The Emerging Role of Medical Transcription in the Electronic Health Record

A White Paper

By Darice M. Grzybowski, MA, RHIA, FAHIMA

AHIMA Academy Approved ICD-10-CM/PCS Trainer

President, H.I.Mentors, LLC 

July 6, 2017

Concerns Regarding the Sub-Optimal Documentation Environment of the EHR

As electronic health record (EHR) system usage continues to accelerate in the hospital inpatient, outpatient, and professional practice settings – we unfortunately continue to see a gap in the ability of the medical record to accurately reflect the story of the patient as well as the paper record historically has done.   In addition, clinicians, heath information management professionals, and risk managers continue to voice concerns about the integrity and usability of the data and the documentation within the record.  If we are failing to produce a quality record for basic business and legal means, can we really feel confident that we are producing documentation which supports continuity of care and prevents patient errors?  

Examining the Causes of the Deficient EHR

It would be easy to point to the poor design of workflow by the vendors that does not reflect the reality of both dynamic patient care documentation and the post discharge needs for a persistent document based archived record for retention and access purposes.  It is also evident that the rushed implementation of these systems due to government incentivization (within the U.S.) caused facilities to begin to use their systems prior to organization readiness, creating a state of automated dysfunction.   However, at times, we are our own worst enemy in prematurely reducing or eliminating quality control best practices which are intended to improve documentation, in exchange for the potential of reducing costs.  

This has never been truer than in situations where organizations have attempted to replace clinical dictation and transcription with template based data entry, drop down list selection, or other dictation shortcuts, such as clinical self-edited notes based on a combination of speech recognition and/or natural language processing.   

Why Transcribed Reports Are the Clinical Link to Improved EHR Documentation

Routine free form dictation, with or without speech recognition editing, is a critical tool for maintaining the integrity of the clinical record.  Key reports which historically have been dictated and transcribed, but are sometimes not visible to the care team using the medical record include: History and Physical, Consultation Reports, Operative Reports, Pathology Reports, Radiology/Imaging Reports, and Discharge Summaries.  Current problems are amplified due to copy and paste, automatic template populations or pull-through data, and excessive use of pre-filled templates based on drop down list data, have made the EHR cumbersome to work with for both those creating the documentation and those reviewing it.  

The function of release of information (ROI) in an organization provides copies of the EHRs to patients, third party payors, attorneys, and other clinicians.  Across the board, facilities are reporting experiencing a tremendous increase in paper and toner usage due to excessive volumes of poor and redundant documentation within the EHR, and an increase in requests to provide amendments to errors in the documentation and/or potential litigation settlement cases.   In addition to quality problem which are created when there is a lack of transcribed core documents, the cost of producing a copy of the record has increased tremendously due to the poor formatting of printed output data within the EHR. 

Coding, and thus reimbursement, has the potential to also being negatively impacted from a record that fails to tell the story of the patient’s episode of care.  Coders must follow strict ethical standards when coding, and are also heavily monitored around productivity standards, thus often ‘rush’ through reading an overly bulky or repetitive record, missing small details which can be coded to more accurately reflect the severity and morbidity of the cases.  Excessive volume of documentation, as well as the inability to differentiate duplicative documentation add to the confusion of the end reader.  Template based data may help with longitudinal displays of data for reporting purposes, but does little to assist a care team member, auditor, or even the patient read the story of the patient. 

With advancing technologies today, which help to extract documentation elements from within transcribed reports, as well as digital technologies which allow for greater transfer of whole document elements for review and long-term storage, use of medical dictation and transcription has become an increasingly important element in the creation of electronic health records. 

Conclusion and Recommendations

• Healthcare organizations must assess the current documentation process including form and format of input (i.e. template vs. transcribed documents) and its impact on clinicians and other users to assure optimal efficiencies in the documentation creation process of the health record.
• Healthcare organizations must evaluate the integrity of the record content, and the accuracy and usability of it’s digital as well as printed legal health record format and output.
• Healthcare organizations must set up appropriate quality controls and ongoing audits to ensure the completeness, conciseness, compliance, concurrency, and clarity (5 Cs) of legal health record documentation to ensure patient safety, risk mitigation, and correct communication between clinicians for continuity of care is being met. 
• Healthcare organizations must work with electronic health record vendors to continually evolve the dynamic capture as well as the long term archival capture of documentation to assure persistence and accuracy of documentation to help communicate the story of the patient. 
• Healthcare organizations must consider all mechanisms and methods of data and documentation available to clinicians including medical dictation/ transcription, direct key data entry, dictation to data, natural language processing, scanned input, biometric data receipt, and use of medical scribes and other processes which are most appropriate for efficient and quality record keeping as defined through information governance, security, and privacy protocols.

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Darice Grzybowski, MA, RHIA, FAHIMA is President of H.I.Mentors, LLC (www.himentors.com) – a best practice HIM consulting, revenue cycle, software development, and strategic marketing firm founded in 2005.  Ms. Grzybowski is a subject matter expert and author of the 2015 AHIMA Triumph Literary Legacy Award for her book “Strategies for Electronic Document and Health Record Management” (AHIMA Press, July 2014).  She has over 30 years of healthcare experience as a hospital administrator, consultant, and subject matter expert as well an Adjunct Assistant Professor with the University of Illinois at Chicago.  She is a nationally recognized leader, speaker, past president of the Illinois Health Information Management Association, and winner of the AHIMA Triumph Award in Advancement in Computerization of Health Records, Advance Magazines Top 10 HIM Professionals in 2010, and recipient of the ILHIMA and CAHIMA Distinguished Member awards. 

Sponsored by iData^TM – iData is an industry leading company providing clinical documentation services, and coding and consulting services.  iData’s approach to the problems with Document Integrity flow directly out of a decade long approach to providing quality documents using their transcription, speech recognition editing, and coding modules.   In order to navigate through the various systems, processes, regulations, and stakeholder expectations, iData brings its proprietary approach to our customers called iD3: Preeminent focus on the customer (Client iD), world class management of people (Workforce iD), and attention to all facets of security (Secure iD).  Heightened issues surrounding Document Integrity has also compelled iData to start a consulting service related to solving document integrity problems.  For more information, visit iDataMedical.com