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).

How Free-standing Emergency Rooms Increase Healthcare Costs

12-November-2018 Rajeev Rajagopal Emergency Room Transcription

Every hospital has an emergency room that provides health care services to patients without any prior appointment. It is one of the most important and busiest medical departments that provide immediate care to patients at the time of emergency. The notes taken by medical professionals in the emergency room are very critical in providing efficient patient care. These notes are later transcribed into accurate notes with the help of medical transcription services. Transcripts prepared either this way or using speech recognition technology have a significant role as regards patient care as well as physician reimbursement. A major concern the U.S. healthcare sector faces is the increasing costs associated with emergency rooms. Let us examine how this happens.

Free-standing Emergency Room and Emergency Room

Emergency rooms often face the problem of overcrowding and long wait times. This has led to the emergence of the Free-standing Emergency Room.

Free-standing Emergency Department (FSED), also known as Stand Alone Emergency Department, is a new addition to the healthcare system that is developing in both urban and rural areas. FSEDs are not attached to a hospital but have all the benefits of a hospital-based emergency room. Both FSED and emergency room treat all kinds of emergency conditions and operate 24*7. However, FSED and emergency room are different. Emergency rooms are situated only in specific areas of a city whereas FSEDs are situated in more accessible areas. FSEDs are not the same as Urgent Care Centers and due to greater acuity of care provided at an FSED, patient charges may be higher than at an Urgent Care Centre.

Free Standing Emergency Rooms have seen a major growth in states like Texas, Colorado and Arizona. Some of the major hospitals that operate FSED are in network with the major insurance companies. But FSEDs may be out of network with these same insurance companies. Patients sometimes assume that all of their facilities are in network and go for procedures and treatments that may not be covered. This creates higher healthcare costs and complexities that the average consumer does not understand. Proponents of FSED say that they provide care to patients who do not have access to emergency room services. However, it is important that healthcare costs are efficiently contained.

A Solution

It is important to educate patients about when to go to an emergency room and an urgent care centre i.e. if it is a life-threatening injury, then you must visit an emergency room whereas if it is a minor fever, cold or flu then you must visit an urgent care centre. Help them understand the price difference between these two facilities and educate them about free-standing emergency room too. All individuals should be aware of the nearby urgent care and emergency room facility.

In Colorado, a new law was passed last April to make the cost of free-standing emergency rooms clearer. This law has disclosure requirements to help patients understand which kind of facility they need and the network status of that facility. This law will bring transparency about free-standing emergency departments. But it is still important to keep the patients aware of when they should go to the emergency room and when they should not. Similarly, the cost involved in both facilities should also be clarified.

Whether an emergency room or free-standing emergency room, note-taking and transcribing are necessary requirements. This in turn makes medical transcription companies an important consideration for emergency departments.

How to Avoid Costly Emergency Room Bills

08-November-2018 MTS TEAM Emergency Room Transcription

As a company outsourcing medical transcription services for ER departments, we know that ER bills can be huge. Many people visiting emergency rooms are later told by their insurance company that it was not a true emergency. This makes the patient responsible for the bill. Many health insurers try to discourage costly ER care by charging higher co-pay for ER visits, compared to walk-in retail clinics or urgent care centers. Patients visiting emergency rooms will have to answer questions related to their medical history and their health insurance. In addition, they may have to make crucial decisions regarding tests and procedures. Patients have to be prepared to avoid huge medical bills.

New York Times recently posted an article highlighting how Jim Burton, a 37-year-old resident of Lexington, Ky, got a surprise medical bill. Though he had come to the ER fearing a slipped disk, it was found on examination that he only had a back sprain with no signs of other injury and was sent home. His health insurer, Anthem, refused to pay the medical bills of $1,722 saying that his care in the emergency room had not been needed “right away to avoid a serious risk to health.” Insurers like Anthem use this tactic to reduce costs-patients who visit the ER for ailments considered minor are not reimbursed for their treatment. According to the American College of Emergency Physicians, last year Anthem denied thousands of claims under avoidable ER program. ER physicians said that the company did not routinely request for denied patients and so they cannot review the symptoms that brought them to ER. The policy goal of the company is to reduce ER cases as it is one of the most expensive places to get medical care and recommends patients with sprains and respiratory issues to consult primary care physicians. The doctors say that this policy forces the patients to diagnose their own illness and also discourages people with severe illness from seeking good medical care. Members of Congress have written to Anthem expressing displeasure and state lawmakers have drafted bills to stop this practice.

After all the modification, Anthem is now denying only fewer claims. They say that ER is a time-consuming place to receive care and it is 10 times costlier than urgent care. At the beginning of this year, Anthem said that they would make more exceptions for patients who live far from an urgent care facility, those who are under 15 etc. Visits of these people will be covered even if they have avoidable diagnosis. This policy is expanded to four more states – Indiana, Ohio, Connecticut, and New Hampshire. In Missouri, a bill was passed recently to shield patients from dysfunction of the emergency department. The bill will also force physicians to sign insurance contracts and thereby protect the consumers, and to prevent them from getting into a fight with the insurance company.

Webmd.com provides some useful tips to get better and more affordable care during a medical emergency.

Patients shouldn’t assume that the ER is the right place for them: Patients can avoid a long wait and save money by going to an urgent care center instead of the ER. Urgent care centers can handle many illnesses and injuries such as broken bones, burns, and cuts that require stitches. For life-threatening conditions such as seizures, severe pain, head injuries, pain signifying heart attack or stroke, visit the emergency room. Many urgent care centers also accept insurance coverage.
Provide all health information that is necessary: Be ready to provide your medical history that includes:
- List of medications, antibiotics or supplements you are taking, have been recently prescribed or recently completed.
- Any allergies, especially to medications
- Info regarding past surgeries
- Info regarding past or chronic illnesses
- Info regarding previous hospital stays
- Vaccines received
- Any specialists you may be seeing

This information can be stored on your cell phone using a good medical records app.
Understand your ER rights: The Affordable Care Act requires insurers to cover the care patients receive in the ER if they have an emergency medical condition. There is no need to get approval ahead of time and it does not matter whether the hospital/facility is in or outside of the patient’s insurance network.
Find out whether there is any risk in putting off tests and scans until you can see your family doctor who might decide you don’t need them. If you need them, they will be less costly at the doctor’s office than when done at the ER.
Check your ER bills and insurance reports carefully: For most of the ER care you receive, you should be charged in-network rates. If someone outside your network – ER doctor, specialist or a technician – provides the treatment, they can bill you directly for the difference between what they charge and what your health insurance plan pays. If you are treated for a true emergency, most health plans will cover all the emergency room fees. Make sure that you submit them personally to your insurance company.

It is important that patients clearly understand their insurance. A medical transcription company assisting physicians knows how important it is for providers to understand what treatments a patient’s health plan covers and explain the same to him/her. Patients should be advised to check their insurer’s “emergency service benefits” coverage to see how it defines an emergency and what the plan will/will not cover. Most insurers offer general guidelines regarding what constitutes an emergency, and don’t usually limit members to specific injuries or illnesses. Patients should also know which area hospitals accept their insurance plan. They should ask the billing department at their chosen hospital whether the ER doctors participate in their particular insurance plan. Patients can always file an appeal if the insurer rejects a claim.

Tips to Make Patient Handoffs Safer and More Effective

05-November-2018 Julie Clements Medical Transcription Outsourcing

The handoff of a patient from one physician to another is a frequent and unavoidable aspect of care. Medical transcription outsourcing helps health care providers produce the electronic component of the handoff. However, clinical handoffs are prone to errors due to breakdown in communication between care providers. In fact, handoffs have been found to be one of the most risky procedures in hospitals. A 2012 Joint Commission report, about 80% of serious medical errors occurred due to poor communication between providers during patient handoffs.

In addition to communication that is misspoken or misunderstood, errors often occur because of the failure to record information or due to information that is misdirected, never received, never retrieved, or ignored. Hospitals need to have proper measures in place to ensure a seamless handoff process by ensuring effective clinician-to-clinician communication to promote continuity of care, eradicate preventable errors, and improve patient safety. Here are some expert tips to effectiveness of clinical handoffs:

Ensure accurate and complete written signouts: Effective communication means communication that is complete, clear, concise and timely. The Agency for Healthcare Research and Quality (AHRQ) points out that the I-PASS signout format put forward by a seminal study is regarded as the gold standard for effective signout communication between physicians and that it can improve the quality of nursing handoffs. “I-PASS” stands for:
- Illness severity: one-word summary of patient acuity such as “stable,” “watcher,” or “unstable”
- Patient summary: summary of the patient’s diagnoses and treatment plan
- Action list: to-do items to be completed by the clinician receiving signout
- Situation awareness and contingency plans: instructions to follow if there are changes in the patient’s status
- Synthesis by receiver: an opportunity for the receiver to ask questions and confirm the plan of care
Convey the unique needs of each patient: In a recent report, the American Medical Association (AMA) advises medical residents to ensure that they communicate the unique needs of the patient during the handoff. The daily progress note should clearly communicate the physician’s findings, thoughts and plans. However, the misuse of copy-paste functionality in the electronic health record (EHR) often compromises the reliability of the patient information, affecting the clinical handoff process. Copy pasting should be confined to verified, static information such as demographic information, drug lists, and previous medical history. When handing off patients, providers should ensure that relevant and important information about each patient is conveyed. Situational awareness should also be conveyed in an “if-then” format. On the other hand, if the physician is permanently signing away the patient, it would be important to convey more details in terms of history and other matters.
Take steps to improve communication during handoffs: This includes:
- Discussions in an environment without distractions: The American College of Obstetricians and Gynecologists (ACOG) says that the circumstances, setting, and content of the handoff communication should be based on clinical acuity of the patient’s condition.
- Maintain confidentiality: Due consideration should be given to confidentiality and Health Insurance Portability and Accountability Act regulations when conveying patient information.
- Use standardized medical terminology: The documentation involved in the clinical handover should be prepared using standardized medical terminology. Medical transcription outsourcing can ease this task. Reliable medical transcription companies have trained and experienced team well versed in medical terminology and jargon. These experts can provide quality documentation of all types of reports including history and physical reports, clinic notes, consultation reports, procedures, ER reports, follow up notes, and health reports.
- Assign responsibility: ACOG recommends that each patient should be assigned to a primary person or team that will also manage the transfer. If the primary contact is unavailable, there should be a backup system.
- Method of communication: Providers can use verbal communication, written communication, or both. Face-to-face exchange of information is the preferred option because it allows for direct interaction and expression of nonverbal information by expression and body language. On the other hand, written communication allows the information to be relayed in an organized, hard copy format, which is important for reference.
- Documentation: Relevant demographic information, history, physical exam results, an active problem list, medications and allergies, pending test results, ongoing or anticipated therapy, key patient values and preferences, and all other critical information should be clearly documented in the patient’s medical record. This is where medical transcription services come in handy.

Providers should keep in mind that malpractice dangers lurk in patient handoffs. Medscape reported that though hospital care has significantly improved over the years, a study of malpractice claims by The Doctors Company found several incidents of preventable harm to patients, often due to a failed handoff. ACOG notes that barriers to effective communication include factors such as lack of time, hierarchies, defensiveness, varying communication styles, distraction, fatigue, conflict, and workload. Having an environment free of interruptions and distractions is critical to effective handoffs. Medical transcription outsourcing is an effective strategy to ease documentation workload and help clinicians find more time to engage in discussions and manage patient care and handoffs effectively.

Study: Combining Dictation and Natural Language Processing can aid Clinical Documentation Improvement

01-November-2018 Rajeev Rajagopal Medical Transcription

Physicians need to document information about patient health events, clinical status, and office visits in EHRs. Clinical data has to be captured accurately for quality reporting, claims reimbursement, public health information, and disease tracking. Medical transcription outsourcing plays an important role in reducing the burden to data entry on providers. Clinical documentation improvement (CDI) is the key to ensuring the EHR correctly reflects the services that were furnished. EHR Intelligence reported that a 2016 study found that dictation and natural language processing (NLP) can support CDI efforts.

Clinical documentation that is legible, timely, complete, specific and clear is necessary to:

Improve health outcomes and hospital/practice management
Boost clinical efficiency
Communicate with other providers about the care of the patient
Minimize physician queries
Increase coding accuracy
Decrease claim denials and enhance reimbursement
Validate the care that was provided
Demonstrate compliance with quality and safety guidelines
Maintain a legal health record

According to a 2016 Black Book Market Research report, nearly 90 percent of hospitals with more than 150 beds that used CDI tools experienced an increase in healthcare revenue and claims reimbursement amounting to at least $1.5 million. Up to 87 percent of the hospitals reported that case mix index improvement was the largest driver of CDI adoption due to its potential “to increase healthcare revenue and optimize high-value specialist utilization”.

However, reports say that many providers are already facing burnout due to the demands of EHR documentation and are reluctant to take on the additional burden of implementing CDI projects. In fact, physicians find entering data into EHRs a cumbersome and difficult task, and this has led to lower quality medical records with redundant, inaccurate information.

According to the 2016 study led by David R. Kaufman, PhD, using natural language processing (NLP) in clinical documentation improved outcomes compared to using the conventional keyboard-and-mouse entry approach alone. NLP leverages artificial intelligence (AI) to process key information from unstructured spoken or written input and according to a KLAS report, and is the second-most frequently utilized CDI functionality, after query templates. However, Kaufman’s team noted that using only NLP can affect accuracy. The researchers suggested that a combination of dictation and NLP can improve clinical documentation, increase usability, and save time.

“A pure protocol of NLP Entry as well as hybrid protocols (involving both NLP Entry and Standard Entry) showed promise for EHR documentation, relative to Standard Entry alone (Standard-Standard Entry),” wrote the researchers.

“EHR documentation methods using a combination of dictation and NLP show potential for reducing documentation time and increasing usability while maintaining documentation quality, relative to EHR documentation via standard keyboard-and-mouse entry,” according to the study.

The researchers said that though the hybrid approach would work best, further study would be required to understand the optimal method of documentation for each part of the clinical note.

The findings of this study suggest that medical transcription services continue to be a relevant option when it comes to improving clinical documentation. Medical transcription outsourcing now ensures EHR-integrated documentation solutions for all specialties.

AHIMA recommends that providers utilize all their operational and personnel resources at every stage to implement efficient CDI strategies, according to the EHR Intelligence report. Furthermore, the organization recommends that practices should collaborate with their EHR vendor to “remediate documentation vulnerabilities, tweak templates, and update documentation alerts and prompts.”

However, the report notes that it will be challenging for providers to focus more attention on EHR documentation when existing administrative requirements are already such a strain. In these circumstances, medical transcription outsourcing to an experienced company could be the answer to optimizing both accuracy and efficiency.

How Can Doctors Add Value to Their Time With Patients?

29-October-2018 MTS TEAM Medical Transcription

Consultation time and waiting time are key factors that affect patient satisfaction. Several reports bring up the fact that medical appointments are getting shorter by the year, resulting in doctors having very little time to spend with their patients. According to the latest report from Statista, as of 2018, 5% of U.S. physicians say that they spend less than nine minutes with each of their patients, while over 60% say that they spend between 13 and 24 minutes with each patient. More than half of the physicians said that they spend around 30-45 hours per week seeing patients. Good communication is central to the doctor-patient relationship, which can be difficult to accomplish within this strict time limit. Physicians getting busy with electronic health records (EHR) is also a factor contributing to these brief clinical interactions, which can be improved with assistance from medical transcription companies providing EHR-integrated services.

The most important way to improve patient care through the doctor-patient relationship is to increase the amount and quality of time for the doctor to spend with his/her patient in the clinic or office. Examining the patient thoroughly and then spending adequate time discussing everything would improve patient care as well as satisfaction.

A recent blog published in MedPage Today provides tips for physicians to make the most of their rushed time slots and how to make the patient feel well cared for. Rising demand for treatments, falling reimbursements, and more complex diagnoses and treatments can make the condition worse. Here’s what physicians can do to make the most out of the time they have and provide a better healthcare experience for patients.

Verbal Communication Techniques Work Better

The MedPage Today blog suggests that it is better to use verbal communication techniques than non-verbal, even if you’re in a hurry to end the session. Some of these communication techniques that don’t require more time or a huge amount of effort include:

Allowing a certain amount of uninterrupted talk time for the patient (while actively listening)
Sitting down at the same level
Using open-ended questions so that patients can discuss all their concerns
Finding time for a summary at the end of the consultation

How to Improve Patient-Physician Communication

For instance, the American College of Obstetricians and Gynecologists provides certain tips to improve patient-physician communication, which involves –

Using patient-centered interviewing and conversing in a caring way in daily practice and engaging in shared decision making with patients
You can encourage patients to write down questions in preparation for appointment. Providing an organized list of questions can facilitate conversation on important topics.
Arranging a communications consultant to conduct a workshop on cultural and gender sensitivity for physicians and office staff based on the needs of individual practices.
Hiring non-physician health care providers – advanced practice nurses or physician assistants, with patient-centered interviewing skills to assist with established patients.

Certain effective communication skills that are crucial for a physician to understand the patient’s point of view and incorporate it into the treatment include comfort, acceptance, responsiveness, and empathy. While comfort and acceptance refers to the physician’s ability to discuss difficult topics without displaying uneasiness and the ability to accept the patient’s attitudes without showing irritation, responsiveness and empathy refer to the ability to react positively to indirect messages expressed by a patient.

While doctors can rely on medical transcription services to save time for patient care and reduce their documentation tasks, they should also be concerned about patient’s long wait times. Read our blog on tips to reduce patient wait times in any practice.

Some Challenges That Impact Patient Access to Healthcare

22-October-2018 Rajeev Rajagopal Medical Transcription

The Electronic Health Record (EHR) has completely changed the landscape of healthcare industry and the way physicians treat their patients. The new systems provide improved patient access to healthcare and allow patients and their families to take charge of their own health. With EHR-integrated medical transcription services, physicians can quickly generate medical documentation that can be viewed by patients also. It improves patient engagement and satisfaction. However, many patients across the country do not have easy access to healthcare.

What are some of the challenges involved?

Limited availability of appointments: Majority of healthcare units have fixed working or consultation hours and this may not be useful for everyone. Patients need convenient hours to visit doctors outside of their work. So, healthcare organizations are now trying to expand their office hours. Some organizations are using health IT and connected health that allows patients to get medical advice without coming to the office. Telehealth or Telemedicine is one such innovation that allows patients to seek medical assistance without coming into the clinic or hospital. This system is highly useful for emergency cases to connect with the doctor. Organizations can adjust their office hours to provide patients more easy access to the clinicians at any time.
Clinician shortage in rural areas: Shortage of clinicians in rural areas is a major concern in many countries. According to the American Hospital Association, there are about 57 million Americans who live in rural areas. They also say that remote geographic location, small size, physician shortage and often constrained financial resources pose a unique challenge for rural hospitals. Healthcare organizations have started tapping telemedicine to close care gaps caused by geographic barriers. Direct-to-consumer telemedicine allows patients to make use of their own devices like smartphones or computers to video call a provider. Many smaller facilities in rural areas use telemedicine to connect with experts in more urban areas. This helps patients avoid travelling to faraway places to receive treatment or specialized care. Patients in rural areas also struggle with shortage of physicians and the situation is much severe than urban area shortage issues. According to National Rural Health Association statistics, the patient to primary care physicians ratio in rural areas is 39.8 physicians for 100,000 people compared to 53.3 physicians per 100,000 patients in urban areas. As per a report by University of Nebraska Medical Centre, clinicians’ shortage issues are plaguing rural areas across the country. Although primary care clinicians’ access is up 11 percent from 2008 doctors are still bracing to get hit hard by the growing national clinicians shortage issues. Healthcare professionals are now looking for policy changes that would help channel more providers to rural areas. Some visa waivers could encourage foreign-born but American-educated providers to serve in rural areas.
Transportation barriers: Patients can easily fix an appointment with their doctors whenever they want but transportation barriers can keep them from visiting their physicians, especially for people with disabilities or those who cannot obtain transportation to the clinician’s office. According to AHA statistics, around 3.5 million patients do not have access to proper care as they don’t have transportation to the physician’s place. Transportation is a critical social determinant of health that has recently gained nationwide attention. In 2018’s HIMSS conference rideshare giants Uber and Lyft announced plans to close care gaps emerging from medical transportation woes. Uber introduced its own healthcare offshoot and Lyft partnered with an EHR vendor to help healthcare providers and patients to connect with rides to medical appointments.
Limited education regarding care site: It is important for organizations to remove all obstacles that prevent patients from getting to the clinic. This will ensure that the patients reach the right place. This is very important to integrate alternative treatment sites into their repertories. Patients can access care at an urgent care centre, a retail clinic, a micro hospital, a freestanding emergency department and numerous other emerging treatment facilities. It is important for medical practices to deliver proper patient education which enables patients to identify providers ideal for certain healthcare needs. According to a February 2017 survey from CityMD, many patients do not know where they should receive care for various symptoms. 46 percent of respondents correctly selected urgent care as the appropriate choice for a scenario in which a child is suffering from 104 degree fever.

Medical professionals should educate their patients on the specific uses of different care sites. Clinicians and offices and hospitals should display information in their own facilities and circulate patient education materials. Providing proper patient care and accurate medical records is highly important for quality patient care. According to the Association for Healthcare Documentation Integrity, accurate and high integrity documentation requires collaboration between physicians and the organization’s documentation scheme or with medical transcription services.
It is important to ensure that the medical records are accurate and reliable. Medical errors can occur anywhere – it may be in medication, surgery, after care, lab reports etc and it can even lead to death. Below are some tips to follow to ensure more accurate medical documentation.

Ask your patients if they have any questions. Ensure that the patients are sharing all necessary personal health information.
Physicians and surgeons treat patients and create records according to the strict policies of EHR. But the duty of the physician is to focus on their patients and not on documenting records. EHR documentation could be outsourced to a scribe or a good medical transcription company. Only the task of approving the entries should be given to the doctors.
In the EHR system, bring a balance between structured and unstructured data.
Standardization of general layout is important. It helps physicians to spend less time searching for the right button and it also minimizes the chances of errors.

Providing the right care at the right time is very important. Today, many healthcare organizations hire reliable medical transcription services to ensure streamlined documentation. They offer customized services at affordable rates and also help physicians and other healthcare professionals to focus more on providing quality patient care and services.