Patient medical records are extremely important for the smooth functioning of healthcare units. Healthcare organizations that maintain accurate, structured narrative reports and update their electronic health record system promptly can retain an edge over their competition. How are these reports significant?
- These reports are the initial source of information for financial and medical coding processes.
- Physicians and other clinicians rely on dictated text to convey the patient story effectively to other healthcare providers.
EHR and Consequent Changes
With the entry of EHR, narrative reports have to be modified into interoperable and distinct patient data provided in scannable and readable formats. EHR has also transformed the medical transcription process as well as the role of the medical transcriptionist.
So, can EHR ensure a better quality medical record? Not necessarily, going by certain findings. In a report that identified the most challenging requirements of the first half of 2013, the Joint Commission found that 55% of the hospitals did not maintain complete and accurate records for their patients.
Many believe that physicians should not be involved in documenting EMR. Physicians spend more time documenting onscreen rather than spending their valuable time interacting with the patients. Some physicians are forced to document the details of patient interactions after office hours every day. In such situations, the electronic medical record’s value is low for physicians and even lower for patients.
Some healthcare providers point out that EMR documentation has certain inherent flaws such as they do not have the provision to include all details of the patients. Most of them are cookie-cutter templates, and naturally no one size can fit all. In that way, electronic medical records may not accurately reflect the patient’s actual state.
Another important point is that physicians, nurses and other care providers are not skilled at documentation, which is best done by people trained to perform the task. When the EHR entries are made by clinicians who are hard pressed for time and concerned about the speed with which medical record details are filled up, quality suffers and in turn patient safety also suffers. Electronic records have excellent benefits, but they should not be used in a way that may compromise patients’ wellbeing.
In the EHR era what is the role of medical transcription and the medical transcriptionist? Both these concepts have evolved. Let us see how.
How Transcription and Transcriptionist Have Evolved
- EHRs can interface directly with transcription platforms to parse data. Now transcription creates discrete data fields in lieu of flat files or static snapshots of information. Along with HL7 data requirement compliance, these capabilities created the demand for advanced dictation software with speech understanding capabilities to ensure more efficient data transfer.
- Manual transcription is eliminated now; admission, discharge, clinical dictation and transfer feeds can be integrated between systems. Patient demographics can be systematically merged for editing. This helps speed up turnaround time.
- Medical transcriptionists have evolved into editors now. Transcriptionists don’t need to create typed documents now with the availability of speech recognition software. Instead, they edit the documents produced for medical accuracy.
Functioning Efficiently in the Changed Scenario
With the availability of speech recognition technology, physician dictations can be converted into electronic text that is parsed and mapped to particular data fields. Healthcare providers can team up with transcription services to integrate dictation into their EHR. Advanced transcription management software used by transcription companies ensure accurate positioning of data within the electronic record. Transcriptionists on their part don’t need to spend time formatting clinical narratives to meet individual requirements of healthcare providers because the formatting part is handled by the software. As a result, benefits such as faster turnaround time, higher productivity and greater standardization are offered.
The transition to EHR is being made at an increasing rate. Providers should closely watch for the impact of the changes it brings. Healthcare units utilizing medical transcription services report the following benefits:
- Advantage offered by advanced transcription management software
- Greater efficiency and increased revenue
- Takes administrative burden off doctors and other healthcare providers and help them to spend their valuable time providing patient care
- Enables them to stay abreast of the latest developments
- Eliminates delays and inefficiencies.
