EMR Daily News

Webmedx Launches New Data-Mining Solution for Medical Transcription and Speech-Generated Documents

September 22, 2009

Webmedx, the fourth largest medical transcription service provider in the U.S. and a premier supplier of clinical documentation technology, today announced a new module within their Enterprise(TM) Clinical Documentation Platform, QualityAnalytics(TM). QualityAnalytics makes reporting quality measures easier and automates data abstraction for other types of queries including Medicare’s Recovery Audit Recovery (RAC) program. Future plans include the ability to abstract and submit quality measures data electronically from transcribed reports to support CMS meaningful use reporting requirements as outlined in the HITECH Act.

“QualityAnalytics is particularly valuable for quality managers and HIM Directors as they identify JCAHO core measures patients and abstract data from transcribed reports,” mentions Sean Carroll, CEO, Webmedx. JCAHO core measure abstracts contain upwards of 60 data elements that must be manually abstracted by nurses and coders. The online application replaces core measures man hours with discrete data from narrative transcription and speech-generated documents.

“With QualityAnalytics I am able to identify in-house patients for review by specific diagnosis, such as heart failure or pneumonia, without wasting time doing a general search on every inpatient chart,” mentions Sondra Hess, CCS, CCDS, Clinical Documentation Improvement Specialist for Alvarado Hospital, San Diego, CA.

Leah Scalf, RN, NE-BC, Data Outcomes Specialist for St. Francis Beech Grove Hospital, Indianapolis, IN, also appreciates the ability to save time and streamline the quality review process. “In addition to finding patients with admitting diagnosis of congestive heart failure or acute myocardial infarction, we can identify patients with history of these diagnoses; a capability our other systems don’t offer,” Scalf mentions. “Every day the system finds two or three patients I would have missed otherwise and since it is available on-line, I can easily pull up my patient action list at any time and from any location.”

The module collects words and phrases from rich, narrative, transcribed documents in the form of discrete data elements. Termed “narradata(TM)” by Webmedx, this information can then be used to create patient action lists for core measure reporting, identify RAC targets for pre-emptive reviews, and fulfill EHR content requirements.


Article Source : http://emrdailynews.com/?p=1087

Organizing Your Medical Records

If you’ve ever had a major medical problem you know that the paperwork can be as painful as the actual health issue. And if you’re a doctor or nurse paperwork and charting is time consuming and frustrating. You’d think with all the technologies on today’s market something would be out there to simplify all the form work that goes into the medical profession. Well, there is a way to cut down on paperwork and keep your records straight and organized. It’s called medical transcription.
Medical transcription is a multi medium way to transcribe written and oral medical records into a digital, computerized format. Many doctor’s offices and hospitals have turned to medical transcription services in recent years to cut down on busy work and on money lost having their own employees do all the work. Many medical transcribing companies offer services to medical facilities all over the country to aid doctors and nurses in keeping their records straight.

Handing over all the medical records in an office to an outside firm requires that firm to be well trusted and efficient. No doctor will trust his or her patient’s information to an un-reviewed and unknown company. There are a few medical transcription companies out there that have years of experience and clout and are worth some review.

One such transcription company guys have been in the business for years and have a reputation for quality and efficiency. They specialize in digital transcriptions from recorded dictation or written charts. Their staff is all based in the United States and each member of the staff has, on average, 15 years of experience in the field of transcription.
If you are a doctor or a medical professional, They have lots of information explaining the various services and products they offer. They also boast state-of-the-art, web based digital technology to speed along your transcription needs. This means you can access your records off site from a database network. They have a quick turn around time so you won’t have to wait weeks and weeks to get back any records you send to them.

Scrupulous and well organized medial records can save time and even lives. Many patients have immediate medical needs that have to be address within moments. Digitizing medical records makes them easy to access in a moment’s time and can save precious seconds in an emergency situation.

When I was younger, my mother had a major stroke and needed to be hospitalized for a long period of time. She underwent serious heart surgery while she was there to replace a malfunctioning valve. About ten days after her surgery, her blood pressure sky-rocketed and she had to go under the knife again to have her valve replaced once more. I know those doctors kept meticulous records because every time one would change out the other was completely abreast of what was going one. I credit the organization and planning of the doctors, coupled with their well-kept records, for keeping my mother alive.

I’m sure this same scenario is played out daily in hospitals and doctors offices around the country. And now with the amount of technology that goes into preserving and digitizing medical records, doctors have more time to spend with their patients and have to dedicate less time to filling out charts and paper work.

Another great advantage to digitizing medical records is the amount of space it saves in an office or records room. A large portion on the space in doctor’s offices in the past was dedicated to the actual medical charts. By placing records on digital files it frees up so much more space to be used for more exam rooms and lab space. Digital records are also much more portable in the event of an emergency like a fire or a flood.

In my own experience as a patient in many various doctor’s offices and labs, I appreciate when the records seem to be well kept and organized. I’m always impressed when I see a different doctor working at a practice I’ve been to before know exactly what my symptoms and specific medical needs are based on the chart in from of him. Paper charting is a necessity only in that they’re mobile and readily accessible when a doctor goes in to meet with a patient. But outside of an exam -room setting, digitized records are the way to go for convenience and ease.

Another great feature of modern medical transcriptions is medical dictation transcribing. Many doctors in hospitals use small hand held recording devices to make oral notes and changes to a patient’s care. Nurses then have to listen to what can be sometimes hours of tape to learn all the necessary details of a medical case. With oral dictation transcription, a medical transcriber can type the notes quickly and have them back to the doctor in a timely and efficient manner. This way, nurses and other doctors can quickly flip to a particular patient’s notes and learn the needed information.

Whatever your role is in the medical world, whether it be that of a doctor, a nurse, or a patient, you have at some point been frustrated by the amount of paper work necessary to get anything done. With medical transcription, the tediousness of keeping so many records and files organized and safe is all but removed from the equation. Having less paper work and charting to worry about frees a doctor up to spend more time with each patient.

And it gives patients the reassurance that their precious and confidential medical information is being kept safe. And in the event of a serious medical emergency, having all the records digitized and networked can save time and even could save a life. And that’s worth it to me to make sure all my records are sent to a trusted and well-experienced medical transcription firm. Because my health is too important to trust to just anyone.


Article Source : http://www.healthreform.biz/health/organizing-your-medical-records/

Medical Transcription Companies in USA

Medical transcription companies are increasing at a rapid rate in the USA. These companies maintain up-to-date digital technologies to provide value-added transcription services

As the demand for medical transcription work is increasing at a rapid rate, medical transcription companies are mushrooming in the USA. Medical transcription is a necessity in all healthcare facilities, whether they are clinics, hospitals, or other organizations. Medical transcription companies in the USA occupy a unique niche in the medical transcription field. No matter where you are located in the USA, these firms can help your practice in every stage of transcription process -- all from dictation capture to document distribution.

Most of the medical transcription companies in the USA can provide superior quality, accurate medical transcription services as they employ highly skilled and experienced medical transcriptionists on staff. Moreover, these services are mostly cost-effective to cater to all kinds of budgets. These companies take care to apply and maintain up-to-date digital technologies to provide value-added transcription services.

In the USA, medical transcription companies provide services in almost all medical specialties. Professionals in these firms can undertake transcription of various medical reports including cardiology reports, operative reports, patient discharge summaries, emergency room reports, history and physical examination reports, chart notes, medical evaluations, peer reviews, psychiatric evaluations, x-ray reports and many more.

The greatest advantage of availing of the medical transcription services from a standard MT firm in the USA is that you can get access to accurate and efficient services within fast turnaround time. Apart from this, other benefits that you can gain include:

* 99% accuracy * Security and confidentiality of the medical records and documents * Three-tier quality checking with assured high quality work * HIPAA compliant medical transcription services * Electronic Medical Record (EMR) solution * Total dictation and transcription solution

If you need a complete medical transcription solution or if you are considering outsourcing your medical transcription assignments, you will be able to find medical transcription companies online that can meet your needs. If you are interested in finding a standard medical transcription company in the USA, there are some important considerations that you need to take into account before making your choice. It is an excellent idea to conduct some research on your own in order to get the best deals.

Article Source : http://www.ideamarketers.com/?articleid=686533

EMR, EHR and HIPAA Wiki

A while back I decided to take a weekend and create an EMR, EHR and HIPAA wiki to go alongside this website. I still think it’s a really good idea that still has yet to be full realized. That said, considering the relatively little amount of effort that I’ve put into the project, we’ve had 53 people make contributions to the wiki with a little over 20,000 pageviews. Not a bad start for a side project.

My favorite page on the wiki is the EMR and EHR matrix of companies. As you’ll see, it still needs some more love, but a couple EMR and EHR vendors are being listed each week. If you see your EMR/EHR not listed in the matrix, then sign up and add it. That’s the beauty of a wiki. Otherwise, you can also leave a comment and I’ll add your EMR company. As everyone contributes I see that page becoming a very valuable resource.

A couple other of my favorite pages is the list of open source and Free EMR and EHR companies. I’m sure that’s missing some of the players in this area, but still is a popular resource. Considering the current economic situation and unemployment rate, I also love this page listing a bunch of the various EMR, EHR and HIT jobs websites.

Also, a relatively new addition to the site is this Glossary of EMR, EHR, HIT and HIPAA terms. It needs a little formatting help, but represents a lot of work trying to help those new to the healthcare IT field.

Anyway, I hadn’t talked about it for a while and so I wanted to point it out to everyone and encourage people to contribute to the effort. If everyone helps just a little it will become a pretty good resource for those learning about EMR, EHR and HIT.

Article Source : http://www.emrandhipaa.com/emr-and-hipaa/2009/09/16/emr-ehr-and-hipaa-wiki/

EMR and the smaller office.

Below is an excerpt from an article I found about EMR (electronic medical records). This is a pretty complex issue all physicians are faced with. Most of what we read about with respect to EMR are related to the hospital environment and is now beginning to enter the area of small to medium-sized private practices. One of the big concerns surrounding the issue of EMR is interoperability, which means how do we get millions of patient records online in a format that any medical practitioner can access? Also, most of the EMR will be formatted as point and click for services, drugs and recommendations provided to patients. The dilemma that smaller offices are facing is price versus ROI (return on investment) and as you can see below some of the costs of converting to EMR are pretty steep. However, for the smaller practice they really do not have to spend $30,000 just for the hardware and the practitioner need only to invest in a digital dictation machine and some additional CRTs.

We have developed an online transcription company geared for the smaller offices that are new to the EMR world and provide a simple easy to use software system that will store your records in a format that is currently universally accepted by most PC-based computer systems. As a small office we believe there is no reason to spend thousands of dollars for a software system that is loaded with bells and whistles you may never need to use, but rather we feel that basic storage and recall of patients records can save your office in areas of paper costs and labor while keeping you abreast of the current trend to have EMR. So, read below then pay us a visit . We think as a small to medium-sized business you will be surprised to learn how inexpensive it can really be.

“Southwest Medical Associates, a 250-physician group affiliated with Nevada’s largest private health insurer, has been paperless since 2008 after a four-year, $5 million EMR implementation, and has already recouped the expense in drug savings alone and likely prevented many errors.

The process, of course, is much more difficult for a small, low-margin, primary-care practice like that of Dr. Tony Alamo (if that’s not a name made for Vegas, I don’t know what is). His three-physician practice saved on software by agreeing to test a system being developed by a cardiologist friend, but still spent $30,000 on hardware, the Sun reports. Alamo, 45, has had to overcome 20 years of practicing with paper charts, a process he calls “cumbersome” and “difficult,” but still refers to it as “my comfort zone.” Now, he pulls up records on a computer and shares the information with patients on monitors in each exam room.”

Article Source : http://www.aonemt.com/blog/?p=29

New Recommendations Can Help Health Providers Prepare For Electronic Record Push

A new framework of recommendations created by health informatics researchers may help doctors and hospitals prepare for a federal initiative to expand the use of electronic health records (EHRs).

The recommendations from faculty at The University of Texas Health Science Center at Houston, the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine appear in a commentary in the Sept. 9 edition of JAMA, the Journal of the American Medical Association.

“With high-quality, well-designed, and carefully implemented systems, highly-reliable, safe health care will be achieved,” said Dean Sittig, Ph.D., commentary author, associate professor at The University of Texas School of Health Information Sciences at Houston and member of The University of Texas - Memorial Hermann Center for Healthcare Quality and Safety.

The American Recovery and Reinvestment Act of 2009 created approximately $20 billion in incentives for individuals and organizations to “meaningfully” use electronic health records beginning next year. Previous studies report that 4 percent of physicians in the outpatient setting and 1.5 percent of U.S. hospitals have a comprehensive electronic health record system.

“This framework can help make sure that electronic health records are used safely and effectively as doctors continue to adopt them,” said Hardeep Singh, M.D., M.P.H. co-author and assistant professor of medicine and health services research at the VA Health Services Research and Development Center of Excellence and Baylor in Houston.

This framework of recommendations proposed by Sittig and Singh provides guidance for key stakeholders who are either currently involved or who will soon be involved with electronic health records.

“While using electronic health records, we not only have to consider issues related to technology, but also issues related to people who use them, how they interact with technology and how the electronic health record fits with the work flow of the clinic or organization that adopts it,” said Singh, who noted that if the Computerized Patient Record System developed by the Department of Veterans Affairs was included in the EHR-use study, the percentage of U.S. hospitals with a comprehensive electronic health record system would nearly double to 2.9 percent.

VA’s electronic health record system covers many aspects of patient care, including reminders for preventive health care, electronic entry of orders, display of laboratory test results, consultation requests, and pathology and imaging studies.

“The American Recovery and Reinvestment Act stipulates that clinicians and healthcare organizations can receive incentive payments for ‘meaningful use’ of EHRs. Depending on the definition and timeline for ‘meaningful use,’ this legislation could result in a rush to implement sub-optimal systems,” said Sittig, co-author of a new book that addresses EHR issues and is titled “Clinical Information Systems: Overcoming Adverse Consequences.”

For Americans to realize the full potential of electronic health records, which include reduced cost, less duplication and greater quality, Sittig and Singh believe all eight essentials, which are based on a systems engineering model for patient safety, should be followed.

  1. Hardware and software - Before implementation starts, the clinician and healthcare organization must have the proper hardware and software. “Anything that slows or disrupts the clinician’s work flow could negatively affect patient safety,” the authors wrote. “While free electronic health record software available is available, such as Veterans Information Systems and Technology Architecture (VistA ) developed by VA, all of the other seven essentials in the framework must also be addressed for safe and effective use,” Sittig said.
  2. Content - To make sure that information is shared effectively, the federal government has taken steps to standardize the terms used to describe clinical findings. “Adoption of a standard vocabulary is prerequisite to implementing advanced clinical decision support,” the authors wrote.
  3. User interface - The information should be easy to access and to enter. Ideally, the interface should present all the important patient information in a way so that clinicians can rapidly recognize problems, and respond to them appropriately.
  4. Personnel - For EHRs to work safely, healthcare organizations will need to hire trained and knowledgeable software designers, developers, trainers and implementation and maintenance staff. The American Medical Informatics Association has identified the knowledge and skills necessary for many of these jobs. The School of Health Information Sciences at Houston currently offers educational programs and degrees in these areas.
  5. Work flow and communication - The EHR system needs to be thoroughly tested within the clinic or hospital prior to implementation. Any bugs in the system should be fixed ahead of time.
  6. Organizational characteristics - There should be a system to report errors and identify obstacles to care. “Innovation, exploration and continual improvement are key organizational factors for safe EHR use. The VA is a model of many of these organizational features,” the authors state.
  7. State and federal rules and regulations - Care must to be taken to make sure regulations protect patient safety and privacy.
  8. Monitoring - Oversight, even after initial adoption and use, is crucial to the success of the switch from paper-based patient records to electronic records.
Article source: http://www.emrspecialists.com/2009/09/recommendations-health-providers-prepare-electronic-record-push/

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