Archive: 17 December 2018

Dictation: Giving Physicians a Break While Avoiding Costly Medical Errors

Overworked professionals, regardless of industry, are far more likely to make mistakes. For medical professionals, however, particularly when it comes to documentation, those mistakes risk profound repercussions for both medical providers and their patients. They’re also notoriously difficult to correct once they’ve been made.


Earlier this year, researchers from Johns Hopkins released a report pointing to medical errors as the third leading cause of death in the United States behind heart disease and cancer. From typos to incorrect dosing to misdiagnoses, the consequences of these mistakes can range from mundane to catastrophic—blamed for 250,000 to 400,000 deaths annually. Beyond medical mistakes, documentation errors can also wreak havoc in other areas of patients’ lives, such as when applying for life insurance.


Although completely eliminating such errors would require both industry and regulatory efforts of enormous proportions, providers can leverage a simple workflow strategy to safeguard against many of these mistakes. Dictation allows doctors to spend less of their time on documentation while sharing the workload with trained specialists who can process the records—ensuring accuracy and integrity are maintained.


medical dictation


As we recently highlighted, the advent of electronic medical records (EMRs), which originally heralded a new age of documentation ease and efficiency, actually created more administrative work for doctors. As a result, EMRs are cited in study after study as a leading factor in the twin epidemics of physician and nurse burnout. In many of those same studies, however, dictation and transcription have been highlighted as preferred strategies to make EMRs more physician friendly.


By relying on dictation, which can be seamlessly integrated into the EMR, physicians can get back to the reason they entered medicine—to care for patients. Because, as the Johns Hopkins researchers were quick to note, these errors rarely stem from poor medical care but rather a systemic problem that places undue—and out-of-scope—burden on chronically overworked doctors and providers.

A state-of-the-art dictation and transcription platform can deliver proven benefits to physician practices, hospitals, integrated delivery networks (IDNs) and medical transcription services organizations (MTSOs) of all sizes. To learn more about how these can be successfully integrated with leading EMR systems, read about Doc-U-Scribe or contact Saince.




EHRs, Documentation Leading to a Physician Burnout Crisis

Dictation and Transcription Improvements Cited as No. 1 Fix by Docs

When they were kids thinking about their future career, physicians didn’t dream of taking care of administrative record-keeping. They dreamed about taking care of patients.

But extensive documentation fatigue has become a leading concern for the healthcare industry. Just this week, the U.S. Department of Health and Human Services (HHS) released a draft strategy aimed at reducing the amount of time clinicians spend recording information in electronic health records (EHRs). Now there’s an open 60-day comment period for clinicians and others to provide feedback to the draft strategy.

The healthcare industry is waking up to the reality of doctors’ serious unhappiness with EHRs. Many physicians seems to agree with one emergency room physician who sees EHRs as “predominantly a billing tool, secondarily a compliance tool … [There are] too many boxes to click, too many irrelevant alerts, soft or hard stops which create alert fatigue. [There is] very little useful clinical decision support.”


EHR(Electronic Health Records)









And that unhappiness with the tools is leading to overall dissatisfaction. In a nationwide survey of 254 physicians from different specialties, physicians cite EHRs as the biggest contributing factor to burnout.


Incredibly, the amount of time physicians spend on administrative work has surpassed the amount of time spent with patients. A study published last year in Health Affairs reveals that physicians spend more of their time doing “desktop medicine” as they do seeing patients. Desktop medicine includes “communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results.” The study, which analyzed 31 million EHR transactions over four years by primary care physicians, shows that physicians are logging an average of 3.08 hours with patients and 3.17 hours on documentation every day.


With the demands for a more physician-friendly EHR, doctors have identified dictation and transcription as a preferred part of a better EHR solution. In the same survey where EHRs are blamed as the primary contributor to physician burnout, the No. 1 suggestion (17 percent) for fixing the problem was to add dictation and scribe features to EHRs. The second and third suggestions were not even solutions, but complaints, with 13 percent recommending that less time be spent in the system and 9 percent of respondents recommending that EHRs be replaced altogether.


The survey respondents were clear that the EHR workflow was not an innovation. Restoring dictation and transcription would help, respondents say. One orthopedic surgeon commented, “Develop a better and more user-friendly EHR. It shouldn’t take 20 minutes to do something that dictation takes three minutes.”


For help understanding how a state-of-the-art dictation and transcription platform can deliver proven benefits to physician practices, hospitals, integrated delivery networks (IDNs) and medical transcription services organizations (MTSOs) of all sizes, and successfully integrate with leading EHR systems, read about Doc-U-Scribe or contact Saince.








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Getting CDI Compliance Right From the Start

For decades, countless market observers have warned of turmoil in the healthcare space. The upheaval and endless changes have created a cacophony of compliance requirements that leave healthcare providers—both new players and those pursuing improvements—scratching their heads about where to begin.

Organizations focusing on clinical documentation improvement (CDI) must foster an environment of effective compliance from the outset. If they hope to improve outcomes while also increasing revenues and reducing costs, those organizations must evolve CDI practices in support of shifting trends in reimbursement and its documentation requirements.

Get the Workflow Right, and Quality Will Follow

Outpatient CDI efforts are designed to address a variety of needs, including Hierarchical Condition Categories (HCC) capture, quality improvement, risk adjustment and more. Without thoughtful attention to the development of an efficient and effective workflow, however, these goals will compete as varied teams within the organization focus on different aspects.

For instance, what may appear to be an issue with quality may actually be an issue with documentation, or vice versa. Aligning staff around common goals—ensuring not only that they’re tracking the same metrics, but also prioritizing them in the same order—will help teams more quickly identify operational issues and their true causes.

Understand How CDI Efforts Affect Reimbursement

Whether through HCC capture, risk adjustment or other areas, CDI efforts are helping providers better adjust as the healthcare landscape shifts away from fee-for-service and increasingly toward value-based, alternative reimbursement models. But as noted above, leveraging these capabilities requires that teams align around these metrics and how coding and CDI work synergistically to achieve these ends.

clinical documentation improvement

Although fee-for-service remains the norm in many settings, even those once-reliable revenue streams are increasingly in jeopardy as a result of penalties surrounding poor quality or, conversely, failure on the part of organizations to properly code and capture reimbursement incentives. Capturing HCCs, in particular, is becoming a vitally important CDI task as the high-value diagnoses play a central role in risk adjustment—requiring ongoing, accurate documentation to reflect patient and population health risk.

Under this new payment paradigm, teams need to understand the relationship of day-to-day compliance, accuracy and the longitudinal effects they have on reimbursement and organizational efficacy.

Understand How Outpatient CDI Affects Population

If your organization has decided to address outpatient CDI, then many of the above strategies become even more vital. Streamlining workflows and organizational compliance is more challenging in the outpatient setting, which places a greater emphasis on effective intra-team cooperation and communication.

On the upside, however, by implementing effective outpatient CDI efforts as part of an overall CDI strategy, healthcare organizations can capture opportunities for medical necessity documentation as well as reduce error-driven medical necessity denials for patients.

For more tips on Outpatient CDI efforts, see our previous blog post. For help designing your organization’s CDI efforts or to learn about  PracticePerfect, a platform to help you address outpatient CDI, and Doc-U-Aide, a revolutionary platform for inpatient CDI, contact Saince.

Safeguarding Cyber security Amid CDI Efforts

Original: Cyber security, Coding and CDI. Best practices to ensure best practices for cyber security are employed.


To say that the present state of healthcare cyber security poses a challenge for organizations undertaking clinical documentation improvement (CDI) efforts is a drastic understatement. Under the ever-present specter of costly cyber attacks, providers across the country continue to grapple with myriad, big-picture challenges such as information governance (IG), highly ambiguous government oversight and unstable compliance landscapes as well as shifting care settings.


Providers are required to adhere to strict security laws like HIPAA and HITECH while simultaneously acceding the regulatory demands of fluid information sharing contained in the 21st Century Cures Act—all while adapting to the logistical reality of increasingly frequent outpatient care delivery. Further intensifying those challenges, the shift to outpatient care means that greater volumes of protected health information (PHI) is being routed through ambulatory and other non-hospital settings, making them increasingly attractive targets for hackers. Additionally, a recent survey of medical coders also found that roughly one-third reported working remotely at some point, highlighting the potential vulnerability many providers face.


Healthcare Cyber Security


As they approach this challenging future, however, smart organizations can balance conflicting security and compliance concerns as well as inpatient and outpatient CDI initiatives by sharpening their focus in a few key areas.


Staffing and Training. In CDI, overwhelmed and under-trained teams are more apt to make costly mistakes. The same is true for cyber security. A misaligned and overworked team is a liability and leading cause of security breaches, but one with the tools, training and cohesion to efficiently manage their workflow is a powerful safeguard. The quickest way for any organization to promote quality and compliance—as well as security—while executing CDI efforts is to ensure its staff is trained well. Fostering alignment between providers, coding and other administrative staff must include education on common security risks, drills to identify weak points and emphasis on a culture where anomalies, breaches and prevention are openly discussed and addressed.


Emphasis on Accuracy and Clarity. Just as optimized CDI and streamlined organizational compliance—from the point of care to the submission of a claim—can reduce error-driven medical necessity denials, that same focus on accuracy and clarity can reduce security errors as well. As provider organizations seek to improve overall IG while also contending with growing troves of clinical data, enhanced CDI workflow is a necessary component strategy, intricately linked with all others.


Encryption of All Devices. Loss of mobile devices is a major cause of healthcare data breach, particularly in outpatient settings. As mobile devices become increasingly common tools in clinical documentation, ensuring that these devices and all computers are encrypted is an important, albeit not-HIPAA-required, step for organizations to take.


Vetting Vendors. An organization must safeguard its own internal protocols, but it must also ensure that its vendors—particularly those offering Software as a Service (Saas)—are taking all reasonable steps to protect data, confidentiality and security as well. It’s a must to understand a vendor’s risk assessments and require indemnification provisions and cyber security insurance in business associate agreements.


Designing your organization’s CDI efforts is a significant undertaking. To learn about  PracticePerfect, a platform to help you address outpatient CDI, or Doc-U-Aide, a revolutionary platform for inpatient CDI, contact Saince.