Medical transcription outsourcing: Producing documentation support based on AHDI guidelines

The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.

As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA(now CDIA) and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.

Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.

Plan: Planning policy guidelines for quality

This part of best practices for maintaining quality involves a set of standards for documentation that ensures accuracy, accessibility and overall value of the patient medical record as a resource for understanding the care process including diagnosis, treatment and progress.

To ensure this, the planning process should have principles that ensure:

• Verifiability: Any quality program should have standards and measures that are easily verifiable and these measures should be available to personnel at every level of the organization and to the end user of the transcript to ensure cross verification
• Definability: The error categories should be clearly defined
• Measurability: Measurable values for clearly defined error categories should be assigned and measurement methodology for errors should be clear to all the parties involved
• Consistency: The quality program should define error categories, values to be assigned to each category and there should be a standard method error determination.
• Integrity: The integrity of document can only be assured when there is a synchronized partnership between the originator of dictation and the medical transcriptionist. The healthcare professional dictating the notes should present information in a clear and concise manner and the medical transcriptionist should transcribe the document preserving the essence of the information provided by the healthcare professional

To this end the quality assurance program should be based on Quality Guidelines that ensure the following:

• Accurate and complete documentation ensuring that the essence of the encounter is captured
• A process of distribution of reports on a timely basis and a system for easy accessibility of past records to the relevant personnel
• A practice of periodical quality audits to study the process and assess where errors occur as a part of the ongoing quality process
• This process to be applied to medical transcription at all levels
• The assessment program should be consistent and unbiased
• The assessment program should be according to the principles of assessment agreed upon
• The results from the assessment process to be used as a learning tool to ensure recurrence of errors
• Access to the Quality Guidelines, assessment process to be made available to all the people involved in the transcription process.

To be successful a quality assurance program should be:

Proactive: Medical transcription being such a critical activity that contributes to the healthcare process, it is important for quality assurance program for medical transcription to be proactive. Being proactive ensures that solutions are available for problems before they turn into major issues

Realistic, scalable and financially feasible: Quality in medical transcription is a continuous process; therefore it is important that the quality assurance program should be realistic and cost effective

Simple and easy to implement: Medical transcription is a process that consistently needs to meet the quality constraints of accuracy and timeliness, keeping this in mind any quality assurance process has to be simple to be workable.

Secure and Confidential: Considering that medical transcription involves working with confidential patient information and comes under the purview of HIPAA it is important that any feedback regarding quality keeps in mind the confidentiality norms

Inclusive of all aspects: Quality in the medical transcription process involves all aspects starting from the origin of the data down to the medical transcriptionist, proofreader and quality team, the quality assurance program needs to plan measures to include all these aspects

Reportable for trending and tracking purposes: The process of quality assurance is not only to ensure consistent quality documentation but is also a valuable input for education purposes

Timely: The quality assurance process should be scheduled in timely manner to ensure maximum results

TransDyne, a leader in the medical transcription industry has made quality a key word in their work processes. This attitude of adopting quality as the basis of their services and their aptitude in information technology has helped them come up with easy to use medical transcription solutions that help save on time, money and efforts.

 

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

 

To avail complete medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Integrating naturally into the workflow of healthcare facilities

Medical transcription services have aided the process of providing healthcare by documenting the patient- healthcare professional encounter, converting audio to text in an accurate, timely, secure and cost effective manner. As medical transcription services require the right team, the right process and the right technology to be able to meet all these criteria, the prudent and practical solution for healthcare facilities to maintain focus on their core business is to outsource the entire process to a professional medical transcription service provider.

While transcribing audio to text is the essence of the services provided by medical transcription service providers, medical transcription has risen above being just a typing service by seamlessly integrating into the workflow of healthcare facilities. To examine how medical transcription has blended seamlessly into the working of healthcare facilities it is essential to take a look at the changing face of clinical documentation.

With the introduction of ARRA and the announcement of incentives for the meaningful use of certified EHR/EMR systems, the entire healthcare documentation scenario is going through major changes. However as adoption of this new technology involves time- starved healthcare professionals there have been a few barriers to adopting this technology, namely:

Lack of time: One of the barrier to adopting new technology is the lack of time; healthcare professionals lack the time to acquaint themselves with the technology and moreover using this new technology can adversely affect their productivity

Need for new infrastructure: Using point and click templates to feed information into the EHR at the point of care needs new infrastructure which could affect the dynamics of the process of healthcare

Extensive training: Use of technology to be used by the healthcare professional at the point of care could require extensive training to produce the required results

Requiring major changes in the workflow: The introduction of new technology would require in the workflow of the healthcare professional and the healthcare facility

Outsourcing medical transcription ensures that healthcare professionals can retain their tried and trusted method of capturing information and still enable adoption of EMR/EHR by using HL7 interface.

Some of the advantages of outsourcing medical transcription to a technologically savvy and professional medical transcription service provider are:

Familiar method of documenting the patient- healthcare professional encounter: Outsourcing medical transcription enables healthcare professionals to retain not only their familiar method of documenting the patient encounter, but also allows them to use dictation devices of their choice. This enables healthcare professionals to optimize their limited time in the best way possible.

Quality creation of patient medical records: Outsourcing medical transcription ensures that the quality of patient medical records is maintained due to the following:

• Medical transcriptionists trained in the specialty they are transcribing in, ensure that errors are minimized
• Quality processes involving checks at several levels ensure that quality levels are high
• Turnaround time is ensured due to availability of skilled medical transcriptionists and the right technology

Flexible services: Outsourced medical transcription services afford healthcare facilities flexibility with regard to all aspects of transcription including specialty, volume, turnaround time, formats/templates and even editing/proofreading services for speech recognition software transcription.

TransDyne, a leader in the outsourced medical transcription industry has used their extensive background in information technology to come up with medical transcription services that provide easy to use solutions for the needs of healthcare professionals and other staff of the healthcare facilities. TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

To avail outsourced medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Seamlessly integrating with the working of healthcare facilities

The healthcare sector provides valuable services that help save lives and improve the quality of life. In the modern world healthcare services have gained a more significant role considering the stress levels of today's lifestyles. To provide quality services healthcare facilities and healthcare professionals draw quality inputs from various sources. To enable the continuous provision of quality healthcare it is equally important for healthcare facilities to have a healthy bottom line

The key to empowering the main goals of providing quality healthcare and maintaining a healthy bottom line it is important to evaluate each input to the healthcare process on the following basis:

• Ability to seamlessly integrate with the working of the healthcare facilities
• Ability to maintain quality services
• Help lower costs

One of the components for providing quality healthcare and maintaining a healthy bottom line is the information from patient medical records. Patient medical records provide support to healthcare facilities and healthcare professionals in the many aspects of successfully running the healthcare facility. Information from the patient medical records is essential as:

• A chronicle of the treatment process
• Forms the basis of continued care and future care plans
• Is the basis of referrals
• Provides important evidence in case of litigation
• Helps fulfill statutory requirements
• Provides the basis for coding and billing

Healthcare facilities and healthcare professionals have many options available to them to document the patient- healthcare professional encounter to create patient medical records. However outsourced medical transcription services have been found to be the most preferred, cost- effective, versatile and convenient option for documenting the care process. Medical transcription services also have the additional advantage of being able to seamlessly integrating into the working style of healthcare professionals and healthcare facility operations.

 

 

How do outsourced medical transcription service providers seamlessly integrate with the operations of healthcare facilities?

 

No change in working style: Healthcare professionals are starved for time and adapting to new styles of capturing information could result in loss of productivity or even result in errors. Outsourced medical transcription services are fully aware of the pressures of healthcare professionals and have made it convenient for healthcare professionals to capture information regarding the patient encounter. Healthcare professionals are provided with options to use dictation devices they are comfortable with. Once the dictation is finished, systems are put in place to help upload these audio files for transcription by configuring the system to check for dictation files at agreed intervals.

 

Once the audio files are downloaded for transcription, the files are allocated according to the specialty the medical transcriptionists have trained in, this ensures maximum accuracy. Medical transcription service providers have quality processes in place to  ensure that each transcript is put through rigorous quality assurance process to ensure minimum errors. The role of the healthcare professional is limited to clear and audible dictation, which can be easily integrated into their working life.

 

Customized services: Outsourced medical transcription service providers realize that the needs of different healthcare professionals and healthcare facilities are specific. Therefore medical transcription services are customized to meet all the special requirements as specified by the healthcare professional/ healthcare facility. Factors like templates, turnaround time, the modes of delivery and even the option of delivery to multiple healthcare professionals is offered and inculcated into the medical transcription services package. Additional services like editing and proofreading services for speech recognition transcription are also provided as per the preference of the healthcare professional.

 

Easy access: Outsourced medical transcription services provide easy access to services in terms of the technology required for medical transcription and the team.  Outsourced services also provide easy access to older transcripts and summary of work.

 

Cost savings: Additionally outsourced medical transcription services have the added advantage of providing substantial savings on costs both in terms direct as well as indirect costs with regards to transcription.

 

TransDyne, a leader in the outsourced medical transcription industry has utilized their extensive background in information technology and their experience in providing medical transcription services to come up with medical transcription solutions that help healthcare facilities save on time, money and effort. TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

 

To avail complete outsourced medical transcription services from TransDyne, click here.