Dr Susmit Jain, Assistant Professor, Institute of Health Management Research, informs about the vital role of hospital personnel who work closely with physicians and yet remain in the silent background
Capturing and recording the performance of clinical methods and conclusions in conjunction with specific therapies and their outcomes are the key elements of ‘intelligence’ in healthcare that allow future generations to make better decisions and permit breakthrough advances in improving the human condition. Hospital personnel who work closely with the physician and remain in the silent background, such as medical scribes, play a vital role in laying the ground work for the information infrastructure required for this purpose.
What is health intelligence?
Health intelligence is the recording, analysis, interpretation, creation and dissemination of useful products that assist public health practitioners, clinicians, nurses, doctors, policy makers and other stakeholders make crucial decisions related to meeting public and individual health challenges. A related term is Health Surveillance. Health surveillance is the painstaking task of collecting epidemiological and other relevant data from health systems, populations, formal statistical record agencies or various informal systems. The two are complementary and operate in harmony to form an effective health information system.
Feeding data into the system requires an unmistakable strategy toward stated objectives and must be based on meticulous and diligent reporting standards of data which is free from bias and logical pitfalls. Usually, health surveillance records the quantity of disease incidence, the number of people subject to particular interventions, the amount of medical resources being used and their rate of depletion, type and number of critical events, duration of prevalence, geographical distribution etc. With the advent of the computer age, every patient record in now maintained electronically.
Distinction between medical scribes, transcriptionists and coders
A medical scribe is a person who accompanies a doctor on his patient visits and captures, records, generates and maintains the patient’s medical record. The scribe’s work includes recording medical procedures or clinical tests performed and has to be signed and approved by the doctor involved. In doing so, the document becomes an authentic medico-legal resource to refer to when disposing of claims and suits. Current practice renders documentation in the form of Electronic Health Records (EHRs) or Electronic Medical Records (EMRs). Governments, health insurance companies and other large medical institutions have made it mandatory to maintain such records. A medical scribe permits a physician to save valuable time and focus on the efficiency of patient care rather than working on the maintenance of paper-work.
Hospitals, these days, use virtual scribe services to generate EHRs and EMRs. All that is needed is a microphone and a secure scribble application to be installed on a desktop computer and each patient visit will be conveniently recorded. A remotely located Virtual Physician Partner (VPP) gets hold of the encrypted audio file, plays back the file as often as necessary to obtain all significant details and create a comprehensive clinical note according to an established EHR template. A separate Medical Coding record is prepared by a specialist according to WHO approved international classification of diseases (ICD-10). Within 24 hours, the doctor receives reviews, edits and signs the final EHR. Hence, a doctor is able to focus on patient care rather than documentation and is able to see more patients in a day. This method is prevalent with American doctors delegating to Indian doctors one on one. Over the first month, a relationship based on trust and synchronisation of documentation style, strengths and areas of opportunity has been built. VPPs are, in every case, highly trained clinicians who have obtained proficiency in various medical specialties.
A medical transcriptionist is distinct from a medical scribe because the former’s work involves simply listening to the doctor’s verbal dictation and converting the raw data into a readable report. The transcriptionist is not involved in shadowing the doctor’s interaction with the patient and/ or drawing conclusions or judgments from them.
A medical coder on the other hand, translates patient diagnoses, procedures and services into standard alphanumeric code for easy recognition and association with known injuries, diseases, medical procedures and practices for use by accountants, insurance agencies, litigants and governments. The World Health Organization prescribed standard patient care symbols for medical coders, now in its 10th revision and better known as ICD-10. ICD-11 may be introduced in 2018. India’s Central Bureau of Health Intelligence adopted ICD-10 in 2000.
Rising demand for healthcare managers
With regulations mandating computer documentation in the US, the demand for skilled medical scribes, medical transcriptionists and medical coders has been rapidly rising. Doctors and managers who additionally complete healthcare management courses in quality assurance, operations management or medical coding specialists are likely to find a huge job market in the very near future.