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Medical Documentation and Meaningful Use

July 29, 2010
by John DeGaspari
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While researching an article on medical transcription recently, I had an opportunity to interview Peter Preziosi, CEO of the Medical Transcription Industry Association (MTIA). Preziosi is confident that medical transcriptionists will continue to play a crucial role in providing an accurate record of the communication between doctor and patient. Yet he is worried that the nuanced, accurate record that transcriptionists have long provided may be jeopardized by too much emphasis by federal policymakers on discrete data elements.

“Discrete data does not tell the whole story of what happens during an encounter between doctor and patient,” Preziosi says. “The narrative story with dictation is a nuanced account of what happens. It provides more detail. If you don’t have that story, it’s difficult to say what is going on with the individual.”

Policymakers, he says, have been too caught up in discrete data fields, putting the narrative element of the medical transcription process in jeopardy. Preziosi thinks that meaningful use rules do not go far enough in guaranteeing that information is robust enough to provide a basis for complex clinical decisions and coordinate patient care. “Granularity and specificity have been overlooked,” he says.

I think Preziosi makes a good point. After all, electronic medical records mean timely data will be delivered to a range of end-users, including clinicians, patients, administrators, coders, and billers. It would be unfortunate to sacrifice the nuanced reporting by an over emphasis on discrete data. Structured reporting does not necessarily mean sacrificing the whole, nuanced record, he says. That is why his organization is pressing for a standardized interface solution to the dictation process. The goal, he says, is structured narrative reporting that is computable and searchable, so complete, rich information can be retrieved and analyzed.


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