Medical Transcription Mt And Electronic Medical Records Emr Software

Medical Transcription Mt And Electronic Medical Records Emr Software

Medical Transcription MT and Electronic Medical Records EMR Software
Electronic Medical Records EMR has revolutionized the​ healthcare industry in​ recent times. Many experts felt that EMR & Voice Recognition would totally replace Medical Transcription however; the​ industry soon realized that transcription has certain advantages over point & click charting and many physicians preferred to​ dictate notes rather than document the​ data at​ the​ point of​ care themselves.
The most critical part of​ any Electronic Medical Record EMR is​ the​ method of​ data entry. EMR is​ about aggregation of​ patient encounter data at​ the​ point of​ care in​ order to​ provide a​ complete,​ accurate,​ and timely view of​ patient information. An electronic medical record is​ not just a​ typed record of​ the​ patient encounter,​ but an extremely useful decision support tool. the​ data can be entered into the​ EMR via any of​ the​ two general mechanisms direct entry by the​ physician using point and click templates or​ transcription of​ dictated notes. Point and click template indicates that each data element,​ which is​ to​ be inserted,​ requires selection,​ navigation,​ point and click process for capturing patient information.
Transcriptions have been around for years for documenting patient encounters. a​ medical provider dictates the​ medical note into a​ phone or​ a​ recording device. the​ transcriptionist receives the​ dictation and transcribes it. it​ may be reviewed by the​ supervisor for checking errors. the​ final computerized file is​ then either emailed directly to​ the​ healthcare provider or​ the​ file is​ transferred to​ a​ web site and is​ later downloaded by the​ provider.
Each method has its pros and cons.
Point and Click Templates
Most EMR systems allow providers to​ generate clinical documentation,​ by selecting variable terms from prestructured pointandclick templates. Users simply point and click to​ select appropriate choices from lists of​ choices to​ record a​ patient encounter. the​ end result would be a​ document that closely resembles a​ transcribed procedure note.
* Completely customizable templates. the​ doctor can specify the​ layout of​ the​ template,​ which helps him to​ adjust the​ template as​ per his practice & procedure.
* Provide consistent,​ complete and accurate data. the​ chances of​ medical erros are reduced since the​ data is​ documented in​ customised forms.
* Notes for similar type of​ exams will appear to​ be standard and similar
* Store / organize data for subsequent retrieval.
* Each click adds data elements to​ the​ database. Pointandclick systems create data that can be used to​ generate clinically useful reports,​ such as​ health maintenance reminders,​ disease management etc.
* One of​ the​ major advantages of​ template based charting is​ the​ time needed to​ make the​ document available as​ a​ medical record. Since notes are created within the​ EMR,​ they are available immediately upon completion.

* it​ takes more time,​ and definitely more concentration for a​ physician to​ navigate through large data set and create progress notes using point and click templates.
* Templates must be customized as​ per the​ physician’s requirement.
* Customization can be inflexible and costly.
* Well accepted by only techsavvy doctors.
* the​ approach of​ direct data entry by the​ physician has generally failed because busy providers reject it​ altogether.
* Output from these templates is​ too canned and identical. it​ loses individuality for each patient.
* it​ is​ difficult for a​ provider to​ capture complete patient encounter on​ computer in​ front of​ a​ patient.
Medical Transcription
Transcription has long been the​ standard for documenting patient encounters. it​ is​ more convenient for a​ provider as​ compared to​ handwritten notes or​ electronic data entry. There are many advantages of​ transcription in​ comparison to​ point and click charting. There are a​ few disadvantages as​ well.
* Correspond intuitively to​ the​ physicians usual method of​ working. Dictation remains the​ most intuitive and least timeconsuming means of​ data entry.
* Physicians can dictate anytime,​ anywhere using PDA,​ Dictaphone or​ telephone at​ their convenience.
* Providers need not change the​ way they practice just to​ accommodate an EMR. EMR can interact with transcription service so that transcriptions can be attached directly into the​ patient’s electronic medical record,​ if​ such a​ facility is​ provided by the​ EMR vendor.
* it​ requires minimal training for physicians.
* Provides expressive power to​ describe patient’s condition and other health related events
* Details of​ the​ exam can easily be forgotten and omitted while dictating,​ if​ dictation is​ not captured immediately at​ the​ point of​ care
* it​ cannot be queried for generating reports unless transcribed in​ preformatted templates
* Transcribed reports are not immediately accessible. Physicians would normally have to​ wait for 12 to​ 24 hours for charts to​ be delivered,​ unless few vendors supporting 24 hours short turn around time.
* Transcription provides for more efficient use of​ doctors time.
* Although average transcribed report costs $2 to​ $4,​ it​ can reduce the​ doctors time spent on​ data entry.
Considering the​ value of​ doctor’s time,​ transcription is​ not a​ costly proposition.

EMR should give the​ freedom to​ the​ physician to​ decide to​ use either Point & Click or​ Medical Transcription. For a​ physician,​ the​ EMR that fits into his practice workflow would be invaluable. a​ competent EMR must have a​ template driven charting feature and the​ ability to​ interact with a​ transcription service at​ the​ same time. Both are indispensable features of​ Electronic Medical Record Software,​ as​ doctors are not unanimous on​ point and click charting or​ transcription. Such an EMR will be both efficient and cost effective.
The trends in​ transcription itself are changing with Medical Transcription service providers aiming to​ adopt new technologies. These technologies will evolve to​ increase efficiency & accuracy,​ decrease turnaround time and support data capture. While many of​ these technologies like such as​ digital dictation and electronic signature exist today,​ several technologies are still on​ the​ horizon.
The author,​ Divan Dave,​ is​ the​ founder and CEO of​ OmniMD,​ a​ developer of​ HIPAA compliant Pocket PC and Internetbased enterprise clinical solutions,​ designed to​ fully automate the​ workflow of​ contemporary healthcare organizations. the​ company is​ a​ division of​ Integrated Systems Management,​ Inc. ISM,​ a​ leader in​ Internet consulting and ebusiness development since 1989. For details visit http//www. omnimd. com

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