Medical transcription: Importance of multiple reviews for assuring quality

Medical transcription  is the process of creating patient medical records, converting the audio of the patient- healthcare professional encounter into text format. Quality or accuracy of the information in the patient transcript is one of the most important factors, as the information in patient medical records is vital for providing quality care, to start the process of reimbursement and as a component of risk management. To this end while outsourcing medical transcription it is important to assess whether the medical transcription service provider has methods for quality assessment.

As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.

Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.

Do: Assessment policies and procedure

This part is very important as it shows that there is a formal policy, which lays out the procedure for quality assessment. Assessment and improvement procedures should be throughout the documentation process, instead of an exercise used for filling blanks, flagging errors or tabulating error rates.

The purpose of this exercise should be to help provide feedback, play a significant role in ensuring patient safety and maintain integrity of the document.

The assessment policy should include:

• Concurrent review: This means that the transcripts that have gone through the first stage of transcription by the medical transcriptionists, are subject to complete and comprehensive review. This is absolutely essential when the expertise of the medical transcriptionist has not been established or when the medical transcriptionist transcribes for a new specialty or when transcribing for a new healthcare professional.

• Retrospective review: Though concurrent reviews are ideal for the quality process, it may not be possible to review 100% given the tight turnaround time requirements. However reviews are an essential learning tool especially for medical transcriptionists, it is important to have retrospective reviews

• Review of flagged documents: This type of review occurs when the initial or first stage of medical transcription has flagged blanks/ error etc. It is important to review these transcripts and resolve the flagged errors before transmitting for final authentication to the healthcare professional/ healthcare facility.

• Using the findings from these reviews as feedback: The purpose of these reviews is to help improve the quality and reduce errors. Therefore the findings from these reviews are used as a learning tool to improve the work of medical transcriptionists. Another important aspect of these findings is also to provide feedback to healthcare professionals. The findings can be used to educate healthcare professionals in best practices for dictation. 

The purpose of reviews is to improve quality, provide feedback, enabling medical transcriptionists to improve quality/ accuracy of the medical transcription.

TransDyne, a leader in the medical transcription industry has a well-established process in place of quality assurance. Each and every document is subject to multiple levels of quality check. Moreover the quality assurance team does random checks of transcripts and the findings are used as learning tools to improve quality

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!  

To avail complete medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Benefit from the best practices of the service provider

The practice of medicine requires expert inputs to meet the high standards of quality care and profitability. Keeping in mind that healthcare is a specialized skill requiring intense focus and concentration to produce the desired results it is important for both healthcare professionals and healthcare facilities to focus on the core business of providing quality healthcare and outsource all support activities.

Outsourcing all activities other than the core process of providing healthcare not only endows numerous benefits like reduction in costs, renewed focus of efforts and resources on the core business, but also ensures that the healthcare facility can benefit from the expertise and best practices established by the service provider.

Medical transcription is one such activity that plays an important part in the healthcare process by creating patient medical records, converting the audio dictation of the patient- healthcare professional encounter into text. Though the information in patient medical records is vital to the smooth running of healthcare facilities; contributing to the process of providing care, providing the basis of coding and billing and providing an important support in risk management, medical transcription is not part of the core activities of the healthcare facility.

The best solution available to healthcare facilities to avail accurate, timely, secure and cost effective medical transcription is to outsource their medical transcription needs to a professional service provider. Outsourcing medical transcription to a professional medical transcription service provider ensures that the healthcare facility can benefit by the best practices established by the medical transcription service provider.

What are best practices in medical transcription that can benefit healthcare facilities?

Best practices have been defined as a method, process, activity that is believed to be more effective at delivering a desired outcome than any other technique, method, process etc when applied to a particular condition or circumstance.

In the context of outsourced medical transcription services, best practices can be defined as those process that produce the desired outcome, namely:

• Accuracy: One of the main quality criteria that medical transcription needs to meet is the accuracy of the information transcribed. The best practices established by the medical transcription service provider have a role to play in this regard. The accuracy would be affected by:         

1.     The skill of the medical transcriptionists: The medical transcription service provider would have best practices with regard to recruiting the best talent and for training policies to ensure expert transcription

2.     Quality check methods: Due to various factors like distorted audio, the style of dictation, the specialty and the skill level of the medical transcriptionists, it is important for medical transcription service providers to have best practices in place that ensure that more than one set of skilled “ears and eyes” are involved in the process of quality assurance.

• Speed: Apart from the accuracy, the other most important quality factor is turnaround time. It is important for healthcare professionals and healthcare facilities to have patient medical records available to them within specific time periods. The best practices of the medical transcription service provider towards maintaining tight turnaround time would involve having: 

1.     A huge pool of skilled and trained medical transcriptionists in different specialties to ensure quick turnaround time without compromising on accuracy

2.     The right technology to ensure speedy and secure delivery of audio for transcription and convenient modes for document delivery

• Convenient: The best practices of the medical transcription company with regard to convenient options could extend to: 

1.     Helping retain familiar modes of dictation enabling healthcare professionals to optimize their limited time

2.     Options for document delivery as per the need of the healthcare professional

• Secure: The best practices of the medical transcription service provider regarding the HIPAA/ HITECH compliance during the medical transcription process would include: 

1.     Secure technology

2.     Secure processes including 100% in-house transcription

3.     Secure infrastructure

• Flexible: The best practices of the medical transcription service provider with regard to flexibility would include volume flexibility, flexibility with regard to turnaround time and other factors like weekend and holiday transcription etc.

• Economical: The best practices of the medical transcription service provider in this regard would be billing methods as per AHDC norms, limiting cost to cost per line of transcription, elimination of fixed costs, no hidden costs and conversion of fixed costs of medical transcription to variable costs. 

TransDyne, a leader in the outsourced medical transcription industry has been serving the needs of some of the leaders in the healthcare sector for over a decade. Drawing on their experience in serving the needs of healthcare facilities and their expertise in information technology, TransDyne has established best practices that help healthcare professionals and healthcare facilities save on money, efforts and time.

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!            

To avail outsourced medical transcription services from TransDyne, click here.

Medical transcription: Procedure for quality assessment

The healthcare process is dependent on various inputs to provide safe, effective and quality services. To this end every factor that contributes to the healthcare process has to meet the highest standard of quality.  One such contributor to the healthcare process is information from patient medical records. The information from the patient medical records act as a reference point for various activities, involving the healthcare, operational and commercial aspects of the healthcare facility. Medical transcription is the process of creating patient medical records from the narration of the healthcare professionals regarding the patient encounter.

As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.

Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.

Do: Providing training to all the personnel involved in the medical transcription process

This part is very important, as the quality of the transcripts is dependent to a large extent on the skill level and experience of the medical transcriptionists. The skill level of the medical transcriptionist team in turn is dependent on the recruitment policies and the training provided to medical transcriptionists based on their specific capacities.

This consists of the following steps:

• Sourcing the right talent: Medical transcription is a skill, which requires a combination of language skills, knowledge of medicine, adequate keyboarding skills, dexterity with computers, good listening skills and an attitude for perfectionism & discipline. It is important to source candidates with the right attitude and aptitude

• Selecting the candidates: This would involve testing the skill level of the potential medical transcriptionists subjecting them to tests and process of evaluation.

• Segregating the candidates as per skill level: Based on the level of skills displayed by the potential medical transcriptionists, they could be segregated based on specialties and as proofreaders & editors

• Training process: The training process will provide the medical transcriptionists with the knowledge base required for optimum transcription and hone their existing skills to perfection. This part of the process is a continuous process involving keeping the medical transcriptionists updated regarding the latest developments in medicine and empowering them with the right reference resources to enable accurate transcription.

• Assessment and feedback: One important aspect of the training exercise is to put medical transcriptionists through the actual process of transcription and then providing them with assessment of their work. The feedback provided enables medical transcriptionists to focus on honing their skills. 

TransDyne, a leader in the medical transcription industry has processes in place to facilitate the recruitment of the right talent. The next step involves segregating medical transcriptionists into teams that specialize in one or two specialties. Extensive training is provided by TransDyne to the medical transcriptionists on the specialty making them domain experts in that specialty ensuring quality from the very start.

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!  

To avail complete medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Providing meaningful context

The world of healthcare has evolved so much with the advent of new remedies, new inventions and the discovery of numerous methods for improving the health of those seeking healthcare services. Considering that the number of people seeking healthcare services have increased, the demand for these services has also increased. In such a scenario it is important for healthcare professionals to maximize their productivity in such a way as to focus on providing quality care consistently. In such a situation it is important that the healthcare professional – patient encounter be documented in its entirety.

While the importance of documenting the patient- healthcare professional encounter is undeniable as it provides support in numerous ways including, providing the base for planning care, keeping track of progress, the basis for coding & billing, and forming an important component of risk management among many other numerous purposes, it is important to choose the right means of documenting the process.

Out of the many options available to healthcare professionals and healthcare facilities for documenting the patient encounter, outsourced medical transcription services have proven to be one of the most convenient and cost effective solutions.

Why are outsourced medical transcription services the most convenient and cost-effective method of documenting the patient encounter?

Medical transcription service providers have added value to the process of documenting the patient- healthcare professional encounter by taking the data provided by healthcare professionals and support staff by converting it into meaningful information applying their considerable expertise. Medical transcription services have provided value to the process of documentation by applying context to reduce inconsistencies, to make documentation useful and meaningful.  Medical transcription service providers are able to provide meaningful context to the process of documentation using:

• An inherent understanding of the working of healthcare professionals/ healthcare facilities: Medical transcription services have worked with the healthcare sector for such a long time that they have an inherent understanding of the needs of healthcare professionals and healthcare facilities with regard to documenting the healthcare process. This inherent understanding combined with their expertise in terms of people skills and technology enables them to provide services that match the needs of the healthcare professional without hindering the healthcare process. Some of the notable ways that outsourced medical transcription services ease the working life of healthcare professionals are: 

1.     Enabling healthcare professionals to retain the familiar methods of dictation to transcription without compromising on quality or turnaround time

2.     Enabling healthcare professionals to retain their preferred mode of dictation to optimize their time productively

3.     Providing a system for transcription that enables all functions required for effective functioning while still being easy to use.

4.     Providing modes of document delivery as per the preference of the healthcare professional

5.     Providing healthcare professionals with medical transcriptionists who are trained in their specialty to enable immaculate services from the beginning

• Understanding the importance of HIPAA compliance in the documentation process: Outsourced medical transcription service providers understand not only the security norms laid down by HIPAA/ HITECH, but they also have a deeper understanding of the need for these norms. Outsourced medical transcription service providers have stylized their working processes, premises and technology to allow for HIPAA compliance.

• The ability to customize services as per the need of the healthcare professionals: Medical transcription is a dynamic field and there are new innovations in the way the patient- healthcare professional encounter is documented. Healthcare professionals have adopted technology like speech recognition software for their transcription needs. However transcription using this software requires further editing and proofreading services. Outsourced medical transcription service providers have stepped into the breach providing editing services for these transcripts, allowing healthcare professionals to maximize their productivity and concentrate on their core task of providing healthcare services. Outsourced medical transcription service providers have also enabled HL7 interface to allow for transmission of data to the EHR/EMR. 

It can be seen that outsourcing medical transcription to the right service provider can convert the data from the patient- healthcare professional encounter into meaningful information that provides the right context to the treatment process.

TransDyne, a leader in the outsourced medical transcription industry has utilized their extensive background in information technology and their experience in providing medical transcription services to come up with medical transcription solutions that help healthcare facilities save on time, money and effort. TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!              

To avail complete outsourced medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Establishing procedure for quality assurance

As medical transcription is the process of creating patient medical records from the dictation of the healthcare professionals of their encounter with patients, quality is one of the most important criteria. Most outsourced medical transcription service providers have an established procedure for ensuring high standards of quality. Quality of transcripts is the responsibility of everyone who is involved in the creation of transcripts.

One of the significant factors that affect the quality/ accuracy of transcripts is blanks. While in some cases leaving blanks in the final transcript is unavoidable or sometimes even preferred by the healthcare professional, in most cases blanks left in the transcripts affects the accuracy and should be avoided.

What causes blanks to occur?

There could be various reasons for the occurrence of blanks in transcripts transmitted back by medical transcription companies, some of which are listed below:

• Faulty audio
• Incomplete dictation
• Less than desirable dictation practices
• Discrepancy in the details dictated
• Blanks specifically requested by authors
• Unfamiliar or unverifiable terminology
• Preexisting blanks 

To minimize the occurrence of blanks in transcripts it necessary to employ a strategy that pervades all the entities involved in the creation of patient medical records.

• Author: As the healthcare professional is the originator of the patient record it is important to concentrate efforts on improving quality from this level itself. The measures to be taken to improve the quality of transcripts from the healthcare professional end are: 

1.     Familiarize healthcare professional with recording equipment

2.     Enable them to use dictation devices of their choice

3.     Educate them on dictation best practices

4.     Provide feedback on the quality of dictation provided by them

5.     Provide them with template/format for dictation

• Healthcare facility staff: As the dictation originates from the healthcare facility premises it is important to educate the healthcare facility staff on the importance of providing a HIPAA compliant and relatively quiet environment for healthcare professionals to record their dictation

• Medical transcriptionist: Apart from the healthcare professional, one of the most important contributors to the quality of the transcript is the medical transcriptionist/ medical transcriptionists working on the transcription. To ensure that errors are minimized and quality is maximized, medical transcriptionists have to be empowered with:

1.     Proper training in the specialty they are transcribing in

2.     The know how to adjust audio speed to ensure maximum clarity

3.     Reference materials to help find elusive words

4.     Train them to apply context to help fill the blanks as accurately as possible

5.     Provide them with feedback to enable improvement

6.     Collect feedback from medical transcriptionists to be given to healthcare professionals  for improving their dictation practices. 

• Medical transcription service provider: The medical transcription service provider has a definitive role to play in improvement of quality and minimizing blanks. The medical transcription service provider can help maximize quality by:         

1.     Have a process in place to ensure that each transcript undergoes a stringent quality assurance process involving more than one set of “eyes and ears”

2.     Have a complete set of updated templates and macros for each healthcare professional/ healthcare facility, which should be provided to the medical transcriptionist team working on it

3.     Having quality audits on a regular basis

4.     Using the findings from quality audits as learning tools

5.     Provide medical transcriptionists with good training

6.     Make updating and educating medical transcriptionists a continuous and automatic process

It can be seen that while outsourcing medical transcription it is not only important to assess the medical transcription service provider based on the quality commitment given by them but also assess the quality program of the medical transcription service provider to ensure that they have sound quality processes in place to ensure quality transcripts.

TransDyne, a leader in the outsourced medical transcription industry has been servicing the needs of healthcare facilities and healthcare professionals for over a decade. TransDyne understands the importance of quality in medical transcription and has provisions in place to ensure the right support to enable quality transcription.

TransDyne has made quality a key word in their work processes. This attitude of adopting quality as the basis of their services and their aptitude in information technology has helped them come up with easy to use medical transcription solutions that help save on time, money and efforts.

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!  

To avail complete medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Producing documentation support based on AHDI guidelines

Planning for factors affecting quality:

The accuracy of information in patient records is perhaps one of the most critical factors that are considered while availing outsourced medical transcription services. It is important for a medical transcription service provider to have a policy in place to deal with all the factors that affect the quality of transcripts.

What are the factors that affect quality of medical transcription?

• Author: The origin or substance of the patient medical record is from dictation of the healthcare professional, detailing the patient encounter. It is important for the healthcare professional to be aware of the impact of proper dictation practices. The medical transcription service provider could help in enhancing the quality of dictation by providing feedback to the healthcare professional and help them improve the quality of dictation by providing them with dictation best practices that produces optimum quality.

• Experience of the medical transcriptionist: One of the factors that help in maintaining quality is the skill set and experience of the medical transcriptionist. The medical transcription service provider should allot difficult-to-interpret audio files to medical transcriptionists with experience in transcribing such files. The quality policy should also include quality checks involving several levels by experienced and skilled personnel.

• The audio equipment used for dictation: The quality of dictation is dependent as much on the author as the quality of equipment used. It is important for the outsourced medical transcription service providers to orient the healthcare professionals with the audio equipment to enhance the quality of dictation.

• Patient demographics: While transcribing the patient medical record it is important to ensure that all the demographic details of the patients have been included accurately.

• Specification of the healthcare professional/ healthcare facility: Another factor that adds to the quality of the final transcript is ensuring that they are created according to the specifications of the healthcare professionals/ healthcare facilities. These could vary based on the specialty/ type of report/ preference of the healthcare professional/ healthcare facility. The specifications specified by the healthcare facility/ healthcare professional should be updated to enable quality output.

• Resources for improving quality: The medical transcriptionists should be empowered with resources that help them produce transcripts of maximum accuracy like dictionaries, latest drug references, specialty word dictionaries, references for anatomy, physiology and diseases etc, both in physical and virtual form

• Software resources for enhancing quality: Software and tools like spell checkers, word expansion software etc should be provided to medical transcriptionists to enhance quality. 

TransDyne, a leader in the outsourced medical transcription industry has been serving the needs of healthcare facilities and healthcare professionals for over a decade. TransDyne understands the importance of quality in medical transcription and has provisions in place to ensure the right support to enable quality transcription.

TransDyne has made quality a key word in their work processes. This attitude of adopting quality as the basis of their services and their aptitude in information technology has helped them come up with easy to use medical transcription solutions that help save on time, money and efforts.

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!  

To avail complete medical transcription services from TransDyne, click here.

Medical transcription outsourcing: Producing documentation support based on AHDI guidelines

The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.

As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.

Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.

Plan: Planning policy guidelines for quality

This part of best practices for maintaining quality involves a set of standards for documentation that ensures accuracy, accessibility and overall value of the patient medical record as a resource for understanding the care process including diagnosis, treatment and progress.

To ensure this, the planning process should have principles that ensure:

• Verifiability: Any quality program should have standards and measures that are easily verifiable and these measures should be available to personnel at every level of the organization and to the end user of the transcript to ensure cross verification

• Definability: The error categories should be clearly defined

• Measurability: Measurable values for clearly defined error categories should be assigned and measurement methodology for errors should be clear to all the parties involved

• Consistency: The quality program should define error categories, values to be assigned to each category and there should be a standard method error determination.

• Integrity: The integrity of document can only be assured when there is a synchronized partnership between the originator of dictation and the medical transcriptionist. The healthcare professional dictating the notes should present information in a clear and concise manner and the medical transcriptionist should transcribe the document preserving the essence of the information provided by the healthcare professional.

To this end the quality assurance program should be based on Quality Guidelines that ensure the following:

• Accurate and complete documentation ensuring that the essence of the encounter is captured
• A process of distribution of reports on a timely basis and a system for easy accessibility of past records to the relevant personnel
• A practice of periodical quality audits to study the process and assess where errors occur as a part of the ongoing quality process
• This process to be applied to medical transcription at all levels
• The assessment program should be consistent and unbiased
• The assessment program should be according to the principles of assessment agreed upon
• The results from the assessment process to be used as a learning tool to ensure recurrence of errors
• Access to the Quality Guidelines, assessment process to be made available to all the people involved in the transcription process. 

To be successful a quality assurance program should be:

Proactive: Medical transcription being such a critical activity that contributes to the healthcare process, it is important for quality assurance program for medical transcription to be proactive. Being proactive ensures that solutions are available for problems before they turn into major issues

Realistic, scalable and financially feasible: Quality in medical transcription is a continuous process; therefore it is important that the quality assurance program should be realistic and cost effective

Simple and easy to implement: Medical transcription is a process that consistently needs to meet the quality constraints of accuracy and timeliness, keeping this in mind any quality assurance process has to be simple to be workable.

Secure and Confidential: Considering that medical transcription involves working with confidential patient information and comes under the purview of HIPAA it is important that any feedback regarding quality keeps in mind the confidentiality norms

Inclusive of all aspects: Quality in the medical transcription process involves all aspects starting from the origin of the data down to the medical transcriptionist, proofreader and quality team, the quality assurance program needs to plan measures to include all these aspects

Reportable for trending and tracking purposes: The process of quality assurance is not only to ensure consistent quality documentation but is also a valuable input for education purposes

Timely: The quality assurance process should be scheduled in timely manner to ensure maximum results

TransDyne, a leader in the medical transcription industry has made quality a key word in their work processes. This attitude of adopting quality as the basis of their services and their aptitude in information technology has helped them come up with easy to use medical transcription solutions that help save on time, money and efforts.

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!  

To avail complete medical transcription services from TransDyne, click here.