Wednesday, March 31, 2010

Medical Transcriptionist – Bridging Gap between Transcription, EMR and Speech Recognition Software

The medical transcriptionist converts the voice file, which contains patient health information, into an electronic file. The file is encrypted as per HIPAA norms and sent back safely to the physician, who then decrypts it back to the original form. The stored information can be accessed, whenever needed during the course of treatment. Transcription process takes time and the turnaround time generally varies from 4 hours to 48 hours depending upon type of medical reports and service of transcription provider.

The emergence of new applications like speech recognition software and Electronic medical record (EMR) has increased the speed and ease with which the patient health data can be processed and stored in the computer.

Electronic Medical Record

In EMR, during the patient-doctor encounter, the clinical observations of the patient are fed into the computer by selecting the related terms from the pre-structured point-and-click template. The physician enters the appropriate clinical term from the available choices to make complete electronic record of the patient. This record can be accessed or updated by other physician during the course of treatment and thus provides great flexibility in treating the patient. EMR has inbuilt safety system, which provides medication warnings or drug allergy alerts.

One main loophole is that there is no crosschecking mechanism present in EMR, which ensures that no wrong information is entered and carried forward into treatment .This can seriously jeopardize the safety of the patient. Since the information is stored on basis of pre-structured template the output from the template is too canned and loses the individuality.

Speech Recognition Software

Speech recognition software is an excellent tool, which directly converts the spoken words into text on computer screen. Thus a physician can directly speak into the computer and see for him or herself the text on the screen. This saves times as the there is no need to send the file to the transcriptionist and this reduces the turnaround time considerably.

Shortcomings in Speech recognition Software

In spite of latest advancements is this field, the software is not completely accurate. There are errors in it and it requires human intervention to guarantee the accuracy of the final outcome. Further the software requires human training to condition it to the voice pattern and dictation style of the end user.

Medical Transcriptionist Bridging the Gap

The above shortcomings can be easily overcome by integrating the transcription process with EMR and speech recognition software. The medical transcriptionist can work in tandem with back-end speech recognition software to edit the errors in report transcribed by the software. The voice file is sent along with electronic file to transcriptionist, who then edits it. The transcribing speed increases considerably, without compromising the accuracy of the report.

The medical transcriptionist also overcomes the shortcomings of EMR. The presence of well trained transcriptionist and team of quality control department guarantees high degree of accuracy of the medical report. A pair of fresh and trained human eyes, ensure that no wrong information is fed in the electronic medical records of the patient. The transcription provides other advantage in form vivid and detailed description of the patient health which is missing in the EMR. This detailed account is necessary where the physician needs in depth knowledge about the past and present medical observations of the patient to arrive at conclusion, especially in critical and difficult cases.

Thus a medical transcriptionist plays a crucial role in integration of transcription process with EMR and speech recognition software to by overriding their shortcomings. It provides the human intelligence, vigilance and instinct to successfully integrate man, machine and software smoothly.

Transcription, EMR and voice recognition software can be integrated successfully.

Jason Gaya

Read more on medical transcription at, www.mediscribes.com

Tuesday, March 30, 2010

Medical Transcription: Employing Six Sigma Principle to Reduce TAT and Improve Quality

The medical observations of patient are dictated into a voice recorder and transmitted to the transcription service provider. The transcribed report, an electronic file, is then sent back to the hospital records for digital signature. The total time taken is known as turn around time. The HIPAA compliant audit generally includes the following trail of activities to measure the turn around time.

  • Recording time- time taken towards reading the report into the recording instrument
  • Transcription time - time taken by transcriptionist to convert the dictation into the computer text file.
  • Quality audit time- time taken towards removing errors in the transcribed report before its dispatch back to the hospital or the physician.
  • Electronic signature- time taken towards verification by the concerned physician
  • Distribution time- time taken towards initiation of the reports towards faxing, emailing, etc

Turn around time or TAT as it is known plays a decisive role in the success or the failure of the service provider to win the outsourcing contract from the hospital or the physician. Generally the turnaround time differs for different providers. A TAT of 48 hours is counted as high while a turn around time of 4 to 24 hours is preferred. The turn around time varies with type of medical reports transcribed. A short TAT is highly desirable by the hospitals as it enables them to provide faster treatment to the patients.

The voice quality of the file may not be proper and it requires the transcriptionist to spend more time to grasp it or there might be errors while converting the voice into electronic text. This reduces the overall efficiency of transcription process and can seriously affect the health of patient due to errors.

This is where the Six Sigma can play a pivotal role in by eliminating the recurrent errors, which inhibit the productivity of the process. It is basically a quality control program that consists of the management and technical strategies. The management aspect of the strategy sees to fact that all the set goals are realized successfully and that the success is sustained over a period of time. The technical part of the program ensures that process is analyzed sharply and all the bumps or shortcomings are effectively removed by adopting a strategy that measures, analyzes, improves and controls the quality of the medical transcription process.

Medical transcription involves daily conversion of data on a voluminous scale hence it very difficult to keep track on each and every mistake committed in spite of well trained transcriptionists and a quality control department. Looking minutely into each and every mistake is not possible as it slows down the whole process and hinders the timely dispatch of the transcribed reports back to the physician.

The Six Sigma provides solution to this problem by creating an inbuilt safety mechanism in the transcription process, which automatically filters out errors like poor voice quality and data capture, spelling and grammar mistakes, wrong terminology, etc. Thus Six Sigma irons outs all the shortcomings from the transcription process so that the final output is free of errors and is available to the end user in a shorter turnaround time.

Six Sigma governs the productivity and quality of transcription process.

Jason Gaya

Read more on medical transcription at, www.mediscribes.com


Friday, March 26, 2010

Medical Transcription - Achieving Super TAT

The medical transcription industry is facing lot of competition from other medical documentation systems like EMR and speech recognition software. These new applications make the entry or access of patient health information quite easy, for physicians, specialists and other medical personnel. EMR saves time and space and thus reduces the overheads. This increases the overall productivity of the facility.

Medical transcription is made of series of process which involve dictation, which is recorded and sent to the transcriptionist for conversion in to an electronic file. This file is sent back the dictator, who stores it in the computer. As more number of people are involved in medical transcription and because of series of different processes, the turnaround time increases. In EMR the point-and-click mechanism helps for easy input of patient information into the computer while speech recognition software directly prints the spoken words into text on computer screen.

Hence it is necessary to shorten the turnaround time of the transcribed report so that it can be integrated easily with latest technology easily. To achieve super turn around time some steps need to be taken, which are presented below:

  • Provide Rigorous training to MT
  • Create small groups of medical transcriptionists. Every group should be assigned to a specific dictator. This will allow transcriptionists to develop a good rapport with their dictation providers by understanding their voice pattern and dictation style. This will drastically reduce the transcribed errors and thus improve the accuracy of the report.
  • Offer incentives to transcriptionists for reducing TAT.
  • Provide toll free number to dictators because they provide you business.
  • Synchronize transcriptionists with speech recognition software to reduce TAT. Software will speed up transcription process while a trained transcriptionist will edit the errors made by software. This will increase productivity and eliminate reworking on files due to overlooked errors.
  • Line-up the best medical transcriptionists with your biggest business provider.
  • Know very well the desired TAT for your individual customers. Identify which data needs to be transcribed and sent to customer, first. In short prioritize the transcription process.
  • Ensure maximum availability of transcribing staff during peak loads and streamline the file allocation process. Associate clearly, individual file allocator with a group of transcriptionist.
  • Plan the transcription process, keeping in mind the arrival time of maximum data. The shifts should be scheduled accordingly so that the highly trained transcribers are available in maximum strength to efficiently tackle the peak workload.
  • Ensure maximum feedback to transcribers.The Quality control and audit department should work in tandem with transcriptionists and train them how to improve the quality standards of their output.
  • Create smooth link between dictators, file allocators and transcribers so that series of commands and instructions are smoothly executed and there is no communication gap, which hinders the timely execution and delivery of transcribed reports to the health service provider.

The main focus is to reduce the turnaround time so that the physicians can receive the patient health reports in time and thus enhance the quality of patient care.

A streamlined medical transcription process shortens TAT.

Jason Gaya

Read more on medical transcription on, www.mediscribes.com


Thursday, March 25, 2010

Medical Transcription - Reducing TAT for Better Integration With EMR

The Turn around time or TAT, as it popularly known is the total time taken towards dictation of medical records of patient into the voice recorder, it’s conversion into electronic file and dispatch back the physician. There is no prevalent standard, which clearly defines the ideal turnaround time for the health providers and their business associates.The turn around time varies from one transcription service provider to the other.

The latest developments in the EMR and speech recognition software technology have increased the speed and ease, with which the patient health information can converted into electronic format. Medical transcription consists of series of different processes,which increase the time taken to document the information. In EMR, during patient-doctor encounter, the point-and-click template method converts health information of the patient directly into electronic format. This is a quick and easy way to store huge amount of data in a cost effective way as it saves the organization money, which would have been spent towards creating and managing the records storage area.

The development of front end speech recognition software has made it easier for the physicians to directly speak into the computer and convert the voice into electronic text. The text is then edited by the doctor himself and there is no need of an editor or transcriptionist. The software is not completely accurate and there and are errors in the transcribed report.This drawback is overcome in the back-end speech recognition software because the voice file is sent along with draft to transcriptionist, who then edits it and sends back to the physician.

The emergence and acceptance of EMR has made it necessary for the transcription service providers needs to reduce the turnaround time so that the physicians can easily avail the patient information at a short notice because time is of an essence in treatment. Thus electronic medical record and speech recognition software offer better medical documentation options compared to a slow transcribed report.

This drawback in medical transcription can be overcome by reducing turn around time so that transcription can be smoothly integrated with electronic medical record. At same time the expertise of the transcriptionist will ensure that high level of accuracy is maintained, which is missing from speech recognition software.

A short TAT helps to integrate EMR with medical transcription.

Jason Gaya

Read more on medical transcription at, www.mediscribes.com

Friday, March 19, 2010

Medical Transcriptionist - Creating a Streamlined and Secure Medical Documentation System

The Physician or health specialist after diagnosing a patient dictates all the noted clinical observations into a recording device. The recorded report is transmitted over the internet, as a voice file to the medical transcription service provider. The transcriptionist attentively listens to the recorded voice and types the information into the computer, to create an electronic file. This file after stringent quality control checks is sent back to the physician, who stores it in computer for future reference. During the transcription process, following equipments are used:

• A computer connected to internet.
• A head set to listen to voice file.
• A foot pedal to pause the recording whenever necessary.

The medical transcriptionist transcribes variety of health reports and these include:

• Patient Discharge reports.
• Medical history of patient
• Physical examination reports.
• Operative reports.
• Consultation reports.
• Autopsy reports.
• Diagnostic-imaging reports like radiology, MRI and ultrasound.
• Post operative progress reports.
• Referral letters.

It is important that transcriptionist must be trained in medical terminology and should have good knowledge of:

• Human anatomy and physiology.
• Medical diagnostic procedures.
• Pharmacology.
• Treatment assessments.
• Medical jargon and translate them into expanded form.
• Standard reference handbook both in, electronic and printed version.

The medical transcriptionist should be skilled enough to spot mistakes or inconsistencies in the medical report. This saves the patient from receiving wrong treatment as a result of errors in the transcribed reports. Besides accuracy, the transcriptionist should to also have good speed to deliver back the transcribed report in a very short turnaround time. This helps concerned physician to deliver the requisite treatment to the patient in minimal time, thereby increasing the patient care. Finally the HIPAA compliance norms make it mandatory for the covered entities like the hospitals, clinics and doctors to protect the privacy of patient health information. Hence it is moral duty of the transcriptionist to maintain the secrecy of the patient information as per HIPAA norms.

Medical Transcriptionist plays an important role in increasing patient care through better documentation of health information.

Jason Gaya

Read more on Medical Transcription at, www.mediscribes.com