WHERE DO WE GO FROM HERE?

Out of curiosity, I decided to take a look at the history of medical transcription. What I was wondering was how medical transcription started and what was the impact of the medical transcription profession on the healthcare industry. Researching history, I discovered a similarity in today’s electronic medical record systems to the period before the 1960s and now I wonder: where do we go from here?

What I learned was that before the 1960s, doctors basically acted as their own scribes. Each physician created their own personal notes regarding a patient visit, test, or surgery using their own style of notation and abbreviation. This made it difficult for others to need the information but could not decipher a doctor’s handwriting or understand the annotations and abbreviations used. With the growth of practices and hospitals and the need for research and study, it became necessary to work on standardization and find ways to help the physician capture medical documentation. Over the next several decades, the profession of medical transcription was born and continued to transform as new technologies developed.

In the 1960s, doctors began using medical stenographers who wrote doctors’ dictation in shorthand and then wrote their notes on electric typewriters. With the development of the mini and micro cassette recorder in the late 1960s, the doctor and scribe no longer had to be face to face, allowing transcription to occur in a separate room and at a later time. Shorthand was no longer necessary as stenographers could now type documentation directly from dictation on cassettes.

The 1970s ushered in the first word processing machines, making the job of editing and correcting text faster and more efficient. The introduction of new technology helped expand the profession of medical transcription and in 1978 the American Association for Medical Transcription (AAMT), now known as the Association for the Integrity of Healthcare Documentation (AHDI), was formed to help support and promote the profession of medical transcription. .

From the 1980s to the present, we have seen technology transform from word processing machines to personal computers that initially used floppy disks to digital in-line capabilities with faster processors and software with automatic correction and spelling and grammar checking. . Dictation technology has also moved from microcassettes to digital recorders and speech recognition. With this evolving technology, the medical transcriptionist must learn and adapt to perfection. However, more than just typists, medical transcriptionists are experts in medical language as well as experts in medical documentation.

According to the AHDI website, quality medical transcription requires an above-average knowledge of English grammar and punctuation; excellent listening skills, which allow the transcriber to interpret sounds almost simultaneously with the keyboard; advanced proofreading and editing skills, ensuring the accuracy of the transcribed material; versatility in the 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 it into quality documentation.

The medical transcriptionist has been a quality link for documentation between the physician and medical records since the 1960s. This relationship allowed the physician to place the primary focus on patient care. Recent technological advancements of electronic medical records (EHR) and the Health Information Technology for Economic and Clinical Health Act (HITECH) that requires physicians and hospitals to transition to EHR, however, have declined this valuable link and they have returned physicians to the role of scribes.

EHR systems have many positive benefits, but these benefits are outweighed by the fact that clinicians are dissatisfied with having to spend more time on data entry and administrative documentation, which affects their interactions with patients, since They divide their time between the patient and the documentation of the patient record. In response to the plummeting level of physician satisfaction with EHR systems, there is a new developing transcription trend: the medical scribe. This trend distances the scribe paper, once again, from the doctor.

So where does the scribe doctor go from here or are there other trends waiting behind the scenes for us to discover? Clearly, the medical profession works best in the interest of the patient when the roles of physician and clerk are separated. Doctors can do what they are best trained to do in treating and curing patients, and scribes can do what they are best trained to do to deliver quality documentation. This mutually beneficial relationship between doctor and clerk not only benefits each other, but is also positive for the healthcare industry.