I Have an EHR: Can I Still Use Transcription Services?
Transcription services have always played an important role in health information management.Although there has been an explosion of EHR vendors and technological capabilities within the industry,many physicians still rely on transcription service as their primary way of documenting a patient encounter. Even large multi-specialty, multi-location facilities employ in-house staff or utilize transcription services to perform these tasks. Now, organizations are looking to leverage the benefits of transcription service to capture structured data within their EHR – with structured data capture being a prerequisite to achieving meaningful use. Traditionally,providers have had two methods available to document medical care:hand-writing and dictating. Historically, these methods have been used by the medical community for many years; however, the outcome has always been a report containing unstructured data. With the Health Information for Economic and Clinical Health (HITECH) Act in place, many physicians will need to make a transition that enables structured data to be captured. This structured data can then be used and shared amongst other physicians nationwide and increase the effectiveness of patient care. Organizations currently undergoing the transition to an EMR system are finding it difficult to capture the needed data elements to meet objectives and qualify for meaningful use incentives. As a result,some are employing abstractors to retrieve specific information from unstructured transcribed reports and re-enter the data into the system for structured data capture.However,this re-entering (and time-consuming) process should be conducted on a short-term basis,be supported by management, include a quality assurance plan,and be managed by well-trained staff members. Capturing data to generate accurate and timely information is no easy task.Typing or keying structured data into a system can be accomplished by using tools such as templates,forms,or drop-down menus,but this manual entry can be time consuming.Effective use of speech recognition and integrated tools can promote and enhance structured data capture. However,this approach can potentially produce more errors in a report and would still require a second person to review the report.To get the most accurate reports,physicians should seekTranscription Services vendors that Transcription Service offer the ability to interface with EMR software for a complete solution – eliminating the need for timely redundant data entry.
Questions and Answers
Transcription services should be reliable, accurate, and secure. Transcription deals with sensitive data that requires attention to detail and high level of security.
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