February 11, 2013

Partial to Dictation
By Lisa A. Eramo
For The Record
Vol. 25 No. 3 P. 10

Could partial dictation be a happy medium for physicians disenchanted with documenting in an EHR?

If you had to write your EHR memoir, it might go a little something like this: Your hospital chooses a vendor. You begin the arduous journey toward implementation. You have high hopes of obtaining physician buy-in, achieving greater efficiency, reaping financial incentives, and ultimately providing better patient care. However, this utopian vision quickly becomes a nightmare as physicians lament the need to insert information using rigid templates. The quality of documentation decreases, and even your reimbursement begins to suffer.

Unfortunately, experts say this isn’t an exaggerated picture of doom and gloom in some hospitals.

It all goes back to whether physicians view an EHR as an impediment or an enhancement to patient care, says Sherry Doggett, director of corporate transcription services at UC Health, a large teaching facility in Cincinnati. If the EHR doesn’t interrupt workflow and actually makes tasks easier for physicians, they’re more likely to naturally buy into it, she notes.

“Physicians want choice,” Doggett says. Although some don’t mind using drop-down menus and templates to enter information, they’ll continue to want the ability to dictate for patients whose circumstances are more complicated or unique. Although some EHR vendors may argue otherwise, forcing physicians to abandon dictation entirely isn’t the answer, she says.

So what is the solution? Can there be a happy outcome? The desired results are achievable, Doggett says, permitted physicians can enter information into the EHR using a method of their choice: either manually or via dictation.

This a la carte model—referred to as partial dictation—gives physicians the ability to quickly enter certain data manually using drop-down menus, check boxes, and templates within the EHR while also being able to dictate as necessary. The technology can be used with traditional transcription or front- or back-end speech recognition.

If physicians choose to dictate, they simply click a dictation button/icon while in the body of the template, grab a microphone attached to the workstation, and begin to speak. Health Level Seven International (HL7) interfaces insert the content directly into the appropriate section of the EHR.

Physicians also can use a traditional telephone or mobile device when dictating. In those cases, information is automatically routed to the EHR, at which point a healthcare documentation specialist takes over to transcribe the information via a text platform or directly into the electronic record. Data transfer via XML files and HL7 interface technology handle the “behind-the-scenes” integration to make this a seamless process. 

In similar models, such as those that rely on discrete reportable transcription, physicians dictate all reports and don’t use any templates or drop-down menus within the EHR. That’s because data are extracted from transcribed text and automatically populated into the appropriate EHR fields.

Discrete reportable transcription minimizes workflow changes for physicians, ensures detailed documentation, and encourages physician satisfaction, says Susan M. Lucci, RHIT, CHPS, CMT, AHDI-F, a consultant with Just Associates, Inc. Disadvantages of this model include longer turnaround times and higher transcription costs, she notes.

UC Health recently went live with partial dictation in its inpatient setting after having used the model in ambulatory care for more than two years. Approximately 30 physicians actively use this model of data entry, and Doggett expects the number to grow commensurate with physician awareness.

Those who aren’t using partial dictation continue to either dictate all information or enter it manually into the EHR. Doggett hopes that all physicians eventually will feel comfortable transitioning to a partial model that the hospital will continue to use indefinitely as a best practice.

Keeping Everyone Happy
What makes partial dictation so appealing to physicians and hospitals alike?

For physicians, it’s about having choices. Partial dictation allows them the flexibility to manually enter certain information (eg, vitals, current medications) while dictating the detail-rich portions of an encounter (eg, family history, medical history, treatment plan). Lucci says the goal is to allow as many options as possible to meet the needs of each physician—and patient.

UC Health physicians appreciate being able to choose what they dictate, Doggett says. Specifically, they can dictate elements of the history of present illness, medical decision making, and treatment plan while using drop-down menus, check boxes, and manual typing for other information. Having choices makes them more open to using the technology in general, Doggett says.

Partial dictation can help ease physicians into using an EHR because it retains traditional dictation with which physicians are already familiar, explains Judy Arrendale, president of Arrendale Associates, a technology firm dedicated to clinical documentation.

“If physicians are all of a sudden being asked to type their own notes, whereas they used to pick up a telephone and dictate for a few minutes, that’s a big change to their workflow and daily habits,” she says. “Even with front-end speech recognition, there’s a learning curve. The voice engines do improve over time, but if the physician is making the transition from his or her old environment to an EHR and possibly to self-edited front-end speech recognition, that’s a lot of change at once in the daily workflow.”

Because physicians are more apt to complete dictations in a timely manner, hospitals ultimately end up with more detailed documentation that better supports patient care. “If physicians know that they can perform partial dictation, where they used to have to do an entire dictation, they may be more encouraged to get the dictation done sooner because they only have to do smaller sections of the report,” Lucci says.

In some cases, partial dictation is necessary as hospitals transition to an EHR. “We find that in the beginning, a hospital may not have all the templates completed or may even phase them in, meaning for a time some or most or all patient reports are dictated,” Arrendale says.

However, the model also is crucial to long-term success, according to Lucci. “I acknowledge that there are many aspects of care that can easily be entered into an EHR and that it may be faster and more efficient, especially for the newer generation of physicians who are very tech savvy,” she says. “But I think that for doctors who have been in practice for many years, this does help bridge that gap. It will allow them to continue to dictate what they feel is important to dictate.”

The Perfect Storm
Experts say there are several reasons hospitals may start to gravitate toward a partial dictation model in which portions of the record are dictated in a narrative format.

First, stage 2 meaningful use criteria specifically address and allow the ability to collect both narrative and structured data in the EHR, Lucci says, adding that the Office of the National Coordinator for Health Information Technology recognizes the importance of both formats in terms of patient care.

Also, physician efficiency will be paramount as healthcare reform goes into effect. “There are so many places in the country where there is already a physician shortage,” Arrendale says. “With all of the other changes in healthcare that are coming down the pipe—and all of these extra patients who are going to be covered because of new legislation—access [to healthcare] and the ratio between patients and physicians will be very important.”

It will be crucial for hospitals to make the most of physicians’ time. “Should time be spent documenting at a keyboard or seeing patients?” Arrendale asks. “The industry is learning there are ways to make physicians more productive in an EHR world, and the ability to partially dictate is just one of them.”

Lucci agrees that physicians can spend their time more wisely. “One of the challenges that EHR technology has had all along is that by eliminating transcription, it places the sole burden of healthcare encounter documentation on the physician. This just doesn’t make sense,” she says, adding that transcription is a time-saver, allowing physicians to see more patients.

Adopting partial dictation also can help ease the burden of ICD-10-CM/PCS demands, which include greater specificity. Templates and drop-down menus simply don’t capture the necessary level of detail, Arrendale says, adding that at some point reimbursement could be compromised if hospitals don’t take advantage of ICD-10’s added specificity. “If history tells us anything, I would be very surprised if CMS [the Centers for Medicare & Medicaid Services] doesn’t modify reimbursement models to align with specificity,” she says.

The best way to prepare for such a decision is to preserve the narrative in which these important details are located, Lucci says.

As hospitals undergo recovery auditor contractor and other third-party payer audits, there is greater focus on documentation quality and compliance. Auditors are looking for specific details relevant to each patient’s unique circumstances, not canned documentation or templates that may be irrelevant, Lucci says. “I think progress notes are the ideal candidate for partial dictation because you avoid the copy-and-paste dilemma altogether,” she says.

The Role of Healthcare Documentation Specialists
The anticipated rise in partial dictation use likely will have a positive effect on healthcare documentation specialists, many of whom experience layoffs and suffer cutbacks when EHR technology is implemented.

As hospitals prepare for ICD-10, Doggett says they’ll likely realize that to achieve buy-in and maximize an EHR’s potential, they need to offer dictation capabilities. “With the advent of ICD-10, I believe there will be a surge in the volume of dictation and transcription, and I think it will be the partial narrative that will increase,” she says. “We’re not going to return to the robust volumes of the past, but I think we’ve been on the downside for a while, and we’re going to see an increase.”

“For those people who say that dictation and transcription are going away, I would say that’s not the case,” Lucci says. “Technology is enabling dictation and transcription to do more than it ever did before.”

How will partial dictation affect the workflow of healthcare documentation specialists? Dictation is broken into snippets (for example, a sentence or two in the history and physical or assessment and plan), each of which is subsequently merged into the EHR. Healthcare documentation specialists will complete more jobs per day, but the total number of transcribed lines per patient visit will be reduced significantly, according to Arrendale. Another change is that multiple healthcare documentation specialists may work on various audio clips for the same patient visit.

Specialists may not have direct access to the EHR, which could be problematic from a quality assurance standpoint because there is no context for the information being transcribed, says Karen Fox-Acosta, CMT, AHDI-F, president of the Association for Healthcare Documentation Integrity. “The ability to be able to discern context has changed. To me, this has significantly affected the workers’ ability to apply their critical thinking skills because they’re not seeing everything,” she says.

In some cases, healthcare documentation specialists do have access to the EHR because they’re transcribing directly into it. At UC Health, for example, specialists in the ambulatory setting input information directly into the EHR. On the patient side, they don’t input directly into the EHR, but they do have access to the technology and can peruse the record when questions arise, Doggett says.

Addressing Potential Challenges
Although partial dictation has many advantages, experts say several drawbacks could prevent hospitals from further exploring the technology. “When you’re talking about health information exchange and true interoperability, there is resistance from the technology side for any type of narrative because they do see it as the black hole of information, even if the text is codified in the background. It’s still so much information. IT prefers everything to be discrete data,” Fox-Acosta says.

Integration with the EHR also can be complicated. “With partial dictation, you’re relying on the technology to get the text into the proper spot, so the interfaces are critical,” Arrendale says.

However, technological advances have made it possible to better capitalize on narrative information, which has, in turn, spurred a movement toward preserving it, Fox-Acosta says. “With NLP [natural language processing] and other technologies, software can compute and use this information. NLP, HL7, and advances in SNOMED have all given narrative text broader adoption in the electronic world,” she says. For example, narrative text now can be used for computer-assisted coding as well as data exchange using the continuity of care document.

Transcription costs may be another drawback. “Even if the facility offers partial dictation, they’re going to continue to pay some cost for transcription,” Arrendale says. “However, we certainly feel that the increased physician efficiency and the fact that the physician can see three or four additional patients per day offsets the cost of paying a transcriptionist.”

Perhaps the biggest challenge is that with the exception of a select few major EHR vendors, most companies simply don’t offer a partial dictation model. “Partial dictation may be on a vendor’s list of potential enhancements, but it may not move to priority status until if and when enough customers ask for it,” Arrendale says. “Some EHR vendors may never offer it simply because they promote being able to eliminate dictation and transcription entirely.”

However, that line of thinking may change as the industry places more emphasis on documentation quality in preparation for ICD-10 and other data-driven initiatives. Arrendale says hospitals or physician practices that are interested in partial dictation technology should ask their vendor whether the functionality can be coded into the software.

“Some of us who have been later adopters of EHR technology have seen those lessons learned, and we are asking our EHR vendors to incorporate a transcription interface and to work with us on a partial narrative interface,” Doggett says. “I think over time and with ICD-10, hospitals are going to require more robust reporting. We’re going to see a return to some blend [of manual entry and dictation] in which physicians embrace and use the electronic health record.”

The bottom line is that technology must be able to help providers tell the patient’s story. “The integrity of the data as well as the accuracy and completeness of the patient’s story is the most compelling reason for clinicians to have multiple options in how they choose to document a patient’s health encounter in an EHR environment,” Fox-Acosta says. “Incorporating a healthcare documentation specialist as a partner in that workflow process elevates physician efficiency and further enhances the integrity of the patient’s health story.”

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in healthcare regulatory, HIM, and medical coding topics.