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Ways to optimize EHR documentation at your medical practice


Electronic health record (EHR) systems are built to help physicians improve their practices. But EHRs may also come between a physician and a patient during an encounter. Voice recognition software and scribes may help optimize your documentation.

Electronic health record (EHR) systems are built to help physicians improve their practices. But EHRs may also come between a physician and a patient during an encounter. Many physicians believe they spend more time typing into a computer instead of looking their patients in the eye. The bottom line: EHRs require physicians to rethink their documentation strategies.

When physicians are trying to decide what is best, Peter Basch, MD, chair of the American College of Physician’s Medical Informatics Committee, advises them to look at their overall goals.

“The issue is not just typing. The issue is understanding where we are in the evolution of having a computer in the room with a patient,” he says. “Is there is value in having a third party in the room with the doctor and patient? That third party is information that helps us deliver better, safer and perhaps even less expensive healthcare.”

He compares the new paradigm to a pilot using a checklist prior to takeoff.

“A good pilot doesn’t just make eye contact with the copilot or stare out the window. A good pilot also attends to other appropriate information for helping to better assure a safe flight,” Basch says. “The same is true in medical care. We quickly forget why the computer is there. It’s not a punishment for not taking typing in eighth grade. The primary purpose is not the documentation. The primary purpose is, at least in my opinion, how we better interact with the information.”

Options are available to physicians looking for a way to improve their doucmentation strategies. They range from typing furiously, while potentially ignoring the patient, to using scribes, voice recognition technology, or even continuing to take notes by hand and entering them into the computer later.

Next: Is typing a real option?


How EHR is used is key

No matter what input method is used, physicians must prevent the computer from impeding communication with ­patients, Basch says.

“Triangulate the screen so that the doctor, patient, and family can see it and use it as a tool to improve education, safety, and outcomes,” he suggests. “Do not keep the back of your head to the patient the entire visit and shield the screen so the patient can’t see what you are doing. That’s like paper records, but worse.”

Jason M. Mitchell, MD, who directs the Center for Health IT at the American Academy of Family Physicians, suggests that one way to keep the physician focused more on the patient rather than the computer is to have patients and office staff enter key information before the physician comes in to visit with the patient.

Also, “having polished typing skills makes a huge difference, as does the use of keyboard shortcuts, ‘auto text’ abbreviations, checkboxes, dropdowns, pick lists, templates, and appropriate history reuse from the longitudinal record,” he adds.

Is typing a real option?

Among the various options for documentation, some physicians find that frantically typing during the visit works for them. It can slow a physician down, but it doesn’t involve additional costs or staffing.

 “I have seen examples of this approach working really well,” Basch says. “If you are a ‘touch typist,’ a good approach is do the minimum. Pay close attention to making sure the right boxes are clicked, but have someplace in your EHR field in which you can type quick notes so that you have accurate, contemporaneous notes.

“You don’t have to ask the patient to stop talking so you can type grammatically correct sentences such as ‘Patients has had a sore throat since Tuesday.’ We certainly didn’t do that on paper. We scribbled TUES-sore throat. You don’t have to do any more on the computer,” Basch adds.

Voice Recognition software

However, Nick van Terheyden, MD, chief medical information officer for Nuance, whose Dragon Medical software is the most commonly used voice recognition technology in healthcare today, sees that technology as a much better option.

“Historically, physicians wrote their notes on paper. Starting in the 1970s, documentation had to be legible in order for them to be paid. This gave rise to a large transcription industry,” he says.

Early voice recognition technology could create a first draft, but it had to be cleaned up by a medical editor. However, today’s technology can create a highly accurate transcript that the physician can review in real time and share immediately with other providers if needed, he says.

Most physicians can learn to use voice recognition very quickly, he says. The technology lets users specify the dialect with which they speak and their medical specialty, and creates a profile to assist them. Some physicians may find they need to adjust their style of dictation, though.

Van Terheyden’s brother is a physician who realized through using voice recognition that he wasn’t as fluent as he thought he was when he dictated, and worked to improve how he presents information.

“He is now proud of his clinical notes,” van Terheyden says.

Such improved clinical notes offer a complete narrative of the patient’s story. More intricate details from the visit that may have been missed in the past are captured.

“We all look at lab results and vital signs, but we are really interested in the details of how patients present,” he says. “Eighty percent of my diagnostic process comes from the patient history, about 15% from my examination, and about a 5% contribution from the investigations and tests that confirm or refute my findings.

“If you only capture information from drop-down lists and checked boxes, you lose some of the fine details,” he adds. “Speech preserves it.”

Next: Scribes


As a bonus, patients can review the dictated notes on the computer screen with the physician and correct any errors. “Who has the most vested interest in the successful outcome of the interaction? The patient,” he says. “They can make a wonderful, positive contribution.”

Voice recognition is a time saver for many physicians, he says. One physician he knows works in several locations, one of which does not have speech recognition capabilities. This physician often works an extra hour or more a day to complete his documentation at that location.

Van Terheyden notes that there are many pricing models for voice recognition technology, based on how many patients the provider sees and the activities he or she needs to document. Some EHR systems come with the technology built in, so physicians do not see it as a separate cost. For others, the software needs to be added. Most systems will work with piggybacked voice recognition software, although not all.

Many primary care practices can save enough money from eliminating transcription to recoup the cost of the software and microphone in three to six months, he adds.

Also, voice recognition turns dictation into actionable data tagged against a medical vocabulary, van Terheyden says. This gives providers real-time feedback, such as suggesting a diagnosis that might be indicated by the constellation of symptoms. It can also help ease the transition to the International Classification of Diseases-10th Revision (ICD-10) because it prompts the physician to enter details, such as laterality, up front. 

Basch notes that some physicians use voice recognition in a hybrid manner, using a minimal template with key boxes and using voice recognition to add a narrative that accurately reflects what the patient said.

“This is a very powerful thing, particularly for patients who have had bad experiences with other doctors,” he says.


Another documentation strategy is hiring scribes. Scribes can be highly accurate and serve as a backstop for catching physician errors. However, they have several disadvantages, namely their ongoing salary, which they likely will expect to increase each year. Also, having a third person in the exam room can make some patients reticent to discuss their condition in a frank manner.

Basch recalls that when he was in training decades ago, the most efficient doctor he ever saw was an ear, nose, and throat specialist who used a scribe. The scribe would tell the doctor the key points from the last visit or remind him of things he wanted to recheck, while he examined the patient and offered comments aloud.

“Certainly that is a way to do it but since it is expensive, it is not for everybody,” Basch says. “If you hire the right person and they know medical terminology, it can be a time saver. But know that you are still signing the notes, so you still need to review them.

Mitchell says that the usefulness of scribes can depend on the physician’s practice style.

“Significant benefit comes from a bidirectional interaction of the physician and the EHR. Data validation tools, data reuse mechanisms, and clinical decision support tools are all dependent on the provider directly interacting with the EHR. This is complicated by putting a scribe between the physician and the EHR,” he says.

“Some systems (SOAPware, for example) are introducing the concept of ‘virtual scribes’ as a part of the EHR itself. This keeps the physician interacting with the record and the patient and benefiting from the data management and decision support tools that EHRs have to offer,” Mitchell adds.

Next: Still attached to paper?


Still attached to paper?

Despite the spread of EHRs, paper charts are still very much in use. Basch, who has been in practice for 33 years, says they appeal particularly to older physicians who feel unskilled in rapid typing or proper use of voice recognition.

“If this is an issue for you, don’t struggle with it,” he says. “Work with colleagues, a physician champion, your organization, or a vendor to come up with alternate mechanisms for data entry in the room with a patient so you can focus on the things that you need to. See if you can get a tablet that supports handwriting recognition. Or even stick with paper. In contrast to what some say, paper doesn’t kill. Paper usually cuts. Medical errors can kill.”

Using paper in the exam room and inputting your notes later is better than leaving medicine, he says. “If you are a talented person, don’t give up.”

Mobile platforms can provide a mid-point for some physicians. For example, iPads can accept dictation and allow interaction. A software program that Nuance makes, called Florence, helps physicians access information from complex medical records. Instead of navigating a menu tree to find lab results, they can just say, “Show me the lab results.”

Mitchell agrees that physicians must use whatever tools are necessary to provide the best care to their patients. “The wrong EHR badly implemented and poorly used by a physician can cause far more harm than effective use of a paper chart. However, the right EHR, well implemented and skillfully used by a physician is far better than a paper chart,” he says. 

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