Study Shows That Good EHR Use Help Improve Prescription Management in Infectious Diseases

15-October-2015 Rajeev Rajagopal Infectious Diseases Transcription

EHR Documentation Though antibiotic drugs greatly reduce illness and death from infectious diseases, unnecessary and prolonged use of such drugs allows infectious organisms (that were targeted to kill by the drugs) to get adapted to them and cause antibiotic-resistant infections. The most effective way to tackle this illness is by prescribing the right antibiotic(s) when the patient truly needs it. Documentation of antibiotic indication during infectious disease transcription is essential to ensure appropriate provision of care. However, a recent study revealed that a pilot antibiotic stewardship program launched at a pediatric long-term care facility brought about a significant decrease in the use of a topical antibiotic without proper documentation of antibiotic indication, and EHR documentation played a significant role in it.

As per the study published in the Association for Professionals in Infection Control and Epidemiology (APIC) new release, the infection prevention team at the pediatric long-term care facility noticed some antibiotics being prescribed for a prolonged period of time and for non-infection indications. They launched a trial program to improve the antibiotic prescribing procedure and reduce the risk of antibiotic-resistant infections in their vulnerable patients. The aims of this program were to reduce the number of prescriptions without a documented indication and also reduce the use of a topical antibiotic ointment named mupirocin for non-infectious conditions including skin rashes and abrasions. The program achieved both these goals. There occurred a 59 percent decrease in use of a topical antibiotic and an 83 percent decrease in antibiotic ordering without proper documentation during a six-month period.

Role of EHR

As per the researchers, healthcare providers in the pediatric facility often faced two problems such as the following regarding antibiotic use, before transitioning to an electronic medical records system:

They often failed to document a proper reason for antibiotic prescriptions
They often failed to put an end to the treatment even if an appropriate duration had been completed

With the templates built into the electronic health records, providers find it is necessary to document the specific condition that states the need for the antibiotic they want to order for a particular patient. The inclusion of such a facility resulted in a sharper decline in prescription numbers. In short, poor antibiotic prescribing practices increase the risk for super-resistant infections in patients and electronic health records provide comprehensive and standardized documentation to curb such practices.

However, you should remain cautious about the limited narrative description with EHR templates and inadvertent errors caused by the frequent use of EHR shortcuts (for example, copy and paste errors). An integrated approach of EHR and medical transcription can improve the efficiency of your EHR documentation and ensure more accurate antibiotic prescribing. This approach involves transcribing physician recordings with skilled transcriptionists and using DRT (discrete reportable transcription) technology to populate the transcribed and reviewed data into relevant EHR fields.

DR Screening Is Best Delayed for Children with Diabetes Mellitus, Says Study

12-October-2015 MTS TEAM Medical Transcription

Diabetic retinopathy (DR) refers to retinal changes, which is a complication of Type 1 diabetes mellitus (DM) and is a major cause of blindness in young adults. As this disease may not have any symptoms and affect eyesight at an advanced stage, DR screening with accurate documentation of patient history and screening examinations via ophthalmology transcription can help physicians diagnose this condition at an early stage and provide timely treatment. The American Academy of Pediatrics recommends an initial screening at 3 to 5 years after diagnosing diabetes mellitus if the child is older than 9 years with annual-follow up thereafter. However, a new study suggests that DR screening should start later in children with diabetes mellitus.

In the opinion of the study co-author, though many young patients come for DR screening every year, they consistently show no sign of the disease. This study published in the journal Ophthalmology aimed at examining the prevalence and onset of ocular disease as well as its risk factors in children with diabetes. Children with below 18 years with type 1 or 2 DM were examined over a 4-year period. There were 370 children with a mean DM duration of 5.2 years, who had 693 examinations. No children had diabetic retinopathy while 12 children had cataract and 5 required extraction (identified by decreased vision, not diabetic screening). When 19 children had strabismus, 41 children had high refractive error. The study found no association between these conditions and duration or control of DM. The youngest age at diagnosis of severe DR was 15 years, and the shortest duration of disease was 5 years in literature.

The study concluded that DR is rare in children in spite of duration and control of DM and DR screening could begin at age 15 years or at 5 years after the diagnosis of DM, whichever occurs later, if the child is not at unusually high risk as judged by the endocrinologist. Existing amblyopia screening methods are effective for other ocular complications. Overall, the study recommends delayed screening regimen for asymptomatic children so that healthcare systems and families can avoid the extra burden of screening at a period when DR is not traceable.

While focusing on DR screening, you should give equal importance to your documentation. Ask for the symptoms of decreased vision or fluctuating vision, flashes of lights or defects in the field of vision and document them correctly in the patient’s history reports. Details regarding hemoglobin and blood pressure should be included as well. You should also document the results of physical examination (slit lamp examination and dilated fundus examination) performed. Apart from documenting screening examinations, update the medical documentation with details of follow-up examination for effective treatment.

Medical Documentation Tips to Address RAC Audits

10-October-2015 MTS TEAM Medical Transcription

The Centers for Medicare and Medicaid Services (CMS) closely scrutinizes hospitals and physicians to identify healthcare fraud and abuse. The actual target is not the quality of care, but the documentation that supports why a particular service or procedure was offered. CMS has contracted various organizations, collectively known as recovery audit contractors or RACs to conduct audits for reviewing the claim documents and impose penalties if fraudulent claims are detected. Physicians and hospitals should carry out their documentation effectively via accurate medical transcription to comply with CMS requirements and survive RAC audits. Here are some effective tips for that.

Detailed and Specific Documentation

You should document everything clearly and specifically without skipping any details. Patient medical records should address and/or reflect the following very clearly:

Admission status, inpatient or observation care
Primary diagnosis of patient’s condition
Medical co-morbidities
Severity of patient’s illness
Intensity of the service rendered
Date and time of service

The medical record must also indicate why hospitalization is required instead of a lower level of care. In order to meet the requirements of all patients that you see everyday, prepare bigger, better progress notes. Include the following while structuring progress notes:

Significant interval history
Review of systems
Physical examination
Summary of diagnostic studies
Impressions (diagnoses)
Medical decision making
Plan

Lastly, all entries in the medical record including the progress notes, dictations and orders as well as documentation from nurses, physical therapists, dieticians and other health professionals must be dated, timed and authenticated by the provider ordering or delivering the service.

Expand SOAP Notes

Your SOAP notes need to be expanded to include the details more clearly. The patient quotes and opinions can be added in the Subjective section. Use reproducible and supportive medical data and document all the treatment options discussed with your patients. This would be helpful as additional documentation and will add more credibility when filing your claims.

Timing

Good timing is very important for your documentation workflow. Avoid delays as much as possible. While history and physical notes should be signed within 24 hours after seeing the patient, operative notes should be documented and signed within 24 hours after the operation. You should complete the medical records within a week of the patient’s discharge.

Avoid EHR Shortcuts

It is better not to use EHR shortcuts such as copying and pasting information and pick-lists for documenting patient records. If you depend completely on them, it will result in selective and restricted documentation. Frequent copy-pasting may lead to inadvertent errors as well. Your documentation must be patient-specific. You can expect greater scrutiny for patient specificity in 2015 and beyond as the Office of Inspector General (OIG) has rebuked RACs for not giving enough attention to this issue. Customize your EHR to deal with this.

Thorough Review

Always double check the data entered into your EMR. Identifying the discrepancies before they are a part of electronic records is very important as it is quite difficult to trace the errors from numerous templates. Physicians should check the accuracy of their medical records before signing them.

Hire Trained Staffs

Since the documentation is extensive, detailed and the most critical component across the care continuum, the best option is to hire skilled and trained transcriptionists to handle and maintain your documentation. You can save a lot of time and effort with this. Reliable medical transcription companies provide the service of proofreaders and editors to review and edit the transcripts produced and ensure the accuracy of your documentation.

EHR Shortcuts – Are They Really Advantageous?

08-October-2015 Julie Clements EHR Transcription

EHR Shortcuts Many providers use shortcuts during EHR documentation to reduce the time taken for documenting a patient encounter. Though shortcut features may make you efficient, there is a greater chance for errors if you use those features inappropriately. Errors entering EHR are difficult to track and may lead to serious issues. Physicians may even end up providing poor quality of care to their patients. If the auditors find errors within EHR documentation, you will lose payments as well. Let’s see whether shortcuts are really advantageous as they seem and the role of a combined approach of EHR and medical transcription.

Here are some documentation shortcuts and their major shortcomings.

Copy-Pasting – Known by several names such as cloning or carry forward, this practice involves copying information from a previous note and pasting it on a current note or simply reusing the previous information. Copy-pasting without reviewing and updating the note can lead to serious consequences for patient care and reimbursement owing to the errors that may enter the patient records, and fraudulent claims. Documentation should be specific to each encounter.
Using Templates – The templates with auto-populated fields save a lot of time as physicians only require to scroll through the templates, and point and click on items to choose positive or negative. However, the templates can also become erroneous if providers do not change a result that may have been positive during a previous visit and negative during the current visit or pull forward any process that was not actually performed. In a busy practice, there is more chance for such kind of incidents to happen.
Favorite Lists – Certain EHR systems provide favorites list that stores the diagnoses physicians use most with a view to help them record diagnoses faster. But, the physicians must choose a diagnosis from that list only if the history and exam supports it. When it comes to documenting a large amount of patient data, physicians tend to use this shortcut to save time without a true assessment at that particular visit.

In short, shortcuts may make physician documentation efficient, but they also make the documentation error prone. In order to ensure quality care and proper payments, you should either remain more vigilant while using shortcuts or completely avoid using shortcuts. It is always better to avoid using shortcuts in a busy practice with mounting work pressure as there is greater possibility to make mistakes while hurrying to finish the documentation.

Enhancing EHR Documentation via Transcription

By combining EHR and transcription, you can avoid the use of shortcuts and save your time significantly at the same time. If you are adopting this approach for your practice, you can transcribe physicians’ recordings with the help of transcriptionists and review the transcribed data utilizing editors and proofreaders. You can then populate that data into relevant EMR fields. With a reliable medical transcription service in place, physicians need not bear the brunt of using EHR shortcuts anymore. On the other hand, they can benefit from accurate and timely patient data.

Advances in Septic Shock Care and Why Proper Documentation Is Critical

05-October-2015 Rajeev Rajagopal Medical Transcription

Septic Shock Care Septic shock is a clinical emergency condition, which involves a lethal drop in the blood pressure of the patient due to the presence of bacteria in the blood. This condition will prevent the delivery of blood to the organs and lead to multiple organ failure and even cause rapid death. It is estimated that this condition occurs in more than 230,000 U.S. patients every year. Recently, JAMA published new advances in septic shock diagnosis and treatment in the hope of reducing such a mass figure. These advancements along with proper documentation through emergency room transcription can make a huge positive impact on septic shock care.

As per the JAMA report, there are three main advancements in septic shock care such as:

The authors recommend focused ultrasonography to detect complicating factors such as hypovolemia or cardiogenic shock in patients. Both invasive (for example, pulmonary artery catheter) and noninvasive hemodynamic monitoring are recommended only for selected subgroups of septic shock.
Three randomized clinical trials revealed that protocolized care (protocol-guided fluid resuscitation) for septic shock offers little advantage compared to the management by clinical assessment without a protocol.
Hydroxyethyl starch is no longer recommended for the treatment of septic shock patients as it may be associated with worst outcomes. The debate regarding the role of various crystalloid solutions and albumin continues as well.

Though lactate is widely used in shock assessment, further evaluation is required for its specific role in diagnostic and treatment algorithms.

Importance of More Focused Documentation

Septic shock is an emergency event for which prompt clinical diagnosis is critical. The JAMA report states that prompt diagnosis starts with a focused history and physical examination for signs and symptoms. Though focused ultrasonography will help to detect complex physiologic manifestations of shock, you should record all details retrieved during a physical examination for accurate diagnosis. Proper emergency room documentation involves a comprehensive and focused history and physical examination report, which will help doctors to make the correct diagnosis as early as possible.

When it comes to septic shock treatment, accurate documentation plays a crucial role. The first step to the treatment itself is properly addressing suspected or documented infection as per the report. Depending on the details provided in the patient’s medical reports, appropriate treatment is provided for the septic shock. Prompt administration of intravenous fluids for restoring adequate circulation is vital for septic shock patients. The doses and type of intravenous fluids recommended by doctors should be documented correctly in patients’ records for prompt administration.

In short, the new advances in septic shock care will be truly beneficial only if your documentation remains accurate and complete. Rather than spending your precious time for documentation, consider obtaining assistance from skilled and experienced transcriptionists providing emergency room transcription services. This will help ensure accurate medical records and timely septic shock care.

Global Medical Transcription Market to Grow At CAGR of 6% during 2015-2019

01-October-2015 MTS TEAM Medical Transcription

Healthcare documentation has become more efficient with professional medical transcription, and the industry is growing. Research by TechNavio indicates that the global medical transcription market is set to grow at a CAGR of about 6% over the period 2015-2019.

The TechNavio report covers the present scenario and the growth prospects of the market for the forecast period 2015-2019. It identifies the key factors driving the growth of the market as increased patient care and focus on automation and cost-effectiveness. Factors that pose challenges for the growth of the market, according to the report, are intense competition, and data quality and security concerns.

Key market trends include the growing popularity of speech recognition software and use of mobile health solutions. The report states that the market is well established but highly fragmented with the presence of many global and regional vendors offering multiple products and services, fueling competition and preventing the entry of new players.

Accurate and timely documentation of medical records helps in the interpretation and analysis of patient details, enabling physicians to take prompt treatment decisions. As the transcribed records are stored in a structured digital format, they are easy to interpret. With the adoption of new technology and improvements in the healthcare sector, the global medical transcription market is expected to gain various opportunities.

The report by Technavio indicates the growing popularity of speech recognition software, which, it is said, will transform the role of medical transcription services from speech to editing texts in the near future. Nevertheless, it must be noted that many physicians prefer manual transcription over voice recognition as the latter cannot correct many types of errors and does not work with simple or complex formatting, such as boldface, italics, automatically numbered lists, bulleted lists, tables, indents, and font changes. Moreover, with voice recognition and self-editing being done at the same time, the physician will have to continually shift his attention between both. Clearly, quality clinical documentation would require a proper blend of manual transcription services and these new technologies.

Why EHR-integrated Documentation Is the Need of the Hour

28-September-2015 Julie Clements EHR Transcription

EHR-integrated Documentation EHR-integrated medical transcription and documentation can serve the needs of physicians and practices by enhancing their efficiency and improving patient care.

EHR-integrated Medical Documentation

The electronic health record was introduced to improve the medical documentation process, and make it more efficient and reliable. But since then, while some doctors and hospitals have reported improved performance, others have felt that the complex nature of EHR is actually slowing them down, compromising patient care and increasing their workload. This confusing trend is made more astonishing by the fact there seem to be only two extremes and no middle ground – doctors are either singing praises of it or complaining about its introduction.

Positive Response towards EHR Adoption

Market research firm Black Book conducted a survey recently which revealed that physicians in large practices and clinics were increasingly experiencing satisfaction with EHR usage since the survey was first conducted six years earlier. The larger physician practices were more satisfied with electronic health record usability and the productivity improvements it helped achieve than the smaller practices.

The survey involved 1,304 large practices. Physician satisfaction with EHR rose from a mere 8% in 2013 to 67% in the second quarter of 2015. There were also improvements in physician documentation from 10% in 2013 to 63% in the second quarter of 2015. Practice productivity enhancements rose from just 7% to a massive 68% in the second quarter of 2015.

Contrasting Results in AMA Survey

However, a survey conducted by AmericanEHR Partners and the American Medical Association (AMA) revealed that physicians are more dissatisfied now with electronic health record usage than they were five years ago. The survey covered 940 physicians and revealed that only 34% of them were pleased with their system of EHR, which is a significant drop from the 62% reported when the survey was conducted in 2010.

Respondents largely gave negative reactions with regard to their EHR system’s intended goals of cost savings and improved efficiency and productivity. Up to 72% of respondents believed it was difficult or extremely difficult to bring down their workload, 54% believed it was increasing their operating costs, and 43% believed they had productivity challenges that needed to be overcome.

Primitive or Inefficient EHR Systems

This is in striking contrast to the Black Book findings mentioned earlier. However, Black Book’s survey also revealed that 71% of dissatisfied clinics and large practices were struggling with their original electronic health record systems implemented before the fourth quarter of 2012. As a result, 18% of these large practices are either planning or executing the replacement of their original EHR before the end of 2016.

The reason for the dissatisfaction with EHR could then be pinned on primitive and inefficient software, and it is important that practices realize this and make the required changes since EHR here to stay. EHR-integrated medical transcription services can help improve user-friendliness and performance for physicians and practices. They can also help physicians in their transition from conventional dictation platforms to EHR/EMR systems. Judging by the prevailing discontent, such seamless integration is the need of the hour.

Majority of Physicians Still Not Happy with Their EHR Use

24-September-2015 Rajeev Rajagopal EHR Transcription

EHR Last year, we discussed how many healthcare providers were unhappy with their EHR despite investing a huge amount in such systems. Now, a new survey from AmericanEHR Partners and the American Medical Association (AMA) shows that physicians are still not satisfied with the use of EHR in their practice. In this survey on Physician Use of EHR Systems 2014, more than half of all participants responded negatively to the questions regarding how their EHR systems improved costs, efficiency or productivity. This new study again highlighted the significance and efficacy of a combined approach of EHR and medical transcription.

The above mentioned online survey collected data on EHR use, satisfaction with EHRs and health information technology. The key findings of this survey are as follows:

Around 42 percent of respondents believed that the ability of their EHR system to improve efficiency was difficult or very difficult.
72 percent of respondents believed that the ability of their EHR system to reduce workload was difficult or very difficult.
54 percent of respondents said that their EHR system increased their total operating costs.
43 percent of respondents said they had yet to overcome the productivity challenges associated with their EHR system.

While 37 percent of primary care physicians said they were satisfied with their system, only 28 percent specialists were satisfied with their system. As per the survey, the specialists cope up with the EHR by hiring scribes to perform the data entry. Around 13 percent of physicians surveyed said they employ a scribe while 9% said they are planning to employ a scribe in the future.

Medical Scribes or EHR Transcription – Which Is the Better Alternative?

Scribes document patients’ data in electronic templates through relatively minimal use of text. They don’t listen to recordings, but listen to the physicians directly, clarify their doubts in real time and ask physicians to provide more details if the template requires that. In other words, we can say it is a bilateral communication process. Though scribes can save physicians’ time and increase the efficiency of completing patients’ reports, there are several drawbacks involved such as:

Most scribes receive very little training and therefore their knowledge of medical terminology may not be very commendable. This may negatively affect the communication between the physician and scribe, which would increase the chance of medical error in patient reports.
Physicians may respond to the doubts raised by the scribes, clarify them or provide appropriate details during a patient encounter. This may prevent physicians from spending quality time with their patients and providing appropriate care.
The patients may not be comfortable with a third person during the visit to their physician, especially in the case of physical examination or an issue that is very intimate.

EHR transcription involves a blended approach of transcription and EHR. First, the physicians’ recordings are transcribed with the help of experienced and skilled transcriptionists. The transcripts are checked thoroughly and populated into the appropriate fields within the EHR system. Professional transcriptionists ensure maximum accuracy for your reports. By relying on a dedicated medical transcription service provider, you can give full attention to your patients and enhance productivity. There are medical transcription companies which provide three-level quality assurance with proofreaders and editors to ensure maximum accuracy for your reports.

Good Documentation Practices to Ensure Quality Nursing Care

21-September-2015 MTS TEAM Nursing Transcription

Nursing Care Accurate and comprehensive nursing documentation is critical to provide superior quality care to patients. Quality care can be ensured with excellent team effort. Nursing charts should be easily accessible to physicians and other clinicians to help them understand the status of the patient’s condition and care. Proper documentation with effective nursing transcription ensures that each patient’s individual needs are clearly communicated to team members. This will also help nurses to avoid medication errors. Here are some good documentation practices that can in turn ensure quality care and patient safety.

Chart Objective Information

You should accurately document what you see, feel, smell and hear. If you are documenting what someone else observed, mention that in the notes. Exactness of documentation is vital. For instance, if a patient refuses to take medications and throws them away, you should not document “the patient is not taking medications properly.” Make sure that you document “the patient refused to take medications and threw them away.”

Chart Immediately after Giving Care

It is better to chart as soon as possible after providing care as you can remember everything vividly and document correctly to avoid medication errors. Besides, it is required to report critical values to the physician within 30 minutes. You should follow the facility’s safe plan in case the physician can’t be reached. Even if you are busy, be aware of critical items (such as abnormal vital signs, transfer, nursing shift or patient hand offs, taking verbal orders, verifying medication orders and notifying physician’s orders) and document everything as fast as you can.

Use Only Approved Abbreviations

Do not use abbreviations that are non-medical or not approved in your chart. Avoid using texting language as well. Although abbreviations may save your time, make sure that they are correct and do not end up as a threat to the patient.

Review Charting

It is very important to review the chart to find out inadvertent errors and correct them. This will not only help you to correct your mistakes, but also eliminate the mistakes made by your co-workers.

Document Follow-up Care

You should document in what way you followed up a medical situation with the appropriate patient care. When the patient’s status changed and you have notified the physician, document the exact change in the patient’s status and also that you have notified the physician. Document the changes made by the physician and how the patient responded to those changes.

Be Careful with Late Entries

Be very careful with adding late entries. They should be documented per policy and procedure. Late entries should not be squeezed into the chart to appear as if they were documented on time. The same principle applies to corrections as well.

You should highlight allergies and fill out flow sheets completely. If you observe new onset of pain, evaluate thoroughly and document it appropriately in your chart. Relying upon transcription services a midst your busy schedule would be a great relief and help you generate more accurate documentation. You can record all your observations, interactions with patients and caregivers, and services provided and have the recordings transcribed. With transcription provided by professional transcriptionists and thorough review by editors and proofreaders, you can have the documentation prepared and returned to you within the required turnaround time. In this way, you get to save a lot of time while also ensuring the accuracy and completeness of your documentation.

Avoiding Transcription Errors in Medication Administration

17-September-2015 Julie Clements Medical Transcription

Transcription Errors Transcribing a medication order or the transfer of information from an order sheet to nursing documentation is a crucial step in medication administration. With accurate transcription, the other steps in medication administration such as dispensing the drug and delivering the drug to the patient can be really effective. Understanding the possible errors that you may encounter while transcribing the order can help you to remain alert and further enhance your nursing transcription.

Medication errors related to transcription can be generally divided into four types such as:

Errors from Poor Handwriting – Incomplete or illegible handwriting can lead to misinterpretation and grave mistakes. Healthcare providers adopting computerized medication records can eliminate this problem of misinterpretation. Even so, nurses and pharmacists at facilities where typed medication orders are not a common practice should carefully check handwritten medication orders, clarify they are legible and ensure they are interpreted correctly.
Decimal Errors – Placing a decimal and zero after a whole number (trailing zero) while transcribing orders is not a good practice. It can lead to serious mistakes. For example, if you transcribe 5 ml as 5.0 mL, it might be read as 50 mL. Document it as 5 mL. Make sure that you don’t forget to place a zero (leading zero) before fractions that are less than one. For example, instead of writing .5mL, you should write 0.5 mL. Otherwise, it may be interpreted as 5mL.
Misused Abbreviations – Take care to use abbreviations sparingly. Do not use abbreviations such as q.d, q.o.d, IU or u. Instead, you should write everyday, every other day, international unit or unit respectively. Latin abbreviations for the eyes and ears should not be used. Avoid using abbreviations such as µg (write mcg) because this is often misinterpreted as “mg”; H.S. (write out “half strength” or “at bed time,” whichever is appropriate,); and cc (write mL), because “cc” is often mistaken as “u” (units). You should also persuade prescribers to write out instructions instead of using abbreviations.
Incorrect Dosage – Be alert when interpreting large medication doses more than 1000. Use commas for dosing units at or above 1,000 or use words (for example 100 thousand). There may be mathematical errors while calculating dosage. Double check all math calculation before entering the dosage into the nursing documentation form.

If you find a medication error, it is very important to notify your nurse manager and complete an incident report, generally within 24 hours. Include the following information in that report along with any additional information specified by your facility.

Patient information
Location and time of incident
Detailed description of what happened
What was done about it
The condition of the patient
Your signature

There are several factors that contribute to transcription errors including incomplete or illegible prescriber orders, lack of familiarity with drug names and so on. It is very difficult and time-consuming for nurses to check on all these factors and find solutions, especially if they are on a busy schedule. They can consider obtaining the support of medical transcription companies that offer the service of skilled and experienced transcriptionists, and have stringent QA measures in place to ensure accuracy and quality.