We’re eliminating transcription

Participating in healthcare related conferences and talking with prospective clients, I hear many people say that they are eliminating transcription.  They point to their electronic medical record, front end speech and other means to reduce transcription and the associated cost, but that’s not where the conversation ends.

NEMT New Business Development Director Rick Bisson

Admittedly, they haven’t eliminated all transcription … certain specialties, practices or doctors are still relying on transcription.

Then when the conversation progresses to the practicality of the facility’s highest income producing assets – who are also the highest paid staff members – spending up to two hours a day doing clerical work, there is general agreement – maybe that’s not the best use of their time.  Not only are these highly educated and skilled providers typing their own reports, they are also responsible for editing and correcting any errors or omissions.  Ask yourself: Is this a best practice for a health care provider?

And what about errors and omissions?  Certainly the doctors typing, cutting and pasting and clicking are well intended but doesn’t their responsibility to accurately document the patient’s encounter create legal liability? With the advent of the electronic medical record, isn’t there heightened exposure?  As each of us gains greater access, awareness and involvement in our own medical records and those of our loved ones, we will become critics of the documented narrative in our reports.  Soon many of us will have an electronic folder on our desktop computer, or in a shared folder on Dropbox.  From time to time we’ll review the reports, especially before or after appointments or surgery.  If we find errors or omissions then we’ll be quick to expect corrections.  Some may be quick to take advantage for any potential financial gain.

Inevitably the topic of ICD-10 emerges.  Clearly ICD-10 increases the need for more specificity of the patient encounter.  Will this increase the provider’s narrative and increase the need for editing?  Most agree it will.  Are providers going to spend more time as typists and editors and less as healers?  Will they be rushed to cut and paste more, thus reducing the individual narrative specific to each patient encounter?  Could this lead to more errors?

Now don’t get me wrong, certain routine functions within the EMR and advancements in dictation options speed the delivery of patient information.  More on that topic will be covered in a future posting.

The end game is the creation of a document summarizing a patient encounter.  This document becomes a permanent addition to the patient’s health record.  The accuracy and clarity of this report is critical to the immediate and future care of that patient.

What better system exists to effectively and efficiently permanently capture the patient encounter than a provider dictating their report and a skilled transcriptionists or editor finalizing the document?

What do you think?

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4 Responses to We’re eliminating transcription

  1. Very important topic.

    As for “What better system exists ?”, the answer is none.

    Here is my advice for anyone thinking of eliminating transcription.

    “Bad mistake to try to eliminate transcription.

    In the past it was necessary to dictate, ship a voice file to the transcriptionist, wait for the text file to be sent back, review the file, possibly send it back to the transcriptionist or to some internal administrative assistant for final edits, wait for the final text, then import the text to the EMR,

    Thanks to new technology, all of this can be streamlined and made seamless.

    1. physician directly dictates into an MS Word, Wordpad etc window.
    2. the EMR attaches the file to the patient EMR at a “dictate” step along a patient care pathway.
    3. the EMR automatically “sends” the file to the transcriptionist as the next step along that patient care pathway (“transcribe”)
    4. the transcriptionist immediately sees the file at his/her InTray and simultaneously listens/types/edits and then commits the ‘transcribed” step.
    5. the EMR automatically picks up the typed/edited text and posts this back to the patient care pathway as a “review” step.
    . . . .

    As you can see the major contribution of automation is automation of gaps between the contributions of various skilled human resources, greatly reducing the time between dictation and final progress note and eliminating 90% of coordination/tracking.

    So, bottom line, look for an increase in the use (now efficient use) of transcription.

    If you are in the process of eliminating transcription, you are on the wrong track. “

  2. Judy Noecker says:

    I had a visit with a cardiologist. The hospital I went to just had emplimented EPIC a total electronic medical record. (NO PAPER) The Dr during the whole visit was busy asking me questions and typing!!! He was not looking at me at all during the typing.
    He then listened to my chest and then the visit was over…..
    I now have a new cardiologist. He looks and listens to me and is not typing during the visit.

  3. Sue McKeown says:

    I have a friend who works in a community mental health center. She recently told me that they are gradually phasing out transcription via speech-to-text. The transcriptionists receive the results of the speech-to-text dictation from the clinicians and serve as editors, rather than transcribing the dictation. She reports that the quality of the speech-to-text software continues to improve, they do not replace transcriptionists when they leave their jobs, and the remaining transcriptionists find their jobs more challenging. They also encourage transcriptionists to apply for other positions in the agency for which they qualify to avoid layoffs.

  4. Anonymous says:

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