WHERE DO WE GO FROM HERE?
Out of curiosity, I decided to take a look at the history of medical transcription. What I have wondered about is the start and the impact of the medical profession in the healthcare industry. In researching the history, I discovered a similarity in today’s electronic health records systems with the pre-1960’s time and now question period – where do we go from here?
What I learned was prior to the 1960s, doctors basically acted as their own scribe. Each physician created their own personal notes regarding patient visit, test or surgery using their own style of notation and abbreviation. This is made it difficult on the other hand, but we have not to decipher a physician’s handwriting or make sense of the notations and abbreviations used. With a number of doctors and hospitals, the physician in capturing the medical documentation. Over the next few decades the profession of transcription profession was born and continued to transform as new technologies developed Medical Condition.
In the 1960’s, physicians started to use medical professionals who would write down the doctors in Shorthand and then type up their notes on electric typewriters. With the development of the mini and micro cassette recorders in the late 1960’s, physicians and scribes have not been able to deal with the possibility of being able to separate rooms and at a later time. The shorthand was needed as the designer could now type up the dictation on the cassettes.
The 1970s were focused on early word processing machines, making the job of editing and correcting text quicker and more efficient. The American Association for Medical Transcription (AAMT), now known as the Association for Healthcare Documentation Integrity (AHDI), was formed to help support and promote the medical transcription profession. .
From the 1980’s up through today, we have seen technology that is used for personal computers that initially used floppy disks for digital online capabilities and processors with auto-correcting plus spelling and grammar checking. Dictation technology has also gone from micro-cassettes to digital recorders to voice recognition. With this evolving technology, the medical transcriptionist must learn and adapt right along with it. More than just typists, however, medical transcriptionists are medical experts.
According to the AHDI website, quality transcription requires above-average knowledge of English grammar and punctuation; excellent auditory skills, allowing the transcriptionist to interpret almost simultaneously with keyboarding; advanced proofreading and editing skills, ensuring accuracy of transcribed material; versatility in use of transcription equipment and computers; and highly developed analytical skills, employing deductive reasoning to convert sounds into meaningful forms. The medical transcriptionist is a professional who takes the raw audio file and translates into the quality documentation.
The medical transcriptionist has been a quality link for documentation between physicians and medical records since the 1960’s. This relationship is allowed to be maintained on patient care by the physician. Recent technologies for electronic health records (EHR) and the Health Information Technology for Economic and Clinical Health Act (HITECH) which mandate physicians and transition to EHR, nonetheless, have links and brought physicians back into the scribe role.
The EHR systems have many positive advantages, but these are the most effective methods for having a data entry and clerical documentation which affects their interactions with patients as they divide their time between the patient and documenting the patient record. In response to the plummeting level of satisfaction of EHR systems by physicians, the new developing transcription trend is occurring – the medical scribe. This trend moves the role of the away, once again, from the physician.