Different Methods of EMR Documentation
and
the
Significance of the Human Element
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Physicians document their findings and other details on electronic medical records (EMRs) in different ways. If some use the ‘point and click’ method, some may incorporate medical transcription, while some others may fully rely on speech recognition technology. Depending on the technology used to capture patient data, there are four types of EMR documentation styles. Manually–driven EMR In this style of documentation, physicians use neither traditional nor speech-assisted transcription services wit their EMR system to create free-text narratives. Instead, they point, click and type to enter patient information into their electronic record system. Of course, transcription savings are significant in this case.
However,
this
significant
method
reduction
leads
in
to
physician
productivity. This is because physicians need
to
focus
on
their
computer
screens even when talking to their patients, which may prevent them from noticing the patient’s body language, behavior and from listening to what patients actually say. As the number of patients is bound to increase as a result of
the
Affordable
Care
Act
(ACA),
physicians may find it more challenging to provide quality care and take care of documentation
requirements
at
the
same time as they would have to enter huge data into their EMR system by themselves.
Traditional Transcription In this method, physicians can dictate their findings into a digital microphone or standard telephone. This will be transcribed by medical transcriptionists. Physicians can then simply review and sign the transcribed documents within the EMR system. Transcription service providers offer EMR transcription by which the physician’s dictated data can be populated into the relevant EMR fields after transcription. Discrete reportable transcription (DRT) technology is the new trend, wherein narrative dictation is converted into text documents with discrete data elements easily imported into appropriate fields inside the electronic record system. Speech–assisted Transcription This type of documentation style involves the use of ‘back-end’ speech recognition software. As a first step, the physician’s dictation is captured and recognized by the speech recognition software. After that, the initial transcript is reviewed, edited and corrected by a medical transcription editor (medical transcriptionist). Physicians can then review and sign the documents within the EMR system. Studies have shown that the approach of back-end speech recognition combined with manual editing can lead to significant cost savings and improved efficiency. Speech–driven or Speech-enabled EMRs With speech-enabled EMRs, physicians can dictate directly into the free-text fields within their electronic record system, observe their findings on the screen and make necessary edits in real-time. Front-end speech recognition software is used in this approach. Since this approach requires far fewer process steps, it represents the fastest
and
most
cost-effective
documentation
method.
Voice
macros
allow
physicians to navigate any electronic record system with a single voice command and improve ease of use immensely. Role of Healthcare Documentation Specialists According to the Association for Healthcare Documentation Integrity (AHDI), human interface is still relevant for making the electronic clinical documentation work
optimally and that interface already exists in the form of skilled healthcare documentation specialists. This group of documentation specialists comprises medical transcriptionists, speech recognition editors, QA specialists and others involved in clinical documentation and data capture. Whatever documentation method you use apart from real-time documentation, the service of these specialists is inevitable to ensure the standardization and quality of medical documents within the EMR system due to the following reasons.
Point and click technology limits the selection of choices and impairs the comprehensiveness of clinical documentation. Apart from that, physicians tend to copy and paste data within the EMR in order to save time. Due to lack of time, they often copy and paste data without thorough checking. Frequent copy pasting without thorough checking can lead to grave errors within the electronic records.
Even with the most effective speech recognition software, there may be errors due to the difference in the voice of the dictator (due to cold or some other reasons) and noise in the environment. Human intervention is required to correct such kind of issues.
Healthcare documentation specialists constantly monitor your documentation to reveal and correct the following discrepancies.
Wrong patient or wrong content such as demographic mismatches
Wrong provider name
Wrong dates of service
Medication dosage errors
Right/left, male/female inconsistencies
Incorrect work types
Medical contradictions
Missing elements
Speech recognition errors
They strive hard to ensure your documentation contains comprehensive data of high quality. Professional medical transcription companies offer the service of these specialists at every phase of your documentation. Three level quality checks by transcriptionists, editors and proofreaders ensure that you benefit from accurate data. Implementing speech-enabled EMRs completely may be a bit risky as it will also result in the same time management problems for physicians. As the number of patients increases, providers may overlook errors while monitoring their transcribed findings on-screen. Dividing physicians into two groups and incorporating both backend and front-end speech recognition for complex data and simple data respectively would be a reliable option.