Posted by: adelvecchio
EHR, EHR Adoption, transcription
From meaningful use compliance to value-based purchasing, the ability to compete for today’s healthcare organizations is driven by the accuracy of structured narrative reports and the speed with which they are fed into their electronic health record systems.
Financial and clinical coding processes rely upon these reports — which make up 50% of a patient’s record — as their primary source of information. Providers depend upon dictated text to communicate the unique, expressive and complete patient story to other healthcare providers. However, to be leveraged by the EHR, narrative reports have had to evolve into discrete and interoperable patient data available in readable and scannable formats.
The impact of an EHR doesn’t end there. It has also altered the process of transcription and the role of the medical transcriptionist.
When conversation turns to the aspects of healthcare most affected by EHR adoption, the move toward a fully digital environment characterized by real-time data sharing and exchange is not commonly mentioned. The truth is that the move to digital has technically and functionally transformed transcription.
On the technology front, EHRs are able to interface directly with transcription platforms to parse data. Transcription now creates discrete data fields rather than flat files or static information snapshots. In addition to complying with HL7 data requirements, these capabilities created demand for dictation software with advanced speech understanding to create greater efficiencies in data transfer.
Specifically, admission, discharge, transfer feeds and clinical dictation can now be integrated between systems, eliminating manual transcription. Instead, patient demographic information can be systematically merged for editing, which also speeds turnaround times.
That transition to editor is perhaps the most significant effect EHR adoption has had on the role of medical transcriptionists. As speech understanding software becomes more commonplace, creation of a typed document will become extinct. Instead of creating documents, transcriptionists are now responsible for editing them for medical accuracy. Adapting to this new role has been a challenge for some transcriptionists. For others, it has opened doors to new professional opportunities, including quality assurance and coding.
Making the transition
Just as the role of transcriptionists has evolved under the influence of the EHR, so too must the technology infrastructure, in order to effectively transition reports from one-dimensional text to reusable patient data. Today’s narratives are now subject to natural language processing (NLP) — technology capable of “understanding” spoken dictation and converting it to electronic text that can be parsed and mapped to specific data fields.
When paired with transcription management software, NLP technology enables hospitals to seamlessly integrate dictation into the EHR based on pre-defined templates that determine where the data should wind up within the electronic record. While the presence of an EHR on its own does not alter the front-end look or content of the narrative report, it does introduce greater flexibility into the look and feel of the templates themselves.
This is particularly useful for transcriptionists working with multi-facility systems or outsourced transcription vendors. In a manual environment, these transcriptionists would spend a portion of their time formatting clinical narratives to meet the requirements of individual hospitals. Now, formatting is handled by the software behind the scenes. The end result is higher productivity levels, faster turnaround times and greater standardization.
One of the most important aspects of a successful transition to the new era of transcription is establishing the framework to guide software implementation and adoption. In many cases, hospitals find it helpful to seek out the support of a vendor experienced in identifying needs and capable of designing an effective strategy to meet them.
The best firms will follow established best practices, which should include early and ongoing involvement of the facility’s leadership and medical staff to ensure top-down adoption of and compliance with the new processes. Proper training and education is at the heart of any successful transition, which is why it is important the vendor selected to guide the process provides education at appropriate milestones. At a minimum, education should be given during the kickoff phase and at go-live.
The typical training plan should include, at minimum:
- Identification of training facility needs
- Initial training of in-house trainers (“training the trainers”)
- Identification and selection of an in-house training coordinator
Identification, design and development of facility-specific training materials should also be provided, including roles-based guides for instructors, administrative users and report users. Finally, customized workflow mapping should be conducted to ensure any areas of weakness are identified and addressed.
Whether it is the promise of incentive funds or the threat of reimbursement cuts, the pressure to transition to an EHR is increasing. To maximize the return on their investment, hospitals and other healthcare organizations should pay close attention to the impact the resulting changes has on their transcription processes — and the transcriptionists themselves.
The adoption of NLP and front-end speech understanding software, combined with targeted transcriptionist training and education will ultimately increase accuracy, efficiency and productivity. It will also speed access to patient information by those who need it to make the decisions that impact care quality and financial outcomes.