February 19, 2007

Selecting Expandability in Clinical Documentation Technology
By Sanjay Bajaj
For The Record
Vol. 19 No. 4 P. 10

One goal of every hospital, clinic, and private medical practice in the United States is accurate, high-quality clinical documentation. While the process for achieving this goal differs greatly from one facility to the next, it is inevitably complex and requires various technologies working together seamlessly. Separate modules of technology must be incorporated into a single platform, despite the fact that each module may come from a different vendor.

Too often, a healthcare facility selects a technology platform without thinking ahead about the potential difficulties of adding new functionalities. The facility then incorporates future modules in a piecemeal fashion, stringing together different technologies one at a time, year by year. It may eventually be necessary for the facility to make a costly investment in a completely new platform so all the desired technologies work together effectively.

Instead, hospital administrators and HIM directors should consider expandability on the front end when choosing a clinical documentation solution. Platforms should be easily expanded to support the entire range of technologies that the hospital may consider implementing in the future, even if those plans seem far distant at the time.

Modules
The following are common modules available as part of the clinical documentation platform. Any given hospital or healthcare facility will not need all forms of all modules. However, it is important to select a platform capable of easily integrating all these options as needs change or facilities expand.

Dictation
The dictation module is the first technology required in the clinical documentation process. Historically, dictation took place over a telephone. Today, microcassette recorders are being replaced by handheld digital recorders and PDAs. Radiologists and other specialists often require even more sophisticated technologies, such as picture archiving and communication system modules that allow them to automatically attach images and patient information to their dictation files.

Most healthcare facilities offer their practitioners multiple dictation technologies, which is important because of the different work types and personal preferences involved. Adding new dictation modules is a given as the technology continues to evolve and healthcare facilities grow.

Transcription
If transcription is performed in house, the facility requires a transcription module that provides an immediate and intelligent distribution of dictation files to the appropriate medical transcription personnel. The module should include autoformatting software, full spell-checker capabilities, and tool sets such as Stedman’s Quick Look Drugs.

Clinical documentation platforms should make it simple to add or replace transcription modules as new technologies become available. In addition, those platforms should interface seamlessly with outside clinical documentation providers if transcription services are outsourced or may be in the future.

E-signature
Allowing physicians to sign clinical documents electronically has become vital to fast, efficient medical transcription. E-signature technology may be a stand-alone module or it may be incorporated into another part of the platform.

Distribution
Various distribution modules exist, and most healthcare facilities will require several. Common modules include everything from simple printing, which may be part of the HIM system, to auto fax modules that link several facilities, whether they are clinics within a healthcare system or referring physicians from a separate organization. Web-based distribution modules allow physicians and administrators to quickly search for electronic files and share them by faxing, printing, or e-mail.

Speech Recognition
The industry is buzzing with claims about speech-recognition technology. Some sound too good to be true, while others are cautionary tales of disappointment. Speech recognition can produce dramatic improvements in productivity and turnaround time, but not every healthcare organization is positioned to take full advantage of the technology.

There are two forms of speech recognition on the market today: front-end and back-end. A front-end speech-recognition module allows physicians to instantly edit their transcribed files while they are still dictating them. This form is generally most effective for radiology and work types with highly specific vocabulary and formatting requirements. A back-end speech-recognition module, on the other hand, leaves the editing to a medical language specialist who takes the place of a traditional medical transcriptionist.

Expandability
A clinical documentation platform will likely undergo numerous changes and additions over its lifetime. Thus, expandability is one of the most important features to consider when investing in a new platform. It is important to select a platform that allows a facility to incorporate all the above modules as needed and roll out each new technology at its own pace.

There are four primary reasons for choosing an expandable platform with a full range of technologies and modules available from a single vendor:

1. To reduce the number of interfaces. Each interface between separate modules slows the flow of information. Rather than stringing together separate technologies, choose a platform that allows future modules to be fully integrated into the system.

2. To track documents throughout the entire process. When modules are interacting through interfaces, no single part of the system can provide an overall view of the entire process. A fully integrated platform allows for the creation of a richer document trail. A user can search for and track a file no matter where it is in the system, ascertaining immediately who is accessing a file, as well as when, where, and how.

3. To provide a uniform experience. With a fully integrated platform, users need only access and understand a single system. Physicians will be able to work with the same technology to check the status of a dictation file, provide an e-signature, or ensure proper distribution of the document.

4. To reduce potential points of failure. Each interface between modules from different vendors increases the complexity of the platform and the potential for failure.

Many healthcare facilities do consider expandability when selecting a platform that will tie multiple technologies together. However, bringing together two technologies that were not specifically written to work together always adds risk. Aside from the complexity and expense of working with separate vendors, selecting modules from different companies may affect the efficiency and productivity of clinical documentation technology.

Numerous technologies must work together for the clinical documentation process to run smoothly and efficiently. Ideally, all these technologies should be part of a single system, whether or not they were purchased at the same time. Incorporating technologies from a single source into a unified platform can improve the speed of medical transcription, increase the functionality of the platform, and reduce the potential for errors and failures.

— Sanjay Bajaj is vice president of application engineering at Spheris.