Professionally executed, high-quality medical transcription is vital to healthcare providers and practitioners for a variety of reasons, but is difficult to source and have confidence with the final product. Organizations frequently have debates about whether to use in-house transcriptionists or to outsource the data to transcription companies and weigh the differences in costs, delivery capabilities, and accuracy.
The scope of this article will cover the ABCs in how organizations will see great benefits from using a professional medical transcription company like TranscribeMe, which are: Accuracy and Burnout.
Table of Contents
1. Ensuring Medical Record Accuracy
Keeping accurate medical records is a crucial requirement for healthcare providers on both the legal and professional front. Without accurate and professional printed or electronic medical records, including records on personal information and data, physical and mental conditions, medical history, and current medical care, there is increased risk for patients to be improperly or outright mistreated.
Sheila Burgess, RN, RHIA, CDIP, CHTS-CP, director of CDI at Sutherland Global Healthcare Solutions, points out that even a small typo such as “hyper” versus “hypo” in a medical record can have dire consequences. “If a patient comes into the ER unconscious, they could be emergently treated for a condition they don’t have if a physician pulls up their record and the documentation is incorrect or it’s the wrong patient’s information,” Burgess says. “That’s one thing that could be detrimental.”
On the legal front, the Federal False Claims Act requires that patient medical records be kept for 10 years. All medical procedures, treatments, care, and instructions must be documented, and all entries made are legally binding. Improper, inaccurate, or poorly managed documentation may result in serious HIPAA violations which can result in fines and a loss of reputation. Additionally, further legal, civil, or professional liability may be incurred if patients are mis-diagnosed or mistreated stemming from poorly maintained or inaccurate medical records.
At TranscribeMe, we have built a platform around a focus to deliver consistent, high quality data. For medical transcription, a robust workflow that requires medical transcriptionists to demonstrate competency with medical terminology, language, and general grammar and dialogue in order to receive access to transcription tasks.
Additionally, multiple layers of review are built in to make sure that workers are constantly checked and that data is accurately transcribed with consistency. This results in a process that delivers consistent high quality data affordably and quickly.
TranscribeMe’s medical transcription service teams are able to provide customized outputs for special writing styles or proprietary formats required by health providers regarding the transcription of their medical records.
As a company with a dedicated medical transcription division, TranscribeMe can retain such requirements in portfolios according to individual customers, and the medical teams know which styles are to be used for which providers. Sometimes the same healthcare providers may even have several different style requirements according to format: letters, diagnoses, reports, etc. The final output can be customized to your needs.
According to Health Information Management (HIM) experts, the most common errors made in medical documentation are mixed messages from a physician via misunderstood dictation or illegible handwriting; misuse of copy-paste functions in the electronic health record (EHR); incomplete or missing documentation; misplaced documentation. Errors such as these can be mitigated by the use of a trained, experienced medical transcription team.
2. Relieving Physician Burnout Maintaining Electronic Health Records
Keeping accurate medical records is a crucial requirement for healthcare providers on both the legal and professional front. Without accurate and professional printed or electronic medical records, including records on personal information and data, physical and mental conditions, medical history, and current medical care, there is increased risk for patients to be improperly or outright mistreated.
The results of two surveys conducted in 2013 and 2015 by Medscape showed the same list of causes that lead to physician burnout. The top cause was revealed as too many bureaucratic tasks, and the second as too many hours at work. Surprisingly, the fourth was increasing computerization, a factor that should seemingly help with the bureaucratic tasks and decrease work time instead of hindering them.
In a 2014 Medscape survey, 70% of physicians noted that the implementation of EHR in their practices decreased face-to-face time with patients, and 57% said that it detracted from their ability to see patients. The survey did show indications of it becoming less problematic in the future – 81% of the physicians surveyed said they are becoming more comfortable with their EHRs over time – but being more comfortable with computerization does not necessarily mean solving issues that cause burnout.
According to Medical Economics magazine’s 3rd annual Physician Burnout and Wellness Survey in 2021, physician burnout has reached a crisis point. When asked what contributed the most to their feelings of burnout, the number one answer given by physicians was too much paperwork and regulations, followed by work too many hours/poor work-life balance. These results are directly in line with the survey results obtained by Medscape seven and nine years prior, respectively.
In his article We Must Address the Causes of Burnout, L. Allen Dobson Jr., MD, FAAFP, the editor-in-chief of Medical Economics, describes how in the early years of his practice the causes of physician burnout were most often attributed to long hours, lack of work-life balance, the pressure of clinical responsibility, and the burdens of call and leadership. “Now the most cited reason in numerous studies and surveys is administrative burden (EHRs, prior approval, administrative tasks).”
Utilizing the Services of a Medical Transcription Company
By utilizing a transcription company such as TranscribeMe, providers can allocate more time to duties of greater urgency and have the peace of mind knowing their transcription needs are taken care of. Healthcare providers can simply use a recording device or mobile phone to record diagnoses, treatments, reports, schedules, and more, instead of typing out the records themselves. In this way, important medical information will be captured with minimum effort and the recordings can be forwarded for transcription by professionals of the field.
Not only is this beneficial to the physician due to medical records becoming a no-hassle process that will help to alleviate the main causes of physician burnout, patients will benefit as well because records and transcripts will be implemented quickly and professionally.
In addition, the healthcare provider can also be under less pressure in knowing that medical transcripts will ensure that key data and metrics are available in a timely manner to healthcare insurers for proper claims handling. Outsourcing transcription can also help to free up the administrative personnel in a physician’s office for higher priority tasks, thereby helping to alleviate staff burnout as well.
HIPAA-Compliant Transcription
Confidentiality requirements and the protection of personal data continue to increase as a major priority across the globe. Many countries have implemented laws and regulations that require the protection of certain types of data by anyone who is in possession of this data. However, not all medical data requires this type of protection, and not all data that does require this protection is medical data.
The Health Insurance Portability and Accountability Act (HIPAA) was created to “improve the portability and accountability of health insurance coverage” for employees between jobs. After it was signed into law on August 21, 1996, the US Department of Health and Human Services began creating the first HIPAA Privacy and Security Rules such as the HIPAA Privacy Rule, which came into force April 14, 2003, and the HIPAA Security Rule, which went into effect on April 21, 2005. HIPAA and its related regulations have since become an informally accepted global standard.
HIPAA requires that healthcare facilities and providers, as well as anyone with access to Protected Health Information (PHI), take serious measures to ensure the privacy and security of personal patient data. Healthcare professionals must have firm security precautions in place or face dire legal consequences.
A HIPAA-compliant transcription service such as TranscribeMe comes with multi-layer security features. Security protocols include encrypting data in-transit and at rest, limiting access to records for only essential personnel, deleting data off of our servers after a short period of time, and many others to ensure compliance is met.
Office administrative staff in a doctor’s office or clinic may find it difficult to keep up with all the complexities and details of HIPAA compliance. TranscribeMe employs staff that is specifically dedicated to meeting HIPAA requirements and restrictions. This staff continuously educate themselves on the regulatory updates, make company administrators aware of the latest developments, and write company policies, guides, and informational material to ensure that our process remains truly HIPAA compliant
Furthermore, TranscribeMe keeps control of and tracks all who have access to sensitive data. Individuals on the HIPAA medical transcription team must pass through several levels of identity verification. They are also required to sign a non-disclosure agreement (NDA), a business associate agreement (BAA), pass a HIPAA compliance exam annually, and fill out a Transcription Security Declaration form after each project verifying no HIPAA-related material was improperly copied or taken.
Increasing quality (Accuracy) and eliminating barriers to productivity (Burnout) may be the main driving force for choosing TranscribeMe to process medical records, but guaranteeing the safety of personally identifying information in doctor-patient exchanges (Compliance) remains paramount. No matter which of these specific ABCs takes priority in your practice or facility, TranscribeMe can help take the worry out of handling medical data.
