Transcription Interoperability and Exportability in the EMR/EHR

AHDI Position Statement

Position

AHDI believes that EMR/EHR technology vendors should be required to provide methods of supporting external dictation and transcription protocols. These methods would include data import/export functionality, voice exportation, and/or direct interface. In addition, such methods should have appropriate abilities to audit and track external feeds and embedded text and allow for alternative quality review components to be incorporated. Where voice-to-text insertion points exist, unique identifiers must be defined and supported to allow for external data import.

Rationale

AHDI recognizes that the evolution of healthcare documentation technologies will continue to be a driver of change in the industry and that these technologies are critical to the overall efficiency of healthcare delivery in the future. AHDI also concedes that the implementation of some template-based data capture systems will further streamline the process and create greater efficiency in documentation. However, AHDI believes that while templates are a viable method for some patient encounters, the documentation of most encounters, particularly at the acute-care level, will not be readily facilitated by template solutions. To force complex data into a restricted template has the potential to greatly compromise both the scope and quality of the patient encounter record with the risk of compromising care and treatment. Likewise, voice recognition products are of great benefit to the documentation cycle but only as a back end solution where quality monitoring is in place.

These technologies will continue to require interoperability with a healthcare documentation specialist. Given the reality that a great percentage of healthcare facilities (whether acute-care, ambulatory care, or private practice) long ago transitioned their documentation services off-site, utilizing either an at-home workforce or an outsourced service provider, these emerging technologies will need to provide and support protocols that will continue to work in that remote environment. Many physicians and hospitals have made the decision to carry out this phase of the charting cycle in an external environment and prefer to do so. Many EMR systems do not currently have a way to export voice dictation that is embedded into the EMR software. This greatly limits the outsourcing ability of the practice and restricts transcription or voice-recognition editing to an on-site scenario only.

Recommendation

To avoid a scenario where the limitations of EMR/EHR technologies force providers to choose between the high cost of transitioning documentation services back in house or eliminating quality assurance altogether, AHDI has made the formal recommendation to the Certification Commission for Healthcare Information Technology (CCHIT) that EMR/EHR vendors be required to incorporate interoperability protocols and support for remote documentation through the EMR/EHR platform.