Balancing need for Electronic record with need for Narrative
Written by Bob Bryan
Many healthcare providers have transitioned to an Electronic Medical Record (EMR). Others are evaluating systems. All will eventually need to adopt some sort of electronic record to comply with Federal initiatives.
All agree the advantages of an electronic record outweigh the pain of change. Savings in cost to deliver healthcare, ability to analyze data and ease of sharing information are just a few of the advantages of an electronic record, however EMRs have drawbacks as well.
A major topic of discussion and point of controversy in many of these systems are poorly designed documentation capabilities. While the provider’s attested diagnosis and treatment is the basis for reimbursement, most EMRs offer awkward tools for including this critical part of the record.
Today’s EMRs require the provider to interact directly in the documentation process. Many require a physician or other provider to introduce documentation of the encounter into the record. Point and click, templating and voice recognition are common strategies. While in many cases these methods provide some advantages to a provider keyboarding information, these systems can limit the choices offered to the provider and in some cases actually introduce inaccuracies into the record. Some systems restrict or eliminate narrative altogether.
Other systems incorporate voice recognition technology for entering narrative into the record. Voice recognition technology is improving; however it requires extensive training by the user, not the best use of a provider’s time. An untrained voice recognition system introduces many errors.
A recent industry study found that documentation created by providers contains up to 5 times the errors as does documentation created through traditional dictation/transcription.
What is the solution?
Many current dictation/transcription platforms interface with EMR systems. These systems offer the provider the choice of dictation/transcription, delivering the transcribed documentation into the EMR. The provider can review and approve the encounter in the EMR. This system leverages all of the advantages of the EMR such as the availability of patient history and eliminating re-dictation of medical history, current meds and physical exam.
MedEDocs is among a number of dictation/transcription system providers that currently offer this technology. Providers prefer dictation over point and click or voice recognition. It is far quicker, allowing them to spend more time with the patient and less time in documentation. This marriage of technologies with dictation transcribed by a medical language specialists should prove to be both cost effective and a convenient way for more providers to transition to an EMR.