Being in the medical transcription field for so long, I'm always fascinated by the different processes that clinics use to document visits, and I almost always bring up dictation to them. Maybe I'll talk to the right person and get a sale out of it, but that's not my primary goal. My goal is to understand real-world examples of how people are doing medical documentation, so that we can improve our product.
I recently had a doctor's appointment, and noticed that there was a computer in the exam room with me. The nurse came in, took my vitals, entered them in on the computer, and left. When the doctor came in, he worked with me for quite some time, and entered his findings into the computer.
Instinctively, I asked the doctor if he ever dictated any of his notes. He said that the policy at their clinic was to not do this, and that more and more facilities are moving to EMRs. I told him what I our company did, and we talked about the pros and cons of their methods. He was definitely spending more time in the room with me, which as a patient I felt was great, but his attention was focused on the computer for half of the time, and it took him forever to enter his notes. Most of his notes were standardized - templated - so he was able to do that quickly, but when it came time to enter a unique comment about the visit, he had to type it all in by hand.
Of course EMRs are not going away, I told him, and templates are a great method of input for some EMR's, but what some clients have discovered is that you can do your templated entry on a computer and then dictate just the portion that would normally take you three-to-four times as long to type. EMR vendors are calling this a Dictation Marker or Placeholder. Transcription companies can now type these smaller pieces of dictation and send them back to the EMR with the Placeholder (usually a numeric code), which the EMR uses to place that transcribed text into the previously started note.
As medical documentation evolves and EMRs become more popular, there will always be a push for reducing costs. But if you examine the costs of dictation and transcription to the costs of the loss of time a doctor experiences between patients, you rapidly see that his time is better used dictating and seeing patients than typing reports. Several methods of cost reductions are already available - templating, voice recognition, dictation markers - but there are still times where good old fashioned dictation-transcription is the best method to use.
Fortunately, by talking to physicians like this, we're keeping that focus, and also improving our application to work with any other cost savings methods that come out. Emdat supports templating, voice recognition, and dictation marker integration with EMRs. And we're always keeping our eyes open for the next industry trend.
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