For decades, narrative transcription has contained a wealth of important patient information. Dictation is the fastest, easiest way for physicians to document encounters and the output, a transcribed report, is easily read by downstream users – clinicians, coders, billers, payers.
For decades, narrative transcription has contained a wealth of important patient information. Dictation is the fastest, easiest way for physicians to document encounters and the output, a transcribed report, is easily read by downstream users – clinicians, coders, billers, payers.
The problem is that transcribed documents have been largely unusable as a source of meaningful, discrete data. Next-generation transcription technology is changing that.
Coined discrete-reportable transcription (DRT) by industry expert Mark Anderson of the AC Group, today’s transcription technology not only gives physicians a choice in how they document encounters, but also yields discrete data for meaningful use reporting, quality measurement and electronic health records. Data derived from narrative transcription, termed “narradata” by Webmedx, helps bridge the gap between physician choice and meaningful use of health information technology.
One provider, Wellstar Health System, a five-hospital integrated delivery network in Atlanta, is beginning to use DRT and narradata to determine its use in supporting Centers for Medicare and Medicaid Services (CMS) core measure reporting. The ability to automatically identify core measures patients admitted to the hospital for acute-myocardial infarction (AMI) from transcribed reports will save time and money for the organization’s team of 10 care coordinators.
“Core measure abstracts often contain upwards of over 60 data elements that must be manually abstracted by our team,” says Beth Kost-Woodrow, BS, RHIA, assistant vice president and chief privacy officer for Wellstar. “That’s a lot of valuable time spent simply reviewing cases and manually pulling core measure data elements from various parts of the medical record, including transcribed reports .”
By automatically abstracting pieces of information from dictated history, and physicals and consultation reports, Kost hopes to replace core measures staff hours with discrete data. “Not only will our core measure nurses receive a complete action list of cases every morning for their rounds, but they’ll also see a boost in productivity as they use the system to mine data from the narrative transcription,” she adds.
Several technologies from Webmedx are used in combination with Wellstar’s core medical dictation and transcription platform to perform quality analytics and electronically abstract specific data elements. The system identifies all patients with AMI documented anywhere in the transcribed reports. Armed with a list of in-house AMI patients, core measure nurses can promptly review cases on the nursing unit and begin completing CMS core measure abstracts, while the patient is admitted to the hospital.
An additional benefit for Wellstar is the ability to compare volumes of patients entering the health system with specific diagnosis against numbers reported by outside agencies.
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September 2009
