WHERE DO WE GO FROM HERE?
Out of curiosity, I decided to take a look back at the history of medical transcription. What I wondered was how did medical transcription get its start and what was the impact of the medical transcription profession in the healthcare industry. In researching the history, I discovered a similarity in today’s electronic health record systems with the pre-1960’s time period and now question – where do we go from here?
What I learned was that prior to the 1960’s physicians basically acted as their own scribe. 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 on the occasion where others may have need of the information but were unable to decipher a physician’s handwriting or make sense of the notations 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 assist the physician in capturing the medical documentation. Over the next few decades the medical transcription profession was born and continued to transform as new technologies developed.
In the 1960’s, physicians started to use medical stenographers who would write down the doctors’ dictation in shorthand and then type up their notes on electric typewriters. With the development of the mini and micro cassette recorder in the late 1960’s, physician and scribe no longer had to be face to face which allowed the transcribing to occur in a separate room and at a later time. Shorthand was no longer necessary as the stenographers could now type up the documentation directly from the dictation on the cassettes.
The 1970’s ushered in the early word processing machines, making the job of editing and correcting text quicker and more efficient. The introduction of the new technology helped to expand the medical transcription profession and in 1978 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 transform from the word processing machines to personal computers that initially used floppy disks to digital online capabilities with faster processors and software 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 language experts in addition to being medical documentation experts.
According to the AHDI website, quality medical transcription requires above-average knowledge of English grammar and punctuation; excellent auditory skills, allowing the transcriptionist to interpret sounds 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 form. The medical transcriptionist is a professional who takes the raw audio file and translates that into quality documentation.
The medical transcriptionist has been a quality link for documentation between physician and medical records since the 1960’s. This relationship allowed the primary focus to be placed on patient care by the physician. Recent technology advances of electronic health records (EHR) and the Health Information Technology for Economic and Clinical Health Act (HITECH) which mandates physicians and hospitals to transition to EHR, nonetheless, has lessened this valuable link and brought physicians back into the scribe role.
The EHR systems have many positive advantages but these advantages are offset by physicians being dissatisfied with having to spend more time doing 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 a response to the plummeting level of satisfaction of EHR systems by physicians, a new developing transcription trend is occurring – the medical scribe. This trend moves the scribe role away, once again, from the physician.
So, is the medical scribe where we go from here or are there other trends waiting in the wings for us to discover? Clearly, the medical profession works best for the interest of the patient when the physician and scribe roles are separated. Physicians can do what they are best trained to do in treating and healing patients and scribes can do what they are best trained to do in delivering quality documentation. This mutually beneficial relationship between physician and scribe benefits not only each other but is a positive for the healthcare industry.