With copy and paste rampant, UW Health chief medical information officer Shannon Dean says toolkits and vendors can help, but physicians need to take responsibility for proper clinical documentation.
Overuse of copy and paste in electronic health records is a problem. Sure, it’s convenient. And it’s entirely understandable why it’s a common shortcut used by scores of physicians. But it often results in note bloat – unwieldy patient records overflowing with repetitive documentation – that can potentially lead to serious safety risks.
“Copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error,” wrote researchers in a 2017 study in Journal of the American Medical Association.
[Also: EHRs are overflowing with copy-and-paste records, JAMA study shows]
The practice of copy and paste has to be reigned in, and one chief medical information officer, writing for the Agency for Healthcare Research and Quality, says that has to start with the physicians themselves.
Shannon Dean, MD, CMIO at University of Wisconsin School of Medicine and Public Health, penned a column this month for AHRQ’s Perspectives on Patient Safety. She began with an example of what can happen when notation gets lazy.
She cites the case of a 78-year-old man who, “with an alleged history of ‘PE’ (interpreted by the clinicians as pulmonary embolism) received an unnecessary CT scan to rule out a suspected ‘recurrence’ of pulmonary embolus.
[Also: NIST weighs in on EHR copy-and-paste safety]
“As it happens, years earlier, the abbreviation ‘PE’ had been used in the electronic note to indicate that the patient had had a physical examination, not a pulmonary embolism!” said Dean. “In a vivid example of copy and paste, once the diagnosis of pulmonary embolism was mistakenly given to the patient, it lived on in the EHR.”
Beyond the risks to patient safety, that also points to the unnecessary costs that can pile up when unwitting clinicians order tests that are based on erroneous and repetitive data.
Nonetheless, said Dean, too many clinicians still copy and paste as a habit: “Perhaps we are complacent about copy and paste because we remain unconvinced that there is a correlation between its use and patient safety.”
In her article, she surveys more than a dozen studies on the subject, and finds that published research into adverse outcomes isn’t as voluminous as one might expect, even if it’s understood, intuitively, that the practice isn’t ideal.
So “it is clear that much work remains to be done,” said Dean. She points to toolkits like the one put together by AHIMA, and the fact that Epic has rolled out functionality that can “identify the source of every character within a note, whether it is newly typed, imported from another source, or copied and pasted.”
Still, “I am aware of very few organizations that are actively using these tools to educate and mentor clinicians in a systematic way to improve documentation quality,” she said.
While more academic research would be welcome on the correlation between copy and paste and patient safety, she said, it’s fairly widely accepted that it’s a shortcut that should only be used sparingly and in specific instances.
Healthcare organizations need to start making use of resources such as AHIMA’s toolkits, Epic’s auditing features and innovations like natural language processing technology to help physicians do better with their EHR documentation.
She also points to the OpenNotes initiative, which continues to gain momentum, as another big opportunity: Giving patients the ability to read their own doctor’s clinical notes allows them to “hold us accountable for quality documentation.”
But at the end of the day, “physicians need to reestablish ownership of the accuracy of clinical documentation,” said Dean. “We must stop blaming the EHR for our carelessness and start educating ourselves about how to use documentation efficiency tools, including copy and paste, more responsibly.”
Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com
Category: Transcription
National MT Week: May 14-20
As we get ready for National MT week, let’s take a look at the importance [still] of the Medical Transcriptionist in today’s healthcare industry:
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- A skilled workforce produces quality documentation. Healthcare documentation specialists (HDSs) and medical transcriptionists (MTs) ease the documentation burden from physicians.
- HDSs and MTs consistently achieve documentation accuracy rates higher than 99%,¹ and by harnessing this workforce’s expertise, clinicians’ time, coding, and revenue are optimized and the data governance strategy is strengthened.
- The narrative allows physicians the opportunity to add the qualitative information that provides context to the patient’s medical history and care. HDSs and MTs understand the complex story-telling of patient care and are experts in document standards and data capture.
- Your healthcare documentation team are highly skilled, analytical quality assurance specialists who provide risk management support in capturing healthcare encounters and making sure they are documented in a way that promotes clinical clarity and coordinated care.
- HDSs and MTs need to be positioned to ensure accurate documentation of care encounters and to identify gaps, errors, and inconsistencies in the record that may compromise care or compliance goals.
- HDSs’ and MTs’ body of knowledge is vast and includes pharmacology, human disease processes, anatomy and physiology, HIPAA, privacy and security, and diverse technologies used to capture health data.
- Certify to healthcare delivery that HDSs and MTs have the training and expertise to be valued among the allied health and HIM delivery teams by earning and maintaining your professional certification.
#NMTW #PrecisionMatters
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing, Medical Transcription, Scribe Services, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #MedicalTranscription #AzaleaHealthEHR #RevenueCycleManagement #MDSofKansas #MedicalBillingService #MedicalScribes
KMGMA 2017
#MDSofKansas will once again be at the #KMGMA2017 Spring Conference (04/20/17) and we are looking forward to seeing YOU! Please stop by our booth and check out some of the great giveaways, and learn what we’ve been up to! We are saving many clinics and businesses lots of money on everyday fees. If you would like to save money, too, stop by and ask us how!
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing, Medical Transcription, Scribe Services, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #MedicalTranscription #AzaleaHealthEHR #RevenueCycleManagement #MDSofKansas #MedicalBillingService #MedicalScribes
Highlights From The 2016 State of The Medicine Address
GomerBlog highlights the major points from tonight’s State of The Medicine Address given by the President of Hospital Administrators, Mr. Cutter Salary.
- Hospitals now have the highest patient satisfaction in the history of healthcare and probably correlates to increased quality of care according to patients and lawmakers
- WiFi, fast food restaurants, and pianos are distributed throughout hospital lobbies replacing exam rooms and useless medical equipment
- Doctors now spend 50% of their time coding which is a vast improvement over last year and has led to spectacular reimbursement rates to enable hiring of more administrators. Remember Caring IS Coding!
- Unnecessary Nurse bonuses were removed in a major cost saving move this year. To save even more money, cuts will start with the nursing staff and end with the nursing staff
- More paperwork was passed by the Joint Commission providing critical safety measures requiring timeouts before codes to prevent wrong sided CPR
- Drinks were finally stripped from the Nursing Station. This year we must continue with stripping any fun or laughter from the Station. We don’t want our patients thinking we are making fun of them
- Breaks are vanishing from the workplace and we need to continue that for our medical providers. Foley catheters were distributed to staff to help our providers perform flawless and uninterrupted care
- Surgeons are required to perform 3 more surgeries a day and leave when it is dark outside. Skin cancer rates are drastically down in our employees now thanks to this move.
- Patient to Nurse ratios are at an all-time high providing a challenging and dynamic work environment to our nursing staff, which we know they enjoy
- Physicians are burning out quicker than ever and we are replacing them with cost cutting google university graduated patients
- The new Secretary of The Medicine, Dr. Oz, continues to utilize his charismatic charm to educate the public before they come to the hospital
- And finally, our budget has been passed and includes hiring another 1.2 million hospital administrators to oversee and provide outstanding medical care to our hospitals!
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“God Bless The Medicine and God Bless my obnoxiously large pension!”
- READ MORE
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing and RCM, Medical Transcription, Pre-Certs with AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #medicaltranscription #azaleahealthEHR #revenuecyclemanagement
EXCELLENT NEWS for MEDICAL TRANSCRIPTIONISTS
Annie Martinez writes a great article for Dummies.com titled Ten Myths About Medical Transcription. Clearly there has been much confusion about our profession over the last few years, and she puts in all in perspective. We have been bullied to believe that transcription is being replaced by technology or going overseas, and we have certainly seen some of that occur. Although in recent years, we have seen much more come back. Annie clearly outlines Transcription is back, here to stay, and as important as it was 20 years ago.
Ten Myths about Medical Transcription
There’s a lot of misinformation floating around about the ins and outs of a medical transcription career. Some of it comes from honest misconceptions; the rest comes from training companies that want your money.
Medical transcription (MT) is interesting and challenging. You can train from home and work from practically anywhere you can get an Internet connection. There are opportunities to work nontraditional hours, part-time or full-time, as an employee or as self-employed independent contractor. MT has a lot going for it. It isn’t, however, a free ticket to prosperity with no strings attached.
Medical transcriptionists make $50,000 a year working from home
This particularly alluring myth frequently appears in advertisements promising to take you from zero to medical transcriptionist in a matter of months — just come to our free seminar to find out how! Don’t believe it, and don’t sign up for training (or even attend a seminar) from any company that makes such a claim.
Are there medical transcriptionists who make $50,000 a year? Yes, but they’re few and far between. A quick trip to the U.S. Bureau of Labor Statistics (BLS) website reveals that the average annual salary for a full-time medical transcriptionist is closer to $34,000.
Medical transcriptionists can work and take care of the kids at the same time
If you’re picturing yourself tapping away at the keyboard while your little darling plays quietly at your feet, pinch yourself and wake up! There’s no way you can transcribe medical reports and take care of children at the same time.
MT work requires intense concentration and undivided attention, two things that aren’t compatible with supervising little ones (or much of anything else). If you have young children at home, you’ll need to arrange for childcare during your work hours or work while they’re sleeping.
Medical transcriptionists just need to type really fast
The ability to type at warp speed is a great asset, but it isn’t an automatic ticket to success as an medical transcriptionist. The things that really make the difference are largely mental:
An inquisitive mind and love of language so you can learn (and keep learning) all those medical terms
An independent, pressure-resistant mindset
The ability and motivation to concentrate intently for extended periods of time
Medical transcriptionists need little or no training
Unless you have formal medical transcription training, your résumé will never make it into the “to interview” stack. The training must be from a recognized, reputable source, such as a community college program or well-established medical transcription school. Otherwise, you’re toast.
Plan on spending a bare minimum of nine months preparing for your new career. You’ll study anatomy and physiology, medical terminology, formatting of the different report types, and many more skills you may not anticipate needing but definitely will. When you graduate, you’ll have that crucial formal training to include on your résumé and the know-how to do the job.
Speech recognition technology will make medical transcriptionists obsolete
Speech recognition technology (SRT) is in widespread use as a way (in theory) for medical facilities to cut transcription costs. Working medical transcriptionists refer to it as “speech wreck,” because the results sometimes have more in common with a multicar pileup than a quality healthcare document. Under ideal dictation conditions, SRT can do a decent job, but it takes very little to send things awry.
Despite its substantial shortcomings, SRT seems to be here to stay. Because the results of SRT are unreliable and require constant supervision, it now figures into what medical transcriptionists do on a daily basis. Speech recognition has added a fresh twist to the ever-evolving MT profession, not made it obsolete.
Electronic health records will eliminate the need for medical transcriptionists
This is only true in the minds and marketing materials of people who sell EHR software. Somewhere along the way, the idea of digitizing medical information seems to have become equated with transforming the recording of healthcare details into an entirely point-and-click process, but it’s increasingly evident that it can’t be done.
Some elements of healthcare documentation are enhanced by restricting input via check boxes and drop-down lists, but for some things, fill in the blanks just doesn’t cut it. Healthcare providers need a way to incorporate narrative observations, opinions, and conclusions — in other words, dictation.
Most medical transcription work is being outsourced overseas
Everything else seems to be going to cheaper, offshore workforces — why not medical transcription? After all, who can afford to pass up a chance to save some green? Medical transcription began going abroad in the 1990s, and more was headed that way, but then things changed.
In 2010, changes in federal laws related to protecting patient health information made compliance with federal Health Insurance Portability and Accountability Act (HIPAA) rules an even higher priority for medical transcription companies and healthcare facilities. In order to achieve tighter control over patient information, it’s being kept closer to home.
Getting certified is the best way to break into medical transcription
Any advertisement that entices you to “become a certified medical transcriptionist” is feeding you a line of hogwash. You don’t need a certification or a license to become a medical transcriptionist. There is a Certified Medical Transcriptionist (CMT) credential, but it’s not an entry-level kind of thing, and no training program can give it to you.
You may opt to earn it eventually, but you’ll need at least two years of experience under your belt first. Even then, you’ll have to pass a rigorous exam that will test your medical knowledge and transcription skills across multiple medical specialties.
Medical transcription is low-stress work
You may think medical transcription is a low-pressure job. How hard can it be to listen to what somebody says and type it up in a report? A lot harder than you can ever imagine until you’ve actually done it. You’ll be astounded by what comes across your headphones — guaranteed!
For starters, medical dictation often arrives amply stocked with background noise and interruptions — and don’t forget the crackers (dictators seem to frequently have a mouthful of them). It includes words you haven’t ever heard before and have no idea how to spell, especially at first. Many times, a thick foreign accent will be slathered on top. So, let’s just say the clarity isn’t always the best. . . .
Real men don’t become medical transcriptionists
Okay, maybe nobody says that, but you may get that impression when researching the field. The current crop of medical transcriptionists is overwhelmingly female, but men and women are equally capable of becoming excellent medical transcriptionists.
It’s not any harder for a man to break into the field than it is for a woman. As more men seek out work they can do from home or on a flexible schedule, they’re discovering medical transcription. Medical transcriptionist employers care how many reports you can produce, how fast, and how accurately.
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing and RCM, Medical Transcription, Pre-Certs with AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #medicaltranscription #azaleahealthEHR #revenuecyclemanagement
EHR Buyer Trends for 2014
Recent research reveals new trends among EHR buying. Take a look at the data on top EHR buyer trends of 2014 provided by Softwareadvice.com. #EHRtrends2014
Key findings when analyzing 385 interactions with EHR buyers reveal their primary reasons for evaluating new software, and their most desired features and applications, include:
- Mobile support topped the list of desired capabilities, with 40% of the buyers requesting this feature, followed by e-prescribing (24%) and lab integration (20%)
- 85% of buyers overwhelmingly prefer a web-based over an on-premise system
- The majority of buyers (89%) aren seeking an integrated system, that includes applications such as billing or scheduling
AzaleaHealth is certainly at the cutting edge in addressing buyers’ needs. Azalea Health enhances the workflow of your practice, giving you the power to connect the medical side with the financial side. It is a true cloud-based solution so you don’t have to worry about maintaining servers and software. We take care of it. The fully integrated solution enables physician and specialty practices to afford a sophisticated technology that meets all their practice management needs at a fraction of the complexity and cost. #azaleahealthEHR
Azalea Health’s integrated EHR and billing solution has the flexibility to accommodate multiple specialties of any size practice. The company provides Electronic Health Records (EHR), Practice Management (PM), Revenue Cycle Management Services (RCM), mhealth app, and a Patient Health Records Portal.
Recently the company announced its merger with EHR provider, simplifyMD. The merged company, with their combined skills and products, will be able to offer expanded services and product options, as well as the tools and resources to help customers with meeting their Meaningful Use and ICD-10 requirements. The company will continue to be dedicated to simplifying the life of physicians and administrators byproviding a complete solution that is easy to implement and use. #azaleahealthmerger
Implications for EHR Vendors
Mobile support topped the list of requested EHR features, with nearly 40 percent of buyers in our sample requesting support for tablets and/or smartphones. With practices increasingly integrating mobile devices into their charting workflows, mobile support will be a key determinant in EHR purchasing decisions for buyers in 2014. Products that offer mobile applications will be well positioned to win business this year.
Vendors should also highlight their products’ meaningful use-mandated elements; e-prescribing and lab integration ranked highly on the list of requested features, thanks in no small part to their inclusion in MU requirement criteria.
Additionally, integrated suites are the future of EHRs. Nearly 90 percent of buyers explicitly requested to evaluate a system that integrates EHR with other applications (such as billing and scheduling). With nearly a quarter of the buyers replacing existing EHR solutions doing so because of a lack of integration, it seems the days of the standalone EHR are numbered.
Implications for EHR Buyers
Most of the buyers in our sample wanted to implement their new EHR software within three months. However, the climbing percentage of buyers replacing existing systems due to dissatisfaction suggests buyers would be well served by dedicating as much time as needed to the evaluation process.
Researcher Commentary
“We’re seeing significant demand for mobile solutions that allow users to access the EHR on tablets, or even on smartphones while on-the-go. Mobile devices are increasingly being integrated into practices’ workflows, and buyers need solutions that facilitate the efficiency those mobile devices can offer.”
“The percentage of buyers replacing existing implementations continues to rise. With so many buyers beginning their research with rapid-fire implementation timelines, I expect that proportion to continue growing. My advice to buyers is this: don’t impose a hard deadline on your evaluation process. Find a system that truly addresses your needs before making a purchase, rather than adopting a system and attempting to make it suit your purposes once in place.”
Methodology
Software Advice regularly speaks on the phone with medical practices seeking new EHR software. For this analysis, we randomly selected 385 of our phone interactions from Q1 2014 to analyze. Buyers were asked about their reasons for evaluating systems, the most critical features required and deployment preferences, among other criteria.
Emily King
Media Relations
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing and RCM, Medical Transcription, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists and Healthcare Documentation Specialists. #medicaltranscription #azaleahealthEHR #revenuecyclemanagement
Doctors Complain EHRs Destroy the Patient Encounter
Transcription provides the clear, cost-effective solution to the on-going crisis in healthcare documentation.
JOHNSON CITY, TN – EHRs continue to adversely affect the doctor-patient relationship, according to a new article published in Medscape. The article (requires free membership with Medscape, click here), titled “Doctors are Talking: EHRs Destroy the Patient Encounter”, describes in detail the toll EHRs are taking on both physicians and patients.
The article cites three main physician gripes:
1. EHRs have made the patient encounter “far more annoying and complex than it ever was before.”
2. EHRs “make (physicians) feel like data entry clerks, with a computer telling them how to practice medicine.”
3. EHRs “erode the doctor-patient relationship by creating a barrier between the two.”
Scribes – A Good, But Not Best, Solution
The article continues with a discussion of the pros and cons of using an in-office Scribe. While some physicians favored the use of Scribes, others vehemently opposed it. As one physician commented, “We have to hire a person to deal with the already expensive EHR. At the end of the day, we are still worse off than before we had the EHR forced on us.”
Another physician added, “So adding another $25,000/year employee on top of the $80,000 for the EHR is the ‘happy’ solution?” a doctor asked. “I am not the government with unlimited money.”
MTSOs Are Offsite Scribes
In contrast to the more expensive approach of onsite scribes is the model of the offsite transcription vendor, which is a superior option for three key reasons:
1. Deep history and familiarity with the doctors’ and their clinical documentation preferences and style.
2. Strong expertise in medical language terminology and usage.
3. Significantly lower expense than onsite scribes, with no lost time for holidays or sick days.
EHR Vendors: Barrier or Facilitator?
Despite the clear advantages of offsite transcription, it cannot be implemented without the cooperation of EHR vendors, which are the gatekeepers for the implementation of the all-important interface for importing transcribed notes — or sections of notes — into the EHR’s patient record. In many cases, interfaces remain expensive, non-standardized, and difficult to implement — all of which act as a deterrent to implementation.
“The high barriers to entry for getting an interface in place limits the options many physicians have regarding the clinical documentation workflow,” said Mark Christensen, CEO of WebChartMD. “We’re asking EHR companies to join us in making it possible for physicians to choose the documentation modality best suited to them and their practice of patient care. If physicians prefer some modality other than dictation, that’s their choice. But if their preference is dictation and transcription, we’re asking EHR companies to remove the financial and technological barriers that restrict a physician’s ability to make that choice.”
For more information, or to dialogue further on this topic, contact Mark Christensen directly at mark@webchartmd.com or 1-423-343-5702.
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Transcription, Revenue Cycle Management, AzaleaHealth EHR, and REAL-TIME solutions with Medical Scribes. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists and Healthcare Documentation Specialists.
2013 Reflections
MDS reflects on the many blessings of 2013. We have great appreciation for our customers, new and old, our friends, our business alliances and partners, and most of all … our incredible MDS team! We are confident in what 2014 brings and wish good health, happiness and true peace for all!
AHDI reflects on most read healthcare articles for 2013. Take a look …
UPMC transcriptionists protest after outsourcing
Pittsburgh Post-Gazette
From Nov. 6: Cindy Cromie was a medical transcriptionist working for UPMC Hamot in Erie, Pa., when she, like the rest of the 130 people who provided medical transcriptions for the hospital system, got a call this spring to come to a meeting in Pittsburgh. They gathered in the Western Psychiatric Institute and Clinic of UPMC, where they were told that their work was being outsourced to Nuance Communications of Burlington, Mass.
Share this article: Job changes coming for transcriptionists
Healthcare IT News
From July 17: Nearly 90 percent of medical transcriptionists say that transitioning to documentation roles with electronic health records means that gaps in skills need to be identified and new career paths charted, according to new a study. New speech and language processing technologies have set the stage for a fundamental transformation in the way transcriptionists work, according to the survey – conducted by the American Health Information Management Association and the Association for Healthcare Documentation Integrity — which found that 87 percent of respondents are preparing for new ways of doing things.
Share this article: AMA: EHRs create ‘appalling Catch-22’
HealthcareIT News
From May 8: As the healthcare industry moves to EHRs, the medical record has essentially been reduced to a tool for billing, compliance and litigation that also has a sustained negative impact on doctors’ productivity, according to Steven J. Stack, M.D., chair of the American Medical Association’s board of trustees. “Documenting a full clinical encounter in an EHR is pure torment,” Stack said during the CMS Listening Session: Billing and Coding with Electronic Health Records.
Share this article: Speech recognition software: Does it help or hinder care workflow?
FierceHealthIT
From Nov. 20: Does front-end speech recognition make for a smooth-running operation, or does it simply complicate documentation and patient care? Doctors and researchers debate this question in the November 2013 issue of health information management magazine For the Record. Gary David, Ph.D., an associate professor of sociology at Bentley University in Waltham, Mass., notes in the article that front-end speech recognition does not always save labor, but it does change workflow.
Share this article: Scribes can be beneficial in medical practices
HealthDay News via Doctors Lounge
From Oct. 23: Medical scribes can accurately document physician or independent practitioner dictation and activities, allowing providers to spend more time with patients, according to an article published in Medical Economics. Maxine Lewis, president of Medical Coding & Reimbursement in Cincinnati, discusses the role of scribes in medical practices.
Share this article: EHR copy and paste? Better think twice
Healthcare IT News
From Oct. 9: Who would have thought that something so simple as copy and paste could have such serious consequences? Speaking at the MGMA annual conference in San Diego, Diana Warner, director at AHIMA, confirmed the seriousness of inappropriately using copy and paste functions in electronic health records. And the government agrees — it’s no laughing matter.
Share this article: Digital health records’ risks emerge as deaths blamed on systems
Bloomberg
From June 26: Electronic health records are supposed to improve medical care by providing physicians quick and easy access to a patient’s history, prescriptions, lab results and other vital data. While the new computerized systems have decreased some kinds of errors, such as those caused by doctors’ illegible prescriptions, the shift away from paper has also created new problems, with sometimes dire consequences.
Share this article: Medical scribes boost EHR productivity, streamline workflow
EHR Intelligence
From Sept 25: While EHRs are sold to physicians as a way to increase quality while making documentation more efficient, few providers have seen as much return on that promise as they could like. EHRs can be time consuming to use on a daily basis, and patient interaction can suffer when being forced to peer at a computer screen during consult after consult. The solution, according to one cardiology practice, is to let a professional typist do the typing, and allow the physician to use his skills where they do the most good.
Share this article: Updated HIPAA rules posing challenges for healthcare providers
The Wall Street Journal via iHealthBeat
From May 8: Health care providers say they likely will face challenges complying with new rules that expand and update HIPAA provisions. One of the biggest challenges under the new HIPAA rules is a provision allowing patients to request that insurers not be informed of treatments that patients paid for themselves.
Share this article: Speech recognition: A work in progress
For The Record
From May 1: While controversy remains within the healthcare community regarding the best approach to using speech recognition technology, there are some points that most industry professionals agree on. Few would dispute that the vendor community has made tremendous strides to advance applications to better meet the needs of the healthcare industry, and innovation continues as developers look for ways to make the technology more intelligent and accurate.
Share this article:
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Transcription, Revenue Cycle Management, AzaleaHealth EHR, and REAL-TIME solutions. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information.
Clinical Documentation Trends – Must READ
I know you will want to read this over carefully. There are some VERY interesting points made in this study by the Health Business Group on healthcare documentation trends for the next several years. Please take time and read, as it is well worth it … (my medical transcription and healthcare documentation friends)!
Clinical_Documentation_Trends_2013_2016
“CLINICAL DOCUMENTATION TODAY
• Medical transcription is the most common form of documentation in the acute care market and is also utilized, though to a lesser extent, in the ambulatory space.
• About half of medical transcription is performed by provider organizations using their own staff; half is outsourced to Medical Transcription Service Organizations (MTSOs).
• Acute care providers frequently use both in-house and outsourced resources; ambulatory practices tend to use one or the other but not both.
• Most provider organizations type their transcription directly from audio files.
• A substantial portion of documentation is done using the electronic health record (EHR), especially in the ambulatory market.
• Despite increasing EHR penetration, health care providers express some uncertainty about the ability of EHRs to meet clinical documentation needs and to tell the complete patient story.
• A significant share of clinical documentation is still handwritten.
CLINICAL DOCUMENTATION IN 2016
• The clinical documentation market will undergo substantial change between 2013 and 2016.
• Documentation volume will continue to grow at approximately 2 to 3 percent per year.
• The use of EHRs for documentation will increase, especially in ambulatory settings.
• The use of front-end speech recognition to enter data into EHRs will grow faster than the use of keyboard and mouse.
• Integrated delivery networks (IDNs) will increasingly determine the method of clinical documentation for affiliated practices.
• Documentation on paper will vanish almost completely.
• Transcription will remain an important documentation method, but more of the market will be outsourced.
• There will be increasing use of back-end technology among those who continue to perform transcription in-house.
• New technologies such as Clinical Language Understanding (CLU) will enter the mainstream.
• The introduction of ICD-10 may increase the need for high-quality clinical documentation and Computer-Assisted Coding.”
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Transcription, Revenue Cycle Management, EHR technology, and REAL-TIME solutions. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information.
Copy & Paste is not okay? Say what???
“Seventy-four to 90 percent of physicians use the copy/paste function in their EHRs, and between 20 to 78 percent of physician notes are copied text, according to a September AHIMA report.”
We have spent a lot of time educating our students and MTs about the deadliness of the copy/paste function in medical transcription. There can be serious errors made and the veteran healthcare documentation specialist has learned this over the last decade or two. However, it is apparently common to see this going on in the EHR. Take a look …
EHR copy and paste? Better think twice
Healthcare IT News
Who would have thought that something so simple as copy and paste could have such serious consequences? Speaking at the MGMA annual conference in San Diego, Diana Warner, director at AHIMA, confirmed the seriousness of inappropriately using copy and paste functions in electronic health records. And the government agrees — it’s no laughing matter.
Medical Documentation (transcription) & ICD-10
So much buzz out there with M-Modal’s crappy news. It is sad to see US jobs lost to off-shore (again). It is very frustrating, as well as devastating, for those affected. Now more than ever, it is important for MTs, the ones who really want to stay in this industry, to educate and re-tool, and just be diverse! Be ready for whatever comes our way. However, we are believers in dictation because we are listening to our physician friends. We hear what they are saying and we are listening to insurance auditors for major companies. Increased documentation is coming; it will be sink or swim for some and many experts believe the only way physicians will survive is to go back to dictating. Take some time and read the articles below. They contain interesting information on why we could see a push-back on dictation. The Affordable Care Act (Obamacare) and ICD-10 are key reasons. Then you have the physicians who are tired of the clerical roles they have had to assume with EHR.
“These new changes will increase the need for skilled medical transcription and medical coding” Read More.
“Whether you are an advocate or a detractor of Obamacare, we do know that it is going to dramatically increase the required amount of documentation. Secondly, we know that the buzzword for ICD-10 (beyond the other buzzword “PAIN”) is “specificity.” Read more.
“Assuming those medical transcription companies that are here today are still on the scene on Oct. 1, 2013, not having been acquired or retired, (and there certainly are fewer and fewer of them!) I believe they will enjoy increased dictation with the changeover from ICD-9 to ICD-10.” Read more.
The Perfect Storm! Opportunities!
AAMT Dangerous Abbreviations (3rd Edition)
CMT & RMT Practice Exams
In the News: Credentialing Practice Exams Coming Soon
AHDI will soon be releasing Credentialing Practice Exams for both the RMT and CMT. These exams, developed by the same group of professionals who developed the exams, will simulate a real test environment, complete with the hands-on experience of the Kryterion testing platform. After taking a practice exam, you will be provided feedback on objectives from questions answered incorrectly so that you have a guide on which skills you need to brush up on before taking the real exam.
Look for the RMT Practice Exam to be available in March, and the CMT Practice Exam to follow in April. Check www.ahdionline.org frequently for our most recent updates.
Off-Shore Transcription Caused Death? Jury Says Yes With $140M
Jury awards plaintiff $140 million dollars for wrongful death. Who is at fault? Was it the American transcription company, the Indian outsource, the doctor or the nurse? You decide if you agree. Read More
Medical Transcription – Quality before Quantity
It has always been very important to me to remember that the patient is first. We have an obligation to get it right … this is their story. It is oftentimes easy for the MT to focus first on their paycheck and second on their job.
Here’s a good article to read on productivity, using expanders and shortcuts and the importance of keeping the patient’s history and record first and center! Remember … your spouse, child, mother, and even YOU are the patient.
Productivity in Medical Transcription and Documentation – Expand Responsibly