We’re eliminating transcription.

                                                                                      By Rick Bisson

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.
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?