Selected Content Portfolio

Below are some examples of previously published content I wrote for ZyDoc MediSapien, a New York-based technology leader in medical transcription and informatics. Some text and images have been redacted.

Is Speech Recognition Safe … Enough?

Anyone who has tried to seriously use speech recognition in the last few years for clinical documentation – or any other purpose – knows two things: SR is far from perfect, and SR is getting better all the time. It’s popular in emergency departments for obvious reasons. The concept is a natural match for the rapid pace of an ER or radiology department – it allows doctors to transmit critical information quickly so that more patients can be seen, diagnosed more quickly, and treated more effectively.

Speaking is much faster than keyboarding. Using front-end SR (dictation with no editorial intervention by a third party on the back end), the near-instant conversion of speech to text is faster than dictating for later editing or transcription for entry into the EHR. But speed over accuracy is never a comfortable trade-off in healthcare. In non-emergency clinical settings poor quality documentation is even less acceptable. And the speed of front-end SR is deceptive. Compared to a short delay for transcription or back-end editing, the front-end method loses some of its edge when the time and frustration required for error corrections are factored in. An experienced human transcriptionist or editor will produce much better results In terms of accuracy, with the bonus of expedited STAT turnaround as needed, and automated section-level EHR entry.

Time considerations aside, accuracy is a big deal, whether in the ER, a hospital, or clinic. A mis-captured term or drug name, not caught, can seriously impact patient safety. We’ve all laughed or been horrified at bizarre text output from an SR app. As an app learns a speaker’s voice and phrasing, these errors are theoretically reduced, producing increasingly more reliable results. Even so, trusting SR without human supervision could be likened to leaping off a high cliff at night with a parachute that intermittently works. Or doesn’t.

On balance, is speech recognition safe? One experimental study, published in JAMIA in 2017, of SR use by 35 emergency department clinicians showed “significant increases in the occurrence of all classes of PPH [Potential for Patient Harm] errors when using SR across both task types: major PPH simple task …, complex task …, moderate PPH simple task …, minor PPH simple task …, and complex task.1

That the stakes are huge is not subject to debate. At the top of the list are patient health, privacy, happiness, quality of living, life itself, and death. Minor errors that don’t affect patient safety may be relatively tolerable; critical errors could be disastrous.2 Quality Assurance for clinical documentation is at least as important as speed, even in an ER or radiology setting.

So the answer to whether SR is safe enough is “maybe.” The only way to reduce risks associated with front-end speech recognition errors is to mandate immediate careful and detailed review.  On the other hand, transcription and edited SR are more reliable from the outset – the industry minimum standard is 98% accuracy – and they are comparatively fast when all factors are considered.

References
1 https://academic.oup.com/jamia/article/24/6/1127/4049461
Efficiency and safety of speech recognition for documentation in the electronic health record.
Tobias Hodgson, Farah Magrabi, Enrico Coiera
Journal of the American Medical Informatics Association, Volume 24, Issue 6, 1 November 2017, Pages 1127–1133, https://doi.org/10.1093/jamia/ocx073
Published: 27 July 2017

2 AHDI definition:
A critical error is any error in a patient care record that has the potential to:

  1. Adversely impact patient safety.
    2. Alter the patient’s care or treatment.
    3. Adversely impact the accuracy of coding and billing.
    4. Result in a HIPAA violation.
    5. Adversely affect medicolegal outcomes.

Source: Association for Healthcare Documentation Integrity (AHDI), www.ahdionline.org.
“Healthcare Documentation Quality Assessment and Management Best Practices” https://c.ymcdn.com/sites/www.ahdionline.org/resource/resmgr/toolkits/QABP17_Error_Values.pdf

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Scribes vs. transcription for EHR data entry? It’s not just about speed.

Transcriptionists and scribes share a common Latin word origin, scribere, “to write,” and can trace their roots back to antiquity. They have been around since the days of committing words and transactions to papyrus for philosophers and kings. In the current era of electronic health records, employing elite corps of language specialists is still the go-to solution for navigating the complexities of documentation. Both transcriptionists and scribes generate clinical documentation under the guidance of physicians for inclusion in the EHR. Both reduce the time-consuming, unnecessary cognitive overload imposed on clinicians by suboptimal EHR user interfaces that require counter-intuitive data entry by keyboard and mouse. Both solve the same problem, but they do it differently.

Medical transcription, once considered “old-school,” is now typically cloud-based, using secure cutting-edge technologies such as smartphone dictation, remote EHR connectivity, and natural language processing (NLP) to extract  structured data elements from narrative. Scribes are enjoying a new wave of popularity among clinicians who want to offload basic data entry and other non-medical tasks for completion in near real-time during patient encounters.

While the efficacy of scribes vs. transcriptionists is debatable, and seemingly a matter of individual physician preference, there are advantages to each but some serious risks to take into account.

Scribes

Pro’s: Documentation captured and entered in the EHR in near real-time. Physicians gain more meaningful time with patients, and improve their own work-life balance when they can untether from their computers.

Cons: No certification or training standards. No background for understanding medical and legal issues. Hiring challenges such as expense and turnover. Risks associated with errors may affect patient safety.

Scribes can work onsite or remotely (virtual scribes). They may be in-house employees with the ensuing overhead of salaries, benefits, and training; or they may be provided by a staffing agency. Scribe companies charge an average of around $15/hour per scribe, and may require a long-term contract and/or setup fees. On the plus side, physicians who use scribes may be able to offer patients more undivided attention, see more patients on a daily basis, bill more accurately, and have a better work-life balance when they are able to reduce screen and typing time, and confidently hand off EHR-related charting tasks.

That confidence has to be individually earned and maintained however. Various organizations and commercial entities offer training and accreditation programs, but there is no standardized certification for scribes. A high school diploma may be all that is required, with limited formal training if any. It’s very unlikely that a typical scribe will have a background sufficient to understand the medical and legal issues associated with patient health information, after perfunctory (if any) training in HIPAA and OSHA compliance. On the other end of the spectrum are pre-med and other healthcare students who are initially better qualified but see the job as a temporary stepping stone to their real career goals, resulting in high (and expensive) turnover. Recruiting an existing in-house medical assistant for scribe duties avoids the longevity issue, but often to the detriment of normal office operations.

If the first challenge is finding and keeping competent scribes, the second is acclimating to their physical presence and effectively utilizing their strengths. Some patients will reject the idea of a third party in the examination room, and the physician must handle those encounters without a scribe, but typically, scribes develop a strong rapport with and closely shadow their physicians. Breaks and, certainly, longer absences then become a problem, so multiple scribes may be necessary.

Risks related to over-documentation, patient safety, and malpractice represent the greatest challenge associated with the use of scribes. Although virtual scribes sometimes work from recordings, most scribes enter data into the EHR during patient encounters, with some pre-encounter data gathering, and post-encounter notes-processing. Without a strong background in medical terminology or pharmacology, or experience in a clinical setting, scribes struggle to keep up with their physicians to do the best they can. A 2017 research study published in JMIR Medical Informatics, “Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study,”1 showed wide variability between scribes in accuracy and length of notes, reflecting errors of omission and commission (elements not present in the control note, and thus assumed inaccurate). While entries must be attested by the scribe and then the physician before inclusion in the official health record, the physician may be saving neither time nor money if close review and extensive corrections are needed. Scribes are prohibited by CMS and Joint Commission guidelines from ordering prescriptions, but they may enter an order pending final signoff by the physician. If serious errors are not caught, the physician’s liability and patient safety are at stake.

Transcription

Pro’s: Extensive training in medical terminology and HIPAA compliance, and if relevant to their specialty, OSHA regulations. Standardized, accepted certification standards. Longevity of transcription as a career, not a stopgap. Most transcription is outsourced, reducing HR expenses and problems. Completeness and quality of notes. Physician’s full narrative captured from dictation to document the rich, nuanced patient health story. Automatic insertion into specific EHR sections reduces physicians’ keyboard and mouse usage. Accuracy easier to achieve because dictation is typed verbatim and reviewed by the doctor who will catch discrepancies between what was said and what was typed.

Cons: Documentation not accomplished real-time, although delay is minimal with typical 24hr or less, or optional STAT, turnaround. Other EHR-related clinical tasks are not performed, such as helping the doctor find previously stored information, or collecting pre-exam patient history in person.

Transcription is enjoying a resurgence as a response to the poor usability of most EHR systems. Doctors need to document extensively to meet government mandates and payer requirements, but they shouldn’t spend a disproportionate amount of time navigating the EHR with keyboard and mouse to accomplish clerical tasks that can be delegated to others. Transcriptionists, like scribes, fill the bill. Transcriptionists are less intrusive because they are not in the exam room during the patient encounter. Often they are not in-house at all; many work remotely under the auspices of a medical transcription service organization (MTSO) which charges the healthcare practitioner on a per-line or per-minute basis. No overhead, no HR headaches, no scheduling difficulties, non-impactful turnover if any. Transcriptionists choose their profession because they are detail-oriented medical language specialists who take pride in their role in the healthcare ecosystem by accurately and quickly transcribing doctor dictation for the primary purpose of patient care and for documentation in the EHR. While they may get to know a particular doctor by working with the doctor’s narrative style and learning frequently dictated phrases or prescribed drugs and tests over time, transcriptionists who demonstrate their excellence but never actually meet their doctors in person still become trusted, integral partners in the documentation process.

From a medical and legal standpoint, the use of transcriptionists may be less risky than using scribes. One, transcriptionists are generally better trained in medical terminology and thus apt to understand and transcribe exactly what the doctor says and means. (If they have questions, they can leave blanks or ask for clarification.) Two, transcriptionists’ responsibilities are limited to documenting encounters and reports as dictated. Transcriptionists do not also work independently in the EHR or support doctors with other aspects of patient engagement. They do not interpret a real-time doctor-patient interaction from their own perspective, which could result not only in individual variations (see above reference to the study, “Use of Simulation Based on an Electronic Health Records Environment …” 1), but also in errors of omission or commission (elements not present in the control note, and thus assumed inaccurate).

Transcription in the 21st century is largely web-based, requiring sophisticated, ultra-secure technology for recorded and transcribed data in transmission and at rest. Patient safety is paramount; HIPAA and PHI breaches incur serious penalties, and EHRs have their own security issues to factor in. The days of an individual typing on an unsecured computer a report from a cassette and delivering a paper printout or file on CD are gone, not just because digital processing is more efficient, but also because it can be made more secure. A good cloud-based MTSO, with stringent, verifiable security protocols in place, as well as a rigorous quality assurance program, significantly reduces provider risk. A full and accurate transcript also affords protection against claim denials, inadvertent over-billing, and audits. To achieve these benefits and comply with government mandates for reporting and information exchange (interoperability), an MTSO must employ state-of-the-art technology that can interface with EHRs in order to extract and insert the requisite data from transcriptions into the correct EHR sections.

An MTSO that has invested in highly trained specialized transcriptionists, strict quality assurance measures, and state-of-the-art secure cloud-based technology should be considered the gold standard for producing accurate, complete, and compliant clinical documentation. Can a scribe ensure the same level of trust and results? Weigh the pro’s and cons carefully, and give one or both methods a try. The right answer is the one that works best for your practice.

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Don’t choose, upgrade, or switch EHRs without asking these questions

ALL EHRs are not created equal. EHR usability directly impacts the burden of documentation.

The leading EHRs securely manage patient health information, but the way they do this can be vastly different. When clinical documentation is a source of frustration for doctors, there is a mismatch between their preferred documentation workflow and the EHR user interface. In fact, a top cause of physician dissatisfaction with their EHRs is spending too much time on tedious data entry tasks. EHR usability should be a primary consideration because it can alleviate — or conversely, increase — the burden of documentation.

Here are five critical questions to ask when evaluating the usability of an EHR.

  1. How do you insert information into the appropriate EHR sections?
  2. Is there remote access for when a doctor is out of the office?
  3. What is the degree of Interoperability? Does the EHR provide the ability for sharing data with authorized providers for coordination of care?
  4. Does the EHR provide coding assistance to help avoid claim denials?
  5. How extensive and easy to use are the data mining and reporting capabilities for audit trails or meeting government requirements?

Make a decision based on usability

EHR usability is a big deal because you and your staff will be using it every day, all day. Your EHR shapes your office’s workflow, affects doctor-patient interaction, and impacts, for better or worse, your revenue.

Weigh the pro’s and cons. Talk to other users, search EHR / EMR reviews on 3rd-party sites like capterra.com, g2crowd.com, and the annual Best in KLAS report, and request in-depth demos for the stakeholders in your organization. A decision-making spreadsheet is helpful to rank features and compare vendor platforms. If your IT team (or consultant) is not leading the search already, get them involved early on in the evaluation process to determine the feasibility of implementation and system management, and not least, to review security safeguards.

What if you can’t find the perfect system? Or the functionalities are there, but the EHR user experience is not a good fit for each of your doctors? (This is likely the case, because physicians’ cognitive processes are highly individual.) Ultimately, you’ll need to make a choice that checks off most of the important boxes for your practice. In many cases, missing features you need can be supplied by 3rd-party vendors who specialize in EHR integrations.

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6 Critical Considerations for Choosing an EHR

Which EHR Should You Choose?

  1. Is your practice ready to adopt a new workflow?

Do your research to learn how closely the proposed new EHR’s workflow will approximate your current (legacy) methods of handling PHI. If the new workflow logic will force a radically different approach to entering, organizing, and accessing patient health records, there will be a difficult period of adjustment for your physicians and staff. EHR usability is a hot-button issue, with many vendors falling short. Poor usability will cause significant frustration and inefficiency for your EHR users. If the user interface feels very difficult or will require significantly more staff resources than available, look for another EHR. Charting in an EHR requires a constant flow of data in and data out, a process that can take up to 2 hours per patient visit. An interface that is not user-friendly can make this process onerous. On the other hand, if the interface is generally user-friendly, it may be a good choice for your practice.

Make a list of what you want the EHR to do, and compare features between several different systems.

A specific EHR might be the best fit for your practice, but still lack certain functionalities that you want or need. There are third-party apps and service partners that can fill these gaps and enhance EHR usability. For example, a dictation-transcription service may solve the data entry bottleneck. Computer-assisted coding (CAC) and clinical decision support (CDS) can be integrated as add-ons. A mobile app can be used by physicians to connect remotely into the EHR by smartphone and securely view patient schedules and other information away from the office.

  1. Is the EHR certified for Meaningful Use?

To comply with Meaningful Use measures and qualify for MU payment incentives, CMS requires you to use a certified EHR. According to the ONC Quick Stats Dashboard (#30), “Certified health information technology (health IT) meets the technological capability, functionality, and security requirements adopted by the Department of Health and Human Services.”

Below are some helpful resources to check out.

  1. Financial viability factors: Does the EHR have a wide user base? Does it integrate with other EHRs and applications?

An EHR with a large user base is a good sign of financial viability. The last thing you want is for your EHR company to go out of business, leaving you with an orphan system that is no longer supported. Another good indication of stability is integration with other EHRs or third party platforms.

  1. Does the EHR system include a billing (RCM) component, or support integration with a claims management clearinghouse?

Clinical documentation entered into the patient health record provides the data needed for coding and billing, so it must be available to your billing system. Many EHRs have a revenue cycle management (RCM) component or can integrate with a third-party electronic clearinghouse like Change Healthcare (formerly Emdeon). This function may also be part of a practice management system integrated with the EHR. Given the complexities of claims management and payer networks, RCM connectivity to the EHR is a must. Having all information accessible in one system streamlines the generation of reports and audit trails, and minimizes delays and errors. An important caveat: if the EHR you are considering has a billing component, do your research and speak to other users regarding their satisfaction with the ease and accuracy of the interface.

  1. Can the EHR communicate with other EHRs, providers, and agencies outside your network?

Interoperability – the ability to achieve successful information exchange across disparate platforms and systems – is one of the strongest tenets of Meaningful Use. Siloed data is antithetical to coordination of care. Data blocking (aka information blocking) is worse. Clinical documentation frequently must be shared with, or available to, another physician, hospital, or healthcare agency for longitudinal patient care. Registry submissions and other mandatory reporting requirements also necessitate the sharing of data.

MACRA requires healthcare providers (eligible providers, hospitals, and critical access hospitals) to attest to three statements, referred to as “Prevention of Information Blocking Attestation,” about how they implement and use certified EHR technology (CEHRT). But while some EHR vendors are making efforts toward enabling seamless data exchange because of the government’s push for interoperability, the reality is that proprietary system architectures typically can’t communicate with each other without a separate connectivity solution, often at a hefty cost for the healthcare provider.

Interoperability within a vendor’s own closed ecosystem, e.g., communication across all users of that particular EHR, does not address the challenges of sharing data with other EHRs. There can also be financial incentives that discourage an EHR’s willingness to share data. For a statement of the problem, see testimony by David C. Kendrick, MD, MPH, before the U.S. Senate, “Achieving the Promise of Health Information Technology: Information Blocking and Potential Solutions,” July 23, 2015.

When systems don’t talk to each other, this is difficult or impossible to do electronically. Some EHRs are “walled” proprietary systems that guard your clinical data and severely limit its shareability. Various protocols exist to share data that are platform-agnostic, but the EHR must be able to transmit and accept data in those formats. Some of these protocols are HL7 messaging (CDA, CCD, ADT, FHIR); and DICOM (for radiology images). Application Programming Interfaces (APIs) also offer a bridge, by allowing two disparate software platforms to connect via an API key. As an example, an EHR’s API can be used to populate EHR sections with transcribed documentation. Depending on the EHR vendor, the vendor may charge from $2,500 to $40,000 for this connectivity. Or, a third party such as ZyDoc may be able to implement its own generic open source API. In either case, the end result is that the API will enable documentation to be transmitted across systems to other providers using an HL7 or other standard messaging protocol.

  1. Discuss your needs with third-party ancillary service partners that will need to interface with your EHR. Manual cut and paste? Look elsewhere.

Learn what connectivity solutions the EHR offers, and at what cost. Is a proprietary API required? Does the EHR communicate only with other users of the same vendor’s EHR? Does the EHR have existing interfaces for ancillary services such as RCM or transcription? For example, a dictation-based transcription service such as ZyDoc can seamlessly populate EHR sections to alleviate time-consuming pointing, clicking, and typing in multiple screens if a viable interface exists or can be implemented. Getting clinical documentation into and out of the EHR is one of the biggest hurdles for practitioners. Doctors’ frustration with EHR usability has been well publicized. While there are other methods for populating your EHR, if youuse transcription you will want to carefully weigh the security and accuracy risks of using manual cut and paste. A better option to accomplish section-level EHR insertion relatively painlessly is a secure, automated connection with a transcription provider – unless the EHR vendor’s fee for connectivity is prohibitive.

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Is your clinical documentation method leading to burnout?

While a variety, and combination, of factors contribute to physician burnout, it is indisputable that burnout is real, and it is increasingly pervasive in the medical community. There is, in fact, a code for it. The ICD-10 code for burnout is Z273.0, categorized under Z273, “Problems related to life management difficulty.” Read the full post. 

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21 Tips for Getting Accurate Transcription from Medical Dictation

Based on AHIMA transcription guidelines and expanded, to share with dictation clients.

Accurate transcription of clinical notes starts with good dictation, but there are many other factors that also contribute to transcription quality. As a physician or medical facility using dictation, you are all too aware of the potentially serious legal, financial, and patient health impacts that transcribing mistakes can cause. Transcribed reports are part of the medical record and must be highly accurate. Downstream uses such as coding for billing, backup for potential audits, or Meaningful Use attestation, are also dependent on the integrity of clinical documentation. The following tips provide helpful guidelines for getting accurate results from your transcription service.

  1. Speak clearly.Talk in a conversational tone at a normal rate. Getting the dictation done faster is not the goal, quality documentation is.
  2. Speak to the mic.Depending on the type of microphone used, the recorder should be about 3/4″ from the mouth in an upright, level position so that sound goes over the top of the microphone and not directly into it. If using a smartphone or tablet as a recording device, know where the mics are and make sure they are not covered with your hand. In some cases a smartphone will have multiple omnidirectional mikes.
  3. Avoid noisy environments and distractions.Choose a quiet, secure location to record from. Dictating in a quiet and secure environment will significantly improve results and maintain patient confidentiality. Avoid areas prone to background noise and distractions. Other voices talking, telephones ringing, overhead speakers, music, vacuums, and beepers in the background can obscure the intended dictation. If you have to dictate in an outdoor location, avoid traffic noise. Wind, even a slight breeze, can compromise audio quality.
  4. Dictate promptly.The best time to dictate is soon after your patient encounter, so that the information is fresh in your mind and possibly more complete.
  5. Interruptions will happen, but don’t record them.Overlapping dialogue in the background will make your dictation hard to hear and follow. If you are called into another conversation or experience another temporary interruption, hit PAUSE on your recording device and return to your dictation when you are no longer distracted. In some systems, hitting STOP will create a new audio file, and you must re-dictate the patient’s name to continue.
  6. Take care with difficult words.Be mindful of unusual or difficult terms, drugs, sound-alikes, and names of referring physicians. If there is any chance of confusion, spell out a word. A competent transcriptionist will double-check spelling in context using reference resources such as Steadman’s Medical Dictionary, but should not have to guess your intended meaning. If words cannot be transcribed, leaving blanks in the transcript, then extra turnaround time, staff, and costs will be incurred before the document can be completed.
  7. Clarify numerical descriptions and units of measure. Pay special attention to numbers and measurements. Separate all individual numbers. (Appropriate to the meaning, either say, “One hundred twenty-six” or “one hundred twenty milligrams of [x] and six milligrams of [x]”.) Clearly state dosage units to avoid misunderstandings such as “milligram” vs. “microgram,” which could cause an error leading to irrevocable patient harm.
  8. Don’t run words together.Small words can change meaning, but may be lost if glossed over by being spoken too quickly. “The patient has no history of asthma” is very different from the same sentence without the word “no.” If the transcriptionist misses hearing the negative, the erroneous transcription could impact care coordination and clinical decision making, with adverse consequences for the patient, and possible litigation for the physician.
  9. Know how to use your device.Be familiar with your recording device, so you know how to access the basic functions such as RECORD, PAUSE, STOP, INSERT, OVERWRITE, SEND. Practice with several test dictations.
  10. Learn how to access the dictation system.Know the call-in or log-in procedures, including your I.D. credentials. Ask for a “cheat sheet” with user instructions. Most MTSOs will also provide a pocket-sized instruction card that you can carry with you.
  11. Turn the recorder on and wait a beat.Make sure your device is powered on, and in RECORD mode. It can take a few seconds for the dictation/recording to begin, so give it a moment before you start to speak. Note that with some handheld USB recorders, words or phrases may be “cut off” if the dictation and button activation are performed simultaneously.
  12. Set up approval protocols in advance.If you are using electronic signature, provide the MTSO ahead of time with the appropriate permission in writing and a copy of your handwritten signature if appropriate.
  13. Start with complete, accurate demographics.Patients must be correctly and unambiguously identified. Have all pertinent information available during the time of dictation. Always begin dictation by identifying the patient, the medical record number, appropriate dates, and the report type (or work type). Two types of identification must be dictated for each report, such as the patient’s name and medical record number, in order to avoid documenting for the wrong patient (who may have a similar name, for instance). An MTSO should be capable of accepting an ADT feed if available from your facility.
  14. Make sure the MTSO has updated lists of names.The transcriptionist or MTSO should have a complete list of physician names, including dictating authors and referral doctors, before any transcription begins. An omission in these names will delay your expected turnaround time. A contact at your facility should be available for related questions at all times, either by phone, fax, or email.
  15. Note special instructions first.Provide any special instructions at the beginning of the dictation.
  16. Create a new file for each dictation.Do not “piggyback” reports by recording more than one dictation on a single audio file. Create a single audio file for each document, by pressing STOP after each dictation. This will reduce the chance of lost dictation.
  17. Create a new audio file in the event of later amendments.If you need to add to or amend a dictation at a later time, create a new audio file. State the patient’s name and indicate if you would like the typist to add something to a previously dictated report, or if you want a separate report labeled as an amended report.
  18. 1 Send encrypted files only.HIPAA patient privacy and information security regulations mandate severe penalties for breaches. Your audio files must be encrypted for transmission to your transcription provider. In general, email is not considered a secure means of transmission. Always follow your facility’s and MTSO’s protocol for sending and receiving electronic audio files. If the dictation is very long, or the file is very large, the MTSO may provide proprietary software (such as ZyDoc’s “ZyFile”) for such transmissions.
  19. Use qualified transcriptionists.Most well-qualified transcriptionists can successfully understand a wide spectrum of accents and ESL dictators, to a point. In evaluating a transcription service, ask what experience the transcriptionists have with this type of dictator (dictating authors), and if in doubt, submit a sample dictation as a test. Assuming that accents are not a problem, and standard English is the norm for your organization, then speed, clarity, audio volume, and environment are the top considerations related to recording quality.
  20. Learn about Quality Assurance.When evaluating an MTSO, ask what quality assurance measures are in place, and what guarantees are offered. A reputable, full-service transcription service will review transcriptions for any errors, including critical and major errors. According to the Association for Healthcare Documentation Integrity (AHDI), “critical errors are those which could compromise patient safety or continuity of care. Major errors are those which could compromise the integrity of a note without risk to patient care.” 1 An accuracy rate of 95-98% is considered acceptable, although your facility’s requirements may differ.
  21. Provide feedback.Timely feedback is essential when working with a new transcriptionist, and continues to be important if an issue arises. Corrections should be performed for free prior to final approval. Changes due to author error (“dication error) or amended information generally incur a charge.

In Summary, Good Dictation and Work Habits are Key
Using speech to document encounters is more natural than using a keyboard and mouse. In a recent NIH-supported research study by ZyDoc, clinical dictation was shown to be an average of 2.5 times faster than typing. Although speaking is a more natural modality, good speech habits when dictating may need to be learned. Fortunately, dictating effectively is a skill that is easily learned.

Beyond generating clear audio, achieving excellent transcription results also requires attention to workflow details such as providing complete and correct information, clear identification of any STAT or amended reports, alerting the transcriptionist to special instructions, and secure transmission of files. Getting this aspect right saves time and frustration for both the author and the transcriptionist, and reduces the potential for errors.

A Note about Speech Recognition
Speech recognition technology, or “SRT,” has matured greatly since it emerged as a proposed solution to save clinical documentation time. Front-end SRT allows an author to dictate, view the appearance of the text onscreen with minimal lag time, and perform immediate edits. Back-end SRT, usually considered more accurate, is accomplished by converting speech to text after completion of a dictation session for subsequent routing to a transcriptionist or editor, who then reviews, corrects, or in some cases, re-types the report. A speech recognition system that incorporates no human review is not currently available with the level of accuracy needed for clinical documentation. Front-end, or preferably back-end, SRT may be cost-effective and feasible for certain organizations, and is generally deployed as a component of an integrated transcription system such as Philips SpeechExec, and/or for dictation into an EHR.