April 12, 2010

Realize the Full Value of Partial Dictation
By Michael Clark
For The Record
Vol. 22 No. 7 P. 8

Even with the government-mandated drive toward EHRs, physicians who have traditionally used dictation as their primary process to document patient interactions can be slow to adopt a structured text template-driven platform. This can result in one of the following issues:

• The physicians use only the structured text without dictation. For various reasons, this can result in an incomplete note, compromising document content quality and accuracy and ultimately costing the physician more time than simply dictating.

• The physicians do not use the structured text and choose to dictate 100% of the time even though some or all of the note could be completed with structured input through a template. This does not provide the facility with optimal productivity levels or the desired return on investment in EHR technology.

However, a different approach is now available. The combination of structured text and voice input in so-called partial dictation can drive higher adoption and save physicians time. Partial dictation fits within providers’ existing documentation workflow and allows them to capture specific, detailed narrative context of a patient encounter and meet other more in-depth documentation requirements that are not a good fit for a template.

In one EHR integration of voice and structured input, partial dictations are associated with the template-based report creation process, and physicians can create a more comprehensive clinical document note that incorporates both voice and structured text through a single application. They can choose to dictate in conjunction with the creation of structured text or dictate normally as narrative free text.

For example, a user can dictate an entire report through partial dictation or dictate only snippets of it. Multiple partial dictations relevant to specific sections within a report can also be created during a single patient encounter. This snippet (or snippets) of voice converted to text then “lives” within an encounter in the EHR.

The Challenge
Facilities that use template-based systems to create clinical documentation sometimes must capture more complex medical histories, medical decision making, or simple contextual color unique to an encounter, requiring the ability to use both structured text and free text dictation to achieve their documentation goals. The challenge is how to combine the advantages (the ease and speed of a structured template with the flexibility that dictation can provide) of two different methods of information capture within a single useful workflow.

Physicians may be resistant to changing long-held dictation habits. With greater adoption, physicians produce more structured text. And while there would be the same number of—or even fewer—dictations, those dictations would be shorter but of tremendous value. Fewer and shorter documents help reduce costs, but combined with the structured text, they create the content-rich, high-quality documentation mandated for patient care and reimbursement.

A Good Example
Gundersen Lutheran Health System in La Crosse, Wis., a not-for-profit healthcare network serving southwestern Wisconsin, northeastern Iowa, and southeastern Minnesota, has been using the DocQment Enterprise Platform since August 2002. During that time, its providers dictated all patient encounters into the system using methods ranging from phones to digital handhelds.

In 2008, the decision was made to implement the Epic Hyperspace Client platform inclusive of partial dictation. Gundersen Lutheran’s providers, led by Associate Director of Medical Informatics Jonathan Zlabek, MD (who also served as physician champion for Epic inpatient implementation), believed that enabling dictation with the new system using the existing transcription workflow would help make the template-driven system more user friendly and efficient. It was also believed it would help facilitate physician adoption from the start.

Integrating the two systems provided Gundersen Lutheran with numerous advantages, including the following:

• After dictation, voice and relevant encounter information are transmitted to the transcription workflow platform.

• Both partial dictation and full dictation reports may be edited and authenticated within the workflow.

• After transcription, voice and data are returned to the appropriate section within the templated document.

• A single enterprise tracking, reporting, and accounting system can be used for all dictated jobs, including the ability to route those voice jobs to in-house and third-party medical transcription service organizations.

“Having the ability to pull patient history data into the notes and then partially dictate the unique narrative story to create a complete, accurate document was a huge victory,” Zlabek says. “The learning curve for providers was brief, and overall satisfaction with the process has been high. Partial dictation was one of the big wins of our electronic health record implementation project.”

To encourage physician adoption, Gundersen Lutheran, which completed its simultaneous implementation in late 2008, included dictation training along with the Epic training and instructed providers to use that system’s templates and smart links rather than performing a complete dictation. “We knew some areas would be more efficient for them to dictate—specifically H&Ps [history & physicals] and discharge summaries,” says systems analyst Karen Freese. “We provided handouts and posted dictation instructions at the workstations so that the providers became comfortable with when to dictate and when to use templates.”

According to Freese, implementing partial dictation integrated with template-based documentation resulted in a 70% decrease in total minutes dictated on inpatient reports. Other facilities, such as the University of Kansas Cancer Center in Kansas City, are realizing similar results.

“The adoption of partial dictation allows the physician to quickly integrate structured template entries, as well as free-form narrative, in one step,” notes Gundersen Lutheran Chief Information Officer Deb Rislow, RN, MBA. “Not having to move to different areas of the documentation system while preparing their notes has not only improved efficiency, completeness, and accuracy but has also increased physician satisfaction.”

Transcriptionists’ Evolving Role
Transcriptionists understandably may have concerns that a template-driven approach with fewer dictated documents will lessen physicians’ reliance on their services. However, partial dictation requires their skill to interpret the dictated portion of the reports and their expertise as medical editors to ensure document integrity, accuracy, and compliance. They serve an essential quality assurance and risk management function, acting as the quality “control point” as more data standards emerge.

According to transcriptionists currently working with partial dictation, the system draws their focus to individual components of a patient record to support higher quality. They are able to provide a second set of eyes and ears to verify the accuracy of the clinical documentation, identify discrepancies, help prevent the perpetuation of errors, and facilitate the coding and billing process. And in terms of productivity and career development, they are finding that the system allows them to complete more reports per day without having to worry about format. The human touch of these workers will continue to be needed to amend patient records that include narrative.

Final Thoughts
When the simplicity of structured text is combined with the freestyle nature and richness of dictation, healthcare facilities can produce a more complete and comprehensive clinical document. Such a document will capture the unique aspects of each patient interaction, embedded in a single encounter readily available within the EHR, and support the continuity of care and derivative demands of medical, legal, and reimbursement compliance.

— Michael Clark is chief operating officer at MedQuist.