Do Electronic Health Records Improve Diabetes Care?

14-November-2016 Rajeev Rajagopal EHR Transcription

EHR Improve Diabetes Care With 1.4 million Americans diagnosed with diabetes every year, many endocrinology practices in the U.S. depend on electronic health record (EHR) integrated medical transcription services to manage the heavy influx of patients with this chronic condition. But do EHRs improve diabetes care? Has the shift from paper-based records to electronic made a difference to the treatment of diabetes? Healthcare experts are closely monitoring the situation to find the answers to these questions.

The battle against diabetes got a big boost when the World Health Organization declared “Beat Diabetes” as the theme of World Health Day 2016. According to HealthIT electronic health records (EHRs) do improve the quality of health care and outcomes for patients with diabetes. This portal for the Office of the National Coordination for Health Information Technology lists many EHR benefits for physicians managing diabetic patients:

Allows generation and meaningful use of lists of patients with diabetes for health care quality improvement, research, and individual outreach
Provides reminders on preventive care, screenings, or immunizations
Enables better communication with patients and allows physicians to educate them about self-management techniques
Generates “patient report cards” so that patients can better engage in and coordinate their care
Allows monitoring of the trends of diabetes-related tests over time, thereby enhancing clinicians’ decision-making capabilities
Improves better management of prescriptions for patients with diabetes

A 2011 study out of Cleveland, Ohio supported this. Following an analysis of the medical records of more than 27,000 adults who received care for diabetes at clinics in the Cleveland area, the researchers found that people got treated at clinics implemented electronic medical records (EMRs) were more likely to have received care that met four clinical benchmarks, which require that patients undergo eye examinations, get a pneumococcal vaccination, get support to manage kidney health, and receive help to track HbA1c for monitoring blood sugar control.

It was also found that patients got better help to manage their personal health, such as specific ranges for blood pressure, cholesterol, and weight at EMR-equipped clinics. The researchers concluded there were remarkable differences between results at clinics that had adopted electronic records and those that had not.

More recent studies which presented their findings in 2016 determined that effective use of EHR for diabetes management depended also on factors such as:

the organizational support and environment to support the transition to EHRs
the extent of team cohesion

In addition to storing comprehensive data about the patient, EHRs should help physicians simplify and automate clinical workflow and importantly, avoid medical errors. Meaningful use of EHRs is crucial to provide better care for patients with diabetes, improve the quality of health care and enhance patient outcomes. Experienced US based medical transcription companies provide timely and accurate EHR-integrated endocrinology medical transcription services to help physicians meet these goals.

Integrated Medical Transcription Services and It Can Improve Medical Practice Efficiency

10-November-2016 MTS TEAM Allergy & Sleep Medicine Transcription, Medical Transcription

Integrated Medical Transcription In the traditional medical transcription scenario, the physician dictated clinical notes into a recorder and sent the tape via courier or email to a medical transcription company for documentation. After the files were transcribed, they were sent back to the doctor’s office for review, printing, and filing. This time consuming process delayed care and often caused HIPAA compliance problems.

The introduction and widespread adoption of electronic health records (EHRs) changed all of this. In May 2016, Modern Healthcare reported that data from the Office for the National Coordinator for Health Information Technology showed that up to 96% of hospitals have a federally approved EHR that meets Meaningful Use requirements. The Office also reported that 83% of office-based physicians had adopted an electronic health records (EHR) by January 2015.

With these real-time records, authorized users can access patient information instantly and securely. In addition to standard information such as medical and treatment histories of patients, EHR software is designed to:

Include diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.
Ensure provider access to evidence-based tools that facilitate decision-making about the patient’s care.
Automate and simplify provider workflow.

One of the key features of an EHR is that they enable all clinicians involved in a patient’s care to document and share information.

Despite their efficiency and increased adoption, EHRs are not without challenges. Physicians report difficulties with data entry, including delays and errors in creating notes. Lack of accountability for making updates results in poor documentation. Moreover, the system detracts from the quality of the patient-provider encounter as the physician is too busy entering data into the system.

However, EHRs are the future of medicine, and today, efficient integrated medical transcription services are available to meet the needs of both physicians and patients. Outsourcing medical transcription to an established HIPAA-compliant company ensures safe, smart integrated dictation and documentation services. These service providers have full electronic record transcription capabilities and can:

Integrate dictation capture and transcription, and import documents directly into the EMR – EHR system.
Transcribe dictation sent from mobile devices and enter the information in the system.
Ensure rich patient summaries.
Provide reports showing the progress on each file, so that providers can modify and edit the files at their convenience.
Perform quality audits.

Such services are especially useful for oncologists and other specialists who have much higher documentation needs. A professional oncology medical transcription service provider can meet these requirements in customized turnaround time.

In the current scenario of shifting payment models, new government mandates, ICD-10 coding changes and other developments, reliable medical transcription companies are doing a great job in helping physicians harness technology, leverage the power of the EHR, enhance patient care, and manage their revenue cycle.

Study: EMRs underpredict Atrial Fibrillation Risk

07-November-2016 Julie Clements Healthcare News

Modern electronic documentation tools are designed to better equip physicians and medical transcription companies to improve the quality and the efficacy of medical documentation, and enhance communication between all healthcare providers. However, EurekAlert reports that a new study published in JAMA Cardiology found that atrial fibrillation risk prediction algorithms failed to work properly when applied to electronic medical records (EMRs).

Atrial fibrillation, also called AFib or AF, is irregular and often rapid heart rate which can increase a person’s risk of stroke, heart failure and other heart-related complications. According to the U.S. Centers for Disease Control and Prevention, up to 6.1 million people in the United States have AF and that the condition contributes to about 130,000 deaths each year.

Although AF itself is usually not life-threatening, it is nevertheless a serious medical condition that could require emergency treatment.Early identification of patients at risk for atrial fibrillation can reduce complications.

Given that EMRs are a powerful tool in medical practice, the cardiology team at the University of Illinois Hospital & Health Sciences System worked with other experts to find out if a widely accepted AF risk prediction model would work when applied to the electronic medical record. The team found that the algorithm could not accurately predict the incidence of AF when applied to the EMRs of a large group of patients. The key points of the research are as follows:

The study was based on the medical records of patients who as of December 2005 did not have AF but returned for follow-up care at least three times within the next two years.
EMR was used to follow the subjects’ health for five years to see how many developed atrial fibrillation
The Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) AF risk model, when applied to the EMR, under predicted the incidence of atrial fibrillation among low-risk subjects and over predicted the incidence among high-risk subjects.

The researchers concluded that accurate risk prediction is possible only by developing AF algorithms that work when applied to EMR. This would allow the development of customized preventive strategies.

The study suggests the model’s failure to accurately predict atrial fibrillation may be due to varying baseline features of the prospective and EMR cohorts and an “indication bias,” wherein people who developed AF possibly had more clinical interactions than those who did not.

The researchers also highlighted inconsistent EMR data-entry procedures as a limitation of the study. It has been found that physicians are likely to make mistakes when entering data in the electronic record’s customizable documentation applications, leading to an inaccurate picture of the patient’s condition at admission and over time. Outsourcing medical transcription is a widely recommended strategy to ensure documentation integrity. EMR-integrated medical transcription services can ensure the accuracy of the health record and prevent issues that could compromise patient care,quality reporting, and research.

Video Conferencing in Mobile Stroke Units Could Ensure Timely Stroke Care

03-November-2016 Rajeev Rajagopal Medical Transcription

Videoconferencing Mobile Strokes Units Mobile video conferencing helps businesses reduce overheads, increase revenues, enhance employee and customer engagement, and retain the best staff. In health care, mobile video conferencing can save lives. According to a recent report in Medical News Today, a mobile videoconferencing system that allows paramedics accompanying patients in ambulances to interact with doctors could help stroke patients receive timely treatment and reduce the risk of disability and death.

Researchers from the University of Virginia (UVA) Health System in Charlottesville arrived at this conclusion based on their study of a mobile conferencing system through which paramedics in ambulances discussed the patient’s condition with doctors using computer tablets. Their study was published in the journal Neurology.

A stroke occurs when blood flow to an area of the brain is cut off. An ischemic stroke is the most common type and involves a blocked blood vessel. Stroke is the fifth leading cause of death in America and a major reason for adult disability. Symptoms include difficulty walking, paralysis, weak/stiff muscles, coordination problems, weakness of one side of the body, paralysis of one side of the body, and blurred vision.

Getting medical help in the early minutes after symptoms start is crucial to reduce complications and improve chances of survival. Quick diagnosis means the patient can be given medication to dissolve the clot or have surgery performed to remove the blockage and restore blood supply to the brain.

As an ischemic stroke is a critical emergency, the first line of action is to call an ambulance. Modern mobile stroke units (MSUs) are specialized ambulances equipped with a mobile blood lab, a CT scanner (head) and telemedicine equipment that paramedics can use to send diagnostic images to neurologists at the hospital. The UVA study assessed a low-cost computer tablet in the ambulance. Called Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine (iTREAT), the tablet is suction-mounted to the wall of the ambulance. It allows the doctor to confer with the patient and the paramedic through encrypted video signals. The researchers found that 96 percent of the iTREAT assessments were as effective as evaluations performed at the bedside in the hospital. Such conferencing would facilitate better decision-making while the patient is in the ambulance so that quick, quality treatment can be provided.

Whether it’s in a stroke unit or in a hospital setting, proper measures and tools are necessary for the shared understanding of a patient’s care history. This will promote continuous and efficient intra- and interdisciplinary communication and decision-making about the patient’s future care. Medical transcription companies play a crucial role in facilitating clinical documentation and record keeping for all specialties, including neurology. They provide customized EHR-integrated neurology transcription services to ensure the information flow that is needed to ensure the continuity, quality, and safety of care as well as meet legal requirements, accountability, medical billing, and more.

Mobile Clinical Documentation to Be at the Core of the U.S. Healthcare Industry

31-October-2016 MTS TEAM Healthcare News

Mobile clinical documentation is predicted to be at the center of the healthcare industry and this leads one to think about the relevance of medical transcription and the role of medical transcription services in that not-so-distant future. While the dictation-transcription model has been and still is in popular use among healthcare practitioners, one cannot deny that with the advent of new and advanced technology, the healthcare industry is undergoing some serious changes including the implementation of EHR. However, the introduction of EHR has led physicians and nurses to spend more time on the accurate documentation of clinical records and spend less time with their patients. This has set healthcare providers thinking about various ways to address this issue.

How to Lessen the Medical Documentation Workload

In many medical specialties, physicians face more documentation workload following Meaningful Use and regulatory pressures.

Most of these doctors prefer either the good old transcription or the new speech recognition workflow though they are slightly wary about the latter, which is machine controlled.
Anyway, the situation now is rather stressful with physicians and nurses having to spend a lot of valuable time on documentation entry that has become necessary for hospital regulations, regulatory programs and quality programs.
EHRs have not been completely successful in relieving the documentation burden.

Experts in the field feel that one of the best methods to resolve this problem is the use of transcription and recording software. Recording and transcription software systems are available now that allow clinicians to dictate their clinical documentation and thereby spend more quality time with their patients.

Mobile Clinical Documentation Could Help

Documentation of patient interactions and patient medical history into an accurate medical record is a lengthy process for physicians. With everything going mobile, observers in the industry believe that the healthcare industry will also see a mobile revolution with physicians using mobile devices – their phones or other appliances that would allow them to speak freely while they are providing services to their patients. They would be looking for technology that will transcribe the spoken information accurately and insert the data in the right areas within the medical chart.

Software that combines real time speech, intuitive templates and transcription that is accessible from a secure mobile app would help speed up the documentation process and also improve the efficiency of clinicians. It should offer a variety of documentation options so that physicians can choose their preferred option, enjoy more control and flexibility and also focus more on providing quality patient care. Mobile clinical documentation technology that delivers structured documentation and high quality narrative to the EHR can be a great support to clinicians.

Healthcare IT Emerging As a Growing Market

Speaking of the electronic health record or EHR, today healthcare IT is emerging as a large and growing market. Healthcare IT consists of the Electronic Health Record, Revenue Cycle Management, Practice Management and Mobile Health sectors. Currently the total market size is estimated to be between $32 billion and $47 billion and is growing at 10 -14% annually.

According to the latest report from Technavio, the global medical transcription IT spending market is projected to grow at a CAGR of over 6% during 2016 – 2020. One of the primary market growth drivers is the need for a digital healthcare ecosystem, with hospitals and super specialty clinics increasingly using healthcare informatics technology such as EHR integrated with medical transcription solutions. This is with a view to reduce medical documentation timelines and help to invest more effort in diagnostic procedures. This integration requires additional IT investments, which is bound to attract start-up vendors and medical outsourcing solutions providers in the medical transcription market.

In 2015, America had a market share of 52% of global medical transcription IT spending market in terms of the overall IT investments. In America, healthcare settings have been mandated to implement ICD 10 in the workflow that has more diagnosis codes than ICD 9. As a result, physicians and medical transcriptionists will have to include more comprehensive patient information in the medical chart. The need for more organized and detailed patient records drives market growth in the United States.

US is a major market for medical transcription services and this is because of the sharper focus on improving healthcare and establishing consistent healthcare data models. Advanced technology such as speech recognition platforms and medical healthcare applications would help minimize errors and optimize the working process. Vendors in the U.S also focus on developing innovative platforms that enhance the privacy and safety of medical data. It is to be hoped that mobile clinical documentation would also improve with highly advanced technology in the future, helping clinicians effectively reduce their medical documentation burden.

Report: Superior Machine-learning Algorithms Set to Revolutionize Radiology Services

27-October-2016 Julie Clements Radiology Transcription

Machine-learning Algorithms Set to Revolutionize Radiology Services Accurate and timely reporting of patient care information is crucial for all medical specialties and especially significant for radiology. Each provider of patient care in the radiology service system needs to know that the information sent is accurate, and has been successfully received and understood by the intended recipient. Professional radiology transcription companies ensure quality documentation of operative reports and procedure notes for a wide variety of imaging techniques, which is critical for reimbursement, medico-legal and quality assurance activities, and research.

According to a recent report in Health Imaging, superior technologies are set to revolutionize the delivery of radiology services. Radiologists and all medical practitioners will need to adapt to the challenge of machine learning’s expansive capacity to transform big health data into evidence-based care, says the report. Authored by physicians from Harvard and the University of Pennsylvania, the commentary was published online in the Sept. 29 issue of the New England Journal of Medicine. According to them, machine-learning algorithms will feed on and transform massive datasets into knowledge to empower healthcare professionals.

The authors describe three ways by which the upcoming data-into-knowledge transformation will transform the field of medicine:

Advanced machine-learning algorithms will help physicians to establish a prognosis more easily and accurately. Communication of prognosis is crucial in palliative care as it helps in decision making for seriously ill patients. The study’s authors cite early evidence from their current work which uses machine learning to predict death in patients with metastatic cancer.
Machine learning algorithms will read digitized images more accurately than human beings, the work that is presently done by radiologists and anatomical pathologists. Faster and more accurate interpretation of digitized images such as mammograms can save lives. The authors expect the patient-safety movement to increasingly back algorithms over humans for the speed they offer.
Machine learning will reduce medical errors and enhance diagnostic accuracy. The report predicts that machine-learning algorithms will soon produce differential diagnoses, recommend high-value tests, and reduce overuse of diagnostic testing.

Patients will benefit the most from these machine-learning algorithms which are poised to transform the clinical medicine scenario.

Accurate documentation of patient histories and other medical data is crucial as it is this information that shapes the algorithms. In fact, the Health Imaging report cites the researchers as saying that in order to perform well, “medical machine-learning algorithms need to feed on massive datasets incorporating millions of medical observations”. This clearly shows the importance of accurate and timely medical transcription services. Whether radiology or any other specialty, a professional medical transcription company is committed to delivering accurate, complete and timely transcripts of physician dictation integrated to the electronic health record (EHR). By ensuring data integrity, medical transcriptionists ensure the availability of quality data sets that form the foundation of ongoing and future medical research.

Resolving Documentation Issues in Ambulatory Surgical Centers (ASCs)

24-October-2016 Rajeev Rajagopal Medical Transcription

Resolving Documentation Issues in Ambulatory Surgical Centers According a recent study, encouraging patients to use ambulatory surgery centers (ASCs) instead of hospital outpatient departments for common procedures is a cost-effective option. According to a report published by the Society for Human Resource Management (SHRM), the study which was led by Healthcare Bluebook, a national provider of quality and cost data for health care services, found that lower costs for surgical procedures reduced the out-of-pocket costs of ASC health plan enrollees lower by more than $5 billion annually. However, even as ASCs have successfully transformed the way healthcare services are delivered, they face serious documentation issues that can affect their revenue.

ASC quality reporting requirements: In 2012, CMS implemented a pay-for-reporting program known as the Ambulatory Surgical Center Quality Reporting Program under which ASCs need to report quality data for standardized measures to receive the full update to their annual payment rate. ASCs that do not report the necessary quality data suffer pay cuts. According to a Becker’s Healthcare report, ASCs must report the following quality measures to avoid the pay cuts for 2016:
- Patient Burn
- Patient Fall
- Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
- Hospital Transfer/Admission
- Prophylactic Intravenous (IV) Antibiotic Timing
- Safe Surgery Checklist Use
- Facility Volume Data on Selected ASC Surgical Procedures
- Influenza Vaccination Coverage among Healthcare Personnel
ASCs need to have rigorous data capture and reporting systems in place to capture, track and report key quality indicators.
Individualized OP report tailored to patient and procedure performed: Using a canned report template in the patient’s record may save time for physicians, but will lead to incomplete documentation for surgical procedures. ASCs need to provide accurate, detailed and individualized reports to prevent potential malpractice issues. Complete operative reports ensure comprehensive information pertaining to each patient procedure including patient complications, procedure complications, changes in medication, and laterality.
Timely dictation and medical transcription: Capturing data is a key challenge in ASCs, according to a Wolters Kluwer report. While health technology vendors now offer ASC-specific software and systems that can capture, track and analyze QI and outcomes data, timely dictation and EHR-integrated medical transcription services are essential for error-free documentation.
Accurate medical coding: As they provide highly detailed operative notes, physicians in ASCs should ensure accurate ICD-10 and CPT codes. Claims documentation should be clean, complete and accurate to ensure proper billing and reimbursement.

Having a clear-cut plan to track documentation compliance can help ASCs avoid documentation issues. Physicians and nurses who contribute to the medical record should be involved in the implementation of the compliance program. Each physician’s reporting activities need to be tracked and graded based on critical factors such as timeliness, level of detail and proper signatures.

The Healthcare Bluebook study found that that ASC prices are significantly lower than hospital outpatient prices for the same procedures throughout the U.S. However, ASCs need to avoid documentation gaps and errors to stay competitive. Outsourcing medical transcription can help ASCs meet their documentation goals. Professional medical transcription companies ensure accurate and comprehensive documentation of operative reports, as well as physician orders, history and physicals, intra-operative records, progress notes and discharge orders. Their solutions go a long way in simplifying and improving the creation and management of ASC documents.

Big Data Finding New Applications in Psychiatry

20-October-2016 MTS TEAM Psychiatry Transcription

Data Finding New Applications in Psychiatry Big data plays an important role in the healthcare industry. In addition to human-generated information such as medical transcription services – data in electronic medical records (EMRs), paper documents, physicians’ notes, and email – examples of big data sources in the medical industry include web and social media data, news feeds and journal articles, health plan websites and smartphone apps, claims and other billing records, diagnostic images and blood pressure, pulse and pulse-oximetry readings, data from IT performance tracking, fingerprints, genetics, handwriting, retinal scans, and staffing schedules. So a healthcare organization’s operations data includes all the information that supports its capability to function on a day-to-day basis. Big data is now driving value and innovation to improve care and provider performance.

Big data is now finding new applications in psychiatry. According to a recent report in Psychiatry Advisor, big data in psychiatry is a useful tool to improve treatment and to understand various disorders. The report lists the benefits of big data management in the field of mental health as follows:

Big data can enhance the general understanding about human behavior.
Management and analysis of observational data offers good prospects for research and exploration.
Advanced analysis of the data could help in establishing new clinical distinctions between cases and symptoms, as well as various phenotypes, which in turn, would increase understanding of the variety present in psychiatric diagnoses, and the role of genetics in specific cases.
Big data could provide more information about marginalized subpopulations by establishing sufficient sample sizes of these groups.
It could process large volumes of multisite neuroimaging data thereby improving the understanding of human brain processes in the normal and in the diseased state.
Big data gleaned from social media could help suicide prevention. By studying massive samples, of the complete medical history of millions of individuals and their social media posts, experts can develop successful interventions for individuals with suicidal tendencies who are usually excluded from clinical trials.

For the healthcare industry, the key is to become skilled in using the potential that big data offers in order to improve patient care, drive innovation, and enhance organizational performance.

Today, electronic health records are one of the most important sources of big data. However, an article published in Healthcare IT News last year reported on a JABFM study which found that when it comes to behavioral health, the EHR’s ability to deliver the “complete, current, just-in-time information” necessary for physicians to treat patients effectively is limited. One of the key findings of the study was that current EHR systems posed challenges for documenting and tracking relevant behavioral health and physical health information. What providers should know is that outsourcing medical transcription to a company that provides mental health transcription services will help ensure comprehensive, accurate and timely documentation including EHR-integrated solutions and reporting to support tracking patients with behavioral problems over time and settings.

Exertional Heat Stroke – What Sports Medicine Specialists Need to Know

17-October-2016 Julie Clements Medical Transcription

Exertional Heat Stroke

A recent article in the American Journal of Orthopedics analyzes the impact of exertional heat stroke (EHS) on American football and provides critical information for team physicians on prevention, diagnosis, management, and return-to-play issues. Outsourcing medical transcription is a great option to document such health events as well as for injury/illness tracking and clinical audits.

Heat strokes occur because of the body’s inability to cope with heat. Unlike standard heat stroke which typically affects sedentary older adults, exertional heat stroke (EHS) occurs in younger people and athletes who engage in strenuous physical activity for a prolonged period of time in hot weather. EHS is not always serious, but it can cause severe organ damage and lead to death if not recognized and treated promptly and properly.

During exercise, the body’s mechanisms regulate heat gain by increasing skin blood flow and sweating. However, this process can be affected by elevated environmental temperatures, increased humidity, and dehydration. Imbalances in thermoregulation can result in further complications and lead to EHI.

Football players face unique challenges that expose them to higher risks of exertional heat injury (EHI). According to the above-mentioned report, about 9000 cases of EHI occur every year across all high school sports, but studies show that EHI occurs in football 11.4 times more often than in all other high school sports combined. The main points of the study are as follows:

EHS is preventable and team physicians should pay close attention to mitigating risk factors prior to the onset of preseason practice.
Rapid diagnosis and treatment of EHS is crucial as any delay in the treatment can dramatically increase the risks of morbidity and mortality.
EHS is diagnosed by an elevated rectal temperature ≥40°C (104°F) and associated central nervous system (CNS) dysfunction.
Symptoms indicative of EHS include: CNS dysfunction (disorientation, confusion, dizziness, irritability, headache, delirium, collapse, seizures), and heat exhaustion, (fatigue, tachycardia, vomiting, diarrhea, hypotension).
Treatment should focus on cooling the whole body rapidly at the first sign of heat illness, and to bring down rectal temperature to <38.9°C within 30 minutes of the onset of the heat stroke.
Based on the physician’s assessment, intravenous fluid resuscitation should be started.
Once the optimal rectal temperature is reached, the cooling process should be stopped and the individual should be transported to a hospital for further treatment, if necessary.
The decisions surrounding return to play are highly individualized as recovery from heat injury depends on the duration of internal body temperature elevation above the critical level.

Football team physicians should be alert to the early symptoms of heat illnesses and prepared implement timely interventions to prevent progression to EHS. They should also educate coaches and players about EHI prevention practices and policies. As EHS is a unique life-threatening condition, the authors recommend that it is best to treat the patient on the sidelines before transport. They also stress that team physicians should develop a site-specific emergency action plan to address potential EHS events.

Proper clinical communication and record-keeping strategies are key elements in athlete health management. Professional companies provide accurate and timely electronic health record integrated medical transcription services to meet the needs of these providers. Their documentation solutions allow the physicians and their medical team rapid and remote access to comprehensive health data from any location. Such support would help them focus on their core tasks of developing and implementing comprehensive prevention strategies and emergency action plans to minimize athletes’ risk of adverse outcomes from an EHI.

National Physical Therapy Month highlights Physical Therapy as an Effective Option for Pain Management

13-October-2016 Rajeev Rajagopal Healthcare News

Physical Therapy Effective Option for Pain Management October is National Physical Therapy Month. What’s special about the campaign this year is that the American Physical Therapy Association (APTA) is promoting physical therapy as a safe and effective alternative to opioids for pain management.

In spring 2014, the FDA cited statistics indicating that 100 million Americans suffered from chronic pain. Painkillers are one of the most widely prescribed medications in the U.S. and this has led to widespread opioid addiction and misuse. Earlier this year, the Centers for Disease Control and Prevention (CDC) published guidelines aimed at reducing opioid prescribing. The CDC conveyed that for most people with chronic pain, the risks of opioid use were much greater than the benefits, and therefore physicians should consider alternatives like physical therapy. This Physical Therapy Month, the APTA is educating the public on the benefits of physical therapy to manage pain without the risks and side effects of opioids.

Independent therapists already have a high utilization rate for outpatient physical therapy services. With the new spotlight on PT as a safe pain management option, providers can expect to see an influx of patients. Busy hospitals, outpatient clinics, group practices and individual orthopedists need to get their documentation in order as they manage their patients. In fact, reports say that in recent years, the Office of Inspector General (OIG) found that some outpatient therapy claims by independent physical therapists were not reasonable, medically necessary, or properly documented. In these circumstances, the importance of reliable physical therapy medical transcription services hardly needs to be stressed.

Physical therapy has elaborate documentation guidelines. Documentation is required for every visit/encounter. Furthermore, documentation must:

Comply with the applicable jurisdictional/regulatory requirements
Have all handwritten entries made in ink and include original signatures
Adhere to appropriate security and confidentiality provisions for electronic entries
Include proper identification of the patient/client and the physical therapist or physical therapy assistant
Include the referral mechanism by which physical therapy services are initiated
Include indication of no shows and cancellations

The support of a medical transcription company can prove invaluable when it comes to meeting these requirements. Experienced transcriptionists produce accurate transcripts of initial evaluations, reevaluations, progress notes, daily notes, follow-up notes, procedure notes, letters, and discharge summaries. With extensive subject-specific knowledge, they can provide timely and error-free transcripts of all specific conditions associated with physical therapy. As physicians concentrate on providing individualized treatment programs to meet the needs of their patients, they can rest assured that their documentation requirements are taken care of by outsourcing medical transcription.