This article is written specifically for iData Medical by Darice Grzybowski, MA, RHIA, FAHIMA, President and Founder, H.I.Mentors, LLC and is a certified AHIMA Approved ICD-10-CM and ICD-10-PCS Trainer and Ambassador.

BACKGROUND

The electronic health record (EHR) is still in very much of an infancy state when it comes to accurately being used to tell the story of the patient.  There is much fragmentation in the method of recording information into the record vs. how it is displayed and organized for the end-user (reader) of such information.  Often lost in translation is the continuity from one note to the following report, from one order to the results, and between one caregiver and the next.

Much of this was due to the very confusing requirements of the Meaningful Use standards that tried to force practitioners into too heavy use of structured discrete data within template, while EHR vendors simultaneously were limiting physician flexibility due to restrictive designs in format. Adding to this decline of dictation use was the provider organization’s push to eliminate costs associated with the practice of dictation and transcription to justify the expensive purchase of an EHR. The EHR vendors were also supporting this push toward use of templates to build a return on investment case, but with no one considering the impact that the loss of dictation would have on the integrity of the medical record itself.

IMPACT OF TEMPLATE OVER-USE IN THE EHR

When clinicians are forced, or choose to use templated documentation, they fall into bad habits.  These habits include such problematic documentation short cuts such as copy and paste, auto-fill-in of existing templates from previously recorded information, over-use of drop down menus which are pre-populated with erroneous or old data, and data pulled from other sources or records that are not appropriate to be re-copied.

Rushing the act of documentation, or performing template fill-ins may allow the doctor to see more patients, but can result in several problematic and risk prone situations that can result in harm to the patient as well as create legal risk for the organization.   For example:

1. Copy and paste can create fraudulent billing as coders may accidentally code a situation more than once or bill for something that was documented more than once, but truly only completed once
2. Automatic filling of templates from previous information from another record or practitioner speeds up documentation, but fails to update current information such as the status of medications, conditions, allergies or other items that change frequently. When relying on old data, a safety risk is present for patients.
3. Incorrectly populated drop down menus that come from limited diagnostic problems lists can omit critical detail necessary for care of the patient, communication to other providers, and denials for medical necessity.

It is no wonder why physicians are demanding the use of dictation and transcription once again, and why the CMS has come out with statements supporting the use of dictation once again within the EHR and many hospitals are returning to fully transcribed core documents such as history and physicals, operative reports, consultation reports, and discharge summaries.

Please refer to the article “Transcription and EHR’s: Benefits of a Blended Approach” by Jay Cannon and Susan Lucci to understand many of the industry issues that support a return to dictation and transcription as a core strategy for the EHR. http://bok.ahima.org/doc?oid=97974#.WIlUUIcryuU  [i]

Although this article was penned in 2010, very little has changed and it is still relevant today to the need in the physician community for the documentation of clear, concise, complete, chronologic and compliant documentation in the medical record.

USE OF DICTATION AND TRANSCRIPTION

Caring for patients is a very human business. It consists of the simple actions of

1. assessing a patient
2. creating differential diagnoses as to the cause of a symptom/condition
3. ordering diagnostic testing
4. creating a treatment plan based on results of testing (which may include procedural-surgical components as well as therapeutic/pharmaceutical modalities)
5. monitoring the patient over time to validate the diagnoses
6. and then eventually repeating the evaluation, diagnostic, and therapeutic cycle

To describe these stages effectively, the SOAP process was put into place (Subjective, Objective, Assessment and Plan) as a guideline for clinicians to document their care. These principles are still taught in medical schools today as a proper form of documentation that follows language in a spoken format to describe each of these components.   The problem is that EHR’s tend to require discrete templated documentation that consists of fields of drop down choices that do not appear in very SOAP oriented format and certainly don’t convey that phased process when reading the output of the documentation.

It is ONLY in use of dictation and transcription that one can truly read a formatted note within the EHR to help support SOAP charting, and to create the true infrastructure of the medical record content that supports telling the story of the patient during each episode of care.

Disclaimer: This blog represents the opinion of the author and is not to be considered legal advice. Grzybowski is the author of the award-winning book “Strategies for Electronic Document and Health Record Management” (AHIMA, 2014) You can read more about her at http://www.himentors.com/about-himentors/

[i] Cannon, Jay; Lucci, Susan. “Transcription and EHRs: Benefits of a Blended Approach” Journal of AHIMA 81, no.2 (February 2010): 36-40.