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Transcription and EHRs
Benefits of a Blended Approach

Mixing transcription and templates for physician documentation offers a practical way forward in organizations transitioning to electronic records.
By Jay Cannon and Susan Lucci, RHIT, CMT, AHDI-F

One of the biggest roadblocks to successful adoption of electronic health record (EHR) systems concerns physician documentation; specifically, use of point-and-click, structured templates. While hospital administrators and CIOs sometimes prefer full utilization of the EHR’s structured documentation capabilities over narrative dictation and transcription, physicians struggle with capturing the complexity of their patients’ stories within checkbox templates. Many prefer traditional narrative dictation and transcription.

HIM professionals and CIOs face a considerable challenge: how to balance physician productivity, satisfaction, and preferences with the need for structured, discrete data and meaningful EHR adoption. For physicians, every minute counts, and template-based documentation have the unintended consequence of lowering physician productivity. In addition, templates can tempt busy physicians to simply copy and paste documentation, thwarting HIM mandates for complete and accurate reports.

Likewise, CIOs are facing a technology challenge. They must establish data-reporting infrastructures to support internal and external clinical outcomes reporting, statewide hospital reporting programs, application for HITECH funding, and preparation for broader transparency and accountability. However, those infrastructures must balance physician productivity and satisfaction against the heightened discrete data reporting requirements. It is a difficult balance to achieve and even harder to maintain. Some organizations are approaching the challenge with a blend, integrating medical transcription as a component of the EHR. By doing so, HIM professionals can work with CIOs to balance physician satisfaction, achieve meaningful use of EHRs, and most importantly, ensure accurate clinical documentation for quality patient care. Perhaps transcription has found a solid role for the future: an integrated partnership with the EHR.

Transcription and the EHR: Reality versus Perception

Over the past decade, most EHR return-on-investment calculations have included the assumption that physicians would adopt template-based documentation, and medical transcription costs would be significantly reduced or eliminated. When return is based largely on reduced transcription costs, EHRs almost always fall short.

A survey of 2,212 providers conducted by the AC Group one year following its purchase of an EHR system found that 53 percent of physicians had gone back to dictation or handwriting and 18 percent had stopped using the EHR all together.1 HIMSS Analytics reports only 27 hospitals nationwide at the stage at which the majority of physicians use structured templates for their clinical documentation. Provider organizations that originally hoped to entirely eliminate their transcription costs have discovered that approximately 30 percent of transcription still remains. For example, Fallon Clinic in Worcester, MA, was only able to reduce transcription costs by a third, far lower than the 75 percent reduction projected by its EHR vendor.

2 A survey of HIMSS Analytics stage 6 hospitals—those almost completely automated and using paperless medical records—revealed a mix of report capture options that included speech recognition, voice recognition, and structured EHR templates (see table). Hospitals in the survey averaged 35 percent use of structured templates within the EHR, 62 percent dictation and transcription, and 4 percent voice recognition. At Mayo Clinic in Jacksonville, FL, 70 percent of physician notes are created using dictation and transcription, estimates Andrea M. Seymour-Sonnier, director of appointment and transcription services. The use of structured templates is growing (currently 25 percent of total notes are created using structure templates), but more than 620 dictators still use the organization’s medical transcriptionist and editor services, Seymour-Sonnier says.

For these organizations and thousands like them, a blended approach to physician documentation appears to be the norm. According to Mark Anderson, CEO of the AC Group, this approach will probably be the most ideal for physician documentation needs in the foreseeable future. See the full content of this article.

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