Modern day healthcare depends on the input from various sources to be effective and profitable. One such aspect that plays a vital role in healthcare is health information management. Health information management is the practice of maintenance and care of health records. Health information professional have been described to play a critical role in the delivery of healthcare. They focus on collection, maintenance and the use of quality healthcare data to support the information intensive and information reliant healthcare system.
One important aspect of health information management is medical transcription, which is the process of documenting the patient-healthcare professional encounter. Medical transcription is a specialized process requiring the optimum combination of people skills, processes and technology. Outsourcing medical transcription ensures that patient records are created in a professional manner making the process efficient, effective and economical. Patient records need to fit a certain criteria to be useful in the healthcare process. The service provider needs to be evaluated based on the criteria used to evaluate data characteristics:
- Accuracy: Medical records of patients are vital to the process of healthcare. They provide continuity, basis for planning future care, assist in case of litigation and can be used for education and research. Therefore the accuracy of the data captured should be as close to 100% as possible.
- Accessibility: To provide quality healthcare it is important that information is easily accessible. It not only helps healthcare professionals and support staff provide quality care but also organize their time better. Outsourcing can help in this aspect by providing archiving facilities, which make it easier to trace file.
- Comprehensive: Patient records need to encompass all the details of the patient’s medical history. This aids healthcare professionals in making the right treatment plan. The service provider needs to ensure that all the details are comprehensively captured during the transcription process.
- Consistency: Healthcare is a complex field and it is important that the value of the data should be reliable and standard across various applications. This is the responsibility of the transcriptionists who actually transcribe the records. It is important that their training program encompasses all the details of the specialty they are transcribing for.
- Currency: The patient records should reflect current data. Creating timely records is an important duty of the service provider.
- Definition: This means that the data should be clearly defined with no room for misunderstanding. This requires the transcription team to have in-depth knowledge of medical terms and definitions.
- Granularity: This means the attributes and value of data should be defined at the correct level of detail.
- Precision: The details in the medical record, documenting the essentials so that no details are missed but unnecessary data is not included.
- Relevancy: The data captured in the medical records should be relevant.
- Timeliness: The medical records need to be created with all the above given attributes within a reasonable time frame. The optimum turnaround time would aid both quality healthcare and quicker reimbursements.
Outsourcing to a professional medical transcription service provider ensures that medical records are created with all the attributes.