The Medical Transcription industry, recently rechristened as the Clinical Documentation industry, is gearing up to counter the challenges posed by technology and outsourcing. In order to reinvent itself, the industry has resolved to move beyond conventional medical transcription services to encompass every touch point in the clinical documentation continuum, according to the newly-formed Clinical Documentation [...]
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admin on August 9th, 2010
The Medical Transcription industry has been evolving for years and is today a respectable profession that pays well and professional medical transcriptionists (MT) get all the required support from various medical transcription industry organizations. With the rapid growth expected for the entire health care sector there has been a spurt in the growth of transcription companies at all levels world wide. In the US on March 7, 2006, the Medical transcription occupation became eligible for the U.S. Department of Labor Apprenticeship.
The Association for Healthcare Documentation Integrity (AHDI) was formerly known by the name of the American Association for Medical Transcription (AAMT) and was established in the year 1978. It was formed to obtain recognition and contribute towards patient safety and more accurate medical records. The AHDI is an organization that the MTs join for validation and protection. The association also offers many resources that are of use to those in the MT industry and it takes pride in following the latest and modern trends. What are the types of services offered by AHDI? Well the primary services are concerned with,
Giving of advice
Networking
Job opportunities
Today, advances in digital technology has made it possible for many medical transcriptionists to work more efficiently and comfortably even from the privacy of their homes.
One other organization that promotes the MT industry is the Medical Transcription Industry Association (MTIA). MTIA is a non-profit trade association that represents the companies, vendors, and health professionals. Working alongside AHDI, the association has greatly helped to improve the medical transcription industry and maintain health records world wide. MTIA services include,
Access to thousands of vendor suppliers through a transcription service finder
Sponsors events and conferences annually
Networking through its website.
Provides cutting edge technology know-how to MTs .
Source : http://maryanngarth.easyworldwidemall.com/2010/05/29/the-medical-transcription-industry-organizations/
admin on July 23rd, 2010
Medicines and drugs are an integral part of mainstream western allopathic medicines that are consumed around the world. A medical transcription professional who daily transcribes the dictations by the physicians or any specialist doctors will often come across prescription of drugs both old and new. A medical transcriptionist has to be aware of the latest drugs introduced in the concerned market and this can be done with the following pharmacology (drug) reference books which should always be a part of his library.
Physician’s Desk Reference (PDR)
American Drug Index (ADI)
Saunders Pharmaceutical Word Book
Understanding Pharmacology
Whenever a transcriptionist comes across a new drug name he must know how to search for it and become familiar with the drugs, their indications and dosages. Being up to date can save a lot of search time. Remember, good productivity in transcription is a critical factor as payment is usually made on a per line basis.
While a drug’s trade name or brand name is selected for its appeal to prescribing physicians, the generic drug can have several trade names, each copyrighted by different manufacturers. While transcribing drug names these are some of the main factors that should be kept in mind by the transcriptionist.
Generic names are in lower case
Trade names start in capitals and can have internal caps as well
PDR (Physicians’ Desk Reference) is for prescribed drugs
Separate publication for non prescribed drugs
Drugs can sound similar but be totally different in spelling and usage
Do not capitalize words like tablet / capsule / solution / cream etc
One of the biggest challenges medical transcriptionists often come across is when listening to tapes that may not be very clear in the dictation. It can be confusing when there are two drugs that are spelled differently but sound very much alike. These two drugs could be for completely different uses and the transcription professional has to be very alert to all such names.
Source : http://maryanngarth.easyworldwidemall.com/2010/05/22/medical-transcription-and-drug-reference/
admin on July 14th, 2010
Medical transcription technology has been fast evolving according to the needs of the times. The US healthcare system demands that all medical transactions be on record. Thus today we have medical transcription dictations that are even given over the telephone. To make the whole process easier physicians and doctors can now just dial in using a telephone and a PIN number anytime of the day or night and dictate for a transcript.
Most of the renowned transcription service providers usually have work units both domestically within the US and also in Asian locations like India or the Philippines. Thus they are able to be very flexible with regards to the turnaround time, pricing etc. Transcripts can be got even within a few hours if required. As all data sent over the Internet is always encrypted (using 256-bit encryption) there is total security and safety for all client files / information.
There are a few challenges in Medical dictation transcription and certain rules that all physicians have to follow if they are to get transcripts with over 99% accuracy. These are some of the points.
- Be aware of the background sounds/ noise
- Mention title of the document at the outset itself
- Do not forget to dictate basic demographic information
- Difficult medical terms should be pronounced well
- Avoid summarizing in long sentences
- Please expand uncommon abbreviations
- Avoid eating/ drinking/ coughing near microphone/ while dictating
Besides dictation on the phone there is a wide range other dictation equipment available that include desk top stations and various hand held digital dictation units. Thus recordings can be also transferred to the computer and transmitted as audio files for transcription. Dictation equipment accessories include devices like microphones and hands free kits.
Source:http://maryanngarth.easyworldwidemall.com/2010/04/10/medical-dictation-transcription/
admin on July 8th, 2010
A key factor that persuades developed economies such as the US to outsource their medical transcription jobs to developing countries such as India and the Philippines is the availability of cheap and qualified labor in these countries
Medical transcription is one of the most widely outsourced jobs in the healthcare industry and is adopted as a part of easing the tedious process of medical records documentation. Processing of medical transcription jobs in-house means medical care providers have to invest a lot in terms of time and money for selecting and training the right manpower, apart from installing and maintaining costly infrastructure such as dictation equipments and computers. To keep operating costs low, outsourcing of medical transcription is the preferred choice for most healthcare firms operating in the US and UK.
A key factor that persuades developed economies such as the US to outsource their medical transcription jobs to developing countries such as India and the Philippines is the availability of cheap and qualified labor in these countries. The medical transcription firms in these countries have better infrastructures with backups for labor and internet and are thus capable of providing round-the-clock uninterrupted transcription services. The skills of medical transcriptionists in these countries include a better understanding of the spoken English language. The majority of these professionals have excellent academic qualifications and in-depth awareness of the subject.
Another major benefit of outsourcing these medical transcription jobs is that backup copies of patient records are always available at the servers of these outsourcing companies and hence it is easier to search and access patient records which are years old. Moreover, these documents can be sent across multiple destinations through the internet so that doctors, regardless of their location can keep in touch with their patients and their medical treatments.
Source: http://www.globalservicesmedia.com/BPO/Industry-specific-Processes/Medical-Transcription-Outsourcing-Benefits/23/29/0/GS100615518457
admin on July 2nd, 2010
In today’s business world, the demands for medical transcription services are increasing at a rapid rate. It is basically the process of transcribing the dictated medical recording made by physicians and other healthcare professionals into soft copy format. Today there are a wide range of medical transcription services that encompass almost most of the different specialties in medicine.
As the health care industry grows, one finds that the number of companies that are specializing in providing MT services is growing by the day as these services are provided to a wide range of practices and organizations that can include healthcare facilities, hospitals, laboratories, clinics, individual doctors and physicians’ groups. Because of the development of ITES (Information Technology Enabled Services), many of the medical transcription companies are outsourcing their jobs to offshore centers located in India and the Philippines.
In order to provide reliable and error free documents to the clients, the companies have to appoint technically trained medical language specialists who have an in-depth knowledge of all the medical terminologies. How else will someone understand the technical dictations of the physician, surgeon or an anesthesiologist? Specialized professional medical transcriptionists help in transcribing patients’ physical reports, clinical notes, operative reports, consultation notes, autopsy reports, psychiatric evaluations, laboratory reports, X-ray reports, referral letters, and discharge summaries.
Medical transcription outsourcing units provide specialty services such as:
- Cardiology Transcription
- Emergency Room Transcription
- Radiology Transcription
- Gastroenterology Transcription
- Surgery Transcription
- Chiropractic Transcription
- Internal Medicine Transcription
- Physical Medicine Transcription
- Maxillofacial Surgery Transcription
- Plastic Surgery Transcription
- General Surgery Transcription
For detailing, the MT companies support toll free numbers, digital recorders, and computer dictation systems and almost all the other necessary medical transcription devices. Depending on the client’s needs and document management systems, the medical reports are delivered in the appropriate data/ file format. Medical transcription services can consistently give you the combined unique experience of 99% accuracy, data security, and absolute privacy for your records and documents. Medical transcription industry strives to support all professionals and also ensure that all services are HIPAA compliant besides secured with 256 bit AES encryption.
Source:http://maryanngarth.easyworldwidemall.com/2010/05/30/medical-transcription-services/
admin on June 21st, 2010
The Association for Healthcare Documentation Integrity (AHDI) and The Medical Transcription Industry Association (MTIA) have combined to create the Manual of Ethical Best Practices for the Healthcare Documentation Sector.
The manual will help health care documentation and medical transcription businesses and professionals to adopt policies and procedures for complying with HIPAA privacy and security laws and operating in a manner consistent with best ethical practices related to transcription billing, compensation, and outsourcing. The manual is part of the associations’ ongoing commitment to safeguarding protected health information and upholding the integrity of the profession and industry.
“With the emerging demand from healthcare delivery for increased standardization and greater specificity around exchange of health information, the time is ripe for the healthcare documentation sector to look closely at its compliance practices to ensure that the sector is best positioned to respond to the future needs of health care,” stated AHDI/MTIA CEO Peter Preziosi, PhD, CAE. “We want to be a resource for business owners and healthcare documentation professionals in developing policies, procedures, and contracts that reflect high-integrity business practices and promote transparency around key issues that reflect well on the industry as a whole.”
The associations convened an advisory council composed of industry content and practice experts including transcription professionals, managers, quality assurance coordinators, educators, and medical transcription service owners and executives to provide input regarding areas that could benefit from the creation of ethical best practices and to assist in content development for the manual. Council participants recognize that a set of ethical best practices is a necessity at this time of greater regulation, scrutiny, and enforcement by the federal government.
“The medical transcription/healthcare documentation industry is entering a new age of regulation with the increased emphasis on data privacy and security by consumers, the healthcare industry and the government combined with the trend towards increased governmental scrutiny of healthcare vendors,” added Scott Edelstein, Esq., a partner in the health law practice of Squire, Sanders & Dempsey LLP.
Source: http://health-information.advanceweb.com/News/Industry-Buzz/AHDI-MTIA-Combine-to-Create-Compliance-and-Transparency-Manual.aspx
admin on June 15th, 2010
MTIA (Medical Transcription Industry Association) along with AHIMA (American Health Information Management Association) recommends a standard unit of measure for medical transcription of patient medical records. It recommends the visible black character (VBC) measurement standard to be the best document counting method. What was the purpose of having such a standard?
The final goal was to implement a standard for content measurement that the health information management (HIM) practitioners can use to evaluate in-house transcription staff and external transcription service suppliers. The earlier 65-character line standard (also called as the AAMT line) had previously been a standard industry wide unit of measure for content measurement that includes space bar, shift key, bold, underscore, and other keystrokes. With this system the cost for the line/character goes beyond just labor as the cost of the technology is bundled along with domain knowledge and human resources. Thus it became mandatory to develop/choose the best possible Industry standard. The benefits of having such a standard include ease in maintaining service level agreements, better business relationships and having a better tool for evaluation.
According to The MTIA /AHIMA task force among all the different counting methods like ASCII line, the 65-character line, gross line, gross page, per minute pricing, and visible black character (VBC) measurement standards, VBC is the only counting method that can be easily understood, verified, and replicated by all parties in the medical transcription business processes.
Whenever a transcription document is reviewed for quality what are the principles that establish the quality of the documents?
The transcribed report should be reviewed against the actual dictation. Reading the report without listening to the dictation does not provide an accurate comparison of the transcription to the dictation.
The review should apply industry-specific standards as provided by current resources and references. When evaluating style, punctuation, or grammar, The AAMT Book of Style is the industry standard.
The review should encompass attention to risk management issues and the documentation standards of accreditation and healthcare compliance agencies.
Accuracy scores (ratings) should be quantified with the use of a numeric calculation that weights varying degrees of error against the length of the report. AAMT recommends the following quality goals: 100% accuracy with respect to critical errors; 98% accuracy with respect to major errors; and 98% accuracy with respect to all errors in the report, including minor errors (see below for definitions of “critical,” “major,” and “minor” errors).
The reviewer (or the review process) should provide timely and consistent feedback to the medical transcriptionist in order to eliminate repetition of errors.
All measurements, standards, and benchmarks should be disclosed to the medical transcriptionist and should be set forth in written guidelines by the healthcare provider or transcription service.
Source:http://maryanngarth.easyworldwidemall.com/2010/06/02/medical-transcription-standard/
admin on June 8th, 2010
The medical transcription industry has been evolving for years and is today a respectable profession that pays well and professional medical transcriptionists (MT) get all the required support from various medical transcription industry organizations. With the rapid growth expected for the entire health care sector there has been a spurt in the growth of transcription companies at all levels world wide. In the US on March 7, 2006, the Medical transcription occupation became eligible for the U.S. Department of Labor Apprenticeship.
The Association for Healthcare Documentation Integrity (AHDI) was formerly known by the name of the American Association for Medical Transcription (AAMT) and was established in the year 1978. It was formed to obtain recognition and contribute towards patient safety and more accurate medical records. The AHDI is an organization that the MTs join for validation and protection. The association also offers many resources that are of use to those in the MT industry and it takes pride in following the latest and modern trends. What are the types of services offered by AHDI? Well the primary services are concerned with,
Giving of advice
Networking
Job opportunities
Today, advances in digital technology has made it possible for many medical transcriptionists to work more efficiently and comfortably even from the privacy of their homes.
One other organization that promotes the MT industry is the Medical Transcription Industry Association (MTIA). MTIA is a non-profit trade association that represents the companies, vendors, and health professionals. Working alongside AHDI, the association has greatly helped to improve the medical transcription industry and maintain health records world wide. MTIA services include,
Access to thousands of vendor suppliers through a transcription service finder
Sponsors events and conferences annually
Networking through its website.
Provides cutting edge technology know-how to MTs
Source: http://maryanngarth.easyworldwidemall.com/2010/05/29/the-medical-transcription-industry-organizations/
admin on June 1st, 2010
By, Lea M. Sims
With our nation engaged in dialogue around health care reform, and health care delivery engaged in discussions around what “meaningful use” of EHRs will look like, there has never been a more important time for the health care documentation sector to stand up and demonstrate its contributory value to these critical issues. This means aligning our key messages with health care’s goals and demonstrating why we matter to the health data capture process, both now and in the evolving EHR.
What is health care delivery telling us?
More than anything, health care needs cost-effective, technology-centric solutions that ensure quality of care, eliminate redundancy and inefficiency, and improve the quality and accessibility of patient information within and between health care enterprises. When it comes to our sector, the health care system is looking for the right solutions to securely and accurately capture, consume and repurpose health information. It needs partners and advocates who will advance its EHR adoption goals, facilitate reliable data exchange, and deliver robust health encounter information that allows providers to make real-time clinical decisions. And out of the evolving debate around “meaningful use,” a new concern is also emerging-How much of the EHR documentation burden should be shouldered by the physician?
How can our sector respond to those challenges?
The Association for Healthcare Documentation Integrity (AHDI) and the Medical Transcription Industry Association have been delivering a core message to legislators, policymakers and health care stakeholders around the ability of the health care documentation sector to meet these evolving needs for managing health information. Our key messages around EHR adoption have focused on the following points:
1. Preservation of narrative capture is critical to meaningful use of EHRs because:
- More than 1.2 billion clinical records are produced in the U.S. every year.
- 60 percent of all clinical records are documented via traditional dictation/transcription.
- No documentation method captures complex patient stories better than narrative dictation.
- Dictation/transcription is still the preferred method among U.S. physicians for documenting patient encounters.
- Point-and-click templates cannot adequately capture a comprehensive, complete patient story.
- Physician-driven data entry is costing health care time and money; physicians are better deployed in frontline care than burdened with clerical capture.
2. Health care documentation specialists are critical to effective capture of health information because we:
- Understand the diagnostic process and the complex story-telling of patient care.
- Provide risk management support and oversight to ensure health encounters are captured accurately.
- Are able to indentify error/inconsistency in the record as well as support pay-for-performance goals through documentation improvement measures.
- Know how to apply data capture standards that ensure health information is available at point of care for clinical decision-making.
- Integrate seamlessly with data capture technologies, such as EHRs and speech recognition technology (SRT) solutions.
- Partner with physicians to document care encounters in a way that frees up providers for hands-on patient care.
How can you promote this campaign in 2010?
Be an advocate. First and foremost, our sector needs you to promote the concepts above to your providers, clients, health care facilities and legislators. Be proactive in advocating for your current and future value in advancing health care’s goals for EHR adoption. Download the MT Week flyer/poster-Capturing America’s Healthcare Story: Why We Matter to Health Care-at www.ahdionline.org and share it with your professional contacts.
Be ready to deliver. The value proposition we’re making to health care is predicated on the assumption that our workforce can facilitate EHR adoption by being an extra set of eyes on the health record, well-oriented to the diagnostic process, and capable of recognizing error and inconsistency in health information. This will require MTs to embrace professional development, continuing education and credentialing. Position yourself well for evolving and future roles by seeking additional training in new roles/technologies (receive $100 off the cost of our SRT training course if you register in the months of April/May for May/June courses), obtaining your certified medical transcription (CMT) or registered medical transcription (RMT) credential, becoming an AHDI member to stay in the stream of cutting-edge information, and embracing long-term continuing education.
Above article publish on http://health-information.advanceweb.com/Columns/AHDI-Track/Why-We-Matter-to-Health-Care.aspx
admin on May 21st, 2010
By Maureen McKinney
Using bar-code verification technology for medication administration can significantly reduce error rates and decrease the likelihood of adverse events, according to a newly published study in the New England Journal of Medicine.
In the study funded by the Agency for Healthcare Research and Quality, researchers at Brigham and Women’s Hospital, Boston, examined data from several units in the hospital as they rolled out a staggered implementation of an electronic medication administration record, or eMAR, with bar-coding technology. The use of a bar-code eMAR was associated with a 27% decrease in timing errors, such as late or early medication administration, and a 41% drop in the rate of errors not related to timing, which include incorrect dosages and administration without an order.
Also, researchers noted that the rate of potential adverse events associated with errors not related to timing fell from 3.1% to 1.6%—what they described as a nearly 51% relative reduction. Not surprisingly, use of a bar-code eMAR also eliminated transcription errors, which occurred at a rate of 6% on units that did not yet have the system in place.
Bar-code eMAR systems allow nurses to receive medication orders electronically from a pharmacist or from a computerized physician order-entry system, and then use a bar-code scanner to verify medications at the patient’s bedside.
The results of the study demonstrate that bar-coding can have a substantial effect on safety, according to Eric Poon, director of clinical informatics at Brigham and Women’s, and lead author of the study. Poon also expressed confidence that the observed improvements were due to the implementation of bar-code eMAR systems and not another factor.
“We took measurements within a pretty small time frame, and the implementation was the main project we were doing at the hospital during that time period,” Poon said.
Still unclear, however, is whether hospitals with limited resources should implement a CPOE or bar-code eMAR system, Poon said, adding that Brigham and Women’s has had a CPOE system in place for many years. The two systems catch different types of errors and complement one another, he said.
For instance, a CPOE system is more likely to prevent errors related to incorrect judgment or insufficient clinical knowledge when choosing a treatment plan, while a bar-code eMAR usually catches errors associated with lapses in memory or mental slips, the study said.
“If a hospital can only afford one, we need to know which one makes the most sense to implement first,” Poon said. “That question is still unanswered.”
Above article publish on http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100506/NEWS/100509970
