Medical Transcription Process

Medical Transcription ProcessMedical transcription service providers adhere to stringent processes to ensure 100 percent precision in their service delivery. The medical transcription processes have been standardized based on HIPAA stipulations to avoid risks associated with poor transcription quality.

1. Dictation:

Medical practitioners record patient information into recording devices such as hand-held digital or analog recording devices, phone-in recorders, personal computers or other state-of-the-art recording equipment. The choice of recording equipment has direct bearing on the voice quality of the dictation and consequently on the quality and accuracy of the transcription.

Digital recording devices such as Olympus give superior voice quality and clarity to dictations. Sophisticated software modules are also installed into PCs of medical practitioners and doctors allowing them ease of use in dictating and transmitting the voice file to hospital servers thereby enhancing the medical transcription process.

2. Transmission of Voice Files

The digitally recorded dictations are transmitted from the doctors' PCs to the hospital's central server by using a memory card from where they are accessed by the medical transcription service provider for transcribing. Alternatively, with outsourcing of medical transcription processes becoming an increasingly common practice, voice files are often directly routed to the transcription vendor's secure, encrypted server in real-time via the internet, from where they are accessed by transcriptionists for immediate typing. This allows 24x7 access to dictations and faster turnaround in the outsourced medical transcription process.

3. Transcribing

The voice files once downloaded from the central server of the medical transcription vendor are allotted to the transcription team. Individual files have distinct job IDs and a centralized allocation system is put in place, to avoid duplication of the same files by different transcriptionists.

This is the actual production stage in the medical transcription process where voice files are converted into text format.

Transcriptionists use the following tools:

• Foot-pedals: This is used to run the dictations and is useful to editors as well, as it allows the voice file to be replayed for purposes of retyping and correcting where required.

• Headphones: The dictations are accessed using these.

• PCs

• Word processing packages: The files are typed in text format using these packages.

Transcribers are expected to type the dictation 'verbatim' and are not authorized to make changes to the dictation except in case of obvious grammar or usage errors. However, minimum editorial intervention is the way to go in the medical transcription process. Where the transcriber faces inconsistencies or obviously illogical medical facts in a dictation, the file has to be flagged off for the relevant doctor's attention and comments.

To improve the medical transcription process and make it completely error free transcriptionists are encouraged to research extensively and access standard medical references available both in print and on the internet.

Problems faced in transcribing:

• Unfamiliar medication names or terminology

• Unclear enunciation/dictation by doctors

• Speedy dictations by doctors in departments such as ER(emergency room) which are severely time-challenged

• Poor voice quality due to technical snags in the recording device

To overcome these, medical transcriptionists are encouraged to:

• Research intensively on the internet, when in doubt

• Access printed and online resources and medical dictionaries

• Flag off any file that is incomplete, unclear or inconsistent

4. QA processes

The stipulated accuracy rate in the medical transcription process for experienced transcriptionists is 98.5% with a 12 hour turnaround. There are no concessions to this stipulation and compensation packages and incentive schemes are directly linked to quality levels.

There are multiple levels of QA (Quality Assurance) in medical transcription services, with the larger players offering as many as 3 levels of quality assurance.

a) Editing

Experienced transcriptionists are moved up as editors in the medical transcription process and undertake:

• Proofreading

• Electronic spell-check

• Check for accuracy of data

• Check formatting, standardization, dates etc.

Stringent quality control processes are necessary at the medical transcription service provider's end to ensure that medical records are error-free and 100 percent accurate. Strong QA measures ensure that patients do not face the risks associated with the entry of incorrect medical records. It also raises the medical fraternity's confidence in outsourced medical transcription processes.

b) Reviewing

Completed transcripts are reviewed by the doctor concerned or a designated member of the medical staff of the healthcare facility. This ensures that all comments are seen by the designated doctor and all transcripts that are flagged off can be checked. Reviewing also ensures that the medical transcription outsourcing process is 100 percent accurate.

5. Returning Completed Transcriptions:

The medical records are returned to the hospital servers in real-time, ready to be accessed. The entire medical transcription outsourcing process is designed to be performed seamlessly and within stringent turnaround time. The completed transcripts are uploaded to the client in any of the following ways:

• Zipped e-mail attachment

• Uploaded into the client hospital's server storage to be accesses by their staff

• Send to specialized service providers for automated downloading and saving for in-house batch processing, printing and filing at the hospital

All transcriptions sent back to the clients' servers are available for download at the medical transcription service provider's server for 2 years.

Medical Transcription Outsourcing

In recent times medical centers and hospitals in the U.S. and UK have taken to medical transcription outsourcing as a cost effective solution. The medical transcription service is outsourced to offshore locations like India, China and Philippines where the data conversion from voice to electronic format is executed by dedicated medical transcriptionists who work round the clock.