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Dictation in the EMR/EHR

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Last Post by Anonymous 12 years ago

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Dan Karn

(@karnfamily)

Posts: 37

Trusted Member

Topic starter

One of my physicians is really pushing lately to go to dictation in the EHR. Hot on this "request" I keep coming across thie following reference lately: http://www.nextgov.com/health/.....ng-HPriver

I was wondering about everyone's thoughts on this.

Dan

Posted : June 5, 2012 9:26 am

eliasp

(@eliasp)

Posts: 18

Eminent Member

If I understand the study correctly, it shows a difference in outcomes related to what sort of documentation tool a clinician prefers using, but does not provide data about outcomes related to the documentation tool itself. That would require a study where clinicians were randomly assigned to different approaches to documentation, and outcomes compared.

I am not aware of valid data, but common sense suggests (to me, at least) that because we need to document different kinds of information in different settings, there will be no single tool that is always best.

I type well and fairly quickly and am pretty comfortable documenting the details of a simple problem (ankle injury, URI) in real time by free text typing. However, more complex HPIs and certainly complex assessments or letters to a consultant work better for me with dictation.

I would love a seamless way to toggle back and forth, using tagged data from drop downs for things like smoking Y/N, ppd, but able to dictate with a low profile bluetooth style headpiece when more complex information is appropriate. The computer likes tagged data (smoking Y/N) but when I see the patient in 3 months and want to resume the conversation, my more complex comment ('smokes when bowling and after arguments with supervisor at work') is more useful than binary data.

Peter

Posted : June 5, 2012 8:40 pm

Anonymous

(@Anonymous)

Posts: 0

New Member Guest

The article raises a valid issue. Let me rephrase it: 100% dictation does not take advantage of the efficiencies and quality of care built into the EMR. Dictation has it's place. So does structured data capture (drop downs and pick lists.) So does typing. I always urge providers to use all three, but they should be able to choose what which method to emphasize.

So what is the right balance?

I recommend that providers dictate in some instances. Picture the amount of work that it takes to see a new patient who requires a complex specialty consultation in which the provider must synthesize extensive history and findings and then make sure that the document is distributed to a series of other providers who will follow recommendations. Most specialists feel that this is best done through dictation and transcription. I'm fine with that.

But the best use of the EMR involves a creative combination, like what Peter describes in his practice. Every note should contain at least a few free text sentences that are either typed or dictated (preferably voice recognition), particularly to be sure that the assessment and plan is clear to all who might need to care for the patient later. Certain elements MUST be captured as structured data such as problems, medications and allergies, but also smoking status and diabetic foot exam - things you will need to know later.

Don't miss out on the most important reason to NOT dictate - it takes longer and is less accurate! How can I say that? When writing a note on an existing patient who already has information in the system, the EMR should provide 50% to 80% of the content of the note for you. As you place orders and prescribe medications and check off findings, and review histories, most of your note should be completed. Who wants to dictate an extensive medication list when it can be included with just the click of a box?

See if this reasoning makes sense to your physician. I hope so.

Sue Thomas MD

Posted : June 6, 2012 4:28 am

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