Medical Transcription: Understanding and Overcoming Transcription Errors
In medical transcription the dictation is converted into a voice file and sent to the medical transcriptionist through internet. The transcriptionist attentively listens to it and converts it into an electronic file. A poor recording, heavy accented voice, background disturbances, loss of concentration, improper knowledge of medical terminology and typing errors are some of the major reasons behind errors in transcribed reports.
Generally any transcribed report having accuracy of more than 98% is accepted as reliable medical document and is used by the physician to treat the patient. The errors are categorized as follows:
- Critical Errors – The mistakes in Patient ID, omission in dictation or a missing part and misuse of medical word so that it severely compromises the safety of the patient information. A transcription report, which has one or more, such type of errors, is rejected.
- Major errors- The errors like wrong verb usage, spelling mistakes, failure to raise flag for quality audit or misusing the flagging right. A transcribed report having three or more such types of errors is rejected.
- Minor errors- The grammar or format mistakes or any other errors, which have very less impact on the safety or the integrity of the medical report, fall under this category. A transcription report, which has nine or more such type of errors, is rejected.
A higher frequency of errors in the medical transcription report points towards poor quality standards of the transcription company and casts a bad impression about the professional competence of the service provider. The time, money and manpower spent towards correcting the errors increases the production cost and thus reduces productivity. The turnaround time also increases and prevents in timely delivery of treatment to the patient.
Overcoming Errors
To increase the productivity it necessary to attain high degree of accuracy. A detailed analysis of the transcription process will help to identify bottlenecks, which induce errors in the final outcome. Mentioned below are the some important quality enhancing steps, which increase the accuracy of the transcription report.
- Provide rigorous training to medical transcriptionists.
- Assign a small group of transcriptionists to a particular dictator so that voice pattern and dictation style can be familiarized.
- Synchronize use of Speech recognition software with transcriptionists. The software will speed up process, while the transcribers will edit errors in the report. This will reduce fatigue on medical trancriptionists and thus minimise errors .
- The MT should update their knowledge of medical terminology, regularly.
- The quality control department should work closely with transcribers and provide a complete feedback of the quality of transcribed reports. The audit department should help transcriptionist of identify their weakness and work with training department to iron them out. This will surely raise the quality standards of the final output.
- Sharpen listening skills of the transcribers and editing skills of proofreaders or editors through in house training to filter out the errors.
The accuracy of the transcribed is of paramount importance because the physician depends on it to deliver the treatment to the patients. Any error, carried forward can alter the outcome of the treatment and seriously undermine the health of the patient.
To eliminate the transcription error it is necessary to understand it’s source.
Jason Gaya
Read more on medical transcription at, www.mediscribes.com
March 30, 2010
Medical Transcription: Employing Six Sigma Principle to Reduce TAT and Improve Quality
The medical observations of patient are dictated into a voice recorder and transmitted to the transcription service provider. The transcribed report, an electronic file, is then sent back to the hospital records for digital signature. The total time taken is known as turn around time. The HIPAA compliant audit generally includes the following trail of activities to measure the turn around time.
• Recording time- time taken towards reading the report into the recording instrument
• Transcription time – time taken by transcriptionist to convert the dictation into the computer text file.
• Quality audit time- time taken towards removing errors in the transcribed report.
• Electronic signature- time taken towards verification by the concerned physician
• Distribution time- time taken towards initiation of the reports towards faxing, emailing, etc
Turn around time or TAT as it is known plays a decisive role in the success or the failure of the service provider to win the outsourcing contract from the hospital or the physician. Generally the turnaround time differs for different providers. A TAT of 48 hours is counted as high while a turn around time of 4 to 24 hours is preferred. The turn around time varies with type of medical reports transcribed. A short TAT is highly desirable by the hospitals as it enables them to provide faster treatment to the patients.
The voice quality of the file may not be proper and it requires the transcriptionist to spend more time to grasp it or there might be errors while converting the voice into electronic text. This reduces the overall efficiency of transcription process and can seriously affect the outcome of treatment due to errors in the transcribed report.
This is where the Six Sigma can play a pivotal role in by eliminating the recurrent errors, which inhibit the productivity of the process. It is basically a quality control program that consists of the management and technical strategies. The management aspect of the strategy sees to fact that all the set goals are realized successfully and that the success is sustained over a period of time. The technical part of the program ensures that process is analyzed sharply and all the bumps or shortcomings are effectively removed by adopting a strategy that measures, analyzes, improves and controls the quality of the medical transcription process.
Medical transcription involves daily conversion of data on a voluminous scale hence it very difficult to keep track on each and every mistake committed in spite of well trained transcriptionists and a quality control department. Looking minutely into each and every mistake is not possible as it slows down the whole process and hinders the timely dispatch of the transcribed reports back to the physician.
The Six Sigma provides solution to this problem by creating an inbuilt safety mechanism in the transcription process, which automatically filters out errors like poor voice quality and data capture, spelling and grammar mistakes, wrong terminology, etc. Thus Six Sigma irons outs all the shortcomings from the transcription process so that the final output is free of errors and is available to the end user in a shorter turnaround time.
Six Sigma governs the productivity and quality of transcription process.
Jason Gaya
Read more on medical transcription at, www.mediscribes.com
March 26, 2010
Medical Transcription – Achieving Super TAT
The medical transcription industry is facing lot of competition from other medical documentation systems like EMR and speech recognition software. These new applications make the entry or access of patient health information quite easy, for physicians, specialists and other medical personnel. EMR saves time and space and thus reduces the overheads. This increases the overall productivity of the facility.
Medical transcription is made of series of process which involve dictation, which is recorded and sent to the transcriptionist for conversion in to an electronic file.This file is sent back the dictator, who stores it in the computer. As more number of people are involved in medical transcription and because of series of different processes, the turnaround time increases. In EMR the point-and-click mechanism helps for easy input of patient information into the computer while speech recognition software directly prints the spoken words into text on computer screen.
Hence it is necessary to shorten the turnaround time of the transcribed report so that it can be integrated easily with latest technology easily. To achieve super turn around time some steps need to be taken, which are presented below:
- Provide Rigorous training to MT.
- Create small groups of medical transcriptionists. Every group should be assigned to a specific dictator. This will allow transcriptionists to develop a good rapport with their dictation providers by understanding their voice pattern and dictation style.This will drastically reduce the transcribed errors and thus improve the accuracy of the report.
- Offer incentives to transcriptionists for reducing TAT.
- Provide toll free number to dictators because they provide you business.
- Synchronize transcriptionists with speech recognition software to reduce TAT. Software will speed up transcription process while a trained transcriptionist will edit the errors made by software. This will increase productivity and eliminate reworking on files due to overlooked errors.
- Line-up the best medical transcriptionists with your biggest business provider.
- Know very well the desired TAT for your individual customers. Identify which data needs to be transcribed and sent to customer, first. In short prioritize the transcription process.
- Ensure maximum availability of transcribing staff during peak loads and streamline the file allocation process. Associate clearly, individual file allocator with a group of transcriptionist.
- Plan the transcription process, keeping in mind the arrival time of maximum data. The shifts should be scheduled accordingly so that the highly trained transcribers are available in maximum strength to efficiently tackle the peak workload.
- Ensure maximum feedback to transcribers.The Quality control and audit department should work in tandem with transcriptionists and train them how to improve the quality standards of their output.
- Create smooth link between dictators, file allocators and transcribers so that series of commands and instructions are smoothly executed and there is no communication gap, which hinders the timely execution and delivery of transcribed reports to the health service provider.
The main focus is to reduce the turnaround time so that the physicians can receive the patient health reports in time and thus enhance the quality of patient care.
A streamlined medical transcription process shortens TAT.
Jason Gaya
Read more on medical transcription on, www.mediscribes.com
Medical Transcription – Reducing TAT for Better Integration With EMR
The turn around time or TAT, as it popularly known is the total time taken towards dictation of medical records of patient into the voice recorder, it’s conversion into electronic file and dispatch back the physician. There is no prevalent standard, which clearly defines the ideal turnaround time for the health providers and their business associates.The turn around time varies from one transcription service provider to the other.
The latest developments in the EMR and speech recognition software technology have increased the speed and ease, with which the patient health information can converted into electronic format. Medical transcription consists of series of different processes,which increase the time taken to document the information. In EMR, during patient-doctor encounter, the point-and-click template method converts health information of the patient directly into electronic format. This is a quick and easy way to store huge amount of data in a cost effective way as it saves the organization money, which would have been spent towards creating and managing the records storage area.
The development of front end speech recognition software has made it easier for the physicians to directly speak into the computer and convert the voice into electronic text. The text is then edited by the doctor himself and there is no need of an editor or transcriptionist. The software is not completely accurate and there and are errors in the transcribed report.This drawback is overcome in the back-end speech recognition software because the voice file is sent along with draft to transcriptionist, who then edits it and sends back to the physician.
The emergence and acceptance of EMR has made it necessary for the transcription service providers needs to reduce the turnaround time so that the physicians can easily avail the patient information at a short notice because time is of an essence in treatment. Thus electronic medical record and speech recognition software offer better medical documentation options compared to a slow transcribed report.
This drawback in medical transcription can be overcome by reducing turn around time so that transcription can be smoothly integrated with electronic medical record. At same time the expertise of the transcriptionist will ensure that high level of accuracy is maintained, which is missing from speech recognition software.
A short TAT helps to integrate EMR with medical transcription.
Jason Gay
Read more on medical transcription at, www.mediscribes.com
March 20, 2010
Medical Transcriptionist – Creating a Streamlined and Secure Medical Documentation System
The Physician or health specialist after diagnosing a patient dictates all the noted clinical observations into a recording device. The recorded report is transmitted over the internet, as a voice file to the medical transcription service provider. The transcriptionist attentively listens to the recorded voice and types the information into the computer, to create an electronic file. This file after stringent quality control checks is sent back to the physician, who stores it in computer for future reference. During the transcription process, following equipments are used:
• A computer connected to internet.
• A head set to listen to voice file.
• A foot pedal to pause the recording whenever necessary.
The medical transcriptionist transcribes variety of health reports and these include:
• Patient Discharge reports.
• Medical history of patient
• Physical examination reports.
• Operative reports.
• Consultation reports.
• Autopsy reports.
• Diagnostic-imaging reports like radiology, MRI and ultrasound.
• Post operative progress reports.
• Referral letters.
It is important that transcriptionist must be trained in medical terminology and should have good knowledge of:
• Human anatomy and physiology.
• Medical diagnostic procedures.
• Pharmacology.
• Treatment assessments.
• Medical jargon and translate them into expanded form.
• Standard reference handbook both in, electronic and printed version.
The medical transcriptionist should be skilled enough to spot mistakes or inconsistencies in the medical report. This saves the patient from receiving wrong treatment as a result of errors in the transcribed reports. Besides accuracy, the transcriptionist should to also have good speed to deliver back the transcribed report in a very short turnaround time. This helps concerned physician to deliver the requisite treatment to the patient in minimal time, thereby increasing the patient care. Finally the HIPAA compliance norms make it mandatory for the covered entities like the hospitals, clinics and doctors to protect the privacy of patient health information. Hence it is moral duty of the transcriptionist to maintain the secrecy of the patient information as per HIPAA norms.
Medical transcriptionist play an important role in increasing patient care through better documentation of health information.
Jason Gaya
Read more on medical transcription at, www.mediscribes.com
February 13, 2010
Introducing Cardioscribes
Before I start sharing my posts on the blog, I wish to give you a brief idea about what this blog is all about. All your thoughts, suggestions, questions and inquires are welcomed over here. I would try my best to inform you as much as possible about cardiology and the role of cardioscribes in this medical vertical. Hope you would find it interesting!
Let’s start with knowing more about what is Cardiology!
Cardiology is the study of cardiovascular illness, basically the diagnosis and management of diseases which affect the heart and circulatory system. It is a specialized field among physicians, wherein cardiologists perform tests and procedures like angioplasty.
Through conducting investigations a Cardiologist studies your current stipulations like blood pressure, obesity, diabetes, hypertension, cholesterol and other diseases that endanger damaging the heart. He helps patients to manage a variety of heart disorders including arterial blockages, angina, heart attacks, aortic dissection, rhythm disturbances, heart failure, and congenital heart diseases.
Because of the specific nature of Cardiology, the treatment is suppose to be taken from a cardiology specialist rather than going to a normal healthcare provider.
Hope this gives you some what idea about Cardiology, if you are a physician or a cardiologist, it would be great if you can add up your comprehensions to it, which would be more helpful to our readers.
What is Cardioscribes?
Cardioscribes is a very significant part of Mediscribes, Inc. specializing in medical transcription for the vertical of cardiology! Cardioscribes has been set up to specifically focus on transcription activities pertaining to cardiology. The transcriptionists at Cardioscribes have received focused training in cardiology related subjects, to offer you a high quality & accurate cardio-transcriptions.
You’ll be able to find out more details about cardioscribes on www.cardioscribes.com
We’ll discuss more about Cardiology and some new updates about the healthcare industry in the coming post…So stay connected.
Jason Gaya
February 2, 2010
Medical Transcription- Synchronizing with EMR to create a Better Medical Documentation system.
Medical transcription is a process in which the health information of the patient is dictated, stored and transmitted to a transcriptionist as voice file. This is converted into an electronic format like a computer text file and sent back to the physician, who stores it in his or her computer, for later use.
The EMR or Electronic medical record is medical documentation system in which the information of the patient is directly fed into the computer by selecting related terms from pre-structured point-and-click templates. The doctor simply points and clicks on the appropriate clinical terms from the available choices to enter medical observations of the patient.
Electronic medical record or electronic health record is gaining in importance as it allows the doctors to store and manage efficiently voluminous protected health information in safely. The information can be retrieved easily whenever needed. The medical information of a particular patient stored by one doctor can be easily used or updated by another doctor during the course of treatment. This provides a greater flexibility to the treatment process. As this form of documentation process has lesser human interference it is prefered by tech savvy doctors over medical transcription.
But medical transcriptionists can bridge this gap between these two forms of medical documentation systems to create more efficient system where both of them complement each other. The transcriptionists provide the trained eyes and are better trained to process the information without errors. Also extra safe guards like, quality control audits ensure high accuracy rates in the medical transcription. This feature is missing in the EMR as everything depends on what the doctor enters into the template with no crosschecks in place. Wrong information entered can be carried forward or used by other doctors.
Further the output from templates is too canned and identical in EMR. It loses individuality for each patient and this shortcoming can be well addressed in the transcription process where the description of the patient is vividly converted into a detailed electronic record that is customized to address medical requirement of the patient. Some doctors prefer EMR while other prefer medical transcription due to their own advantages and disadvantage that these two form of documentation offer.
But transcriptionists can play a pivotal role by helping the medical fraternity to harmonize EMR with medical transcription by providing the much needed reliability in form of trained eyes and human instinct. By synchronizing both these documentation systems it is possible create a better and larger medical documentation system, which efficiently manages the protected health information of the masses in accost effective manner and at same time adhere to HIPPA norms.
Medical Transcriptionist can bridge the gap between medical transcription and EMR to create a better documentation process.
Jason Gaya.
Read more at, www.mediscribes.com
Medical Transcription Outsourcing- Boon to Hospitals
The health care industry is growing at a rapid pace. As a result the hospitals and health centers need better infrastructure and more trained staff to efficiently manage patient health records. The documentation process should be such that all the medical records are created and stored in safe and secure manner, and retrieved conveniently whenever the need arises.
To do this efficiently, the hospitals should to have in-house transcription house that has state-of-art computer systems, transcribing machines and highly skilled transcriptionists. This additional setup is quite expensive and reduces overall efficiency and productivity of the health facility. The medical transcription outsourcing provides the right solutions by offering many benefits to the heath care facilities and they are:
- The transcription service providers take care of all the transcription needs of the hospitals. This means that the hospitals do not have to spend money on costly transcription infrastructure.
- The Human resources department of the health facility does not have to allocate time, effort and resources on the transcriptionists. This reduces the manpower overheads.
- The transcription service providers are generally HIPAA compliant and it becomes easy for the health organization to outsource the medical transcription to them at a cheaper price, without compromising the quality standards of the transcribed reports.
- The transcribed reports remain available on the providers’ server for two years. Any old medical record can be easily retrieved and sent to multiple destinations through internet. This all is done is highly secure manner through a system of encrypted files and passwords.
- The transcribed reports are available to users in rapid turn around time. The full fledged infrastructure and skilled manpower make it possible to cut drastically the process time and at same time maintain high accuracy by adopting quality audits on a regular basis.
- The transcription service provider takes care of documentation process through an in built communication system with the client through fax, emails, tracking reports, quality control feedback and billing to maintain a seamless connectivity and ensure that there is no communication gap, which slows down the whole process.
- The electronic exchange and storage of the patient health information is kept highly confidential by adhering to HIPAA norms. The transcription service has in built safety mechanisms, which ensure that all the health data processed is safe and secure, and in no way creates liabilities for the hospitals in form of lawsuits or fines for non-compliance of HIPAA norms.
Thus, medical transcription outsourcing eliminates the burden of medical documentation on hospitals and allows them to allocate their precious time and resource to other critical areas. This helps them to achieve the desired levels of excellence in providing the patient care.
Medical transcription improves the quality of patient care through better documentation of patient health information.
Jason Gaya,
Read more at, www.mediscribes.com
December 19, 2009
Understanding Medical Transcription
Medical transcription has come a long way from the manual typewriter to modern day computer. The transcription process is about converting a dictation into a text format that can be stored and retrieved as per convenience. It requires a skilled person who is known as a transcriptionist to accurately convert the recorded medical dictation into an electronic text, which can be saved as a file in the computer.
When ever a patient visits the doctor for a health check up, the concerned doctor after medical examination records the all the observations, which are later dictated into a hand held cassette player or a telephone that is connected to the central server of the hospital. From here the recorded voice is sent to the transcription services provider, where a transcriptionist attentively listens to the recorded voice and starts to convert into written text.
It is important that the medical transcription is highly accurate because it involves the safety of the patient. Any error in dictation or transcription can pose a serious risk to life of the patient. Hence a doctor speaks slowly and clearly in the recording instrument and on the other hand the transcriptionist carefully converts the recorded voice into an error free text. To do this, he or she needs to have some special qualities like:
- Sharp listening ability and memory
- Good grammar and typing skills
- Understand foreign accent easily
- Well versed in medical terminology and is able to update the knowledge regularly
- Ability to sort, check and verify data accurately.
The medical transcription is boon to patients and doctors. There are many benefits that are associated with it and are mentioned below:
- It considerably reduces the retrieval time for patient health data
- The medical facility is able to reduce infrastructure cost by outsourcing the work to qualified transcription services provider at a cheaper price.
- The inclusion of HIPAA norms in medical transcription process has made it very safe and secure to transfer and store confidential patient health data.
- The HIPAA regulations and high quality transcription procedures adopted ensure high accuracy of stored health data of patient that can be easily relied on by the doctors, for later use.
In the end medical transcription is at highly skilled process that ensures that health records of all the patients are securely stored in an electronic form, which can be later retrieved by the doctor to treat the patient.