Medical transcription has a long history. Western physicians first starting documenting health care 4,000 years ago. As early as 1600 BC, Egyptian doctors were using papyrus to write surgery notes for teaching purposes.
In the intervening years both the purpose and process of medical transcription have changed. We now convert spoken physician reports into text not only for research and teaching purposes but also to improve patient outcomes. And as for the process? Let’s just say that electronic tablets are pretty different than papyrus.
The history of medical transcription
Medical transcription didn’t become mainstream until medical record keeping became common in Europe and America around 1900. Before then, some doctors wrote down case histories for basically the same reason the Egyptians did in 1600 BC – to remember what works and teach others. It wasn’t until the early 20th century, when hospitals began evolving into major healthcare centers, that medical records became a common method for improving patient outcomes.
With widespread hospital record keeping, standardization of medical data became critical for research. Instead of doctors providing care and taking notes, a new profession emerged – the medical stenographer or transcriptionist. For most of the 20th century it became common for scribes to record physician notes in shorthand.
Transcribed medical notes evolved with technology, from hand-written to typewriters to computers. Audio recordings brought an initial wave of change, allowing transcriptionists to record physician notes after the patient visit. The internet eventually made medical transcription the process we think of today, in which a doctor takes dictations and a remote scribe transcribes them.
Enter Natural Language Processing
With the advent of automated dictation, medical transcription is facing its biggest transition yet. Natural Language Processing (NLP) – or the ability for computers to understand human speech – has created possibilities to make medical transcription more efficient.
Many worried that automated dictation, enabled by NLP, would render medical transcriptionists obsolete. But it’s clear that trained professionals still play an important role as dictation editors. As CareerStep summarizes neatly, “Now instead of tedious typists, medical transcription requires skilled professionals who can edit computer-generated healthcare reports for quality and accuracy.”
The industry has clearly embraced the transition from manual transcription to a machine-assisted process. In 2012, American Association for Medical Transcription changed its name to the Association for Healthcare Documentation Integrity (AHDI).
More than just software
Dictation technology has made huge progress in the past decade. By automating most of the transcription process, new tools are improving efficiency in healthcare documentation.
An example of NLP in action is Mobius Scribe, a live transcription function for smartphones and tablets that’s part of the Mobius Clinic suite of applications. Scribe draws on NLP technology developed by transcription giant Nuance to provide the world’s most reliable speech-to-text medical dictation. With Mobius Scribe, physicians can dictate to a patient’s EHR and instantly have an accurate transcription recorded in the patient’s record.
Like the EHR more broadly, changing the process of medical transcription does more than create efficiencies. It also changes the physician’s role and how providers interact with patients.
Take Dr. Casillas for example, an orthopedic surgeon in San Antonio, Texas. Casillas uses Scribe to record notes in the EHR while meeting with his patients. “I like dictating the history, physical exam and my plan in front of the patient,” he explains, “because I can pause and ask them, ‘Is there anything I should have added or emphasized?’ They like to hear that I can dictate everything, and for me it’s a matter of convenience that it’s all documented.”
By taking the best dictation technology mobile, applications like Mobius Scribe are taking the next logical step in the evolution of medical transcription. Using the smartphone as a clinical tool, live transcription allows providers to make medical dictation a positive part of patient care.