Medical transcription is the process of documenting the patient-healthcare professional encounter in detail. Patient records are an important component of healthcare. Patient records play an important role in the following:
- Record of symptoms, diagnoses and treatment
- Record of pre-existing health conditions
- Record of Allergies and current medication
- Progress of treatment
- Basis for referrals
- Statutory requirement
- Evidence in case of litigation
- Basis for coding and billing
Outsourcing the process of creating patient medical records has been found to be one of the most efficient, effective and economic methods for creating patient records. Time and again emphasis has been placed on the importance of ensuring security of confidential patient information. And the service provider has an enormous responsibility in protecting patient information, as they are involved in the process of creating these records. The entire process also involves transmission of this information back and forth and this adds to the need for stringent security measures.
HIPAA (Health Insurance Portability and Accountability Act) was established to protect confidential patient information. More recently HITECH has come into force and has expanded the concerns of HIPAA and enhanced the powers of HIPAA to enforce measures and standards for protection of confidential patient information.
Why is security of confidential patient information, an important component of medical transcription?
The root of protecting patient information arises from the sacrosanct patient-healthcare professional relationship. A patient-healthcare professional relationship is central to the practice of medicine and is essential for the delivery of high-quality healthcare. The quality of patient-healthcare professional relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspective about diseases & life, the better the amount of information, enhancing accuracy of diagnosis and quality of care.
In fact the confidentiality of the information regarding the patient as provided to the healthcare professional/healthcare facility is one of the components of the foundation for the medical code of ethics
As medical transcription is a vital link in the chain for delivering quality healthcare, it is important that the transcription vendor understands and acknowledges the need for confidentiality and has measures in place to ensure security. Security of patient records is not only mandatory by law, but also the moral responsibility of the service provider.
What are measures to be taken by the transcription vendor to protect confidential patient information?
The process of outsourcing the process of creating patient medical records would involve:
- Uploading audio files (narration of patient-healthcare professional encounter) to the server
- Transmission of audio files
- Downloading the audio files
- Transcribing the audio files
- Transmission of the finished transcripts
- Downloading the finished transcripts by the healthcare facility.
Considering the procedure involved security of data is applicable at all stages:
When Data is at rest: This would be safety of data when it is stored prior to transmission and when the finished transcripts are stored before transmitting back to the healthcare facility.
When Data is in motion: This would include safety of data during uploading audio files, transmission of audio files, downloading audio files and transmission of finished transcripts
When Data is in use: This would involve safety of data when the audio files are being transcribed.
When Data is disposed: This would involve safely disposing of defunct files in such a way to ensure that they are completely destroyed and cannot be accessed by unauthorized entities.
It can be concluded that while outsourcing medical transcription it is important to assess the HIPAA compliance of the transcription vendor.