Addressing the Problem of Overuse of Medical Care

04-October-2018 Julie Clements Medical Transcription Outsourcing

Electronic health record (EHR) systems serve as powerful technology platforms for data collection on office visits, diagnoses, treatments, and prescriptions, and medical transcription outsourcing helps physicians ensure accurate EHR documentation. EHR data is widely used for research and to study issues in clinical medicine such as medical overuse. Overuse of medical care or subjecting a patient to unnecessary care is a costly and pervasive problem in the United States.

What is “overuse of medical care”?

The Lown Institute defines overuse as “catchall term for medical tests, treatments, and other services that patients don’t need or don’t want”. Instances of overuse of medical care are:

When a patient is hospitalized unnecessarily – the treatment is very unlikely to benefit the patient because there is no evidence of the disease or symptom to diagnose or treat, or because the potential risks of treatment are greater than the possible benefits.
If the patient receives a test, treatment, drug, or procedure that is unnecessary, ineffective, or unwanted. “Ineffective” means the treatment makes no difference to the patient’s condition and “unwanted” means that, if fully informed, the patient would choose another testing or treatment option.
Overdiagnosis, where patients are diagnosed with conditions that were unlikely to cause symptoms or shorten life.

According to an August 2018 Dark Daily report, a Washington State healthcare watchdog organization maintains that “wasteful” spending for “low-value” clinical laboratory tests and other procedures amounted to a whopping $282-million in a single year. The report also presents the results of a Washington Health Alliance (WHA) study “First, Do No Harm: Calculating Health Care Waste in Washington State,” on medical overuse over the period July 2015 and June 2016 on 1.3 million patients who had one of 47 procedures or tests that the US Preventive Services Task Force had labeled as overused:

More than 45% of the healthcare services examined are determined to be “low value” since they offer little benefit in certain clinical scenarios.
47.9% of patients had a low-value test or procedure that was unnecessary.
An estimated $282 million (36% of spending) was wasted on low-value services.
11 common tests, procedures, and treatments such as preoperative tests, laboratory studies prior to surgery, and too frequent cancer screenings account for 93% of low-value services and 89% of the estimated wasted spending.

Common Examples of Overused Medical Procedures

According to the WHA study, the most overused low-value services are:

Too frequent cervical cancer screening in women
Preoperative baseline laboratory studies before low-risk surgery
Unnecessary imaging for eye disease
Annual EKGs or cardiac screening in low-risk, asymptomatic individuals
Prescribing antibiotics for acute upper respiratory and ear infections
PSA (prostate specific antigen) screening
Population-based screening for 25(OH)-D deficiency
Imaging for uncomplicated low back pain in the first six weeks
Preoperative EKG, chest x-ray, and pulmonary function testing prior to low-risk surgery
Cardiac stress testing
Imaging for uncomplicated headache

Participants in a National Summit on Overuse convened in September 2012 in Chicago identified five treatments as overused: use of antibiotics for viral upper respiratory infections; over-transfusion of red blood cells; tympanostomy tubes for middle ear effusion for brief periods; early scheduled births without medical need; and elective percutaneous coronary intervention.

Why does medical overuse occur?

Physicians generally make well-informed treatment decisions based on clinical evidence and expertise, but choices may be also driven by other factors such as economic incentives, fear of liability, worry about uncertainty, habit, and hunches. On their part, many patients tend to believe that more health care is better, and are not accepting of recommendations that seem to limit choice or of advice to wait to see whether a symptom improves. For instance, a Propublica report notes that patients’ mindset contributes to overuse of medical care. Patients often insist that their healthcare provider write a prescription or perform a test, which has led to problems like the overuse of antibiotics.

How can the problem be tackled?

Physicians and patients must work together to minimize waste in health care. In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to encourage doctors and patients to discuss the issue of unnecessary tests and treatments. The Choosing Wisely campaign makes a difference by focusing on the following aspects, according to a Harvard Business Review report:

Putting quantity in the context of quality: The campaign focuses on making patients and physicians see that more care is not always better care. Patients are about why an unnecessary test could be detrimental to them so that doctors and patients can have more constructive conversations about the tests. The campaign also looks to change the way many doctors practice by avoiding ordering of unnecessary prescriptions and tests.

Changing how quality is managed: This involves putting in place a quality management system which helps providers and patients make better decisions about when care is necessary or improper. For example, new heart disease prevention guidelines use a personalized assessment that helps physicians detect a patient’s risk for a heart attack and whether the patient should take a cholesterol-lowering statin drug as well as its dose.

Guiding physicians about reconsidering the value of their services: Many physicians tend to orders unnecessary tests at least once per week due to fear of lawsuits and general clinical uncertainty. One important goal of Choosing Wisely is to educate physicians that not ordering unnecessary services can have as much value for patients as ordering appropriate tests and treatments.

The Choosing Wisely campaign recommends that patients ask their physician five basic questions before undergoing any test or treatment:

Do I really need this test or procedure?
What are the risks and side effects?
Are there simpler, safer options?
What happens if I don’t do anything?
How much does it cost, and will my insurance pay for it?

The WHA believes the shift from fee-for-service healthcare to value-based reimbursement models can provide a solution to overuse. The WHA report states: “We need to keep our collective ‘foot on the gas’ to transition from paying for volume to paying for value in healthcare.” It also proposes value-based provider contracts should include measures of overuse and not just measures of access and underuse.

Medical care overuse is the subject of active research. A study published in the Journal of the American Medical Association (JAMA) in 2017 reported that EHRs have the potential to decrease overuse of low-value care by allowing for better data collection and direct intervention. Medical transcription companies play an important role in ensuring error-free medical records to support research applications as well as provision of quality care.

Tips to Write Good Patient Record Notes

01-October-2018 Rajeev Rajagopal Medical Transcription

Good patient record notes are necessary for proper record-keeping, communicating with other providers, billing and reimbursement, and medico-legal purposes. Medical transcription outsourcing is a viable strategy to convert recorded physician’s dictated notes into text format for inclusion in the electronic health record (EHR). However, the quality of patient record notes depends on the physician. Adhering to best practices improves the quality and efficiency of notes that physicians create about their patients, according to a recent study led by UCLA researchers. Here are the key considerations that shape good note-taking by physicians.

Use SOAP format: The traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format is the most common method of clinical note-taking. EHRs incorporate SOAP methodology which must be followed sequentially to make the patient note. Received from the patient, the initial subjective portion includes history of illnesses, surgical history, current medications and allergies. Next, the physician fills in the objective portion with vital signs and measurements, abnormalities in any, and results of physical examinations and previous laboratory and diagnostic tests. The assessment component includes the diagnosis of the patient’s condition based on the medical history and objective data. The final portion is the plan, referring to what the physician will do to treat the patient’s concerns and goal of the therapy. This section includes lab orders, radiological work, referrals, procedures performed, medications given, and education provided. It will also include a note of what was discussed or advised as well as timings for further patient review or follow-up.
Balance note-taking styles: Most physicians’ notes combine the narrative style and the bullet-point/checklist style. A www.psychiatrictimes.com report points out that an ideal clinical note is one that balances both these styles. The narrative style is ideal to provide a meaningful account of the history of present illness as well as the patient’s present condition. While providing a clear picture, the narrative style can be lengthy and time consuming. The bullet point format overcomes this problem as it provides a concise list of the relevant information and symptoms. In fact, in electronic medical records (EMRs), much of the note is in bullet-point format. While it is efficient and time-saving and helps billing, checklists tend to generalize the nature of symptoms.
Be organized: This is especially important for junior residents taking notes. Patients may not be organized when discussing their symptoms or condition. That’s why it’s important to conduct the interview in an organized manner. The best strategy is to listen carefully and note down the points in the relevant section of the history. Rather than start with the present illness, Psychiatry Times recommends beginning the interview with past psychiatry history or social history.
Keep a log of every patient outside of the medical record: An article published by the AMA Journal of Ethics says that note-taking by residents can benefit from telling patients’ stories in places other than the medical record. This is especially useful in the emergency room. The log should include the patient’s initials, gender, date seen, and chief complaint or diagnosis as well as any procedure performed, and other information. When captured correctly, a specific component of the interaction could help jog the physician’s memory about the entire encounter, according to the report.
Record only pertinent information: Only relevant information with diagnostic and prognostic utility should be included in the clinical documentation. Information that does not impact treatment or disposition would not serve any purpose. To avoid EHR note bloat, the focus should be patient-centric rather than documentation-centric.
Be brief: Brevity is an essential quality when it comes to EMR notes. Including non-relevant review of symptoms, family, social, environmental, extensively documented physical, etc. can bury the essential patient information in the note. Moreover, busy clinicians would find it extremely taxing to read through lengthy notes and even ignore notes that are too long. Physicians should practice making short snippets that can communicate the relevant information for documentation.

Other tips for effective clinical note-taking:

Use brief patient quotes as needed
Document to maintain the standard of care
Discuss and document the risks and benefits of a proposed treatment with the patient
Note down the justification for medication changes
Use specifiers when writing diagnoses
Maintain documentation consistency by ensuring that the diagnosis, assessment, and treatment plan should support each other
Avoid excessive copy-paste
Organize the notes before signing them
Avoid being vague especially when documenting initial evaluation of symptoms
Avoid being judgmental and keep in mind the possible reader audiences for the record when writing the record

The ULCA study found that the quality of progress notes improved significantly when physicians were prompted to document only what is relevant for that day and limit the use of EHR “efficiency tools” such as copying-forward and autofill. Being mindful about note-taking best practices can overcome many of the challenges associated with creating patient record notes. When it comes to transcribing and charting patient’s medical history, diagnosis, treatment and care in the EHR, the support of an experienced medical transcription company can prove invaluable for time-strapped clinicians.

Text Messaging between Physicians and Patients – Pros and Cons

27-September-2018 MTS TEAM Medical Transcription

Text Messaging between Physicians and Patients

Text messaging has emerged as a valuable tool for physician-patient interaction, allowing them to connect more efficiently and conveniently. Physicians often face challenges in managing their time as they have various responsibilities, from providing preventive services to adhering to guidelines and delivering patient-centered care. While text messaging improves real-time communication with patients, medical transcription outsourcing remains a valuable solution for maintaining accurate EHR documentation—relieving physicians of administrative burden and allowing them to focus more on quality patient care.

Benefits of Physician-Patient Communication via Text

Improves communication: Text messaging improves communication between physicians and patients. Improving patient engagement through text messaging allows physicians to monitor patient health effectively. For instance, patients can send their blood pressure results and glucose readings electronically allowing the physician to understand their health status and respond to these readings instantly. In a January 2018 Healthcare IT News article, a hospitalist who treats patients addicted to opioids explains how a secure text messaging platform allows him to remotely manage his patient population to ensure their care and recovery. The physician often engages with patients via text messaging to discuss doses, their treatment and all-around wellness during the sensitive and crucial recovery period. Secure messaging gives patients direct access to their physician. They can text the physician if they are not feeling well or if they have a question. Text-messaging is useful for weight management, diabetes management, medication management, pain management and wellness.

Reduces phone calls: Text messaging can reduce the number of phone calls that practices make and receive each day. In general, physicians, nurses and receptionists find the repeated interruptions of phone calls quite frustrating. The buzzing rings can also affect workflow. In addition to outgoing phone calls, practices have to handle calls from patients seeking to make, cancel or change an appointment, get directions to the practice, and other concerns. Text message reminders for medical appointments can replace phone calls. This approach is also useful for alerting patients that their test results are ready, etc.

Convenient, time saving option: Text messages only take a few seconds to type and send. Phone calls may be missed and can end up in a voice message that may not be heard. Again, compared to phone calls, text conversations take just a short time and convey all the necessary information in a few seconds. Physicians can even type text messages while they are doing other tasks, including helping patients who arrive at the office while they wait for a reply.

Improves the patient experience: Using text messages to communicate with patients would give practice staff more time for preparing for upcoming appointments, assisting patients in the office, and other important matters. Texting allows practices to improve the patient experience. Missed appointments can pose a risk to the patient’s health. Sending appointment reminders via SMS can reduce no-shows.

According to a recent Forbes article, many pharmacies are looking into the feasibility of using text messages to send notifications to patients. Younger patients are likely more responsive to texts than calls. SMS communication in medical practice is a useful way to provide patients with a written record of the pharmacy’s information, which is more efficient than taking notes from a voicemail.

Cons of Text Messaging in Healthcare

While text messages are an effective means of communicating with patients, this option also comes with certain risks.

Security risks: A common concern among healthcare providers and patients alike is: how secure is texting between physicians and patients? As SMS lacks encryption, it can compromise patient confidentiality. As a recent Forbes article points out, anyone who intercepts the data can read it. Automated texts that pharmacies send are not encrypted and the Centers for Disease Control and Prevention (CMS) prohibit texting of orders by physicians or other healthcare providers regardless of the platform. Sending any PHI in a text message (without consent) constitutes a HIPAA violation. While a voice mail gets deleted after a specific period, many text messages remain on a device. If the phone is hacked, and mHealth (mobile health) messaging is compromised or discarded, third parties would be able to access the PHI. The The Joint Commission bans physicians from using traditional SMS for any communication that contains ePHI data or includes an order for a patient to any healthcare provider. Practices can end up paying hefty HIPAA penalties for not adequately protecting personal health information (PHI).

Risks of misinterpretation: Similar to emails, electronic messages come with the risk of miscommunication. The recipient and sender may not be clear of their expectations, leading to confusion and concern. If patients are distraught or angry when sending an email or SMS, their emotions would be reflected in their message and physicians may find it difficult to respond to it. Also, as with email, an immediate response is important. These challenges make electronic patient messages a major task to complete for busy physicians.

Onboarding: According to a www.kevinmd.com report, getting patient consent to receiving messages is a key challenge. Also, to initiate the messaging campaign, text message sent should always be an ‘opt-in’ message that the patient has to reply to.

Text Messaging Patients

The pros of text messaging in healthcare clearly outweigh the cons when implemented responsibly. Physicians can enhance secure physician-patient communication by using HIPAA-compliant texting platforms and obtaining patients’ written consent before sending messages. To protect sensitive information, healthcare providers should take proper steps to ensure the security of transmitted patient data. When sharing protected health information (PHI)with other providers, it’s essential to use encrypted, secure communication channels. Additionally, secure messaging apps can be leveraged to send push notifications and encrypted text messages, ensuring both efficiency and compliance.

The bottom line: never transfer PHI through unsafe or unprotected means of communication. When it comes to EHR documentation, choose a HIPAA-compliant medical transcription company.

Enhance efficiency and compliance with medical transcription outsourcing. Contact our HIPAA-compliant transcription service company today!

Medication Reconciliation using Electronic Heath Records

24-September-2018 Julie Clements EHR Transcription

Errors in medical records can have disastrous consequences, which is why many healthcare facilities outsource medical transcription to experienced service providers. Medication lists are one of the most important elements of the electronic health record (EHR). Patients’ medication records need to be accurate, up-to-date, and accessible. As patients change their medications frequently, maintaining these records is a challenge. When information on medications is incomplete or inaccurate, it can lead to discontinuities in care. In fact, adverse drug events (ADEs) or harm from medications are the most common type of medical error and can result from discrepancies in patient medications during transition of care.

Medical Reconciliation to Improve Patient Safety

Common medication errors include:

Inadvertently excluding a medication a patient was taking at home during the hospital stay
Not ensuring that home medications that may be temporarily stopped during hospital stay are restarted after patient transfer or discharge
Duplicating medication orders which could occur either because the patient is already taking the drug or due to confusion between brand and generic versions.
Prescribing wrong dosages
Transcribing errors – Common transcribing errors include wrong drug name, dose, route, frequency or patient. Reasons for such errors include incomplete or illegible prescriber orders, incomplete or illegible nurse handwriting, using error-prone abbreviations, inappropriate EHR defaults, and lack of familiarity with drug names, doses, or frequencies.

There are various reasons why medication management is difficult, such as lack of patient knowledge about medication details, multiple care providers, different medication lists for the same patient from numerous sources, and industry regulations. Hospitals need to have a consistent, streamlined process that will improve medication management during a patient’s hospital stay. Implementing medical reconciliation at patient admission, transfer, and discharge is an effective strategy to reduce/prevent medical errors.

The Institute of Healthcare Improvement defines medical reconciliation as “the process of creating the most accurate list possible of all medications a patient is taking – including drug name, dosage, frequency, and route – and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital”. Medication reconciliation involves three steps:

Verification: collecting an accurate medication history – involves documenting details of current and recently discontinued medicines such as antibiotics and corticosteroids as well as details of drug allergies or sensitivities if any.
Clarification: Ensuring medication and dosages are appropriate for the patient. This involves comparing the medication history and the physician orders. Omissions or discrepancies such as a medication that appears on the history but not on the order and has no documented reasons for discontinuation, or changes in dose, frequency or route should be noted and documented.
Reconciliation: Resolving discrepancies and documenting changes and new orders.

EHR Tools and Medication Reconciliation – Research Findings

According to a recent study, EHRs have an important role in improving hospitals’ medication reconciliation, though issues related to data quality, technology and workflow persist. Researchers from the National Institute for Health Care Reform (NIHCR) identified the main challenges to effective medication reconciliation as:

improving access to reliable medication histories
enhancing EHR usability
engaging physicians more fully, and
consistently sharing patient information with the next providers of care

The key findings of the study as reported by Healthcare IT News are as follows:

Over a third of the hospitals in the study continued to rely on a partially paper-based process at admission, discharge or both, though they reported that EHRs had added medication reconciliation functionality over time.
Many hospitals had some access to affiliated physicians practices’ EHRs which helped generate more accurate pre-admission medication lists from medication histories. However, there were doubts about the reliability of the information.
Hospitals that have fully electronic admission or discharge processes had implemented EHR medication reconciliation modules which allow comparison of medication lists at those transitions. Actions taken on each medication are automatically converted into orders. This eliminated the need to re-enter data and improved workflow.
Hospitals with fully electronic discharge processes benefited from information about discharge medications in the EHR and could used it to generate legible and more patient-friendly discharge instructions and electronic prescriptions. EHRs also allowed hospitals to integrate the same medication list into the discharge summary and share discharge medication information electronically with the next providers of care.

Another new study published in Pediatrics, reported on the efficacy of EHR software alerts that can reduce medication errors, such as concurrent prescriptions that might cause drug-drug interaction (DDI). However, the researchers point out that to provide truly reliable alerts to potentially dangerous DDI, EHRs must exchange data with other EHRs. The team found that only a minority of office-based physicians use such a health information exchange. As a result, the prescribing physician may fail to get an EHR alert to a problem. While medication reconciliation could fix this problem, the researchers noted that it has had limited effectiveness.

Internet Health Management reported on another recent study by Northwestern University researchers which found that while use of EHR tools in isolation improves medication reconciliation, it does not improve systolic blood pressure among patients with hypertension. The study, which was published online in JAMA Internal Medicine, found that expanded EHR use improved patients’ understanding their medications, access to digital monitoring tools at home did not result in continued use at or improve their conditions. They reported that blood pressure even worsened in the EHR-only group. Researchers note that information on adverse drug effects in the medication sheet may have led some patients to stop or reduce anti-hypertension medications when used without guidance from a healthcare professional.

The key takeaway from these studies is that it is necessary to find effective ways to support patient medication self-management and make the path easier for them. At the same time, it is critical to improve EHR usability, physician engagement, and access to reliable medication histories by next providers of care. Healthcare workers often work long hours, causing errors in transcription of medication orders. The support of an experienced medical transcription company can go a long way in improving the quality of nursing transcription. With a reliable medical transcription service provider managing the transcription of history and physical reports, clinic notes, office notes, or operative reports, clinicians can ensure EHR data accuracy and reduce the risk of documentation-related medication errors.

How Google is Working to Harness AI to Address Physicians’ EHR Documentation Burden

20-September-2018 Rajeev Rajagopal EHR Transcription

Physicians’ electronic health record (EHR) documentation processes are a subject of much debate. Physicians’ focus on EHR charting during the office visit is believed affect provider-patient communication and also clinical outcomes. Moreover, EHR data entry is associated with physician stress and burnout. Medical transcription outsourcing helps reduce the documentation burden to a great extent, but continuous efforts are being made to improve the medical charting process for physicians. The latest development is Google’s attempts to harness artificial intelligence (AI) to improve note-taking for physicians.

Components of EHR Charts and Medical Notes

Systematic documentation of a patient’s medical history, diagnosis, treatment and care is necessary for accurate and complete EHR notes. Medical notes are a record of everything related to the patient, including diseases, major and minor illnesses, and growth milestones. Information is the EHR chart will include:

Surgical history
Obstetric history
Medications and medical allergies
Family history
Social history
Habits
Immunization records
Developmental history
Demographics
Medical encounters

During the medical encounter, the provider has to enter all the information relevant to the patient’s care such as:

Chief complaint
History of the present illness
Physical examination
Evaluation, diagnosis, and treatment plan
Orders and prescriptions
Progress notes
Laboratory and imaging test results

There are basically two formats for physician note-taking: the narrative style and the bullet-point/checklist style. Notes may be also a combination of these formats. The narrative style, which describes “what happened?” and “what is going on?, is suitable for the history of present illness section. The narrative style offers a clear picture, but can be lengthy and time consuming. On the other hand, the bullet-point style allows clinicians to list the relevant information and symptoms without much detail or context.

In digital patient records, much of the notes are limited to checklists and bullets. Though this improves efficiency, saves time, and supports medical billing, it can make notes difficult to comprehend. Moreover, EHR checklists tend to oversimplify serious problems

Automating the Physician EHR Note-taking Process

According to a 2016 study:

For every hour physicians spend with patients, they spend about two additional hours on EHR and desk work within the clinic day.
Physicians spend nearly half of the total office day on EHR and desk work and less than one third on direct clinical face time with patients.
Physicians spend another 1 to 2 hours of personal time outside office hours doing additional computer and other clerical work.

The use of dictation and medical transcription services as well as scribes help clinicians to reduce time spent on note-taking. Google believes that physicians’ EHR documentation processes can be improved using AI tools, according to a research paper cited in a TechXplore report.

Peter Liu, a researcher at Google Brain, proposes a new language modeling task that can predict the content of new notes by analyzing demographics, laboratory measurements, medications and past notes in patient medical records. Published on arXiv, the paper proposes automated EHR note-taking as the solution to physicians’ EHR documentation burden.

The focus of the paper was on building language models for clinical notes. Liu put forward two language models: a transformer architecture model for shorter notes and a transformer-based model for longer sequences. The models were able to correctly predict a lot of the content of physicians’ notes. According to Liu, these models could help in the creation of more advanced spell-check and auto-complete features, which could be integrated into tools to support clinicians in performing their administrative tasks.

“We find that much of the content can be predicted, and that many common templates found in notes can be learned,” Liu writes in the paper. “Such models can be useful in supporting assistive note-writing features such as error-detection and auto-complete.”

Liu points out that there are challenges to be overcome before these models can be put to practical use. Limitations include the insufficiency of context provided by the EHR such as the lack of imaging data and lack of information about the latest patient-provider interactions. The researchers say that future work could involve combining EHR data with information from outside a patient’s medical record, such as imaging data or transcripts of patient-physician interactions.

Medical Transcription Outsourcing is still Relevant

Till such new models are perfected, the services provided by experienced medical transcription companies will continue to be relevant to ensure complete and accurate medical charts. With expert support, health care providers do not have to worry about incomplete or inaccurate medical charts. They can focus on patient care as their EHR documentation needs are taken care of by their reliable medical transcription service provider.

Hospitals to Invest More in Medical Transcription Tools

17-September-2018 MTS TEAM Medical Transcription

Medical transcription service refers to the process of transcribing the patient information dictated by physicians into text format. Physicians record patient information using audio recorders and send such recordings to medical transcriptionists for further processing. Such data is used largely by healthcare organizations and electronic health record initiatives. With more and more medical professionals and organizations benefiting from transcription, the demand for the associated tools and professionals is on the rise. Various tools are critical to provide accurate and reliable transcripts of physician notes and patient records. These tools range from Voice Operated Recordings to transcription software. Based on the latest market reports, most hospitals will install more medical transcription tools from companies such as Acusis, Nuance, MModal, iMedX, Precyse, Scribe Healthcare, Superior Global Solutions, Transcend Services and TransTech Medical Solution, among others.

Voice recognition software can automate the process of transcribing medical reports. The software converts audio files to text without human intervention. This software also reduces the efforts by physicians to record and send voice files for transcription. Despite language barriers, speed of speech, and incorrect pronunciations, the software reduces the time needed to transcribe medical reports. However, transcriptionists will be required to edit and proofread these automated transcripts.

Some of the top medical transcription software include Dragon NaturallySpeaking speech recognition software, which is 3x faster than typing and is 99% accurate; Intelligent Medical Software, an integrated Electronic Health Records (EHR) and Practice Management solution which includes applications for e-prescribing, practice reporting, patient portal and communication tools; Express Scribe, a professional audio player software for PC or Mac designed to help transcribe audio recordings; and Winscribe Text, an integrated, end-to-end medical report and documentation management solution for healthcare organizations that handles all steps in the documentation process.

According to the latest market report from Radiant Insights, Inc, technological advancement is one of the important factors driving the growth of the medical transcription industry and this market will witness a substantial growth due to the growing focus on automation of healthcare services and increasing adoption of advanced reporting techniques. Another report from Technavio finds the emergence of voice recognition technologies as the recent market trend.

Both the reports predict the Asia-Pacific (APAC) region would hold the major market share in the medical transcription industry during 2018-2022. The end users of this market are hospitals, physician practices, clinical laboratories, and academic medical centers. According to the Technavio report, the hospital sector will grow during the forecast period owing to the increasing number of patients suffering from chronic diseases. Even with the availability of such advanced MT software, many physicians are still considering medical transcription outsourcing to HIPAA-compliant transcription companies to enjoy benefits such as faster turnaround time, advanced technology, and reduced cost compared to in-house process, safe handling of patient data, quality transcripts and experienced proofreaders as well as improved report accessibility.

Best Practices to Improve Accuracy in Medical Transcripts

13-September-2018 Julie Clements Medical Transcription Outsourcing

Medical records are a combination of both self-reported patient information and a physician’s notes on the diagnosis, care and treatment given to the patient. When a patient visits a physician, the latter makes a diagnosis and dictates the patient’s medical condition via a digital recording machine. Many doctors use medical transcription services to transcribe these recordings into accurate medical records. Now EHR systems have been implemented in most provider facilities, and with HL7 interface transcriptionists can access the physician’s EHR and upload accurate medical records. Medical records should be documented in a timely and error-free manner.

Accuracy is a prime requirement for medical records. Only with accurate medical records, healthcare providers can develop an appropriate treatment plan and provide the necessary care. Errors in medical transcription can have grave financial, legal, and patient health impacts. In addition, important processes such as medical coding and billing, backup for potential audits, Meaningful Use attestation, all are dependent on the integrity of medical records. For good quality transcription, good quality audio is indispensable.

Tips for Achieving Excellent Quality Medical Transcripts

Here are some tips to ensure good quality audio and other requirements needed to achieve excellent quality medical transcripts.

Speak clearly: Talk in a normal tone and depending on the microphone used, the recorder should be about ¾” from your mouth in an upright position. This helps the sound to go over the microphone and not directly into it. If you are using a smartphone or tablet as your recording device, ensure that the mics are not covered by your hand.
Avoid a noisy environment: Choose a secure and quiet location for better results. Avoid areas that have background noises and cause distraction. Avoid telephone rings, music, vacuums, and beepers that can distract dictation and compromise quality.
Be careful with difficult words: Medical terminology is complex, and new words are being added frequently. Then there are similar-sounding words that create confusion or lead to spelling mistakes. Be extra careful when using such words. Ideally, medical transcriptionists should use references resources like Stedman’s Medical Dictionary for double checking. They should never try to guess a word as it can lead to misinterpretation. If the words are not clear, then the best practice is to leave a blank space in the transcript till the term is clarified. Any doubts related to numerical description or units of measure should also be cleared.
Be familiar with your device: Know how to use your recording system and basic functions such as Record, Pause, Play, Insert, Overwrite, Send etc. Make sure that the device is powered on. Give it a moment before you start speaking.
Begin with complete and accurate demographics: Patients should be unambiguously identified and all their data should be available at the time of dictation. Begin dictation by mentioning their record number, appropriate dates and the report type. This will avoid confusion and documentation of wrong patients.
Medical transcriptionists should have the updated list of names: MTs should have a complete list of all names, including dictating authors, and referral doctors. If you are using an electronic signature, make sure that you provide the medical transcription company, ahead of time, with the appropriate permission in writing and a copy of your handwritten signature if necessary.
Send only encrypted files: Heavy penalties are imposed on data breaches. HIPAA compliance is very important and patient privacy must be safeguarded at all costs. All files must be encrypted for transmission to the transcription provider. Follow your facility’s and the medical transcription company’s protocol for sending and receiving files. For long recordings, the medical transcription company may provide proprietary software. Do not use emails to transfer files because they may not provide the required safety.
Quality Assurance is a must: Quality should not be compromised as it will risk patient safety and quality of patient care. Make sure that the medical transcription company you partner with follows reliable QA standards. Learn about their QA measures and what guarantees they offer.
Give timely feedback to the MTs: When working with a new MT, this is important. It will help improve the quality of the transcript. Ensure that the MTs are well qualified to successfully understand various accents and ESL dictators. Consider giving a sample dictation as a test when making a selection.

Accurate medical reports are essential for any hospital, clinic or healthcare unit and outsourcing medical transcription tasks is a practical solution to ensure that. The above-mentioned tips can help ensure more clarity in the transcripts. Apart from generating clear audio, to achieve excellent quality transcription maximum attention should be given to workflow details such as providing complete and correct information, alerting the transcriptionist to any special instructions, clear identification of STAT or amended reports, and secure file transmission.

Why is Good Documentation Important in Nursing Homes? Common Mistakes and Legal Significance

06-September-2018 Rajeev Rajagopal Medical Transcription

Charting is a necessary element of nurses’ daily tasks. In addition to charting, nurses have numerous roles and responsibilities and outsourcing medical transcription is a practical strategy to maintain error-free EHR documentation. According to the American Nurses Association (ANA), clear and accurate documentation is essential for safe, quality, evidence-based nursing practice. Proper charting prevents errors, supports accurate assessment and diagnosis, and improves patient outcomes.

When it comes to nursing documentation, knowing how to accurately document a patient in the EHR is critical, meaning the nurses should be EHR-savvy. They should be well aware of the risks of erroneous and incomplete documentation. Improper documentation can lead to legal issues. An article published in American Nurse noted that nursing documentation with incorrect patient information is responsible for up to 72% of all electronic health record (EHR) related risk issues.

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What are the Features of Good Quality Nursing Documentation?

Documentation of nurses’ work is critical as well for effective communication with the healthcare team. According to the ANA, high quality nursing documentation is that which is:

Accessible
Timely
Contemporaneous
Concise
Thorough
Organized
Confidential
Reflective of the nursing process
Legible/readable (particularly in terms of the resolution and related qualities of EHR content as it is displayed on the screens of various devices)
Retrievable on a permanent basis in a nursing-specific manner

Good documentation provides a chronological record of the patient’s progress, the care provided, and how the patient responded to that care, noted Cherlyn Shultz-Ruth, Dean of Nursing at Arizona College of Nursing — Dallas Campus in an article on the Importance Of Quality Charting In Nursing published by the Arizona College of Nursing.

Legal Significance of Nursing Documentation

Nursing records have immense legal significance. Meticulous charting plays a vital role in ensuring both patient well-being and professional integrity. Experts highlight that by maintaining effective documentation, nurses not only safeguard patients and improve care outcomes, but also protect themselves.

Nurses’ record-keeping practices are under increasing scrutiny. Nurses should stay up to date with the legal requirements and best practices in record-keeping. They should ensure that the health care record provides an accurate account of treatment, care planning and delivery states a Nursing Times article. In the event of malpractice litigation, providers need to present evidence of proper charting and documentation to show that standards of care were maintained. From the legal perspective, Nursing Times states that the documentation should demonstrate:

The nurse’s assessment and the patient care planned and provided
Pertinent information about the patient’s condition at any point
Measures taken by the nurse to meet the patient’s needs
Evidence that the nurse has taken all appropriate steps to care for the patient and that patient safety has not been compromised by any action or omission
Documentation of arrangements made by the nurse for the continuing care of the patient

Nursing records that are incomplete, inaccurate, untimely, illegible or inaccessible, or that are false or ambiguous can obstruct legal fact finding, endanger the legal rights, claims, and defense of both patients and health care providers, and increase risk of liability of the healthcare organization and providers.

Medical Records – Common Mistakes to Avoid

EHR Documentation

Here are 10 actions to avoid during EHR documentation

1. Not recording pertinent health or drug information: Effective charting means avoiding fragmented documentation and providing information necessary for the continuity of care. It’s necessary to document food and drug allergies, diseases, or chronic health problems. Nurses should record such information in their notes and on the admission sheet, and alert other staff members to do so. Not doing so could result in the nurse being accused of negligence.
2. Not detailing medication administration: Nurses should record the dose, route, and time of every medication given to the patient. They should ensure that only medications that are prescribed are administered and investigate if they suspect that medication may have been given but not recorded.
3. Not recording nursing actions: To ensure timely recording of all care provided, experts recommend inserting flow sheets in the patient’s chart for review at the end of each shift. This will provide a starting point for each staff member at the start of and through the shift.
4. Using unfamiliar shorthand and abbreviations: As far as possible, nurses should avoid using unfamiliar shorthand and abbreviations and don’t clearly convey the patient’s condition.
5. Copy-pasting: Nurses should avoid copy-pasting from other team members. Make your own assessment of the patient and document it.
6. Making entries on the wrong chart: Recording on the wrong chart can occur, for example, if two patients have same last name, share same room, suffer the same condition, or see the same doctor. This error can become part of a permanent record, resulting negligence and medical malpractice. Best practice is to highlight patients’ names on charts and medication records and check their identity before administering medications.
7. Not documenting discontinued medication: If the physician discontinued a medication and the nurse did not document this, the patient may continue receiving the drug – with disastrous medical consequences. The nurses can be sued for negligence. To avoid this, the nurse should crosscheck the physician’s orders and medication sheet before giving any medication.
8. Failure to document adverse reactions to drugs: Nurses should be vigilant for adverse effects in patients. Certain drugs can lead to harmful reactions in some patients. Nurses should document such adverse reactions and follow them with the physician.
9. Errors or negligence in transcribing physician orders: Nurses receive physician orders face-to-face, and via telephone or voicemail. These verbal orders should be transcribed into the patient’s medical record or onto a prescription pad as they are being communicated. Nurses can be held responsible if they transcribe or carry out an order as it is written or if they suspect something is wrong. For instance, entering “hyper” instead of “hypo” or vice versa, and typing “he” instead of “she” are common EHR-related transcription mistakes. Outsourcing medical transcription is a feasible strategy when it comes to avoiding such documentation errors. As they are knowledgeable about medications, terminology, and procedures, experienced medical transcriptionist can detect and avoid such mistakes. They will only use abbreviations that are on the hospital’s approved list of abbreviations.
10. Illegible or incomplete records: This is another documentation disaster. Incomplete documentation can affect patient safety. Specificity and completeness in documentation is crucial to avoid legal issues as well as to ensure proper reimbursement.

Importantly, nurses should document only the facts. “Stick with what you’re seeing or experiencing versus what you feel and what you think,” said Natalia Cineas, Senior Vice President and Chief Nursing Executive at New York City (NYC) Health and Hospitals in the Arizona Nursing College article “[Because a] medical record medical record is subject to review – whether it’s by a regulatory agency or from a legal perspective,” Cineas noted.

Addressing the Challenges

Adequate training in EHR use, including drop-down menus, flow charts, and free texting, is critical to ensure quality nursing documentation.

Employers should also pay attention to nurses’ concerns about documentation. For instance, if there are different platforms where nurses need to enter the same information multiple times, it can lead to double documentation – an entry in the patient record of information that already exists. Double documentation results in wasted time and work overload.

To make charting seamless, it’s important that nursing documentation interfaces with the EMR. Relying on a medical transcription company that provides EHR-integrated transcription services can accurate and up-to-date charting that enhances nursing workflow.

Ease your EHR documentation process!

Free up time for your patients!

Tips for Patients and Physicians to Optimize the Office Visit [Infographics]

03-September-2018 MTS TEAM Infographics

Optimizing the office visit is critical for patients and physicians, as it can improve patient care and improve practice efficiency and productivity.

Optimizing an office visit requires participation from both doctors and patients. Busy physicians often rely on medical transcription companies to ease EHR data entry and outsource their medical billing tasks.

Tips for Patients and Physicians to Optimize the Office Visit [Infographics]

Why Patients Lie to Doctors and How It Affects Their Care Plan

30-August-2018 MTS TEAM Medical Transcription Outsourcing

Proper communication between patients and healthcare providers is vital for better patient care. Patients should feel free to express their feelings to their physician because this can ensure better outcomes. A genuine concern at present is the EHR, which forces the physician to look away from the patient and make entries in the electronic health record. While documentation requirements can be met by hiring a good medical transcription service, physicians have to do more to ensure their patients are actively engaged and value their opinion.

A major problem that physicians face and which affects the patient – doctor relationship is patients lying to doctors. For patients, going to their doctor and facing uncomfortable questions about their bad habits can be stressful. The information that a patient tells a doctor plays a crucial role in providing maximum care. The main reason why patients lie to their doctors are embarrassment, simple ignorance, fear of being judged etc, but whatever the reason, this can be dangerous for their health.

The following are the common lies that patients tell doctors.

They lie about taking supplements: Many patients take nutritional supplements and herbs, but do not admit this to the doctor. Many of these supplements can be harmful and interfere with the medicines and drugs physicians prescribe and this can distort test results and reflect in the physician’s diagnoses.
Smoking: Patients lie about smoking and also about how they smoke. This is very dangerous for their health, especially for heart patients because any nicotine and tobacco derivatives in the body can slow down the process of healing. Patients feel ashamed about their habit of smoking and don’t want to discuss it.
Lie about their sugar intake: Diabetes is very risky, especially for patients who have surgical wounds and uncontrolled sugar levels can affect the patient’s recovery. Some patients with diabetes are unaware of their blood sugar levels or can’t recall it. It is important for patients to track their blood sugar levels because they are at more risk of developing eye diseasessuch as cataract, glaucoma, and diabetic retinopathy that goes undetected sometimes and chronic diabetes can even lead to heart diseases and strokes etc.
Women lie about heavy menstrual periods: Women often feel embarrassed about heavy periods when they have to change pads or change clothes several times a day. They try to hide their need for frequent bathroom visits. Many of them believe that there is no safe treatment for vaginal issues and this can lead to severe health issues. They are also worried about surgical treatment on such sensitive areas.
About their drinking habits: This is a very common lie that patients tell their doctors. Consuming more than 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirit can be harmful and negatively affect the treatments provided. It will increase the chances of hospitalization.
About exercise: Some doctors advise their patients to exercise and be physically active. It is a therapy and a treatment of diseases and also helps in preventing diseases. However, many patients lie about exercise saying they exercise regularly when in fact they do not. Exercise is very important for patients who are obese, which can later lead to increased diabetes, coronary diseases etc.

Another important thing people don’t reveal to doctors or lie about is their financial hardships. A recent report from the University of Texas’s South-western Center for Patient-centered Outcomes Research reveals that low-income individuals don’t always tell their doctors the truth about their financial hardships, or that they are choosing to pay for their food and rent rather than medications and other healthcare. When patients do this, doctors feel they are not following the instructions given. The study authors say that as a solution to this problem, doctors and patients should have more open discussions regarding the cost of medicines and find one that the patient can afford. They could also identify medications that patients can safely skip. Medical transcription outsourcing companies have a role to play in studies such as these. Typically, physician-patient conversations that are recorded need to be transcribed and studied to find out how physicians are handling individual cases, and what changes can be brought about to ensure smoother, and more open communication between the provider and the patient.

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Text Messaging between Physicians and Patients – Pros and Cons

Benefits of Physician-Patient Communication via Text

Cons of Text Messaging in Healthcare

Medication Reconciliation using Electronic Heath Records

How Google is Working to Harness AI to Address Physicians’ EHR Documentation Burden

Hospitals to Invest More in Medical Transcription Tools

Best Practices to Improve Accuracy in Medical Transcripts

Tips for Achieving Excellent Quality Medical Transcripts

Why is Good Documentation Important in Nursing Homes? Common Mistakes and Legal Significance

What are the Features of Good Quality Nursing Documentation?

Legal Significance of Nursing Documentation

Medical Records – Common Mistakes to Avoid

Addressing the Challenges

Tips for Patients and Physicians to Optimize the Office Visit [Infographics]

Why Patients Lie to Doctors and How It Affects Their Care Plan

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