Significance of EMR in 2015 and Why You Need Speech-enabled EMRs

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Significance of EMR in 2015 and Why You Need Speech-enabled EMRs Electronic Medical Record (EMR) system combined with medical transcription can dramatically improve the quality of healthcare. If EMR reduces the documentation time, transcriptionists now working more in the capacity of editors, correct the errors in the records before sending them into the electronic record system. Speech-enabled EMRs can better help you achieve your documentation goals.

This

system

recognition

to

uses

voice

dictate

the

findings into the electronic records instead of typing or using point-and-click option and therefore you need not spend a lot of time in front of

your

computer

screen.

Let’s take a detailed look at the trend of EMR adoption and the benefits as well as challenges

of

using

speech-enabled system.

a

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Reasons for Wide Adoption of EMR The key reasons that drive U.S. healthcare towards EMR adoption are as follows. 

Standardized electronic healthcare information can save a significant amount in overhead and unnecessary spending.



According to the Institute of Medicine (IOM), health information technology or HIT is identified as one of the most significant tools that can help improve healthcare quality.



The reimbursement philosophy of U.S. healthcare has been changing from ‘fee for service’ to ‘pay for performance’ and both private and government payers need to base a portion of their reimbursement on measurable outcomes. EMR systems are required to keep the score.



Federal government initiatives that offer incentives for eligible professionals, eligible hospitals, and critical access hospitals (CAHs) when they adopt, implement, upgrade or demonstrate

meaningful use of certified EMR

technology.

The rising number of patients that is a consequence of the implementation of the Affordable Care Act (ACA) is another factor that drives healthcare providers to adopt EMR to reduce their documentation time.

Benefits of Using Speech-enabled EMRs 

Increase Physician Productivity – One of the drawbacks with EMR is that physicians need to find out the point-and-click templates where they have to enter data and type data into them using a keyboard. This will take a long time and prevent them from properly listening to and observing their patients during a visit. On the other hand, searches, queries and form filling are faster to perform by voice. Charting, prescription writing, database searches, order entry and other kind of documentation are highly conducive to control by speech. Speech recognition software can be customized to

www.medicaltranscriptionservicecompany.com record voice macros or templates of frequently used reports, which are very easy to create and are a critical time-saving feature. Since these macros support all standard elements to guide the physician’s documentation, it can also keep physicians in compliance with the guidelines of the Centers for Medicare and Medicaid Services (CMS). Overall, this will significantly increase physician productivity as they will get more time to spend with their patients.



Improve Patient Care with Detailed Documentation and Faster Delivery

–

Point-and-click

technology

with

EMR

limits

the

comprehensiveness of the documentation since there are only limited selections. However, patient notes created through speech would contain deeper and more descriptive information with vital details required for a complete

patient

assessment.

Since

the

documentation

time

is

less,

information will be quickly available to physicians in need so that it is possible to formulate treatment plans more rapidly and reduce the chance of adverse medical effects.



Increased Cash Flow and Revenue – When the patient notes are immediately available for hospital case workers and discharge planners, unreimbursed days can be reduced and thereby cash flow can be improved.

When

patient

charts

created

using

speech

recognition

are

available

immediately, practices can deliver charge capture information, superbill and supporting clinical information to billing far more readily than handwritten notes.

Voice-enabled

speech

templates

can

accommodate

‘pay

for

performance’ related documentation to increase reimbursement and practice revenue.

Crucial Role of Speech Recognition Editors Though effective, speech recognition alone is not sufficient to ensure accurate and timely electronic medical records as no physician is a perfect dictator and verbatim transcription is impossible to use in a patient’s file. Even with the best voice recognition software, editing for clarity and consistency is required due to the following reasons.

www.medicaltranscriptionservicecompany.com 

The physician’s dictation is not always clear enough for the software to capture, especially when the physician is tired or in a hurry.



A physician dictating his notes will not always use appropriate grammar, punctuation or word choices to express the meanings, which may later affect the quality of the documentation.



Dictation often includes inaudible words as well as sounds that need to be resolved or flagged for review.



Transposition of test values or inconsistencies in medical dosage left uncorrected

without

editing

the

document

produced

through

speech

recognition can cause life threatening results. 

Sometimes, dictated notes may contain contradictory details that need to be resolved.

To resolve all these problems, human intervention in the form of speech recognition editors is very important for monitoring the speech recognition data. They will perform voice recognition editing, data mining abstraction, data tagging and ensure data quality. You can already see the role of medical transcriptionists, who were responsible for transcribing the entire dictation changing to editors when using backend speech recognition system. In this case, dictation is captured by the speech recognition software as a first step, which is reviewed, edited and corrected by the medical transcriptionist and then released for review and signature within the EMR. When choosing speech recognition editors, make sure that they have the following qualities: 

Thorough knowledge of medical terminology, anatomy and physiology, pharmacology, diagnostic procedures and treatment assessments.



Familiar with EHR systems with the ability to enter reports, create templates and help in developing documentation policies.

www.medicaltranscriptionservicecompany.com Many

reliable

transcription

companies

provide

the

service

of

such

transcriptionists along with three-level quality assurance. Go for the services offered by such companies, and benefit from effort saved as well as time and money savings.

However, there is no role of transcriptionists in the case of front-end speech recognition where real-time transcription takes place. In this system, physicians are responsible for correcting the mistakes while they dictate. If you want to ensure data quality in this scenario, you should divide the physician group into two for back-end and front-end and give simple tasks for the front-end group. This will reduce the workload of physicians working with front-end system so that they can concentrate more on their work and avoid making mistakes.

Contact MTS Transcription Services 8596 E. 101st Street, Suite H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442 E-mail: info@managedoutsource.com