CMS Confirms: Transcription Is Acceptable – If Used Correctly

CMS Confirms: Transcription Is Acceptable – If Used Correctly

One of Meaningful Use's most misunderstood requirements is the extent to which data needs to be captured in a structured format. As one transcription company owner recently wrote, "Right now, I feel (that) most transcription companies don't have the expertise to talk meaningfully about 'meaningful use'. I think we need to get to the 'meat'".

The "meat" transcription industry professionals are grappling to understand is: can a physician use dictation and transcription and still meet Meaningful Use's requirements for structured data?

The answer is yes, according to The Center for Medicaid and Medicare Services (CMS) - providing the physician is capturing a select number of data points the CMS requires in a structured format within an ONC-certified EHR.

What patient data does Meaningful Use require to be captured in a structured format? Of the twenty-three Objectives of Meaningful Use, only eight pertain to MU's requirement for structured data entry into the EHR. Those are:

  1. Patient demographics
  2. Problem list
  3. Medication list
  4. Medication allergy list
  5. Patient Vitals
  6. Smoking status
  7. Family health history
  8. Lab Results (LOINC format)

(One additional Meaningful Use Objective - "Record electronic notes in patient records", specifically states that the patient note can be dictated and transcribed, providing the document is in a searchable format. See #19 on attached Summary Table on page 3.

For the above eight Objectives, those data must be captured within the structured format of the EHR in order to meet Meaningful Use requirements. But all other patient information routinely documented as part of the patient encounter - such as the History of Present Illness, Subjective, Objective, Review of Systems, Social History, Assessment, and Plan, to name a few - can be dictated and transcribed without in any way preventing the physician and clinic from meeting Meaningful Use.

Structured vs. Unstructured Data

What is the difference between structured and unstructured data? Simply put, structured data is information captured within a field or format that can be automatically identified by the EHR. The CMS requires certain data to be structured for two key reasons: first, to make it portable to other EHRs or electronic applications; and secondly, to enable it to be associated with standardized code sets and clinical terminologies like SNOMED CT. Structured data is recorded within EHRs via documentation tools, including but not limited to, drop-downs, check boxes, radial buttons, and in limited cases via text entry (such as the entry of like blood pressure measures or patient weight, height, age, etc.).

The other type of data found within EHRs is "unstructured data", so named because it is not entered in a field or format automatically recognized or identified by the EHR. Examples of unstructured data are the free text notes typed into a text box by a healthcare professional, and transcribed patient notes which are interfaced into the patient record. Unstructured data is often, but not limited to, qualitative information about the patient's health history or health context that provides additional decision-making support.

The Structured Data Monster

Since Meaningful Use requires only a limited subset of patient data to be structured, could it be that EHRs are placing an over-emphasis on structured data at the expense of physician efficiency and patient care? Have we created a monster out of the EHR-based clinical documentation workflow, placing unnecessary demands on physicians to structure data that in many ways is better captured in an unstructured, or narrative, format?

A large population of physicians - as many as 30% or more - express on-going frustration with their EHR-based clinical documentation workflow. For many of those physicians, a greater use of dictation and transcription - provided it is in a searchable text format - could represent a faster, easier and less frustrating means of documenting their patient encounters.

In sum, there is nothing in Meaningful Use that restricts healthcare providers from using dictation and transcription to document those sections of the patient encounter not specifically cited as needing to be structured. For those physicians experiencing high levels of frustration with their EHR-based clinical documentation tools, transcription could provide an effective alternative for documenting those parts of the patient encounter that are not mandated for capture via the EHR's structured data capture tools.

Summary Table: Meaningful Use Stage 2 Objectives

as of July, 2014

Stage 2 MeasureDescriptionImpacts
1Use computerized physician order entry (CPOE)Physician order labs, medication, xray, radiology orders via the EHRLittle to none
2Generate prescriptions electronicallyUse EHR to send prescriptions to pharmaciesNone
3Record demographics as structured dataLanguage, gender, race, ethnicity, date of birthYes
4Maintain an up to date problem list as structured
Maintain an up to date problem list as structured dataYes
5Maintain active medication list as structured dataMaintain active medication list as structured dataYes
6Maintain active medication allergy list as structured
Maintain active medication allergy list as structured
7Record and chart changes in vital signs as structured
Height, weight, BP, BMI, children growth chartYes
8Record smoking status as structured dataRecord smoking status as structured dataYes
9Implementation of clinical decision support toolsUse EHR-based applications to improve patient careNo
10Report Clinical Quality Measures (CQMs) to CMSCQMs measure “degree to which a provider
competently and safely delivers clinical services that are
appropriate for the patient in an optimal timeframe.”
11Provide patients with an electronic copy of their
health information
Includes online access and ability to downloadNo
12Provide clinical summaries for patientsProvide clinical summaries for patientsNo
13Protect electronic health information within the EHRProtect electronic health information within the EHRNo
14Incorporate clinical lab-test results into EHRIncorporate clinical lab-test results into EHR. Lab results do require some structured data in LOINC for the purposes of the CCDA in transitions of careYes
15Perform medication reconciliation on new patientsInsures that receiving physician has complete
knowledge of patient’s medications
16Provide summary of patient care for patients transitioning to other source of careWhen transitioning a patient to a new source of care, patient documentation needs to be provided with transition. This objective incorporates the structured data into a C-CDA for transitions of care and that is fundamentally the biggest use of structured data.Yes
17Transmit electronic data to immunization registriesFunctionality within EHR to transmit specific dataNo
18 *NEWUse electronic messaging to communicate with patientsUse electronic messaging to communicate with patientsNo
19 *NEWRecord electronic notes in patient recordsNotes can be dictated, text must be searchableYes
20 *NEWScans and test accessible via EHRScans and test accessible via EHRNo
21 *NEWRecord patient family health history as structured dataIndicate that first-degree family history has been reviewed or enter one structured dataYes
22 *NEWReport cancer cases to a registryReport cancer cases to a registryNo
23 *NEWReport cases other than cancer to specialized registriesReport cases other than cancer to specialized registriesNo

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