Transcription

Philosophy of Doctations Encounter Reports (EMR)

The transcription component of the Doctations EMR System actually consists of three different functions providing coordinated ways to use audio recording to speed up the documentation of electronic patient medical records. This technology is state-of-the-art and very reasonably priced because we believe that dictation/transcription should be a routine component of most if not all encounter reports.

Many EMRs provide templates that are very specific for particular medical problems. There must be a template for the majority of common problems that a provider sees in order for the system to be useful. Needless to say, this type of template is very rigid and often there is little or no room for entering narrative information.

The templates of the Doctations Web Based EMR are linked to the headers, subheaders and sections normally found in a report. And these templates can be customized on the fly.

Doctations helps doctors build encounter reports and other forms of medical documentation and correspondence very rapidly by providing a variety of very flexible tools for entering informationinto the report.For example, the user can quickly add the user's custom NORMAL PHRASE to a section, or one or more NAMED PHRASES to a section.Another data entry means is the NAMED PHRASE PLUS tool, also called the eProbe.

Every section can have two types of information:

Free text and
Structured data (such as values, e.g. temperature)
Codified data (such as diagnosis codes)
Multimedia data (such as dictation, images or video)

Doctations helps doctors build encounter reports and other forms of medical documentation and correspondence very rapidly by providing a variety of very flexible tools for entering information into sections of the report. For example, the user can quickly add the user's custom NORMAL PHRASE to a section, or one or more NAMED PHRASES to a section. Another data entry means is the NAMED PHRASE PLUS tool, also called the eProbe, to hold time-related structured data.

Most of the HISTORY sections of an electronic patient medical record, for example, allergies, medications, social history, medical history, surgical history, vaccination history, review of systems, hospitalizations, etc., are stored as structured or codified data in central repositories called the SPDB (shared patient database). These sections MUST contain structured and codified data for decision support technology because free text often has ambiguous meaning in the digital domain. Frequently, the Physical Exam sections of a report are completed using a combination of NORMAL PHRASES, NAMED PHRASES and NAMED PHRASE PLUS elements.

ROLE OF DICTATIONS in DOCTATIONS Encounter Reports:

The Doctations Web Based EMR enables the user to add a dictation by placing an insertion point in the FREE TEXT part of ANY report SECTION and pressing the record button. When the recording is saved, a small tape icon appears at the insertion point. Clicking on the tape icon causes the recording to be played.

Depending on user preferences, these recordings can be sent through the Doctations transcription service automatically upon closing the document. Of course, it is possible to manually track all active transcription jobs, but this is unnecessary because documents are automatically tracked until all transcriptions are complete, then those documents are flagged for eSigning and finalization. The text of completed transcriptions are automatically inserted to the right of the tape icon. Transcribed text is BLUE and text typed directly into Doctations reports is BLACK. Upon review of the transcribed text, including the opportunity to grade the transcription, the tape icon is removed.

With the use of NAMED PHRASES, NORMAL PHRASES, SPDB SECTION INFO, and NAMED PHRASE PLUS tools, the role for dictation/transcription is for CLINICAL NARRATIVE. Because we can talk SEVEN times faster than we can write or type, there is NO BETTER WAY TO ENTER CLINICAL NARRATIVE than DICTATION/TRANSCRIPTION. The Doctations EMR System makes it very easy for the provider to dictate while reducing effort for staff because they no longer need to track and manage the entire transcription process.

WHY IS DOCTATIONS TRANSCRIPTION SO POWERFUL?

The Doctations Web Based EMR transcription feature is state-of-the-art because it is automated and fully integrated into the Doctations application suite, and because it is based on MMODAL, Inc.’s back-end voice recognition technology. Every time the Doctations dictation capture files are forwarded for transcription, they first go for automated voice recognition. The intelligent MMODAL voice recognition engine learns from human editors that correct the automatically transcribed text. Over time, less and less editing is required as the MMODAL voice recognition engine becomes more accurate for the particular end user.

DIFFERENT TYPES OF TRANSCRIPTION in DOCTATIONS:

The Doctations EMR System supports several dictation/transcription processes:

Batch dictation/transcription (red button) - this is the standard dictation process and is as described above and uses the intelligent "learning" by the MMODAL voice recognition engine.
Real Time Voice Recognition (green button) - this very powerful tool actually benefits from prior learning in the Batch Dictation/Transcription process.
Scribe Service (white button) - this transcription is done by a human transcriber who has been trained in Doctations technology. The provider can dictate commands and data and the transcriber does data entry for the provider. For example, the provider can dictate a list of medications in the MEDICATION section under the HISTORY header and the SCRIBE will do data entry into the MEDICATION SPDB.
Dictation & Hold: recordings are not transcribed until the medical practice requests transcription.
Voice Annotation: these are audio recordings that are never transcribed.

Cost of Doctations Transcription:

The cost of transcription per line is listed HERE

The actual transcription costs using Doctations as described above are considerably less than whole document dictations and the resulting reports are intrinsically more accurate and more complete.

Typically, transcribed lines in a Doctations electronic patient medical record or encounter report represent only about 10% of all of the lines in the report. The remaining lines result from the free text and structured or codified data selected by the provider in preparing the report.

This results in excellent quality reports from both the clinical perspective and from the clinical coding perspective.