Although healthcare professionals do their best to maintain accurate documentation, mistakes can still happen—that’s just human nature. However, many of these mistakes have life-threatening consequences. Fortunately, this problem can be solved by one thing: accurate medical transcription services that provide a practical approach to minimizing electronic health care records errors.
The question is, how can we achieve accurate EHRs? What are the best practices? And, are there solutions?
In this article, you’ll learn:
- Medical transcription services can significantly reduce mistakes in your Electronic Health Records, thanks to our high accuracy rates.
- User-friendly platforms make the process smoother and allow you to securely & efficiently upload files, track progress, and access transcripts.
- Medical transcription services can provide high-quality transcripts you can trust, ensuring patient data security through HIPAA compliance, all at affordable rates.
What Is An Electronic Health Record?
An electronic health record is a digital version of a patient’s medical chart that provides a real-time view of their health information. EHRs go beyond standard clinical data, including patient’s medical history, diagnoses, medications, treatment plans, test results, and more.
These digital copies enable healthcare providers to access and share a patient’s information across multiple healthcare organizations. This allows them to make the most appropriate decisions and smooth workflows while ensuring the patient receives adequate care.
Uses of Electronic Health Records
EHRs have their fair share of importance; we’ve listed scenarios where these solutions are very much needed.
| Medical Case | Importance of EHRs |
| Patients with chronic conditions | Track long-term treatment, monitor disease progression, and ensure continuity of care. |
| Patients with complex medical histories | Centralized, accessible records of past and current health status for informed decision-making. |
| Patients receiving care from multiple providers | Facilitate communication and coordination among providers, reducing errors and omissions. |
| Emergency and critical care situations | Quick access to medical history, allergies, and medications for informed decisions and timely treatment. |
| Patients undergoing transitions of care | Accurate and efficient transfer of medical information, maintaining continuity of care, and reducing errors. |
Most Common Challenges Associated with EHRs
Now that we’ve covered the practices for producing accurate EHRs, let’s discuss the common challenges related to these systems.
Cost of EHR Systems
Although it may seem unlikely, maintaining an EHR system can financially burden medical organizations. On average, medical practices spend $1,200 annually per user for an EHR system. The initial costs include software licenses, hardware upgrades, and data storage solutions. On the other hand, ongoing expenses include staff training, troubleshooting, and subscription fees for cloud-based EHR solutions—though not all are cloud-based.
Due to this, smaller practices with limited budgets may find those costs challenging.
Workflow Inefficiencies
Transitioning to an EHR system can disrupt existing workflows if not implemented properly. Medical staff accustomed to the “old ways” may spend considerable time documenting information in the EHR. While it may not seem much, it can shorten patient interaction time dedicated to understanding their needs.
Physicians spend an average of 15.5 hours per week on paperwork and administration, and poorly designed EHR systems can also create additional work. For instance, data may need to be manually re-entered into different platforms, which could result in inefficiency, frustration, and decreased productivity.
Security Concerns
As we already know, EHRs are like digital repositories for a huge amount of patient data that includes detailed medical history, medications prescribed, diagnoses received, treatment plans implemented, and even billing information.
Breaches of this data and exposed information could be used for anything from identity theft to financial damages. In worst-case scenarios, leaked data could even lead to physical harm if a patient’s medical condition is exploited for malicious intent.
Data Compatibility
Some EHR systems have compatibility issues with those from different EHR vendors, which is a serious setback for seamless communication. In an ideal world, healthcare providers from different organizations should be compatible- at least to the point of being able to easily share information.
However, the lack of standardized data formats or communication protocols between EHR providers can make this challenging. For instance, a specialist may be unable to access a patient’s medical history from another hospital’s EHR system. This can cause delays in diagnosis or even duplicate tests that will only waste resources.
Potential Data Inaccuracy
Maintaining accurate data in EHRs should be an SOP as it is crucial for the patient’s life. However, EHRs can introduce new challenges to data quality. For example, medical staff who are short on time may resort to abbreviations during data entry, which could lead to potential errors.
Poorly designed EHR interfaces require more time to navigate, increasing the risk of data omissions. Inaccurate data within EHRs can have serious consequences for patients, such as misdiagnosis, incorrect treatment plans, and compromising patient safety.
Legal Compliance
An EHR implementation must meet certain regulatory requirements, like HIPAA. Consequently, any adjacent services—like medical transcription (and scribing)—must meet the same HIPAA guidelines to protect your practice from legal and regulatory penalties.
Best Practices For Accurate Electronic Health Records
If you are a healthcare professional who works with EHR systems, you understand the importance of their accuracy. However, the best practices for producing accurate records aren’t common knowledge within the healthcare industry. So, we’ll take a moment to list them below:
Document Every Interaction
Every interaction with a patient should be documented in the EHR. This includes interactions such as presenting complaints, checking vital signs, physical examination, diagnoses, treatment plans, medications prescribed, and any procedures performed.
Accurate documentation gives a clear picture of the patient’s condition and the care needed, which allows for more appropriate decisions from every healthcare professional involved.
Conduct Regular Internal Audits
Healthcare organizations should establish a regular program for conducting internal audits of their EHR systems and, if possible, assign a team to conduct these audits periodically.
Audits work by pulling up patient records to confirm accuracy or identify potential errors. Doing so helps proactively identify issues and address them before they escalate.
Use Data Effectively
EHR systems contain a lot of data that can be used to improve patient care, health management, and, most especially, healthcare research. However, the effectiveness of this data largely depends on its accuracy—the more accurate, the more usable.
That said, healthcare organizations are better off implementing data validation checks to confirm that details encoded into the EHR are correct and within expected ranges. Accurate data can generate much more reliable reports and analytics for different types of health research.
Prevent Excessive Documentation
Although complete documentation is important, healthcare professionals can forget the difference between complete and excessive EHR entries. Though we understand that even robots make mistakes, medical staff should focus on documenting the most pertinent details of every patient encounter to avoid over-documentation.
Thankfully, templates and standardized documentation tools can help with this process without sacrificing accuracy. Finding this balance will ensure that EHRs remain useful to medical staff.
Get a User-Friendly EHR System
Not everyone is well-versed in EHR systems; therefore, usability is a huge factor in data accuracy. If you’re new to this, cumbersome interfaces can frustrate you, which could lead to errors in data entry.
That said, healthcare organizations should carefully evaluate their prospective EHR systems. Consider user-friendliness, design, and ease of navigation. A user-friendly EHR system allows medical staff to focus on accurately documenting patient information.
Provide Enough EHR Training
Adequate training for all staff is crucial, especially for those who deal with the EHR system firsthand. This training should go beyond basic functionalities and get into proper data entry techniques, coding practices, documentation standards, etc.
Regular training updates are also crucial to ensure your medical staff stays current with system changes for accurate EHR use. Investing in training allows staff to utilize EHR systems effectively and contributes to the overall usability of patient data.
Enlist The Services Of A Professional EHR Transcription Service
At the end of the day, you need to balance the cost of hiring outside help with the potential benefits. Professional transcription service providers like Ditto Transcripts can address your EHR issues and improve efficiency, accuracy, and legal compliance.
How Ditto Transcripts Can Help You With EHR Challenges
Ditto Transcripts is a premier EHR transcription service provider that offers the best medical transcription in the industry at affordable costs. Here’s how we can help with all your EHR woes:
Time Savings
With Ditto Transcripts, doctors and healthcare professionals no longer need to juggle EHR input and focused note-taking simultaneously. Here’s how we do it:
- Doctors, nurses, and medical staff can dictate patient information, chart notes, histories, treatment plans, medication, and other relevant EHR data.
- Audio recordings through dictation mobile apps or other means are sent to us via our secure cloud interface.
- We assign a skilled medical transcriptionist to produce and proofread the transcripts. Dictations are transcribed and saved as PDFs, RTFs, or other text file formats as required.
- We send the completed work back to you. The transcripts, formatted into structured EHR templates, allow your system to read and auto-populate proper text fields using an HL7 interface.
Accuracy
We are serious about maintaining our 99% accuracy rate in the market. Everyone on our team understands that even minor errors in patient details can have heavy consequences, so we take a multi-layered approach to guaranteeing the accuracy of your transcripts.
100% US-based Human Medical Transcription
At Ditto, we only work with the best native English speakers in the market to ensure quality across the board. Also, our full operation, including all our transcriptionists, are US-based, meaning you get the type of quality you can get from someone who’s spoken the language their whole lives. Plus, our transcriptionists can be contacted, provide certified transcripts, and appear in court in person if required by law.
Experience
We’ve been around since 2010, so our medical transcription team isn’t just skilled; they’re passionate about it. They deeply understand medical terminology, disease processes, and proper documentation practices. You can be confident that your electronic medical records have the necessary information.
Timeliness
We understand how important timely access to patient information is. That is why we do our best to have swift turnaround times. Receiving your transcripts promptly allows for faster chart completion and better workflows. This means less time waiting and more time focusing on what matters most: your patients. Ditto offers fast turnaround times of up to four hours for STAT transcription jobs.
Medico-Legal Compliance And HIPAA Compliance
Everyone at Ditto Transcripts understands the importance of securing the patient’s medical record. To ensure that every patient’s information is safe, we’ve taken steps to gain 100% HIPAA compliance. Our services include audit trails, long-term storage, redundant security protocols, on-site security, advanced user access management, and 256-bit encryption.
This way, we can help you maintain trust with your patients and guarantee compliance with regulatory requirements.
Customizable Formats
Based on experience, we find every healthcare organization is unique. Because of that, we offer customizable services to help with different requirements. This may include pre-defined templates and formatting transcripts to integrate with your EHR system that matches your preferences.
Affordable Solution
We believe that high-quality medical transcription shouldn’t break the bank. So, we offer competitive pricing without compromising on quality. Ditto Transcripts’ medical transcription cost is 7-14 cents per line. Per-line pricing means charging a client per predetermined line in a completed transcript. Outsourcing transcription tasks to us will reduce in-house transcription staff or manual data entry costs—imagine the compounded savings and ROI in the long run.
24/7 Customer Support
We understand that expected issues can arise. Worry not; we have 24/7 customer support to address any concerns you may have. Our technical support staff is always available to assist you with any challenges, troubleshoot technical issues, or answer questions regarding our platform or service.
User-Friendly Platform
We believe in simplicity, so we’ve designed our online platform with busy healthcare professionals in mind. It’s easy to use and allows you to upload dictation files. We’ll stay in touch from start to finish, allowing you to access completed reports securely—all within a convenient location.
Reach Out To Us For Accurate Medical Documentation
Eliminate EHR & EMR errors and free up time for patient care with Ditto Transcripts. Our medical transcriptionists deliver 99% accurate transcripts quickly so you can focus on what matters most. We offer HIPAA-compliant solutions at competitive rates. Contact us today!
Ditto Transcripts is a HIPAA-compliant, Denver, Colorado-based transcription company that provides fast, accurate, and affordable transcription services for hospitals, clinics, facilities, and individual practices of all sizes. Call (720) 287-3710 today for a free quote, and ask about our free five-day trial.
