June 4, 2012

Utterly Essential
By Susan Chapman
For The Record
Vol. 24 No. 11 P. 20

Many physicians view dictation as a fundamental component of everyday operations. Can EHRs compensate for this long-held attraction?

Earlier this year, Florida-based radiation oncologist Paul Schilling, MD, chose to retire from his profession at the age of 50. He told The Gainesville Sun that his decision to hang up his stethoscope at a relatively young age was based in part on his practice’s decision to move from paper records to an EHR. Schilling, who preferred to document care by dictating his notes and having them transcribed, claimed the technology slowed his work pace.

Schilling isn’t alone in his preference for dictation. In fact, the Medical Records Institute reported that in 2008, some 90% of medical documents were created via the combination of dictation and transcription.

The meaningful use incentives have been a powerful lure for physician practices to scrap their old methods and join the ongoing movement toward a more electronic environment. For the most part, this trend has been widely praised throughout the industry. Widespread use of EHRs has many benefits, say proponents, and any drawbacks are easily outweighed by those gains.

Still, finding a way to incorporate dictation and EHR use would seem to be an ideal solution for many physicians. “As healthcare professionals, it is our duty to assist the physicians in the most appropriate way possible. Technology is rapidly emerging, and we need our physicians to embrace it rather than thinking retirement is the best solution,” says Kengia Johnson-Sabree, RHIA, HIM operations manager at Bayfront Medical Center in St Petersburg, Florida.

The Value of Dictation
For many patient encounters, dictation offers opportunities for physicians to provide details that can’t be captured in EHRs, which use discrete, or structured, data entry.

In a March 2007 Family Practice Management article, David E. Trachtenbarg, MD, wrote that “clicking or typing text multiple times is generally slower than dictating. Consider, for example, the time it takes to document a thorough history of a patient’s back pain. Using discrete data, it took me 95 seconds to complete 17 clicks for yes-or-no questions, five text boxes that required typing and two drop-down lists. In contrast, it took me 41 seconds to document the same history using dictation.”

In addition, if physicians choose to bypass discrete data entry, opting instead to enter text, the system can no longer create accurate reports based on the structured data entry fields.

Linda Sullivan, CEO of New England Medical Transcription, notes that some doctors who are not skilled typists “just do better with dictation. And some things have to be described in words rather than by a pull-down menu.”

Sullivan has witnessed scenarios similar to the one that helped Schilling decide to hang up his white coat. “It’s not cost-efficient for doctors to become data-entry clerks,” she says. “They see fewer patients that way. I spoke with one gynecological oncologist recently who said that her caseload dropped from 30 to 18 cases per day. Sometimes it’s better to capture the record in a narrative.”

Jason Mitchell, MD, assistant director of the American Academy of Family Physicians’ Center for Health IT, says dictation is an excellent way for physicians to record what is on their minds regarding their patients. It allows them to capture nuances and subtleties that cannot be communicated strictly through EHR fields.

“Most doctors will dictate a note after the patient leaves,” he says. “For some more progressive doctors, though, they will dictate in front of a patient, which is helpful for clarity. This can create more of a discussion that involves the patient. When the doctor dictates something that doesn’t sound quite right to the patient or triggers another thought, the patient can have input and help generate a more accurate record.”

Sullivan points out that having a doctor stare at a computer screen while examining a patient changes the patient experience. “This is another reason dictation is so valuable,” she says. “Whether the physician dictates with the patient present or after the visit, patients are more comfortable if the doctor is interacting with them rather than looking at a screen. Ultimately, we always want to improve patient care.”

Dictation’s Limitations
While dictation affords physicians an avenue to tell patients’ stories, in some ways it can fall short when compared with an EHR.

“For example, a patient is on a medication and needs a diagnostic test,” Mitchell says. “The software can suggest next steps based on the evidence created by structured data entry. Dictation can’t do this. And with meaningful use, a number of quality measures need to be addressed. This requires interaction within the system. Consequently, dictation requires a workaround to make meaningful use work.”

Gathering data and putting them to good use is more difficult when their origins reside in dictated notes, says Raj Dharampuriya, MD, an internist with Clinton Medical Associates in Massachusetts and chief medical officer and cofounder of eClinicalWorks, an ambulatory clinical solutions vendor. “Dictation is not hard to do from a physician’s point of view [but] it’s challenging when someone tries to extract data and compare it to other data,” he says. “When a doctor tries to compare blood pressure from dictation, for instance, against blood pressure from earlier data, that type of information is difficult to access because of the way it currently has to be entered into the record.”

How the Industry Is Adapting
One way the healthcare industry is changing to accommodate physicians’ desire to dictate notes and more easily input data into EHRs is by employing scribes, who are typically young healthcare professionals who will document patient encounters through direct observation.

“We’re seeing a more consistent use of scribes in practices,” Mitchell says. “Scribes are individuals who interact with the EHR. The doctor dictates to the scribe, who is present while the doctor is examining the patient and who then enters the information into the EHR.”

As the EHR offers prompts, the scribe communicates with the physician. Because many practices have more than one physician, several scribes are usually employed. “It’s similar to the experience you have at the dentist. Just as the dentist talks to the hygienist, the physician talks to the scribe, whose role it is to document the visit,” says Mitchell, adding that scribes who have other responsibilities (ie, a nurse) may not be the most ideal candidates from a financial perspective.

“While a nurse can also serve as a scribe, having a nurse perform the scribe’s duties is more expensive,” he says. “It’s more cost-effective to bring someone in on a lower pay scale. It involves balancing the cost of adding a new employee to the practice as opposed to using an employee who performs other duties as well.”

Mitchell says as software becomes more developed—particularly as natural language processing evolves—the scribe’s role will eventually become obsolete. “If the scribe serves solely as a secretary,” he says, “then that role would easily be replaced by advanced software.”

Dictation and EHR Together
Certain programs allow physicians to interact with the EHR. A patient’s story can be dictated into a specified field, so there is some narrative. Facilities can also mark dictation and send it to the correct component in the EHR. Other programs enable physicians to dictate through voice-recognition software and move from one screen to another while filling in the required values.

Sullivan believes the use of dictation often comes down to the features offered by the EHR. “Whether or not a physician continues to use dictation really depends on whether the EHR software allows it,” she says. “It also depends on the facility’s attitude toward it.”

Attitudes toward dictation are having a ripple effect in the medical transcription industry. “In many ways, we’re moving away from transcription and more toward editing,” Sullivan says. “Technology is playing a much bigger role, which means that transcription must stay on the cutting edge.”

Bayfront Medical Center recently went live with a discharge medication reconciliation process that helps improve the dictation process and save time for busy physicians. The process allows the dictation software to interface with the EHR and extract discharge medications to automatically populate into the discharge summary.

“What I think is brilliant about this process is patients no longer have to try and memorize their blood pressure medication,” Johnson-Sabree says. “How often do patients remember exactly what was given to them during their stay in a hospital? Now they do not have to because the medication and the dosage will automatically be placed onto the discharge summary to be given to their next healthcare provider.”

Johnson-Sabree says the process has helped build trust between physicians and nurses. “The nurses are responsible for typing this information into the EMR so the more accurate, the better. This reduces the amount of time spent on edits and duplication of effort,” she says.

Because Bayfront Medical Center physicians sometimes dictate in odd places (eg, their cars) where they do not have specifics such as medications or dosage available to include in the dictations, the technology becomes even more valuable. “Such pertinent information should never be left out and, at times, it may take a physician several minutes to run down the list of medications. Thanks to our transcription company [Landmark], they no longer have to. It’s a win-win for all of us,” Johnson-Sabree says.

Natural Language Processing
Sam Bhat, a vice president at eClinicalWorks, says a growing number of physicians want to dictate the entire medical note in a single session, and technology is advancing to address this need. “We’re rolling out even more sophisticated software that allows physicians to dictate the whole note via voice recognition, and the software then puts the entire note into the appropriate EHR fields,” he says. “The technology will ‘read’ through the data and enter it in such a way that it goes to the appropriate places.”

Bhat says the technology will enable doctors to compare data. For example, a physician can graph vital signs over time whether the information was entered initially as voice or typed data. This capability can enhance the physician-patient experience and meet meaningful use requirements.

Brendan Harnett, vice president of strategic projects at Etransmedia Technology, believes dictation provides a place in the EHR that can’t be summarized by ICD and CPT codes. “I see a lot of ways software is moving toward making all data into small blocks of discrete, ‘codeable’ information,” he says. “Meaningful use is driving this movement. Natural language processing can scan text and extrapolate data from it. Without this ability, dictation will have to disappear.”

Natural language processing technology is expensive, especially in settings with small volumes, such as private practices, Harnett adds. However, that cost can be reduced if dictation markers enable dictated notes to be inserted into the proper places in the EHR. “This would be the best of both worlds,” he says. “It would meet all the requirements without spending a lot of money.”

What Lies Ahead
EHR technology is a two-way process, requiring that data not only be entered but also that the system produces valuable information to help practitioners proceed both clinically and administratively. Dictation, a one-way mechanism, must conform to this functionality.

“What we need to be able to do is extract discrete data from the narrative,” Sullivan says. “There needs to be a narrative that a physician can use in consultation, and we have to be able to put everything into data fields. There are huge amounts of data that have been input and can save lives, but we haven’t been able to extract it yet. Looking for trends in patient care, for example, is one of the goals of the HITECH Act.”

While the challenge of making it more acceptable to have a physician interact with a computer during an examination remains, there are ways around the perceived problem. After all, Mitchell points out that in a paper-based world, doctors are frequently consumed by patient charts. “The EHR takes more mental effort on the part of the provider,” he says. “The doctor is searching for the correct field or struggling to type. This creates the same types of problems.”

He says physicians are making the process more interactive by creating a triangle with the patient and provider both viewing the computer screen. Analogous to a physician dictating while the patient is in the room, this configuration allows patients to be involved in a collaborative process that helps generate an effective treatment plan.

While physicians and patients find new ways to adapt to EHRs, software developers understand that technology must adjust to provider preferences and needs. “I do feel like we can’t take dictation entirely away from physicians,” Dharampuriya says. “We shouldn’t take the dictaphone away from doctors; we should empower the dictaphone to do more for them.”

— Susan Chapman is a Los Angeles-based writer.