Saturday, February 6, 2010

Integrating Cardilogy Transcription with EMR to Create a Better Documentation System

Cardiology transcription is a process in which the health information of the patient is dictated, stored and transmitted to a transcriptionist as voice file. This is converted into an electronic format like a computer text file and sent back to the physician, who stores it in his or her computer, for later use.

The EMR or Electronic medical record is medical documentation system in which the information of the patient is directly fed into the computer by selecting related terms from pre-structured point-and-click templates. The doctor simply points and clicks on the appropriate clinical terms from the available choices to enter medical observations of the patient.

Electronic medical record or electronic health record is gaining in importance as it allows the doctors to store and manage efficiently voluminous protected health information in safely. The information can be retrieved easily whenever needed. The medical information of a particular patient stored by one doctor can be easily used or updated by another doctor during the course of treatment. This provides a greater flexibility to the treatment process. As this form of documentation process has lesser human interference it is prefered by tech savvy doctors over medical transcription.

But cardiology transcriptionists can bridge this gap between these two forms of medical documentation systems to create more efficient system where both of them complement each other. The transcriptionists provide the trained eyes and are better trained to process the information without errors. Also extra safe guards like, quality control audits ensure high accuracy rates in the cardiology transcription. This feature is missing in the EMR as everything depends on what the doctor enters into the template with no crosschecks in place. Wrong information entered can be carried forward or used by other doctors.

Further the output from templates is too canned and identical in EMR. It loses individuality for each patient and this shortcoming can be well addressed in the transcription process where the description of the patient is vividly converted into a detailed electronic record that is customized to address medical requirement of the patient. Some doctors prefer EMR while other prefer medical transcription due to their own advantages and disadvantage that these two form of documentation offer.

But transcriptionists can play a pivotal role by helping the medical fraternity to harmonize EMR with medical transcription by providing the much needed reliability in form of trained eyes and human instinct. By synchronizing both these documentation systems it is possible create a better and larger medical documentation system, which efficiently manages the protected health information of the masses in accost effective manner and at same time adhere to HIPPA norms.

Cardiology transcriptionists can bridge the gap between cardiology transcription and EMR to create a better documentation process.

Jason Gaya

Read more on cardiology transcription, on www.cardioscribes.com

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