Medical Transcription Outsourcing - Bridging The Gap To Meaningful Use

Medical transcription has been a part of the healthcare scenario providing invaluable services by helping document the patient encounter in a format that is accurate, timely and easily accessible. Patient medical records help doctors/support staff/clinics/hospitals in the process of providing quality healthcare and healthcare facilities in accelerating reimbursements and meeting statutory requirements. Moreover documenting the patient encounter is also an important part of risk management and preventive disease management.

With the introduction of the recent stimulus plan encouraging the adoption of nationwide electronic health records, the role of medical transcription has become unclear. But with more and more doctors/clinics/hospitals moving towards adoption of electronic health records, the role of these services in the process of adoption has emerged clearly.

What is the role of these services in the current scenario?
Medical transcription is a specialized skill requiring the right inputs to ensure quality documentation. Over the years outsourced transcription vendors have developed the right resources to enable services that meet all the parameters; quality, speed, and security. These resources namely, trained and skilled transcriptionists and the right processes and technology can play an invaluable in the process of transitioning to EMR/EHR systems.

There are many options available to healthcare professionals to enter information into electronic health records systems:

· Use of front-end speech recognition software: Experts are of the opinion that speech recognition software is here to stay and will play a major role in the healthcare documentation scenario. However this software has some inherent shortcomings. In spite of extensive training of the software, the accuracy of the transcripts produced by this software require extensive proofreading and editing to meet acceptable standards. Though using front end speech recognition software helps them document the patient encounter instantaneously, it hinders their productivity and the quality of the transcript

· Entry into the system by the healthcare professional using point and click templates at the point of care: Under this method the door/ nurse could document the encounter at the point of care using point and click templates with drop down menu options. However using this method has some shortcomings like:

1. Taking the focus away from the patient
2. Lack of narrative
3. Curbs the productivity doctor/nurse
4. Can lead to mistakes in documentation due to the pressure on the doctors to be limited to the options provided in the menu
5. Limits the diagnostic process

Given below are options for documenting the patient encounter that use the expert services of transcription vendors:

· Back end speech recognition software: This software works the same way as front end speech recognition software, except that the first draft of the transcript produced by this software is sent for expert editing and proofreading by skilled transcriptionists. This ensures that the productivity of the healthcare professional is not curbed and the quality standards are maintained.

· Dictation transcribed to patient medical records transmitted to EHR using HL7 interface: This method is probably the method most preferred by healthcare professionals. Under this method they can dictate notes of the patient encounter using his/ her preferred mode of dictation, the dictation is then transferred to the vendor for transcription by expert teams. The transcripts are made available to the healthcare professionals through their preferred delivery mode/s. Technologically savvy service providers enable transmission to the EMR/ EHR using HL7 interface.

It can be seen that medical transcription services act as a bridge to the process of achieving the meaningful use criteria by using the right team, the right processes and the right technology. Considering the rich source of knowledge, skills and understanding of the working of healthcare professionals and healthcare facilities accumulated by this industry it is important to include this sector in the transition to electronic health systems.