Medical Transcription and the EHR: Let’s Stay Together

medical recordsTechnology is a pretty amazing thing. When I was younger, I really didn’t understand anything about my health record. It seemed to be an unattainable file kept in a vault with other secret files somewhere far away. With the adoption of EHRs, though, we have ready access to our medical records any time of day.

Even so, many of us have a love/hate relationship with EHRs. Back in the day, our doctors would talk to us directly and then dictate a clinic note on our visit after we had left. Now, computers are in every exam room and some doctors seem to be more concerned with clicking check boxes than examining their patients.  I’m not here to argue the merits of either system, but rather to suggest a few ways that medical transcriptionists and EHRs can go hand in hand to make our medical records the most accurate and effective tools they can be for proper treatment.

Capturing complexity of patient situations
While point-and-click and fill-in-the-blank EHRs are just fine for many clinical applications—like plugging in vital signs, medications and dosage information, etc.—there are circumstances where such systems limit the ability of the physician to effectively document the complexity of a patient case. Take for example a complex surgery. A narrative describing the full procedure and exactly what happened is far superior for the followup care of the patient and proper coding and billing than choosing from a preformed checklist. Another example is patients who have very complex medical histories or circumstances that caused them to come to the doctor in the first place. Medical transcriptionists can assist by properly capturing the complexity of these situations through their medical reports.

Accuracy of information
While recently checking my EHR from my doctor’s visit, I saw a night and day difference between the information that was quickly typed into the EHR and the radiology report that was transcribed by a qualified MT. The EHR, which had been filled out by the medical assistant, had spelling mistakes, wrong information, and didn’t fully capture the reason why I came into the office in the first place. On the flipside, the radiology report was detailed and accurate and ruled out any major health problems.

Qualified medical transcriptionist editors can help to ensure the accuracy of medical record information, whether they are typing a full report, editing a speech recognition document, or verifying EHR information.  Some clinics and hospitals are even employing medical transcriptionists to verify EHR information and improve accuracy.

For doctors, every minute counts. Dictating a long report can take time, but EHRs have had the unintended consequence of lowering physician productivity even more. With traditional dictation, the doctor just had to dictate the report without worrying about creating the physical document for it. With EHRs, the doctors are often filling them out themselves, which takes away from face-to-face time with the patients, frustrating not only the doctors but the patients themselves.

One solution some clinics have adopted is employing medical assistants or scribes (check out our article on those here) to be in the room at the same time so that the patient can have the doctor’s undivided attention and the doctor doesn’t have to fuss with the computer. This frees the doctor up to fully focus on the patient and decreases the time between patients since the doctor isn’t inputting all the information themselves.

Was transcription a perfect solution? No. Are EHRs a perfect solution? No. When combined together, though, these two solutions can go hand in hand to provide better documentation, accuracy, and (most importantly) patient care. And these are just a few examples of blending these two methods together. There’s a great article here that discusses this topic in more depth. We encourage you to check it out if you are interested in learning more on this subject.

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