Next Big Thing in Clinical Documentation

The Next Big Thing in Clinical Documentation

September 24, 2019 | 04.30 PM EDT

The year is about 1600 BC and the place is Egypt. The surgeon is performing a complicated surgical procedure, one never attempted before, is successful in saving his patient. “Tell me you got all that on the papyrus! I plan on covering this in my next lecture.” he nudges his assistant, who had been feverishly taking notes on the procedure, looks up and nods at the surgeon.

While this might sound like the opening scene from a historical fiction film, this is not entirely fictitious. Clinical documentation is not something new and has been around since the time of the ancient Egyptians, primarily as a teaching tool. And as societies evolved, so did clinical documentation. It wasn’t until the turn of the last century that clinical documentation became prevalent and a mandated practice to provide a more holistic approach to healthcare.

Clinical Documentation in Modern History

Around this time, hospitals became major centers for providing healthcare, there was more emphasis on record-keeping. And when the doctors got too busy to be taking notes on their patients and the procedures, they recruited scribes to do the work for them. These medical transcriptionists worked in tandem with the physicians and took notes, mostly in shorthand, while the physicians focused on the patient.

The Growth with Technology

With the advancements in technology came the ability to record our voices. This coupled with the advent of the internet meant that the transcriptionists can work remotely, from anywhere in the world. Many of these jobs were outsourced from the west to developing countries such as India, which sprouted a thriving medical transcription market.

Hospitals, big and small, from across Europe and America, would send audio files of the dictations made by the physicians, to these transcription agencies. The agencies’ workforce would then listen to the received audio files and type it out manually into a transcript which was then sent back to the hospital via electronic or physical means.

These transcription centers operated around the clock to maximize throughput and revenue. The quality of the transcript depended largely on the experience of the transcriptionist and their ability to understand the accented voices easily. But it was still a hard day’s work for the digital scribes.

Transcription in the Age of Artificial Intelligence (AI)

The turn of the century brought about tremendous acceleration in the development of artificial intelligence. AI found widespread application in the field of transcription, especially in speech understanding. AI-driven clinical documentation extended its support beyond transcribing audio files into transcripts. It extracted meaningful information from unstructured text and compiled them into a structured document for physicians and insurance providers.

As for the physicians, they were able to receive good quality transcripts with shorter turnaround times and at lower costs. However, they still had to spend hours every month, manually filling out the fields in their Electronic Medical Records. As a result, productivity took a hit as did the hospitals’ revenue potential.

Healthcare apps like CascadeMD are transforming the healthcare ecosystem with AI-powered smart clinical documentation. CascadeMD, for example, uses NLP and machine learning to not only convert the dictated speech to text, but also makes sense of the unstructured information. The unstructured text is converted into structured data and populated in the respective fields in pre-defined templates.

Transcriptionists can now work in tandem with the engine to create transcripts and provide AI-augmented value-added services. It helps unleash the Untapped Revenue Potential (URP) of Medical Transcription Service Organizations (MTSOs) and healthcare institutions.

With its arrival, CascadeMD is poised to resolve many outstanding issues pertaining to clinical documentation. As for the physicians, the AI engine extracts relevant information from the transcript, and populated the appropriate fields on the patient’s EMR form. This means that physicians no longer need to type out these forms manually or spend tens of thousands of dollars on scribes. They can fill out EMR effortlessly while being more productive and cost-effective.

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