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The Ultimate Guide to Medical Transcription Services

Recognizing & Treating a Growing Phenomenon

Table of Contents

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Part 1

What are Medical Transcription Services?

Medical transcription services are a type of clinical documentation that uses voice recognition software to transcribe the medical reports that physicians, nurses, and other healthcare practitioners dictate. Medical reports can include voice files, notes taken during an exam, or any other spoken material. With today’s technology, there are several electronic devices that make the reporting process easier for healthcare practitioners. Medical transcription services type and format the necessary notes provided by the doctor or clinician into a usable medical report that can be uploaded to the clinic’s electronic health records (EHR).

Unless your practice still doesn’t have computers, or you’ve invested in technology to reduce time in front of them, assume you and your colleagues now face higher risk of physician burnout as well. Like any good coworker, we should reach out to those we think might be suffering. The rest of this article will help you unofficially diagnose possible symptoms of physician burnout, and provide solutions for mitigating burnout within your practice. Hopefully, the more we know as an industry, the better we can care for our colleagues, and thus patients, in the future.

Part 2

Why Are They Important?

Medical transcription services enable your healthcare practitioners to direct their focus back to the patient rather than having to worry about typing and formatting EHR documentation. Because of this, these services provide the following benefits:

Increased Productivity

The number one priority of any healthcare practitioner is the patient. Other forms of clinical documentation are inefficient and require physicians to spend hours typing and clicking boxes. Medical transcription services solve that problem by taking on your documentation needs and allow you to keep your focus where it really matters: on your patients. By transcribing your notes, these services can be employed to save you countless hours by creating reports for you. With all this saved time, you can maximize your productivity and drive your focus back to patient engagement and quality of care.

Cut Costs

Although it’s easy to forget, many hospitals and clinics are still private businesses. Therefore, keeping costs low is crucial to running a successful healthcare facility. Medical transcription services allow you to save money by saving time. Doctors can focus on more important aspects of their job while medical transcription services handle the dirty work. For example, Pulmonary Associates of Mobile, AL used a dictation service that cost $1,400 a month per physician. After implementing iScribe into their existing system, their costs decreased to $400 a month per physician. These savings add up over time, so finding the right medical transcription service is important to cut your costs.

Better Accuracy

Because of the amount of time and effort it takes to document in the EHR, doctors don’t always fill them out to the best of their abilities. This puts patients in danger! Medical transcription services take the human component out of reporting to ensure higher accuracy. As a result, hospitals and clinics are better able to take care of their patients.

Improved Patient Interactions

Lastly, medical transcription services have a tremendous impact on patient interactions. Since physicians, nurses, and other practitioners no longer need to manually fill out reports, they have more time to focus on the patient to ensure their best interests. With an accurate and complete note, hospitals and clinics can have better information when treating patients, allowing you to focus on what’s most important: patient safety and well-being.

Part 3

Who Can Use Them?

Medical transcription services are meant to be a tool used by any of these types of healthcare facilities. Most healthcare facilities encounter the same problems when it comes to clinical documentation in EHR systems (increased number of administrative tasks, physician burnout, loss of productivity, and loss of patient engagement). There really is no difference in the way these facilities use medical transcription services. In all cases, the voice recognition is used to record dictation, which is then pushed to the EHR system. However, there are various types of transcription services available in the market, so take the time to consider which is best for your organization.

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Part 4

Types of Medical Transcription Services

There are a variety of medical transcription services available, but it can be difficult—and confusing—to keep up with the nomenclature of clinical documentation. While they all have different techniques of recording your notes, they all provide you with the ability to improve efficiency and productivity. These are the four core types of medical transcription services to familiarize yourself with:

Traditional Transcription: Live Person In-House

Live person, in-house transcription is the most old-school (and most expensive!) method of transcription services. It involves depending upon an actual transcriptionist who types your notes manually in order to accurately complete your documentation. While this may seem straightforward, there are several myths about this profession. It may seem like all these people do is type fast, but they still need a foundation for understanding medical terminology as well as training from a reputable source, such as a college program or a well-established medical transcription school. Using a medical transcriptionist is a great method for those who want face-to-face interactions, but they tend to have high costs, and there is still potential for human error.

Transcription with Human Intervention and Voice Recognition (Editing)

This method is essentially a combination of traditional transcription using a live person either in-house or remote with back-end voice recognition software. It uses voice recognition technology to translate the healthcare practitioner’s words into a detailed clinical narrative that feeds into the EHR. If necessary, a medical transcriptionist can edit any mistakes in the report. Speaking their notes helps to save both time and money, but this process can take 24-48 hours to enter the data into the EHR, which lessens efficiency.

Real-Time Speech-to-Text

Think of this method as a medical version of “Siri.” Compared to the second method, real-time speech-to-text differs in that a doctor or clinician uses front-end speech recognition, and the report can be immediately transmitted into the EHR system. This method cuts out the inefficiency of waiting 24 hours for the report to upload and using human intervention for editing. Healthcare practitioners can avoid typing (most physicians are terrible!) but still must edit the note themselves. Those providers that are willing to invest the time and have the patience for self-editing can achieve the highest levels of productivity and efficiency with this model at the lowest cost.

Virtual Scribe Service

Dedicated in-office resources or scribes that are tasked with shadowing the physician for the sole purpose of documenting patient encounters have become increasingly popular. Primarily due to the rampant dissatisfaction that exists regarding EHRs and their lack of usability, many physicians, particularly high volume specialists, prefer to have a scribe handle all aspects of patient encounter documentation. Scribes have become polarizing however due to reports of many patients feeling awkward with another person in the exam room particularly if there is a sensitive issue to discuss. Virtual scribes present an attractive alternative as the scribe is located in a remote location and accesses the patient encounter via a recording device of some sort (mobile app, smart watch, etc) and then remotely accesses the EHR and documents in as close to real-time as possible on behalf of the physician. Virtual scribe services are poised to grow substantially industry wide as technology improves in the areas of artificial intelligence and machine learning.

Part 5

Are They Secure?

Patient records are highly confidential, so privacy and security related to these sensitive documents is critical to both the patient and the healthcare provider. To maintain this confidentiality, medical transcription services have a few compliance standards they should adhere to.

HIPAA Compliance

Health Insurance Portability and Accountability Act (HIPAA) compliance is designed to provide protection and security of an individual’s health information. There are two pieces to HIPAA compliance: the Privacy Rule and the Security Rule. The Privacy Rule covers protecting health information no matter the medium in which it takes place. The Security Rule works to protect health information specifically in electronic form. These two rules help to ensure that healthcare facilities take significant precautions when it comes to the privacy and security of patient data; noncompliance can be penalized by law.

HITECH Compliance

The Health Information Technology for Economic and Clinical Health Act (HITECH Act) is built to drive meaningful use into the use of EHR systems. This means they are using a certified EHR technology and use of that technology provides the exchange of health information to improve the quality of care for the patient. The HITECH Act is also meant to create a stricter enforcement of HIPAA by requiring health care providers to perform security audits.

Real-Time Support

Depending on the company providing the medical transcription services, access to real-time expertise may be available. Having a support team there to work with your practice if any security concerns arise is a highly valuable resource to assist in resolving problems as quickly as possible and prevent patient data from being stolen, spread, or lost.

By following these two major healthcare compliance stipulations, along with offering a real-time support team, your medical transcription services are sure to be secure, and private patient information will not be compromised.

Part 6

Integration with EHR and Business Operations

Overview of EHR Systems

Electronic health record (EHR) systems have been around for a while, built to replace the original method of recording on pen and paper, but they have yet to become simple and efficient enough to make impactful differences in the lives of the health care practitioners who use them. Many hospitals, clinics, and other healthcare businesses have come to the realization that EHR systems have actually created more hassle for healthcare practitioners, have given rise to physician burnout, and have lowered productivity.

Impact of Integration

Medical transcription and virtual or remote scribe services have become one of the most effective solutions to bring productivity back to EHR systems and reduce physician burnout. You talk faster than you type, so if you have the ability to use a tool that documents encounters for you, it prevents physicians from staying later at the office simply to finish administrative tasks and eliminates pajama time.

An example of this is in reporting. The documentation from the recorded transcriptions allows for EHR systems to run the reporting processes more efficiently. Healthcare practitioners use a variety of reports to determine a patient’s prognosis status. If they can dictate these reports using a transcription device, the documentation process from the recording is done much faster and is easier to send to other people if and when it’s necessary. There are a variety of reports that this workflow can apply toward such as consultation reports, client medical history reports, laboratory reports, and discharge reports among others.

Integration Concerns

Common issues that health facilities encounter with using voice recognition software have less to do with the integration with the EHR system and more to do with how it integrates with current business operations. A study was conducted when the Naval Hospital Pensacola offered transcription services to its medical staff and found that much of the success of this integration is based on training and basic logistics of the transcription services.

In regards to training, those who received training were less likely to stop using the device, while of those who did discontinue, 30% cited inadequate training as a reason for quitting. Other common reasons for discontinuation included slowness (due to time to correct errors), failure to recognize the user’s voice, and inability to live up to expectations. Therefore it’s critical to communicate reasonable expectations and best practices to ensure success with the integration. Examples of best practices include speaking clearly, not mumbling, and being consistent in the format you use to record information rather than jumping all over the place. This will prevent wasting time on correcting errors and make information easier to find.

For those who continued to use the voice recognition tools, 93% stated that it saved them 11 to over 60 minutes per day, 93% said it improved their EHR notes, and 63% said it resulted in same-day encounter closing more than 75% of the time. Overall, those who received training and continued to use it found great utility with this tool.

When deciding what transcription service to use, be sure that it integrates with your existing EHR system. Most medical transcription services are not able to integrate with a variety of EHR systems, so choose wisely or you will still be forced to manually copy and paste information into the EHR.

If you don’t want to worry about setting up integration with the EHR system yourself and the potential troubleshooting that comes with it, note that some companies will offer set-up services to take that concern off your hands. They also have flexible versions of the transcription tools based on how your practice operates its business because they are available in a variety of forms. Many are software products to install on your computers, but if you want your healthcare practitioners to be mobile in the clinical documentation process, there are mobile app options that you can download onto phones or tablets instead.

The Power of Mobile Integration

Having mobility can add a completely new layer of efficiency to your healthcare facility because your healthcare practitioners don’t have to wait until they are back in their office to finish paperwork; they are able to do it wherever they are. In addition, being mobile can actually deliver better patient engagement and patient satisfaction by helping to restore face-to-face interaction in the patient encounter experience.

Click here to learn the untapped potential of mobile by downloading this free, ultimate guide to mobile in healthcare.

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Take Back Your Time with Medical Transcription Services

Download this free, ultimate guide to medical transcription services to learn their benefits, how they integrate with your current EHR system, and which type of medical transcription service is best for you.