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AUTHOR: Anna williams
July 31, 2019

Errors To Avoid During Medical Dictation Process!

If you are a health care service provider or a health care practitioner, you would know that health care documentation is a top critical process of the health care industry that requires experienced and skilled professionals to document each and every detail with the utmost precision!

Health care documentation in the medical transcription industry includes all the patient health information (PHI) and medical data that require experienced and skilled professionals to accurately document details! But how does this data impact the health care industry? Well, either the process of health care documentation has a direct impact on either the revenue cycle management of the practice or the wellness of the patient, both very critical aspects!

Any error in clinical documentation cannot only compromise the ongoing patient care but it can also influence the future treatments as well which is why it is absolutely essential that there are no errors in the process of medical transcription as well as medical dictation. We have all-ready covered how you can prevent errors in the medical transcription process over here and now lets’ get into how you can avoid and minimize errors through medical dictation!

Below is a set of guidelines to ensure that the errors through the medical dictation process are minimized to ensure smooth workflow of operations:

Always Speak clearly and Record in silence: A clear audio is equal to clarity in information provide to the transcriber to yield an error free transcribed report! If you are a health care practitioner, you know by now that the implementation of these steps is key in developing an error free transcribed report. These factors ensure that there is no hindrance in the medical dictation process! Here are some of the ways you can do so:

1) Ensure that every speaker in the audio speaks clearly and slowly. It is one of the ways to ensure that the audio quality is discernible and of the highest quality!

2) If there are various speakers, only 1 person should talk at a time to avoid any overlapping of speeches.

3) When recording among various speakers, you could center the device so that so that every speaker is clearly recorded in the audio.

4) Try to record in a silent room – you should ensure that the surroundings are quiet and the backgrounds aren’t noisy!

5) Ensure that there are no echoes while you are recording – This is another key factor that can greatly disturb your medical dictation audios! It is essential that you set up a recording room where there are no echoes while you speak.

Turning off digital devices that can cause interference with the medical dictation process: Very often, digital devices cause interference with the medical dictation process so in order to ensure that the process minimizes errors, it must be ensured that all digital devices such as TV, radio or smartphones are turned off while conducting medical dictation. The primary reason for this is that digital devices often emit signals that interfere with the microphones thus, to ensure that the quality of the recorded audio is optimally high, it is suggested that you turn off any digital device in the vicinity!

Complex Terms should be explained clearly: The medical transcription process often requires the transcriptionist to be well versed with medical terminologies so that the transcribed reports are error free but it is also essential that the recorded audio in the medical dictation process enlists all the details in a lucid manner! This is particularly because there are various complex terminologies that are involved in the medical transcription process. For instance: surgical procedures, medical terminologies, drug names, etc. These complex terms if explained clearly can reduce all types of confusion for the medical transcriptionists leaving no room for errors. One of the ways you can simplify the complex terms in your medical dictation is by always providing context when discussing something complex. Another way to reduce errors is to spell out each terminology that may be complex. These practices can help the medical transcriptionist a great deal – They are simply no longer simply guessing the terminologies and in this way, there is no room for error!

Provide detailed description whenever and wherever necessary: Another way to ensure that the final transcribed report is error free is by always providing a detailed description so that there is no room for error! The more information you provide in the medical dictation, the lesser are the chances of erroneous data reporting. Detailed descriptions provide supplementary information to the transcriptionist. These details may include enlisting dosage units for a particular drug e.g. milligrams or micrograms to enlisting patients demographics details. When you as a health care practitioner provide detailed description whenever and wherever necessary, you are enabling the transcriptionist to develop an error free report!

READ MORE: IMPORTANT TECHNIQUES TO USE DURING MEDICAL DICTATION

Employ high quality recording devices: Many a times, a cheap microphone or a low quality recording device may be responsible for creating disturbances in the medical dictation process Thus, in order to avoid errors, it is advised to invest in high quality recording devices.
Although medical transcriptionists today, are trained and skilled to develop error free reports, these are some of the ways, you can avoid errors through the medical dictation process! The audio generated during the medical dictation process will only further the accuracy level of the transcribed report such that there is no room for error!

By: Anna williams Category: blog
July 29, 2019

The Process of Medical Transcription and its’ Service Provider’s Role in the Health Care Industry!

Keeping a few health care processes aside, most of the health care processes either have an impact on the wellness aspect of the patient or they influence the revenue cycle management of the practice or the physician. For this particular reason, Health care practitioners and professionals like doctors, nurses, para-medicals and surgeons have some of the most stressful profiles across the globe! And aside from performing daily responsibilities of their health care processes diligently, health care professionals often need to document clinical and medical data for their records as well as future references. The documentation of patients’ health information and medical data is one of top critical processes that require experienced and skilled professionals to accurately document details!

One of the allied health care processes that rely on the accurate documentation of details is the medical transcription process – Any discrepancy in the medical transcription process needs to be immediately and effectively resolved and the reasoning for this is lucid: Any information that is incorrectly entered can lead to the hampering of current as well as future health care processes. For these particular reasons, it is absolutely essential that while transcribing each and every detail is documented accurately. It also needs to be ensured that there is no detail spared from the documentation process of medical transcription!

So lets’ understand, what role medical transcription process and its’ service provider’s play in the health care industry: 

  • – The Health care industry today, is more of a collaborative community than it was ever before! This has led to the adoption of novice technology that has in turn sophisticated the processes leading to smoother work flow operations. The same holds true for the medical transcription industry! The process of medical transcription is especially essential in solving complex surgical cases where the opinion of various medical specialists is required. In such cases, the medical transcriptionist ensures that the flow of patient health information is facilitated in the most efficient manner! Thus, a collaborative process here helps the various health care professionals such as doctors, nurses, para-medicals and surgeons to implement the required diagnostic procedures and treatment plan.
  • – The medical transcription process ensures that every health care professional involved in the process has the same patient health information and medical data to refer to. So whether its’ a doctor, surgeon, medical specialist or a nurse or any other supporting staff, they will all have the same set of data! This ensures that there are no communication errors within the staff and it also avoids any complications. It also helps the health care professionals to provide a high quality care to their patients!
  • – It cannot be stressed enough that the process of medical transcription requires each and every detail to be documented with the utmost accuracy. There is almost no room for error and while that is obvious, lets’ explore but why is that the case? Well, the medical transcription process enlists the details of the diagnosis, treatment and the progress of the patient that has happened so far! These details further help the health care professionals to assess and plan patients future treatment plans. The details transcribed in the medical report help health care professionals to develop strategies and follow up plans to avoid any complications and ensure that the patient’s condition doesn’t worsen and there are no relapses especially in the case of chronic diseases.   
  • – The medical transcription process not only helps to ensure that the work flow operations are smooth but it also helps in creating records for billing purposes. It helps to ensure that the health care professionals’ revenue cycle will not be hampered due to lack of records but how does the process exactly helps in the billing processes? Well, the process of medical transcription ensures that the transcribed medical records are not only accurate but also consistent and this is of tremendous value for the purpose of medical insurances and billing processes. A transcribed medical report that is consistent and accurate helps to verify insurance details easily thereby, preventing the hampering of a physician or clinic’s revenue cycle management!
  • – The compliance requirements of Health Insurance Portability and Accountability Act (HIPPA) truly revolutionized the health care industry! It is today, one of the most critical elements of the health care industry and requires health care professionals to protect patient health information with due diligence. How does a medical transcription service provider contribute to the compliance requirements of HIPPA? Well, not only does a transcribed report help to ensure that the treatment plan provided to the patient is of highest quality but it is also a record of details that can be provided in case there are any law-suits. A correctly transcribed medical report gives a security to health care providers against any legal battles that may arise in the future. If your medical transcription service provider is focused in providing you with high quality medical reports that are consistent and accurate, then these high quality medical reports can be employed to protect your practice and medical staff from any law-suits that may arise in the future. Thus, the medical transcriptionist carries a considerable amount of responsibility in delivering high quality medical reports that are correctly transcribed to each and every detail!     

These are some of the roles that the medical transcription and its’ service providers play in the health care industry! It is important to note that the health care industry is constantly evolving but during this progress, it requires to not only upgrade itself with education and technology but also maintain the documentation work-flow. The medical transcription process and its’ service providers help in the same which is why it is an integral and allied health care process that streamlines the workflow operations!

By: Anna williams Category: blog
July 23, 2019

HIPAA Compliance Measures to FOllow for a Medical Transcription Company

It’s no secret that today, one of the most booming industries across the globe is the health care industry but along with being one of the most booming industries across the globe, it is also one of the most heavily regulated industries that are required to follow the HIPAA compliance with strict adherence! Now, if you are wondering the reasons then, it is primarily because medical and health care processes directly impact either the patient’s wellness which is why it is absolutely essential that the health care professionals adhere to the regulations and follow the various compliances that are laid down by the industry professionals.

One of the compliances that no health care professional is unfamiliar with is HIPAA compliancy that requires the health care professional to protect the patient health information at all times! But how do you ensure as a health care professional that the medical transcription service company you sough to hire is taking all the measures to ensure HIPAA compliance?

Read More: Partial List Of the Rules and Regulations that We Strictly Follow While Delivering the Medical Transcription Services:

Well, lets’ explore the factors section by section that any medical transcription service company should undertake to ensure HIPAA compliance:

  • Understanding the importance of privacy, security, and confidentiality

Make sure that the medical transcription service company you seek to hire understands the meaning and difference between the three legs of the health care industry i.e. privacy, security, and confidentiality! These three terms privacy, confidentiality and security are quite often intertwined and they are used very interchangeably within the health care industry. However; each one of these plays a unique role in the health care industry. If you are a health care professional, you expect your medical transcription service company to understand the following in order to ensure HIPAA compliance:

  • The Medical transcription service company you seek to hire must understand how HIPAA regulates confidentiality, privacy, and security for patient data!
    • What does HIPAA’s Act of privacy and Act of security govern?
    • Your medical transcription service company should understand the means of securing confidential information and maintaining the privacy of patient data.
  • Customize Current Process to ensure HIPAA compliance

A medical transcription service company must be willing to customize their current processes in order to take apt measures to ensure HIPAA compliance and there are various means of developing such processes. For instance: Developing a customized algorithm to splice audio/video files for random assignments to various medical transcriptionists is one way to ensure HIPAA compliance. Through this process, they don’t have access to the entire audio/video files and will only have access to a fraction of the file. This is one of the few ways to customize your current transcription processes and ensure HIPAA compliance!

  • Developing robust infrastructure and impenetrable security walls

In order to maintain HIPAA compliance, a medical transcription service company should be willing to develop infrastructure that has security walls to prevent both kinds of intrusion – physical as well as digital! Here, developing robust infrastructure means installing fingerprint access to restrict entries. This process allows only authorized personnel to access the operation areas. Another way to ensure robust infrastructure is by securing the servers so that there is no breach of patient data via digital means.

  • Training Professionals in order to ensure they are HIPAA compliant

The next measure that ensures HIPAA compliancy within a medical transcription service company is the willingness to train the employees! It is essential that every professional employed within the medical transcription service company understand why it is important to protect and secure patient data at all times – They should be HIPAA compliant and trained to always adhere to HIPAA guidelines. Additionally, it must be ensured that the transcription professionals are securing patient data at all times and in order to do so, the medical transcription service company needs to conduct periodic HIPAA training for their employees.

  • Offering Services of Extra Security and advanced confidentiality

Very often, there are instances when the doctor or the physician needs to ensure extra caution for particular cases. These cases may be very sensitive and it may be required by the physician to maintain discretion! In such cases, the medical transcription service company must be equipped to provide a service of advanced confidentiality. These services through a medical transcription service company can entail the following:

  • If required, providing background checks of the employees. 
  • The client should be able to interview the chosen employees so they can make sure they are the right candidate to carry out the project.  
  • Ability to sign any specific non-disclosure agreement and any other legal contracts as deemed necessary.
  • Ability to customize the transcription process according to the requirements  

These measures ensure that the medical transcription service company is capable of providing the necessary security to maintain the confidentiality and privacy of the patient health information and their medical data! If the medical transcription service company is willing to exercise caution, then they are focused on providing these security measures. These security measures ensure that the medical transcription service company is dedicated to taking all the steps to ensure HIPAA compliance!  

We, at EyeRed Transcription Services, are not only focused on providing you with high-quality transcription services but we are also focused on ensuring that we take all the measures to be HIPAA compliant. We ensure that each and every transcriptionist professional handling your project is not only skilled to deliver high-quality reports but also understands the need to maintain confidentiality and protect the privacy of patient data.

We assure you that, with us as your medical transcription service provider, you will not have to worry about the requirements of HIPAA compliance as they are readily met!

By: Anna williams Category: blog
July 18, 2019

Speech Recognition transformed the process of Medical Dictation and Transcription?

It would be an understatement to say that the technological advancements have had some impact on the health care industry because if we explore how technology has impacted the medical and health care industry, we will notice a pattern of revolutionary growth with every technological advent. It has affected the procees of medical dictation too.

Technological advancements have been responsible for profoundly upgrading the documentation workflow of the health care industry. Every technological innovation builds applications that not only transforms the processes but also streamlines the operations – They are truly responsible for revolutionizing the growth aspect of not just the industry of health care but any industry! Though such technological transformations are revolutionary, they almost always pose a threat of replacement to the industry professionals and while that is a cause of concern, we must remember that with every challenge, comes an opportunity to evolve. One such technological advancement that has had an impact on the process of medical dictation and subsequently medical transcription is speech recognition technology! But before we learn the extent of the impact that speech recognition has had on medical dictation and medical transcription let’s first understand what speech recognition is?

READ MORE:-  Important Medical Dictation Techniques To Use For Physicians

Speech recognition technology commonly abbreviated as SRT is a type of artificial intelligence in which the software identifies the spoken words and transforms them into digitized text. To facilitate this process, there are handheld devices, apps and software are through which SRT identifies the phrases of the speech and the spoken words into texts. The technology of speech recognition goes back to the early 1900s when the first Dictaphone was invented but today, this technology has come a far way! The advent of speech recognition technology in the modern era was met with an enthusiastic response by various departments especially the law enforcement and legal industry.

Doctor investigating something

Today, speech recognition is not just predominant in law enforcement and legal departments but it is very actively being used in the health care and medical industry. Through its integration within the health care industry has not been entirely successful, there have been some advantages to integrating SRT with medical dictation. Let’s explore these advantages and the way speech recognition technology has impacted medical dictation and the industry of medical transcription:

• SRT enables the doctor to conduct the medical dictation as well as create a structured clinical document. Though these documents are not accurate as the ones’ transcribed by transcriptionist professionals, it does enables the physicians to create a draft document during medical dictation on a real-time basis.

• In extension to the above fact, implementation of SRT in the medical dictation process has allowed now allows the physician to create a preliminary draft of the patient health information that can be made available to other health care professionals in an emergency case scenario.

• A survey conducted in Quebec, Canada, where a total of five reviews were systematically studied determined that the overall quality of the transcribed document is not as accurate as expected. Medical dictation, when conducted with SRT software’s, do yield structured clinical documents but they need to be thoroughly reviewed. However, the study also states that there is an upside of SRT! The upside is that the time taken by the transcriptionist to yield the final report is drastically reduced.

• Medical dictation processes integrated with SRT also has had an impact on the process of medical transcription. Though SRT’s are themselves not able to deliver an accurate report, Speech recognition software’s do enable the transcriptionist to develop transcription reports with better accuracy. This is because there is an initial draft available with the transcriptionist to edit and work upon – In a way, the advent of SRT has enhanced the quality of clinical documentation.

• Physicians that conduct medical dictation with an integrated SRT software yield an initial draft thereby reducing the occurrence of error that might have happened due to either heavy accents of the speaker or local slang language however, such reports must still thoroughly be reviewed to ensure that they have been transcribed according to the data mentioned in the voice recording.

• The advent of SRT in the medical dictation subsequently transformed the role of medical transcriptionist too! Now, a SRT integrated medical dictation is dealt by an editor. SRT has transformed the role of medical transcriptionist from a typist to an editor and now, their tasks are far more challenging! The integration of SRT in medical dictation enables the medical transcriptionist to take on more challenging roles that requires them to use their problem solving and analytical skills. This in turn leads to transcribing documents with high quality.

• Since an initial draft is now available with the transcriptionist, the time taken to complete a transcribed report is now reduced to a great extent. Thus, SRT’s integration in medical dictation has made it possible to reduce the turnaround time.

Today, an initial draft of the transcribed medical report can be made available if the physician conducts medical dictation with an SRT integrated software – This technological invention was met with weariness by the medical transcription industry. And though SRT has transformed the medical dictation process to an extent, it cannot completely replace the medical transcription process – It still has a far way to go to match the accuracy of transcription carried out by medical transcription professionals.

READ MORE:-  A GUIDE ON TECHNIQUES USED DURING MEDICAL DICTATION

It can also be said that SRT is one of the cutting edge technologies that has replaced the traditional devices with comprehensive devices and software’s to convert speech into digitized texts. The advent of speech recognition technology did create weariness within the medical transcription industry but as we know today, it was embraced and accepted with the focus of enhancing clinical documentation. Medical dictation processes integrated with SRT’s have not been able to yield accurate report by themselves but in conjunction to the current medical transcription process, they have improved the output.

By: Anna williams Category: blog
July 15, 2019

Introduction to EMR and its benefits within the health care system!

The implementation of digitized techniques within the health care system has truly revolutionized the industry and this revolution has brought parallel developments that have not only structured the health care system but also provided better means of communication. These, in turn, have positively affected the quality of care and services provided by the health care industry. One such technology that has led the health care industry towards improving their quality is Electronic Medical Records, commonly abbreviated as EMR.

What is an Electronic Medical Record or EMR?

An Electronic Medical Record is a digital version of the patients’ medical records. These medical records are systemized and available at one digitized location. They are usually maintained with one physician at one digital location. An EMR enables the health care provider to examine a patient’s medical information over a period of time. This data is not limited to but may include the following details:

• Demographics details of the patient
• Billing information of the insurance companies
• Past and current medical history
• Seasonal allergies, medicinal allergies, food allergies, etc
• Any surgery details or report
• Previous vaccinations
• Pathology laboratory reports
• Medical radiology reports

Electronic Medical Records makes it possible to securely exchange medical information of a patient electronically. Through EMR, it is possible for various authorized users to access a patient’s medical data instantly and securely. It is one of the revolutionary digital technologies that have been able to produce a system for seamless documentation workflow of patients.
Despite the various benefits that the EMR systems pose on the health care industry, its’ integration within the health care system was not seen for a very long time. The implementation of electronic medical records significantly ramped up in 2014 due to a certification program by the CDC. Though that was one of the factors that fast-tracked the adoption of EMR, today, more and more physicians are realizing its’ benefits and adopting it into their systems!

READ MORE:- The Need to Use Transcription With EMR System

Benefits of implementing EMR systems:

Lets’ understand how EMR systems help to provide better health care and improve the quality of patient care:

• Immediate access to patients’ medical records: EMR significantly reduces and sometimes even eliminates the time taken to access patients’ medical records. It allows instantaneous access to patients’ medical records thereby, significantly reducing the turnaround time of telephonic messages.

• Reduction in communication errors: Due to the implementation of EMR, the requirement to communicate details is reduced. Today, health care professionals can directly access the medical data thus; comparatively, there are fewer communication errors. This implementation of electronic medical records has benefitted the health care system and enabled them to increase the quality of care provided by them!

• Chronicle organization of patient data: EMR allows administrative medical assistants to chronically organize the records of patient data. Health care professionals can now not only find patient’s data and history at a centralized location but they can also review the data in chronological order. This also allows multiple health professionals to collaborate so that the patient receives the best care and effective treatment for their condition.

• Scheduling of appointments and automatic reminders: EMR also helps to organize appointments for a physician. It allows the administrative in charge or the medical assistant to keep track of all the appointments of the patient. Since the EMR system is searchable through various parameters such as physician’s name, patients name, etc., the appointments can be previewed and scheduled without any clash by the medical assistant. The electronic medical records systems also help in efficiently managing the schedule of a patient who is undergoing various medical procedures. For instance: If a patient is undergoing an extensive medical treatment that involves different procedures, then appointments can be scheduled accordingly with the aid of electronic medical records. Also, the EMR system can be programmed in a way that it sends out confirmation calls and reminders to the patients. This is particularly helpful in reducing the list of no show appointments.

• Electronic Prescription: Through EMR, it is possible to send electronic prescriptions directly to the pharmacy stores. It is also possible for the medical assistant to pass the electronic prescription to the patient.
• Management of Medical Billing and Accounting: Though not completely but to an extent, EMR systems can manage the billing and accounting of a physician by creating an interface to track the denial of claims, thus electronic medical records systems can help to improve the revenue cycle management of a physician’s practice.

• Insurance eligibility verification: In addition to managing medical billing and accounting, the electronic medical records systems can also help the physician’s office to verify insurance eligibility for patients. This process helps to streamline the entire billing workflow.

• Integration with Laboratory Software’s: The EMR system allows the administrative medical assistant to integrate the system with pathology, radiology and other laboratories so that they are able to order test results directly from the EMR. The electronic medical records system also allows the laboratory to send back the test results. Thus, the electronic medical records system allows an efficient process to order and obtain test results from a laboratory for a patient.

• An increment in patients’ involvement – The electronic medical records system does not only benefits the health care system but it also helps to increase the patients’ involvement in their health. Through electronic medical records, the patients can themselves set appointments. In cases of chronic conditions, EMR can also help patients to self-test and home-monitor their conditions. This can be achieved through an interactive education module of electronic medical records.

The integration and implementation of electronic medical records systems within the health care industry have not only streamlined the processes but it has also managed to consolidate the medical information of a patient in one digitized location. The above-mentioned benefits form only an inclusive list! These are some of the ways that describe EMR’s beneficiary roles within the health care system but as more and more physicians integrate electronic medical records into the systems, EMR will continue to evolve itself and revolutionize the health care industry further.

By: Anna williams Category: blog