protocols for handling telephone calls.
  • Time constraints: Limited time with patients during appointments can result in rushed assessments and potential oversights. When physicians have only limited time to assess patients, it can lead to rushed decisions and potentially overlooking crucial information, increasing the likelihood of misdiagnoses or delayed diagnoses. This is often due to high patient volumes within a limited timeframe, leading to hurried evaluations and missed critical details. Medical transcription services can help to a certain extent by allowing physicians to focus on the patient rather than on entering information into the EHR.
  • Overconfidence: Overconfidence is a risky trait in medicine, particularly in fields like emergency medicine, where patient outcomes depend on accurate and timely decisions. A study published in February 2024 (Adv Med Educ Pract) that looked into the possibility of a relationship between overconfidence, time-on-task, and medical errors, noted that overconfidence occurs when physicians overestimate their abilities, believing they perform better than they actually do. This can lead to diagnoses based more on personal opinion than on sufficient patient data. Instead of relying on relevant and reasonable information, overconfident individuals tend to trust their instincts.
  •  “The VIP Syndrome”: Researchers also highlight the VIP Syndrome as a reason for diagnostic errors. The VIP Syndrome is when the physician is intimidated or is unwilling to recommend things which may be unpleasant for their patient. This may lead them to prioritize special treatment or expedite care, potentially leading to diagnostic errors by rushing through assessments, overlooking crucial details, or ordering unnecessary tests, all in an attempt to please the patient. This can potentially cause misdiagnoses and compromise the quality of care.

Preventing Diagnostic Errors

Measures to prevent diagnostic errors include Improve clinician training, evaluate physician workloads and develop more accurate diagnostic tools and techniques. According to research published in JAMA Internal Medicine in January 2024, this could include using AI to evaluate patients, select the most appropriate tests and reduce delays. However, the study cautions that care must be taken to ensure the models are performing correctly without introducing errors or widening health disparities.

“In the end, helping physicians become better diagnosticians means coaching and training physicians, and helping physicians clearly explain diagnoses to patients,” says the paper’s first author, Andrew Auerbach, MD, MPH. “I suspect AI will help with many tasks, but we still have work to improve communication between patients and healthcare team members to fully advance the field,” he notes (source: UCSF).

Outsourcing Medical Transcription Can Help

Partnering with a medical transcription company is a viable strategy to deal with EHR-related documentation concerns and prevent missed diagnosis due to reduced time that physicians have with their patients at the appointment. Professional transcriptionists can ensure clear and accurate documentation, which can play a crucial role in minimizing diagnostic errors by providing a comprehensive record of a patient’s medical history, symptoms, examination findings, and test results. This allows healthcare providers to make informed decisions based on complete information, thus reducing the risk of misinterpretations or overlooking vital details that could lead to incorrect diagnoses.

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How Technology is Making a Difference in the Emergency Department

11-April-2019 Rajeev Rajagopal Medical Transcription

Technology now impacts every aspect of our lives. In the medical field, technological innovations have transformed healthcare delivery. Innovative software and other advancements allow medical transcription service providers to work with physicians to turn their clinical dictations into notes for integration into electronic health records (EHRs). Recent reports draw attention to the role of technology in the emergency department (ED). IT implementation in the ED is making a difference by boosting operational efficiency, reducing costs, and improving patient outcomes and staff retention.technology-making-difference-emergency-department

  • Telemedicine: Telemedicine is a great example of medical technology. In the ED, telemedicine is decreasing improper admissions and readmissions, saving costs and promoting efficient resource allocation (www.healthtechmagazines.com). One of the main concerns in EDs is high patient volume, which strains resources. With video technology, the ability to share and review images, and to interact with the patient, telemedicine can reduce ED response times greatly and improve access to specialty care. Providers can use the technology to make risk-based decisions about patients’ care. ED visits for individuals with behavioral health issues are rising and patients may have to wait for hours for an evaluation. Telepsychiatry programs can reduce behavioral health load in the ED and deliver quality, cost-effective, timely mental health services.
  • Artificial Intelligence: A 2018 UC Irvine (UCI) health report described how artificial intelligence tools speed emergency care at the UCI Medical Center. The center has implemented an innovative app that takes just about 20 seconds to analyze a CT scan for cerebral hemorrhages. This task can take more than an hour in a busy ED. Another AI tool at the center assesses magnetic resonance imaging (MRI) results to grade genetic mutations in deadly brain tumors that cannot be examined safely via surgical biopsy as they are too deep. The technology can also predict a tumor’s growth and recommend countermeasures. According to the UCI center’s scientists, technology can even learn to interpret all sorts of medical images and data.
  • Communication tools: Technology continues to improve communication in the ED. While EHRs have helped streamline health management and communication in emergency situations, a 2016 Business Journal report discussed several technologies that have reduced the stress associated with ED visits and made them more patient-friendly. Technology helps patients make the important decision on where to go in an emergency. They learn about estimated ER wait times on hospital websites or digital freeway billboards. ER staff can be notified of the patient’s symptoms via a web or mobile emergency room notification app, including expected arrival time. This will help ED staff better prepare for treatment. Patients can also use the app to fill out a registration form online or expedite the process at a registration kiosk. Some systems let patients scan their health care card, whereby information about them will be instantly downloaded from a health information exchange.

Once patients are in the virtual line, they can sign up to track their wait time via text messages. Text updates from the hospital team will also keep the patient’s loved ones informed about treatment progress. After they return home following the treatment, patients can continue to manage their health online. They can access their electronic medical record (EMR), find a physician, make appointments, and get answers to health care questions.

  • Smartphones and tablets for ECG review: Physicians can review ECGs on tablets and smartphones (www.dicardiology.com). Cardiologists can get immediate access to ECGs wherever they are and immediately evaluate chest pain patients for potential ST-elevation myocardial infarction (STEMI). By enabling earlier activation of the cath lab, especially during off-hours, this technology can help reduce door-to-balloon times. It can also simplify and speed collaboration in hospitals, allowing the ED or ICU staff to get a cardiologist’s opinion on abnormal ECGs. Physicians can also review regular ECG exams in between procedures or at their convenience.
  • Electrocardiogram-transmitting technology: Paramedics and physicians in Roseville, Calif., are using state-of-the-art electrocardiogram-transmitting technology to get things move faster in the ED (ww.gov.tech). This wireless technology can cut about 20 minutes off of the time it takes from when a patient enters a hospital until doctors provide life-saving intervention. It allows paramedics to send 12-lead electrocardiogram (ECG) results, or data from 12 angles of the heart’s electrical system, to a specially designated hospital where emergency room doctors and cardiologists can assess the patient’s heart condition before arrival. This is improving patient outcomes and patient lives.

Patients who arrive in the ED may be unresponsive or unable to supply the requisite details. While medical transcription outsourcing can ensure quality EHR documentation, interoperable EHRs are necessary for ER physicians to create a complete picture of the patient’s health history and develop the emergency care plan. However, true EHR interoperability is far from fruition. Industry stakeholders need to work towards EHR interoperability to improve quality of healthcare processes in general and in the ED in particular.

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