Clinical Documentation Challenges

One of the most difficult tasks for EHR software is to capture clinical documentation. For many EHR implementers this is one of the last functions to be "turned on." There is a tremendous diversity in the breadth and depth of clinical notes. This is an area where "one size fits all" solutions usually do not apply. An advantage of EHR adoption purportedly has been reduction in transcription costs. This is achieved by clinical documentation software that eliminates the need for dictation and manual transcription. Often this accomplished through use of templates. Check boxes are filled in by the provider and then the narrative text representing the clinical note is generated by computer to provide a traditional-appearing note. Another method is the use of voice recognition software that in real-time converts voice to written text. As usual, I will relate my own experiences and thoughts:

Templates: I work with another surgeon who does mostly one type of operation over and over. He has a very standardized method with few variations. Previously, he dictated an operative report for each case. This task took at least several minutes of his time. That does no account for the time and expense of transcribing his dictations. I was able to create a template that accommodated almost all of his variations. There was one blank that required free text (the name of the anesthesiologist), two drop-down lists, and 5 fields that need to be completed with a typed number for the size of implants used. The surgeon is now able to complete an accurate operative with the template in about a minute. There is no doubt that this is a more efficient way for him to create his operative reports. In my experience templates work well for generally simple clinical documents where there are a limited number of possible variations.

On the other hand, templates do not work so well for me. I think it is hard to capture the nuances that are so important to recognize and report in clinical medicine. The majority of my surgical practice is individually tailored to each patient. The multiple types of conditions that I see and the complexity of co-morbidities make template-based documentation impractical. The types of procedures I perform are numerous and cannot be distilled down to simple templates. I need a tool like to dictation to complete operative reports for the surgeries I perform and the preparation of clinic notes for the outpatients that I evaluate.

Voice to text. My hospital eliminated most of the transcription department when the EHR went live in May. Dictation is still permitted but transcription has been scheduled to be eliminated by January 2013. Transcribed dictations follow a different work-flow than notes entered directly into the EHR because they must be scanned. The hospital administration decided to license voice recognition software for use by clinicians to assist in their documentation. (Recall that our EHR implementation was a "Big Bang" so transition was from paper to all electronic without phased introduction of functions or any pilot projects.) For some clinicians, voice recognition works well, with acceptable accuracy. For me, the accuracy is somewhere less than 85%. Some of the mistakes that are made result in text that at best has a number of embarrassing errors and at worst is nonsensical even to the creator of the note. Optimization of software by "training" is not feasible. It takes too much time and disrupts workflow when attempted on the fly. The output rate for voice to text during a dictation is unpredictable so that it can sometimes be near real-time but at other times as much as a sentence or 3 are printed after a delay, then all at once. Corrections on the fly completely disrupt productivity. Besides, with all the extra work the EHR engenders, I do not have the time nor is it the best use of my training to function as a copyeditor to fix transcriptions. I hesitate to admit that I am now resorting to typing most of my notes. This, I think, is definitely an unintended negative consequence of the EHR adoption. A solution that I favor is to have the hospital hire transcriptionists to review and edit each report. They would have access to the original voice files to help with the editing/correction task. (By the way, I used an earlier version of the voice recognition software the hospital licenses for a year in my private office during 2005-2006. I abandoned the software because of the unacceptable number of errors in my reports. I was actually "happy" to spend $1,000 a month to hire a skilled transcription service whose work I could rely on to be accurate and provide a professional result.)

One advantage of voice recognition software that I am impressed with is its potential to orchestrate navigation functions by voice commands rather through use of a mouse. Macros can be developed to facilitate tasks such as user logon, application launches, and page navigation among others. Programming can be as simple as recording a sequence of mouse clicks or it may require specialized programming training. Watch for increased use of voice controlled functions by users of HIT devices in the near future. Here is an interesting article I just read as I was preparing this post.