Scribes and Medical Transcription can save Documentation Time

Scribes and Medical Transcription can save Documentation Time

A recent study recognizes that using scribes and medical transcription helps dermatologists and other specialists improve documentation time.

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A study conducted by the American Medical Association in collaboration with the RAND Corporation showed that EHRs one of the key drivers of physicians’ dissatisfaction with their practice environments. The reason, obviously, is difficulty with data entry, an issue that medical transcription companies strive to address with high quality EHR-integrated documentation solutions.

A recent study published as a research letter in JAMA Dermatology found that medical scribes can save dermatologists’ documentation time and help reduce physician burnout.

The researchers also noted that alternatives such as dermatology transcription service have provided especially good outcomes in situations other than principally face-to-face care.

Experience shows that documentation support by scribes and medical transcription service providers can go a long way in improving patient and patient and clinician satisfaction as well as workflow and productivity.

Clinical Documentation Support can address Physician Burnout Studies have found that though electronic medical records (EMRs) offer care delivery integration, physicians spend up to 2 hours on EMR-related tasks for every 1 patient-care hour. This has resulted in decreased physician satisfaction and increased physician burnout in many specialties including dermatology.

When a new EHR was installed at Boston’s Brigham and Women’s Hospital, dermatologists at the institution conducted a study to test the effectiveness of medical scribes.

The

dermatology department had 39 dermatologists and 11 practice locations. Beginning February 2016, 12 dermatologists were assigned a scribe for 19 weekly half-day general dermatology sessions across 3 clinical sites. The scribes, who were provided by a third-party vendor, underwent specific training on physician specific workflow and documentation preferences. Carrying dedicated laptops across rooms, the scribes documented patientphysician interactions and recorded orders such as pathology requisitions, medications, and diagnoses for approval by the physician.

The study found that employing medical scribes: -

Had a significant impact on dermatology practice workflow, physician satisfaction and productivity

-

Cut physicians’ average time spent on EHR work in half

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-

Increased dermatologists’ willingness to see additional patients with scribe support

-

Increased revenue by 7.7 percent, when each physician’s scribe-supported session was compared to unsupported sessions

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Freed up physicians’ time for “scholarly, leadership, teaching, or personal pursuits”

“Across 690 prescribe time-audited encounters, dermatologists averaged 6.1 minutes of clinical documentation per patient,” the researchers reported. “Across 695 post-scribe visits, physician documentation time significantly decreased, averaging 3.0 minutes per patient.”

The study found that scribe support enhanced physician efficiency, improved patient access, and increased clinical revenue. Moreover, the scribes were well received by patients, with few refusals and unchanged overall patient satisfaction scores.

Study recognizes Significance of Medical Transcription Outsourcing Importantly, the research study recognizes the contribution of medical transcription services for various fields.

“Other solutions combating physician documentation burdens, such as real-time dictation software

or

conventional

transcription

services,

have

been

employed

particularly

successfully in diagnostic specialties, such as pathology and radiology, which have limited point-of-care patient interaction,” the researchers noted.

Tips to Improve Clinical Documentation Taking accurate notes is crucial to boost communication in medical practices. It helps physician enhance continuity of care, improve claim reimbursement, and decrease the chances of a physician queries. Here are some steps that physician practices can take to ensure accurate and timely documentation: •

Define guidelines: According to a report from the American College of Physicians (ACP),

practices

should

define

clinical

documentation

guidelines

based

on

"consensus-driven professional standards unique to individual specialties." The report notes that the primary goal of EHR-generated documentation should be crisp, history-rich notes that reflect the information collected and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up.

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•

Train staff: All new and existing staff should be well trained in clinical documentation standards. The training must be an ongoing process and updated when the electronic health record (EHR) software is updated. When the staff is knowledgeable about documentation standards, there will be less risk of errors.

•

Document thoroughly: All diagnoses associated with the patient should be captured.

By documenting secondary diagnoses, risk and severity adjustments can be made, which will help to reflect the patient’s condition more accurately and improve quality of care.

•

Review past documentation: Evaluating past documentation can help improve the accuracy of EHR documentation. Working with their patients to review notes will help physicians identify errors in the medical record.

•

Establish an organized record-keeping system: It is important to ensure that medical records are easily retrievable for review and available at each patient visit, as well as for use when needed.

•

Select the most appropriate EMR system for the size and type of practice: Physicians should choose EMR software that adapts to the way they conduct their office activities.

For

dermatology

instance,

practices

a

that

www.emrconsultant.com conduct

physical

article

exams,

laser

points

out

that

treatments

and

phlebotomy in different rooms, will need an EMR that can automatically migrate all of the patient’s data so that it is accessible from any computer throughout the office Regardless of whether you prefer outsourcing medical transcription or use scribes, using these strategies can improve clinical documentation, medical coding, and reimbursement.

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