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How to Eliminate Speech Recognition Errors As technology progresses, many providers are relying on speech recognition software to expedite the process of clinical documentation. However, errors due to the mistakes of the clinician, poor audio quality, background noise or equipment malfunction are still common. Errors in dictation can make the patient’s health record erroneous. A patient’s health record represents the plan of care and actual care and documents the outcomes. Errors in such documents could reflect in other records quickly within the EHR system; it can confuse the patient, family, care coordinators and clinicians and even result in the death of patient. There are methods to eliminate these errors and prevent them from appearing in the final transcript. In the case of front-end speech recognition (real-time processing of dictated data), it is up to the physicians to view the structured text document, identify the errors and edit the document as it is dictated. This amounts to heavy work for the physicians. In back-end speech recognition system, a draft of the dictation produced is usually sent to the Health Information Management (HIM) department along with the voice file so that medical editors can listen to it, read the draft and correct any mistakes. Medical editors should consider the following to ensure the accuracy of the data sent to the EHR. Proofreading Proofreading the transcribed documents before routing them to physicians can help identify errors. Apart from proofreading the entire document, double check vital information including patient names, medical record numbers and dates. Make sure that the medical record number matches the relevant patient name. Proofreading also helps to recognize left-right (for example, left hand mistaken as right hand) and he-she inconsistencies. Ensure there is no ambiguity in the information presented.
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www.medicaltranscriptionservicecompany.com Thorough Knowledge in Medical Metrics It is very important for healthcare documentation specialists to have a thorough knowledge of anatomy and physiology, lab and radiology values and surgical as well as
medical
terminology.
Trained
documentation
specialists
know
lab
value
parameters, correct dosages for medications and what makes sense. For example, they know the meaning of the prefix ‘hypo’ is low and the normal potassium values generally range between 3.7 and 5.2 mEq/L so that they can correct the errors more effectively. These professionals should have medical knowledge, especially in the following areas. •
What drugs work for what indication
•
The
most
appropriate
context
for
common
homonyms
including
perineal/peroneal/peritoneal, aphagia/aphakia/aphasia, mucous/mucus, and obfuscation/obstipation •
Common normal lab values for identifying outliers
•
Age-relative ailments
Familiarity with medical terminology, disease processes, diagnostics, medications, anatomy/physiology used for various work types is also vital when editing speech recognition transcripts. Gaining experience is also another crucial factor for medical editors. The longer they listen and edit, the more familiar they become with the terminology to identify correct and incorrect dictation immediately. Expertise with Tools and Resources No matter how knowledgeable the medical editors are, questions will arise during the editing process. The editors should be aware of various tools and resources available to answer such questions quickly. For example, it is possible to ensure whether the dosage for a medication is actually available or the dosage sounds right for a particular situation and patient by checking a drug book. There is a vast spectrum of tools and resources including expander software, word books, and reliable websites CALL US:
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www.medicaltranscriptionservicecompany.com among others. Access to sample files and accurate and efficient expander software is quite useful for editors. Resources like qualified samples i.e., sample dictation after eliminating protected health information from a specific dictator is extremely useful for editors to identify the phrases the dictators use frequently while dictating, which would help them to clarify such phrases in later dictations. Referencing previous documents of a dictation in question can provide editors with enough context and hints to solve an issue. Continuous Training and Education Healthcare documentation specialists should dedicate themselves to continuous learning to follow up with any changes in medical terminology or documentation. Continuous training and education are inevitable to minimize errors. This is because editing a speech recognition document requires specialized training and a different set of skills compared to standard transcription. Even experienced editors can benefit from lifelong learning. Improved Listening Skills It’s not just listening to dictation, but how the editors listen that can have a significant impact on the accuracy and integrity of the transcribed documents. Listening to the dictation as a whole will help to identify more discrepancies than listening to fragments. With this, editors can pay particular attention to disease diagnoses, medications, anatomy/physiology, or diagnostic data that are interrelated as well as relevant to each other. This approach also allows them to look for omissions as well as inaccurate information. The editors should not always just hang on each and every word, but pay heed to what the authors actually meant to say. This is beyond the usual action of simply listening and transcribing what is said and let your brain remain on high alert for discrepancies. Editors should improve their concentration skills, especially when there is a great deal of background noise in the dictation or within the office environment.
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www.medicaltranscriptionservicecompany.com Interaction with Physicians Physicians want to get their documentation right the first time as going back and correcting mistakes demand extra effort and time. This is hectic for medical editors as well. In order to avoid this double work, it is better to work with physicians from the beginning itself. For that, the editors should encourage better communication with the physicians. It is vital to clarify the requirements of physicians before starting the editing process. They should also provide periodic in-services and/or other kinds of communication with physicians regarding the dictation standards and protocols. Flag Doubts If you are not 100% sure of something and left with no way to clarify it (for example, proofreading has already been done), then it is a wrong step to make a guess at what is correct. Medical editors are recommended to flag the document in such cases and ask either the physician or a QA reviewer for clarification. Stay Focused Well-rested healthcare documentation specialists can recognize more discrepancies and create less transcription errors. Avoid fatigue, stay rested, well hydrated and take adequate breaks to stay focused while editing or doing QA review. Hiring medical editors and QA team and giving enough training to them for following up with all these approaches is really cumbersome and expensive for healthcare providers. Hiring professional medical transcription services would be a good option as you can benefit from the service of experienced medical transcriptionists and benefit from three-level QA process involving proofreaders and editors.
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