An article in the April issue of Healthcare Informatics recently highlighted the critical need for standardization in the arena of healthcare documentation. Dictated medical notes and other types of transcribed patient records are usually available in electronic form, but have traditionally not been very useful in the context of an electronic medical record (EMR) system. Transcribed records follow a variety of formats depending on the clinical setting and type of transcription service used, making them difficult to search.

"There’s no real structure to the narrative that’s being inserted into the EMR," says Jay Cannon, president of the Medical Transcription Industry Association (MTIA), Chicago. "The information is visibly accessible, but within the system it’s just a text blob.’

Adds Harry Rhodes, director of practice leadership at the American Health Information Management Association (AHIMA), Chicago, "Presently, a transcribed report looks like a black hole to the average EMR system. It can see there is a document there, but it can’t see inside the document."

Full story:    http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=C13AB846CD6E403496AFD3B4FD65A023