April 2, 2010

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 31, 2010

Medical Transcriptionist – Bridging Gap between Transcription, EMR and Speech Recognition Software to Create a Perfect Medical Documentation System.

The medical transcriptionist converts the voice file, which contains patient health information, into an electronic file. The file is encrypted as per HIPAA norms and sent back safely to the physician, who then decrypts it back to the original form. The stored information can be accessed, whenever needed during the course of treatment. Transcription process takes time and the turnaround time generally varies from 4 hours to 48 hours depending upon type of medical reports and service of transcription provider.

The emergence of new applications like speech recognition software and Electronic medical record (EMR) has increased the speed and ease with which the patient health data can be processed and stored in the computer.

Electronic Medical Record

In EMR, during the patient-doctor encounter, the clinical observations of the patient are fed into the computer by selecting the related terms from the pre-structured point-and-click template. The physician enters the appropriate clinical term from the available choices to make complete electronic record of the patient. This record can be accessed or updated by other physician during the course of treatment and thus provides great flexibility in treating the patient. EMR has inbuilt safety system, which provides medication warnings or drug allergy alerts.

One main loophole is that there is no crosschecking mechanism present in EMR, which ensures that no wrong information is entered and carried forward into treatment .This can seriously jeopardize the safety of the patient. Since the information is stored on basis of pre-structured template the output from the template is too canned and loses the individuality.

Speech Recognition Software

Speech recognition software is an excellent tool, which directly converts the spoken words into text on computer screen. Thus a physician can directly speak into the computer and see for him or herself the text on the screen. This saves times as the there is no need to send the file to the transcriptionist and this reduces the turnaround time considerably.

Shortcomings in Speech recognition Software

In spite of latest advancements is this field, the software is not completely accurate. There are errors in it and it requires human intervention to guarantee the accuracy of the final outcome. Further the software requires human training to condition it to the voice pattern and dictation style of the end user.

Medical Transcriptionist Bridging the Gap

The above shortcomings can be easily overcome by integrating the transcription process with EMR and speech recognition software. The medical transcriptionist can work in tandem with back-end speech recognition software to edit the errors in report transcribed by the software. The voice file is sent along with electronic file to transcriptionist, who then edits it.The transcribing speed increases considerably, without compromising the accuracy of the report.

The medical transcriptionist also overcomes the shortcomings of EMR. The presence of well trained transcriptionist and team of quality control department guarantees high degree of accuracy of the medical report.A pair of fresh and trained human eyes, ensure that no wrong information is fed in the electronic medical records of the patient. The transcription provides other advantage in form vivid and detailed description of the patient health which is missing in the EMR. This detailed account is necessary where the physician needs in depth knowledge about the past and present medical observations of the patient to arrive at conclusion, especially in critical and difficult cases.

Thus a medical transcriptionist plays a crucial role in integration of transcription process with EMR and speech recognition software to by overriding their shortcomings. It provides the human intelligence, vigilance and instinct to successfully integrate man, machine and software smoothly.

Transcription, EMR and voice recognition software can be integrated successfully.

Jason Gaya

Read more on, medical transcription at, www.mediscribes.com

Filed under: medical transcription — Tags: , , — admin @ 1:13 pm






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.