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March 29, 2010

Physician Documentation: Slow No More
By Selena Chavis
For The Record
Vol. 22 No. 6 P. 10

Technological advances and federal mandates are changing the landscape of physician documentation and serving as a catalyst to broader HIT adoption.

For most physicians, the concept of “time is money” rings true, especially in an era in which most must tighten their belts to keep their practice and interests above water. That old adage has resonated across the industry as physicians have considered the larger picture of documentation practices as they relate to EHRs and computerized physician order entry.

For years, the healthcare industry has scratched its head in bewilderment as it has watched the average physician resist adoption of more advanced technologies and lag sorely behind the HIT curve where it bends to meet better efficiencies and improved patient care.

But according to many industry professionals, times are changing—and changing at a frenetic pace. Newer, more advanced technologies arriving on the scene are expected to catapult the industry toward rapid HIT adoption as they make the documentation process easier, allowing physicians to maintain the efficient and timely workflow they desire. Couple this improved workflow with expectations that enhanced speech recognition will help organizations meet federally mandated meaningful use criteria, and many expect that the way physician documentation is done today will look quite different five years from now.

“There is a shifting of the earth. We see predictions that 50% of physicians will buy an EHR by the end of this year … and 90% by the end of next,” says Keith Belton, senior director of product marketing with speech solution provider Nuance, who adds that stimulus funds are having an effect. “It [the technology landscape] is a moving target. The answers today are probably quite different than they would have been two years or even 18 months ago.”   

Industry professionals agree that one of the inherent problems to physician involvement in the EHR movement has been the fact that for most it has meant more time devoted to patient documentation—time that most claim they do not have. Add to that the costs involved with adding infrastructure, training, and realigning workflow processes, and many physicians made the strategic decision to put the technological movement on the back burner.

“Research indicates that technology can add time to [a physician’s] day,” Belton explains, pointing out that the problem becomes more evident with physicians who lack computer skills. “Without technology to make EHRs easier to use, it’s just a burden. By and large, use of the EHR has proven to slow the doctor down.”

Ruthann Russo, PhD, JD, MPH, RHIT, a documentation specialist who works with several leading healthcare organizations, concurs, adding that physician acceptance of the benefits of technology is also growing and will help spur quicker adoption.

“Technology is moving at lightning speed, especially in the mHealth [mobile health] area with mobile phone applications. With the ease of mHealth and Web-based solutions that are affordable, user friendly, and improve productivity, physician receptivity seems to be increasing,” she says, citing the latest statistics from the Association of American Medical Colleges. “Couple this with the 16,000 annual medical school graduates who are encouraged from day one to use technology in the classroom, as well as during their clinical training, and physician attitudes toward technology are no longer a barrier to progression, but rather the vehicle for it.”

Enhancing the Documentation Experience
Many suggest that advancements in speech recognition are being noticed by physicians, who cite the technology’s ability to capture more robust information into the EHR as an achievement that’s been a long time coming.

“We see a growing trend toward using more speech,” says Taras Silecky, senior vice president of strategic business development with speech recognition vendor M*Modal. “It tends to be a richer documentation than traditional documentation methods [found in EHRs through pull-down menus]. Physicians appear to favor speech as a growing modality.”

For years, the problems associated with speech recognition technology have centered around its inability to extract appropriate information from unstructured text. With the advent of natural language processing, Silecky says great strides have been made to automate the dictation process through speech recognition whereby needed patient information is extracted from freely dictated text directly into the appropriate EHR data fields in an accurate and efficient manner.

“It’s taking text and using software to extract clinical concepts,” he points out, adding that voice is converted to text and code. “We do both of these in real time together. Speech is very physician friendly; it’s what they are used to.”

Belton notes that going forward, two scenarios will likely play out for physicians and EHRs. In one scenario, documentation will continue to be carried out via traditional dictation methods, and a physician will simply use the EHR for certain functions.

“That’s a somewhat effective process. It may be less disruptive [to workflow], but a three- to four-day turnaround for transcription makes for poor patient care,” he says, adding that this scenario will also be the most costly as physicians would continue to pay an average of $10,000 to $15,000 per year for transcription services.

The second scenario would entail the adoption of speech recognition technology, essentially eliminating the costs associated with transcription, Belton says.

According to Russo, stimulus funds available through the American Recovery and Reinvestment Act (ARRA) have positioned the healthcare field as a strategic focal point for countless technology companies. Many, she suggests, would not have ventured into the space a decade ago.

“This transformation started the pre-ARRA introduction of Google’s EHR partnership with Cleveland Clinic and Microsoft’s HealthVault to Dell’s marketing of its Affiliated Physician EMR Solution directly to hospitals,” she says. 

And the number of mHealth applications available continue to multiply. Russo points to applications such as iChart, which she says “may be the most comprehensive mHealth suite of applications available to physicians.” Others she singles out include applications such as IMedDoc, which captures images and allows physicians to load them into patient records; 1st Followup, providing a method for emergency department physicians to record significant patient information to enable easy follow-up; and Gynotations, a platform designed for gynecologists to record operating room and patient visit notes.

“These technologies range from free to about $140 for apps like iChart and Gynotations,” Russo says, pointing out that the more expensive applications claim to be HIPAA compliant, while the freebies either don’t specifically address HIPAA or leave that area to the end user. “In the end, while it is important—actually legally required—for the software designers to ensure certain HIPAA compliance requirements are met in their software, it’s the user that often has the final say in whether the patient’s health information was in fact protected in a way to ensure federal legal requirements were met.”

Russo cautions that it would not be surprising to find the Department of Justice or the Office of Inspector General seeking out HIPAA violations resulting from individual users of mHealth apps and slapping them with some hefty fines. And while the speed, cost, and user friendliness of these platforms encourages adoption, Russo also notes that a lack of consistent platform makes interface with hospital records more difficult and may result in issues with quality and fragmentation of information.

The movement toward more mobile offerings designed for physician interface and documentation are the trend among speech recognition vendors. Belton points out that Nuance announced a version of its nonmedical Dragon platform for the iPhone last October and recently unveiled a prototype of its Dragon medical platform at the annual HIMSS conference. “The iPhone is clearly exploding in the healthcare space,” he notes. “It’s pretty safe to say that the iPhone is in high demand from physicians.”

Likewise, M*Modal also recently extended its speech recognition product to the iPhone.

Belton says the next wave of development in this area will be to address the current limitations of the iPhone, which in its current persona provides only a single application platform for use. “You can’t use it like you could a desktop,” Belton explains. “Our hope is that Apple will have a multithreaded version of the iPhone that will meet this need.”

A Meaningful Use Perspective
While technological advances are driving more widespread adoption of new platforms and processes for physician documentation, the role that these platforms play in helping organizations meet meaningful use criteria may be the catalyst that truly moves the system forward, suggest industry professionals.

Last December, the Centers for Medicare & Medicaid Services issued a notice of proposed rulemaking that spelled out parameters governing the Medicare and Medicaid EHR incentive programs, including a proposed definition for the central concept of meaningful use as it relates to EHRs. In order for professionals and hospitals to be eligible to receive payments under the incentive programs provided through ARRA, it is required that they demonstrate meaningful use of a certified EHR system.

To meet these criteria, it has been mandated that a specific percentage of all physician orders be done via an EHR and the data must be placed in a structured format. Silecky says new speech recognition platforms encourage physician use of EHRs by eliminating the frustrations inherent in the pull-down menus of the past.

“You’re going to be required to code concepts electronically,” he notes, pointing out that the first step to meeting the criteria is to actually use the electronic system. “These technologies already operate at that level. These technologies make it more attractive and easier for physicians to use the system.”

Belton says if physicians can easily dictate straight into the EHR and have essential information automatically extracted while at the same time meeting meaningful use criteria, the market will begin to move rapidly in that direction. “That’s the biggest and most exciting breakthrough in the future of documentation,” he says.

Russo says federal requirements via the meaningful use criteria are a fine idea, but she adds that “it is mind-boggling to think that at the beginning of the 21st century, we need to create incentives for healthcare providers to adopt computerized order entry and its related advantages for improving quality of patient care.”

She also cautions providers and vendors to tread forward cautiously. “Stepping back and looking at meaningful use criteria on one hand creates a huge sigh of relief that we are finally doing what many have talked about for decades,” Russo notes. “But on the other hand, another five years of work on issues that have bogged down the system for decades makes one wonder what other equally important issues will arise during those five years that will not be addressed until the incentive payments are completed.”

Alongside that caution, she describes the EHR implementation plan addressed by ARRA incentives to that of a big barge on the river, while mHealth applications are compared with speedboats. “Each serves a specific purpose for its user,” she points out, noting that in the end, it will be the ARRA’s $20 billion treasure chest that will have the largest impact.

To meet ARRA requirements, Russo says there is a clear need for an integrated IT platform that will do the following:

• improve quality, safety, efficiency, and reduce health disparities;

• engage patients and families;

• improve care coordination;

• improve population and public health; and

• ensure adequate privacy security protections for PHRs.

“While the speed boat is attractive to those of us who want to get there faster, we must consider what’s at stake: precious health information, quality of care, and ultimately the lives of healthcare consumers,” she says. “Perhaps the best recommendation, given the formidable developments by the mHealth developers, is to hope that they will find a way to interface their practical and innovative solutions with larger, more capable, HIPAA-compliant platform vendors—and that the larger platform vendors will recognize and embrace the value of these efficiencies.”    

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.