Electronic Health Records, Medical Transcription, and Physicians

With the HITECH Act now completely implemented in the healthcare sector, the drive for the adoption of an electronic health record is gaining traction across the board. We’ve learned about how it can increase patient safety, streamline procedures, and even centralise all of a patient’s data. We hear about electronic records replacing certain transcription roles in our business, and we’ve learned a lot about physicians using scribes instead of MTs, with scribes playing a greater role.You can get additional information at Corvallis Physicians Office Association.

A Doctor’s Point of View
I came across the storey The Doctor vs. The Computer on a New York Times blog while surfing the internet this week. Dr. Danielle Ofri, Associate Professor of Medicine at New York University School of Medicine and Editor-in-Chief of the Bellevue Literary Review, wrote the post. She explains the difficulty of entering data into a patient’s electronic record after performing a preoperative assessment to determine if he is a suitable candidate for surgery. As she types the narrative to explain all of his medical problems, she discovers that narratives are limited to 1,000 characters in the electronic record.
Some of the things that stood out to me were:

However, there are major trade-offs. The electronic medical record, above all, has an effect on how we think. Since the scheme promotes incomplete reporting, with different facets of a patient’s condition hidden in unrelated areas, it’s much more difficult to keep track of the patient as a whole. What will become of the long-standing practise of meticulous clinical reasoning?

The Importance of Narrative
I really encourage you to read her entire article because it will shed light on the difficulties physicians face in making this transition. This is something to consider when discussing the importance medical transcriptionists bring to the table in terms of ensuring the narrative remains part of the record. Furthermore, structures that limit characters to 1,000 don’t leave much space to really tell the patient’s storey. When you consider what we call MTs and a 65-character grid, you’re talking somewhere about 15 lines. Can you tell me all about your medical history in that? What about patients with complex backgrounds, such as Dr. Ofri’s?
Is This The Way Things Will Be In The Future?

When I read stuff like this, it makes me very concerned about the state of documentation in the healthcare industry. It’s concerning to assume that doctors are attempting to save money by cutting corners in their reporting in order to gain “better productivity.” And, like the physician, I was wondering at the end of this blog, “what if there are complications?”

What happens to “thorough clinical thinking” is maybe a more pressing concern. Nobody is going back through a record as thoroughly as they used to with paper maps, according to the physician. We would finally be left with only physicians who have interacted with the electronic record. Would this have an effect on patient care?
Please remind me why it’s called practical use.

Our environment is changing, and it is changing at a breakneck pace. Many doctor’s offices are transitioning to an electronic medical record with a check system, and some are still hiring scribes. Physicians in my town are selling their practises to big companies or the hospital in order to avoid having to come up with the funds to go electronic. For the practitioner, this can make financial sense because they can avoid the expense of purchasing an electronic health record system. It makes sense for the company because it streamlines certain procedures because there is a financial benefit from the government to do so.