subject: Medical Transcription Service & Clinical Documentation [print this page] Medical transcription service has come a long way since the start of clinical documentation. From handwritten notes to digital records and speech recognition software, medical transcription gone from a very costly endeavor to something that can be done easily & cost-effectively. This article will provide you with a history on clinical documentation and today's solutions for medical transcription.
Medical Transcription Service: The History of Clinical Documentation
There are many means of creating clinical documentation. Over the years, hand-written notes have given way to in-house dictation. Then in-house dictation found efficiencies and improved quality by moving to outsourced transcription services. More recently, some physicians have employed the use of self-service voice and speech recognition products to gain immediate access to their clinical documentation. Electronic Health Record ("EHR") adoption and enterprise requirements to collect data in anticipation of standardizing care have led to structure templates and a point and click style of collecting clinical data.
Handwritten Notes: Although quick, hand-written notes generally do not provide robust data required for adequate clinical documentation and are considered an archaic form of documentation.
In-House Medical Transcription Service: In-house medical transcription is often quite costly, and unaffordable for all but the largest practices and hospitals.
Outsourced Medical Transcription Service: Outsourced medical transcription can offer highly advanced technology that help a practice streamline workflow and improve productivity. Local, smaller and often, home-based medical transcription firms often provide less than optimal quality and can be highly variable in their service, often affected by staffing issues. And critical to a medical practice, these firms are often unable to implement updated technology.
Voice and Speech Recognition: Speech recognition technology has been touted for its cost savings without taking into account the workflow changes, acceptance gap, and high cost due to increased time physicians spend on documentation and review, the benefits of speech recognition have not been realized.
Point and Click: While a structured template offering point, click, and type functionality helps capture clinical data, it is a tedious, time-consuming manual process, and the documentation lacks the expressiveness of natural language. A poorly designed and inflexible user interfaces are reasons for slow physician acceptance and resistance.
Medical Transcription & Dictation Challenges
Current dictation and medical transcription processes have been physician-friendly in terms of retaining the physician's current workflow, and the dictation contains the detail and comprehensive scope of patient information. Valuable data contained in physician dictations is often lost because dictations are delivered in unstructured formats, leaving data that is unable to be reported, shared across systems or acted upon to improve clinical outcomes.
As adoption of EHRs grows, as supported by recent financial incentives with the American Recovery and Reinvestment Act of 2009, the workflow of clinical documentation will be challenged by yet another layer of complexity.
Some EHRs have been built for all of the documentation to be provided by the physician through point and click and the use of pre-built structured clinical templates. Often physicians have found this process to be tedious and time consuming - and the resultant notes lack the expressiveness of natural language required to fully document clinical findings and reasoning. The balance of engaging and interacting with the patient on a personal level has also been challenged by the physicians' attention drawn towards completing the clinical documentation within the same timeframe allotted for the face-to-face patient encounter.
Patients and physicians alike have complained that the physician is "typing and not listening." Studies have demonstrated that significant clinical documentation is lost - up to sixty percent (60%) - to point and click EHRs. This impacts quality of care and creates inefficiencies in the care process. In addition, the time to capture clinical documentation increases from approximately 30 minutes a day to 140 minutes a day.1 Yet EHRs do offer significant potential to create efficiencies, and improve the quality of clinical documentation.
The key is in the selection of a clinical documentation system and workflow process which offers the following benefits:
- Superior quality and accuracy
- Structured and encoded information capture compatible with an EHR
- Lower costs
- Speed
- Self-service or full-service, dependent upon the physician's preference
