It wasn’t so long ago that patient records consisted of paper documents created from hand-scribbled notes made by the doctor. Transcriptionists deciphered the details, compiled them, and stuffed them into manila folders tabbed with the first few letters of a patient’s last name. It was inefficient and time consuming, but it worked.
Then came dictation in the 1980s, giving doctors the option of speaking their notes into a voice recorder, from which the transcriptionist interpreted the encounter details and entered data into the patient file. Then came voice recognition software, which ended the bulk of word-for-word typing by transcriptionists. Now, paper files have given way to electronic medical records—digitized information now resides in vast databases accessible at the touch of a button.
Common sense would say advanced technology makes a doctor’s job of capturing and reporting information about daily patient encounters easier. Reality says something quite different. Documenting encounter information into the EMR costs physicians time they could be spending with patients.
There are other impacts—some physicians say that increased documentation demands is one of the factors causing them to reduce the time they spend in patient visits. Others doctors contend that the documentation demands are causing changes in the way they record information from patient encounters. Some feel pressured to understand ICD-10 coding and use it in filing notes on encounters.
Despite these challenges and impacts, physicians do bear an important responsibility with EMRs, because they are important players in developing and maintaining medical records. The problem lies with asking doctors to do things that are time-consuming and distract them from their most important focus.
A physician’s role in documentation shouldn’t be focused on data entry. EMR voice-recognition software allows doctors to directly narrate into the system, but like any other text, narrated notes need to be reviewed for accuracy and then approved. That’s not always the case for time-crunched doctors, some of whom are approving their entries without reviewing them. This increases the risk of inaccurate data and mistakes.
Concern about accuracy is one reason why the need for better transcription is being discussed in multiple forums, including Congress. In late January, the Association for Healthcare Documentation Integrity (AHDI) testified before Sen. Lamar Alexander, R-Tenn., head of the Committee on Health, Education, Labor and Pensions, suggesting expanded language to Draft Bill BAI16031 related to improving the functionality and interoperability of EMR systems, and to ease patient access to healthcare data. AHDI specifically requested “certified healthcare documentation and certified medical transcriptionists” be included in the definition of “non-physician members of the care team.”
AHDI testified that, “Accurate, high-integrity documentation of patient care does not happen in a vacuum, nor can it be accomplished by placing that documentation burden solely on the shoulders of the physician. Ensuring the integrity of clinical documentation will continue to require a partnership between physicians and the documentation team—highly skilled, analytical healthcare documentation specialists who provide risk management support in capturing healthcare encounters and making sure they are documented and formatted in a way that promotes clinical clarity and coordinated care. A certified healthcare documentation specialist or certified medical transcriptionist can ensure accurate documentation of those care encounters and identify gaps, errors, and inconsistencies in the record that may compromise care or compromise compliance goals.”
The key words in AHDI’s statement are “partnership between physicians and the documentation team.” There is no magic documentation and transcription formula that can serve every organization. This partnership should include all players—physicians, documentation specialists, transcription experts, EMR vendors and hospital administrators—who have a hand in creating more effective, accurate and understandable patient medical records.
Medical transcription is poised to play a big part of that structure. Surgeons want to operate. Family practitioners want to help patients. Documentation demands imposed by strict EMR policies and structured data limit their ability to provide the quantity and kind of care they envision.
The industry desperately needs to advance productivity and efficiency in this area. Providers want to deliver quality, impactful care. They will need assistance in ensuring the information captured during patient encounters is accurately and cleanly recorded in their EMRs.
EMRs are a critical part of our healthcare system. The information held within those databases is invaluable as providers strive to measure the quality of patient outcomes, all while taking on more risk under value-based care. By combining strengths, all partners in data collection, dictation, transcription and documentation can optimize the efficiency of doctors, physicians and other healthcare professionals.
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