• September 2008 FEATURE ARTICLES •
Speech Recognition/Transcription: Case History
Hybrid Encounter Documenting
Blending templated and narrated note taking within one EMR offers caregivers multiple ways to document patient visits, swiftly and accurately.
By Betty Rabinowitz, M.D.
I remember going to see our family doctor many
years ago; I must have been about 14 years old. The visit was
probably for something like a sore throat. When he completed the
physical exam he wrote a paper prescription and handed it to me;
he then reached for a black index-card box about the size of a
shoe box. In it were two rows of neatly stacked index cards, one
for each of his patients. He had the index cards of all the
members of a nuclear family neatly attached to one another with
a paper clip. I always fondly think of the symbolism of that
connection. He must have written something like the date, "pharyngitis"
and "Pen VK 500 for 10 days." The visit, and its documentation,
were then over.
Many years later as a practicing primary care
internist, a member of the University of Rochester’s Medical
Center’s Primary Care Network, I follow many of the same
rituals. Today, however, I have the patient’s electronic medical
record (EMR) open in front of me on a computer screen; I
electronically prescribe a medication, and receive alerts
electronically of any drug interactions or allergies. I provide
the patient with a printed information sheet regarding their
condition. I then step out of the room into my office, open a
note in the EMR, put my microphone headset on, and dictate the
narrative sections of the note using speech recognition
software. Indeed much has changed.
EMR Implementation at URMC
In 2005, URMC selected an EMR as its
ambulatory medical record and began implementing it to
approximately 500 physician users and close to 1,500 general
users. A survey recently published in the New England Journal
of Medicine (NEJM) reported that only 4 percent of close to
3,000 respondents had EMRs with full functionality. URMC, being
a large academic medical center, was typical of this group. With
the implementation of the EMR there have been significant gains
in safety, efficiency and cost reduction at URMC. There also has
been very strong physician adoption along with increased patient
and physician satisfaction.
Documenting the Clinical Encounter
Documentation of the clinical encounter has
undergone a gradual evolution. Recording the history, physical
exam, assessment and plan were traditionally undertaken to allow
physicians to recall these facts at a later date. Allowing for
seamless continuity of care, the note was also a means of
communication among different physicians caring for the same
patient. Having this information allowed physicians and members
of the healthcare team to care for the patient with knowledge of
previous evaluations and treatments. The medical note also
serves as a legal document, describing the course of care
provided to the patient.
In the mid 1990s, the Health Care Financing
Administration (HCFA) introduced the first version of the
"Documentation Guidelines for Evaluation and Management (E&M)
Services," which dictate the documentation standards that need
to be met for physicians to justify the level of compensation
for a particular service, thus turning the medical note into a
key billing tool as well. In latter years, E&M guidelines are
among the driving forces shaping the content and form of medical
documentation, sadly sometimes even more than patient care needs
and considerations.
One of the core functions of an EMR is to
provide task-specific tools for documentation of the medical
encounter; this is usually provided by a Note module. Many of
the notes produced within these modules rely heavily on text
templates or templates using discrete codified data.
Unfortunately because of the characteristics of these tools, the
notes produced tend to have a uniform "look and feel" with very
little variation among different documenting clinicians and
patients. These "homogenized" notes are no longer as helpful or
effective in the clinical process. A recently published NEJM
perspective titled "Off the Record — Avoiding the Pitfalls of
Going Electronic" states that patients’ narratives, and clinical
and personal stories, have become lost in a sea of templated,
"canned," repeated chunks of text and verbiage.
At URMC we have worked very hard to find a
balanced approach to medical documentation within our EMR. Three
primary and, at times, conflicting considerations affect our
approach to documentation of the clinical encounter: 1) As an
academic medical center with heavy emphasis on research in
general, and a significant institutional focus on translational
research in particular, we need medical documentation that
includes discrete and codified elements, accessible to research
and data mining tools; 2) We believe the presence of unique
narrative sections that are specific to the patient and the
encounter enable URMC to provide the best patient care; and, 3)
Staff members that are charged with ensuring compliance with
documentation and billing standards have developed an almost
instantaneous suspicion of templated documentation, because they
have difficulty differentiating the various levels of services
provided.
To balance these considerations, we have
developed "best practices" that support a hybrid form of
documentation. They combine the best of both worlds — the
"narrative" and the "templated" — allowing for variations that
stem from disparate specialties’ characteristics, and those
specialties’ research agendas and needs.
For example, our pediatric division is
heavily involved in translational research and has structured
most of its note forms as templated, mineable documents.
However, our primary care network has developed note forms that
combine narrative sections that describe the patient’s history,
and the assessment and plan formulated by the physician, but
also allow liberal use of research-accessible templates for all
other sections of the note. It is in this "hybrid model" of
documentation that speech recognition has thrived at URMC.
Coming of Age
Prior to URMC’s 2005 EMR implementation,
there were individual physicians who experimented with an early
version of the speech recognition software. Those brave early
adopters enthusiastically would start using the software, but
would invariably become frustrated by its inaccuracy, which led
a few months later to abandoning the software. The pattern
repeated often and bills for traditional transcription service
again increased.
Combining these two technologies has provided physicians with tools that capture the patient’s story in narrative form, within a highly structured “mineable” framework.
The full-scale implementation of the EMR at
URMC, and the introduction of version 9 of Nuance’s Dragon
NaturallySpeaking Medical software, presented a unique
opportunity to re-evaluate and combine these two tools, this
time with great success. The voice recognition software had come
of age with remarkable accuracy, and a complete set of medical
vocabularies that collectively span many specialties.
Prior to the EMR implementation, URMC’s
primary care network relied on the medical center’s
transcription service vendor for most of its transcription
needs. A few practices had relationships with small, independent
vendors adhering to varying standards in terms of turn around
times and accuracy. The one constant was the high cost of these
services. It is estimated that the primary care network alone
(just more than 100 providers) was spending well over $1 million
a year on transcription, not calculating the cost of managing
the flow of transcription and staff involved in printing and
filing these transcriptions into the paper charts.
By the middle of 2007, a critical mass of
primary care offices had implemented the new software and they
were reporting great results combining the EMR’s Note module
with the speech recognition software. Physicians were also
reporting significant flexibility creating personal efficiency
enhancing "macros" (short cuts). Interestingly, this was a
"grass roots" IT paradigm shift, driven by early adopting
physicians rather than the institutional IT strategic plan.
Responding to these shifts late in 2007, the
primary care network leadership chose to fully adopt the
combined documentation model and discontinue using external
transcription services. For a majority of physicians this was a
relatively easy transition. However, a small group of physicians
struggled with the decision to fully convert to speech
recognition for dictation within the EMR. They were concerned
that using voice recognition software shifts the onus of proof
reading and correction to the physician from the professional
transcriptionist, and that adding any tasks to already
overburdened physicians could result in errors of transcription,
reducing the accuracy and validity of the documentation.
A handful of physicians also were overwhelmed
by the shift from paper to the EMR and felt they could not
undertake another "electronic adventure." This group was
provided with individual training and work sessions by physician
colleagues who helped them to work through hurdles in the use of
the software.
Interestingly, it became clear early in this
training that the main barriers to adoption had more to do with
deficits in basic computer skills, rather than challenges
inherent to the more sophisticated
software programs.
Success
In February 2008, URMC completed the
transition of the primary care network to the combined
documentation utilizing voice recognition and the EMR Note
module. No line item for transcription costs is included in our
primary care 2009 budget.
ROI not withstanding, combining these two
technologies has provided physicians with tools that capture the
patient’s story in narrative form, within a highly structured
"mineable" framework. Each note has the potential of capturing
what is unique to patients at a specific moment. It also enables
physicians to articulate the thought process behind their
diagnostic and therapeutic decisions. Those responsible for
ensuring the accuracy of the charge process also find it easier
to audit notes that have a narrative component.
The increase in EMR adoption nationally may
eventually render the current E&M framework obsolete; some even
theorize that it will be the narrative description of the
clinical process by which level of service is measured in the
future. Those clinicians using a combination of EMR and speech
recognition will be optimally positioned to meet that new day.
Betty Rabinowitz, M.D., is
associate professor of clinical medicine,
University of Rochester School of Medicine. Contact her at
betty_rabinowitz@urmc.rochester.edu.
