Medical transcription outsourcing: Creating valuable and relevant documentation

Healthcare is based on the premise of providing valuable services by drawing on quality inputs from various sources to meet the standards expected from it. To this end, every healthcare facility has to juggle various demands placed on it  - internally and externally. Some of the internal factors include the need to provide quality services, build up a good reputation, maximize profits and optimum utilization of resources available etc. External factors include fulfilling statutory and insurance requirements.

To this end, healthcare facilities have to concentrate on their core activity - that of providing quality care and outsource activities that are not part of the core business. Medical transcription – the process of creating legible, detailed and accurate patient medical records from the dictation of the healthcare professionals is one of them. Though there are numerous choices available to healthcare facilities and healthcare professionals to document the care process, outsourcing medical transcription to a professional medical transcription company has been found to be an option that helps create valuable and relevant documentation.

Outsourced medical transcription services help create valuable and relevant documentation that helps in all the aspects that the information from patient medical records is used for, like:

Providing care: One of the main objectives for creating detailed patient medical records is to help the care process. Outsourced medical transcription services help in this by ensuring that all the details of the patient encounter are captured completely. Using transcription services to create patient medical records also ensures that the narrative portion of the patient encounter is totally captured, which helps in the care process and certain aspects of risk management.

Automatic reminders and follow-up: The process of care could involve numerous visits or consultation with specialists etc. The detailed, accurate and timely records created by medical transcription service providers help in this aspect too.

Storage and retrieval: The records created by medical transcription companies are periodically archived and access to these archives is provided to healthcare facilities and healthcare professionals. This enables easy search and retrieval options of older records using various criteria.

Submission for reimbursement: Detailed patient medical records created by medical transcription services provide the basis for coding and reimbursements. The right documentation ensures that patient encounters are not under coded and ensures proper reimbursement

Billing: Medical transcription services ensure proper documentation and this ensures that patients are billed for amounts that are not collected from insurance companies

Apart from these valuable and relevant aspects, outsourcing medical transcription services provide advantages like:

Reducing costs: Outsourcing medical transcription also ensures that healthcare facilities and healthcare professionals save on both direct and indirect cost of transcription

Lowering workload: Outsourcing medical transcription also reduces the burden of the support staff at the healthcare facility by providing support in the form of the right team,the right technology and the right process for medical transcription. This ensures accurate, prompt, secure and cost effective creation of patient medical records

Aiding EMR adoption: Outsourced medical transcription service providers also help in the adoption of EMR/ EHR by using HL7 interface.

Medical transcription outsourcing: Providing an effective frame for healthcare information

The complex and complicated process of healthcare is based on the premise of certain quality inputs, one of them being information from patient medical records which not only provide valuable diagnostic inputs but also help in revenue cycle management. Medical transcription is the process of creating patient medical records from the dictation of the healthcare professional’s encounter with the patient.  Medical transcription is a specialized skill requiring the right combination of people, process and technology to meet the criteria of being accurate, timely, secure and cost effective. As the information from patient medical records is vital to the smooth running of healthcare facilities and medical transcription is the process of creating patient medical records, outsourcing medical transcription to a professional medical transcription service provider has been found to be an effective fix for all the diverse uses for patient medical records 

The origin of the information in patient medical records comes from the patient- healthcare professional encounter. Though the material or substance for the patient medical records is provided by the healthcare professionals, outsourced medical transcription services provide the right frame to make this information accessible and user friendly, basically they transform the form of the substance so that it meets the diagnostic, operational and commercial purposes.

How do outsourced medical transcription services provide the right frame for the information provided by healthcare professionals on the patient encounter?

Creating reports according to required formats/ templates: Once the healthcare professionals have dictated the details of the encounter with patient containing valuable details like demographics, symptoms, treatment provided, tests recommended etc, the process of medical transcription takes over. Medical transcription ensures that the records are created according the specifications that apply to the type of report and specialty. This ensures a legible and easy to understand transcript which meets all requirements

Maintaining quality standards: Outsourcing medical transcription ensures that patient records are created within the required quality parameters. This is done using the right process, the right team and the right technology. This would include:

1.                               Reducing errors: Due to the very nature of the healthcare profession, healthcare professionals could be starved for time and the audio provided by them could have inconsistencies leading to errors. The medical transcription process applies quality checks involving several levels to ensure that the patient medical records are as accurate as possible

2.                               Maintaining turnaround time: To serve diagnostic, operational and commercial purposes, patient medical records need to be created on a timely basis. Outsourced medical transcription service providers ensure that turnaround time commitments are met with using the right resources to ensure that turnaround time is met with, without compromising quality

Ensuring security during the process: Apart from being accurate and timely it is important for the patient information to be kept confidential. Outsourced medical transcription service providers ensure that HIPAA/ HITECH compliance is maintained throughout the medical transcription process

Making the process cost effective: Though medical transcription is vital to the smooth running of healthcare facilities, it is an expense, and outsourcing the medical transcription process ensures that this process is kept cost effective

Providing easy access to patient medical records: While ensuring that the form of the substance provided by the patient- healthcare professional encounter meets all quality standards, medical transcription service providers also ensure easy accessibility. Outsourced medical transcription service providers not only provide diverse modes of document delivery they also enable additional features like easy to access archives and HL7 interface for adoption of EMR.

Outsourcing Transcription: The Effective Solution

Outsourcing  transcription service that is performed offsite and can be performed by independent contractors or employees of facilities or medical transcription companies. This ability to have transcription performed outside of either a doctor's office or a hospital setting has become the "norm" due to the latest advances in technology.

Although some hospitals and other facilities prefer to have a transcriptionist physically located on the premises, outsourcing has truly become the most efficient way to handle budgetary concerns without compromising on the quality of work. Medical transcription companies that understand the transcription needs of hospitals and healthcare facilities also understand the importance of adhering to compliance.

A medical transcription company that commits to these values will enforce a business associate agreement with each facility before work can be performed. The business associate agreement protects healthcare facilities in regards to HIPAA (Health Insurance Portability and Accountability Act) regulations. Any healthcare facility that values their integrity as well as protecting their patient information should not have work performed without a business associate agreement in place. This compliance applies to several different components that bring value to transcription service from a Medical Transcription Company.

Some services include the use of a complete web-based system where users can review dictated material, edit transcribed documents, and route the information to other providers. In order to remain compliant with HIPAA in regards to sensitive patient information, these companies should have a secure, encrypted, website that is password protected. Additionally, these companies should have guidelines in place for their medical transcriptionists. It is understood on all levels, that patient information should not be distributed or discussed, due to the sensitive nature of this material.

Through secure and reliable service from reputable medical transcription companies, healthcare facilities can reap the benefits of a more cost effective solution to their documentation needs. Some of these companies are geographically located in different states, offering a buffer to turnaround time constraints. A hospital that is located in California and receiving service from a company in New Jersey can benefits from the 3 hour time difference for early dictation. With these advanced and secure solutions, hospitals and other facilities can focus on delivering the quality patient care that they intend to.

Medical transcription outsourcing: Working as a team with healthcare servicesMedical transcription outsourcing: Working as a team with healthcare services

Quality healthcare is the culmination of several factors, one of the main being the teamwork of healthcare professionals, support staff and other personnel. To be successful in terms of providing quality care and being profitable, healthcare services depend on proper documentation of the care process. Medical transcription is the process of creating patient medical records from the dictation of the patient- healthcare professional encounter. With a view to having an intense focus on their core business of providing healthcare and as a move to decreasing costs, outsourcing medical transcription to a professional medical transcription service provider has been found to be an effective solution for healthcare facilities and healthcare professionals.

Outsourcing medical transcription essentially provides healthcare professionals and healthcare facilities access to the vast resources of the medical transcription service provider with regard to expert medical transcriptionists, technology, best practices and other resources. In effect the personnel of the medical transcription service provider work as a team with the healthcare facility's team. In this instance the acronym of “TEAM – Together Everyone Achieves More” would be an appropriate description of the synergistic effect of healthcare services teaming up with medical transcription services.

Given below are a few instances where medical transcription services work together as a team with healthcare professionals and other staff at the healthcare facility to bring about better results:

Focus on patients: Teaming up with the right medical transcription service provider ensures that healthcare professionals can focus on the care process rather than the documentation process. Outsourced medical transcription service providers provide easy to use options for dictation and also provide editing & proofreading services for healthcare professionals using speech recognition software, leaving them free to focus on patients. Another vital outcome of outsourced medical transcription services is that of timely creation of patient medical records making it easy to be able to treat and track the progress of patients especially in case of long term care.

Freeing up time: The process of medical transcription not only ensures that the time of healthcare professionals is freed up it also ensures that the time of other staff at the healthcare facility is freed up by providing the right software and tools for medical transcription. This includes features like automatic upload of dictation, diverse document delivery modes, features to enable tracking of work-in-progress, archives for searching older transcripts etc.

Freeing up resources: Outsourcing medical transcription frees up the resources of the healthcare facility in terms of overheads like space allocation, utilities, equipment, management & administration personnel with regards to medical transcription.

Reducing expenses: One of the biggest advantages of outsourcing medical transcription is that of cost reduction. The cost per line of transcription would be reduced by as much as 40%. Moreover outsourcing medical transcription also provides the additional advantage of converting fixed cost of medical transcription to variable costs based on usage.

Consistent support:  Another major advantage of partnering with a professional medical transcription service provider is that of consistent support through the changing documentation scenario. Factors like adoption of EMR/ EHR are supported by outsourced medical transcription companies using HL7 interface

Teaming with the right medical transcription service provider can help healthcare facilities and healthcare professionals maximize efficiency, cash flow and increase profitability.

Medical transcription outsourcing: Playing an important role

Patient records are a vital element in the healthcare process. They are essential for not only patient care but play an important role in the commercial, statutory and medico legal aspects. Medical transcription is the process by which patient records are created. Medical transcriptionists are the scribes who faithfully transform the narration of the healthcare professionals into text format, making it available to healthcare professionals and other staff.

Outsourcing medical transcription has been found to be not only economical, but also efficient and effective in terms of accuracy, turnaround time, security and technology. In recent past there have been many arguments over the role of the medical transcriptionists/medical transcription service providers in the process of patient record creation. It is important to enumerate the reasons why medical transcription is so important to the healthcare process. Given below are the reasons that highlight the importance of the role played by medical transcription:

o                              Quantity: Outsourced medical transcription services are essential to the process of record creation because of the sheer volume of records to be created. The number of people seeking healthcare services has dramatically increased due to various reasons like the aging population, lifestyle changes, increased stress levels etc. It is impossible for healthcare professionals or support staff to cope with the huge volumes transcription requirements, while still continuing to provide quality care.

o                              Preference: Medical transcription has been proven to be the preference of healthcare professionals for creation of patient records. Healthcare professionals are starved for time and like the convenience of being able to dictate notes in the time available to them. Moreover outsourced medical transcription service providers offer the options to healthcare professionals to retain their familiar modes of dictation. Outsourced medical transcription also offers added benefits like different document delivery modes as per the preference of the healthcare professionals

o                              Detailed: Medical transcription allows the healthcare professionals to capture maximum information in a patient record. This comes in handy in many circumstances, by allowing the healthcare professional to ponder over the health conditions of the patient and arrive at the correct diagnosis, helps in continued care after a time lag and many other situations where maximum information can aid the treatment process.

o                              Increasing productivity: By outsourcing medical transcription the healthcare professionals are able to maximize their productive hours by concentrating on what they specialize in- providing quality healthcare

o                              Understanding the process: Medical transcription service providers understand the process of healthcare and can tailor their services to suit the needs of healthcare professionals. They are familiar with the requirements of each specialty and are can serve the needs of healthcare facilities and healthcare professionals in the best possible way

o                              Aids risk management: Detailed patient records play an important role in case of litigation.  These provide detailed evidence about the process and quality of care provided to the patient

o                              Applying context: Medical transcription service provider have teams of trained and experienced medical transcriptionists who can apply context to garbled/confusing audio to create accurate records

o                              Maintaining standards: Outsourcing medical transcription helps maintain the standards of patient records. Medical transcription service providers would not only aid in maintaining standards of accuracy, turnaround time and security, they would also ensure reports are created in the formats/ templates required

o                              Helping provide hands on care: Outsourced medical transcription services help the healthcare professionals make the most of their limited time resources and help them focus on what they do best – providing hands on quality healthcare to patients.

Apart from aiding healthcare facilities/healthcare professionals in the process of providing quality healthcare, medical transcription service providers also aid them in the commercial aspects in two ways:

o                              By reducing cost of transcription dramatically

o                              By quickening the receivables cycle

Considering the vital role played by medical transcription services, it is important to choose the right service provider.

Medical Transcription – A Process Of Converting Voice Records To Text Format

Healthcare industry is mainly related to hospitals, clinics and physician offices. With a highly competitive medical assistance industry and the need to see more patients in a timely manner, these healthcare professionals use to allocate the work of maintaining patient’s records and related documents to certain medical transcription professionals.

What is medical transcription?

Medical transcription is an associated healthcare profession, which is a process of converting pre-recorded voice files as dictated by healthcare professionals, into text format. In simple words, it is a methodical representation of language in written form. Persons who perform this process are identified as medical transcriptionists or medical transcription professionals.

Purpose of medical transcription

The sole purpose of medical transcription services is to provide a range of diagnostic, practical, therapeutic and straight patient care and support services. They are decisive to range of healthcare professionals and the patients they serve.

Complete process of medical transcription

It starts when a patient visits a doctor. Doctor sees the patient discussing his health problems, including past history and/or problems. He then executes a physical examination; will make a diagnosis. After that, the doctor decides the healing process for the patient with instructions provided.

When the patient leaves the clinic, the doctor uses a voice-recording device to record the information about the patient. DVR is also used to capture voice audio. He than contacts a medical transcription professional in order to convert pre-recorded voice files as dictated by him into text format. Medical transcription professionals or medical transcriptionists are allied healthcare professionals and have depth knowledge about each concept of transcription world.

They generally have many years of experience in the medical industry. They are well familiar with transcription codes and can offer extremely high quality as well as accuracy. They listen to the voice audio files sent by the doctors and prepare the associated text files with up to 99% quality accuracy. They make sure that prepared documents are HIPAA and DPA-compliant. Generally it is advisable to route your audio files to the same transcription teams so that they become familiar with your speech, style, and patterns for specific dictators.

Doctors can view or download completed documents online via medical transcription professional’s website. A copy of documents is also sent to concerned doctor by transcriptionists. Once downloaded, they can be used to send to other health care providers as well.

Medical transcription: Quality Guidelines to improve the quality of documentation

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 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.

Check: Providing guidelines for quality assessment

Quality Guidelines are an essential tool for assessment of quality in medical transcription. It is important for healthcare facilities to assess the quality policy of the medical transcription service providers by determining the method of quality assurance and Quality Guidelines.

The Quality Guidelines for medical transcription services have been categorized into two main categories:

Critical errors: Errors under this category have been a assigned a value of (-3)

The errors, which are considered critical errors, have been defined as those errors, which can have serious consequences due to their occurrence. These include: 

·                                 Terminology misuse: An incorrect word can lead to a potentially dangerous situation resulting in the wrong diagnosis, the wrong medical decision and wrong billing. Implication of this error can permeate several levels

·                                 Omission/ insertion: Omission of key words or insertion of the wrong word can adversely affect patient safety.

·                                 Incorrect patient demographics/ wrong author identification:This category could include the wrong identification of the patient, the wrong serial number, wrong medical record number, wrong date of encounter etc which could have long reaching implications

Non-critical errors: Errors under this category have been assigned a value of (-1)

Errors under this category have an overall impact on the accuracy and integrity of the document, but do not affect patient safety. These include: 

·                                 Misspelling: This means the wrong spelling of words that compromise the integrity of the document

·                                 Incorrect verbiage: This refers to errors caused by inappropriate or excessive editing which do not have significant impact on the meaning of the document

·                                 Failure to flag: This refers to the failure of the medical transcriptionist to flag reports that need clarification

·                                 Protocol failure: This refers to not following protocol like failing to mark courtesy copy etc.

·                                 Formatting / account specification: This refers to the failure of the medical transcriptionist to follow the formatting or account specification

There are other errors, which have been categorized as providing feedback or educational opportunities, these include: 

·                                 Grammar

·                                 Punctuation

·                                 Capitalization

·                                 Plurals

·                                 Run on/ fragmented sentences

·                                 Abbreviations

·                                 Slang & inflammatory remarks

·                                 Abbreviations

·                                 Inconsequential typos and omissions

·                                 Capitalization of drug names

·                                 Incorrect word forms

Medical transcription: Steps for easy transition to outsourced services

The role of medical transcription in both the operational and commercial aspects of healthcare is undeniable. Outsourcing medical transcription has been found to be an easy, economical, efficient and effective to the process of medical records creation. However the process of choosing the right medical transcription service provider needs a certain process so that it can result in a fruitful and long-term association.

The steps leading to successful outsourcing of medical transcription are:

Defining the purpose of outsourcing medical transcription: This part of the outsourcing process is very important and often overlooked. Overlooking this step in the process of outsourcing can result in:

1.                            Unrealistic expectations: Outsourcing medical transcription can help the healthcare facility in many aspects. But focusing only on factors like reduced cost and ignoring quality can result in outsourcing expectations not being met.

2.                            Inadequate customization: Healthcare professionals of different specialties may have specific requirements. These may not be included while customizing services if the purpose of outsourcing is not clearly defined

3.                            Loss of productivity: Not defining the purpose of outsourcing medical transcription can result in certain tasks being overlooked and resulting in loss of productivity

Consulting the people involved in or affected by outsourcing medical transcription: Outsourcing medical transcription affects personnel of several departments of the healthcare facility. It is important to involve all the people in the process of outsourcing to ensure success. It is important to not only consult the healthcare professionals and support staff, but is also vital to include the inputs of the Information technology, administrative, management and finance departments to gain maximum from outsourcing medical transcription

 Defining the desired outcome from outsourcing medical transcription:

1.                            Reducing cost of medical transcription

2.                            Accuracy levels

3.                            Desired turnaround time

4.                            Formals/templates/fonts

5.                            Document delivery modes

6.                            HIPAA/HITECH compliant transcription

7.                            Adoption of EMR/EHR

Designating key people for implementation: Transition for outsourced medical transcription services can require some adjustments. To ensure smooth transition it is important to designate key people who can coordinate with the medical transcription service provider staff to ensure seamless transition.

Starting the process of outsourcing: To actually start the process of outsourcing medical transcription it is important to undertake the following steps:

1.                             Technology adjustment

2.                            Familiarizing healthcare professionals and support staff with uploading dictation and downloading finished transcripts

3.                            Establishing open channels of communication with the medical transcription service provider.

Outsourcing medical transcription is an important decision and following the due process can result in satisfactory outcome for all the parties concerned.

Quality_Medical_Transcription

Healthcare services have become a part of the basic necessities of life. Though the demand for healthcare services have been on rise there has been increasing pressure on healthcare services to provide quality services at lower costs. Keeping this in mind healthcare facilities and healthcare professionals are looking for ways to maintain high levels of quality, increase productivity and curb expenses.  Outsourcing medical transcription can help in all these areas.

How do outsourced medical transcription services help maintain and improve quality of services?

Though the quality of healthcare services is the culmination of numerous factors including the education, qualification, experience and skill of healthcare professionals, quality of drugs, quality equipment and numerous other factors, the common thread that binds all these together is information in patient medical records. Outsourced medical transcription has a vital role to play in this regard by helping document the care process and ensuring creation of patient medical records that are: 

• Detailed
• Accurate
• Legible
• Timely
• Easily accessible
• Clear
• Consistent
• Complete

How do outsourced medical transcription services help increase the productivity of healthcare professionals and other staff?

Outsourcing medical transcription provides support to healthcare facilities and healthcare professionals in various aspects. Outsourced medical transcription service providers use technology that provides maximum benefits while still remaining easy to use. Some of the benefits of technology used by medical transcription service providers are: 

• Retaining dictation as an option for information collection
• Offering flexible modes of dictation
• Automatic upload of dictation at frequent intervals facilitating timely transcription
• Document delivery modes customized to the specific requirements of healthcare professionals
• Easy to access archives to retrieve older transcripts
• A system for keeping track of transcription status
• Editing and proof reading services for speech recognition software transcription
• HL7 interface for adoption of EMR/EHR
• Facility for electronic signature

How do outsourced medical transcription services help curb expenses?

Outsourcing medical transcription not only allows healthcare professionals and other support staff to focus their total attention on the care process, but also has the additional advantage of enabling the healthcare facility to save on costs. Outsourcing medical transcription helps cut costs by enabling the following: 

• Converting fixed cost of medical transcription to variable costs
• Reducing cost of transcription by more than 40%
• Saving on other expenses for medical transcription like overheads, cost of real estate, utilities etc
• By providing for weekend and holiday medical transcription needs, the service provider helps curb on costs like the cost of extra staff / extra shifts etc.
• Another indirect way that outsourced medical transcription services help in improving the cash flow is by accelerating the receivables cycle

Choosing the right medical transcription service provider can help healthcare facilities and healthcare professionals enhance the efficiency and productivity of the healthcare facility, resulting in increased profitability.