Medical Transcription Outsourcing: Producing Documentation Support Based On AHDI Guidelines

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Medical Transcription Outsourcing: Producing Documentation Support Based On AHDI Guidelines

By: Renee Kelly

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.

Plan: Planning policy guidelines for quality
This part of best practices for maintaining quality involves a set of standards for documentation that ensures accuracy, accessibility and overall value of the patient medical record as a resource for understanding the care process including diagnosis, treatment and progress.

To ensure this, the planning process should have principles that ensure:

· Verifiability: Any quality program should have standards and measures that are easily verifiable and these measures should be available to personnel at every level of the organization and to the end user of the transcript to ensure cross verification

· Definability: The error categories should be clearly defined

· Measurability: Measurable values for clearly defined error categories should be assigned and measurement methodology for errors should be clear to all the parties involved

· Consistency: The quality program should define error categories, values to be assigned to each category and there should be a standard method error determination.

· Integrity: The integrity of document can only be assured when there is a synchronized partnership between the originator of dictation and the medical transcriptionist. The healthcare professional dictating the notes should present information in a clear and concise manner and the medical transcriptionist should transcribe the document preserving the essence of the information provided by the healthcare professional

To this end the quality assurance program should be based on Quality Guidelines that ensure the following:

· Accurate and complete documentation ensuring that the essence of the encounter is captured
· A process of distribution of reports on a timely basis and a system for easy accessibility of past records to the relevant personnel
· A practice of periodical quality audits to study the process and assess where errors occur as a part of the ongoing quality process
· This process to be applied to medical transcription at all levels
· The assessment program should be consistent and unbiased
· The assessment program should be according to the principles of assessment agreed upon
· The results from the assessment process to be used as a learning tool to ensure recurrence of errors
· Access to the Quality Guidelines, assessment process to be made available to all the people involved in the transcription process.

To be successful a quality assurance program should be:

Proactive: Medical transcription being such a critical activity that contributes to the healthcare process, it is important for quality assurance program for medical transcription to be proactive. Being proactive ensures that solutions are available for problems before they turn into major issues

Realistic, scalable and financially feasible: Quality is a continuous process; therefore it is important that the quality assurance program should be realistic and cost effective

Simple and easy to implement: Creating patient medical records is a process that consistently needs to meet the quality constraints of accuracy and timeliness, keeping this in mind any quality assurance process has to be simple to be workable.

Secure and Confidential: Considering that the process of creating patient medical records involves working with confidential patient information and comes under the purview of HIPAA it is important that any feedback regarding quality keeps in mind the confidentiality norms

Inclusive of all aspects: Quality in the transcription process involves all aspects starting from the origin of the data down to the transcriptionist, proofreader and quality team, the quality assurance program needs to plan measures to include all these aspects

Reportable for trending and tracking purposes: The process of quality assurance is not only to ensure consistent quality documentation but is also a valuable input for education purposes

Timely: The quality assurance process should be scheduled in timely manner to ensure maximum results

Author Resource:-> Renee Kelly has written numerous articles on transcription services, which has served as an amazing resource for healthcare facilities and healthcare professionals seeking medical transcription services.

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HIPAA FOR MTs: THE BASICS OF FEDERAL REGULATIONS

Understanding the basics of Federal Regulations can be overwhelming to the Medical Transcriptionist (MT). With a career as a healthcare professional you will here this word a lot HIPAA
(Health Insurance Portability and Accountability Act).

This is a bill that was enacted in congress in 1996, with the main objectives, portability and accountability.

PORTABILITY:

Ensure the continuation of health insurance for workers and their families in times of job changes or loss.

ACCOUNTABILITY:

Protecting health data integrity while increase the effectiveness of the health care system, confidentiality and availability and preventing fraud and abuse.

The experts call this the most sweeping healthcare legislation in the last 33 years.

The most important part for HIM (Health Information Management), the department in which MT is one of its specializations, profession is in the title section: TITLE II, SUBTITLE F.
Administrative Simplification is the name of this part.

Four Rules of Administrative Simplification:

• Electronic Standards Rules
  
• Privacy Standards Rules
  
• Security and Electronic Signature Standard Rule
  
• Standard Identification Rule for Employers and Providers
  

  Go here for more information.
  

Information specifically about HIPAA including complete text of the regulation and more important links can be found Here.

HIPAA and your job as a MT can be quite over whelming, but don't let this stop you. HIPAA is designed to help you save money and time to make everyone's life easier.

HIPAA FOR MTs:

Sample Business Associate Agreement (sample agreement only, seek legal counsel).

MT's Check List

Safeguarding Protected Health Information (PHI): Focus Points for Offsite Transcriptionists

MT Service Providers Transcription Agreement Check List

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Getting Typing and Transcription Work

Copyright © 2008 Leva Duell

Do you want to get typing work? Consider transcription.

Transcription can provide you with many hours of typing work. Transcription is simply typing what's dictated.

You don't need to be a medical transcriptionist to provide transcription services. When speaking about transcription, people think about medical transcription.

In addition to medical professionals, a wide range of individuals and organizations outsource transcription services. Your clients may include insurance companies, universities, financial institutions, authors of books, consultants, focus groups and public speakers.

Business transcription does not require any knowledge of medical terminology.

If you are a business transcriptionist, medical transcriptionist, legal transcriptionist, be aware of the growing popularity of digital dictation and transcription. Although the majority of physicians and businesses are still using tapes to record dictation, many are starting to use digital voice recorders.

To provide transcription services, you will need a transcription machine. Transcribers have a headset and foot pedal that allows you to stop and rewind the cassette with your feet while having your hands available for typing.

Traditional audio tape transcription includes standard cassette transcription, micro cassette and mini tape transcription. These are typically referred to as cassette transcription or tape transcription. Until you have a client, you won't know which size cassettes you'll need. Talk to your prospective clients before buying any transcription equipment.

Digital transcription is becoming more popular and can provide you with additional typing work from long-distance clients who are looking for transcriptionists to perform transcription work from home.

Here's how digital dictation and transcription works: Your clients dictate into a handheld digital voice recorder, upload the files from their recorder to their computer with a USB cable, send an email message to a transcriptionist, and attach the digital files.

Digital transcription has many benefits for the transcriptionists. The audio quality is usually much better than tapes. You can move easier and faster to specific places in the dictation and you have more control over the playback speed. You don't have to deal with pick-up and delivery of tapes.

When the medical transcriptionists receive the email, they can open the file and bring it into their computer with specialized software. They can convert the digital file to different formats, but the most popular file format is the "wav" format.

Specialized transcription software and a foot pedal allow the transcriptionist to move through the digital voice file just like you do when transcribing from a tape. After transcribing the files, the transcriptionist emails the finished work back to the client as an attachment.

The foot pedal is connected to your computer through the USB or serial port. A foot pedal that comes with a tape transcriber will not work. You also need an Internet connection, an email account, and a word processing software program such as Microsoft Word that will work with your digital file transcribing system.

Some foot pedals have the ability to convert files recorded on almost every type of digital handheld recorder. This allows you to perform transcription work for many clients, regardless of the type of digital voice recorder they use.

If you are not looking into transcription work, you may miss opportunities to typing work from home on a contract basis.

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Medical Transcripiton A Green Job

Working from home as a Medical Transcripitonist (MT) is helping save the planet. According to a recent survey in the United States 83% of all MTs work from home, this is considered good for the environment.

Decreasing one of the largest source of pollution in the world, driving automobiles, MTs work from home and there is no need to drive to work. Even so now with digital dictation MTs can receive dictation from the physicians in many different ways. There is the 800 number 24/7 call in dictation, the hand held digital recorder that can be uploaded to the physician's computer and email or directly to the MTs computer. With the smart phones one can just dial a computer and dictate right with their smart phone. There are a lot of HIPAA compliant software programs that allows the physician to view what is in progress and what is finished and this can go straight to the Electronic Health Record (EHR).

The old ways are still in progress, some physicians have gotten comfortable with the tape recorder system where the MT goes and pick up the tape and return home to transcribe what was dictated and then return it on paper every three days or so. This still cuts down on driving every day to work. Soon all the physicians will see how efficient and safe the electronic transfers of EHR and will eventually go all digital or electronic.

MTs working from home is not only helping reducing pollution from automobiles, but helping reducing the use of paper with EHR. These programs are secure, efficient and effective fast way to keep up with all of the paperwork that has to be completed with the EHR. The medical community are moving forward to making all medical records EHRs.

As you can see MTs that work from home are becoming more environmentally friendly and help cut down on carbon emissions. Medical Transcription is a Green Job.

We can practice to use energy efficient light, computers, printers, faxes, and phones. Offering many print materials in a downloadable format to help save paper and making "scratch pads" using backside of waste paper for notes to save paper and last but not least when you need to print try printing on both sides of the paper to save another sheet of paper.

Promote green training programs and careers. Allow employees to work from home to cut down on carbon emissions.

Always practice recycling, and use less plastic materials, then we could all be on our way to making a green track of foot prints all over the world.

We have the right prescription for you, Take the worry off your paper work and concentrate on patient work.

Cut down on Carbon Emissions.

Consider Medical Transcription-2 for your transcription work.


Visit http://medicaltranscription-2.com for a GREENER FUTURE

The Future of Medical Transcription

How can we improve our nation's health care?

John A. Halamka M.D. (Chief Information Officer ─ Harvard ─ Affiliated health─Beth - Israel Deaconess Hospital): In our country it is estimated that 144 billion dollars a year is lost because lack of coordination of medical care.

The electronic medial record enables seamless transmission of patient histories, medications and laboratories from doctor to doctor. It's only through Electronic Medical Records ( EMR) that we will receive coordinated care, safe care and cost-effective care.

The American Association Presents Medical Transcription: Ensuring Safe, Quality Cost-Effective Health Care.

Dee Thomas CMT (Owner Thomas Transcription) : I like the fact that we do play a part of the roll of patient's healthcare in the industry.

Some years in high school originally I've thought about being a nurse, but I could not stomach it. But this is a way to make that same contribution but at the same time, well maybe on the backend of that, we make a significant contribution to patient healthcare.

Did the patient have three kimonos or trichomas?

Valli Pillion CMT, FAAMT: When Medical Records (MR), are accurate, both the patients and the doctor are protected.

Dee Thomas: We have physicians who, you know, who didn't get into the profession, because they wanted to dictate in the first place. They get into the profession because they want to take care of patients. So they do this generally and as fast and as quick as they can so they can get back to what they really wanted to do, which is administer patient care.

I'm not always sure if I hear it or I know it from years of experience. But many times we can get the blanks (garbled phrases).

Did the physician say 5,000 or 50,000 units of insulin?

When we catch a problem in the report that's been dictated, we bring that to the attention of the facility or the physician.An example of that would be; we had a report and the physician did actually dictated 50,000 units of insulin. I know it should be 5,000. Anyone with experience in transcribing reports would automatically know it should have been 5,000.

So we would bring that to the attention of the facility, we would make that correction in the report. Now had that report fallen into the hands with someone with less experience, and it may not be caught, and the patient would receive the wrong dosage of medication.

John A. Halamka M.D. : between 0.7 and 7 percent, all hospital patients have a medication error during their stay. MR provides a foundation for the system support that enables us to do drug-drug, drug-allergy and drug – laboratory interactions check so we can provide high quality care.

The American Association for Medical Transcription: Promoting Quality, Certification and Continuing Education for Medical Transcriptionists.

Jefferson Howe CMT, MSA Maine Medical Center: the American Association for Medical Transcription helps it's members by advocation certification, a focus on quality, and a focus on continued learning in this professional environment. It's changing now and its changing fast and we have to be up to speed with where things are going.

Dee Thomas CMT: I think all medical transcriptionists (MT) should be certified. I think there should be a benchmark in every profession. I think we're are one of the few profession in the health care industry where certification is not required and would you just want anyone handling your patient records.

Valli Pillion CMT, FAAMT: Medical Transcriptionists face the same problem that healthcare system as a whole faces. Our mission and our goal are only for MTs to be the best they can be, but our healthcare system to be the best that they can be.

The American Association for Medical Transcription:
Working To Bring Medical Transcription into The future.

Jefferson Howe CMT, MSA: Technology is changing and it's changing faster all the time. The American Association for Medical Transcription absolutely has to help the MT evolve with the EMR to learn and understand their position today, so they can play an interoral part in it.

John A. Halamka M.D. : we have found even with the voice recognition we have found that their not accurate enough, without human intervention. So our challenge has been to use the machines, the best of technology as well as the human brain and MT to bring a quality product.

How is the electronic medical record changing health care delivery?

Jefferson Howe CMT, MSA: the EMR, is probably the most exciting change in my career and it has made exciting to me. I think that we have to ask; what will we do when we have so much EMR everywhere?

What does it mean to Home Health Care Aids, Nursing Homes, and other health care facilities or agencies, pharmacies, physical therapist, when they can plug in and see my health care information at that point?

Be it at home or in the medical environment make better judgments based on what they have at hand.

John A. Halamka M.D. : We have to deliver safe effective care in our hospitals without the support of our Electronic Systems. In fact, two years ago we had a network outage. It lasted about a day and a half.

We went from the hospital of 2002 to the hospital of 1972. It took 100 extra staff, just to deliver the good quality care that we were doing with EMR. They are an essential part of the modern hospital of today.

MTs: An Integral Part in the Health Care System.

Dee Thomas: the record, the transcription that we do is the first line of defense of making sure that that patient receives the health care that he needed. That the hospital facility receives payment for the services that were rendered.

And we ultimately, even though we work in the background, you know, we have done all of the documentation necessary to see that that happens.

John A. Halamka M.D. : the next five years will be very exciting. We'll ensure that doctors have all the information that they need, in an accurate and timely way, anywhere of the information they need even on the internet, with the oversight of MTs ensure it's accuracy.

Valli Pillion CMT, FAAMT: Every time that we catch an error within the dictation, the patient and the doctor benefits. Ironically most of the patients don't know we exist. But we know that we are making a difference within the industry.


For more information please contact the American Association for Medical Transcriptionists. http://www.aamt.org.