Archive for July 17, 2009

Verbatim Transcription

Should doctors be taken word-for-word?

By Cheryl McEvoy

A run-on sentence. A misspelled drug. A superfluous comma. Heck, maybe even a split infinitive. Dictation errors can irk word-wary MTs, but should they be forced to overlook such grammatical offenses? Thus begins the debate over verbatim transcription, a contractual item that makes MTs withhold all judgment — medical, grammatical or otherwise — and simply type what the dictator says. The controversial practice pits risk management against quality assurance (QA), but MTs’ reputations and patient care are what’s on the line.

While traditional transcription lets MTs correct punctuation, misspellings and dictation errors at their discretion, verbatim transcription requires MTs to transcribe notes exactly as dictated. The practice is usually based on the client’s preferences; if a doctor doesn’t want his words altered, the MT is expected to transcribe word-for-word. There are arguments for and against the no-edits approach, but most MTs aren’t thrilled about it.

The running joke is, “If you want verbatim transcription, I will put in every ‘uh,’ ‘ah,’ ‘oh’ and ‘um’ that you have dictated,” said Barb Marques, CMT, AHDI-F, president-elect of the Association for Healthcare Documentation Integrity (AHDI).

In reality, it’s no laughing matter.

Risky Business

Doctors can make mistakes, so risk managers champion verbatim transcription as a way to keep MTs from taking the fall, according to Donna Brosmer, CMT, AHDI-F, NREMT-B, quality officer, Spheris. If the document ends up in court, an MT can claim no culpability because the doctor requested the dictation be transcribed word for word. If the MT changed any words, he or she might be held accountable for the error – a mark hospitals and medical transcription service organizations (MTSOs) don’t want on their hands.

But many say verbatim transcription neglects the value a skilled MT can bring to the table. With knowledge of diseases, diagnoses, treatments and medical terminology — not to mention, a knack for grammar and punctuation — MTs can serve as the first line of defense against errors, according to Brosmer. “You have a group of very intelligent people creating these reports, transcribing these reports,” she said.

For example, a good MT would know the difference between Xanax and Zantac and could correct the mix-up if a doctor misspoke, Brosmer said. MTs are also trained to notice when a doctor switches between left and right.

“If he said ‘right foot’ five times in the report and he gets down to the bottom and says ‘left,’ 99.9 percent [of the time], he really does mean the right foot,” Marques said.

Errors like that are becoming more common as good dictators become few and far between. With doctors able to dictate from their Blackberrys and iPhones, MTs are struggling to hear over the background sound of gyms, pools and oncoming traffic, Brosmer said.

Physicians are also getting more lax. Marques said today’s rising doctors do not speak in complete sentences, making it harder to understand the report. While a skilled MT would have the confidence to edit and make corrections without delaying the report, with verbatim transcription, the MT would have to query the physician or flag errors in hopes he would re-examine his work.

Making matters worse, many doctors don’t review their transcribed reports, according Lesli McGill, director of U.S. operations, SPi Healthcare. McGill hails from the “old school” of transcription, where she learned to edit as she transcribed. She recalled the “rubber stamp” method physicians used to approve reports — simply passing it on without so much as a glance. In today’s electronic environment, that stamp has been replaced with a click of approval, making it even easier to overlook flagged items.

Employee Pride

What the controversy boils down to is quality. MTs pride themselves on delivering a timely and accurate record, so they loathe initialing a document that isn’t up to par — especially if that document is hauled into court. “[MTs] want people to understand they did the best job they could with that document,” McGill said. “It reflects badly on them if it’s a verbatim account and you’ve got a bad dictator.”

The squabble isn’t likely to end soon, the experts said. The topic was among discussions at the Medical Transcription Industry Association (MTIA) Convention last April, and it’s expected to be on MTs’ minds at the AHDI conference later this month. In health care, quality isn’t something to take lightly; a mistake that slips through the cracks could mean the difference between life and death. MTs are supposed to be the first defense against errors, but amid the skirmish of lawsuits and legal liability, some fear verbatim transcription will push patient care to the wayside.

Cheryl McEvoy is an editorial assistant with ADVANCE

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Association readies for EHR advocacy summit

The proven ability for medical transcription to facilitate accurate, cost-effective EHR adoption will be the key message brought by the members of the Association for Healthcare Documentation Integrity (AHDI) and the Medical Transcription Industry Association (MTIA) to federal legislators on Capitol Hill when the associations convene in Washington, DC, for their annual Advocacy Summit. With the HITECH Act, the Obama Administration’s high priority on nationwide EHR adoption has opened an opportunity for the transcription sector to educate the current Administration and Congress about the need for contemplative, prudent migration to the EHR – one that preserves the role of complex narrative and engages human intelligence in ensuring the accurate, secure capture of patient healthcare encounters.

The Advocacy Summit, being held June 3-4, 2009, in Washington, DC, will focus on the need for standards and regulations in EHR technology integration/adoption, the role of transcription in safeguarding protected health information (PHI), and the need for workforce development funding in healthcare documentation to ensure a knowledgeable, prepared next gen workforce that is capable of functioning in the quality assurance role the EHR will demand.

“Healthcare can ill afford a knee-jerk reaction to the EHR requirements of the HITECH Act,” states Peter Preziosi, PhD, CAE, AHDI/MTIA chief executive officer. “Successful EHR adoption and meaningful interoperability hinge on healthcare’s ability to set standards that promote efficient, cost-effective, quality-driven data capture solutions. The transcription sector is uniquely positioned to offer healthcare delivery the means to make that happen, and that’s what we’ll be sharing with this new Administration and the new Congress.”

The associations will take to the Hill their Transcription: Proven Accelerator to EHR Adoption whitepaper, which includes compelling statistics that demonstrate (a) the loss of income to physicians who integrate EMR/EHR technologies ineffectively, (b) the critical role of transcription technology solutions in facilitating better EHR adoption, (c) the value of solutions that create “rich, interrelated narratives” rather than cookie-cutter records, and (d) the irreplaceable role of a knowledge worker in data integrity management

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Benefits of Outsource Medical Transcription Services

Medical Transcription is the process of understanding and transcribing the transcript made by healthcare professionals, such as doctors, treatment procedures, prognoses, diagnoses etc. It is the wide procedure of transcribing voice-recorded reports done by doctors and healthcare professionals into text formats for various uses.

Today there are extensive medical transcription services are available that cover all kind of the specialties in medicine. As the health care industry grows up, one finds that the number of companies is specialized in providing medical transcription services. Medical transcription is growing day by day. These services are provided to a wide range of practices and organizations that can include healthcare facilities, hospitals, laboratories, clinics, individual doctors and physicians’ groups.

Electronic storing of medical records is preferred by contemporary medical organization because of the giant number of patient information being accumulate. It crafts it very easy to integrate all details including the medicine, diseases details and other diagnostic information. Maintaining of this type of records is primarily to facilitate the patient’s healthcare. Also to use it as a general use data bank while still maintaining privacy of patient data.

Medical transcription services are offered exclusively for all the different medical specialists. Nowadays we have experienced medical transcriptionists who do specializations in transcription of different branches of medicine.

Medical Transcription Services includes:

  • Radiology Transcription
  • Cardiology Transcription
  • Gynecology Transcription
  • Dental Transcription
  • Psychology Transcription
  • Neurology Transcription
  • Dermatology Transcription
  • Orthopedic Transcription
  • Academic Transcription

Medical transcription is one of the most widely outsourced works in the healthcare industry. Medical transcription services can consistently give you the combined unique experience of 99% accuracy, data security and absolute privacy for your records and documents. The concentrated training provided at these outsourcing companies guarantees quality and speed. To guarantee maximum accuracy in medical transcription, all these medical transcription services have experienced editors and proofreaders. Another foremost benefit of outsourcing these medical transcription works is that backup copies of patient data. These are forever available at the servers of these outsourcing companies and so it is easier to search and access patient records. Medical Transcription outsourcing is one of the most important industries in the outsourcing range.

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Why Medical Transcription Services are in High Demand

Medical transcription services are in high demand in a variety of healthcare settings. These services are in high demand mainly because:

  • They help speedy processing of patient insurance claims
  • They ensure accurate and detailed medical records which are of great importance in any healthcare setting
  • They can efficiently handle the growing volume of medical reports in hospitals, clinics, primary healthcare centers, acute care centers
  • They ensure that clients receive properly formatted, edited and reviewed documents

Most companies in the medical transcription field offer HIPAA (Health Insurance Portability and Accountability Act) compliant transcription services. Reliable transcription services are available for operative reports, diagnostic imaging studies, laboratory summaries, x-ray reports, physical examination reports, patient histories, ER reports, clinic notes, referral letters, progress notes, psychiatric evaluations, physical examination reports, pathology reports and death summaries.

Convenient Dictation Options and Flexible File Formats

Leading transcription companies offer affordable and convenient dictation options – toll free number, digital recorders or computer based dictations. The voice-recorded files can be in any format including WMV, MPG, AVI, MOV, ASF, ASX, RM, SWF, DIC or extended audio formats such as WMA and MP.

Qualified Professionals to Handle the Rising Transcription Demands

To handle transcription services in various specialties–including pediatrics, gastroenterology, internal medicine, radiology, orthopedics, cardiology, chiropractic and podiatry–at 99% accuracy, these service providers have a team of skilled and experienced medical transcriptionists, quality analysts and proofreaders. They utilize the best combination of tools and techniques to output transcribed files in various formats (such as JPG, GIF, XML, PageMaker, XML, PDF, HTML, TIFF, FrameMaker, QuarkXpress, Word and Excel) through FTP or browser based 256 bit AES encryption protocol.

If you need medical transcription service for generating accurate transcripts, it is important to get the support of a dependable service provider.

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