Healthcare services have always documented the patient encounter in some or the other way as this aided in the process of providing care and served as reference for research purposes. As the demand for healthcare services grew and the process of reimbursement became complex, it became mandatory to document the patient- healthcare professional encounter.
Patient medical records contain vital information regarding the patient including demographics, patient medical history and valuable details regarding allergies etc. Medical transcription is the process of creating patient medical records from the audio narration of the healthcare professionals regarding the patient encounter. Healthcare services and medical transcription have had a long-term association. These services have evolved from being mere typing or data entry services to services that provide valuable support to healthcare facilities and healthcare professionals in various aspects. Imedical Healthcare Solutions
The healthcare and the healthcare documentation scenario have seen many changes owing to the advent of science and technology. This has enabled the healthcare sector to provide improved services and enabled the healthcare documentation sector to intuit the needs of the healthcare sector and provide services accordingly. ARRA (American Recovery and Reinvestment Act) or Economic Stimulus bill was introduced in February 2009, aimed at spurring economic growth across multiple industries through Government spending. Out of this $ 19 billion was aimed at the healthcare Industry by way of incentives for meaningful adoption and implementation of EHR (Electronic Health Record) also known as EMR (Electronic Medical Record).
With the move for adoption of nationwide electronic healthcare systems, the role played by medical transcription in this process becomes even more significant. In this movement leading to achieving meaningful use of EHR, it is important to consider the two main stakeholders in the healthcare process; the healthcare professional and the patient. Documenting the healthcare process using transcription services helps in achieving this objective by enabling retention of the narrative as part of the patient medical record.
What is the significance of the narrative in the healthcare process?
Preserving the narrative as part of the patient medical record helps in various aspects including:
Patient care: The patient story provides valuable inputs to understand the problem and provide solutions accordingly
Support for making clinical decision:Patient medical records are the basis on which the primary care provider makes clinical decisions regarding further tests or seeking specialist services
Provides support for risk management: Detailed patient records provide valuable support in case of litigation by justifying the care process.
Reimbursement:A detailed patient medical record provides valuable support for the reimbursement process, serving as the basis for coding and billing
Research and disease prevention: Detailed patient medical records are important inputs for research projects. They also help in disease management in case of epidemics.
The process of medical transcription helps in preserving the narrative portion of the patient medical record by intuitively providing services with the following advantages:
Blending in with the workflow of healthcare professionals:These services seamlessly blend in with the working style of healthcare professionals. Furthermore these vendors also allow doctors/support staff/clinics/hospitals to use dictation modes of their choice making it easier to optimize their limited time.
Cost effective:Not only do these services blend effortlessly into the workflow of doctors/support staff/clinics/hospitals; they also help reduce direct and indirect costs of patient medical record creation to a substantial extent
Flexible: One of the main advantages of outsourced services is that they are flexible with regards to various aspects like volume, specialties, modes of document delivery etc. This eases the administrative and information technology burden of healthcare facilities. Additionally transcription providers also play an important role in the adoption of EMR/EHR by enabling HL7 interface and providing editing services for transcripts produced by speech recognition software
