EHR Access Significantly Impact Radiology Decision Making

14-May-2015 MTS TEAM Radiology Transcription

EHR Access Impact Radiology Decision Making Most radiology departments have begun to transition from paper-based imaging requests to electronic orders originating in an EHR system with a view to streamlining their workflow. Access to EHRs can have a significant impact on radiology decision making. Electronic record systems provide a more in-depth clinical documentation that helps radiologists in taking the right decision.

A 2014 study published in Health Affairs found that EHRs play a critical role in radiology decision making and influence medical management in a number of cases involving imaging. In this study, three neuroradiologists analyzed 2,000 consecutive head computed tomography (CT) exams ordered by emergency department (ED) physicians. On comparing the medical information generated by ED physicians with the information generated by the interpreting radiologists who had access to additional EHR-derived patient data for each head CT exam, the following was observed:

In 6.1 percent of the cases, the neuroradiologists came to the conclusion that the additional information available in the electronic record system was very likely to have influenced how the exams were interpreted and how the patients were treated based on the interpretations. In the cases where information from EHR was not available, the neuroradiologists often failed to recommend further imaging or may have gone wrong in patient diagnosis.
In 16 percent of the cases, the neuroradiologists came to a conclusion that the additional information within the electronic record system possibly affected how the cases were interpreted, diagnosed and treated.
In 13.4 percent of the studied cases, without appropriate EHR access there was a negative impact on patient management.

EHR systems act as a decision support tool that can help minimize medical errors that stem from human oversight or error. Within the integrated EHR system, physicians can include accurate medication and patient history lists, notes and make the charts immediately available on a cross use platform so that other providers can quickly access the information they want and take the right decision. Here are the major benefits of having an electronic health record system for radiology documentation.

Possible to transfer a patient’s data from one department to another quickly and efficiently
Transitioning from physical storage space to a digital one opens up more physical space for healthcare operations
With EHRs you can reduce the time required to find, analyze and implement patient records, serve more patients in a day, and enhance your workflow and productivity
EHR solutions are customizable and scalable

However, electronic health records have the risk of copy-paste errors and limitations for narrative descriptions. Blending EHR with transcription would be an effective solution to address these challenges. In this approach, physician dictations are transcribed by skilled and experienced medical transcriptionists, reviewed by editors and proofreaders to ensure accuracy and the transcribed data is entered into appropriate fields in the electronic record systems. Physicians can continue with their practice of dictation and also have their documentation completed in a timely manner.

Acrostic for Quality Pediatric Post-take Ward Rounds Documentation

11-May-2015 Julie Clements Pediatrics Transcription

It is very important to maintain quality and accuracy when documenting pediatric post-take ward rounds (PTWR) since care is evaluated, and coordinated care plans are formulated during this time. This documentation task often left to junior doctors is quite challenging as these rounds are multidisciplinary and a great deal of information is shared. In the wake of previous studies that showed failure in documenting important aspects of post-take ward rounds, a group of researchers in the UK investigated the impact of acrostic, a particular type of mnemonics (mnemonics is any learning technique that helps learners remember large pieces of information) on documentation and got positive results.

Acrostic is a prominent mnemonics learning technique that uses a memorable sentence that helps individuals retrieve letters (actually the first letter of each word used) while the letters represent the information they need to remember. This study evaluated the use of acrostic in improving the completeness of post-take ward rounds documentation. For that, the study used ‘Please Verify Information For Doctors, Please Note Every Plan’ which represents Problem; Vital signs; Investigations; Fluids; Drugs; Patient/parental concerns; Nursing concerns; Examination; Plan. This acrostic was formally introduced to all the consultants at a teaching session and included in the mandatory induction programme for all new doctors.

The introduction of the acrostic resulted in tremendous improvement in the documentation of the following key elements of ward rounds.

Problem (84% vs. 94%)
Investigations (26% vs. 72%)
Fluids (16% vs. 74%)
Drugs (26% vs. 76%)
Patient/Parental concerns (16% vs. 72%)
Nursing concerns (4% vs. 48%)

Overall, patient notes reflected the input of patients, their parents and caregivers and the involvement of the entire multi-professional team much more clearly after using acrostic as a template for documenting ward rounds. Further, around 95% of the junior doctors confirmed that the acrostic offered an easy format to document vital aspects of post-take ward rounds while 90% agreed it helped to reduce the time taken for retrieving information from patients’ notes later for a review.

Mnemonics has been used by medical professionals to promote faster and effective learning of patient details. As this study confirms the importance of acrostic in clinical documentation, mnemonics opens better possibilities for providers to improve their documentation and enhance the quality of patient care. However, support from experts having in-depth knowledge in medical terminology would help in a more effective use of this strategy.

Researchers Find New Treatment Options for Brittle Bone Disease

07-May-2015 Rajeev Rajagopal Diseases and Conditions

Researchers from the Baylor College of Medicine, Oregon Health & Science University in Portland and the Kennedy Krieger Institute in Baltimore have found a new approach for treating osteogenesis imperfecta (OI) or brittle bone disease for which only a few treatment options are available. Being the largest controlled trial ever performed in adults having this disorder, it tested drugs including teriparatide (a kind of parathyroid hormone approved for treating women having osteoporosis), and bone anabolic therapy for the first time. The incidence of fracture did not differ between the study groups due to the limited size. Since there is great variation of fracture patterns and frequencies from patient to patient, a much larger group of patients will be required to test the effects on fracture frequency.

Brittle Bone Disease

For the study, 79 adults suffering from OI were selected randomly and divided into two groups – those that received teriparatide and those that received placebo or an inactive medicine. The study lasted for 18 months and it was found that the bone mineral density increased in the spine and hip of patients who received teriparatide. It was also revealed in the study that patients having Type 1 osteogenesis imperfecta seemed to benefit more from the treatment compared to those having severe forms such as Type 3 and 4. This raised questions on how different genetic mutations in the same gene respond differently to medications. In the opinion of researchers, larger studies using teriparatide are required to determine whether this drug can reduce the risk of fracture.

Studies such as this require copious documentation and transcription of orthopedic reports. Each fact that emerges from the research will have to be clearly recorded for detailed awareness regarding the disease and its treatment options.

The above mentioned research also found that anabolic bone therapy seemed to be more beneficial in patients with mild forms of OI. As per the authors of the study, Bisphosphonates used in children having OI disorder resulted in higher bone density, reduced bone turnover and in certain studies lower fracture rate. But, fewer studies of those drugs were conducted in adults with this disorder and those studies revealed an increase in bone density, but no significant reduction in fracture rate.

Osteogenesis imperfecta (OI) or brittle bone disease has a higher risk of fracture and it is estimated that around 25,000 to 50,000 people in the U.S. have this disorder. This study surely opens up new treatment possibilities and will help doctors to provide quality care for their patients suffering from brittle bone disease.

Why Is a Medical Transcriptionist in High Demand?

04-May-2015 MTS TEAM Medical Transcription

If a youngster with basic college education would ask around for a career that would offer consistent growth, the answer would be medical transcriptionist (MT). Starting as an MT trainee, the candidate could move on to the positions of transcriptionist, supervisor, editor, work-from-home professional, and also head towards consulting or other interesting avenues.

Medical transcription is a lucrative job not only for youngsters fresh out of college, but also homemakers and older individuals looking to earn big and have an interesting life. And the demand for MTs keeps rising since healthcare organizations have been enforced with increasing documentation responsibilities. Though the Bureau of Labor Statistics (BLS) has projected a slower than average 6% growth rate for the job from 2012 to 2020, the ageing population is expected to raise the demand. As of 2012, the median pay for MTs was $34,020 per year and $16.36 per hour.

Medical Transcription Is Integral to Healthcare

Transcription of medical reports serves the needs of hospitals, clinical practices, nursing homes and individual physicians. HIPAA norms are strictly enforced, and the physician needs to stay out of trouble to avoid legal hassles. With greater coding and billing responsibilities, on account of the coming ICD-10 implementation, physicians and other medical professionals have a lot to handle. Their coding has to be accurate if they are to receive prompt and adequate reimbursement for their services.

This makes outsourcing medical transcription or maintaining dedicated staff for the purpose important. The demand will always be there, since efficient transcription can enable physicians to have reliable records of treatment and diagnoses, and retrieve those documents easily whenever required. This ultimately helps in providing better healthcare to patients. Moreover, doctors can focus on providing care.

Need for Accuracy Makes Outsourcing Essential

skilled manpower is a must. This is why trained transcribers are always in demand. The need for precision is also why outsourcing is considered to be a better option. While healthcare practices can maintain staff exclusively for transcription, it could be a drain on the resources while also requiring a significant infrastructural investment. Outsourcing ensures cost-effective and large scale transcription.

Offshore medical transcription is usually more cost effective. Medical transcription providers have software and all the technical nuts and bolts for effective transcription. This technology also filters down to the dictation options. While audio recorders are conventionally provided by transcription companies to doctors for dictating files, speech recognition software is now taking the upper hand since it enables automatic audio conversion to text format.

The bottom-line is, the demand for medical transcription underscores its importance to the healthcare industry – and it has evolved successfully according to the changing needs.

Cyber Attacks on the Rise, Improve your Electronic Data Security

27-April-2015 Julie Clements HIPAA Compliance

A survey published by IDC Health Insights in November 2014 found that healthcare organizations are now more prone to cyber attacks than ever before, partly owing to the widespread use of electronic clinical documentation. Cyber criminals can access your digital health information without authorization, steal or erase it and make you liable for HIPAA violation. If you are depending on outsourced medical transcription services, ensure that your association is with a trusted service provider in the industry.

According to the survey, cyber criminals consider healthcare organizations as soft targets compared to financial services and retailers. The key findings are as follows.

As per the survey, cyber attacks against healthcare organizations will increase in number and level of sophistication over the next 12 to 24 months and organizations have to take a more proactive stance against these cyber threats and attacks. Healthcare organizations should invest in threat intelligence reporting that combines reports from their own network logs and from security vendors. By applying predictive analytics to these internal and external data feeds, it is possible to identify behaviors that suggest whether the systems are being compromised or under attack.

Here are some effective security measures to ensure that your electronic data is secure from cyber attacks and thereby avoid HIPAA violations.

Perform regular checks and updates on the data
Run multiple risk analysis to determine threats and vulnerabilities
Restricted access to data
Contingency plans
Internal auditing

EHR data is prone to errors even with the most effective speech recognition system owing to issues such as a noisy environment or change in dictator’s voice due to cold or other difficulties. If you are relying on reliable transcription outsourcing services to ensure the quality of data within your EHR system, check out that the medical transcription company provides the following provisions to make your data secure.

Password-protection for data
Firewalls and antivirus software installed on all computers and updated daily
Encryption for transferred files
Workforce trained and monitored on HIPAA privacy, security, and confidentiality.

The Versatility of Medical Transcription

20-April-2015 MTS TEAM Medical Transcription

The medical transcription industry owes much of its success to its versatility. The industry has adapted well to ever-evolving technologies and health care documentation policies. One of the primary reasons for the huge success of this health care domain is related to the ability of medical transcription companies and transcriptionists to quickly adapt to these changes.

Medical transcription service providers have come a long way right from the days of collecting dictation tapes of health care professionals from their workplace and working hard to type these into to text reports to be returned to them within the specified deadline. The advent of computers and the Internet made things much easier for the transcriptionist. Service providers from remote locations can offer top quality, secure transcription solutions in custom turnaround time and at affordable rates.

Adapting to Technological Changes

These service providers have come a long way by quickly adapting to rapidly evolving technology. They are utilizing new technology to improve their services for health care providers with additional features such as flexible modes of dictation, automatic uploads and downloads, archiving, HL7 integration and more.

A reliable medical transcription service provider is also HIPAA compliant with measures to safeguard protected health information. Security measures include multi-tiered application architecture, design level security, safeguards, sterilized e-mail servers, 128-bit data encryption, denial of access procedure, and multi modal alerts.
The current advancements in medical transcription industry have not been without hazards. Voice recognition software was introduced as a substitute for medical transcription, but it has been realized that the accuracy of patient information cannot be assured with this software. The tool does not provide complete accuracy even after it has been extensively trained to detect the physician’s voice and dictation style. Speech recognition technology is not good at detecting or recognizing voices with heavy accents and cannot determine poor grammar, disorganized dictation and missing or overused punctuation. It is also prone to errors in data when used in noisy places. The medical transcriptionist role is still valid for proofreading and correcting the transcripts to achieve the required levels of accuracy. In short, the services of a professional and established medical transcription company are irreplaceable in the current scenario.

PDCA Quality Principles for Clinical Documentation

16-April-2015 Julie Clements Medical Transcription

PDCA As the healthcare system in the U.S is shifting from paper-based to electronic health records (EHRs), it has become very important to focus on the quality of patients’ records for improved and consistent patient safety outcomes. This has made the American Health Information Management Association (AHIMA), the Association for Healthcare Documentation Integrity (AHDI), and the Medical Transcription Industry Association (MTIA) reassess the process of quality measurement in clinical documentation and develop the Plan, Do, Check, Act (PDCA) method of continuous quality improvement. Quality principles are set out in the first phase (Plan) of this method, to ensure the quality of healthcare documentation.

The principles of quality are comprehensive codes of conduct which ensure the accuracy, accessibility and overall value of patients’ medical records so as to understand the symptoms, treatments and progress of the patient. The following principles apply to the quality of the documentation.

Verifiability – Customers having quality standards as per the contractual agreement must be able to verify the quality checks performed. The quality check results must be understood clearly without any area of ambiguity. The key to verifiability is well-defined error definitions.
Definability – Error definitions are important to understand the nature of an error and generate quality medical records that meet industry standards.
Measurability – A quality-assessment program for healthcare documentation allows the complete understanding of the methodology and formulas used in the assessment. It is transparent so that all parties can verify it and arrive at a clear and concise quality rating that is statistically valid.
Consistency – It is required to standardize variables (define errors and their point values) and then implement a standardized method for error determination in order to achieve consistency in quality.
Integrity – A good partnership between the author and transcriptionist is needed to achieve integrity in healthcare documentation. The author must provide clear, unambiguous, and complete dictation while medical transcriptionists should retain the author’s style and intended meaning while including accurate demographics and appropriate distribution notations into the transcribed or edited reports. With continuing education and commitment, medical transcriptionists add integrity to the process.

Digital health records prove to be an efficient tool for physicians to generate complete and concise medical documents. They are supposed to reduce transcription errors and support better patient outcomes. A study by the Agency for Healthcare Research and Quality revealed that this digital record system enhances nursing care, coordination and patient safety as well. However, digital health records will become really beneficial for healthcare professionals only if they leverage their EHR to improve its quality through ‘meaningful use’.

To meet the meaningful use criteria, hospitals must implement certified EHR technology and use that technology to achieve specific objectives. The meaningful use criteria, objectives and measures evolve in three stages – Stage 1 (2011-2012) includes data capture and sharing, Stage 2 (2014) includes advanced clinical processes and Stage 3 (2016) includes improved outcomes. The meaningful use objectives are categorized into five patient driven-domains such as:

Enhance quality, safety, efficiency
Encourage engagement with patients and families
Enhance care coordination
Improve public and population health
Ensure the privacy and security of Personal Health Information (PHI)

In order to achieve the objective in any of these categories, it is very important to adhere strictly to these five quality principles.

Not only should you care about the quality principles, but also be well-aware of the following factors that affect quality documentation.

Verbal communication skills of the author
Experience of the medical transcription staff
Technical issues with the voice equipment
Missed, incomplete, or erroneous demographic details of the patient
Availability of up to date and complete account specification sheets
Hard copy and web-based sources (for example, word lists, dictionaries) useful for transcriptionists
Quality Enhancing Software such as Electronic spell checkers and Text expansion software

In short, to eliminate medical errors and provide quality care, healthcare professionals should integrate the above mentioned principles into their quality practices whether they have teamed up with a medical transcription service provider or use in-house transcription.

How the Combined Efforts of MTs and MTSO Can Assure Quality Documentation

13-April-2015 Rajeev Rajagopal Medical Transcription

Quality Documentation Healthcare reform and advancements in health IT have transformed clinical practices and processes. With electronic health records, it has become even more critical to ensure high quality reporting and healthcare documentation to enhance care, assure patient safety and take care of the business aspects of the healthcare provider. The Association for Healthcare Documentation Integrity (AHDI) explains the role of both MTs (medical transcriptionists) and (MTSOs) medical transcription service organizations in its document on best practices for healthcare documentation:

Role of MTs:

Request for review if there are any blanks or doubtful areas of dictation
Review the available records or documents to resolve the discrepancies if any within the specific report
Amend the dictation speed to optimize the clarity level
Make use of reference materials such as online reference sites which are approved
Go for suitable procedures to take the problems if any to the correct level
Apply the updated feedback for improving quality continually

Role of MTSOs

Execute procedures to identify and report problems and divergences to Health Information Management (HIM) staff
Timely reporting of faulty equipment to HIM staff or provider who ever it is concerned
Give proper feedback to HIM concerning dictation best practices which are beneficial. Training may also be provided for all of the authors, especially for fresher residents
Keep a comprehensive and up-to-date list of templates and macros for the provider. Also share it out to transcription and editing staff, and notify them if any missing macros and templates are noticed
Properly coordination with HIM staff to acquire precise and timely ADT feeds
Offer continuous education and support for MTs on errors, questions, and blanks
Allow MTs to make use of a comprehensive range of reference materials and resources to lessen the blanks if any

Established medical transcription companies adhere to such best practices and provide customized medical transcription services for their valuable clients.

Why Medical Transcription Is More Challenging than General Transcription

09-April-2015 MTS TEAM Medical Transcription

Medical Transcription The role of a transcriptionist involves reproducing recorded dictation in accurate digital text format. The recorded content could be interviews, meetings, focus group discussions, single person dictations, voice mails and so on. Transcription generally falls under three broad headings – medical transcription, legal transcription, and general transcription. General transcription covers many areas such as business, finance, academics, media, and more, and involves the documentation of audio and video recordings related to general topics discussed in radio shows, voice mail, conference calls, police reports, interviews, seminars, and podcasts. However, as in the case of legal transcription, medical transcription is industry specific and the task of producing accurate medical reports is much more challenging than documentation for any other type of industry. The reasons for this are as follows:

Professionals doing general transcription deal with a wide variety of interesting topics which are relatively easy to handle. Medical transcriptionists have to document digitally recorded dictation related to complex medical conditions.
Medical transcribing has tougher and tighter deadlines than regular transcribing work which generally involves more flexible turnaround times. Medical transcriptionists have to focus on their work for continuous hours and have a pressure-resistant mindset.
When transcribing for the medical industry, the computer, headphones, dictation tools and all needs to be the best to avoid any interruptions; things could be handled more lightly in regular transcription.
When it comes to matter of accuracy, anything less than 99% is questionable in medical documentation as simple errors can lead to dire consequences and affect patient health and care. Even though accuracy matters in other types of transcription, it not as critical as for medical documentation.
Formal training is not a must for general transcription, whereas it is a must for an individual who wants to perform documentation for health care professionals. Formal medical transcription courses cover medical record formatting, English language and grammar lessons, medical terminology relating to all specialties, medical abbreviations and slang, diagnostic tests, and much more.

Even with the implementation of electronic health record and voice dictation systems, medical transcription services continue to be relevant when it comes to ensuring comprehensive health care documentation for proper patient care and smoother workflow in physician practices.

Quality Assurance for Health Care Documentation

07-April-2015 Julie Clements Medical Transcription

Quality in health care documentation is crucial when it comes to ensuring proper and timely health care. In view of this, the Association for Healthcare Documentation Integrity (AHDI) has paid down best practices to assure quality, timeliness and security in medical transcription reports. Here are the main elements of a comprehensive quality assurance program:

Proactive: The program should be devised in such a way that it can handle problems before they occur as prevention is always better than cure. This would improve efficiency and assure better patient care.
Easy and simple to implement: The quality assurance program should be simple and easy to understand to ensure proper implementation.
Safe and confidential: When it comes to feedback, the overall processes must be HIPAA-compliant and meet the necessary privacy and security guidelines. Processes should also be compliant with state laws and department or facility requirements.
Educational: Constructive feedback is the highlight of quality assurance as it supports positive information exchange and encourages quality improvement.
Sensible and financially practical: The process needs to be practically achievable by both small and big medical transcription service providers.
Reportable: The quality process must have methods of tracking and reporting trends so that areas needing improvement can be identified.
Assessment within day-to-day processes: Quality assessments on a consistent and daily basis would ensure timely feedback for enhanced quality.
Coverage of entire author-to-text process: The program must comprehensively cover all the phases of documentation – authors, medical transcriptionists, quality personnel, equipment, software, and workflow processes.

The key to integrity in healthcare documentation is a successful partnership between healthcare provider who dictates the report and the transcriptionist who transcribes and edits it. Established medical transcription companies set up and implement impressive programs based on the above aspects to ensure quality in medical documentation.