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● Clinical Documentation The hybrid approach

Using dictation to create narrative documentation in EHRs. By Randy Olver


n May 2013, according to the Department of Health and Human Services (HHS), more than 50 percent of eligible providers reported adoption or use of electronic health records (EHRs).1 Widely known as a challeng- ing transition, EHR implementation and use can aff ect three keys areas of healthcare: cost, quality and patient experience. Eff ective use of the documentation system – specifi cally, using dictation to create narrative content placed in the EHR – can positively impact all three.

The benefi ts of dictation T e use of dictation can directly aff ect the bottom line

through both cost-eff ective allotment of resources and retained physician productivity that, in turn, retain revenue capac- ity. While point-and-click and front-end speech-recognition systems are used within many organizations today, they place the burden of documentation creation on the most expensive resource – the physician. When medical documentation specialists complete patient-encounter notes, the data-entry costs associated with creating the EHR documentation are much lower. Continuing to use dictation before, during and after an EHR implementation requires minimal changes in workfl ow, simplifi es training and does not negatively impact productivity. T is approach to documentation is what many specialty physicians desire. “Physicians want to do what they have done for years – and have someone else document in the system,” says Jonathan Bauer, CIO, Somerset (Pa.) Hospital.2 T rough the use of EHR templates to outline dictation content, facilities decrease the amount of typing required (reducing transcription fees) and also speed dictation time by prompting the physician for pertinent information needed to complete the narrative. Dictation protects effi ciency, enabling physicians to keep pace with their patient workload and avoid aff ecting their bottom line. A study published in the March 2013 issue of Health Aff airs noted that one of the ways prac- tices received positive returns from their EHR was to increase revenue by seeing more patients.3 T e medical documentation specialist plays a vital role in

12 October 2013

Randy Olver is CEO of Emdat.

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the quality of patient care by identifying errors and supporting the inclusion of narrative content. An anecdotal study showed that almost a quarter of errors corrected in content generated by speech recognition engines were medication errors.4 By bring- ing another pair of eyes to the documentation – eyes that can correct life-threatening errors – medical transcription can serve an advantageous role in patient safety. In addition, dictation makes it easy for physicians to enhance documentation with a more complete, contextual and meaningful note placed into the EHR. A conversational, narrative expression of the patient story allows physicians to clearly outline their observations, assessments and the patient’s condition – information that can- not be captured in discrete data points – and facilitates quick review and understanding of the complete picture of health. T e more nuanced notes that can distinguish improvement or lack of improvement in a patient’s state of being can only further the physician’s ability to diagnose and treat patients. When the task of documentation can be completed outside

the exam room, physicians can more readily engage with their patients, improving the quality of care. Dictation – especially compounded with the robust functionality and fl exibility of mobile applications now available – benefi ts both the patient and the physician. Gone are the computer screen, keyboard and mouse that hinder the patient interaction. When a physi- cian feels unencumbered by documentation duties, he or she is free to provide more focused care that comforts and reassures the patient.

Key requirements of documenting with dictation System interfaces are key to the eff ective use of dictation as a documentation method. Integration into the EHR of physi- cian schedules, patient demographics, document templates and discrete data broadens the power of dictation. A hybrid documentation method supports meaningful-use objectives by capturing structured data and auto-populating content using standardized terminology. Narrative content that is automati- cally placed into specifi ed sections of the EHR – HPI, physical exam, ROS, assessment, chief complaint and assessment plan


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