Achieving meaningful use of Electronic Health Records (EHRs) is paramount for healthcare organizations and providers seeking both to improve the quality of care and satisfy federal requirements. The recent release of Stage 2 meaningful use final rules has intensified the focus on health information exchange (HIE), leading many hospital administrators and CIOs to champion utilization of the EHR’s structured documentation capabilities over narrative dictation and transcription. We offer a solution technology that — rather than controlling physician input – extracts structured EHR data from physician dictations.
Clinical narrative also drives coding and billing. For years, systems to codify procedures (CPT codes) and diagnoses (ICD-9 and SNOMED) have supported billing initiatives. In the United States, CMS and more than 90% of all payers support the Encounter & Management (E&M) visit coding schema for physician reimbursement. To ensure maximum reimbursement, physicians must document fully the services they provide, but template-based HPI and medical decision-making documentation methods limit physicians’ ability to document encounters accurately and comprehensively.
Long live transcription
There are a variety of ways to create and store the patient narrative. Physicians can type information directly into the notes section. They can dictate and have transcriptionists type the narrative into the notes section, or upload it from the transcription system to the correct section of the EHR. Or they can use speech recognition to create the narrative directly in the note section, eschewing typing or transcription altogether.
Several studies attest to the ongoing use of transcription:
• 53 percent of physicians reverted to dictation or handwriting and 18 percent stopped using the EHR completely one year after purchasing it.
• Nationwide, only 27 hospitals had a majority of physicians using structured templates for clinical documentation.
• Provider organizations actively attempting to eliminate transcription entirely, still use it 30 percent of the time.
• Even in hospitals that are almost completely automated, structured templates within the EHR were used only 35 percent, while dictation and transcription were used 62 percent.
However, there are downsides to typing and traditional dictation. Requiring physicians to type reduces their productivity – and profitability. Dictation and transcription reintroduce some of the costs EHRs are supposed to eliminate.
Speech recognition has some limitations, too. While it gives physicians the ability to document in free-text quickly and easily, which preserves the patient narrative, speech recognition must be combined with sophisticated extraction tools to create structured data for the EHR.
Today’s healthcare organizations must find a way simultaneously to:
• Optimize physician workflows to ensure productivity
• Preserve the patient narrative to enhance the quality of care
• Create codified, structured, discrete data to populate and achieve
Meaningful Use of the EHR
The solution: Speech-driven clinical documentation and clinical transcription solutions that capture the free-form patient narrative and transform it into structured data for the EHR – without disrupting physicians’ workflow or increasing their documentation burden.
• Capture the patient story anywhere, any time and on any device in a physician’s preferred clinical workflow, supporting their adoption of new technologies.
• Understand what is captured, with Medscripts clinical Language Understanding technology,to unlock and transform unstructured clinical data into actionable information.
• Use it for good by providing analytics and insight for clinical good, business good and, most of All, patient good across the healthcare enterprise.
The true value of EHRs rests in the discrete information they contain — not on physicians entering information discretely. Rather than restricting their input, allow physicians to focus on patient care, expressing themselves — clinically — with natural, unrestricted language. Medscripts Charting solutions help healthcare organizations achieve meaningful use and maximize the potential of their EHRs to improve clinical, operational and financial outcomes, while preserving the clinical narrative critical to optimum patient care.
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