Bringing Transcription, EHR Together

By Greg Doggett, JD

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 brought major changes to the medical transcription sector. Medical transcription service organizations (MTSOs) and medical transcriptionists (MTs) have focused their attention on the portion of the Act that created increased HIPAA privacy and security obligations for business associates. That focus is certainly understandable given the potential civil and criminal penalties for failure to fulfill those obligations; however, the Act’s changes to HIPAA will likely have less of a long-term effect on the medical transcription industry than another key part of the legislation.

The HITECH Act makes billions of dollars in financial incentives available to physicians and hospitals that make “meaningful use” of a certified electronic health record (EHR) system. The Act provided little detail on what constitutes meaningful use or a certified EHR, leaving that task up to the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONCHIT). The federal government sought input from stakeholder groups before issuing highly anticipated, proposed regulations at the end of 2009. Organizations, including the Association for Healthcare Documentation Integrity (AHDI) and the Medical Transcription Industry Association (MTIA), have analyzed the proposed regulations to determine their feasibility and consequences for quality of care, patient safety and efficiency.

Most concerning to AHDI and MTIA was the fact that the proposed regulations did not mention the dictation-transcription process or narrative reports. Failure to recognize these elements will have negative consequences for physician acceptance and adoption of EHR systems, the quality of health information, and, in turn, quality of care and patient safety. That is why AHDI and MTIA are calling for the government to explicitly recognize that several means of data capture would allow a physician or hospital to meet the criteria for meaningful use, including utilization of the dictation-transcription process to feed structured narrative reports and discrete data elements through data tagging into the EHR. Failure to recognize these elements will lead to the false perception that physician entry is the only option for capturing this information. In addition, AHDI and MTIA are calling for certified EHR systems to have the functionality to accept structured document formats from the dictation-transcription process, thereby enabling providers’ use of the process.

AHDI and MTIA members will take these messages to Capitol Hill on March 24 during the associations’ fifth annual Advocacy Summit. The event is an opportunity for MTs, MTSO owners and executives, educators, students and others within the medical transcription space to educate legislators on the sector’s vital contribution to quality of care and patient safety and to request their support for legislation and regulations that will capitalize upon the sector’s valuable contribution to improve health information and delivery of care.

The dictation-transcription process remains physicians’ documentation method of choice because it is easy to use and is time-efficient, thus allowing physicians more time to focus on treating their patients. In addition, narrative reports generated from the dictation-transcription process tell the entire patient story, are easier to read and understand among clinicians for coordinating and continuing care, and will be more meaningful to patients seeking information about their health care than a printout with a mere series of discrete, disjointed data elements. By acknowledging the dictation-transcription process as one of the methods to capture health information in the regulations, physicians will be more likely to embrace the push for greater EHR adoption and to find the experience of using an EHR positive and less cumbersome when it comes to the documentation process. Requiring certified EHRs to accept structured narrative reports from the dictation-transcription process will improve the flow of information between narrative reports and EHRs.

The dictation-transcription process is a proven and effective documentation method. MTSOs and MTs have long worked with physicians to deliver accurate, complete, consistent and secured records in the health care system to optimize patient care delivery and to enhance patient safety. By employing health care documentation professionals as a solution to the challenges of EHR adoption, the federal government will ensure wider and more successful adoption, a win-win for physicians and patients.

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