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December 26, 2006
What’s one difference between typing on a computer and writing on paper? Data typed into a computer is in a more useful form. It can be accessed, revised, reformatted, and replicated with great ease. The electronic health record (EHR) offers these same advantages to patient files. Data in an EHR is easy to access, add to, and—most importantly—share in a timely manner. Unfortunately, adoption of the EHR has been slow. According to industry statistics, nearly 70% of healthcare information sharing takes place on paper rather than in electronic form. A handwritten document is simply a solid “block of text” with all data within the document immutably fixed. Traditionally, transcription files have been similarly limited to a “block of text” within which “discrete data” can only be minimally isolated, moved, or duplicated. While dictation and transcription files have always supported the population of a clinical document repository, they have been restricted in populating a clinical data repository. Transcription technology is rapidly changing to meet the needs of healthcare facilities in the transition to EHRs. Rather than providing information in a “block” format, data are kept in a more electronically discrete manner allowing for unique data element population in addition to whole report or document population into the clinical repository. The desire for discrete data within the EHR has set up conflicting incentives between physicians and hospital administrators. Physicians want to dictate their information in a timely manner so they can spend more time with patients and less on paperwork. They also want discrete medical data. However, many administrators are trying to force physicians to format their own data, generally with a point-and-click method involving templates and drop-down menus on a personal computer. This method does result in more useful data; however, it is often more time-consuming for the physician without consideration to additional compensation. Thus, modern healthcare facilities face this essential obstacle when integrating the transcription process into the EHR: achieving discrete data population without slowing down doctors or increasing medical documentation turnaround times. Data Capture and Report Creation Physicians seek the most efficient and data-rich capture method. In fact, most hospital administrators are surprised to discover an increase in dictation following EHR adoption. This is because anything previously handwritten is now dictated, which makes the information much more accessible and functional. Also, it eliminates legibility issues. Enter NLU and XML Whether transcription report creation is accomplished in house or transcription services are outsourced to an external vendor, individual healthcare facilities with a platform incorporating both NLU and XML technologies can create templates for data entry that automatically populate an EHR. Data will be tagged according to the report’s format and the NLU’s output, and lifted directly into the EHR in the appropriate place. It then becomes simple to perform a quality check of the data to ensure that information in the various tables matches the physician’s instructions. Since all data are tagged and discrete, reports can be automatically reformatted to match the new template when transferred to different facilities. Thus, the files will remain easily accessible and comprehensible as they reach different audiences, including data repositories, research facilities, and payor organizations. Adopting the EHR Medical transcription is a vital part of adopting EHRs. Integrating new technologies such as NLU and XML are simplifying the process to help facilities move beyond the written word and embrace the electronic future of clinical documentation and “data.” — Todd R. Charest is director of business development at Spheris Corporation.
This national apprenticeship program, registered by the U.S. Department of Labor, forges a stronger alliance between educational institutions and transcription employers to increase the number of qualified medical transcriptionists employed in the United States. The MTIA Registered Apprenticeship Program is a two-year program in acute care. Eligible candidates must have graduated from a MTIA-approved medical transcriptionist training program, and the candidate must have obtained the AAMT (American Association for Medical Transcription) Registered Medical Transcriptionist credential. The number of apprentice openings will depend on the needs of participating employers, a list of which can be found at www.mtia.com. Applications for an apprenticeship position can also be downloaded from the association’s Web site and submitted to MTIA Executive Director Elaine Olson by January 26 via an e-mail to eolson@mtia.com. The Apprenticeship Committee commits to the following equal opportunity pledge: “The recruitment, selection, employment, and training of apprentices during their apprenticeship will be without discrimination because of race, color, religion, national origin, or sex. The sponsor will take affirmative action to provide equal opportunity in apprenticeship and will operate the apprenticeship program as required under Title 29 of the Code of Federal Regulations, Part 30 (as amended).” In addition, MTIA has announced the results of the recently held election for directors, who will serve a three-year term ending December 31, 2009. The directors are Eileen Dwyer, Keith Flannery, Bob Harvey, Melinda Owen, and David Woodrow. They will begin their term January 1, 2007, and will be formally welcomed to the board at the two-day board retreat scheduled for mid-January. — Source: Medical Transcription Industry Association
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