Important Medical Transcription Practices

Medical transcribing is a fairly new profession. This profession does have its traditions. There are many ways in which to go about this work. Here are 5 medical transcription practices and tips that everyone who enters this profession should know and perfect.

Dictation is something that you should be familiar with. Since most of your job will involve taking dictation from a voice recording, every medical transcriptionist should be familiar with this practice. You will also need to compare dictation notes with the voice records. Another thing that you will be doing on a daily basis is

Proofreading. It is imperative that you are good at grammar and spelling. You will have to correct the grammatical deficiencies of doctors and medical specialists as you prepare your medical documents as it’s your job.

Time Management will take you a long way in this business. Since you have deadlines every day, managing your time well, will be essential.

Performing minor Research from time to time is considered normal for a medical transcriptionist. For instance, to make sure that the proper medical term is being used within context. If you make use of the wrong medical term, it could be a critical error that affects the quality of care of a patient. So brush up on your research skills.

Communication is a key in this profession. As a medical transcriptionist, you need to be very fluent and proficient in oral as well as written communication. Along with proofreading the doctors and medical specialists writing, you will have to craft sentences, maybe even paragraphs of you own. Effective communication will help you correct the bad grammar of those who are dictating to you. You will also need to communicate with clients and that requires good corporate communications knowledge.

So there, you have 5 medical transcription tips. Now it is time for you to learn, practice and eventually perfect them.

I right the above basis my first-hand experience with a transcription company called Acroseas Global Solutions with whom I’ve been working for the past 4 years. Their service speaks for their claims and everything mentioned above results in the output that they deliver timely, efficiently and with top-of-the-line quality.

The Year in Review

It has been an up-and-down year for healthcare informational technology. The biggest story, no doubt, was the impact that national recession had on healthcare investments – way back in January, the picture was bleak. But with the passage of the American Recovery and Reinvestment Act, the industry received a $19 billion shot in the arm from the new Obama Administration. While the money – to be used as incentives for adopting healthcare IT – doesn’t begin to flow in 2011, EHR adoption planning has already begun.

In the second half of the year, the top issue has been healthcare reform. The last sentences on that story have yet to be written, but on Dec. 24, the Senate finally passed its own bill. All that remains is reconciling the Senate and House versions and President Obama’s signature.

Below you’ll find the top issues of the last 12 months, selected by the editors of Healthcare IT News.

Privacy issues dog progess on NHIN

Privacy issues continue to keep the country’s planned nationwide health information network on the slow track, but government and community leaders say it won’t be a problem going forward. Yet things did not go exactly as the Office of the National Coordinator for Health Information Technology planned at a demonstration last month, where 19 cooperative organizations were scheduled to use real patient data to show how interoperability works. Instead, they used fictitious patient records to demonstrate greater depth in capabilities for interoperability than the initial trial run held in September.

IT pledge has market on pins and needles

President Barack Obama’s pledge to inject $50 billion into the healthcare field over the next five years to develop and support technology has many in the industry wondering how and where that money might be spent. On Jan. 22, 117 CEOs and business leaders sent a letter to House and Senate leaders supporting federal investment in healthcare information technology, broadband and energy smart grids, saying they “will provide our nation with a near-term stimulus and long-term comparative advantage.”

$19 billion to fuel healthcare IT

The $787 billion economic stimulus package signed by President Barack Obama on Feb. 17 includes $19 billion toward health information technology. While many healthcare IT industry insiders welcomed the spending as providing a needed impetus to pushing the healthcare system into the 21st Century, many also worried about getting IT done right. “I think it’s a terrible idea by the government to invest in healthcare IT – in EMR systems – without investing in standards,” said Marc Probst, CIO at Intermountain Healthcare in Salt Lake City.

HHS introduces new HIT Czar

Just as the April issue of Healthcare IT News was going to press, the Human Department of the Health and Services introduced David Blumenthal, MD, is Obama administration’s new National Coordinator for Health Information Technology. “I am humbled and honored to have the opportunity to serve President Obama and the American people in the effort to harness the power of health information technology,” Blumenthal said.

Hospitals shun life-saving IT

“Disappointing” and “disturbing” are two words Leah Binder chose to describe the results of a recent survey that revealed only 7 percent of hospitals across the country have adopted CPOE. CPOE, or computerized physician order entry, can reduce adverse events by 88 percent, according to Binder, the CEO of the healthcare watchdog organization The Leapfrog Group.

Obama budget reflects IT promise

President Barack Obama’s expanded fiscal year 2010 budget signals continued commitment to advancing healthcare IT as a way to cut healthcare costs and save lives. Obama’s $3.4 trillion federal budget, released May 8, expanded the outline he presented to Congress at the end of February.

Meaningful use draft approved

The federal health IT policy committee on July 16 approved long-awaited recommendations from its meaningful use workgroup on how providers can qualify to receive incentives through the new stimulus package. Measuring and improving outcomes is a key component.

Reform bill contains IT piece

The Senate Finance Committee health reform package, released Sept. 16, includes measures to advance healthcare IT. The committee’s reform bill has been the most controversial and the last proposal to come out of five Congressional committees that have jurisdiction over healthcare.

50,000 jobs: who will fill them?

The government’s piece of the stimulus package designed to encourage the adoption and use of healthcare information technology is expected to create 50,000 new jobs – maybe more.

Search is on for new CCHIT Chief

Key industry leaders are weighing in on the news that Mark Leavitt, MD, is retiring from his role as chairman of the Certification Commission for Health Information Technology.

How Does Software Aid Electronic Filing of Claims and Improve Collections?

Medical billing providers are using industry standard software that offers clients the advantages of cost, customization, efficiency, accountability and financial reporting. Healthcare providers should examine not only the services of the Medical coding and billing provider but also the quality and features of the medical billing software they use to ensure it is suitable for their practice. Here are a few guidelines on what to look for in the billing software solution.

Features of a Medical coding and billing software

All billing software must have the basic features to submit claims and manage billing electronically. However, this is just the tip of the iceberg. Efficient software provides flexibility, speed, transparency of data, security, point-of-sale bill tracking, extensive reporting, scheduling of patient visits, scanning, printing, credit card processing, email capabilities, and much more.

Standard features of medical billing software include:

* electronic filing of claims

* editing of previous claims and resubmission

* one platform for charges, adjustments and payments

* sending patient statements

* reporting financial statistics for decision making

* customizable screens for accounting

* user friendly interface

* web-based or wireless access to the system

* data security

* one platform for in-house staff and billing service personnel

* transparent transaction processing

* visible charge balance

* full transaction control

* HIPAA compliance

These features ensure medical providers have access to complete information, the billing service is well organized and accurate, and the entire medical practice works more efficiently.

Medical coding and billing service providers ensure their client’s staff is trained in the software and also take care of maintaining it. They are also responsible for upgrading it when required, and regularly backing up data for data security.

Advantages of using Medical coding and billing software

It makes the medical coding and billing process a lot easier and accurate. The manual process of filing claims is fraught with inaccuracies that cause insurance carriers to reject claims.

Some of the major advantages of medical billing software are:

* Standard electronic forms and codes ensure accuracy of forms, which reduces the chances of the claim being rejected.

* Cash flow increases as the time to payment reduces.

* The software is built on industry standards and ensures HIPAA compliance.

* Time and effort is saved because of easy follow-up of claims through reports and tracking features.

* Better decision making due to extensive reporting of financial statistics.

* Data transparency allows medical providers to oversee the electronic submission of claims.

* Billing providers and medical providers can access the same data and work together to improve collection rates.

A billing provider must use a good quality software solution to give the maximum benefit to its clients. The electronic process of filing claims and managing data through software improves the efficiency and revenue of medical providers.

The Importance Of Transcription In The EHR Age

In preparation for the AHIMA (American Health Information Management Association) Conference next week, my publisher and I have been speaking with several transcription services companies that will be exhibiting at the show. Since Healthcare Technology Online is a new media outlet, these conversations typically begin with us describing the focus and purpose of our website and weekly email newsletters. In more than one instance, a representative from a transcription company questioned our interest in their services. “We’re not a technology company,” they’d say. “I don’t see how our content and offerings would be of interest to your audience.”

This response floored me. While it’s true that most transcription companies offer outsourcing services as opposed to hardware or software technologies, these companies still play a vital role in healthcare IT — particularly as more healthcare facilities migrate to an EHR (electronic health record).

Transcription: The EHR On-Ramp

Some proponents of EHR suggest that template-driven electronic documentation capture is the best approach to realize the benefits of EHRs. However, this approach often forces the process and behavioral changes that have been primary barriers to EHR adoption. Furthermore, relying on a physician to key information into an EHR or select data from a series of drop-down menus while with a patient can lead to human error, inaccuracy, and incomplete information.

Using a “migratory” approach to EHR can help you avoid these potential pitfalls. With this approach, physicians can continue to interact with patients the way they always have and continue to leverage their existing dictation and transcription processes. However, getting voice data into a transcribed format that can be seamlessly integrated with or digested by the healthcare facility’s chosen EHR platform becomes a required capability of the transcription services company. In response to these growing EHR integration needs, most transcription services companies leverage the latest NLP (natural language processing), XML (extensible markup language), and HL7 (health level seven)-compliant technologies. These tools can create templates for data entry that automatically populate an EHR. In other words, data is tagged according to the report’s format and the NLP’s output and uploaded directly into the EHR in the appropriate place. It then becomes simple for the transcriptionist to perform a quality check of the data to ensure it matches physician instructions and the requirements of the EHR. In this way, the transcription provider truly serves as a healthcare facility’s on-ramp to an EHR.

Key Transcription Provider Criteria

Ensuring that the transcription service company you select can deliver data that can easily be fed into your EHR is just one step of the process. Other areas to consider when selecting a transcription services company include:

• guaranteed compliance with HIPAA (The Health Information Accountability & Portability Act) when it comes to handling the protected health information of your patients
• storage in a mission-critical data center that provides 99.99% uptime and security
• a guaranteed transcription accuracy rate of 99%
• multiple levels of quality assurance
• transfer of files through FTP (file transfer protocol) or browser-based secure 256 bit AES (advanced encryption standard) encrypted file transfer protocol
• 24/7 technical support

Again, while not a “technology” in and of itself, medical transcription is a vital part of adopting EHRs and other healthcare information management processes. Transcription companies will provide the industry with the guidance and support necessary to accelerate EHR adoption and help us to embrace the electronic age of clinical documentation.