How Physicians Can Reduce Documentation Burden and Optimize Health Information

17-December-2018 Julie Clements Medical Transcription

The innovative system of blending EHR and medical transcription service has helped medical professionals to achieve a higher level of quality in their work. Electronic Health Record or EHR is a systemized collection of patients’ healthrecords that are stored in electronic format. The EHR enhances the ability to exchange health data electronically and ensure high quality service and safe care for patients. EHR documentation includes complete details of the patient which includes name, data, demographics, allergies, medical history, medication, lab test reports, medical bills etc. These health records can be shared through a connected network across various health care settings so that providers can access the data from anywhere and give their expert opinion. The EHR market is expected to grow drastically by 2023. In many countries financial incentives are given for the implementation of EHR. The global electronic health record was valued at $23,592 million in 2016 and is expected to reach $33, 294 million by 2023.

Even though the EHR system provides various advantages, physicians are forced to sit in front of the computer rather than spend time with the patients.

The Centre for Medicare and Medicaid Services are aiming at reducing the burden of paperwork on physicians. Obtaining patient history and completing the documentation on a patient is very important from the point of view of patient care and good clinicians achieve that. Documentation should not be a burden because it is an integral part of patient care. However, documenting and re-documenting is a waste of time. Physicians should ensure that they are not wasting their valuable time by obtaining worthless information that may not be relevant to the care plan. One way to eliminate obtaining valueless information is to stop mandating arbitrary family history and random review of systems.

Here are some suggestions that Dr. Erica E Remer, a qualified and experienced Emergency Medicine physician with over 25 years of experience proposes whereby physicians can obtain valuable information, avoid useless information, and reduce the burden of medical documentation on healthcare providers.

1. History is important it must be obtained by ancillary personnel and reviewed and validated by the provider. Stop copy and paste of previous documentation in prior notes.
  - Family history and pertinent past medical or surgical history should be obtained.
  - Social history of patients which may include tobacco or alcohol use should be collected as it may be relevant.
  - The physical examination should be appropriate for the chief complaints or chronic condition or potential diagnoses.
  - Medical decision making should clearly show what the provider was considering and thinking, the plan to evaluate the problems, and what the investigative studies demonstrated.
  - Review of systems should be obtained and there should not be any numerical value of system so that patient cannot understand the seriousness of the illness.
  - All diagnoses should be addressed.
2. Medical necessity mustbe met for everyone.
3. Submission of bill for payment should be on the basis of:
  - Complexity of medical decision making like acute problems or multiple problems or high risk patients
  - Time: complex history acquisition, review of various diagnostics studies, complex counselling, spending extra time talking to patients in case of unnecessary antibiotic or suicide and should be compensated, consultation and discussion with other healthcare providers.

Healthcare providers should be paid for the amount of work they have done. While documentation is important, giving proper patient care is more crucial. Healthcare units can minimize the burden of medical documentation by hiring a reliable medical transcription company that can ensure complete accuracy in the medical records. With good medical records and reliable health information healthcare centres can make better clinical decisions and also provide improved health care.

Non-alcoholic Fatty Liver Disease a Major Contributor to Increasing US Healthcare Costs

13-December-2018 Rajeev Rajagopal Diseases and Conditions

Healthcare costs are phenomenal in the United States. It is estimated that the nation spent 17.8% of its GDP on healthcare in 2016. In comparison, the average spending of 11 high-income countries – Canada, Germany, the U.K., Australia, Sweden, Japan, France, Switzerland, the Netherlands, Denmark and the U.S – was only 11.5%, according to a new report published in the Journal of the American Medical Association. The U.S. spent $9,403 per capita, which is almost double what the others spent. There are many reasons for this excessive spending in the United States – medicines are more expensive, doctors are paid more, diagnostic tests and hospital services cost more, and considerable money is spent on planning, regulating, and managing medical services at the administrative level. Medical transcription costs are also considerable in hospitals, and many hospitals are looking to reduce in-house transcription costs by adopting medical transcription outsourcing that is more affordable. Among other major factors contributing to increased healthcare costs are certain chronic diseases that Americans suffer from such as cardiovascular diseases, smoking and alcohol related health issues, diabetes, Alzheimer’s disease, cancer, obesity, arthritis, asthma and stroke. Liver disease is looming as another major healthcare threat now in the United States.

According to the American Liver Foundation, around 100 million individuals in the United States suffer from non-alcoholic fatty liver disease (NAFLD) and it costs the U.S. healthcare system around $32 billion annually. It is the most common form of chronic liver disease now, and the prevalence of this disease reflects the increasing trend of obesity in America. The extra fat build-up in the liver cells in this case is not due to alcohol. There is a real need for readily available treatments for this health condition, which could save money as well as valuable human lives.

Researchers at Intermountain Healthcare’s Intermountain Medical Center in Salt Lake City examined medical records from 2005 to 2015 and identified 4,569 patients diagnosed with NAFLD. A control group of 12, 486 patients with no diagnosis of the disease was identified for comparison purposes. With the help of data from SelectHealth, the insurance section of Intermountain Healthcare, the researchers analyzed the healthcare costs per patient and the overall costs per year in both groups. The calculations indicated an economic burden of $32 billion annually for the United States.

The costs of the disease comprised of:

Emergency room visits
Inpatient hospitalization and outpatient appointments
Mortality
New medication or changes to existing medication
Organ transplantation
Medical procedures or new diagnoses

This research is the first ever estimate on actual healthcare utilization associated with non-alcoholic fatty liver disease in the US.

Obesity or gaining fat is one of the main reasons for non alcoholic fatty liver. The liver stores fat in its cells and as the amount of fat increases the disease advances to non-alcoholic steatohepatitis and it is marked by liver inflammation and scarring that may cause irreversible damage. If the disease is ignored, then it leads to liver failure. People who are overweight, have diabetes, or have family members with liver diseases must be screened for non-alcoholic fatty liver disease.

This is an era of rising healthcare costs and diseases that were uncommon and unrecognized a decade before, have now become major epidemics that will further drive costs in the years to come. The study highlighted the fact that if treatments do become available, there could be potential reduction in healthcare costs. The researchers have validated a predictive risk score that uses basic lab values and a patient’s medical history to predict which patients are at a higher risk of developing liver damage due to NAFLD. They intend to use this prediction tool to understand the problem at a population level by intervening with nutritional and therapeutic options that may include clinical trials, before the patient reaches end stage liver disease. Community initiatives can also play a significant role in increasing awareness about NAFLD and motivating people to adopt a healthy and active lifestyle that can prevent obesity and its related complications.

When it comes to treatment and care for liver disease accurate medical records are crucial. Care providers must have easy and anytime access to patients’ medical records and this can be ensured by medical transcription companies that provide value-added medical transcription. Research reports show that hospitals plan to deploy more medical transcription tools or utilize outsourced medical transcription from a good medical transcription firm to control transcription costs.

Hospitals Are Planning to Use More Medical Transcription Tools, Says Study

10-December-2018 MTS TEAM Medical Transcription

Software dealers are adding more modern features to legacy tools and hospitals are increasingly embarking on digital transformation initiatives that involve automation, outsourcing and advanced reporting techniques. In fact, more and more hospitals are considering implementing medical transcription technologies or using medical transcription services. According to recent research reports, hospitals are planning to deploy more medical transcription tools from companies including Acusis, Nuance, MModal, iMedX, Precyse, Scribe Healthcare, Superior Global Solutions, Transcend Services and TransTech Medical Solution among others. In their report released last month, Technavio, a leading market research company, reveals that hospitals worldwide will spend more than 72 billion by 2020, representing 6 percent compound annual growth rate. Voice recognition technologies are a big driver of hospital plans. Another market research company, Radiant Insights, says that the key factors driving hospitals to adopt transcription tools are their reliability, portability and cost-effectiveness.

Radiant Insights also forecasts that the increasing adoption of automatic transcribing technologies is expected to replace various analog devices in the near future. Other factors responsible for the growth of the market are the rise in the value of skilled professionals and an increase in medical transcription outsourcing. Moreover, increase in the number of transcribers coupled with many years of training to learn various methodologies and terminologies are expected to boost the overall market demand in near future.

As more hospitals are focusing on outsourcing medical transcription to third-parties, this is likely to double the number of third-party service providers. The medical transcription (MT) industry is considered to be one of the most vibrant segments in the healthcare management sector, as it is affected by changing technological transformation.

Many initiatives undertaken by local governments including rising adoption of the electrical health record systems in both developed and developing economies are expected to fuel market growth in the coming years. The increasing popularity of automation in the healthcare sector in order to provide superior, safer and quality service to patients is positively influencing the current model of medical transcription industry.

Medical transcription is the process by which doctors and healthcare professionals process health records which are then converted into readable text format from voice and text report. This data is used mainly by Health Information Technology organizations and electronic health record (EHR) initiatives. Instant transcription is provided for storage and transfer of the voice recorded data to the medical transcription department. The recent technological revolution in the healthcare sector has led to growing adoption of electric consoles, word processors and several smart devices. The medical transcription devices available now have in-built speech recognition and memory storage systems. Generally, medical transcription is performed by healthcare professionals or in-house transcriptionists.

The medical transcription industry is categorized into regional market segments such as North America, Europe, Asia-Pacific, Latin America and Africa. North America has shown major growth in recent years due to the rise in the adoption of the latest technologies in medical sciences and the existence of a well-established healthcare infrastructure. The end users of medical transcription services include hospitals, physician practices, clinical laboratories, academic medical centers and others.

Beware of Dangerous Transcription Errors in Medical Records

06-December-2018 Julie Clements Medical Transcription

Accurate clinical documentation is critical to health care quality and safety. As an experienced medical transcription company in the U.S., we understand the importance of accuracy when transcribing medical records. Error-free transcripts ensure the right treatment and help avoid legal consequences. Patients, mainly older adults, have to be very careful about what’s in their medical record.

According to reports from the Office of the National Coordinator for Health Information Technology, 8 in 10 individuals who have viewed their medical record online considered the information useful, and it is estimated that nearly 1 in 10 people who access records online end up requesting that they be corrected for a variety of reasons. The report also finds that 27% individuals were unaware or didn’t believe that they had a right to an electronic copy of their medical record.

Kaiser Health News recently discussed the impact of medical record errors in patient care. Based on the live examples given, diverse errors you can expect in your medical records include:

Your medical records may come with pages and pages of notes that referred to a different person with the same name, but different medical conditions that were much more complicated and numerous than yours
An incorrect diagnosis, scan or lab result may have been inserted into your record, raising the possibility of inappropriate medical evaluation or treatment
Medical conditions you don’t have. For instance, a patient’s record contained “renal cell carcinoma” (kidney cancer), instead of “basal cell carcinoma” (skin cancer) – an illness mentioned while describing his medical history.
Records indicate the patient has an underactive thyroid when in fact he/she has an overactive thyroid.
Certain things may be omitted such as lab results, allergies and medications; and family history may not be conveyed accurately
Demographic information such as patient’s name, address, phone number or personal contacts may also be incorrect, making it difficult to reach them in case of an emergency or causing a bill to be sent to the wrong location.

Under HIPAA guidelines, if an error is discovered in the medical record, patients have the right to ask for a correction. It is recommended to check with your doctor or hospital if they have a form (either a paper or electronic version) to submit a suggested change. Errors such as a wrong phone number can be corrected by drawing a thin line and marking the suggested change in the margins or making an electronic note. At the same time, complicated errors such as incorrect description of symptoms or a diagnosis may require a brief statement explaining what material in the record is wrong, and why and how it should be altered. In most states, physicians and hospitals are required to respond in writing within 60 days, with the possibility of a 30-day extension. Patients also have the option to file a complaint with the government office that oversees HIPAA or a state agency that licenses physicians.

It is also noted that rejections can be warranted when facts or medical judgments are in question. For instance, if the patient needs to eliminate a diagnosis from the record, as she won’t be eligible for an insurance coverage, it wouldn’t be an acceptable reason for making a change.

Errors can also occur in transcripts created by speech recognition software. A July 2018 study published in JAMA found that among 217 clinical notes randomly selected from 2 healthcare organizations, the error rate was 7.4% in the version generated by speech recognition software, 0.4% after transcriptionist review, and 0.3% in the final version signed by physicians. This study notes that 7 in 100 words in unedited clinical documents created with SR technology involve errors and 1 in 250 words contains clinically significant errors. Observed error rate in speech recognition-generated clinical documents also demonstrates the importance of accurate medical transcription services, manual editing and review. Online access to medical records serves as a key tool to help individuals and caregivers understand their health and manage their health care needs. While accessing medical records, patients must make sure to look for possible mistakes in their personal details (name, address, health insurance plan provider, social security number), health information (doctor’s appointment notes, medical history, symptoms, diagnoses, medicines), and their medical bills.

Aligning Radiology Metrics with the Goals of Value-based Care

03-December-2018 Rajeev Rajagopal Radiology Transcription

Correct and timely imaging reports are critical to make the right treatment decision and radiology transcription services play a key role in helping radiologists convert dictated reports into intelligent and accurate documents. The shift to value-based care brings new challenges for radiologists, but also provides new opportunities for them to contribute to better patient outcomes.

The basis of the value-based healthcare approach is paying healthcare providers based on the patient’s health outcome and not on basis of volume of services delivered. How is value in healthcare defined? According to the authors of a book titled Redefining Health Care, value is “the health outcomes achieved per dollar spent.” They state that “improving value requires either improving one or more outcomes without raising costs or lowering costs without compromising outcomes, or both.”

So radiologists need to demonstrate improved value by aligning radiology metrics with the goals of value-based care. However, this is a challenging task. On the one hand, technological advances have transformed the role of radiology imaging tools from static to dynamic. Medical imaging plays a critical role in disease management as it can help diagnose numerous conditions and is used in almost every branch of medicine. However, as a www.hospitalhealthcare.com report points out, the specialty of radiology faces several unique problems such as increased workload, shortage of imaging specialists, and limited time available for interpreting and communicating the imaging exams with patients and referring clinicians. This poses challenges for radiologists to improve operational efficiency, performance and quality, and achieve the goals of value based care. Here are some expert suggestions for improving radiology outcomes without increasing costs:

Reduce duplication of imaging studies: Additional imaging tests should be recommended by radiologists only when such additional testing is truly necessary. However, a study published in the Journal of the American Medical Association reported that there is a high incidence of repeat imaging – CT scans, ultrasound scans, and chest X-rays – in emergency departments (EDs). The researchers said the drivers of unnecessary diagnostic imaging include incentives offered to non-radiologist physician offices to install advance imaging equipment and order abundant imaging tests to generate revenues, self-referrals by patients themselves after hearing about the latest in MR or CT scans, and duplication of tests when a patient switches physicians. Going by the appropriateness criteria published by the American College of Radiology can ensure that imaging is ordered and performed only when warranted.
More effective diagnostic imaging testing for quick, accurate clinical diagnoses: Providing the right image with the right interpretation at the right time is necessary for prompt, accurate diagnosis. However, in a September 2015 report, the Institute of Medicine said that each year, 5 percent of outpatients experience a diagnostic error, and up to 17 percent of adverse events experienced by hospitalized patients each year are caused by diagnostic errors. Leading healthcare company Mckesson says maximize diagnostic imaging in value-based care, radiology departments need to:
- Allow real-time accessibility: Enable images from imaging systems to be accessible to clinicians real-time on a variety of devices in a variety of settings.
- Maximize efficiencies: Assess imaging workflows to identify opportunities to reduce testing and turnaround time.
Establish broad-based health information exchange (HIE): Experts recommend that establishing broad-based health information exchange (HIE) can lead to substantial health care savings by reducing duplicate ED ultrasounds, chest X-rays and CT scans. Clinical data from patients’ electronic medical records, which physicians have access to, should be integrated into workflow of the diagnostic imaging department. This will promote safe and effective diagnostic imaging. Radiologists, technicians and other department staff should have access to all the following patient information:
- History and physical
- ED notes
- Pathology reports
- Surgical history
- Discharge notes
- Laboratory results
- Allergies
- Medications
Medical transcription outsourcing ensures the accuracy of such information which is critical for interpreting images correctly and making accurate diagnoses. Having imaging-relevant patient information from EHRs integrated into the diagnostic workflow also promotes operational efficiency, saves, times and helps avoid unnecessary follow-ups or repeat tests.
Provide high quality, accurate reports: Providing radiologists with two-way access to the EHR can reduce the risk of mistakes, according Carestream. Supplementing radiology reports with multimedia will boost efficiency while adding value to conventional reporting, according to a study published in the Journal of the American College of Radiology. Experts say that multi-media radiology reports with text and images, tables, graphs, and relevant hyperlinks specific images and bookmarks will help the referring physician get a quick understanding of the study, easing collaboration with the radiologist.
Improve communication: Radiology business recently reported on a new study published in Radiology which stressed the importance of good communication between the referring physician and the radiologist. The authors wrote that it is no longer acceptable to use imprecise terms such as ‘interval’, ‘short-term’, ‘non-urgent’ or ‘routine’. They noted that radiologists’ recommendations should follow national guidelines and other accepted practice standards. Attaching disclaimers excusing typographic and grammatical errors was not acceptable, they wrote. Communicating directly with the physician via telephone can also help avoid errors in care.
Reduce the complexity of information technology (IT) tasks: Managing their IT tasks is a challenging task for radiology practices. A recent Radiology Business article says that the complexity of IT tasks can be reduced by bringing together the right systems, software, infrastructure, and team. The report describes how Central Illinois Radiological Associates (CIRA), one of the Midwest’s largest private diagnostic and interventional radiology groups, minimized IT complexity by creating an enterprise worklist. Radiologists can now view all their studies within their specific subspecialty throughout all hospitals and systems they read for, in proper priority. Interfaced systems simplified data and reporting, improved physician workflow, and eliminated manual IT tasks, offering benefits for patients, physicians and the practice at large.

As radiology practices strive to create value, achieve affordable care, and promote better outcomes and patient and physician satisfaction, radiology transcription companies will provide all the support they need to create correct, intelligent, and timely imaging reports to ensure the right treatment decisions.

New Research: Infectious Diseases have a Seasonal Element

29-November-2018 MTS TEAM Infectious Diseases Transcription

Every year, infectious diseases take a heavy toll on health and healthcare resources in the U.S. The most common infectious diseases in the U.S. are influenza, viral hepatitis, measles, mumps and Rubella, pneumonia, STD, AIDS and HIV, and whooping cough. According to the CDC, the number of visits to physician offices for infectious and parasitic diseases stood at 16.8 million in 2015. Many physicians rely on medical transcription services to manage their documentation tasks as they focus on managing their patients. Our medical transcription company sees a rise in demand for infectious diseases transcription services in November-December, commonly called the flu season.

A new study from the Columbia University Mailman School of Public Health suggests that infectious diseases have a seasonal element. The researchers say that although flu can circulate throughout the year, flu viruses are spread most commonly in fall and winter. The study was based on data of 69 infectious diseases, including neglected tropical diseases, collected from the WHO, the US Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control. The main findings of the study published in the journal PLOS Pathogen are as follows:

There are periodic surges in disease incidence correlated with seasons or other annual conditions, though the reasons for this seasonality are not entirely clear.
While outbreaks of influenza in winter and chickenpox in the spring are common, each acute infectious disease has its own “seasonal window of occurrence”.
Seasonality of acute infectious disease can vary among geographic locations and differ from other diseases within the region.
In addition to acute infectious diseases, the incidence of chronic infectious diseases such as hepatitis B virus and HIV/AIDS is higher during certain times of the year.
Many infectious diseases can have a common seasonal driver while differing greatly in many aspects of their biology.

The researchers examined four drivers of seasonal outbreaks: environmental factors, host behavior, host phenology, and exogenous biotic factors.

Environmental factors: Breeding of mosquitoes is influenced by temperature and rainfall, and seasonal weather may affect human immune response through the availability of food or exposure to very cold conditions.
Host behavior: Infectious diseases are spread through some kind of contact such as direct, through the air, and in droplets. Both human behavior and the behavior of pathogens have a seasonal element. The report notes that measles spikes when “susceptible hosts are gathered together”, that is, when school is in cessation. Host behavior also influences transmission. The New York State Department of Health reported an increase in measles cases in October 2018. In Brooklyn, six children were infected by a child who visited Israel, which has experienced an outbreak this year. Similarly, moving to locality with confined areas and inadequate infrastructure also increases the risks of contracting infectious diseases.
Phenology: Circadian rhythms and innate metronomes also impact human immune systems with cells counts fluctuating throughout the day.
Exogenous biotic factors: Many diseases are associated with interactions that occur within the “ecological community of hosts, reservoirs, and vectors,” according to the new study. For instance, the complex relationships between antibiotics and the human gut microbiome causes pathogenic bacteria like Clostridia to grow faster, and reduce bacteria that restrain those more harmful agents.

Previous studies have also drawn attention to the link between influenza outbreaks and climate. A 2016 study in the Proceedings of the National Academy of Sciences of the United States of America examined the correlation between absolute humidity, temperature, and flu outbreaks. The researchers reported that the amount of water vapor in the air drives influenza across latitudes. In colder temperatures, high humidity reduces influenza incidence, while in higher temperatures, high humidity increases influenza incidence.

Researchers call for specific public health initiatives during cold, dry, temperate winters to prevent flu transmission. People can reduce their risk of infectious diseases by taking precautions such as: frequent and thorough hand washing, particularly after coughing or sneezing; cough or sneezing into a tissue instead of hands; not touching the nose, mouth or eyes, the entry points for the influenza virus; not sharing food, cups, bottles, and other materials, and consulting a doctor/staying at home if feeling ill.

Physicians need to urge patients to get the flu vaccine by educating them about its benefits. A recent WKBW report cites Dr. William Schaffner, an infectious disease specialist at the Vanderbilt University School of Medicine as saying, “The vaccine is not perfect, none of us believe it is, but it’s the best thing we have for preventing influenza, and even if it doesn’t prevent the illness completely, and this is very important, it tends to make the illness milder.”

Each year, flu activity varies with different strains spreading across the nation. From May 20 to Oct. 13, 2018, around 197,300 respiratory specimens were tested for influenza by U.S. clinical laboratories. Up to 1.4 percent of the specimens were positive, including about 65 percent positive for influenza A viruses and about 35 percent positive for influenza B viruses. Timely and accurate documentation is essential to ensure appropriate care. Busy physicians can ensure this by partnering with an experienced medical transcription company for infectious disease transcription.

CMS makes Documentation Changes and other Reforms to Promote Patient-centered Care

26-November-2018 Julie Clements Medical Transcription

Patient-centric solutions have been at the core of healthcare for decades. However, there are many challenges to the attainment of true patient-centered care. The 2019 Physician Fee Schedule (PFS) of the Centers for Medicare & Medicaid Services (CMS) renews the focus on achieving this goal by reducing administrative burden and documentation guidelines in order to free up physicians to provide more patient-centered care. The new documentation guidelines also have implications for medical transcription companies as they provide EHR-integrated documentation solutions for healthcare providers.

Reduced Documentation BurdenAs every medical transcription service provider knows, the Evaluation and Management (E/M) visit has three components: the history, the exam, and the medical decision making (MDM). The changes to Evaluation and Management (E/M) documentation rules in 2019 remove the necessity to document the following:
- The medical necessity of a visit
- Repeat information when that information is already contained in the medical record. Providers should still review and update past data.
- For outpatient visits, the patient’s chief complaint in the medical record if that complaint has already been entered by administrative staff or the care beneficiary
- Other potentially repetitious information
The key aspects of E/M documentation under the CMS 2019 proposed rule are as follows:
- New time reporting option: Currently, selecting a visit based on time requires providers to document the duration of face-to-face time with the patient and greater than 50 percent of the visit must be spent in counseling or coordination of care. Beginning Jan. 1, 2019, practitioners can document office and outpatient E/M visits using medical decision-making or using time, regardless of the level of history or physical exam performed. Practitioners can use time as the governing factor in selecting visit level and documenting the E/M visit, whether or not counseling or care coordination dominates the visit.
- Medical decision making: Physicians can now select their level of service for both new and established patient office visits using only the medical decision-making component. Currently, new patient visits have to meet requirements for all three key components of history, examination, and medical decision-making. Meeting requirements for higher levels of service can be difficult especially difficult for new patient visits. The new rules remove the need for unnecessary documentation that does not contribute to patient care.
- Re-recording documentation burden: Expanding current options for history and exam documentation will allow providers to focus on changes since the last visit or pertinent items that have not changed, instead of re-documenting information. Practitioners can review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering it.
TelehealthCMS new proposals include paying for two newly defined physicians’ services provided using communication technology. These services relate to virtual check-ins and remote evaluation of recorded video and/or images submitted by an established patient. Reimbursement is proposed for the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to determine whether an office visit or other service is needed. The service of remote evaluation of recorded video and/or images submitted by an established patient would also allow physicians to receive separate reimbursement for reviewing patient-transmitted photos or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed. There are new reimbursement opportunities for chronic care remote physiologic monitoring and inter professional internet consultation.
Home Health and Remote Patient MonitoringThe PFS also includes provisions that will reimburse providers for patient communications via remote patient monitoring (RPM) tools. A type of telehealth delivery system, RPM refers to the use of digital technologies to collect medical and other types of health data from an individual in a location outside of conventional clinical settings and electronically transmit that information securely to a healthcare provider in a different location for assessment and recommendation. RPM tools allow healthcare providers to connect with their patients more effectively and efficiently at home and collect data for care management and coordination. RPM can improve health outcomes and reduce the cost of care. The three new medical codes have been created to bill Medicare for RPM services in 2019.
Other measures to meet promote better patient care include updated payments for home health care with a new case-mix system and new home infusion therapy services. A case-mix system called the Patient-Driven Groupings Model (PDGM) has been introduced for home health payment models. The PDGM would consider complex patient mixes for reimbursement rather than simply the volume of care.
Interoperability of Medical RecordsCMS is also focusing on redesigning its health IT programs to put patients in charge of their own health data. Patients need to be able to easily access and interact with their medical records in order to participate better in their own care. CMS is striving to improve interoperability to allow patients to carry their data with them as they move through the health care system. This will ensure that providers have the necessary information to make the right diagnosis and provide appropriate treatment for their patients.
Complete and accurate medical records improve the quality and efficiency of medical care, and lower costs. Outsourcing medical transcription can ensure timely and legible EHR documentation to meet the new guidelines, allowing physicians to focus better on their patients’ interests.

Medical Transcription Service Market to Witness Growth through 2019

22-November-2018 Rajeev Rajagopal Medical Transcription

The arrival of the EHR may not after all, spell the doom of the medical transcription services industry. This is what the market analysis figures seem to suggest. Traditionally, physicians have been utilizing reliable transcription solutions to lighten their documentation burden and to ensure timely documentation of all patient care activities. When the electronic health record became mandatory, physicians found themselves in the position of data entry personnel with the responsibility of filling in the various fields in the EHR. Medical transcription companies again rose to the occasion with EHR-integrated transcription service via HL7 interface. For doctors treating patients, medical records are a source that help them assess the current health condition of the patient, decide on the course of treatment and also take follow up measures. Accurate medical records also form the basis on which healthcare insurance carriers are billed and healthcare providers are paid for their service.

According to a market report published by Transparency Market Research “Medical Transcription Service Market – Global Industry Analysis, Size, Share, Growth, Trends and Forecast 2013 to 2019,” the medical transcription market is expected to grow at a CAGR of 5.6 percent and reach an estimated value of USD 60.6 billion in 2019.

The global medical transcription service market is divided on the basis of service types and by the mode of procurement of transcription services. On the basis of service type, the market is classified into History and Physical Report, Discharge summary, Operative Note or Report (OP), Consultation Report, other reports like Pathology report, and Radiology Report market. Among these, the market share of Consultation reports is the largest in medical transcription services. The Consultation report is produced for each and every patient undergoing treatment and in 2019 the global market for Consultation report or Consults is expected to reach USD 2.11 billion. The share of H&P (History and Physical) Report is also rising because earlier H&P reports were made only for hospitalized patients but now these are made for both inpatients and outpatients due to the risk of reimbursement problems.

Outsourcing is regarded as one of the most preferred modes of medical transcription service procurement due to the ease of operation, quick turnaround times and easy allocation of monetary resources on the basis of the nature of reports. Another mode of service procurement is off shoring.

North America currently dominates the market and is expected to retain its position in the future also. The North American medical transcription service market is expected to grow at a CAGR of over 5 percent by 2019. The global medical transcription service market is very competitive in nature with a huge number of market consolidation activities being conducted in the past ten years. Key market players in the transcription service market are Nuance Communications, iMedX Information Service Pvt, Precyse Solutions LLC, and Scribe Healthcare technologies.

Medical transcription is one of the most common outsourced services the healthcare industry uses, and the primary motive of outsourcing medical transcription requirements is to reduce cost and save time that is spent on documentation.

For good quality medical transcription services, it is best to seek the support of a medical transcription company that uses advanced technology to provide flawless services.

EHRs contributing to Pediatric Medication Errors, finds Study

19-November-2018 Rajeev Rajagopal EHR Transcription

Pediatric Medication Errors

Electronic health records (EHRs) are designed to enable physicians to efficiently manage and access comprehensive patient information digitally. EHRs provide a centralized platform for storing medical histories, treatment plans, medications, and test results. However, entering and registering patients’ data in their EHRs can take up to 40–50% of the physician’s time during working hours. This has led most providers to turn to HIPPA-compliant medical transcription companies to better manage their EHR documentation needs. Though outsourcing medical transcription is a practical solution to ensure accurate EHR data entry, studies say that poor EHR design can lead to errors that compromise patient safety.

Streamline your record-keeping process, ensure accuracy, and free up valuable time with our medical transcription services!

Call (800) 670-2809 today!

EHR Usability Issues: What Studies Found

A study published in Health Affairs found that usability of EHRs accounted for more than a third of medication errors noted in 9000 pediatric patient safety event reports. Led by Raj Ratwani, director of the National Center for Human Factors in Healthcare at MedStar Health, the study defined usability as “the extent to which the technology can be used efficiently, effectively, and satisfactorily” based on system design and customization to specific workflows. With physical characteristics that differ from adults, children may be at greater risk of harm from poor EHR usability.

The four general usability categories and warning signals for EHRs were listed as: System feedback (inappropriate), Visual display (clear, confusing, or cluttered), Data entry (difficult or impossible), and EHR workflow and clinician expectations (mismatch).

The study looked into nine types of medical errors defined by the National Medication Errors Reporting Program of the National Coordinating Council for Medication Error Reporting and Prevention: improper dose, wrong strength/concentration, wrong drug, wrong dosage form/technique/route, wrong rate, wrong time, wrong patient, monitoring error, and “other”. The team found that the general pattern of usability challenges and medication errors were similar across the three sites.

EHR usability issues

The researchers recommended that Office of the National Coordinator for Health Information Technology (ONC) add safety with the voluntary certification criteria of EHRs for use with children and include usability measures to assess EHR performance.

In December 2023, the American Medical Association reported on a JAMA study that highlighted these challenges and more in EHR use based on an analysis of 557 reports from healthcare professionals:

Data entry: Clinicians face difficulty entering accurate EHR data, leading to errors such as selecting the wrong frequency for medication administration.

Alerting: Inadequate EHR alerts contribute to issues like overlooking patient allergies while prescribing medication.

Interoperability: Insufficient interoperability within EHR components or with external systems hampers information exchange, impeding access to vital data like laboratory results.

Visual display: Complex, cluttered, or inaccurate EHR displays make it challenging for clinicians to interpret information correctly.

Availability of information: Critical information is hindered due to incorrect entry, storage location, or inaccessibility within the EHR, impacting tasks like ordering diagnostic tests.

System automation and defaults: Unexpected or non-transparent automated defaults in the EHR, such as date settings, can lead to errors in medication orders.

Workflow support: Mismatches between EHR workflows and user intent, like essential instructions being unnoticed by lab staff, result in breakdowns in processes, affecting tasks such as diagnostic test orders.

The report suggests that healthcare providers and EHR developers adopt safety-focused, stringent test case scenarios outlined in the report. This approach aims to identify and rectify issues, thereby preventing patient safety concerns.

Clinician Stress leading to EHR Documentation Errors

A study in JAMIA, for instance, revealed that for every eight hours office-based physicians allocate to patient appointments, over five hours are spent navigating the EHR. Practitioners and nurses burdened with heavy workloads might import inaccurate medication lists into EHRs, unintentionally transmitting erroneous information through electronic copying and pasting of older record sections, or input incorrect examination findings. Other common errors linked to EHR documentation include:

Not documenting patient history
Not recording allergies leading to prescribing errors
Prescribing errors can involve the wrong dose, form, quantity, administration route, concentration, or rate of admission
Communication breakdowns leading to lack of clarity on current or updated information, which could result in an overdose
Omitting to give the medication before the next one is scheduled
Giving a medication outside the predetermined interval
Wrong formulation of a medication

EHR documentation errors could lead to various issues, including wasteful duplication, unnecessary or incorrect treatment, and delayed diagnoses, among other potential problems.

It is critical to resolve EHR usability concerns and ensure access to reliable medication histories by subsequent caregivers. Accurate documentation translates to accurate recording of information such as the name of the drug, the dose, route, time, patient response, and any refusal of the drug by the patient. With advanced systems, physicians can make more informed decisions, improve collaboration among healthcare teams, and ensure accurate and up-to-date patient data, potentially fostering improved care delivery.

The AMA reports that an increasing body of evidence is quantifying how EHRs add to physicians’ clerical burdens and contributing to the crisis of doctor burnout. Initiated in 2019, the AMA’s Electronic Health Record Use Research Grant Program aims to identify EHR usage patterns that may undermine patient care.

Medical transcription services can play an important role in improving provider transcription. Investing in experienced transcriptionists can ensure accurate and timely medical records. This can empower clinicians to provide better care and reduce medication errors, leading to safer patient outcomes.

Deliver quality patient care with precise and timely documentation.

Role of Structured Radiology Reports in improving Practice Efficiency and Patient Outcomes

15-November-2018 Julie Clements Radiology Transcription

Radiology reports are vital to promote appropriate medical decision making and optimize patient outcomes. Outsourcing radiology transcription allows radiologists to ensure accurate and timely EMR/EHR or Radiology Information Systems (RIS) reports as they focus on their core tasks. The adoption of structured reporting is being advocated as a means to improving the quality of radiology reports and patient management.

Imaging reports convey a vast amount of information on:

The type of test performed and indications for it
The results
Differential diagnosis
The radiologist’s recommendations for further evaluation and management

However, the use of free-text and narrative language in conventional reporting make it difficult for physicians to locate the information they need or understand the radiologist’s findings and recommendations. To be effective and promote proper patient care, the communication has to be clear, correct, and complete. Structured reporting is seen as the answer to these issues.

What is Structured Reporting in Radiology?

Conventional radiology reports have structured headings such as “clinical history,” “comparison,” and “findings”. However, advanced structured reporting is characterized by standardized or “constrained” language and consistent formatting. According to a 2014 article in Applied Radiology, structured reporting involves a three-tier system:

Tier I: Common, simple headings such as “Indication” and “Impression”
Tier II: Itemized reporting with sub-headings identifying categories such as organs and organ systems within the “Findings” section
Tier III: The use of standardized language, pick lists, buttons and other form elements. This tier is more difficult to implement than Tiers I and II.

Advantages of Structured Reporting in Radiology

With the adoption of EHRs, structured reporting is has been adopted in various medical specialities to satisfy Meaningful Use criteria. In radiology, structured reporting offers many benefits:

Reduces ambiguity: Structured radiology reports have disease-specific templates. An article in Applied Radiology points out that structured reports reduce ambiguity by ensuring uniformity and the use of a consistent vocabulary by radiologists. The terms used in structured reports allow effective analysis, supporting research and quality improvement.
Reduces diagnostic errors: Missed diagnosis is most common reasons for malpractice lawsuits against radiologists. A January 2018 article in Science Direct reported that review of literature shows that structured reports help radiologists and referring clinicians reduce the rate of diagnostic errors. The article notes that structured checklist style reports can reduce diagnostic errors such as not reporting incidental renal cell carcinoma in a spine MRI performed for back pain.
Reduces the incidence of syntactic and semantic errors: The authors of the Science Direct article provided evidence to show that a high percentage (4%-60%) of free-text reports is associated with grammatical and nongrammatical digital speech recognition errors. While they may not be of much clinical importance, such errors make referring physicians and patients doubt the integrity of the radiological interpretation. Structured reports can reduce nongrammatical errors, including both omission and commission errors.
Improves report quality and consistency: With structured reporting, radiologists can always provide complete and useful reports. This is especially important when radiologists come across uncommon conditions. A structured template will have all the required elements to remind the radiologist to report all important observations about the condition, including the location.
Supports adherence to guidelines: The American College of Radiology (ACR) has developed guidelines to promote quality and safety in radiology practice. Structured templates allow standardized text with the necessary elements to be easily inserted into the radiology report at the time of dictation, improving compliance with guidelines. Adherence to guidelines improves quality and reduces costs.
Allows data mining and statistical analysis: Structured reports make it easier for referring physicians, billing and coding specialists, medicolegal professionals, and researchers to mine and compare information from radiologic reports.
May be financially rewarding: By ensuring the completeness of radiology report documentation, structured reporting allows radiologists to meet the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System (PQRS) measures which can significantly improve reimbursement.

The Breast Imaging Reporting and Data System (BI-RADS) is considered the best example of how structured radiology reporting can be successfully incorporated in clinical practice. The system offers a clear and concise reporting style and also guides patient management.

Radiology Reporting Templates – Challenges Involved

While structured reports provide many benefits, there are certain challenges associated with their adoption:

Resistance to change: Reports say that radiologists may oppose change as they are used to a particular style of reporting and think there is no clinical necessity for change.
Reduce quality of reporting: As they value their freedom of expression, radiologists feel that using structured templates may downgrade the quality and scope of their reports. Use of free-text will allow more information to be included in the report. In complicated cases, templates may not be sufficient to include all the necessary information.
Missed findings: The Science Direct report notes that adherence to rigid structured report templates may result in missed findings due to “eye dwell” or interruption of the visual search pattern. This happens when radiologists are focused on the template rather than the images. According to the report, structured reporting may be feasible for less complex studies such as x-rays or ultrasound rather than more complex studies such as CT or MRI.
Time constraints: The time and effort required to develop report templates and enter information in them can have a negative impact on radiologists’ productivity.

Radiology Transcription Services for Quality Data

Reporting templates offer distinctive opportunities to improve the quality of radiology reports. Many professional societies including the Radiological Society of North America (RSNA) stress the importance of using structured reports to improve practice efficiency and patient outcomes. Using radiology transcription services is a great way to overcome many of the challenges associated with structured reports. Experienced medical transcription companies can ensure efficient dictation capture and also integrate and import medical transcripts into EMRs/EHRs or Radiology Information Systems (RIS).