Medical transcription standards improve patient safety, optimize EHR use

The American Medical Association and other standards developing organizations like the WHO and the American Joint Committee on Cancer have lauded the benefits of relevant documentation standards including units of measure; pharmaceutical regimens; cancer protocols; laboratory studies; genetics; disease classifications; and the use of abbreviations, medical slang and lingo.

Yet, according to Laura Bryan, Chair of the Book Of Style For Medical Transcription's 4th Edition Working Group and the Association For Healthcare Documentation Integrity, there's a real lack of awareness that these standards even exist. That's something Bryan is hoping to change with her upcoming session at HIMSS19 in Orlando.

"There are standards that exist. I think a lot of people don't know these standards. It would help them when they are putting these things together and are asking "how should I write this?" They don't have to guess, they don't have to do a Google search. There is a single reference they can go to," she said.

Applying standards of style to EHR templates, drop-down text, and data dictionaries reduces the need for data normalization, potentially improving results from NLP and emerging technologies such as AI, Bryan said, and the recently developed fourth edition of the book specifically targets information technology, informaticists and others involved in the implementation and development of the EHR so that these professionals can use the book as a reference when building menus, drop down lists, standard text or promoting the standards with physicians to create their own free text.

"On the front side, to the primary users, it helps with consistency. It helps to prevent ambiguity in the communication of technical information, laboratory information," Bryan said. "Of course having a single reference to go to is helpful, and clear concise information that's communicated consistently is good for patient safety."

Bryan will share more insights at her session titled "Style Standards to Improve Data Quality and Interoperability." It's scheduled for Thursday, February 14 from 8:30 am to 9:30 am in room W230A.